Nutrition

Introduction:

Malnutrition is a significant problem in the hospitalised population, particularly in those with cognitive impairment. Malnutrition has been shown to increase rates of infection, pressure sores, length of stay, readmission and morbidity. Malnutrition Universal Screening Tool (MUST) scoring identifies adults at risk of malnutrition and prompts dietetic referrals where appropriate. MUST score recordings across four Complex Medicine Units in the John Radcliffe Hospital were often inaccurate or incomplete, impacting on the identification of malnutrition and timely referral to dietetics. Multi-disciplinary teaching on MUST scores improved identification of malnutrition in this patient population. Further interventions are planned.

Methods:

Electronic patient records for patients >/=75 years of age admitted to the Complex Medical Units at the John Radcliffe Hospital with a diagnosis of cognitive impairment were analysed. The percentage of patients who had either an incomplete or incorrect MUST score were identified. The percentage of patients that did not receive a referral to dietetics due to an underestimated MUST score and the reasons for the underestimation, were determined. Multi-disciplinary teaching interventions focussing on the identification of malnutrition in inpatients were implemented. MUST score recording was re-analysed following intervention.

Results:

71% of MUST scores underestimated risk of malnutrition. 67% of this cohort met criteria for referral to dietetics based on a corrected score, with only 33% of this group receiving the appropriate referral. Failure to identify weight loss in the preceding 3-6 months accounted for 88% of inaccurate scores. Multi-disciplinary teaching interventions improved MUST score accuracy by 14%, indicating improved identification of malnutrition risk.

Conclusion:

Identification of malnutrition is important to improve patient outcomes. Changes to practise will include multi-disciplinary education, improved use of technology to generate accurate MUST scores and the utilisation of transfer boards with integrated weighing scales to ensure all new admissions have an accurate weight.

Introduction

The importance of nutritional support has been extensively investigated in studies of people with hip and fragility fractures. Hospital nutritional assessments vary in quality, and this limits the extent to which risk assessment can be viewed as a meaningful indicator of nutritional support. Provision of supplements is an alternative measure, but only if known to have been consumed. For this reason, we developed a protocol to capture actual consumption of prescribed supplements. Methods Following nutritional risk assessment, the prescription and distribution of supplements was recorded on patients’ drug charts in the usual way. Our protocol required that when supplement cups were cleared, nurses should annotate the drug chart with the volume of supplement each patient had actually consumed. Following this protocol’s introduction, we conducted a point prevalence survey of patients’ supplement consumption in orthogeriatric rehabilitation wards in May 2024.  Results Of 25 inpatients with hip fracture, 21 (84%) had been identified as being at nutritional risk and prescribed Fortisip compact protein. Patients were recorded to have consumed between 50 and 100% of the supplement. This quantification of actual consumption allowed us to calculate that, on average, these patients with hip fracture had consumed an average of 188ml/day — which would provide an additional daily 27.4g of protein and 460 kcal of energy. Figures for 15 patients with other forms of orthopaedic injury indicated that 8 (53%) were at risk. These patients recorded similar levels of supplement consumption. Conclusion The prevalence of nutritional risk and malnutrition among patients with hip fracture would suggest that all should be considered ‘at risk’. A performance indicator might be constructed which starts with this assumption and measures whether such patients have actually consumed nutritional supplements. Our simple approach captures actual consumption, whilst reminding us of the importance of nutrition.

The introduction of an additional meal in nursing homes may be associated with a positive impact on the BMI of residents with dementia.

Abstract

Background

Since 2010, many nursing homes in Norway have introduced an extra meal daily, with a hot lunch, and pushing dinner to later in the day. This initiative aims to reduce the long time interval between breakfast and supper.

Aim

This study examines how an extra meal affects the residents' body mass index (BMI) at nursing homes in Norway. Research questions include how an extra meal affects BMI among residents in the dementia unit.

Methods

We used a cross-sectional design to analyze data from residents over 65 years old in dementia care units. Both parametric and non-parametric statistical tests were used to evaluate changes in BMI.

Results

Our study identified a modest increase in BMI among residents in the dementia care unit after introducing an additional meal. The results imply that incorporating an extra meal to meet residents' needs could support the maintenance of a healthy BMI.

Discussion

Our study reveals that the introduction of an extra meal resulted in a slight increase in BMI among the residents with dementia, which does not correspond with previous studies indicating malnutrition among these residents. The dementia disease reduces functional abilities, and challenges related to mealtime behavior, restlessness, and depression can lead to weight loss. The fact that our results show a slight increase in BMI at the dementia units may be related to these residents often being troubled with restlessness and not finding the peace to consume a full meal. By introducing an extra meal, the total food intake increases since residents still eat a little at each meal, and focusing more on accommodating each resident might have influenced the increase in BMI values.

Conclusion

The study indicates that the introduction of an extra meal has a positive effect on the BMI value of residents with dementia in nursing homes.

Introduction

Reference nutrient intake for protein amongst the general population is 0.75 grammes of protein per kilogram of body weight per day (g/kg BW/d). Expert groups recommend healthy adults over 65years have 1.0-1.2g/kg BW/d to support good health and maintain functionality (Deutz, Bauer and Barrazoni, Clinical Nutrition, 33(6):929-36). A recent paper suggested age specific recommendations of 1.2g/kg BW/d (Dorrington, Fallaize and Hobbs, Journal of Nutrition, 150(9):2245-2256).

This study aimed to quantify percentage of community dwelling older adults meeting recommendations for protein intake and explore factors associated with low consumption.

Methods

The study population comprised >65s completing the NDNS survey years 9-11 (2016-2019)*. Dietary intake was recorded in food diaries. Protein consumption was calculated as grammes per kilogram adjusted body weight per day (g/kg aBW/d). Adjustment made for body mass index (BMI) below 22kg/m² and above 27kg/m². Percentage of participants meeting protein recommendations for 0.75, 1.0 and 1.2g/kg BW/d was calculated. Chi-squared test for independence was utilised to determine association between social, health and lifestyle factors and low protein intake.

Results

Data from 385 participants were included; 43% male, 98% white. Mean protein intake was 0.98g/kg aBW/d (SD ±0.25). Prevalence of protein intake below 0.75g/kg aBW/d was 16.4% (n=63), below 1.0g/kg aBW/d was 52.2% (n=201) and below 1.2g/kg aBW/d 82.1% (n=316).

Current and ex-regular smoking was associated with protein intake <1g/kg aBW/d (p=0.01). No other analysis reached statistical significance although prevalence of low protein intake was higher in those without their own teeth (p=0.08), use of dentures (p=0.14) and BMI of 27-30kg/m² (p=0.09).

Conclusion

A large percentage of older adults are below expert recommendations for protein intake. There is a need for clarity over recommendations so that a clear public message can be given to optimise health and function in ageing. Factors influencing poor protein intake require further examination.

*University of Cambridge, MRC Epidemiology Unit, NatCen Social Research. (2023). National Diet and Nutrition Survey Years 1-11, 2008-2019. [data collection]. 19th Edition. UK Data Service. SN: 6533, DOI: http://doi.org/10.5255/UKDA-SN-6533-19

Introduction 

Dehydration is associated with prolonged hospital admissions and complications. Elderly patients are more susceptible due to physiology, dexterity and cognition. The British Dietetic Association recommends minimum 7 beverages per day whilst The British Nutrition Foundation advises proactive dehydration risk management in hospital. 

This project aimed to reduce the proportion of elderly patients at risk of dehydration in hospital.  
 

Methods  

Staff documented oral hydration over 24 hours for patients on the Care of the Elderly ward. Additional factors obtained retrospectively included demographics, dementia diagnosis, fluid prescriptions and fluid restriction. 

Criteria adapted from a ‘Hydration Care Assessment Tool’ defined risk of dehydration by daily intake as low (>1500mls), medium (800-1500mls), high (400-800mls) or very high (<400mls).  
Approximating each drink as 200mls, we set a daily target of 8 beverages; equating to low risk. Visual hydration trackers were placed at patients' bedsides and junior doctors reminded the multi-disciplinary team each morning. 

Data collection was repeated after 2 weeks.  

Results    

First cycle recruited 13 males, 16 females with mean age 78.5. Over 50% were Very High Risk (5/29) or High Risk (12/29) of dehydration whilst the remainder were Medium Risk (10/29), or Low risk (2/29). 4/5 (80%) at Very High Risk received intravenous fluids. Of the High-Risk group, more than half had a diagnosis of dementia and 3/12 (25%) received fluids intravenously. 

Following intervention, 12 males and 7 females were recruited with mean age 76. Proportion at highest risk was reduced: Very High Risk (5/29 to 0/19; -100%), High Risk (12/29 to 3/19; -61%). Therefore, more were at Medium Risk (10/29 to 13/19; +101%) and Low Risk (2/29 to 3/19; +131%). 

Conclusion 
 
Though improved, few patients meet hydration recommendations. However simple visual reminders are an effective starting point. Further interventions could include oral fluid prescriptions and reflect staff and patient feedback. 

Background:

Nutrition is one of the cornerstones of healthy aging. As we age there are many changes in our bodies, including decreased appetite and poor dentition, that contribute to increasing malnutrition. The MUST (Malnutrition Universal Screening Tool) score is a quick and effective tool to assess this.

Aim:

In this project, we aimed to review MUST score and food chart completion on the frailty wards at EDGH to attempt to improve the nutrition of elderly patients.

Methods:

The charts of 75 patients were reviewed over a period of one month. Following this, a training program for all the nursing staff was put in place. The initial results were discussed and the importance of nutrition in the elderly was highlighted. The staff were shown how to fill in the MUST score and follow management guidelines. Also, a reminder was set up on Nervecentre (electronic patient record) for all staff.

Results:

Of the initial 75 patients;

1 – a MUST score was completed for only 64% on admission.

2 – 41.3% of patients were eating 50% or less of their meals.

3 – In only 27% the reasons why they were not eating were documented.

In the second cycle, 80 patients were included and the results were markedly improved.

1 – The percentage of MUST score completion on admission increased to 91.3%.

2 – Management guidelines were followed in 92.5% of the cases.

3 – 18.8% with a MUST score of two or more, were referred to dietitians at an early stage.

Conclusion:

- Our quality improvement project significantly increased MUST score completion and prompted action at an early stage. 

- The next step is to improve the documentation of patient’s food charts and encourage staff to look for and document the reasons why patients are not eating.

Background:

Good nutrition and hydration are essential to patient’s health and wellbeing. Reduced nutrition leads to increased hospital admissions, re-admissions, longer length of recovery, poor wound healing and sarcopenia. Introduction: In hospital inpatients, especially when frail or vulnerable, the ward’s duty is to ensure that appropriate pathways exist to support their nutritional status and identify those who need additional support, additionally making sure patients have access to food and drink. Our ward wasn’t compliant with hospital standards. Additionally, patients experienced social isolation at mealtimes which negatively impacted on patient mood and calories consumed.

Methods:

Over 4 weeks, utilizing existing ward staff, we implemented a lunch club. This involved facilitating a communal lunch on the ward. Our main outcome measures were calorie and protein consumption. 40 data sets were obtained from what was recorded on the patient’s food chart and cross referencing it with the dietary information provided by the health board catering department. We also gathered data on WAASP score compliance comparing wards who had regular lunch clubs to those who did not.

Results

Attending lunch club resulted in a 68% increase in calorie consumption. In addition to this protein intake was increased by 73%. Wards where there was a DSW 97% of patients were screened for malnutrition, compared to only 61% on the wards without a DSW. Furthermore, on the wards without a DSW only 30% of patients were weighed once a week compared to 100% of those on a ward with a DSW. Not only did we see an objective increase in the calories consumed, patient enjoyment of mealtimes was increased as well as their time socializing during their in-patient stay

Conclusion

Lunch club increased calorie consumption, but it’s not sustainable without appropriate staffing. Comparing wards with and without DSW, there are clear discrepancies managing malnutrition.

Introduction: Oral nutritional supplement (ONS) prescription is commonly recommend for malnourished patients in hospital. However, compliance to ONS is often low. Ice cream may be a promising nutritional intervention. We undertook a study designed to compare the acceptability of high protein, fortified, ice cream called Nottingham-Ice Cream (N-ICE CREAM) with routinely prescribed milkshake ONS.

Methods: Fifty older (≥ 65 years) inpatients with hip or spine fractures were recruited from Queens Medical Centre, Nottingham. Patients were randomised into two groups, receiving two days of N-ICE CREAM and milkshake ONS. Group A received N-ICE CREAM first and Group B, milkshake ONS first. We measured compliance, acceptability (hedonic characteristics; rating 0 dislike a lot to 7 like a lot), attitudes towards length of prescription (rating 0 very unconfident to 4 very confident) and preference.

Results: Mean (standard deviation, SD) age of patients was 80.6 (7.7) years. The majority (n = 21, 67.7%) preferred N-ICE CREAM. Mean compliance to N-ICE CREAM was greater in both Groups (Group A (n = 22) 69.9 (30.0) % and Group B (n = 26) 56.3 (39.3)%) compared to the milkshake ONS (Group A (n = 22) 43.4 (4.7) % and Group B (n = 26) 53.6 ± (40.2) %). This was statistically significant in Group A (p < 0.05). Mean hedonic ratings were higher for N-ICE CREAM with an overall impression score of 5.8 compared with 4.6 for milkshake ONS. Confidence score for both products decreased with increasing time length. Both had an overall confidence score of 2.9.

Conclusions: High protein N-ICE CREAM is more accepted and preferred by older patients with a hip or spine fracture compared to standard milkshake ONS. Further research should explore optimal timing for N-ICE CREAM administration and long-term compliance, as well as clinical outcomes.

Introduction: Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.

Methods: Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.

Results: Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).

Conclusions: Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.

Background: Weight loss in the older adult is often multifactorial and can be associated with increased morbidity and mortality. Our quality improvement project focused on nutritional care of patients 75 years or older. This hospital has a standardised Nutrition and Hydration Policy based on NICE guidelines to prevent malnutrition in hospital inpatients including weighing patients every 72 hours, daily screening and food/hydration charts. Our project aimed to increase adherence, with a focus on increasing the percentage of patients being regularly weighed over a 6-month period to 90%.

Methods: Our stakeholder analysis highlighted the multidisciplinary nature of our project, particularly involving the healthcare assistants. The percentage of patients weighed within 72 hours was recorded weekly. The first PDSA cycle introduced the project and gained buy-in from the MDT, highlighting required weights in MDT meetings/board rounds. The second cycle included an education session for doctors. The third cycle involved a poster in each bay aiming to act as a prompt and promote patient and family involvement.

Results: Our run chart shows that following our first two PDSA cycles eight consecutive results were higher than the baseline (40% of patients weighed). Results ranged from 70-90%. Following the third intervention compliance returned to baseline but coincided with significant disruption to the ward structure and team. Our successful intervention of nutritional teaching was then repeated as a fourth PDSA cycle and the mean returned to 80%.

Conclusions: Nutritional care requires multidisciplinary involvement. The educational session had the most impact and in future could be delivered to additional MDT members. Disappointingly the poster did not stimulate patient or family participation. We would like to create an ethos on elderly wards where nutrition routinely features in ward-based comprehensive geriatric assessments. Future plans hope to further engage patients and families as visiting restrictions eased.