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Background Subjective global assessment (SGA) is a standardized diagnostic tool for malnutrition and identifies those who would benefit from nutrition treatment. SGA has been validated in several patient populations; however, implementation in clinical practice is inconsistent. The objective of this study was to understand and contrast the perceptions on use of SGA before and after it became a regular practice for hospital dietitians. Methods The More-2-Eat implementation project provided the opportunity to undertake this qualitative study, as 5 hospitals adopted INPAC (Integrated Nutrition Pathway for Acute Care), which includes the use of SGA. Between 2015 and 2018, interviews were conducted with dietitians at baseline (n = 9), a year after implementation (n = 18), and a year after project completion (n = 6). Thematic analysis was conducted. Results Themes before SGA adoption included a desire for a malnutrition diagnosis and care planning; lacking comfort in use of SGA; and reflecting on SGA training needs. After a year of implementing INPAC and a year after project completion, themes described becoming a better clinician; allowing dietitians to see the right people, sooner; recognizing the variability in the treatment path for mildly/moderately malnourished (SGA B) patients; improving overall efficiency in delivery of care; and establishing policy and procedures to sustain and spread use of SGA. Conclusion Initially, dietitians were hesitant to use SGA. Adoption through a focused implementation study and experience with implementation of SGA changed these perceptions. Understanding these perceptions before and after use may support adoption of this useful diagnostic tool.

Presently, undernutrition still goes undetected in pediatric hospitals despite its association with poor clinical outcomes and increased annual hospital costs, thus affecting both the patient and the health care system. The reported prevalence of undernutrition in pediatric patients seeking care or hospitalized varies considerably, ranging from 2.5 to 51%. This disparity is mostly due to the diversity of the origin of populations studied, methods used to detect and assess nutritional status, as well as the lack of consensus for defining pediatric undernutrition. The prevalence among inpatients is likely to be higher than that observed for the community at large, since malnourished children are likely to have a pre-existent disease or to develop medical complications. Meanwhile, growing evidence indicates that the nutritional status of sick children deteriorates during the course of hospitalization. Moreover, the absence of systematic nutritional screening in this environment may lead to an underestimation of this condition. The present review aims to critically discuss studies documenting the prevalence of malnutrition in pediatric hospitals in developed and in-transition countries and identifying hospital practices that may jeopardize the nutritional status of hospitalized children.

Objective To assess the prevalence, causes, and consequences of malnutrition, as well as the evolution of nutritional status, in Canadian pediatric health care institutions. Study design In this multicenter prospective cohort study, a total of 371 patients were recruited from pediatric hospitals in 5 Canadian provinces. Subjects were aged 1 month to 18 years; admitted to a medical, surgical, or oncology ward; and had a planned hospital stay of >48 hours. Data on demographics, medical condition, anthropometric measures, and dietary intake were collected. The Screening Tool Risk on Nutritional Status and Growth (STRONGkids) and Subjective Global Nutritional Assessment (SGNA) were applied at admission. Malnutrition was defined as a weight-for-age, height-for-age, body mass index-for-age, or weight-for-length/height z score Results Among 307 subjects (median age, 5.3 years; median length of stay, 5 days), 19.5% were malnourished on admission. Both STRONGkids and SGNA classifications were associated with baseline nutritional status. Mean weight-for-age z score was lower at discharge compared with admission (-0.14 vs -0.09; P Conclusion Nutritional status deterioration and malnutrition are common in hospitalized Canadian children. Screening tools, anthropometric measurements, and dietitian consultation should be used to establish adequate nutritional support.

Background & aims Reducing length of stay (LOS) is a priority for hospitals but patients' decline in nutritional status may have a negative impact. The aims of the study were to assess the change in nutritional status during hospitalization and determine if its decline is associated with prolonged LOS. Methods This is a prospective cohort study conducted in 18 Canadian hospitals. Subjective global assessment (SGA) and weight measurements were performed at admission and discharge. Patient information was collected at admission and extracted from the chart during hospitalization. Association between LOS and changes in SGA or weight loss ≥5% was tested using multivariate Cox PH approach. Results are expressed as hazard ratios (HR) and their 95% CI. Results 409 patients (53% male) with a LOS >7 days were analyzed. Patients' median (q1,q3) age was 68 years (58,79) and LOS was 11 days (8,17). At admission, 49% of patients were well nourished (SGA A), 37% were moderately malnourished (SGA B) and 14% were severely malnourished (SGA C). From admission to discharge, 34% remained well-nourished, 29% remained malnourished (SGA B or C), 20% deteriorated and 17% improved. Of the 409 patients, 373 had weight measurements at admission and discharge: 92 (25%) had ≥5% weight loss. Multivariate models showed that after adjusting for covariates, decline in nutritional status from SGA A to B/C or SGA B to C (HR: 0.62, CI: (0.44, 0.87); HR: 0.35, CI: (0.20, 0.62) respectively) and weight loss ≥5% (HR: 0.52; CI: 0.40, 0.69) were significantly associated with longer LOS. Conclusion In-hospital decline in nutritional status as assessed by SGA or weight loss ≥5% is associated with prolonged LOS independently of factors reflecting demographics, living accommodations and disease severity. This suggests a role for nutrition care in reducing LOS.

Guidelines promote dietitian consult (DC) for nutrition support. In Canada, dietitians are involved in the assessment of malnutrition and provide specialized dietary counseling. It is unknown however, what leads to a DC for patients fed orally. This study identifies independent predictors for a DC and determines what is the proportion of malnourished patients seeing a dietitian.The Canadian Malnutrition Task Force conducted a prospective cohort study in medical and surgical wards of 18 Canadian hospitals. 947 patients who did not receive enteral or parenteral nutrition were analyzed. At admission, subjective global assessment (SGA), body mass index, patient demography were collected. During hospitalization clinical data, including dietary intake and presence of a DC were obtained. Multivariate logistic regression was completed with dietitian consult ≤ 3 days and 4 + days as the outcome variables.The prevalence of malnutrition (SGA B + C) was 45%. Dietitians were consulted for 23% of patients, and of these consults 44% were well nourished (SGA-A), 37% were mildly/moderately malnourished (SGA-B), and 19% were severely malnourished (SGA-C). DC missed 75% of the SGA-B and 60% of SGA-C patients. Predictors of consultation within 3 days of hospitalization were: renal diet (OR 5.75) modified texture diet (OR 5.38), metabolic diagnosis (3.91), ONS use pre-admission (OR 2.33), severe malnutrition (SGA-C, OR 1.88) and age (OR 0.98). Predictors for 4 + days were: dysphagia (OR 11.4), a new medical diagnosis (OR 2.3), severe malnutrition (OR 2.17), constipation (OR 2.16), more than one diagnosis (OR 1.8), antibiotic use (OR 1.6), and male gender (OR 1.6). Consuming50% of food in the first week was not a predictor as only 19% of those with low intake had a DC at 4 + days.Overall predictors of DC were appropriate but SGA B and C patients and those eating50% were missed. Screening at admission with algorithms of care that include referral to the dietitian are needed to improve the process of nutrition care.

Background Poor food intake is common in acute care patients and can exacerbate or develop into malnutrition, influencing both recovery and outcome. Yet, research on barriers and how they can be alleviated is lacking. The present study aimed to (i) describe the prevalence of food intake barriers in diverse hospitals and (ii) determine whether patient, care or hospital characteristics are associated with the experience of these barriers. Methods Patients (n = 890; 87%) completed a validated questionnaire on barriers to food intake, including perceptions of food quality, just before their discharge from a medical or surgical unit in each of 18 hospitals across Canada. Scores were created for barrier domains. Associations between these barriers and selected patient characteristics collected at admission or throughout the hospital stay and site characteristics were determined using bivariate analyses. Results Common barriers were being interrupted at meals (41.8%), not being given food when a meal was missed (69.2%), not wanting ordered food (58%), loss of appetite (63.9%) and feeling too sick (42.7%) or tired (41.1%) to eat. Younger patients were more likely (P

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard. Electronic supplementary material The online version of this article (10.1186/s12937-017-0310-1) contains supplementary material, which is available to authorized users.

Validity and reliability of the new Canadian Nutrition Screening Tool in the ‘real-world’ hospital setting

Background Malnutrition is common in acute care hospitals worldwide and nutritional status can deteriorate during hospitalisation. The aim of the present qualitative study was to identify enablers and challenges and, specifically, the activities, processes and resources, from the perspective of nutrition care personnel, required to provide quality nutrition care. Methods Eight hospitals participating in the Nutrition Care in Canadian Hospitals study provided focus group data (n = 8 focus groups; 91 participants; dietitians, dietetic interns, diet technicians and menu clerks), which were analysed thematically. Results Five themes emerged from the data: (i) developing a nutrition culture, where nutrition practice is considered important to recovery of patients and teams work together to achieve nutrition goals; (ii) using effective tools, such as screening, evidence-based protocols, quality, timely and accurate patient information, and appropriate and quality food; (iii) creating effective systems to support delivery of care, such as communications, food production and delivery; (iv) being responsive to care needs, via flexible food systems, appropriate menus and meal supplements, up to date clinical care and including patient and family in the care processes; and (v) uniting the right person with the right task, by delineating roles, training staff, providing sufficient time to undertake these important tasks and holding staff accountable for their care. Conclusions The findings of the present study are consistent with other work and provide guidance towards improving the nutrition culture in hospitals. Further empirical work on how to support successful implementation of nutrition care processes is needed.

Summary Background Malnutrition at admission, using various parameters, is associated with 30-day readmission. However, the association between 30-day readmission and nutritional parameters at discharge has not been studied. Method From a large cohort study (n = 1022), 413 patients with a length of stay of ≥7 days who had information on readmission and discharge location were included into the analysis. Their nutritional status at discharge was assessed by subjective global assessment, body mass index, albumin, nutritional risk index and handgrip strength. Data on demography, diagnoses and Charlson comorbidity index (CCI) were also collected. Missing data was handled using multiple imputations by chained equations. Association of nutrition related measures with 30 day readmission was tested in logistic regression models. Results Of the 413 patients, 86 (20.8%) were readmitted within 30 days. The proportion of readmitted patients was higher for medical (42.2%) versus surgical patients (25.6%) (p = 0.005) and disease severity was higher in the readmission group with (median (q1, q3) CCI of 3 (2, 6) versus 2(1, 4) for no readmission (p = 0.009). Among the nutritional parameters assessed at discharge, only handgrip strength was significantly associated with 30-day readmission both in unadjusted and adjusted models. Stronger handgrip was associated with decreased chances for readmission where adjusted OR (95% CI) per unit increase were 0.95 (0.92, 0.99). Handgrip strength was not associated with disease severity assessed by CCI (p = 0.14) but was significantly associated with SGA (SGA A and B significantly different from SGA C: both p-values Conclusion Lower handgrip at discharge was associated with 30-day readmission. This assessment may be useful to detect patients at risk of readmission to better individualize discharge planning including nutrition care.

This prospective cohort study was conducted in eighteen Canadian hospitals with the aim of examining factors associated with nutritional decline in medical and surgical patients. Nutritional decline was defined based on subjective global assessment (SGA) performed at admission and discharge. Data were collected on demographics, medical information, food intake and patients’ satisfaction with nutrition care and meals during hospitalisation; 424 long-stay (≥7 d) patients were included; 38 % of them had surgery; 51 % were malnourished at admission (SGA B or C); 37 % had in-hospital changes in SGA; 19·6 % deteriorated (14·6 % from SGA A to B/C and 5 % from SGA B to C); 17·4 % improved (10·6 % from SGA B to A, 6·8 % from SGA C to B/A); and 63·0 % patients were stable (34·4 % were SGA A, 21·3 % SGA B, 7·3 % SGA C). One SGA C patient had weight loss ≥5 %, likely due to fluid loss and was designated as stable. A subset of 364 patients with admission SGA A and B was included in the multiple logistic regression models to determine factors associated with nutritional decline. After controlling for SGA at admission and the presence of a surgical procedure, lower admission BMI, cancer, two or more diagnostic categories, new in-hospital infection, reduced food intake, dissatisfaction with food quality and illness affecting food intake were factors significantly associated with nutritional decline in medical patients. For surgical patients, only male sex was associated with nutritional decline. Factors associated with nutritional decline are different in medical and surgical patients. Identifying these factors may assist nutritional care.

Background Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation. Methods A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel. Results 80 % of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators. Conclusions This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.

The Nutrition Care in Canadian Hospitals (2010-2013) study identified the prevalence of malnutrition on admission to medical and surgical wards as 45%. Nutrition practices in the eighteen hospitals, including diagnosis, treatment and monitoring of malnourished patients, were ad hoc. This lack of a systematic approach has demonstrated the need for the development of improved processes and knowledge translation of practices aimed to advance the culture of nutrition care in hospitals. A narrative review was conducted to identify literature that focused on improved care processes and strategies to promote the nutrition care culture. The key finding was that a multi-level approach is needed to address this complex issue. The organization, staff, patients and their families need to be part of the solution to hospital malnutrition. A variety of strategies to promote the change in nutrition culture have been proposed in the literature, and these are summarized as examples for others to consider. Examples of strategies at the organizational level include developing policies to support change, use of a screening tool, protecting mealtimes, investing in food and additional personnel (healthcare aides, practical nurses and/or diet technicians) to assist patients at mealtimes. Training for hospital staff raises awareness of the issue, but also helps them to identify their role and how it can be modified to improve nutrition care. Patients and families need to be aware of the importance of food to their recovery and how they can advocate for their needs while in hospital, as well as post-hospitalization. It is anticipated that a multi-level approach that promotes being "food aware" for all involved will help hospitals to achieve patient-centred care with respect to nutrition.

Purpose: Information on human resources and costs is needed to plan for the addition of registered dietitian (RD) services to new models of primary health care (PHC). Estimates were developed, based on an analysis of an enhanced RD model of counselling and health promotion services in three Ontario Family Health Networks (FHNs). Methods: Both direct and indirect costs were averaged over the three FHNs. Costs and RD activities were tracked throughout 2005. The FHN staff completed two questionnaires addressing communication, case management, and satisfaction with RD services. Results: Actual and reported case management indicated that an estimated 1.3% to 2.4% of the 60,000 enrolled patients may require individual nutrition counselling in a year. If one full-time equivalent (FTE) RD can manage 380 new referrals, then one FTE RD is needed per 15,800 to 29,000 patients. The estimated direct costs of adding one FTE RD (including expenses and fixed costs) is $78,169 to $80,169, when the RD is an independent contractor. Conclusions: Additional studies are needed to develop better estimates of human resource needs and costs of interdisciplinary nutrition services in all PHC settings. These estimates should be based on population characteristics and direct and indirect costs for all models of nutrition services in PHC settings.

In hospitals, length of stay (LOS) is a priority but it may be prolonged by malnutrition. This study seeks to determine the contributors to malnutrition at admission and evaluate its effect on LOS.This is a prospective cohort study conducted in 18 Canadian hospitals from July 2010 to February 2013 in patients ≥ 18 years admitted for ≥ 2 days. Excluded were those admitted directly to the intensive care unit; obstetric, psychiatry, or palliative wards; or medical day units. At admission, the main nutrition evaluation was subjective global assessment (SGA). Body mass index (BMI) and handgrip strength (HGS) were also performed to assess other aspects of nutrition. Additional information was collected from patients and charts review during hospitalization.One thousand fifteen patients were enrolled: based on SGA, 45% (95% confidence interval [CI], 42%-48%) were malnourished, and based on BMI, 32% (95% CI, 29%-35%) were obese. Independent contributors to malnutrition at admission were Charlson comorbidity index2, having 3 diagnostic categories, relying on adult children for grocery shopping, and living alone. The median (range) LOS was 6 (1-117) days. After controlling for demographic, socioeconomic, and disease-related factors and treatment, malnutrition at admission was independently associated with prolonged LOS (hazard ratio, 0.73; 95% CI, 0.62-0.86). Other nutrition-related factors associated with prolonged LOS were lower HGS at admission, receiving nutrition support, and food intake50%. Obesity was not a predictor.Malnutrition at admission is prevalent and associated with prolonged LOS. Complex disease and age-related social factors are contributors.

BACKGROUND Nutritional assessment commonly includes multiple nutrition indicators (NIs). To promote efficiency, a minimum set is needed for the diagnosis of malnutrition in the acute care setting. OBJECTIVE The objective was to compare the ability of different NIs to predict outcomes of length of hospital stay and readmission to refine the detection of malnutrition in acute care. DESIGN This was a prospective cohort study of 1022 patients recruited from 18 acute care hospitals (academic and community), from 8 provinces across Canada, between 1 July 2010 and 28 February 2013. Participants were patients aged ≥18 y admitted to medical and surgical wards. NIs measured at admission were subjective global assessment (SGA; SGA A = well nourished, SGA B = mild or moderate malnutrition, and SGA C = severe malnutrition), Nutrition Risk Screening (2002), body weight, midarm and calf circumference, serum albumin, handgrip strength (HGS), and patient-self assessment of food intake. Logistic regression determined the independent effect of NIs on the outcomes of length of hospital stay (

Purpose: Patients’ perceptions of preventive lifestyle in primary care practice were examined. Methods: Practice was assessed with a modified version of the Primary Care Assessment Survey (PCAS). This was mailed to random samples of patients twice, using practice mailing lists from three Ontario Family Health Networks (FHNs). Family Health Networks are physician-based group practices, with additional nurse-led telephone advisory services to provide care 24 hours a day, seven days a week. The PCAS questionnaire consisted of nine scales (ranging from 0 to 100). For preventive counselling, additional questions on diet and exercise counselling were included to determine how the physician delivered the intervention. Results: Of the 2184 survey questionnaires mailed to patients, 22% were undeliverable. The response rate was 62% at valid addresses (49% of all mailed questionnaires). Of the nine scales, scores (± standard deviation) for preventive counselling were lowest at 33 ± 25. In particular, rates of diet (37%) and exercise (24%) counselling were low in the FHNs. For most other aspects of primary care services, patients generally rated FHNs highly. The majority of patients advised about diet and exercise were given verbal advice or pamphlets. Conclusions: In these primary health care organizations, considerable room exists for increased preventive counselling, especially about diet and exercise.

Purpose: Primary health care reform presents new opportunities for registered dietitians (RDs) to contribute to health promotion and disease prevention in family practices. Since this is an emerging area of RD practice, a health promotion specialist was contracted to conduct a needs assessment and develop a plan for implementing nutrition-focused healthy lifestyle activities. Methods: The needs assessment was conducted as part of an Ontario-based demonstration project in three Family Health Networks (FHNs). Results: The needs assessment revealed a lack of agreement about what types of activities should be undertaken, a lack of information on the population's needs, a lack of coordination with other agencies in the community, and barriers of time and resources. The health promotion specialist recommended that health care team members in each FHN develop a shared understanding of their goals, and undertake the entire planning and evaluation cycle. Specific strategies were suggested to increase awareness, to provide health education, and to improve environmental support. Conclusions: A significant need exists for conceptual development, planning, testing, and evaluation of disease prevention and health promotion in family physician-based primary health care organizations. The findings may be useful to others interested in increasing the focus on health promotion and disease prevention in such practices.