Addressing malnutrition in acute care
According to research conducted by the Canadian Malnutrition Taskforce, 25 to 50 per cent of patients admitted to a Canadian hospital are malnourished.
“That’s a significant portion of people who we serve in our hospitals,” said Jaki Thornhill, HSA member, dietitian and professional practice leader at St. Paul’s Hospital in Vancouver.
While there is some variability in this statistic based on patient populations and timing of nutrition screening, the prevalence of malnutrition in Canadian hospitals is concerning. Malnutrition has been linked to negative outcomes including impaired wound healing, impaired function and lower quality of life. Those who are malnourished may also have more frequent readmission to hospital and higher mortality rates.
Thornhill is part of a team of dietitians at St. Paul’s Hospital who are tackling malnutrition in acute care head-on. They’ve launched a project to integrate components of the Canadian Malnutrition Taskforce’s Integrated Nutrition Pathway for Acute Care (INPAC) into the hospital’s standards and practices. They are using an interdisciplinary approach to knowledge sharing in order to address patient malnutrition across the spectrum of hospital health care delivery.
The Canadian Malnutrition Taskforce, a standing committee of the Canadian Nutrition Society, released INPAC in 2017. Developed by clinicians, INPAC aims to increase the general awareness of malnutrition in hospitals, improve nutrition screening practices, and ensure standardized nutritional assessments.
As part of the Providence Health Care Knowledge Translation Challenge funded in part by HSA, Thornhill, alongside dietitians Maude Henri-Bhargava, Alena Spears, and Emily Zamora, under the mentorship of Dietitian Jiak Chin Koh, took up the project after participating in the taskforce’s second annual Canadian Malnutrition Awareness Week back in September 2017.
Dietitians Nicole O'Byrne, Vanessa Lewis and Kathy Ho also served as team members, but have since moved on to other roles.
“There was a couple of us wondering what else we can do to facilitate change and improve the care for our patients,” recalled Thornhill.
Shortly after the malnutrition week campaign, INPAC was released, and there was a project callout for the Knowledge Translation Challenge.
“We saw it as an opportunity to take the best practices that had already been established, tried, and implemented at other sites within Canada,” said Thornhill. “We had a way to be supported organizationally to do it well, and to ultimately be successful in some of the initiatives we wanted to roll out.”
While there are some dietary supports available in the hospital once a patient is admitted, if the patient isn’t feeling well and is medically compromised, this could impact a hospital’s ability to meet the patient’s nutritional needs. According to Thornhill, malnutrition can actually worsen after a patient is admitted to hospital.
She said that there are a variety of factors that could cause an acute care patient to be malnourished, “especially when we look at the patient population we serve.”
“A lack of food security is a really big component. If we look at older adults, we know there is more social isolation. There’s less ability to access food, groceries, and social meals,” she said. If they are compromised in the community, “It’s not surprising that when they come to hospital, they are already in a compromised state.”
While knowledge surrounding healthy diets and food is a factor, “what we see more of are the social aspects that impact somebody’s ability to nourish themselves,” she said.
And according to Thornhill, when someone is already feeling unwell, their ability to eat well is compromised. “People are already at a low point when they come to hospital.”
Among its goals, the project seeks to increase awareness across professions regarding multidisciplinary strategies for addressing malnutrition.
“We see a collaborative and team-based approach as important in addressing not only one-on-one patient needs, but also addressing it at a more system level,” said Thornhill.
The team’s multidisciplinary approach began at its early stages. They pulled together an interdisciplinary group at the hospital to inform the direction of the project. The consultation helped the team determine which components of the pathway to focus on.
They asked the group what they thought was important, and where they thought the project could make an impact. “And that is where the patient mealtime experience piece really came through,” explained Thornhill.
Improving the mealtime experience is one of four components to the project. Its other principle objectives are to build general awareness, improve nutrition screening practices, and implement the Subjective Global Assessment, which the Canadian Malnutrition Taskforce calls “the gold standard for diagnosing malnutrition.”
“The building awareness piece and the mealtime experience piece is where we see key interdisciplinary involvement,” said Thornhill.
She said that a patient’s nutritional status is impacted by how health care workers talk about hospital food. “How do you talk about pureed foods? Do you say ‘this is gross?’ Do you say ‘I‘m going to give you some green goop?’ Or do you say, ‘we have some broccoli for you today, and it has X, Y, and Z in it?”
These interactions can impact how a patient perceives their food, said Thornhill, and ultimately, how they eat.
“I think changing the conversation around malnutrition or just nutrition in general in hospitals is something everybody can do, and it needs to be seen as something that’s important.”
According to the Canadian Malnutrition Taskforce, malnourished patients spend two to three days longer in hospital than their nourished counterparts.
“Nutrition does often get seen as an extra when really, nourishment is essential to recovery and ultimately getting back home,” said Thornhill.
At the same time, the team has learned a lot from other health care workers about how their work in the hospital can support patients’ nutritional needs, and how good nutrition supports the interventions they provide.
Speech language pathologists have provided insight to the team about how nutrition affects their patient care. “If a patient is better nourished, it’s more likely that they are going to have a stronger swallow, and they might rehabilitate more effectively from dysphasia or stroke,” explained Thornhill.
“That’s where we saw a mutually beneficial conversation and desire to address this gap that we saw,” she said.
Thornhill also provided the example of physiotherapy. Rehabilitation is positively impacted by good nutrition. For patients “to maintain their functional capacity and build on their functional capacity, they need to be well nourished.”
From nurses to pharmacists, speech language pathologists to occupational therapists, and physiotherapists to social workers, Thornhill said that everyone can play a role in ensuring patients are well nourished.
This article was originally published in the September 2019 issue of The Report Magazine. Click here to view the full issue.