Malnutrition has a significant impact on Canada’s healthcare system. Recent research has shown that malnourished patients have 34 to 53 per cent longer hospital stays and cost the system 31 to 55 per cent more than well-nourished patients.
Malnutrition has also been shown to increase mortality and the risk of readmission to hospital.
Dr. Heather Keller, Schlegel Research Chair in Nutrition and Aging at the University of Waterloo, began researching malnutrition in Canadian hospital patients in 2010, with a study involving 18 hospitals across eight provinces.
“We found it was occurring in about one in three patients or one in two, depending on the unit,” says Dr. Keller. “People were coming in and were not being identified as malnourished. We then found that they were lingering and not making progress.”
Malnutrition is commonly underdiagnosed and undertreated because it’s not routinely screened for when patients are admitted to hospital, says Dr. Leah Cahill, a QEII Health Sciences Centre affiliate scientist and Howard Webster Department of Medicine Research Chair at Dalhousie University.
“Screening patients for malnutrition when they are admitted results in assessments and treatments,” says Dr. Cahill. “This has been shown to reduce infections, pressure sores, length of stay, falls, fractures, hospital readmission and mortality.”
Created in 2014, the national response to patient malnutrition is called the Integrated Nutrition Pathway for Acute Care (INPAC). It’s an evidence and consensus-based pathway, designed to guide healthcare professionals in the prevention, detection and treatment of malnutrition in medical and surgical patients.
Following INPAC protocol, new patients are screened within 24 hours of admission by a designated professional using the Canadian Nutrition Screening Tool (CNST): Have you lost weight in the past six months without trying to lose weight? Have you been eating less than usual for more than a week?
Patients identified to be at risk receive a diagnosis to confirm malnutrition. A Subjective Global Assessment (SGA) is recommended for making a diagnosis and triaging further nutrition care, including intake monitoring, mealtime support and nutrition discharge planning.
“We know how to treat malnutrition once it’s been identified,” says Dr. Keller. “The questions then become: Can you implement this program? And, if you do, does it change practice and change outcomes? Is it sustainable?”
To help answer those questions, the QEII’s Victoria General site became part of a national project in 2018. The More-2-Eat project was designed to implement the INPAC toolkit at 10 hospitals across the country and has been successfully piloted at Unit 9A, the Victoria General’s main general surgery unit.
As approximately 650 patients were screened for malnutrition, the process of implementing More-2-Eat on the ward was a team effort, says Sonya Boudreau, a clinical dietitian at Unit 9A.
“It involved nurses, social workers, pharmacy and physiotherapy,” says Sonya. “I think everybody on the floor
is more aware of the importance of this and we’ve developed a real culture of nutrition.”
In order to scale up More-2-Eat and roll it out to hospitals across Nova Scotia, it’s necessary to confirm whether this model of implementation is sustainable for the long term and the investment and resources required.
Earlier this year, co-principal investigators Dr. Cahill and Tina Strickland, director of policy and planning for Nutrition and Food Services, received funding from a QEII Foundation Translating Research Into Care (TRIC) grant with team members Brenda MacDonald, senior director of Food and Nutrition at Nova Scotia Health, Sonya Boudreau, and Dr. Keller for a study called More-2-Eat Nova Scotia Implementation Phase 2.
Dr. Cahill’s role will be to analyze the data as the program is implemented at four hospitals across the province: Hants Community Hospital, Windsor (general medicine); Glace Bay Hospital (general medicine and surgery); Cumberland Regional Health Care Centre, Amherst (general surgery); and Valley Regional Hospital, Kentville (general surgery).
“We will keep More-2-Eat going at Unit 9A, as we roll it out to the other areas,” says Sonya, who will be the research co-ordinator for the study. As she has now been through the process as site champion with the original implementation on 9A, Sonya will be able to share some of the findings and best practices with her colleagues around the province.
“We will have a community of practice, where we meet every month during the study and support each other with the different challenges that come up,” says Sonya.
If proven effective and sustainable, the long-term goal is that INPAC will be integrated as a standard of care for patients admitted to general medical and surgical units across Nova Scotia Health, explains Dr. Cahill.
“Our vision for the future is that all patients admitted to general medical and surgical units in Nova Scotia will be screened for malnutrition and receive appropriate nutritional care,” adds Dr. Cahill. “This project will be a large step toward this long-term goal.”