Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study

Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study

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Clinical Nutrition xxx (2014) 1e8

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Clinical Nutrition journal homepage: http://www.elsevier.com/locate/clnu

Original article

Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study Q6

Q1

M. Holst a, *, T. Beermann a, M.N. Mortensen b, L.B. Skadhauge a, K. Lindorff-Larsen c, H.H. Rasmussen a a b c

Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital and Aalborg University, Denmark Aalborg Central Hospital Kitchen, Aalborg University Hospital, Aalborg, Denmark Skills and Simulation Unit, Aalborg University Hospital, Denmark

a r t i c l e i n f o

s u m m a r y

Article history: Received 2 January 2013 Accepted 4 May 2014

Background: Good nutritional practice (GNP) includes screening, nutrition plan and monitoring, and is mandatory for targeted treatment of malnourished patients in hospital. Aims: To optimize energy- and protein-intake in patients at nutritional risk and to improve GNP in a hospital setting. Methods: A 12-months observational multi-modal intervention study was done, using the top-down and bottom-up principle. All hospitalized patients (>3 days) were included. Setting: A university hospital with 758 beds and all specialities. Measurements: Record audit of GNP, energy- and protein-intake by 24h recall, patient interviews and staff questionnaire before and after the intervention. Interventions: Based on pre-measurements, nutrition support teams in each department made targeted action plans, supervised by an expert team. Education, diagnose-specific nutrition plans, improved menus and eating environment, and awareness were initiated. Statistics: ManneWhitney and KruskaleWallis test was used for ordinal data, and Pearson Chi square test for nominative data. Results: Overall 545 patients participated (287 before/258 after) from 26/22 departments. There were no significant differences regarding sex, age, BMI or previous weight loss before and after the intervention. Result-indicators: Energy intake improved from 52% to 68% (p < 0.007), and protein intake from 33% to 52% (p < 0.001) (>75% of requirements). Intake of less than 50% of requirements decreased with 50%. Process-indicators: Screening improved from 56% to 77% (p < 0.001), nutrition plans from 21% to 56% (p < 0.0001), and monitoring food intake from 29% to 58% (p < 0.0001). Conclusions: Intake of energy and protein as well as GNP improved using a multi-modal top-down and bottom-up approach. Ó 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Keywords: Undernutrition Multi professional Nutrition teams Nutrition recording Intervention Implementation

Q2

1. Background Undernutrition is common in hospitalized patients, ranging from 20 to 60%, depending on setting, speciality and screening tool. Undernutrition is significantly associated with increased morbidity and mortality [1e4]. Nutritional risk in this study is defined as patients who score 3e7 points by screening with NRS-2002, and therefore are found to benefit clinically from nutritional support

* Corresponding author. Centre for Nutrition and Bowel Disease, Department of Medical Gastroenterology, Aalborg University Hospital, Moelleparkvej 4, 2 East, Reception 3, 9000 Aalborg, Denmark. Tel.: þ45 99326267, þ45 27113236. E-mail addresses: [email protected] (M. Holst), [email protected] (T. Beermann), [email protected] (M.N. Mortensen), [email protected] (L.B. Skadhauge), [email protected] rn.dk (K. Lindorff-Larsen), [email protected] (H.H. Rasmussen).

[5,6]. Socioeconomic consequences include increased treatment costs, prolonged hospital stay and convalescence, as well as increased dependency on care after discharge. For the individual patient, there is an increased risk of social isolation, dependency on others and depression [4]. Optimising individual protein and energy intake in patients at nutritional risk can improve clinical outcome and reduce costs [7e13]. An intake of at least 75% of energy- and protein-requirements has been shown to reduce complications and adverse outcomes in hospitalized patients [7]. Based on this evidence, the Danish Healthcare Quality Programme (www. IKAS.dk) has incorporated nutrition screening, planning and monitoring, as recommended by the ESPEN guidelines, into mandatory quality standards and indicators in hospitals in Denmark. Good Nutrition Practise (GNP) is seen as screening all patients for nutritional risk within 24 h after admission, making a

http://dx.doi.org/10.1016/j.clnu.2014.05.001 0261-5614/Ó 2014 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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nutrition plan for patients at nutrition risk and monitoring nutrition intake to see and eventually adjust the nutrition plan [1]. In spite of guidelines and quality accreditation incentives, local audits of nutritional practice in our institution were not uniformly satisfactory. Although audits of clinical nutrition had only been undertaken in a few especially interested departments, they indicated a need for improvement. Improving patients’ energy and especially protein intake by oral nutrition is difficult to achieve due to a multitude of factors [4,7,14]. Interest, knowledge and priority among doctors and nurses, organisation and structure, communication and documentation of nutritional care are important factors as well as the quality and serving of hospital food [4,15e18]. Logically no single intervention can address such a complex clinical problem. This gave rise to the idea of a multi-modal "bottom-up and top-down" strategic interventional approach, which has been used to improve clinical nutrition practice [19]. 2. Aims The aims of this study were to increase the result-indicators: energy- and protein-intake in patients at nutritional risk and furthermore, generally, to improve the process-indicators: GNP (screening, plan and monitoring as well as communication) as described in the ESPEN guidelines, the Danish National Guidelines and the Danish Healthcare Quality Programme. 3. Methods An observational multi-modal intervention study, including baseline measurements, was followed by a 12 months intervention period, completed by follow-up measurements. The methodology for the intervention sought the "bottom-up and top-down" principle, which both made an available strategic framework and had the intention of motivating participants [19]. This aimed at motivating the involved departments to improve practice, by acknowledging and acting upon own results from the baseline investigation with interventions that were especially pertinent to local conditions, specific patient categories and fields of interest. The study was organised by a multi professional specialist team from the hospital Nutrition Steering Committee. The organisation of the study is seen in Fig. 1a. All hospitalized patients (>3 days after admittance) were included after informed consent. Patients, who suffered from dementia, were terminally ill or age >18 were excluded. The followup measurements took place one year after the baseline measurements. Both baseline and follow-up measurements took place at all included departments at the hospital on the same week and weekday with one year in between. 3.1. Organisation of the baseline and post intervention crosssectional measurements The NST in each department was involved during the study period. On the two days of the cross-sectional measurements studies, all the NST members were assigned only to participate with the study measurements. The involved NST members doing the nutritional audits, were distributed in-between the departments. One member of the NST remained in their own department, and the other 2e4 nurse- and doctor-members of the team were assigned to a department to which they had no affiliation. The dieticians were all assigned to do the 24-h recall interviews. An illustration of the study methods is seen in Fig. 1b.

3.2. Setting The setting was Aalborg University Hospital with 758 beds, including all specialities. The hospital was organized with a hospital nutrition committee, and nutrition support teams in 26 clinical departments, including, surgery, internal medicine, geriatrics, oncology and cardiology. The hospital nutrition committee was chaired by the hospital director, and the study was initiated from this committee. The establishment of multi professional nutrition support teams within each department was a priority from the hospital management, to fulfil new national accreditation criteria. The directors financial advisor participated in the committee meetings, in order to ensure that decisions were financially realistic. The committee was composed of staff from the clinical departments, leader representatives from the clinics, the head of the hospital kitchen, and a development consultant from the kitchen. Centre for Nutrition and Bowel disease, was represented by the head of department, head of clinical dieticians and head of the clinical nutrition research unit. The nutrition support teams (NST) included at a minimum a physician, a nurse, and a leading person (most often the associate head nurse). In the hospital, 9 dieticians were employed in "Centre for Nutrition and Bowel Disease". The dieticians were each predominantly associated with a specific department. For that reason, not all departments had equal access to dieticians, and not all departments had a dietician associated to their NST. Many departments had more participants in their NST e most often 4e6 members. In daily practice, the NST were assigned to take part in the implementation of nutrition guidelines in their own departments, to spread their knowledge about clinical nutrition to colleagues, and to supervise colleagues in specific patient related nutritional problems. Team members were however mostly assigned to general clinical procedures in their departments. As educational basis for their nutrition team-membership, the NST members had a two day nutrition workshop, arranged by the hospital nutrition committee. Many team members had participated in several lectures regarding clinical nutrition. 3.3. Measurements Before and after the intervention period, the following measurements were made:  Basic demographic data  Process-indicators including GNP (screening according to NRS 2002) [5] nutrition plan and monitoring  Structured patient interviews  Result-indicators including energy- and protein-intake by 24h dietary recall interviews [20]  Staff questionnaires

3.4. Basic demographic data Basic demographic data were obtained from patient records. These included age, gender, weight, BMI, weight loss <3 months. Fof co-morbidities, diabetes, COPD and stroke were registered. 3.5. Process-indicators including GNP Process-indicators included nutrition screening on admission, nutrition plan and nutrition monitoring. These data were obtained from the patient records. The audit team performed the patient record audit in a pre-defined room in the department, and performed the structured patient interview at bedside. The NST

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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3

Fig. 1. a. Organisation of the study. b. Study methods.

member who stayed in their own departments, facilitated the audit process for the visiting team, by providing patient paper records, making sure patients were ready for interviews (as some left the department during the day to go to investigations i.e.), updating patient lists, and assisting the audit team in practical issues. The audit team investigated documentation in the medical records for the process related to good nutritional practice, in each individual patient. The audit sought to find whether nutrition screening, nutrition plan, decision about energy and protein requirements, and monitoring of nutrition intake were documented [21]. 3.6. Result-indicators including nutrition intake by 24-h dietary recall interviews Nutrition intake was investigated at bedside, through 24h dietary recalls, by the dieticians. The recalls had been prepared with pictures of the actual meals and beverages, served within the past 24 h. The pictures illustrated all menu options and four different portion sizes. All participants were invited to be included

in the dietary recall investigation, regardless of nutritional risk. The interviewers started with the last served meal, and worked their way 24 h back [20]. If patients had enteral or parenteral nutrition as supplement or single feeding, it was included in the recording. 3.7. Patient interviews Finally a questionnaire-based interview investigation was made at patient bedside by members of the nutrition audit teams. The questionnaire comprised 18 questions and investigated the communication between patients and staff regarding the clinical nutrition process for the individual patient. Questions addressed the following issues:  Did patients receive information about own nutritional screening and the result?  Did the patient experience monitoring of nutrition intake?  Did monitoring of nutrition intake encouraged the patient to improve intake?

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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 Did the patient received written information with dietary advice during admission?  Did the patient received oral information about the importance of nutrition and what would be good to eat during admission?  Did the patient talk to the doctor about nutritional status or nutrition intake?  What was the motivation to increase nutrition intake?  How did the patient apprehend nutrition in relation to disease  How did the patient feel about having a tube placed to help increase nutrition intake, if sufficient intake was not otherwise possible?  How did the patient experience serving of nutritional supplements and sip feeds  How did the patient experience serving hours in the hospital  Did the patient feel appetite at times of serving during the past day. The patients were asked if they were informed about their individual screening results for nutritional risk, whether they had received information about what was the optimal nutritional therapy for their specific disease, and lastly, whether their food intake had been monitored. Furthermore, they were asked if the staff, including doctors and nurses, had talked to them about the results of their individual nutrition monitoring. The questionnaire had been tested earlier in three departments at the hospital [4]. 3.8. Staff questionnaires The staff questionnaire tested attitude, practice, knowledge and organisation regarding clinical nutrition within all clinical staffs who worked in the 24-h slots at the two clinical nutrition days (baseline and follow-up measurement). This questionnaire was based on an earlier questionnaire among clinical staff in the Scandinavian countries [18,22]. The leading person assigned to the NST in each department, took care of organizing the completion of these staff questionnaires. The number of doctors and nursing staff at work on a general weekday was estimated by contact to the head nurse of each department in the beginning of 2009. The number of questionnaires was increased by 10% to make sure there was enough for all staff. Based upon this, 920 questionnaires were distributed. The 24 questions included:  Demography: Profession (doctor, nurse, health care assistant) and years working in the actual department.  Attitude to own impact on nutrition intake for the patients  Knowledge about: Hospital food service, enteral nutrition therapy and parenteral nutrition therapy  Communication between themselves and patient regarding nutrition within the past days at work (seven questions)  Assignment of responsibilities

3.9. Pre-study education for nutrition teams All members of the multi professional NSTs were invited to participate in the pre-study education. The educational sessions included teaching in relation to the record audit as well as the questionnaire investigation practice. Moreover, a four hour workshop was held with the aim of motivating the teams towards leadership in implementation strategies for clinical nutrition in their own departments, where they were assigned to be stakeholders and trendsetters towards the thinking of clinical nutrition in all daily practises. Teaching implementation strategies were found very important, as the nutrition teams were going to be in

charge of the process in their own local improvement projects, based the baseline investigation results. 3.10. Interventions The following multi-modal interventions were made: In all departments the following interventions took place:  Baseline results from their own departments as well as the total hospital baseline results were presented for each department by the hospital nutrition committee members.  Each NTS were asked to identify problem-based areas for improvement in their own department.  Targeted action plans for improvements were made by each department were given.  Supervision from central expert team was given for developing targeted action plans.  Multi professional education regarding baseline GNP, enteral and parenteral nutrition. Individual action plans from the various departments included:  Preparation of disease- and course-specific standard nutrition plans in departments who had this as a plan of action.  Catalogues of ideas  Education for kitchen staff in creating new menus  Host-guest concept [23,24]  Improved focus on eating environment  Disease-specific nutrition education for clinical staff Furthermore, the project management took contact to the media for creating awareness, positive publicity and professional pride among staff. The framework for the study is shown in Fig. 1b. The overall results from the baseline investigation were presented at two common sessions for the NSTs. Furthermore, each department had their own analysis presented in written form, being able to benchmark with the overall hospital results. The local NSTs were given the opportunity by the project management (members of the hospital nutrition committee) to go through the data together. The local NSTs in the departments were recommended to make individual action plans for improvements, based on own and common baseline results. All departments were offered supervision from the project management for making targeted action plans, including assistance to prepare a presentation for their own staff. Furthermore, all NSTs were offered expert assistance regarding specific nutritional practice problems in their department, as found in the baseline investigation. 3.11. Local interventions after baseline The interventions and action plans in the departments were individually based on their results from the baseline investigation, in order to improve clinical practice. 3.12. Food improvement interventions The general idea was to develop the food concept and competences in the kitchen towards a “host-guest” concept, rather than a “production-based” concept. Already before the study, the density of the food served to patients was calculated to follow the recommendations from the National Food Administration for patients at nutritional risk (Fat 50%; Protein 18%; Carbohydrates 32%) {{808 Beck et al., 2010}}. For patients not at nutritional risk, recommendations from the Nordic Council of Ministers were followed (Fat 25e

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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40%; Protein 10e20% and carbohydrates 40e65%) {{809 Nordic Council of Ministers 203}}. Requirements for the individual patient at nutritional risk were calculated by Harris Benedict Equation. All kitchen staff underwent a three day theoretical and practical workshop in order to change the perspective from production to hosting guests. A chef was recruited to ensure gastronomic quality and that the menu was changed, during a three month period. This was funded by a grant from the hospital management. More of the production became based on seasonal and raw ingredients instead of semi-finished products in order to improve menus, and the aesthetics of the servings were prioritized. All patients at nutritional risk were given a multi-vitamin tablet daily. Enteral and parenteral nutrition was given according to local hospital clinical guidelines and standards. 3.13. Publicity For awareness and publicity, the organizing committee contacted local newspapers, radio and TV, who willingly presented the project. This was done as a motivation to patients and staff, and to achieve a general positive awareness. 3.14. Statistical analysis ManneWhitney and KruskaleWallis tests were used for ordinal data, and Pearson Chi square test for nominative data and group comparisons. Pearson’s ChieSquare test was used for unpaired group comparisons between pre- and post-measurements. Cox regression univariate and multiple analyses were generated for the percentage covering of energy and protein requirements in patients at nutritional risk. P < 0.05 was considered significant. 4. Ethical considerations The study was conducted according to the rules of the Helsinki Declaration of 2002. The study was approved by the Ethical Committee for The North Danish Region. 5. Missing data

5

Table 1 The dataset for the baseline and the one year follow-up measurement.

Departments Patient record audits Patient interviews 24-h diet recalls Staff questionnaires

Baseline 2009

Follow-up 2010

N

N

26 286 203 184 626

22 260 178 164 512

were fewer in number than the multi professional NSTs, who performed the overall patient interviews. No significant differences regarding sex, age and BMI were seen in the population before and after the intervention. However, a significant increase of the performance of measuring BMI was found (89% (n ¼ 229) vs. 48% (n ¼ 138), p < 0.05). Weight loss within 3 months was recorded in patient records in 52 of 264 patients in 2009 (19.6%) and 62 of 242 patients in 2010 (25.6) (ns). Weight loss was considered as involuntary loss if <5% body weight within one month [5]. No significant changes were seen between the prevalence of patients at nutritional risk by NRS-2002, when patients were screened by the audit teams on the investigation day (48.2% (n ¼ 137 of 284 patients in 2009) vs. 49.8% (n ¼ 125 of 251 patients in 2010)). The audit teams found more patients at nutritional risk than those screened in the patient records. This was the case for both 2009 and 2010. Demographic data from the patient records are presented in Table 2. 6.2. Result-indicators: energy and protein intake Energy and protein intake were investigated in respectively 150 patients in 2009 and 161 patients in 2010. A significant improvement in energy intake (>75% of requirements) measured by 24h recalls, was seen in 73% (n ¼ 110) in 2010 vs. 53% (n ¼ 80) in 2009 (p ¼ 0.007), as well as protein intake 52% (n ¼ 84) in 2010 vs. 33% (n ¼ 49) in 2009 (p < 0.001). Furthermore, patients who fulfilled less than half of their requirements were decreased from 17.3% % in 2009 of patients to 10.5% in 2010 (p ¼ 0.008). For protein this decreased from 38% in 2009 to 21% in 2010 (p < 0.001).

Data have been treated numerously, and missing data were excluded from statistics.

6.3. Process-indicators: patient record audits

6. Results

A significant improvement for documentation of GNP was found in the patient records after the intervention regarding screening for

6.1. Demographics Overall, 545 patients participated from 26 departments in the baseline measurements (287 patients) and 22 departments in the post intervention measurement investigation (258 patients). The post intervention measurement took place one year after the baseline measurement, on the same weekday, in order to limit confounders. Four departments dropped out of the follow-up investigation due to organisational changes. These four departments were randomly distributed with regard to their results in the baseline measurements (data not shown). The departments, who dropped out of the follow-up patient study, chose to still be included in the staff questionnaire investigation. Table 1 shows baseline data concerning the number of participating departments, questionnaires, audits and 24-h diet recalls performed. Some patients could not cope with both interviews and were given the opportunity to resign from the interview that came last in time of the day, but still participated in the study. This was the case in both 2009 and 2010. No drop out analysis was done. This was moreover the 24 h diet recall, since these were done by the dieticians, who

Table 2 Demographic data according to patient records. Variable

Baseline 2009

Follow-up 2010

Number of participants Sex: N (%) Female Male Age, mean (SD) BMI: N (%) <18.5 18.5e20.5 >20.5 No information in records Weight loss >three months: N (%) Yes No No information Co-morbidity: N (%) Diabetes COPD Stroke

N ¼ 287

N ¼ 258

141 (49) 146 (51) 63.4 (17.2)

134 (52) 124 (48) 64.5 (16.8)

40 (14) 23 (8) 223 (78) 149 (52)

15 (6) 15 (6) 196 (76) 28 (11)*

52 (20) 104 (39) 108 (41)

62 (26) 119 (49) 61 (25)*

48 (17) 26 (9) 14 (5)

41 (16) 23 (9) 13 (5)

*p < 0.05.

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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nutritional risk, setting goals for nutritional requirements, making nutrition plans and monitoring (Fig. 2). Weight loss was documented in 75% in 2010 vs. 59% in 2009 (p < 0.001). Nutrition screening by NRS-2002 was documented in 77 vs. 56% (p < 0.000). Nutrition plan: The documentation of nutritional requirements regarding energy improved (57% vs. 32%, p < 0.000), as well as for protein (56% vs. 27%, p < 0.000). Monitoring of nutrition intake improved by 58% vs. 29% (p < 0.001). Documentation of processindicators is shown in Fig. 2. 6.4. Patient interviews Communication between staff and patients was investigated in 192 patients in 2009 and 168 patients in 2010. An improvement of patient experienced communication was seen in the questionnairebased patient interviews regarding information about nutrition during disease (32% vs. 20%, p ¼ 0.039). Patients experience of talking to staff about the importance of eating while in hospital improved, however marginally significant (54 vs. 46%) (p ¼ 0.058). Patients were informed to a higher degree that they could eat more energy dense food items while they were sick (70% vs. 55%, p < 0.005), and furthermore, the serving of in-between meals and oral nutrition supplements increased (92 vs. 83%) (0.008). There was some inconsistency between patient experienced registration of food intake (experienced in 37% of risk patients) and that seen by audit in patient records (58% of risk patients). Both however improved during the intervention period (25% vs. 37%, p < 0.029) and (29 vs. 58%, p < 0.0001) respectively. Doctor communication with patients about nutrition did not increase according to the questionnaire-based interviews. Table 3 shows the data of communication between patient and staff regarding nutrition. 6.5. Staff questionnaires Of the 920 questionnaires distributed, 68% were replied to in 2009 and 55.6% in 2010. Screening, information to patients, making nutrition plans, how to measure nutritional requirements, when to monitor and when to consider if goals were met, became clearer. Doctors, especially improved their knowledge of to whom and when nutrition plans were made (p < 0.006). Nursing staff increasingly experienced to be able to influence and improve nutrition intake (p < 0.04), as well as the possibilities concerning available choices of food and supplements to support the nutrition effort (p < 0.007). Knowledge about the use of enteral and parenteral nutrition improved significantly in both groups (p < 0.001).

Fig. 2. Process-indicators for good nutritional practice noted in patient records. Developments in one year intervention (P < 0.001).

Table 3 Communication between patient and staff regarding nutritional aspects for patients at nutritional risk by audit teams screening of patient with NRS-2002 on the study day. Question to patients: have you during this hospital stay experienced the following statements? Written information regarding nutrition during disease Nutrition recording of food intake Nutrition recording motivating you to eat more Talked to staff about the importance of eating during disease Being told that you can eat more energy dense foods, than when you are well Having in-between meals and sip feed supplements served Talked to the doctor about nutrition Talked to staff about what you have actually eaten, regarding your requirements Do you find? Nutrition is important for getting well In your nutrition intake was insufficient to a degree, where it would put your health at risk, would you consider accepting tube feeding

2009

2010

N (%)

N (%)

Included:192

Included:168

P-value

39 (20)

53 (32)

0.039

48 (25) 10 (21)

62 (37) 28 (45)

0.029 0.011

89 (46)

91 (54)

0.058

55 (29)

70 (42)

0.005

83 (43)

0.008

22 (12) 21 (10) 189

92 (55) 167 33 (20) 37 (23) 164

180 (95)

161 (97)

0.860

149 (79) 189

141 (85) 167

0.192

0.076 0.086

Where not all patients responded, N is given in italics.

Nursing staff improved their knowledge about energy- and proteindense food for patients (p < 0.007). 6.6. GNP initiatives initiated at the department level 6.6.1. General initiatives The initiatives taken by the NSTs and based upon their results had certain objectives in common as they all aimed at improving knowledge and interest in their departments, but also a huge variation of initiatives was seen, as described in “interventions”. Twenty of the 26 teams accepted the invitation to have a specialist from the hospital nutrition committee discussing their results with them. Four of the remaining departments chose to drop out of the study for organizational reasons, and the last two chose to have their discussions internally within the department. These discussions regarded the nature and causalities of the results. In three departments, it was decided that in-depth investigation and problem-analysis were relevant, since the results gave no single reason for the need for intervention. The local investigations for instance included analysis of workflows around meal serving [25]. Also the distribution of tasks between professions, as well as the documentation procedures were analysed and restated in some departments. Finally, the teams made an action plan for improvement and sent these to the specialists for comments. Education regarding general nutrition, enteral and parenteral nutrition, was attended by 130 staff members, of whom 30 were doctors, 12 were dieticians and the remaining were nursing staff. 6.6.2. Specific initiatives according to action plans Most of the plans included education of doctors and nursing staff in general clinical nutrition and special issues within enteral and parenteral nutrition. Eight of the plans included preparation of local targeted nutrition standard plans as i.e. clinical guidance

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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instrument for a specific diagnosis or condition. These plans were made jointly between the nutrition committee members and the NSTs. Seven of the departments who had this focus were departments with poor (<25%) results regarding screening, nutrition plans and monitoring of nutritional intake. The eight departments had good results (>80% screening) in general, but wished to establish a continuous nutritional treatment, for their head- and neck cancer patients in being cared for by both surgery- and oncology-departments. Three departments performed a common intervention study which aimed at improving food- and eatingenvironment in the meal service area including hosting the patients by welcoming them on admission with a tray with a nutritional supplement, and a questionnaire about nutritional preferences. These three departments, infectious medicine, haematology and thoracic surgery department, had good and improving results in general (>80% screening; >75% nutrition plan), but took the opportunity to make a less clinically focused intervention. This intervention included introducing an improved eating environment with table cloths and music in the dining area, and having a more hosting attitude to patients. Already from the point of admission, patients were introduced to nutritional supplements and menu opportunities [26]. Two departments intervened with in-between meal serving and improved practice for serving supplements. This included serving in-between meals and supplements from a manned trolley, three times a day. The improved use of nutritional supplements was measured by a 75% increase in the expenses used for nutritional supplements. This increased amount of nutritional supplements did not reduce the amount of any other food items from the kitchen. 7. Discussion This study presents a multi professional “Bottom-up and Topdown” approach. Thus, the interventions were individually planned by nutrition teams on basis of their own and common results formed by a baseline study. This study gave the NSTs the opportunity to look at, and to improve own practise, increase interest and enthusiasm, as known in the Bottom-up principal. Furthermore, this was supported by a well-structured organized framework, governmental approved guidelines and the Danish Healthcare Quality Programme. Driving forces were the Nutritional Committee boarded by the director of the hospital, as the Top-down approach. The Top-down approach was necessary to ensure leadership and priority from the overall hospital organisation. The methodology has its limitations and strengths. Limitations are quite clear. In the baseline measurement 26 departments were included, and in the follow-up measurement only 22. The departments who were not participating in the follow-up investigation, dropped out due to organisational matters, including layoffs. Furthermore, it was not possible to determine individual factors in the study that made the improvements. Because of the many similar and different interventions, the study in itself is a confounder to isolation of efficacy of the single intervention. In addition, strategic changes in the hospital took place alongside. These may also be confounders to the results, while the results might have been improved, if strategic changes including layoffs had not been initiated during the time of the study. As for the study validity, it will not be possible to replicate the exact same study again because of the build-in dynamic approach and thus get the same results. However we find that the basic principles of this study, might be studied elsewhere in small-scale setups as well. Interventions were voluntary, and it was moreover the departments with the best results, who put the largest effort into the interventions. Looking on the methodology however, there were also a number of things, which might not confirm the strengths of

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the study validity, but which definitely underlined the value to clinical practice. The improvements made were very much linked to clinical practice (GNP) and thus seemed to be meaningful for improving clinical outcome for the patients. The results might therefore more likely succeed to maintain as positive improvements, despite the competition with implementation of many other strategic changes in the hospital setting. Former studies have shown that lack of knowledge, structure and organization, are amongst barriers for good nutrition therapy [18]. Furthermore, studies have shown that implementation of good nutrition therapy should tackle possible barriers and benefit of local enthusiasts [17]. The bottom-up strategy entails ownership to changes and has turned out to decrease barriers against the clinical nutrition process, as the departments have improved their knowledge, attitudes and especially practice after the intervention period. The knowledge of who was assigned responsibility for nutritional aspects became significantly more clear during the intervention period. The bottom-up principal ensured, that nutrition practice was included in the total care of the patients, taking into consideration the limits and possibilities for improvements in standard care, without compromising other aspects of patient care i.e. if a standardized intervention have been suggested from the hospital management. We furthermore believe, that the bottom-up principal as used in this study, will help the departments to ownership of results and methods, and thereby be more likely to permanently improve practice. Another study has successfully used the bottom-up principal regarding nutrition implementation in intensive care, supporting this belief [19]. Improving energy and especially protein intake as achieved in this study, has been shown to be difficult, but possible, in several studies focusing on oral nutrition [4,15,27]. The aim to improve the fraction of patients, who eat more than 75% of their calculated requirements, is based on the results from at prior study, which found that weight loss could be prevented when at least a 75% intake was achieved [7]. In clinical practice we find, that this is an operational threshold to determine if and when an intervention is needed [28]. In this study we improved the quality of the food in general by educating the kitchen staff, and changing the menu plans in accordance with seasonal variations to use more fresh ingredients. This was done by the belief, that it would enhance the taste and flavour of the food and at the same time it would improve the general impression of the food among staff as well as patients. It was now possible to tell a story about the food as a good and solid homemade meal and a cookbook with recipes was also produced. We have no measurement of this impact, however, the feed-back from the staff was, that it helped them to create an interest about the food and mealtimes, so that patients now were easier to motivate to get out of bed and actually take a look at the food in the trolley and also to try and taste more food. As with most of the results in this study, the positive results are interactive. The focus on communication between patient and staff in this study seems especially important, because the main focus is oral nutrition. The patient is expected to eat and drink up to the measured requirements. While other studies have found a lack of communication between patient and staff, this study has managed to improve communication regarding nutritional aspects. This positive result however does not include the patient-doctor communication or the follow-up on nutrition recording results with patients regarding their nutritional requirements [4,29,30]. The results do not clarify whether patients do not think they had communicated about nutritional condition aspects with their doctor, or they simply understand the question as talking to the doctor about food. This could be an issue in the way the question has been phrased. The communication between doctors and patients regarding nutritional aspects of their condition should be

Please cite this article in press as: Holst M, et al., Multi-modal intervention improved oral intake in hospitalized patients. A one year follow-up study, Clinical Nutrition (2014), http://dx.doi.org/10.1016/j.clnu.2014.05.001

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 Q3 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65

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prioritized and improved, with focusing on motivating the patient by supplying individualized nutritional guidance. Throughout this study, we have found that the “bottom-up approach” has been of great importance for the success, and not least for the enthusiasm for the NSTs and departments to invest time and effort in the study. In spite of differences between departments participating in this study, there was a great consistency between barriers for targeted nutrition effort and ideas for improvement of GNP as also seen in an earlier Danish implementation study among different hospital departments [18]. This means that it might be useful for other hospitals/departments to use the barriers and action plans as inspiration for their own implementation, but it should be emphasized that the process itself is important to obtain ownership and a sense of responsibility for the individual in the department. Seen in this context the pre-measurement is important as a basis for discussion and determination of barriers in the department. The re-measurement is also an important tool in the continuous quality development in this area. 8. Conclusions A multi professional bottom-up and top-down intervention with nutrition support teams taking guided action upon own results improved energy and protein intake as well as nutritional practice. In this study, which is found to be similar to daily practice, it was not possible to differentiate which intervention had the most impact. The study group believes that the overall intervention with a strategic master plan, training of staff, better menus for patients and staff influence, including the hosting of patients and diseasespecific clinical standard nutrition plans (bottom-up) in combination with a well-defined nutritional structure including a nutrition steering committee empowered by the hospital manager and national guidelines (top-down), were responsible for the positive effect. Conflict of interest None declared. Acknowledgements M. Holst, Tina Beermann, M.N. Mortensen, L.B. Skadhauge, K. Lindorff-Larsen and H.H. Rasmussen, wrote the protocol and organized the study. The data collection was done by active involvement of the Aalborg Hospital Multi-professional Nutrition Teams and the hospital dieticians. UNI-C performed the statistics. M. Holst drafted the article and wrote the final version. M. Holst, Tina Beermann, M.N. Mortensen, K Lindorff-Larsen and H.H. Rasmussen, supervised the writing process and revised the manuscript drafts critically. The study was funded by the Hospital Nutrition Committee, and by the Region of North Denmark. References [1] Rasmussen HH, Kondrup J, Staun M, Ladefoged K, Kristensen H, Wengler A. Prevalence of patients at nutritional risk in Danish hospitals. Clin Nutr 2004;23:1009e15. [2] Schindler K, Pernicka E, Laviano A, Howard P, Schutz T, Bauer P, et al., NutritionDay Audit Team. How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007e2008 cross-sectional nutritionDay survey. Clin Nutr 2010;29:552e9. [3] Velasco C, Garcia E, Rodriguez V, Frias L, Garriga R, Alvarez J, et al. Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study. Eur J Clin Nutr 2011;65:269e74.

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Clin Nutr 2008;27:196e202. [23] Hartwell HJ, Shepherd PA, Edwards JSA. Effects of a hospital ward eating environment on patients’ mealtime experience: a pilot study. Nutr Diet 2013;70. 332e338(7), http://dx.doi.org/10.1111/1747-0080.12042. [24] Olsen Tvedebrink TD, Fisker AM, Kirkegaard PH. Architectural theatricality: a food design perspective in hospitality studies. Hosp Soc 2013;3. http:// dx.doi.org/10.1386/hosp.3.3.189_1. 189e210(22). [25] Holst M, Laursen B, Rasmussen H. Caring for dinner in hospital - better organization may improve quality of care around meal serving in a hospital unit. J Nurs Care 2012;1:117. http://dx.doi.org/10.4172/2167-1168.1000117. [26] Beermann T, Mortensen M, Skadhauge L, Rasmussen H, Holst M. Improved environment and individualized serving increased nutrition intake in hospitalized patients. Clin Nutr Suppl 2011;6:114. [27] Naithani S, Whelan K, Thomas J, Gulliford MC, Morgan M. 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