Mo More- e-2- 2-Eat Phase 2: Spr t Phase 2: Spread/ ead/Sc - - PowerPoint PPT Presentation

Mo More- e-2- 2-Eat Phase 2: Spr t Phase 2: Spread/ ead/Sc Scaling Up aling Up Imp Improved ed Nu Nutri> tri>on

• n Car

Care

CFN Sept 21, 2018

Heather Keller RD PhD FDC Schlegel Research Chair Nutri<on & Aging, University of Waterloo

Th The P e Prob

• blem

em…

• Meal<me management
• Ea<ng assistance
• Nutrient dense food
• Oral nutri<onal supplements
• Die<<an counseling
• (Baldwin & Weekes, 2011; Cheung et al.,2103 ; Kimber

et al., 2015; StraTon & Elia, 2007)

Treatment works

Th The S e Sol

• lu>on
• n: Th

The In e Integ egrated ed Nu Nutri>on

• n

Pa Pathway for Acute Care (INPAC)

Keller et al, 2015; CFN Catalyst 2014-2015

Th The ‘Mor e ‘More-2-E e-2-Eat’ Pr ’ Project Ph

• ject Phase 1

ase 1

Objec&ves:

1) Test and evaluate implementa<on process in 5 diverse hospitals in 4 provinces 2) To develop a virtual toolkit to support implementa&on of INPAC

Funding: Canadian Frailty Network (2015-17)

Keller et al. 2017

CFN SIG 2015- 2017

Co-i Co-inves es>gator

• rs/Col

/Collabor

• rator
• rs

for Imp

• r Implemen

lementa> a>on

• n Stu

Study y

Co-inves&gators

• Barbara Liu
• Jack Bell
• Paule Bernier
• Carlota Basualdo-Hammond
• Leah Gramlich
• Manon Laporte
• Donald Duerksen
• Sumantra Ray
• Pauline Douglas
• Lori Cur<s

Collaborators

• Bridget Davidson
• Joel Dubin
• Marina Mourtzakis
• Richard Sawatzky
• Alies Maybee
• Khursheed Jeejeebhoy
• Sarah Robbins
• Linda Dietrich
• Heather Truber

8

INP INPAC Car C Care Ac> e Ac>vi> vi>es Imp es Implemen lemented ed

Ac&vity Implemented? Nutri&on screening at admission (with CNST)

✓ (All sites)

Using SGA to triage pa&ents

✓ (All sites)

MedPass used

✓ (All sites)

Food intake monitoring and following up low intake

✓ (Most sites)

Volunteers available during meal&mes

✓ (Most sites)

Weights taken on admission

✓ (Some sites)

Regular weights taken

✓ (Some sites)

More food available for pa<ents on the unit

✓ (Some sites)

Discharge planning

✓ (Some sites)

Imp Implemen lementa> a>on

• n of Scr
• f Screen

eenin ing a g at t Ad Admission mission

Imp Implemen lementa> a>on

• n of Maln
• f Malnutri>

tri>on

• n Diagn

Diagnosis with

• sis with

Su Subjec> jec>ve Glob e Global Assessmen al Assessment t

Pa&ent Care Processes and Treatment Improved

Propor&on of Pa&ents (%)

Treatment/Care Process Baseline Follow -up Treatment (advanced care) 31 63 Medpass (oral nutri<on supplement) 2 15 Weekly weight 3 21 Food intake monitoring 1 32

(Keller et al., Clin Nutr 2018)

Note: This is across the 5 sites. Not all sites focused

• n weekly weights or food intake monitoring.

Pa&ent outcomes?

Length of Stay (days) Site Baseline Follow-Up A 9 6 B 12 8 C 7 5.5 D 8 9 E 11 9

Meal&me barriers to food intake

(Keller et al., submiTed 2018)

A year acer M2E

Site Screening SGA 1 region region 2 hospital hospital 3 region region 4 region region 5 hospital hospital

Spread Post M2E Phase 1

M2E Champions: Mei Tom, Marlis Atkins, Roseann Nasser, Donna BuTerworth, Brenda Hotson, Marilee S<ckles-White, Suzanne Obiorah M2E Research Associates: Joseph Murphy, Andrea Digweed, Lina Vescio, Chelsa Marcell, Stephanie Barnes, Shannon Cowan, Sheila Doering, Michelle Booth

Trainees

• Celia Laur
• Renata Valai<s
• Tara McNicholl
• Sabrina Iuglio

Th The K e Knowled edge T e To Ac>

• Ac>on
• n Cy

Cycl cle e

Capability

• Educa<on: build skill
• Enablement: consider exis<ng skills and opportuni<es

Opportunity

• Environmental restructuring: make it easy to do the right thing
• Modeling: create a cultural expecta<on for the behavior

Mo<va<on

• Persuasion: make the behaviour a ‘good thing to do’
• Incen<visa<on: make it desirable to do the behavior

Beh Behavi viou

• ur Ch

Chan ange Wh e Wheel: eel: Beh Behavi viou

• ur

Ch Change T e Tech echniques es

Michie et al, 2011

Accoun<ng for Climate Involving Relevant People in the Change Process Building a Reason to Change Improving Nutri<on Care for Pa<ents

Building Strong Rela<onships Within the Hospital Team

Embedding Change into Current Prac<ce

Hosp Hospit ital St al Staff/Man aff/Manag agemen ement Op t Opin inion ions Ab s Abou

• ut Makin

t Making Ch g Chan ange e

Laur et al, 2017

Key Actors

Champion Site Implementa<on Team External coach Co-champions

• Build team engagement
• Staff discussion groups
• Survey to understand KAP, barriers
• Lunch and learns
• Tailor INPAC to specific unit

processes/context

• Collect data to evaluate and

s<mulate change

• Learn about change management
• Use diverse behaviour change

techniques

• Ready-to-use resources
• Build on early success

Key KT ac<vi<es

INP INPAC Au C Audit it

Period 1

Sept – Dec 2015 N=546 4 Audits/site

Period 2

Jan – Mar 2016 N=867 6 Audits/site

Period 3

Apr – June 2016 N=848 6 Audits/site

Period 4

July – Sept 2016 N=837 6 Audits/site

Period 5

Oct – Dec 2016 N=832 6 Audits/site

Period 6

Jan – Mar 2017 N=1100 8 Audits/site

Developmental Implementa<on Sustainability Overview of the More-2-Eat Study Time Frames and INPAC Audit Data Collec<on (n=5036 pa<ents).

INP INPAC Imp C Implemen lementa> a>on

• n T

Toolkit

• olkit

m2e.nutri&oncareincanada.ca

Wha What w t we think help e think helps sus s sustain/ ain/ spr spread ead(Laur et al, submiZed)

Phase 2… Phase 2… (K

(Keller eller, Lau , Laur, V , Vali> ali>s, Du s, Dublin lin, Ch , Chen en, Cu , Cur> r>s, Bell, Ra s, Bell, Ray, Gr , Gramlich amlich, , Mo Morriso rrison) n)

• Can implementa&on be done within current resources?
• 10 hospitals, 6 provinces
• Phase 1 sites expand to 2+ further units
• Sustain and replicate?
• Phase 2 hospitals, 1 unit
• RedCAP Registry for data entry and templates for reports
• self managed
• INPAC toolkit and resources
• Training on behaviour change
• Monthly telephone coaching
• Community of Prac<ce Listserv

Outcome data: LOS, readmission, in –hospital mortality

CFN KT Funding 2018-2019

Publica>ons from M2E to date

• 1. McNicholl T et al., Handgrip strength, but not 5m walk, is a useful func<onal measure to add to clinical

nutri<on Assessment. Nutr Clin Pra<ce (accepted Aug 2018).

• 2. Cur<s L, et al., Low food intake in hospital: pa<ent, ins<tu<onal, and clinical factors. Appl Physiol Nutr
• Metab. 2018. doi 10.1139/apnm-2018-0064
• 3. Keller H, et al., Mul<-site implementa<on of nutri<on screening and diagnosis in medical care units:

success of the project More-2-Eat. Clin Nutr. 2018: 1-9 doi 10.1016/j.clnu.2018.02.009

• 4. Laur C, e al., Nutri<on care acer discharge from hospital: an exploratory analysis from the More-2-Eat
• study. Healthcare. 2018; 6(1): 9. doi 10.3390/healthcare6010009
• 5. Keller H etl al., Update on the Integrated Nutri<on Pathway for Acute Care (INPAC): Post implementa<on

tailoring and toolkit to support prac<ce improvements. BMC Nutr. 2018; 17: 2. doi 10.1186/ s12937-017-0310-1.

• 6. Laur CV, et al. Comparing hospital staff nutri<on knowledge, aqtudes, and prac<ces before and 1 year

acer improving nutri<on care: results from the More-2-Eat Implementa<on Project. J Parenter Enteral Nutr. 2018; 42(4): 786-796. doi 10.1177/0148607117718493

• 7. Valai<s R et al., Need for the Integrated Nutri<on Pathway for Acute Care (INPAC): gaps in current nutri<on

care in five Canadian hospitals. BMC Nutr. 2017; 3: 60. doi 10.1186/s40795-017-0177-8

• 8. Laur C, et al., Changing nutri<on care prac<ces in hospital: a thema<c analysis of hospital staff

perspec<ves. BMC Health Serv Res. 2017; 17(1): 498 doi 10.1186/s12913-017-2409-

• 9. Laur C , Keller H. Making the case for nutri<on screening in older adults in primary care. Nutr Today. 2017;

52(3) :129-136. doi 10.1097/NT.0000000000000218

• 10. Laur C, et al.,. Malnutri<on or frailty? Overlap and evidence gaps in the diagnosis and treatment of frailty

and malnutri<on. Appl Physiol Nutr Metab. 2017; 42(5): 449-458. doi 10.1139/apnm-2016-0652

• 11. Keller H et al., . More-2-Eat: evalua<on protocol of a mul<-site implementa<on of the Integrated

Nutri<on Pathway for Acute Care. BMC Nutr. 2017; 3: 13. doi 10.1186/s40795-017-0127-5

Ackn Acknowled wledgemen ements ts

In-kind Support: Die<<ans of Canada Canadian Society of Nutri<on Management Canadian Nutri<on Society NNEdPro Global Centre for Nutri<on and Health Regional Geriatric Program of Toronto

This research is funded by Canadian Frailty Network (known previously as Technology Evalua<on in the Elderly Network, TVN), supported by Government

• f Canada through Networks of Centres of Excellence (NCE) Program

Ques<ons?