Fighting frailty with food: early screening for malnutrition in hospitals

If you’re over 65 and you’re in the hospital for more than two days, there is a 45 per cent chance you’re malnourished. In other words, you might not be getting enough of the calories or nutrients you need to recover from your illness or injury. As a result, you might have to stay longer in hospital and your health might take a downturn during and after your stay.

“Nutrition is crucial to patients’ ability to recover from surgery or an illness, but many patients are arriving in hospital already malnourished and lose even more ground over the course of their stay… this increases patients’ frailty, leading to longer stays and higher risk of poor outcomes,” says Professor Heather Keller, a nutritional epidemiologist and dietitian at the University of Waterloo Waterloo and the Schlegel-University of Waterloo Research Institute for Aging. “We want to know if better nutrition in hospital can shorten the length of the stay and prevent readmissions.”

Professor Heather Keller has been developing and testing an in-hospital nutrition intervention called More-2-Eat for the past six years. Funding from the Canadian Frailty Network (CFN) has allowed her to create and validate a simple care pathway that involves malnutrition screening. Included is a tool that front line hospital staff can use to identify potentially malnourished patients, as well as steps staff can take to improve patients’ nutrition status. Now, with a CFN Knowledge Translation Grant, she and her collaborators are scaling up the intervention and testing its impact on patient outcomes in ten Canadian hospitals.

The cornerstone of More-2-Eat is a two-question survey front line hospital staff use to screen for malnutrition risk when admitting patients to hospital.

“Staff are simply asking patients if they’ve been eating less than usual over the past couple weeks and if they’ve lost weight for no particular reason over the past six months,” Professor Keller says. “If they answer yes to both questions, they are flagged for a consultation with the hospital dietitian.”

Screening at admission is critically important, Professor Keller explains, because it is not always possible to tell if a person is malnourished merely by their appearance. If they were substantially overweight and then lost 40 pounds due to an illness, for example, they may look like they’re a healthy weight when in fact they are not taking in enough nutrients to recover their strength.

Meghan Reddy, a clinical dietitian at the Napanee Hospital in Ontario has been receiving many more referrals from the acute care unit since the hospital joined the More-2-Eat study in 2018.

“Most patients in our acute care unit are over the age of 65 and more than a third of them are screening as at risk for malnourishment with the two-question survey,” says Reddy, who then does a follow-up assessment to determine if they are malnourished and what their specific eating issues are. “They could have difficulty swallowing, sitting up, or opening plastic packaging… or they may have a poor appetite because they’re not well. I identify their eating issues and work with the unit staff to create a customized solution, such as ordering soft foods or assigning a volunteer to help the patient with their meal.”

One of the primary interventions in the More-2-Eat study, however, is to provide malnourished patients with more protein and energy in the form of a high-energy liquid nutritional supplement given four times a day (60 ml each time) with their medications. These supplements can provide almost 500 calories and 20 grams of high-quality protein.

“We call this ‘med pass,’ or the medication passway,” notes Professor Keller. “This is an efficient way for staff to deliver the supplement, in small-enough quantities at a time that it doesn’t interfere with patients’ appetites. Having the nurse right there also ensures that patients take the whole amount.”

For Reddy, being involved in the More-2-Eat study is making her feel more satisfied in her career. “I see so many more patients now and I can also see how much better they are doing overall, which is so gratifying,” she says. “We’re keeping their protein levels up, so they’re not losing so much muscle and can be more mobile when they leave the hospital.”

The calories and protein also help prevent another common and painful problem that plagues older people—pressure ulcers, also known as bedsores. “When people lose weight, their bones become more prominent, which puts more pressure on the skin,” Reddy says. “On top of this, lack of protein causes older people’s skin, which is very thin, to break down. So then they have pressure ulcers, which can be very hard to heal. Thankfully, fewer patients are having this issue since we started the nutrition intervention.”

By the time the current CFN study is complete, Professor Keller will have data on close to 10,000 patients across the ten hospitals—whether they were screened, assessed and given the supplements, and how they fared in terms of outcomes.

“We feed the data back to the hospitals to let them know how they’re doing so they can make improvements,” she says. “As we scale up, hospitals can compare benchmarks with other hospitals.”

Professor Keller and her team have created a toolkit to help hospitals put More-2-Eat into action, and assembled a team of “champions” to inspire and assist the staff. “Many more hospitals are now screening,” she says, “and we provide coaching for More-2-Eat sites by teleconference to help them make necessary changes as they go.”

The next step is to create a model that will allow More-2-Eat to be rolled out nationwide.

“Malnutrition in the community is still a huge issue that needs to be addressed to help our aging population stay healthy,” says Professor Keller, who is a founding member and former chair of the Canadian Malnutrition Task Force. “More-2-Eat is shining a light on the role of malnourishment in frailty with hospital administrators and staff… it’s an important place to start.”