Nutrition Care Pathway for Hospitalized Older Adults: Content validation and feasibility testing

The objective of this project was to create and validate innovative clinical tools that will guide acute care practitioners in the nutritional care of patients on medical and surgical wards, of which the majority are acutely ill older adults (> 65 years of age).

Research Results


  • An evidence-informed, consensus-based algorithm, the Integrated Nutrition Pathway for Acute Care (INPAC) was developed and face validated. Dissemination and knowledge translation are underway with the CFN- SIG2014F-08 More-2-Eat project
  • The Mealtime Audit Tool (MAT, see below) and My Meal Intake Tool (MMIT, see below) have been developed, and tested for reliability and validity. These two tools are developed for practice and research and will support improved care processes by identifying barriers to food intake and poor food intake
  • Educational materials and guidance documents have been created to support dissemination and knowledge translation
  • A knowledge, attitude, and practice survey for direct care providers focused on nutrition care has been developed and tested for inter-rater reliability. This survey will be used in the More-2-Eat project as a secondary outcome variable

About the Project

In 2013 investigators completed a national study on the prevalence of malnutrition in over 1000 patients, in 18 acute care hospitals, across 8 provinces. Prevalence of malnutrition on admission to medical and surgical wards was 45%, with older patients more likely to be malnourished. Practices for the most part were not systematic with respect to identification, treatment and monitoring of nutritional state. Knowledge gaps and poorly defined roles among the interdisciplinary team perpetuated poor practices.

To enhance care and improve clinical outcomes, an improvement strategy is needed to promote quality practices. The current guidelines recommend nutrition risk screening for all patients at admission, followed by assessment and treatment by a dietitian for those identified to be at risk for malnourishment. However, they are not adhered to and are unsustainable. A nutrition care pathway based on guidelines, evidence, and best practice that is feasible and sustainable is required.

Several steps will be taken to create and validate this pathway, including experts, patients and families and diverse health professionals. Communication tools such as patient/family nutrition care discharge summaries will be developed and tested for feasibility in 5 hospitals. The resulting validated, feasible nutrition care pathway and support materials will be the basis of a future implementation study and will be translated to diverse acute care settings with our knowledge partners. Improved clinical practices resulting from implementation of the pathway will benefit patient outcomes and hospital outputs, especially for the acutely ill older adult.

ObjectivesCurrent evidence and best practices will be used to develop and content validate: (1) a flexible and feasible integrated nutrition care pathway for acute care (INPAC) template for best practice nutrition care in Canada and (2) communication and audit tools (e.g. Mealtime Audit Tool) that support the NCP.

Project Team

Principal Investigator:

Heather Keller, PhD, RD, FDC — University of Waterloo


Johane Allard, MD, FRCPC — University Health Network

Paule Bernier, PDT, MSc — Jewish General Hospital

Donald Duerksen, MD — St. Boniface General Hospital

Leah Gramlich, MD — Alberta Health Services/University of Alberta

Khursheed Jeejeebhoy, MD, PhD, FRCPC — St. Michael’s Hospital

Manon Laporte, PDT, MSc, CNSC — Réseau de santé Vitalité Health Network

Project Contact: Dr. Heather Keller —

CAT 2013-28

Key words: nutrition; clinical pathway; validation; translation

Publications & Presentations


Laur, C., McCullough, J., Davidson, B., Keller, H. Becoming food aware in hospital: A narrative review to advance the culture of nutrition care in hospitals. Health Care 2015,3,393-407; doi:10.3390/healthcare3020393.

Keller, H., McCullough, J., Davidson, B., Vesnaver, E., Laporte, M., Gramlich, L., Allard, J., Bernier, P., Duerksen, D., Jeejeebhoy, K. The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi. Nutrition Journal 2015 14:63 DOI 10.1186/s12937-015-0051-y

Laur, C., Keller, H. Implementing best practice in hospital nutrition care: An application of the Knowledge-to-Action Process. (under review Journal of Multidisciplinary Healthcare)


Vesnaver, E., Keller, H., McCullough, J., Davidson, B., Marcus, H., Lister, T., MacGarvie, D., Nasser, R., Khaddag, M. Developing Quality Tools to Support a Nutrition Screening & Care Process for Use in Canadian Hospitals. Technology Evaluation in the Elderly Network annual meeting (poster). September 21-23, 2014. Toronto, ON.

Keller, H. Changing the culture of nutrition care. Why is it necessary & what is the dietitian’s role? Dietitians of Canada. Central-Southern Ontario Regional Meeting. March 6, 2015.

Laur, C., McCullough, J., Davidson, B., Keller, H. Becoming food aware in hospital: Best practices for a multi-level approach to improve the culture of nutrition in hospitals. Experimental Biology, American Society for Nutrition (late-breaking abstract). April 1, 2015. Boston, U.S.

Keller, H., Basualdo-Hammond, C. An interprofessional approach to improving the oral intake of hospitalized adult patients. Canadian Nutrition Society Annual Meeting. May 29, 2015. Winnipeg, MB. (Symposia)

Laur, C., Keller, H. Applying the Knowledge-to-Action process to implement best practice in hospital nutrition care. Canadian Nutrition Society Annual Meeting (late breaking abstract; poster). May 29-30 2015. Winnipeg, MB.

Communication to Patients & Family

Lay Title: Improving nutrition care in hospitals

Key Findings:

  • Our study created a care pathway that can help identify and treat nutrition problems.
  • Health professionals and researchers used current evidence and their clinical experience to create a reasonable care pathway.
  • Tools to help identify barriers to food intake and information about food intake were created and tested

Why was this study was needed?

Nutritional status and food intake are important to the recovery of patients admitted to hospital. Many older adults are admitted to hospital and need to improve their nutrition. Currently, care practices can be improved to identify those patients who need support to improve their food intake in hospital and post discharge. Improving food intake in hospital supports recovery and an earlier discharge.

Suggestions on how these findings could impact frail older adults and/or their family caregivers and how this might be measured:

  • Family and patients need to be involved in their nutritional care while in and post hospitalization.
  • Adequate nutrients and energy are needed for recovery. Patients/family can inform health professionals of the concerns they have with accessing and eating food, whether in hospital or the community. This can be done with the standardized Mealtime Audit Tool.
  • Patients can continue to do their best with eating even when their appetite is poor, and families can support food intake by ensuring access to healthy food, as well as encouraging eating by helping it be a social experience.
  • The My Meal Intake Tool helps patients track their food intake and inform hospital care workers of their intake. The tool also shows food-related challenges that can prompt further treatment to improve food intake.

Brief comment on type of study in lay terms:

  • This study included the clinical experience and knowledge of health professionals to develop a care pathway that hospital staff can take to help identify poor nutrition and food intake as well as promote food intake while in hospital and after discharge for older patients.
  • Staff from four hospitals across Canada confirmed that the pathway was ‘best practice’.
  • Two tools to support input from families and patients with identifying poor intake and how it can be improved were also determined to be valid and reliable.
Communication to Policy

Lay Title: Improving the nutrition care of hospital patients.

Key Findings:

  • A feasible clinical pathway was developed using a consensus and evidence-based process. Two tools were also created and tested for reliability and validity.
  • These tools support the identification of barriers to food intake as well as food intake, providing an opportunity for intervention.

Why was this study needed?

About 50% of patients admitted to medical and surgical units in Canada are malnourished. Recent research indicates that these patients are not detected or treated and return to the community malnourished. Admission to acute care, although short, provides an opportunity to detect malnutrition and start treatment. Further, patients report several barriers to food intake that result in worsening of nutritional state. Malnourished patients and those who do not consume provided food stay 2-3 days longer, costing for each stay, approximately $2000 more than a well-nourished patient. Longer admissions also negatively affect patient flow. This study was focused on developing a feasible pathway to detect, treat, prevent and monitor nutritional status in acute care and thus improve current care.

Suggestions on how administrators or policy maker could use the findings:

  • The Integrated Nutrition Pathway for Acute Care (INPAC) is a feasible, evidence-based pathway that promotes the detection, treatment and prevention of malnutrition in acute care.
  • Administrators can support the implementation of the pathway by making policy the detecting, treatment and prevention of malnutrition in acute care.

Brief comment on type of study in lay terms:

  • INPAC was created from current evidence and using a rigorous consensus-based process with Canadian clinicians and researchers.
  • INPAC was reviewed by staff at four acute care hospitals in four different provinces. The pathway was consistent with their beliefs about ‘best practice’ and was considered feasible for implementation.
  • The My Meal Intake Tool was completed by 120 older patients (>65 years). Their results were compared with four dietitians in these sites who viewed the completed meal and estimated food intake for each patient.
  • The Mealtime Audit Tool was created to identify barriers to food intake at mealtimes. Two raters completed this tool with the same 90 patients at different time points to determine if ratings were consistent.
Communication to Researchers

Lay Title: Developing a feasible pathway for hospitals to improve their nutritional care of patients.

Key Findings:

  • The Integrated Nutrition Pathway for Acute Care (INPAC) was developed and found to be face valid. It has been published and is now available for broad distribution.
  • The My Meal Intake Tool (MMIT) was found to be valid, with good sensitivity and specificity (~70%).
  • The Mealtime Audit Tool (MAT) is reliable among raters.

Why was this study needed?

To date, a few clinical care pathways for nutrition have been developed. All these pathways start with nutrition screening but have been poorly implemented. One of the challenges is the high proportion identified at risk on admission; approximately one in two medical patients will trigger “at risk” with these tools. A full dietitian assessment to diagnose malnutrition post screening is not feasible in all cases. The pathway developed in this research triages patients with the subjective global assessment (SGA), a standardized method using key criteria to determine malnutrition. This assessment takes 10 minutes. Further, prior pathways were not clear about addressing iatrogenic components of malnutrition (i.e., barriers to food intake in hospital).  Food intake is a more realistic and sensitive indicator of the trajectory of nutritional status in hospital but requires an easy mechanism for collection.

Brief overview of the methodology:

  • Our first objective was to draft a clinical pathway using evidence and consensus among Canadian researchers and clinicians. We used a modified Delphi survey to reach consensus. This draft pathway was then face validated with focus groups of staff in four hospitals to ensure feasibility of care activities.
  • Our second objective was to test for inter-rater reliability and construct validity of two tools that supported the pathway.
    • The Mealtime Audit Tool helps staff to identify barriers to food intake. Using two raters with 90 patients at 30 meals, this tool was found to be reliable.
    • The My Meal Intake Tool, which allows patients to self-assess their food intake. In four hospitals, 120 older adults completed the tool, and this was compared to a dietitian’s estimation of food intake. The My Meal Intake Tool had adequate sensitivity and specificity to determine food intake for a single meal.

Potential impact of findings on clinical practice/patient care and how this impact might be measured:

  • Food intake barriers are well known to exist, but without a measurement tool, they have not been systematically identified or targets for change activities. Ad hoc measures are used to determine if food intake is occurring for patients. Commonly, nursing flow sheets are used with variable quality of data recorded. The development of these two, easy to use and valid and reliable tools will advance nutrition practice.
  • INPAC will also advance nutrition care in hospitals by promoting detection, treatment, monitoring and prevention of malnutrition. Impact of this work will be the uptake of the tools and improved nutrition care practices that result.

Remaining knowledge/research gaps:

  • The capacity, inputs and resources required to implement INPAC are unknown. Research is needed to demonstrate that implementation of IMPAC improves patient reported outcomes such as food intake in hospital and quality of life.
  • Reliability and validity testing of MAT and MMIT with different types assessors (e.g., nursing staff, dietary staff, volunteers) is also required.