Donna Butterworth

The Integrated Nutrition Pathway for Acute Care (INPAC) is an evidence and consensus based pathway developed to guide health care professionals in the prevention, detection, and treatment of malnutrition in medical and surgical patients. From 2015 to 2017, the More-2-Eat implementation project (M2E) used a participatory action research approach to determine the feasibility, and evaluate the implementation of INPAC in 5 hospital units across Canada. Based on the findings of M2E and consensus with M2E stakeholders, updates have been made to INPAC to enhance feasibility in Canadian hospitals. The learnings from M2E have been converted into an online toolkit that outlines how to implement the key steps within INPAC. The aim of this short report is to highlight the updated version of INPAC, and introduce the implementation toolkit that was used to support practice improvements towards this standard.

Malnutrition is common in hospitalized patients and is associated with increased mortality, length of stay, and risk of re-admission. The consensus based Integrated Nutrition Pathway for Acute Care (INPAC) was developed and validated to enhance patients’ nutrition care and improve clinical outcomes. As part of the More-2-Eat project (M2E), five hospitals implemented INPAC activities (e.g. screening) in a single medical unit. The purpose of this paper is to demonstrate the care gaps with respect to INPAC activities on these five units prior to implementation. Results were used as part of a needs assessment on each unit, demonstrating where nutrition care could be improved and tailoring of implementation was required. Cross-sectional data was collected by site research associates (RAs) using a standardized audit form once per week for 4 weeks. The audit contents were based on the INPAC algorithm. All medical charts of patients on the study unit on the day of the audit were reviewed to track routine nutrition care activities (e.g. screening). Data was descriptively displayed with REDCap™ and analyzed using R Studio software. Less than half of patients (249/700, 36%) were screened for malnutrition at admission. Of those screened, 36% (89/246) were at risk for malnutrition yet 36% (32/89) of these patients did not receive a dietitian assessment. Also, 21% (33/157) of patients who were not screened at risk were assessed. At least one barrier to food intake was noted in 85% of patient medical charts, with pain, constipation, nausea or vomiting being the most common. Many of these barriers were addressed through INPAC standard nutrition care strategies that removed the barrier (e.g. 41% were provided medication for nausea). Advanced nutrition care strategies to improve intake were less frequently recorded (39% of patients). These results highlight the current state of nutrition care and areas for improvement regarding INPAC activities, including nutrition screening, assessment, and standard and advanced nutrition care strategies to promote food intake. The results also provided baseline data to support buy-in for INPAC implementation in each M2E study unit. Retrospectively registered ClinTrials.gov Identifier: NCT02800304 , June 7, 2016.