Australian and New Zealand data indicate that 11-67% of acute care patients are malnourished. This large range is attributable to heterogeneity in participants’ demographic and clinical characteristics, and methods of measuring malnutrition, which prevents the generalisation of prevalence rates across the acute care setting. A number of studies suggest that malnourished patients experience worse health-related outcomes (prolonged hospital length of stay (LOS), readmissions, and mortality) in comparison to well-nourished patients. However, the majority of these studies have not controlled for the confounding effects of disease type and severity, thereby potentially overestimating the effect of malnutrition and underestimating the effect of the disease itself on adverse outcomes. Although sub-optimal dietary intake is implicated in the aetiology of malnutrition, only three Australian studies have described dietary intake in hospitalised patients. In 2009, Watterson et al published “Evidence-based guidelines for nutritional management of malnutrition in adult patients across the continuum of care”. These guidelines have been endorsed by the Dietitians Association of Australia and Dietitians New Zealand. The extent of the implementation of these guidelines in Australian and New Zealand acute care wards remains unknown.
The principal aims of the studies in this research program were to examine current nutrition care practices in acute care; determine the prevalence of malnutrition and decreased food intake; and evaluate the independent association between malnutrition and/or decreased food intake and adverse health-related outcomes in acute care patients in Australian and New Zealand hospitals. These studies are collectively referred to as The Australasian Nutrition Care Day Survey (ANCDS). Based on the findings from the ANCDS, a final study was conducted to evaluate if the provision of medical nutrition therapy (MNT) improved dietary intake in acute care patients who ate very poorly during hospitalisation.
The ANCDS was conducted in three stages in 56 hospitals. Research Stage I (Nutrition care practices study) was a cross-sectional, questionnaire-based study in which Directors/Managers from dietetics departments of participating hospitals provided information on ward-based practices (nutrition screening, weighing patients, dietary management of patients at nutrition risk, availability of feeding assistance and protected mealtimes) for 370 wards. Research Stage II (Prevalence study) was a one-day cross-sectional survey wherein the nutritional status and 24-hour percentage food intake (0%, 25%, 50%, 75%, or 100% of the offered food) was evaluated for acute care patients (N= 3122) from participating hospitals. Research Stage III (Outcomes study) was a prospective cohort study, conducted three months post-Stage II. Data regarding (Research Stage II) participants’ disease type and severity, discharge status, LOS, in-hospital mortality, number of readmissions, and allocation of malnutrition codes were recorded. The MNT study (Research Stage IV) was a four-week exploratory study conducted in a Brisbane-based tertiary hospital where patients consuming ≤50% of the offered meals during the 24-hour baseline period (and not already under dietetic intervention) were referred to the ward dietitian for MNT, and re-evaluated on day-7.
The “Nutrition care practices study” indicated that nutrition screening was not conducted in one-in-three hospital wards, while rescreening was not conducted in 86% of the wards (n= 317). The Malnutrition Screening Tool was the most commonly used screening tool. When patients were identified as at ‘nutrition risk’, they were most commonly referred to a dietitian for management. Feeding assistance was available in ~90% of the wards.
The “Prevalence study” found that malnutrition defined using Subjective Global Assessment and body mass index < 18.5kg/m2) was prevalent in 32% (n= 993) of the cohort (65±18years, 47% females); and that two-in-three participants did not consume all the offered food. The “Outcomes study” revealed that malnourished patients had greater median LOS (15 days vs. 10 days, p<0.0001) and readmissions rate (36% vs. 30%, p=0.001) than well-nourished patients. Median LOS for patients consuming ≤25% of the food was higher than those consuming ≥50% (13 vs. 11 days, p< 0.0001). After controlling for confounders (age, disease type and severity), the odds of 90-day in-hospital mortality were at least two-fold for malnourished patients (CI: 1.09-3.34, p=0.023) and for those consuming ≤25% of the offered food (CI: 1.13-3.51, p=0.017).
Less than 20% of the malnourished patients (n=162) were allocated malnutrition codes as per the International Classification of Diseases and Health-Related Problems (version 10, Australian modification).
Of the 184 patients observed in the “MNT study”, 62 patients (34%) consumed ≤50% of the offered meals. Simple interventions (feeding/menu assistance, diet texture modifications) improved intake to ≥75% in 30 patients who did not require further MNT. Of the 32 patients referred for MNT, baseline and day-7 data were available for 20 patients (68±17years, 65% females, median energy, protein intake: 2250kJ, 25g respectively). Although statistically significant (4300kJ, 53g; p<0.01), the improvement in the participants’ dietary intake on day-7 was equivalent to meeting 50% of their requirements only. Ongoing nutrition-impact symptoms were a barrier to optimal dietary intake in the participants.
In conclusion, the ANCDS is the largest and most comprehensive study to report nutritional issues in Australian and New Zealand hospitals. This research project is also significant for identifying key areas of nutrition practice that can be improved and demonstrating that MNT can benefit patients who eat poorly during hospitalisation.