A cross-sectional survey to investigate the quality of care in Tuscan (Italy) nursing homes: the structural, process and outcome indicators of nutritional care

Abstract

BackgroundPrevious studies have investigated process and structure indicators of nutritional care as well as their use in nursing homes (NHs), but the relative weight of these indicators in predicting the risk of malnutrition remains unclear.Aims of the present study are to describe the quality indicators of nutritional care in older residents in a sample of NHs in Tuscany, Italy, and to evaluate the predictors of protein-energy malnutrition risk.MethodsA cross-sectional survey was conducted in 67 NHs. Information was collected to evaluate quality indicators of nutritional care and the individual risk factors for malnutrition, which was assessed using the Malnutrition Universal Screening Tool. A multilevel model was used to analyse the association between risk and predictors.ResultsOut of 2395 participants, 23.7 % were at high, 11 % at medium, and 65.3 % at low risk for malnutrition. Forty-two percent of the NHs had only a personal scale to weigh residents; 88 % did not routinely use a screening test/tool for malnutrition; 60 % used some standardized approach for weight measurement; 43 % did not assess the severity of dysphagia; 12 % were not staffed with dietitians.Patients living in NHs where a chair or platform scale was available had a significantly lower risk of malnutrition (OR = 0.73; 95 % CI = 0.56–0.94). None of the other structural or process quality indicators showed a statistically significant association with malnutrition risk.ConclusionsOf all the process and structural indicators considered, only the absence of an adequate scale to weigh residents predicted the risk of malnutrition, after adjusting for case mix. These findings prompt the conduction of further investigations on the effectiveness of structural and process indicators that are used to describe quality of nutritional care in NHs.

Process, structural, and outcome quality indicators of nutritional care in nursing homes: a systematic review

“… Van Nie, 2014 [ 37 ] The Netherlands, Germany and Austria 214 NHs 19,876 residents Multicentre cross-sectional study To identify structural quality indicators of nutritional care that influence the outcome of quality of care in terms of prevalence of malnutrition and effect of possible differences between malnutrition prevalence in Dutch, German, and Austrian NHs. van Nie-Visser, 2011 [ 33 ] The Netherlands and Germany 151 NHs, 10,771 participants Multicentre cross-sectional study To investigate possible differences in malnutrition prevalence rates in Dutch and German NHs, as well as in structural and process indicators for nutritional care van Nie-Visser, 2014 [ 34 ] The Netherlands, Germany and Austria 214 NHs; 19,876 residents Multicentre cross-sectional study To investigate possible differences in malnutrition prevalence rates in Austrian, Dutch, and German NHs, as well as in structural and process indicators for nutritional care; to investigate whether resident characteristics influence possible differences in malnutrition prevalence between countries. van Nie-Visser, 2015 [ 38 ] The Netherlands, Germany and Austria 214 NH; 22,886 participants, Multicentre cross-sectional study To explore whether structural quality indicators for nutritional care influence malnutrition prevalence in Dutch, German, and Austrian NHs Werner, 2013 [ 43 ] USA 16,623 NHs Cross- sectional study using 2 data sets To test how changes in NH processes improve outcomes of care.…”

“…Seven studies only aimed to measure the prevalence of malnutrition/weight loss (as outcome indicator) and the use of structural or process indicators [ 20 , 27 , 30 – 34 ]. Four others tried to assess both the prevalence of malnutrition and the relationship among the quality indicators [ 35 – 38 ].…”

“… Malnutrition advisory team Auditing of protocol/guideline Dietitians employed in institution Education on malnutrition prevention and treatment in last 2 years Information brochure available for client or family Ward level Person specialized in malnutrition on unit Control of use of prevention/treatment guideline Measurement of weight at admission Interventions on malnutrition stated in patient file Optimal mealtime ambience provided at dinner Process indicators Assessment of weight Use of nutritional screening tool Weight history Use of clinical view Use of biochemical parameters Energy- and protein-enriched diet Energy-enriched snacks between meals Oral nutritional supplements Tube feeding Parenteral feeding Fluid 1–1.5 L/d No interventions Palliative policy van Nie-Visser, 2015 [ 38 ] LPZ See above (….) Malnutrition prevalence b van Nie-Visser, 2014 [ 34 ] LPZ – Malnutrition prevalence b Werner, 2013 [ 43 ] MDS/Nursing Home Compare; OSCAR -% of residents receiving tube feeds Weight loss a -% of residents receiving mechanically altered diets -% of residents with assisted eating devices MUST Malnutrition Universal Screening Tool MDS Minimum Data Set LPZ Landelijke Prevalentiemeting Zorgproblemen (In Dutch) VPSRACS Victorian Public Sector Residential Aged Care Services OSCAR Online Survey, Certification, and Reporting ARF Area Resource File RN Registered Nurse LPN Licensed Practical Nurse CNA certified nursing assistant QIPMO Quality Improvement Program of Missouri PFA Paid Feeding Assistant a loss of 5% or more in the last months or loss of 10% or more in the past six months, as defined in MDS b (1) BMI ≤ 18.5 kg/m2(age 18–65 years) or BMI ≤ 20 kg/m2 (age > 65 years), and/or (2) unintentional weight loss (more than 6 kg in the previous six month or more than 3 kg in the last month) and/or (3) no nu...…”

Focus on Undernutrition in Care Homes: A Retrospective Service Evaluation

“…Chi-Square: (B) p = 0.105 (E) p = 0.580 factors associated with weight loss [70][71][72]. Building on this finding, FoU already incorporates these factors into the dietary assessment part of "MUST" [54] to assist staff to develop appropriate nutrition care plans.…”

“…Such evaluation links to Donabedian's quality theory [111], where outcome is dependent on structural and process indicators. While some [73,101,[112][113][114] identified such evaluation improved nutritional care, others [71] found it failed to predict undernutrition. To evaluate resident outcomes and benchmark homes locally and nationally, it is recommended that BAPEN's nutritional care tool [115] is explored to determine if it can be incorporated into FoU's quality standard (Appendix 1), thereby requiring homes to complete annually during reaccreditation.…”