Identifying Low Value Malnutrition Care Activities for De-Implementation and Systematised, Interdisciplinary Alternatives—A Multi-Site, Nominal Group Technique Approach

Abstract

Malnutrition risk is identified in over one-third of inpatients; reliance on dietetics-delivered nutrition care for all “at-risk” patients is unsustainable, inefficient, and ineffective. This study aimed to identify and prioritise low-value malnutrition care activities for de-implementation and articulate systematised interdisciplinary opportunities. Nine workshops, at eight purposively sampled hospitals, were undertaken using the nominal group technique. Participants were asked “What highly individualised malnutrition care activities do you think we could replace with systematised, interdisciplinary malnutrition care?” and “What systematised, interdisciplinary opportunities do you think we should do to provide more effective and efficient nutrition care in our ward/hospital?” Sixty-three participants were provided five votes per question. The most voted de-implementation activities were low-value nutrition reviews (32); education by dietitian (28); assessments by dietitian for patients with malnutrition screening tool score of two (22); assistants duplicating malnutrition screening (19); and comprehensive, individualised nutrition assessments where unlikely to add value (15). The top voted alternative opportunities were delegated/skill shared interventions (55), delegated/skill shared education (24), abbreviated malnutrition care processes where clinically appropriate (23), delegated/skill shared supportive food/fluids (14), and mealtime assistance (13). Findings highlight opportunities to de-implement perceived low-value malnutrition care activities and replace them with systems and skill shared alternatives across hospital settings.

Use and safety of enteral nutrition protocols in acute care: A scoping review of literature and retrospective audit of practice

“…10 Due to the retrospective nature of the audit of practice, the authors were unable to collect data related to the impact of implementation of a standardised EN protocol for general use on dietetics time. Standardised protocols are recommended as a strategy to improve dietetics workforce efficiency 32 ; however as identified from the scoping review, the evaluation of these remains a gap in the literature.…”

Barriers and Enablers to Delegating Malnutrition Care Activities to Dietitian Assistants

“…It is becoming increasingly clear that dietitian assistant roles can positively influence patient, healthcare, and workforce outcomes, especially when used within the context of a multidisciplinary team [ 18 , 28 , 29 ]. Additionally, the dietetic workforce has identified and prioritised delegation of malnutrition care as an opportunity to facilitate high-value healthcare [ 20 ]. However, malnutrition care appears to still predominately be undertaken by dietitians [ 8 , 14 , 19 ].…”

“…However, a recent report of nutrition care practice, within Queensland hospitals in Australia, suggests poor uptake of delegated nutrition care processes, with 75% or more of dietitians continuing to individually undertake malnutrition care activities [ 19 ]. The dietetic profession has identified and prioritised delegation of elements of malnutrition care as opportunities to facilitate systematised interdisciplinary malnutrition care; however, it was suggested that further investigation into the complexities surrounding implementation of delegation to dietitian assistants is required [ 20 ]. Identifying barriers and enablers to delegation has been highlighted as a crucial step for translation and change in practice [ 19 , 20 ].…”

“…The dietetic profession has identified and prioritised delegation of elements of malnutrition care as opportunities to facilitate systematised interdisciplinary malnutrition care; however, it was suggested that further investigation into the complexities surrounding implementation of delegation to dietitian assistants is required [ 20 ]. Identifying barriers and enablers to delegation has been highlighted as a crucial step for translation and change in practice [ 19 , 20 ]. Consequently, the aim of this study is to use a qualitative approach to identify barriers and enablers to delegating malnutrition care activities to dietitian assistants from the perspectives of dietitian assistants, dietitians, and management.…”

Are Malnourished Inpatients Treated by Dietitians Active Participants in Their Nutrition Care? Findings of an Exploratory Study of Patient-Reported Measures across Nine Australian Hospitals

“…The Systematised Interdisciplinary Malnutrition Program for impLementation and Evaluation (SIMPLE) Phase II implementation program was a knowledge translation, quality assurance program aiming to scale and spread the initial SIMPLE program across hospitals in Queensland, Australia [ 16 , 17 , 30 , 31 , 32 , 33 , 34 , 35 ]. Led by an interdisciplinary knowledge translation team, the program engaged local dietetics and interdisciplinary ward/unit teams, the SIMPLE Champions Network and subgroups, and key site influencers to translate SIMPLE into new wards/units and hospitals.…”