The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi

Abstract

BackgroundMalnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation.MethodsA modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel.Results80 % of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators.ConclusionsThis evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.

More-2-Eat: evaluation protocol of a multi-site implementation of the Integrated Nutrition Pathway for Acute Care

“…Multi-methods are used to address the various research questions and a mixed methods approach Fig. 1 The Integrated Nutrition Pathway for Acute Care [37] with a triangulation design using the convergent model [56] is used to explicitly merge qualitative and quantitative data that will describe how implementation varies by context of hospital site.…”

“…Specifically, that this work was initiated with a prevalence study defining the problem [3,6,7], which resulted in the development of a knowledge translation product (i.e. INPAC) to overcome the problem [37]. M2E is essentially the action process of the KTA theory and specifically includes the following steps: adapting knowledge to the local context; assessing barriers to knowledge use; selecting, tailoring and implementing interventions; monitoring knowledge use; evaluating outcomes; and sustaining knowledge use.…”

“…The Integrated Nutrition Pathway for Acute Care (INPAC) was designed to be a feasible, evidence and consensus-based algorithm to improve nutrition care [37] ( Fig. 1).…”

Need for the Integrated Nutrition Pathway for Acute Care (INPAC): gaps in current nutrition care in five Canadian hospitals

“…Due to the ongoing high prevalence of malnutrition and the pursuit of patient centered care, there is growing focus on the need to build awareness to make improvements and change the culture of nutrition care in hospital [8,9,19,24]. Currently, prevalence rates at admission remain high and research has shown that the lack of a systematic approach to nutrition care in hospitals may exacerbate the issue [25][26][27].…”

“…A study conducted by the Canadian Malnutrition Task Force found that 45% of patients on medical or surgical wards who stayed more than 2 days were malnourished on admission [3]. Malnutrition often goes undetected [9], which is concerning as it increases mortality, length of stay, and risk of re-admission, even when considering other important covariates such as age, sex, socioeconomic and diseaserelated characteristics [3,[10][11][12][13][14][15]. Malnutrition also increases hospital costs [5,16,17] and in Canada, this is by approximately $2000CDN per malnourished patient when compared to a well nourished patient [18].…”