Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: a systematic review of the evidence

“First, in some studies, the researchers were unable to follow‐up with all patients and were subsequently excluded from analyses.(27,34,37,38) This was a result of having been discharged prior to the predetermined follow‐up time intervals or because of death or transfers to other hospitals.”

“This association was weakened by higher levels of healthcare assistant staffing which suggests a potential approach to address such staffing challenges by enabling nursing staff to direct their time to other patient‐related activities.(61) Nurses consistently self‐report that nutrition‐related responsibilities are lik…”

“Hospital malnutrition is a predictor of increased length of stay, impaired wound healing, increased risk of infections and complications, and increased morbidity and mortality.(1,4) Thus, malnourished patients have more substantial care needs with a greater reliance on hospital resources resulting in higher healthcare…”

“These findings are consistent with earlier research suggesting that patient care suffers during periods of inadequate staffing.(67) This association was weakened by higher levels of healthcare assistant staffing which suggests a potential approach to address such staffing challenges by enabling nursing staff to direct…”

“This may partly be a consequence of limited provision of formal nutrition education by medical schools.(64) Although a consensus exists amongst nursing staff regarding the high level of importance of patient nutrition, a lack of clarity regarding nurses' involvement and responsibilities, limited flexibility in food se…”

“The Alliance recommends ensuring malnourished or at‐risk patients are fed within 24 h, making every effort to ensure all EN or PN is administered as prescribed, promoting supportive meal environments, flagging when meal consumption is poor, adopting procedures to ensure meal provision when meals are missed, and avoidi…”

“Ten of the 15 studies used validated tools,; however, three relied on screening tools.(29,40,41) The remaining seven studies used three different nutritional assessment tools (MNA, SGA and AND/ASPEN).”

“Ten of the 15 studies used validated tools,; however, three relied on screening tools.(29,40,41) The remaining seven studies used three different nutritional assessment tools (MNA, SGA and AND/ASPEN).”

“In some cases of disease‐ related malnutrition, nutrition support alone may be inadequate to prevent further nutritional decline despite energy provision corresponding with measured energy expenditures.(5,8) Hospital malnutrition is a predictor of increased length of stay, impaired wound healing, increased risk of inf…”

“This is because BMI cannot delineate between body fat and fat‐free mass, particularly relevant to the sarcopaenic population,(49) nor accommodate changes in fluid resulting from oedema and/or ascites, thereby masking weight loss.(50) Notably, the lowest rates of deterioration were reported by studies that relied on BM…”

“General medicine and surgery patients showed considerable heterogeneity in rates of deterioration across studies, ranging from 2% to 27%.(27,28,36) In a Canadian study, 37% of medical and surgical patients experienced a change in nutritional status from admission to discharge; 19.”

“Forty‐three per cent of orthogeriatric hip fracture patients reported mealtime interruptions as the most common barrier to intake.(30) NBM orders and procedure‐related fasting were also frequently reported by Australian inpatients across specialties.”

“Three studies used BMI(33,35,37) as a measure of nutritional status, and a fourth study used a modified BMI score.(39) BMI is often a useful component of more comprehensive nutritional assessments; however, based on current cut‐off points, BMI alone is not adequately sensitive to identify malnourished hospitalised pat…”

“Patient food services directly impact on nutritional status and should prioritise flexibility within the system to better meet patient needs.(15) The importance of hospital food service quality may not be recognised at times of budget cuts; however, the cost‐ savings associated with shorter lengths of stay and reduced…”

“First, in some studies, the researchers were unable to follow‐up with all patients and were subsequently excluded from analyses.(27,34,37,38) This was a result of having been discharged prior to the predetermined follow‐up time intervals or because of death or transfers to other hospitals.”

“As a result of the busy nature of hospital wards, patients often feel uncomfortable making requests to nursing staff because they fear being a burden and interfering with nurses' abilities to complete other tasks that are perceived to be of higher importance.(53,54,55) Over 40% of patients in Canadian hospitals report…”

“Both studies demonstrated reductions in plate waste and food costs.(59,60) Patient food services directly impact on nutritional status and should prioritise flexibility within the system to better meet patient needs.”

“Given that one‐third of well‐nourished patients are expected to become malnourished, and two‐ thirds of patients who present as malnourished on admission are expected to deteriorate,(4) hospitals seeking to mitigate the consequences of hospital‐acquired malnutrition must establish policies that ensure regular rescreen…”

“As a result of the busy nature of hospital wards, patients often feel uncomfortable making requests to nursing staff because they fear being a burden and interfering with nurses' abilities to complete other tasks that are perceived to be of higher importance.(53,54,55) Over 40% of patients in Canadian hospitals report…”

“0% showed an improvement in nutritional status.(28) Similarly, 3%–27% of acute geriatric patients were observed to decline.”

“In some cases of disease‐ related malnutrition, nutrition support alone may be inadequate to prevent further nutritional decline despite energy provision corresponding with measured energy expenditures.(5,8) Hospital malnutrition is a predictor of increased length of stay, impaired wound healing, increased risk of inf…”

“BMI is often a useful component of more comprehensive nutritional assessments; however, based on current cut‐off points, BMI alone is not adequately sensitive to identify malnourished hospitalised patients.(48) This is because BMI cannot delineate between body fat and fat‐free mass, particularly relevant to the sarcop…”

“Given that one‐third of well‐nourished patients are expected to become malnourished, and two‐ thirds of patients who present as malnourished on admission are expected to deteriorate,(4) hospitals seeking to mitigate the consequences of hospital‐acquired malnutrition must establish policies that ensure regular rescreen…”

“9%.(29,31,35,37) Amongst studies that included patients from only one or two clinical areas, sub‐acute rehab and geriatric patients had the most favourable outcomes with 62.”

“As a result of the busy nature of hospital wards, patients often feel uncomfortable making requests to nursing staff because they fear being a burden and interfering with nurses' abilities to complete other tasks that are perceived to be of higher importance.(53,54,55) Over 40% of patients in Canadian hospitals report…”

“Both studies demonstrated reductions in plate waste and food costs.(59,60) Patient food services directly impact on nutritional status and should prioritise flexibility within the system to better meet patient needs.”

“should be avoided to prevent further nutritional deterioration and delayed convalescence.(61,62,63) Despite it being widely accepted that early initiation of nutrition support remains imperative to preventing nutritional decline, recent findings indicate that more than half of patients with hospital‐acquired malnutrit…”

“First, in some studies, the researchers were unable to follow‐up with all patients and were subsequently excluded from analyses.(27,34,37,38) This was a result of having been discharged prior to the predetermined follow‐up time intervals or because of death or transfers to other hospitals.”

“Although all studies evaluated patients' nutritional evolution over the course of hospital admissions, only four described barriers to optimising nutritional status.(28,30,31,36) Furthermore, only one study delineated cases of preventable hospital‐acquired malnutrition that may have been mitigated with timely and appr…”

“7% had improved since their baseline assessments.(32) Neurology and stroke patients experienced the highest rates of nutritional deterioration ranging from 38% to 65% when malnutrition was assessed using a validated screening tool.”

“Notably, the lowest rates of deterioration were reported by studies that relied on BMI or demiquet/ mindex exclusively as a measure of nutritional status,(33,35,39) suggesting that BMI or similar measures in isolation may not be adequately sensitive to detect clinically relevant nutritional decline in hospitalised pat…”

“Furthermore, despite greater financial capacities and funding within healthcare systems of developed countries, routine nutritional screening using validated tools is not always performed, and often nutrition intervention is more reactive rather than proactive.(15,16) A recent study of patients with hospital acquired…”

“First, in some studies, the researchers were unable to follow‐up with all patients and were subsequently excluded from analyses.(27,34,37,38) This was a result of having been discharged prior to the predetermined follow‐up time intervals or because of death or transfers to other hospitals.”

“Protected mealtimes have been adopted by some hospitals; however, the results of studies examining the efficacy of these interventions have been inconsistent.(57,58) Patient meal satisfaction remains low,(56) although some studies have seen improvements in oral intake with greater attention to the quality and personal…”

“NBM is often prescribed inappropriately as a result of updated clinical practice guidelines not being widely adopted.(19,20) Evidence suggests a strong association between any care‐related gap and increased length of hospital stay.”

“In one study, 76% of malnourished patients experienced at least one institution‐ level care gap including poor dietitian–physician communication, inappropriate nil‐by‐mouth (NBM) orders or inaccurate dietetic discharge instructions.(18) NBM is often prescribed inappropriately as a result of updated clinical practice g…”

“Protected mealtimes have been adopted by some hospitals; however, the results of studies examining the efficacy of these interventions have been inconsistent.(57,58) Patient meal satisfaction remains low,(56) although some studies have seen improvements in oral intake with greater attention to the quality and personal…”

“All but one study was observational in design, with the remaining study being quasi experimental.(41) Eight studies were prospective cohorts, four were prospective cross‐ sectional studies,(29,32,35,40) one was a retrospective cohort study(31) and one was a sequential explanatory mixed‐methods study.”

“Furthermore, patients with extended lengths of stay were less frequently screened relative to those who had shorter admissions.(51) Although all studies evaluated patients' nutritional evolution over the course of hospital admissions, only four described barriers to optimising nutritional status.”

“Even well-nourished patients can become malnourished due to complex metabolic changes occurring in the context of acute inflammation that promote catabolism and disrupt normal nutrient utilization [1].”