The prevention and reduction of weight loss in an acute tertiary care setting: protocol for a pragmatic stepped wedge randomised cluster trial (the PRoWL project)

Alison L Kitson,Timothy J Schultz,Stijn Soenen,Leslye Long,Alison Shanks,Ian Chapman,Rick Wiechula

doi:10.1186/1472-6963-13-299

Abstract

BackgroundMalnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention co-facilitated by clinical nurses and dietitians addressing the nutritional care of patients, particularly those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital.Methods/DesignA pragmatic stepped wedge randomised cluster trial with repeated cross section design will be conducted. The unit of randomisation is the ward, with allocation by a random numbers table. Four groups of wards (n = 6 for three groups, n = 7 for one group) will be randomly allocated to each intervention time point over the trial. Two trained local facilitators (a nurse and dietitian for each group) will introduce the intervention. The primary outcome measure is change in patient’s body weight, secondary patient outcomes are: length of stay, all-cause mortality, discharge destinations, readmission rates and ED presentations. Patient outcomes will be measured on one ward per group, with 20 patients measured per ward per time period by an unblinded researcher. Including baseline, measurements will be conducted at five time periods. Staff perspectives on the context of care will be measured with the Alberta Context Tool.DiscussionUnplanned and unwanted weight loss in hospital is common. Despite the evidence and growing concern about hospital nutrition there are very few evaluations of system-wide nutritional implementation programs. This project will test the implementation of a nutritional intervention across one hospital system using a staged approach, which will allow sequential rolling out of facilitation and project support. This project is one of the first evidence implementation projects to use the stepped wedge design in acute care and we will therefore be testing the appropriateness of the stepped wedge design to evaluate such interventions.Trial registrationACTRN12611000020987

Highlights

Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed
The intervention The evidence-based intervention will consist of three linked activities: the introduction and use of the Malnutrition Universal Screening Tool (MUST), the provision of food supplements to patients identified at risk of malnutrition, and the introduction of a system that uses red feeding trays to flag patients requiring full feeding assistance
0:056 0:267 of 0.21, with four groups of 20 patients measured over five time periods totalling 400 patients, a power of 80% would detect a reduction in the prevalence of weight loss from 26.7% to

Summary

Introduction

Malnutrition, with accompanying weight loss, is an unnecessary risk in hospitalised persons and often remains poorly recognised and managed. The study aims to evaluate a hospital-wide multifaceted intervention cofacilitated by clinical nurses and dietitians addressing the nutritional care of patients, those at risk of malnutrition. Using the best available evidence on reducing and preventing unplanned weight loss, the intervention (introducing universal nutritional screening; the provision of oral nutritional supplements; and providing red trays and additional support for patients in need of feeding) will be introduced by local ward teams in a phased way in a large tertiary acute care hospital. Nutritional status of hospitalised patients The prevalence of malnutrition, defined here as proteinenergy under-nutrition causing measurable adverse effects on tissue/body form and function and clinical outcome [1] During hospitalisation nutritional status often declines in older patients due to a lack of adequate nutritional intake [5,6,7]. Patients were unable to open packaging, missed meals because of scheduled investigatory procedures, were not given food and fluids between mealtimes or these were placed out of reach, and lacked feeding assistance or were interrupted during mealtimes [20]

Methods

Findings

Discussion

Conclusion