My Meal Intake Tool (MMIT) and the Mealtime Audit Tool (MAT) - Criterion Validity and Inter-rater Reliability Testing of two Novel Tools for Improving Food Intake in Acute Care
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BACKGROUND: Forty-five percent of patients in Canada are admitted to hospital already malnourished. Compared to well-nourished patients, those with diminished nutritional status are at an increased risk of in-hospital mortality and several medical complications. As a result, malnourished patients take longer to recover, stay hospitalized longer, and are more likely to be readmitted to hospital after discharge, costing the healthcare system more to care for them. Improving nutritional status in hospital can improve recovery and shorten length of stay. Insufficient food intake (FI) is common in hospital and has also been associated with longer lengths of stay (LOS), leading to further declines in nutritional status. Thus, ensuring sufficient patient FI could improve patient outcomes and reduce costs of care by reducing nutritional decline. However, current FI monitoring practices in hospital are generally ad hoc. Most hospitals don’t have the resource capacity to have staff monitor every patient’s FI, so monitoring practices are sparsely or inaccurately completed for only a portion of patients. There are also barriers to FI that occur in hospital, which include a range of potential mealtime issues patients could experience that further prevent them from consuming enough food. These barriers are simple issues that can easily go unrecognized by staff and their existence isn’t formally assessed or monitored in current practice. Creating practices that allow 1) the accurate monitoring of all patients’ FI, and 2) the identification and removal of FI barriers, could increase the efficacy of hospitals to provide sufficient nutrition care and fight the prevalence of malnutrition through increased patient FI. PURPOSE: The purpose of this thesis was to complete key steps in the development and testing of two novel hospital nutrition care tools. The My Meal Intake Tool (M-MIT), a patient-completed FI monitoring tool, was tested for feasibility and criterion validity in a clinical setting. The Mealtime Audit Tool (MAT), a hospital staff-completed tool for the identification of FI barriers, was tested for feasibility and inter-rater reliability in a clinical setting. METHODS & MAJOR FINDINGS: Two studies were conducted as part of this thesis work. Study 1: Patients from four Canadian hospitals (n=120) were recruited to participate in the feasibility testing of both the M-MIT and the MAT, as well as the criterion validation of the M-MIT. Participants estimated their food and fluid intake using the M-MIT at one mealtime. M-MIT results were validated against dietitian visual estimations of their FI for the same meal. At a separate mealtime, a dietitian completed the MAT with the participants, identifying the barriers that they experienced at that mealtime. 78% of participants were able to estimate their FI on the M-MIT without error. Sensitivity and specificity of M-MIT’s ability to identify participants who consumed < 50% of their meal were 76.2% and 74.0% (p <0.001) respectively, indicating sufficient criterion validity; sensitivity analyses including those who did not complete the tool resulted in a range of sensitivity from 53.3% to 83.3% and specificity from 60.0% to 78.9%. The results of the validity analyses, in combination with patient follow-up interviews and clinician feedback, were used to make revisions to the tool to improve the feasibility and ease of use of M-MIT. Descriptive analyses were conducted to characterize barriers experienced by participants according to the MAT, and clinician feedback was used to make revisions to the MAT before Study 2. Study 2: Ninety patients from multiple medical and surgical units in a Canadian hospital were recruited to participate in the inter-rater reliability testing of the MAT across 30 different mealtimes. Two auditors completed the MAT with each of the 90 participants within a few minutes of each other after the participants had completed their meals. The MAT tabulates a total score of the number of barriers (out of 18) experienced at a mealtime. Total MAT scores between the two auditors showed good agreement, with an intra-class correlation coefficient (ICC) of 0.68 (0.52-0.79). About two-thirds of the 18 barrier items listed on the MAT showed good to excellent agreement between the two auditors, according to calculated kappa statistics. The inter-rater reliability analyses, descriptive analyses, and clinician feedback from Study 1 and Study 2 were used to make revisions to improve functionality and ease of use of the MAT. OVERALL CONCLUSIONS: The studies within this thesis have shown the M-MIT and MAT have good potential for use in clinical practice. If implemented into use, the tools have the potential to play a role in improving nutrition care. These tools could help standardize processes (FI monitoring, assessment of FI barriers) that are currently ad hoc or non-existent. However, changing existing care practices is an extremely complex task. There is still work to be done to further test and refine the tools, as well as to determine whether these tools can feasibly be integrated into routine practices, and if their use leads to improvement in patient outcomes.