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Table 3 Quality indicators of nutritional care reported in the selected papers

From: Process, structural, and outcome quality indicators of nutritional care in nursing homes: a systematic review

1st Author, Year of publication Instruments for collecting data on quality indicators Structural/process indicators Outcome indicators
Bonaccorsi, 2015 [35] Ad hoc instruments (questionnaire/direct observation) Structural indicators Prevalence of subjects with medium to high risk of malnutrition, according to MUST.
Type of scales used to weigh residents
Employment of dietitians and type of consultation
Number of operators assigned to manage the administration of meals in a specific day
Process indicators
Use of a nutrition screening tool
Presence of protocols/guidelines for weight assessment
Presence of protocols or guidelines for administration of food
Assessment of dysphagia
Dyck, 2007 [39] MDS; OSCAR Staffing hours: Weight lossa
- RN hours per resident per day
- LPN hours per resident per day
Halfens, 2013 [30] LPZ Not described Malnutrition prevalenceb
Hjaltadottir, 2012 [27] MDS Weight lossa
Hurtado, 2016 [40] Nursing Home Compare/MDS; ad hoc questionnaire Schedule control (from ad hoc questionnaire): Weight lossa
- to choose when to take day off or vacation
- to choose when to start/end each work day
- to choose when to take a few hours of break
- to decide how many hours to work each day
Lee, 2014 [41] MDS; the Colorado state inspections RN staffing hours (from the Colorado state inspections data) Weight lossa
Meijers, 2009 [59] LPZ Institutional level Malnutrition prevalenceb
Availability of an up-to-date protocol/guideline on malnutrition prevention and treatment
Auditing of protocol/guideline for malnutrition prevention and treatment
Availability of malnutrition advisory teams
Multiple dietitians available in the institution
Malnutrition education (prevention and treatment) given by malnutrition specialist within the last two years
Ward level
Trained malnutrition specialist working on the ward
Control of use of prevention and treatment guidelines
Policy to measure weight at admission
Documentation of malnutrition interventions
Correct mealtime ambience
Meijers, 2014 [36] LPZ Structural indicators Malnutrition prevalenceb
Institutional level
There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition within the institution.
There is an advisory committee for malnutrition at the institution or department level.
There is someone within the institution who is responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol.
Over the last two years, a refresher course and/or a meeting was organized for caregivers, which was/were specifically devoted to the prevention and treatment of malnutrition within the institution.
Ward level
There is at least one person/specialist in the department/basic care unit/team who is specialized in the area of malnutrition.
Work in the department/basic care unit/team is done in a controlled fashion or in accordance with the malnutrition protocol/guideline.
Upon admission, every resident is weighed as a part of standard procedure.
The nutritional status is screened upon admission.
The care file/care plan specifies the activities that must be implemented for residents who are at risk of malnutrition.
The department has a policy on when and how to measure weight.
Process indicators
Assessment of the nutritional status by a validated screening instrument
Weight monitoring in a controlled fashion
Dietitian consultation
Use of nutritional treatment
Moore, 2014 [31] VPSRACS; data routinely collected in the facilities included in the study Weight lossc
Rantz, 2009 [29] MDS Not described (QIPMO—nurse site visits to suggest how to improve quality of care) Weight lossa
Schönherr, 2012 [32] LPZ Structural indicators: Malnutrition prevalenceb
Guideline for prevention and treatment
Auditing of guideline
Advisory committee for malnutrition
Updating of guideline
Criteria for determining malnutrition
Employment of dietitians
Refresher course for caregivers
Information brochure
Standard policy for handover
Process indicators
Assessment of weight
Use of nutritional screening tool
Assessment of weight over time
Use of clinical view
Use of biochemical parameters
Dietitian consulted
Energy- and protein-enriched diet
Energy-enriched snack
Oral nutritional support
Enteral nutrition
Parenteral nutrition
Texture-modified diet
Fluid 1–1.5 L/d
No interventions owing to palliative policy
Shin, 2015 [42] Ad hoc instruments (questionnaire-interviews) Nurse staffing, by type (RN, CNA, qualified care workers): Weight lossa
- hours per resident per day
- skill-mix hours per resident per day
- staff turnover
Simmons, 2006 [28] Ah hoc instruments (direct observation) Feeding Assistance Care Process Measure:
-% of residents who eat less than 50% of meal and receive less than one min of assistance.
-% of residents who eat less than 50% of meal and are not offered a substitute.
-% of residents who receive less than five min of assistance and a supplement.
-% of residents who are independent but receive physical assistance.
- % of residents who receive physical assistance without verbal cue.
Simmons, 2007 [44] Ah hoc instruments (direct observation) Feeding Assistance Care Process Measure, by type of staff (CNAs, PFAs, no assistance from either type of staff):
-% of residents who eat less than 50% of meal and receive less than one min of assistance.
-% of residents who eat less than 50% of meal and are not offered a substitute.
-% of residents who receive less than five min of assistance and a supplement.
-% of residents who are independent but receive physical assistance.
- % of residents who receive physical assistance without verbal cue.
Van Nie, 2014 [37] LPZ Structural indicators Malnutrition prevalenceb
Institutional level
There is an agreed protocol/guideline for the prevention and/or treatment of malnutrition within the institution.
Malnutrition-related work within the institution is carried out in a controlled fashion or in accordance with a malnutrition protocol/guideline.
There is a multidisciplinary advisory committee for malnutrition at the institutional or ward level.
There is someone within the institution who is responsible for updating and ensuring that the necessary attention is devoted to the malnutrition protocol.
Within the institution, criteria have been defined for determining malnutrition.
There are dietitians employed at the institution.
Over the past two years, a refresher course and/or a meeting has been organized for caregivers, which was specifically devoted to the prevention and treatment of malnutrition within the institution.
An information brochure about malnutrition is available at the institution for clients and/or family members.
Ward level
There is at least one nurse in the ward who is specialized in the area of malnutrition
Clients who are at risk of malnourishment or who are malnourished are discussed on the ward during multidisciplinary work consultations.
Work in the ward is conducted in a controlled fashion or in accordance with a malnutrition protocol/guideline.
At admission, every client is weighed as a part of standard procedure.
At admission, the height of each client is determined as a part of standard procedure.
The nutritional status is assessed at admission.
The care file includes an assessment as to each patient’s risk of malnutrition.
The care file/care plan specifies the activities that must be implemented for clients who are at risk of malnutrition.
In case of (expected) malnutrition, a protein- and energy-enriched diet is provided in the ward as a part of standard procedure.
Every client who is malnourished (or is at risk for becoming so) and his or her family receive an informational brochure about malnutrition.
The ambience at mealtimes is taken into account within the ward.
The care file includes the intake for each client.
The ward has a weight policy.
van Nie-Visser, 2011 [33] LPZ Structural indicators Malnutrition prevalenceb and prevalence of subjects with risk of malnutrition.
Institution level
Prevention and treatment protocol/guideline ‘At risk of malnutrition is defined as meeting one or more of the following criteria: (1) BMI 21–23.9 kg/m2, (2) not eaten or hardly eaten anything for three days or not eaten normally for more than a week.
Malnutrition advisory team
Auditing of protocol/guideline
Dietitians employed in institution
Education on malnutrition prevention and treatment in last 2 years
Information brochure available for client or family
Ward level
Person specialized in malnutrition on unit
Control of use of prevention/treatment guideline
Measurement of weight at admission
Interventions on malnutrition stated in patient file
Optimal mealtime ambience provided at dinner
Process indicators
Assessment of weight
Use of nutritional screening tool
Weight history
Use of clinical view
Use of biochemical parameters
Energy- and protein-enriched diet
Energy-enriched snacks between meals
Oral nutritional supplements
Tube feeding
Parenteral feeding
Fluid 1–1.5 L/d
No interventions
Palliative policy
van Nie-Visser, 2015 [38] LPZ See above (….) Malnutrition prevalenceb
van Nie-Visser, 2014 [34] LPZ Malnutrition prevalenceb
Werner, 2013 [43] MDS/Nursing Home Compare; OSCAR -% of residents receiving tube feeds Weight lossa
-% of residents receiving mechanically altered diets
-% of residents with assisted eating devices
  1. MUST Malnutrition Universal Screening Tool
  2. MDS Minimum Data Set
  3. LPZ Landelijke Prevalentiemeting Zorgproblemen (In Dutch)
  4. VPSRACS Victorian Public Sector Residential Aged Care Services
  5. OSCAR Online Survey, Certification, and Reporting
  6. ARF Area Resource File
  7. RN Registered Nurse
  8. LPN Licensed Practical Nurse
  9. CNA certified nursing assistant
  10. QIPMO Quality Improvement Program of Missouri
  11. PFA Paid Feeding Assistant
  12. aloss of 5% or more in the last months or loss of 10% or more in the past six months, as defined in MDS
  13. b(1) BMI ≤ 18.5 kg/m2(age 18–65 years) or BMI ≤ 20 kg/m2 (age > 65 years), and/or (2) unintentional weight loss (more than 6 kg in the previous six month or more than 3 kg in the last month) and/or (3) no nutritional intake for three days or reduced intake for more than 10 days combined with a BMI between 18.5–20 kg/m2 (age18–65 years) or between 20 and 23.9 kg/m2(age > 65 years)
  14. closs of ≥3 kg over three months, or any unplanned weight loss for each consecutive month of the quarter