Table Of ContentRobertsetal.BMCGeriatrics2013,13:5
http://www.biomedcentral.com/1471-2318/13/5
STUDY PROTOCOL Open Access
Southampton mealtime assistance study:
design and methods
Helen C Roberts1, Anna L Pilgrim2,3, Marinos Elia3, Alan A Jackson3, Cyrus Cooper2*, Avan Aihie Sayer1,2
and Sian M Robinson2
Abstract
Background: Malnutrition is common in older people inhospital and is associated with adverse clinical outcomes
including increased mortality, morbidity and lengthof stay. Thishas raised concerns about the nutrition and diet of
hospital in-patients.A numberof factors may contribute to low dietary intakes inhospital, including acute illness
and cognitiveimpairment among in-patients.The extent to which other factors influence intake such as a lack of
helpat mealtimes, for patients who require assistance with eating, is uncertain. This study aims to evaluate the
effectiveness of using trained volunteer mealtimeassistantsto help patients on an acute medical ward for older
people atmealtimes.
Methods/design: The study design is quasi-experimental with a before (year one) and after (year two) comparison
ofpatientson theinterventionward and parallel comparisonwith patients ona control ward inthe same
department. The interventionin thesecond year was theprovision of trained volunteer mealtimeassistanceto
patients inthe intervention ward. There were three components of data collectionthatwere repeatedin both
years on both wards. The first (primary)outcome was patients’dietary intake, collected as individual patient records
and as ward-level balance data over 24 hour periods. The second was clinical outcome data assessed on admission
and discharge from both wards, and 6 and 12 months after discharge.Finally qualitative data onthe views and
experience of patients, carers,staff and volunteers was collected through interviews and focus groups inboth years
to allow a mixed-method evaluation of theintervention.
Discussion: The study will describe theeffect of provision of trained volunteer mealtime assistants onthe dietary
intake ofolder medical in-patients.The association between dietary intake and clinical outcomes including
malnutrition risk, body composition, grip strength,length of hospital stay and mortality will also be determined. An
important component ofthe study is theuse of qualitative approaches to determine the views of patients, relatives,
staff and volunteers on nutrition inhospital and the impact of mealtimeassistance.
Trial registration: Trial registered with ClinicalTrials.gov NCTO1647204
Keywords: Nutrition, Older, Volunteer,Mealtime assistance, Dietary intake, Hospital
Background differences in prevalence of malnutrition according to
Malnutrition is common in older people [1]. For setting, reaching 39% in hospitalised older patients.
example, in a recent pooled analysis of data from 4,500 Although malnutrition is known to be associated with
older individuals across 12 developed countries (mean major adverse clinical outcomes such as increased
age 82 years), 23% were identified as malnourished using mortality [3], morbidity [1] and length of stay [4] at
the Mini Nutritional Assessment, with a further 46% at enormous cost to individuals and health services, and
risk of poor nutrition [2]. However, there were marked despite current prevalence estimates, it still remains
an undertreated problem [5].
*Correspondence:[email protected] One consequence of the estimated rates of malnutri-
2MRCLifecourseEpidemiologyUnit,UniversityofSouthampton,
tion among older hospitalised patients is that concerns
SouthamptonGeneralHospital,TremonaRoad,SouthamptonHampshire
SO166YD,UK have been raised about hospital food, both in terms of
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the quality of food provided as well as adequacy of The Southampton Mealtime Assistance Study was
provision of assistance with eating at mealtimes [6,7]. established in 2010, withthe aim of investigating whether
But it is important to recognise that there are a number the use of trained volunteers employed specifically to
of other contributors to low dietary intake among older focus on mealtime assistance can increase the dietary
patients, which include the effects of acute illness on ap- intakeofolderacutemedicalin-patients.
petite, cognitive impairment, low mood, co-morbidities
and altered taste sensation due to illness and medica- Methods/design
tions, each of which may predate admission to hospital Studydesign
[8,9]. Thus while malnourished older adults may be The study design is quasi-experimental [22,23] with a
disproportionately represented in hospital and much before (year one) and after (year two) comparison of
of the evidence has come from hospital settings [3], patients on an intervention ward and parallel compari-
malnutrition is largely found and originates in the son with patients on a control ward in the same depart-
community [5,10]. ment. The intervention in the second year was the
However, it remains a concern that low energy and nu- provision of trained volunteer mealtime assistance to
trient intakes and poor nutrient status are commonly patientsintheinterventionward.
describedinolderhospitalisedpatients[9,11,12].Whether There were three components to the data collection,
provision of more effective support at mealtimes, includ- which wererepeatedinyearoneandyeartwo (Figure 1).
ing assistance with eating, could improve intake remains Theprimaryoutcomewas dietary intake ofpatients, col-
uncertain. In the UK, the standard of mealtime care in lected as individual patient records and ward-level bal-
hospitals has been an issue of concern for a number of ance data for both wards over 24 hour periods in both
years. A report in 2008 from the Healthcare Commission years. The second component was clinical outcome data
foundthatoneinfivepatientswhowantedhelpeatingdid assessed on admission and discharge from both wards
not get it [13]. More recently, the Care Quality Commis- and at follow-up 6 and 12 months later. Finally, qualita-
sion reported that 15% of 100 hospitals surveyed in 2011 tive data on the views and experience of patients, carers,
were not meeting the minimum legal standards for meal- staff and volunteers was collected through interviews
time care in the elderly, and another 32% needed to im- and focus groups in both years to allow a mixed-method
prove[14].ThisproblemisnotuniquetotheUKandhas evaluation of the intervention [24]. The study received
beenreportedinothercountriessuchasAustraliaandthe fullapprovalbythe localresearchethicscommittee.
USA[15,16].
Mealtime assistance has been defined as the process of Setting
enabling a person to complete the eating process when a The study was conducted on two acute wards in the
mealorsnack isservedinacaresetting [17].Thisassist- Medicine for Older People Department at a university
ance can range from presentation of food in an available hospital in England. Medical and nursing care on both
form and providing verbal encouragement, to cutting wards were very similar, and they had a similar case mix
food into smaller pieces and transferring food from the since both admitted acutely unwell female patients aged
plate to the person’s mouth. Mealtime assistance has 70 years and over direct from the Acute Medical Unit
been identified as a possible means of improving dietary and Accident and Emergency Department to the next
intake as70-80%ofolderin-patientsareestimated tore- availablebed.
quire help [18]. However the use of volunteer meal-
time assistants has been little researched and their Participants
effectiveness is unknown [19]. All patients admitted to these wards as an emergency
Two UK research studies of the use of volunteers to between February 1st 2010 and January 31st 2012 were
help with mealtimes have found conflicting results. A eligible for the study. Exclusioncriteria included patients
study of 318 older women aged 65 years and over with who were nil by mouth, receiving tube feeds, under 70
hip fracture found that additional help from one health years old, male, on the Liverpool Care Pathway for the
care assistant led to increased energy and nutrient dyingpatientorbeingnursedinsiderooms.
intakes and improved clinical outcomes [20]. However a
similar study on acute care of the elderly wards, which Intervention
involved a more heterogeneous group of 592 men and The intervention was the provision of several trained
women aged 65 years and over with a range of medical volunteers to assist at mealtimes. Assistance was given
conditions in a randomised controlled trial, found no by volunteers who had completed a half day hospital
increase in dietary intake when one healthcare assistant training programme run by speech and language
per ward was available to help with eating at two meals therapy, dietetics and voluntary services. The training
onfivedays perweek[21]. included aspects of nutrition in older in-patients, the
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Year 1 Year 2
Ward 1 Ward 2 Ward 1 Ward 2
no mealtime no with no
assistance mealtime mealtime mealtime
assistance assistance assistance
Diet Clinical Diet Clinical Diet Clinical Diet Clinical
records assess- records assess- records assess- records assess-
ments ments ments ments
6 & 12 6 & 12 6 & 12 6 & 12
month month month month
follow- follow- follow- follow-
up up up up
Interviews with patients relatives and staff Interviews with patients relatives staff and volunteers
Figure1Studyoutlinescheme.
role of the volunteer, special diets, safe feeding strategies round. All food and drinks that were not consumed were
and completion of food and fluid charts. Volunteers weighed and recorded. Sip feeds were collected and
were available to assist at weekday lunchtimes. Patients weighed at intervals during each study day and research
needing help were identified by a senior nurse and as- nurses recorded in detail all additional food and drink
sistance included encouragement, opening packages and consumedbyindividualpatients.
cutting up food, physical help with getting spoons ready
and help guiding the spoon to the mouth as required. Calculation of nutrient intake The nutrient intake of
Volunteers did not assist patients with known swallowing individual patients was calculated from the weight of
problemsorwhoweredrowsyorunabletositup. food consumed and its nutrient content. For main meals
the weight of food delivered to each patient was
Datacollection obtained from the hospital caterers, whose portion con-
1.Dietarydatacollection trol measures ensured that each meal component was
The dietary intake of all eligible patients on the wards within10%ofthestatedweight.Forotherfoods,standard
wasstudiedfor24hourperiodson14weekdaysbetween portion sizes [25] and manufacturers’ information was
April and December 2010 in year one, and on 12 week- used. Weights of servings of porridge, soup and custard
days between April and November 2011 in year two. weredeterminedfromtheaverageweightsoftestportions
The spread of study days captured seasonal variation in servedinthecupsandbowlsusedonthewards.Standard
menus and illness patterns. The intake of individual protocols were devised for converting leftover drinks into
patientswasrecordedatthreemealtimesandsevendrinks the constituent components according to the size of
rounds, and for sip feeds, extra food and drinks (such as cup and type of milk used, and for the separation of
those brought in by relatives) and any additional food or uneaten mixed milk and breakfast cereal. Where
drinks taken during the night. Research nurses recorded other uneaten foods were mixed together, e.g. potato
all food items delivered to the patients and collected the and gravy, and could not be weighed separately, the
trays and cups at the end of each mealtime and drinks combined weight of the mixture was recorded and
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the amount consumed was calculated according to Body composition was assessed using anthropometry
the proportion of each component served in the (midupperarmcircumferenceandtricepsskinfoldthick-
original meal. Sip feed containers were weighed and the ness of right arm) [29] and multi-frequency bioelectrical
amount consumed calculated. The weighing scales used impedance(Impedimed;QueenslandAustralia).Maximal
were calibrated three monthly and accurate to ±0.1 g. voluntary grip strength was measured 3 times in each
All data were computerised and the computer records hand using a Jamar dynamometer (Lafayette Instrument
of food type and weight were checked in detail for each Company,USA)andastandardprotocol[30].
patient by a single researcher (SR), who was blinded to Physical function was assessed using the Barthel Score
the status of the wards. Nutrient intake for each patient [31]; a number of patients also had their mobility
™
was calculated from the weight of each food multiplied assessed using a small activity monitor (ActivPAL )
by its nutrient composition, and summed. Food com- attached to their leg [32]. Cognitive function was further
position data was obtained from the hospital caterer assessed using the Mini Mental State Examination
and the UK food composition database. (MMSE) [33]. Folic acid, vitamin B12 and Vitamin D
levels were measured at entry to the study and at
hospital discharge where these time points were at
Additional data collection on dietary study days Each
patient’s height, weight,‘Malnutrition Universal Screening least 2 weeks apart.
Tool’ (‘MUST’) score [26] and Body Mass Index (BMI)
Data collected on discharge At discharge the type of
was abstracted from their clinical records. Height was
domicile and care provided was recorded, along with
derived from information given by the patient or calcu-
changesinmedicationandanyhospitalacquiredinfections
lated using ulnar length[27].Weightwasmeasuredusing
or complications. Anthropometry, bioimpedance, grip
the ward chair scales. On the study days the date of birth
strength, Barthel score and ‘MUST’ score were repeated.
and current primary diagnosis were abstracted from
patients’clinical records. The level of mealtime assistance Patientand/orcarersatisfactionwithhospitalstayandspe-
cificallymealsandmealtimeswereassessedforallpatients
received at lunchtime by each patient was observed and
priorto dischargeusingtheNHS catering satisfactionsur-
recordedasfollows:0=none,1=cuttingandpreparation,
vey published by the Better Hospital Food Panel. The
2=encouragement, 3=feeding, 4=refused. The level of
Warwick-Edinburgh Mental Well-being Scale was also
confusion of each patient at that mealtime was deter-
administered at this point [34]. Staffing number,
mined from the wardnurse responsible for their careand
seniority and multi-disciplinary range was recorded
recorded as follows: 0=none, 1=mild, 2=moderate, 3=
weekly.
severe, 9=unknown. Ward staffing levels were recorded.
On dietary study days ward-level balance data were also
Data collected six and twelve months after discharge
collected:allfooddeliveredtothewardsatmealtimeswas
Participants’ General Practitioners gave permission for a
documented and uneaten food was pooled and frozen for
research nurse to contact the patient prior to either a
analysisofitsnitrogenandenergycontent.
home visit or a telephone call. Any change in the type of
domicile, care provided or medication was recorded, as
2.Clinicaloutcomesdatacollection
well as the number of readmissions and further contacts
Patients were recruited in a prospective consecutive
with healthcare professionals, or any deaths. Anthro-
manner over the two years of the study for collection of
pometry, grip strength, Barthel Score and MMSE were
clinical outcomes data, and written informed consent
repeatedonthehome visits.
was obtained. If a patient was unable to give consent the
next of kin were asked if routinely collected clinical data 3.Qualitativedatacollection
could be recorded to allow the inclusion of patients who
A qualitative researcher conducted semi-structured inter-
lacked mentalcapacity inthestudygroup. views in both years with a purposive sample of 15–20
patients, or relatives/carers in cases where the patient
Data collected on admission Demographic information lacked the capacity to participate, drawn from the inter-
including diagnoses, co-morbidities, geriatric syndromes, vention and control ward and selected to provide a
medicationandusuallivingarrangementswereabstracted breadthofviewsandexperience.
from the medical records, as well as routinely collected Small group and individual semi-structured interviews
clinical dataincludingnutritionalstatus(weight, BMI and were held with a range of senior and junior staff drawn
‘MUST’ score), cognitive function (Abbreviated Mental from each ward in both years to elicit their views and
Test Score (AMTS) [28] and standard blood tests (full experience of providing nutritional care for older people
blood count, renal, liver and thyroid function tests, in hospital. A series of focus groups were held with
blood glucose, C reactive protein). volunteers in the second year to exploretheir experience
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of providing mealtime assistance on the wards. Both the on-going. The interviews and focus groups have taken
semi–structured interview schedule and the focus group place in both year one and in year two, and analysis
topic guide were developed with the hospital catering of this data is underway.
user group, which included service users and staff. They
were refined to allow themes emerging from early
Discussion
interviews to be explored in subsequent interviews.
Poor nutrition of older people in hospital is an issue of
concern in the UK and many other countries and is
Sample size Sample size calculations were based on a
associated with major adverse clinical outcomes. The
change in energy intake resulting from the intervention.
use of volunteer mealtime assistants has been advocated
A sample size of 100 subjects per ward per year is esti-
as a means of improving the nutrition of older in-
mated to be sufficient to detect a difference in intake of
patients but there is currently little evidence that they
218 kcal/day with 80% power and p=0.05, based on a
improve dietary intake or clinical outcomes. This study
mean (SD)intake of1300(550) kcal/day.
will measure dietary intake in older patients before and
after the introduction of trained volunteer mealtime
Statistical analysis Descriptive statistics will be used to
assistants onto an acute medicine for older persons ward
describe the participants during both years of the study,
and evaluate their effectiveness at increasing intake
in conjunction with statistical tests for differences in
among patients on the intervention ward by comparison
characteristics between participants in the two wards in
with contemporaneous data collection on patients in a
the baseline year. Descriptive statistics will also be used
control ward. The association of dietary intake and
to describe the characteristics and mealtime duties of
clinicaloutcomesincludingmalnutritionrisk,bodycom-
the volunteer mealtimeassistants.
position, grip strength, length of stay and mortality will
Differencesinfoodandnutrientintakewillbeevaluated
be assessed. Qualitative data will provide valuable data
between patients on the intervention and control wards,
on the views, experience and satisfaction of patients,
andbeforeandafterthemealtimeassistanceontheinter-
carers, staff and volunteers with nutrition in hospital
vention ward. Analyses, using Stata release 11, will con-
andtheimpactofmealtimeassistance.
sider differences between wards and year one and two,
including planned subgroup analysis of dietary intake
Abbreviations
examining patients who required assistance, those who MRC:MedicalResearchCouncil;NIHR:NationalInstituteforHealthResearch;
had soft diets, and those who were malnourished. In NHS:NationalHealthService;UK:UnitedKingdom;‘MUST':‘Malnutrition
UniversalScreeningTool’;BMI:BodyMassIndex;AMTS:AbbreviatedMental
additiontostandarddescriptivestatistics,aGeneralLinear
TestScore;MMSE:MiniMentalStateExamination;SD:StandardDeviation.
Model will be used to compare wards and time periods,
andtheanalysiswillincludeanalysisofcovariance.
Competinginterests
The patient/carer and staff interviews and the volun- Theauthorsdeclarethattheyhavenocompetinginterests.
teer focus groups were audio recorded with express con-
sent from the participants and the audiofiles were Authors'contributions
HRcontributedtostudydesign,co-ordinatedandsuperviseddatacollection,
transcribed verbatim. The data will be managed using a
analysedqualitativedataanddraftedthemanuscript.APparticipatedin
systematic framework approach facilitated by the soft- dietarydatacollectionandanalysisandassistedwithdraftingthe
ware package NVivo 9 and analysed thematically. Two manuscript.ME,AJandCCcontributedtostudydesignandcoordination
andhelpeddraftthemanuscript.AASconceivedofthestudy,contributedto
researchers will work separately and together to agree
studycoordinationandhelpeddraftthemanuscript.SMRconceivedofthe
on key issues for the analytic framework [35], based on study,collectedandanalyseddietarydataandhelpeddraftthemanuscript.
close reading of the transcripts, and will work through Allauthorsreadandapprovedthefinalmanuscript.
the data to draw out the full range of experiences and
views, looking for commonality and differences within Acknowledgements
TheSouthamptonMealtimeAssistanceStudywassupportedbytheNIHR
andbetweentheparticipants.
BiomedicalResearchCentreforNutritionDietandLifestyle.Wearegrateful
fortheco-operationofthehospitalwardandcateringstaff,SanetdeWet
Progress to date Trained volunteer mealtime assistants (speechandlanguagetherapist),KirstyPorter(dietician),KimSutton
(voluntaryservicesmanager),GemmaRood,NormaDiaperandAnne-Marie
have been working on the intervention ward since
Lewis(researchnurses),andallofthevolunteersandstudyparticipants.
February 2011. They have been well received by patients
andstaff,andare enjoying theirrole.Dietarydata collec- Authordetails
1AcademicGeriatricMedicine,UniversityofSouthampton,Southampton
tion has been completed for both years, totalling 222
GeneralHospital,TremonaRoad,SouthamptonHampshireSO166YD,UK.
patients’ food diaries in year one and 185 food diaries in 2MRCLifecourseEpidemiologyUnit,UniversityofSouthampton,
year two. Clinical outcomes data have been collected SouthamptonGeneralHospital,TremonaRoad,SouthamptonHampshire
SO166YD,UK.3SouthamptonNIHRBiomedicalResearchCentreinNutrition,
during the admissions of 205 patients in year one and
DietandLifestyle,UniversityHospitalSouthamptonNHSFoundationTrust,
137 patients in year two, and the follow-up visits are SouthamptonSO166YD,UK.
Robertsetal.BMCGeriatrics2013,13:5 Page6of6
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Received:29May2012Accepted:30August2012 26. StrattonRJ,HackstonA,LongmoreD,DixonR,PriceS,StroudM,etal:
Published:7January2013 Malnutritioninhospitaloutpatientsandinpatients:prevalence,
concurrentvalidityandeaseofuseofthe'malnutritionuniversal
screeningtool'('MUST')foradults.BrJNutr2004,92:799–808.
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