. 2018 Jan 26;18:43. doi: 10.1186/s12913-018-2828-0

Table 3.

Quality indicators of nutritional care reported in the selected papers

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 loss^a
		- RN hours per resident per day
		- LPN hours per resident per day
Halfens, 2013 [30]	LPZ	Not described	Malnutrition prevalence^b
Hjaltadottir, 2012 [27]	MDS	–	Weight loss^a
Hurtado, 2016 [40]	Nursing Home Compare/MDS; ad hoc questionnaire	Schedule control (from ad hoc questionnaire):	Weight loss^a
		- 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 loss^a
Meijers, 2009 [59]	LPZ	Institutional level	Malnutrition prevalence^b
		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 prevalence^b
		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 loss^c
Rantz, 2009 [29]	MDS	Not described (QIPMO—nurse site visits to suggest how to improve quality of care)	Weight loss^a
Schönherr, 2012 [32]	LPZ	Structural indicators:	Malnutrition prevalence^b
		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 loss^a
		- 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 prevalence^b
		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 prevalence^b 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 prevalence^b
van Nie-Visser, 2014 [34]	LPZ	–	Malnutrition prevalence^b
Werner, 2013 [43]	MDS/Nursing Home Compare; OSCAR	-% of residents receiving tube feeds	Weight loss^a
		-% of residents receiving mechanically altered diets
		-% of residents with assisted eating devices

MUST Malnutrition Universal Screening Tool

MDS Minimum Data Set

LPZ Landelijke Prevalentiemeting Zorgproblemen (In Dutch)

VPSRACS Victorian Public Sector Residential Aged Care Services

OSCAR Online Survey, Certification, and Reporting

ARF Area Resource File

RN Registered Nurse

LPN Licensed Practical Nurse

CNA certified nursing assistant

QIPMO Quality Improvement Program of Missouri

PFA Paid Feeding Assistant

^aloss of 5% or more in the last months or loss of 10% or more in the past six months, as defined in MDS

^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)

^closs of ≥3 kg over three months, or any unplanned weight loss for each consecutive month of the quarter