Implementation of P-INPAC (P-INPAC)

Towards Implementation of the Pediatric Integrated Nutrition Pathway for Acute Care Pathway (P-INPAC) - Pilot Study

The framework for Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) was developed by the Canadian Malnutrition Task Force (CMTF); however, it has not been implemented in a research setting. The framework by CMTF for Integrated Nutrition Pathway for Acute Care (INPAC) in adults was also implemented in the "More-2-Eat" project which led to development of best practices in nutritional culture of the hospitals. Therefore, we intend to undertake this feasibility project at 3-sites to train staff and evaluate the implementation of P-INPAC components as part of routine healthcare procedure.

Study Overview

• Status: Active, not recruiting
• Conditions: Malnutrition, Child; Nutrition Poor
• Intervention / Treatment: Other: Pediatric Integrated Nutrition Pathway for Acute Care Pathway (P-INPAC)

Detailed Description

The P-INPAC pilot study will be a 3-phase multi-center research study in hospitalized children, conducted at The Hospital for Sick Children, Toronto, and two other Canadian pediatric centres: Centre hospitalier universitaire Sainte-Justine, Montreal, Quebec and McMaster Children's Hospital, Hamilton, Ontario. P-INPAC is an algorithm which helps to identify, assess, and treat children with malnutrition.

In the first phase of the study, we will perform an audit of health records of all hospitalized patients at one selected study ward, one day of every other week for 8 weeks, at each of the 3 study sites to track their routine nutrition care. We anticipate auditing 80-100 patients/site in this cycle (total 240-300 patients). In addition, ≈12- 20 patients/ site (≈ 60 in total) who consent to detailed malnutrition screening and assessment would also be identified, assessed, and followed up one month after discharge. In addition, a questionnaire assessing the malnutrition knowledge, attitude, and self-perceived practices (KAP) amongst healthcare professionals will be conducted with staff, including trainees, at each site's study ward. Further, the workload of the study ward's Registered Dietitian (RD) will be assessed for 3 days.

In the second phase of the study, the health care team from each site's study ward will be trained by the site implementation research team about the P-INPAC, and how to administer nutritional screening and perform nutritional assessments, which is the Subjective Global Nutrition Assessment (SGNA).

Finally, in the third phase, we will monitor and evaluate the implementation of the first 2 steps of the P-INPAC (screening & assessment) over a period of 4 months assessing the acceptability, adoption, and coverage of improved nutrition care practices on the same pediatric study wards. We anticipate auditing 160-200 patients/site in this cycle (total 480-600 patients). In addition, detailed patient level data collection will take place in a selected group of consented patients, ≈24-40 patients per site from the 3 sites (≈120 in total). We would also follow-up with these patients a month after discharge.

Healthcare providers will be invited to answer the KAP questionnaire post-implementation version. We will compare responses from phase 1 with phase 3 (pre-/ post-follow up). And, the workload of the ward RD will be assessed again over 3 days.

• Study Type: Observational
• Enrollment (Estimated): 600

Contacts and Locations

Study Locations

• Canada
  • Ontario
    • Hamilton, Ontario, Canada, L8N 3Z5
      • McMaster Children's Hospital
    • Toronto, Ontario, Canada, M5G 1X8
      • The Hospital for Sick Children
  • Quebec
    • Montreal, Quebec, Canada, H3T 1C5
      • Ste-Justine UHC

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult
• Accepts Healthy Volunteers: Yes

• Sampling Method: Non-Probability Sample

Study Population

2 Patient Groups (Audit and Detailed)

1 Health care providers group comprising of all the healthcare providers on the participating wards.

Description

Phase 1 and Phase 3 - Audited patient group inclusion Criteria:

1. ≥ 30 days of age and less than18 years of age on day of assessment
2. Anticipated Length of hospital stay ≥24 hours from day of assessment

Phase 1 & Phase 3 Detailed patient group inclusion Criteria:

1. Admitted to either a general medical or surgical ward
2. ≥ 30 days of age and less than 18 years of age on day of assessment
3. Anticipated Length of stay ≥ 24 hours from day of assessment
4. Speak English (or French at Quebec site) or have a family proxy available at the meal to provide information if first language of patient is not English (or French at Quebec site)
5. Patient/ caregiver provides written consent to participate

Exclusion Criteria:

a. Patients with eating disorder, somatization disorders, ARFID, FORM 1 etc. where the study interaction might interfere with the messaging or therapeutic plan as set out by the responsible team.

Phase 1 and 3 for Health Care Providers inclusion criteria:

1. Implied consent to participate by completing the KAP questionnaire
2. Providing clinical service for the select ward

Study Plan

How is the study designed?

Number of groups / cohorts

3

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Audit Group; We will perform an audit of health records of all hospitalized patients at one selected study ward, one day of every other week, at each of the 3 study sites to track their routine nutrition care in phase 1 and changes in nutrition care post-implementation in phase 3.	Other: Pediatric Integrated Nutrition Pathway for Acute Care Pathway (P-INPAC); The pediatric working group of Canadian Malnutrition Task Force has developed an evidence-informed algorithm named the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). The P-INPAC outlines a process to improve nutrition care by: implementing nutrition screening at point-of-admission; introducing standard care measures to prevent the development of malnutrition in children admitted with normal nutrition status, including standardizing the process of monitoring food intake early and systematically to identify when standard care measures are not sufficient; ensuring the moderately and severely malnourished patients receive timely specialized care in the form of a comprehensive assessment and treatment; and; ensuring moderately and severely malnourished patients receive adequate post discharge follow-up and nutrition care. In this pilot study, we will be implementing the first two steps of P-INPAC only (screening and assessment).
Detailed Patient Group; Patients will be recruited in this group from one selected study ward, one day of every other week, at each of the 3 study sites to track their routine nutrition care in phase 1 and changes in nutrition care post-implementation in phase 3. They will also be followed up over a phone call one month after discharge.	Other: Pediatric Integrated Nutrition Pathway for Acute Care Pathway (P-INPAC); The pediatric working group of Canadian Malnutrition Task Force has developed an evidence-informed algorithm named the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). The P-INPAC outlines a process to improve nutrition care by: implementing nutrition screening at point-of-admission; introducing standard care measures to prevent the development of malnutrition in children admitted with normal nutrition status, including standardizing the process of monitoring food intake early and systematically to identify when standard care measures are not sufficient; ensuring the moderately and severely malnourished patients receive timely specialized care in the form of a comprehensive assessment and treatment; and; ensuring moderately and severely malnourished patients receive adequate post discharge follow-up and nutrition care. In this pilot study, we will be implementing the first two steps of P-INPAC only (screening and assessment).
Healthcare Provider Group; A questionnaire assessing the knowledge, attitude, and self-perceived practices (KAP) amongst healthcare professionals will be conducted with staff, including trainees, at each site's study ward. Further, the workload of the study ward's Registered Dietitian will be assessed for 3 days.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Baseline nutrition risk screening using STRONGkids or PNST	Determine routine standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 1 of study using a validated tool, such as, STRONGkids or PNST.	2-month period (phase 1)
Baseline nutrition risk screening using weight	Determine routine standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 1 of study using routine anthropometrics - weight	2-month period (phase 1)
Baseline nutrition risk screening using height or length	Determine routine standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 1 of study using routine anthropometrics - height or length in children under 2 years of age	2-month period (phase 1)
Baseline nutrition risk screening using head circumference	Determine routine standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 1 of study using routine anthropometrics - head circumference in children under 2 years of age	2-month period (phase 1)
Determine baseline knowledge among healthcare providers using the KAP questionnaire	Determine baseline knowledge among healthcare providers on recognizing malnutrition and its management in hospitalized children, including perceived barriers and practices, using the KAP questionnaire	2-month period (phase 1)
Determine changes in knowledge among healthcare providers using the KAP questionnaire	Determine changes in knowledge among healthcare providers on recognizing malnutrition and its management in hospitalized children in Phase 3, including perceived barriers and practices, using the KAP questionnaire after training was completed in phase 2	4-month period (phase 3)
Determine success with training and feasibility of nutrition risk screening in hospitalized children using STRONGkids and PNST	Determine success with training and feasibility of implementing the P-INPAC framework by assessing changes in standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 3 of study using a validated tool, such as, STRONGkids and PNST	4-month period (phase 3)
Determine success with training and feasibility of nutrition risk screening in hospitalized children using weight	Determine success with training and feasibility of implementing the P-INPAC framework by assessing changes in standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 3 of study using routine anthropometrics - weight	4-month period (phase 3)
Determine success with training and feasibility of nutrition risk screening in hospitalized children using height/ length	Determine success with training and feasibility of implementing the P-INPAC framework by assessing changes in standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 3 of study using routine anthropometrics - height or length in children under 2 years of age	4-month period (phase 3)
Determine success with training and feasibility of nutrition risk screening in hospitalized children using head circumference	Determine success with training and feasibility of implementing the P-INPAC framework by assessing changes in standard nutritional care practices related to nutrition risk screening in hospitalized children during phase 3 of study using routine anthropometrics - head circumference in children under 2 years of age	4-month period (phase 3)

Collaborators and Investigators

• Sponsor: The Hospital for Sick Children
• Collaborators: McMaster Children's Hospital; St. Justine's Hospital

Publications and helpful links

General Publications

• Secker DJ, Jeejeebhoy KN. How to perform Subjective Global Nutritional assessment in children. J Acad Nutr Diet. 2012 Mar;112(3):424-431.e6. doi: 10.1016/j.jada.2011.08.039. Epub 2012 Mar 1.
• Hulst JM, Zwart H, Hop WC, Joosten KF. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clin Nutr. 2010 Feb;29(1):106-11. doi: 10.1016/j.clnu.2009.07.006. Epub 2009 Aug 13.
• Huysentruyt K, Brunet-Wood K, Bandsma R, Gramlich L, Fleming-Carroll B, Hotson B, Byers R, Lovelace H, Persad R, Kalnins D, Martinez A, Marchand V, Vachon M, Hulst JM, On Behalf Of The Canadian Malnutrition Task Force-Pediatric Working Group. Canadian Nationwide Survey on Pediatric Malnutrition Management in Tertiary Hospitals. Nutrients. 2021 Jul 30;13(8):2635. doi: 10.3390/nu13082635.
• Keller H, Laur C, Atkins M, Bernier P, Butterworth D, Davidson B, Hotson B, Nasser R, Laporte M, Marcell C, Ray S, Bell J. Update on the Integrated Nutrition Pathway for Acute Care (INPAC): post implementation tailoring and toolkit to support practice improvements. Nutr J. 2018 Jan 5;17(1):2. doi: 10.1186/s12937-017-0310-1.

Helpful Links

• P-INPAC Pathway

Study record dates

Study Major Dates

• Study Start (Actual): September 4, 2023
• Primary Completion (Actual): September 30, 2025
• Study Completion (Estimated): December 30, 2026

Study Registration Dates

• First Submitted: July 24, 2024
• First Submitted That Met QC Criteria: October 15, 2024
• First Posted (Actual): October 17, 2024

Study Record Updates

• Last Update Posted (Actual): June 24, 2026
• Last Update Submitted That Met QC Criteria: June 19, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nutrition Disorders; Nutritional and Metabolic Diseases; Malnutrition; Child Nutrition Disorders
• Other Study ID Numbers: 1000079853

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: The data entered the REDCap data collection form will be completely confidential and de-identified and can only be rendered identifiable by linking the study IDs in the data collection form to the study IDs encrypted master linking log. The master linking log will be maintained by the site and not shared by the other site. Confidentiality will be respected and no information that discloses the identity of the participants will be released or published. The data will be kept stored for a minimum of 7 years following collection of the study in accordance with SickKids data retention policy, or longer as per study site institutional research ethics board requirements.
• IPD Sharing Time Frame: The data will be kept stored for a minimum of 7 years following collection of the study in accordance with SickKids data retention policy, or longer as per study site institutional research ethics board requirements.
• IPD Sharing Access Criteria: Research team members
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No