Nutrition care provided to patients discharged from hospital post alcohol withdrawal: a mixed methods study
Cameron McLean
1 2 * , Linda Tapsell 2 , Hannah Mozejko 2 , Sara Grafenauer 3 , Anne-Therese McMahon 2
1
2
3
Abstract
Patients discharged from hospital following alcohol withdrawal may require follow up of chronic nutrition concerns such as malnutrition and micronutrient deficiency. There is little known about the nutrition care provided in the primary healthcare setting supporting patients discharged from hospital.
The aim of this study was to explore the nutrition care provided across New South Wales for patients discharged post alcohol withdrawal.
A survey was distributed to all Primary Health Networks (PHNs) in New South Wales (NSW) and included participant demographics, information regarding participant confidence providing nutrition care and the types of care provided in this setting. Survey participants were also invited to undertake a semi-structured interview to explore hospital discharge processes using case studies. Survey responses were descriptively analysed and all data provided were utilised, even if incomplete. Qualitative data were thematically analysed and a description provided.
Of the 37 survey responses, 15 were fully completed with 41.1% of respondents rating themselves as confident to very confident to provide nutrition-related care. Four respondents participated in the follow-on interviews. Three themes emerged: the importance of person-centred and collaborative approaches; barriers to accessing nutrition services; and the impact of COVID-19 on discharge care.
The level of reported confidence was variable among healthcare professionals providing nutrition care to patients discharged from hospital post alcohol withdrawal. This may represent a gap in service provision, implicating the need for advocacy on nutrition care following alcohol withdrawal.
Keywords: alcohol, alcohol withdrawal, dietitian, hospital, malnutrition, nutrition, primary care, primary health network.
| WHAT GAP THIS FILLS |
| What is known about the topic: Individuals who hazardously consume alcohol may also present with nutritional problems such as weight loss, underweight, malnutrition, micronutrient deficiency and/or low food security. Previous research has shown limited input from the dietitian during admission to hospital for alcohol withdrawal. |
| What this study adds: Healthcare professionals working within Primary Health Networks have variable confidence providing nutrition-related care to patients discharged from hospital post alcohol withdrawal, indicating a gap in nutrition-related service provision. These insights support the need for best practice guidelines for nutritional management in this population to enhance the role of dietitians within the multidisciplinary team. |
Introduction
Alcohol remains a leading risk factor for death and disability significantly contributing to global disease burden.1 Hazardous alcohol consumption is associated with both acute and chronic consequences contributing to cardiovascular disease, cancers, road traffic injuries and mental health disorders.1 Alcohol withdrawal syndrome may involve admission to hospital for detoxification.2,3 Following discharge, careful coordination with primary care is required.
Primary care involves a range of health services.4 Primary Health Networks (PHNs) collaborate with local health providers, including hospitals and drug or alcohol services.5 General practitioners (GPs) may follow up on test results and may refer to other services, such as dietitians, as nutrition plays an important role in the management of chronic health conditions.6 Patients who hazardously consume alcohol may be underweight or malnourished, have micronutrient deficiency or low food security (difficulty accessing or preparing safe food).7,8 Dietitians are a group of healthcare professionals with qualifications and skills to implement medical nutrition therapy (MNT) to help address these nutritional vulnerabilities.9 While hospital admission may address acute nutritional concerns, chronic nutritional problems require support through primary care providers post discharge. However, little is known about the confidence in nutrition care of providers or types of nutrition care delivered in the community.
Methods
Participants were purposively recruited through social media advertisements and organisational newsletters. Eligible participants were any healthcare professionals in a PHN within NSW; those working in inpatient hospital settings were excluded.
Study design
An online survey was distributed in June 2022 via 10 PHNs in NSW, with additional contact made with relevant healthcare organisations in August 2022. Survey participants were invited to semi-structured interviews to explore the hospital discharge process with case studies. All responses, including incomplete surveys, were analysed.
Measures
The survey included multiple choice and free text responses, managed using Qualtrics (Provo, UT, United States). This study was approved by the South Eastern Sydney Local Health District Human Research Ethics Committee (2022/ETH00150). Participants were required to agree to participate via the online survey before proceeding to the questionnaire. For participants who agreed to be interviewed, written informed consent was required.
Demographics
Demographic data collected included age, gender, PHN, occupation, years of experience and highest qualification.
Nutrition-related questions
A Likert scale was used to assess confidence in providing nutrition care, including information about the type of nutrition care provided.10 Further information was collected on what would support healthcare professionals.
Semi-structured interviews
Semi-structured interviews incorporating a case study reflecting the discharge process were conducted by co-investigator HM. Interview guides were developed by CM, LT, SG and ATM. Interview guides were piloted with stakeholders for face validity. Semi-structured interviews provided an open framework for communication.11 Rigour and authenticity were achieved through reflexivity, peer debriefing, purposive sampling and providing a description of methods used.12 Interviews were audio-taped for transcription and analysis.
Following the completion of interviews, a de-briefing occurred with CM and memos were made. Each recording was transcribed using online transcription software (Otter™ 2022) and verified for accuracy by HM. A follow up phone call was scheduled within 1 week to allow participants to review and confirm their transcript and amend if required.13
Data analysis
Survey data were exported from Qualtrics to Microsoft Excel™. Quantitative data were descriptively analysed (frequencies and percentages). Free text responses were reviewed and collated. A descriptive summary is provided.
Cleaned transcripts were analysed using thematic analysis.14 This involved familiarisation with the data, identification of preliminary codes and sorting codes into potential themes. Potential themes were reviewed and defined. Qualitative data were managed using QRS Nvivo 10.0 (QRS International Pty. Ltd, Melbourne, Vic, Australia). A qualitative description is provided.
Results
Survey results
Thirty-seven (n = 37) responses were obtained, many were incomplete, with 15 (n = 15) complete questionnaires (40.5%). The response rate could not be determined due to insufficient data on the total number of eligible participants or those invited to participate in the study. Most participants were female (n = 17, 85.0%), aged 55 to 64 years (n = 7, 35.0%) and were allied health professionals (n = 7, 33.3%) with a post graduate degree (n = 10, 47.6%), primarily from Central and Eastern Sydney PHN (n = 7, 33.3%), with over 15 years’ experience (n = 10, 50.0%). No response was recorded for the Nepean Blue Mountains or Western NSW PHNs. Notably, there were only two survey responses recorded from dietitians (Table 1).
| Characteristic | n (%) | |
|---|---|---|
| Primary health network | n = 21 | |
| Central and Eastern Sydney | 7 (33.3) | |
| Hunter New England and Central Coast | 1 (4.7) | |
| Murrumbidgee | 1 (4.7) | |
| Nepean Blue Mountains | 0 | |
| North Coast | 2 (9.5) | |
| Northern Sydney | 2 (9.5) | |
| South Eastern New South Wales | 6 (28.6) | |
| South Western Sydney | 1 (4.7) | |
| Western New South Wales | 0 | |
| Western Sydney | 1 (4.7) | |
| Reported health profession | n = 21 | |
| Nursing | 6 (28.6) | |
| Medical | 6 (28.6) | |
| Allied Health | 7 (33.3) | |
| Other | 2 (9.5) | |
| Highest level of qualification | n = 20 | |
| Year 10 | 1 (4.7) | |
| Certificate III/IV | 1 (4.7) | |
| Graduate Diploma/Graduate Certificate | 2 (9.5) | |
| Bachelors Degree | 7 (33.3) | |
| Postgraduate Degree | 10 (47.6) | |
| Gender | n = 20 | |
| Prefer not to say | 1 (5.0) | |
| Male | 2 (10.0) | |
| Female | 17 (85.0) | |
| Age categories | n = 20 | |
| 25–34 years | 5 (25.0) | |
| 35–44 years | 2 (10.0) | |
| 45–54 years | 4 (20.0) | |
| 55–64 years | 7 (35.0) | |
| 65 years and older | 2 (10.0) | |
| Years of experience | n = 20 | |
| Less than 5 years | 3 (15.0) | |
| 5–10 years | 4 (20.0) | |
| 10–15 years | 3 (15.0) | |
| More than 15 years | 10 (50.0) |
A majority of participants rated themselves as somewhat confident (n = 5, 26.3%), confident (n = 7, 36.8%) or very confident (n = 2, 10.5%) supporting patients post hospital discharge. Helpful approaches included ‘support with access to company and opportunities for social connection’ and ‘providing realistic care options taking the patients social circumstances into account’. Unhelpful approaches included ‘… telling people what to do … lack of empathy … lack of respect’, ‘unrealistic treatment regime(s)’, ‘expectation of abstinence’, ‘judgemental’ and ‘no bulk billing dietitians in area … no bulk billing psychologists in area’. A majority of participants reported themselves as somewhat confident (n = 3, 17.6%), confident (n = 5, 29.4%) or very confident (n = 2, 11.7%) providing nutrition advice (Table 2).
| Response to question | n (%) | |
|---|---|---|
| Confidence providing support | n = 19 | |
| Not very confident | 2 (10.5) | |
| Not confident | 3 (15.8) | |
| Somewhat confident | 5 (26.3) | |
| Confident | 7 (36.8) | |
| Very confident | 2 (10.5) | |
| Confidence providing nutrition advice or services to | n = 17 | |
| Not very confident | 3 (17.6) | |
| Not confident | 4 (23.5) | |
| Somewhat confident | 3 (17.6) | |
| Confident | 5 (29.4) | |
| Very confident | 2 (11.7) | |
| Types of nutrition advice provided | n = 14 | |
| Nutrition education | 7 (50.0) | |
| Food vouchers | 5 (35.7) | |
| Nutrition assessment | 5 (35.7) | |
| Supplementation | 7 (50.0) | |
| Other | 4 (28.6) |
Half of respondents reported providing nutrition education (n = 7, 50.0%) or advising supplementation (n = 7, 50.0%). Those who completed nutrition assessment (n = 5, 35.7%) described this as ‘asking what they eat routinely’, ‘preventative health … diet history, body mass index, blood pressure … amongst other things’ and an assessment of ‘anthro[pometry], biochemistry, clinical symptoms, dietary intake’. Nutrition education topics included ‘malnutrition’, ‘lifestyle modification’, and ‘liver disease’. Supplementation was reported as, ‘vitamin’, ‘mineral’, ‘electrolyte’ and ‘sip supplement’, with specific mention of ‘thiamine’, considering ‘what they could access and afford’ (Table 2).
Participants (n = 15) reported the need for resources (n = 10, 66.6%), training (n = 9, 60.0%) and support networks (n = 9, 60.0%) when engaging with this patient cohort. This included patient resources (n = 10, 66.6%), clinical resources (n = 9, 60.0%), dedicated (n = 8, 53.3%) or referral services (n = 6, 40.0%), written guidelines (n = 8, 53.3%) and mentoring (n = 5, 33.3%). Additional nutrition-related supports were identified as ‘correspondence from Drug and Alcohol’.
Semi-structured interviews
Four (n = 4) interviews were conducted lasting from 20 to 40 min, including three (n = 3) nursing and one medical professional (n = 1) from different healthcare settings and practices. Experience ranged from 5 to 15 years. Three key themes emerged: importance of person-centred and collaborative approaches; barriers to accessing nutrition services; and impact of COVID-19 on discharge care.
Person-centred approaches by healthcare professionals were identified as fundamental to effective practice. This included having an interest in the patient, observing non-verbal cues and individualising treatment. When arranging follow up, participants noted attention needed to be paid to the patients’ real-life needs. This may involve clarifying access to transport, finances or support from others. Participants reported it moved beyond providing an appointment and included handover from one health service to another. In some instances, appointments may be opportunistic and focus on rapport building (Box 1).
| Box 1.Theme 1: importance of person-centred and collaborative approaches, exemplar quotations. |
| Importance of person-centred and collaborative approaches |
| …if patients clearly don’t want to follow up, then they’ve got the right to do that. But I always try and make sure I’ve explained the process. So what I really want to identify if there’s any barriers, like do they understand what the follow up is, they think they have to come somewhere for three hours, or they might be refusing to follow up because it is on a day that doesn’t suit them. (Participant 01) |
| …if I know a patient’s (going to) liver clinic or something and I want to do something about their diabetes, I will try and (meet) them at their other appointment to save them having separate appointments. So minimising the burden of appointments. (Participant 01) |
| I start with the basics of what do you eat? What prompts you to actually get food? Because it might be that they’ve got spare money. And if they don’t, they don’t eat. (Participant 02) |
Participants noted the lack of access to nutrition care for patients in the hospital and outpatient setting. Government referral pathways, such as Medicare, were often prohibitive as these still involved a financial cost patients may be unable to afford. Patient barriers included poor dentition, food insecurity related to financial barriers, or looking after food such as inability to store or prepare safe food, which were compounded by limited nutrition knowledge. In some instances, the focus of nutrition was getting the basics right (Box 2).
| Box 2.Theme 2: barriers to accessing nutrition services, exemplar quotations. |
| Barriers to accessing nutrition services |
| In all my years in Drug and Alcohol, I’ve never actually heard anyone address the nutritional management of these patients. (Participant 03) |
| I’ve not seen any nutrition support for any person with alcohol (related problems). I’m not seeing it from hospital. I’ve not been offered it after they’ve left hospital. (Participant 04) |
| There’s too many barriers to good nutrition for certain groups like poor dentition, financial reasons, not having access to a kitchen, not having had the education of what it even looks like to have a healthy diet. (Participant 01) |
| Our main problem is (that) it’s almost nigh on impossible to get people seen by a dietitian that bulk bills… These people are homeless living in a park, they haven’t got a chance of seeing them. (Participant 04) |
| I would be setting her up with, you know the free meals… like all those places you can get some food. I mean, I don’t know what else at that point, you can really do. (Participant 03) |
The COVID-19 pandemic was specifically noted to impact on health care and resources. Telehealth was an opportunity to engage when social distancing and offered flexibility with appointments. However, some observational cues may be missed that would be seen face-to-face (Box 3).
| Box 3.Theme 3: impact of COVID-19 on discharge care, exemplar quotations. |
| Impact of COVID-19 on discharge care |
| During COVID-19 telehealth like the video was better and preferable to telephone because you’re getting kind of a better engagement from the patient. But I mean, a lot of people don’t have access to a computer or an iPhone. (Participant 01) |
| There’s so many visual cues as a healthcare worker that you pick up sitting with someone, like if they smell, their skin looks bad, if they are having a bit of trouble breathing, even their weight. And of course you cannot weigh them, you cannot do a blood (test), just like the vital observations cannot be done. (Participant 01) |
Discussion
This study offered insights into challenges faced by healthcare professionals providing nutrition-related care to patients discharged from hospital after alcohol withdrawal. Confidence in providing nutrition care varied, with less than half reporting high confidence. Perhaps this is related to a limited understanding of the complexities of nutrition issues faced by this patient cohort. Surprisingly, the most confident respondents were not nutrition professionals, likely due to the absence of specific guidelines on nutrition. Interviews identified barriers to accessing dietitians and addressing nutritional concerns, raising questions about the quality of nutritional care. This aligns with previous research identifying limited input from dietitians during inpatient alcohol withdrawal.7,15
Patients undergoing alcohol withdrawal present with several nutritional risks including weight loss, malnutrition, micronutrient and/or electrolyte deficiency and food insecurity.7,8 While a hospital admission may provide an opportunity to identify and manage acute nutritional concerns, ongoing nutritional management and education on discharge is essential to support continued monitoring and evaluation of MNT and limit readmission due to issues relating to malnutrition. The integration of dietitians into multidisciplinary teams to support patients admitted to hospital and when discharged from hospital following alcohol withdrawal has been described.16 Establishing multidisciplinary teams that include dietitians could support and improve patient health outcomes and requires further evaluation.
The limited input from nutrition professionals in this survey raises a serious gap in nutrition-related service provision within the community and is a finding in itself. In 2022–23, only 0.9% of Medicare-subsidised allied health services were for dietetics.17 Dietetic services may be accessed through other services or privately, however, many patients are unlikely able to afford the out-of-pocket expenses. Research in Australia has identified a lack of awareness of the role of the dietitian in mental health services, and this may include those who hazardously consume alcohol.18 Research and advocacy are required to integrate dietitians into drug and alcohol teams, to enhance nutrition care but also to up-skill a variety of other healthcare professionals working in the community.
Limitations to the present study include a low participation rate, this may be due to no incentive being offered to participate and relying on PHNs for survey distribution. Therefore, the survey may not represent all healthcare professionals who provide nutrition care in PHNs. However, the data provide exploratory findings to generate future research directions and draw attention to the absence of nutrition care post discharge for this vulnerable group.
Conclusion
In conclusion, healthcare professionals working in PHNs had variable confidence providing nutrition-related care to patients discharged from hospital post alcohol withdrawal, indicating a gap in nutrition-related service provision. Future research should focus on establishing best practice nutrition guidelines for nutritional management in this population to enhance the role of dietitians in multidisciplinary teams.
Data availability
The data that support this study cannot be publicly shared due to ethical or privacy reasons and may be shared upon reasonable request to the corresponding author if appropriate.
Acknowledgements
The authors acknowledge the healthcare professionals who provided feedback on the semi-structured interview guide.
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