title: The Integrated Nutrition Pathway for Acute Care (INPAC): Building consensus with a modified Delphi.
abstract: BACKGROUND
  Malnutrition is commonly underdiagnosed and undertreated in acute care patients. Implementation of current pathways of care is limited, potentially as a result of the perception that they are not feasible with current resources. There is a need for a pathway based on expert consensus, best practice and evidence that addresses this crisis in acute care, while still being feasible for implementation.
  
  
  METHODS
  A modified Delphi was used to develop consensus on a new pathway. Extant literature and other resources were reviewed to develop an evidence-informed background document and draft pathway, which were considered at a stakeholder meeting of 24 experts. Two rounds of an on-line Delphi survey were completed (n = 28 and 26 participants respectively). Diverse clinicians from four hospitals participated in focus groups to face validate the draft pathway and a final stakeholder meeting confirmed format changes to make the pathway conceptually clear and easy to follow for end-users. Experts involved in this process were researchers and clinicians from dietetics, medicine and nursing, including management and frontline personnel.
  
  
  RESULTS
  80% of stakeholders who were invited, participated in the first Delphi survey. The two rounds of the Delphi resulted in consensus for all but two minor components of the Integrated Nutrition Pathway for Acute Care (INPAC). The format of the INPAC was revised based on the input of focus group participants, stakeholders and investigators.
  
  
  CONCLUSIONS
  This evidence-informed, consensus based pathway for nutrition care has greater depth and breadth than prior guidelines that were commonly based on systematic reviews. As extant evidence for many best practices is absent, the modified Delphi process has allowed for consensus to be developed based on better practices. Attention to feasibility during development has created a pathway that has greater implementation potential. External validation specifically with practitioner groups promoted a conceptually easy to use format. Test site implementation and evaluation is needed to identify resource requirements and demonstrate process and patient reported outcomes resulting from embedding INPAC into clinical practice.
authors.affiliation: Schlegel- University of Waterloo Research Institute for Aging, University of Waterloo, Waterloo, Canada. hkeller@uwaterloo.ca.
authors.forename: Heather H
authors.initials: HH
authors.lastname: Keller
authors.affiliation: Department of Kinesiology, University of Waterloo, Waterloo, Canada. jrmccull@uwaterloo.ca.
authors.forename: James
authors.initials: J
authors.lastname: McCullough
authors.affiliation: Canadian Malnutrition Task Force, Canadian Nutrition Society, Ottawa, Canada. bdavidson@golden.net.
authors.forename: Bridget
authors.initials: B
authors.lastname: Davidson
authors.affiliation: Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, Canada. evesnave@uoguelph.ca.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Vesnaver
authors.affiliation: Réseau de Santé Vitalité Health Network, Campbellton, NB, Canada. Manon.Laporte@vitalitenb.ca.
authors.forename: Manon
authors.initials: M
authors.lastname: Laporte
authors.affiliation: Department of Medicine, University of Alberta, Alberta Health Services, Edmonton, Canada. lg3@ualberta.ca.
authors.forename: Leah
authors.initials: L
authors.lastname: Gramlich
authors.affiliation: Department of Medicine, University Hospital Network,University of Toronto, Toronto, Canada. Dr.Johane.Allard@uhn.ca.
authors.forename: Johane
authors.initials: J
authors.lastname: Allard
authors.affiliation: Jewish General Hospital, Montréal, Canada. pbernier@jgh.mcgill.ca.
authors.forename: Paule
authors.initials: P
authors.lastname: Bernier
authors.affiliation: Department of Medicine St-Boniface Hospital, University of Manitoba, Winnipeg, Canada. dduerkse@sbgh.mb.ca.
authors.forename: Donald
authors.initials: D
authors.lastname: Duerksen
authors.affiliation: Department of Medicine St-Michael's Hospital, University of Toronto, Toronto, Canada. khushjeejeebhoy@hotmail.com.
authors.forename: Khursheed
authors.initials: K
authors.lastname: Jeejeebhoy
mesh_terms: D000328:Adult; D032921:Consensus; D003422:Critical Care / Q000379:methods*; D003697:Delphi Technique; D005260:Female; D017144:Focus Groups; D006801:Humans; D008297:Male; D044342:Malnutrition / Q000178:diet therapy*; D008875:Middle Aged; D009749:Nutrition Surveys; D044623:Nutrition Therapy / Q000379:methods*; D009752:Nutritional Status