The Malnutrition Screening Tool in Geriatric Rehabilitation: A Comparison of Validity When Completed by Health Professionals With and Without Malnutrition Screening Training Has Implications for Practice

Harnessing delegation and technology to identify and manage malnutrition in a digital hospital: An implementation study

AIMS

Delegation of nutrition care activities to Dietetic Assistants in hospitals has been identified as one innovative malnutrition model of care, but there has been limited evaluation of their roles. This study aimed to develop, implement and evaluate a new Malnutrition Model of Care embracing automated delegation and digital systems.

METHODS

The Malnutrition Model of Care was created to detect patients at risk of malnutrition (using the Malnutrition Screening Tool) and nutritional decline (via routine intake tracking at all meals and snacks). Digital systems generated automated referrals to dietetics, with protocols to support Dietetic Assistants to action these to direct care escalation to the ward dietitian. Dietetic Assistant training included simulations and clinical task instructions. Implementation evaluation was guided by the Donabedian model of quality and included a review of inpatient dietetics occasions of service, survey of Dietetic Assistant role satisfaction and task confidence, and hospital-wide cross-sectional malnutrition audit. Data was descriptively analysed.

RESULTS

During the first year of implementation, 60% of Dietetics inpatient occasions of service were completed by Dietetic Assistants, with 26% of Dietetic Assistant inpatient tasks initiated from nursing malnutrition risk screening. Most Dietetic Assistants reported adequate training and confidence in completing delegated tasks. Malnutrition prevalence was 14% with no hospital-acquired malnutrition identified. No clinical incidents were reported.

CONCLUSIONS

The Dietetic Assistant workforce and technology were harnessed to implement an innovative delegated Malnutrition Model of Care that appears to be safe and effective at managing malnutrition from preliminary evaluation. Work continues to formally assess service efficiencies, cost and patient experience.

The prevalence of malnutrition and impact on patient outcomes among older adults presenting at an Irish emergency department: a secondary analysis of the OPTI-MEND trial

Background

Malnutrition is common among older adults and is associated with adverse outcomes but remains undiagnosed on healthcare admissions. Older adults use emergency departments (EDs) more than any other age group. This study aimed to determine the prevalence and factors associated with malnutrition on admission and with adverse outcomes post-admission among older adults attending an Irish ED.

Methods

Secondary analysis of data collected from a randomised controlled trial exploring the impact of a dedicated team of health and social care professionals on the care of older adults in the ED. Nutritional status was determined using the Mini Nutritional Assessment- short form. Patient parameters and outcomes included health related quality of life, functional ability, risk of adverse health outcomes, frailty, hospital admissions, falls history and clinical outcomes at index visit, 30-day and 6-month follow up. Aggregate anonymised participant data linked from index visit to 30-days and 6-month follow-up were used for statistical analysis.

Results

Among 353 older adults (mean age 79.6 years (SD = 7.0); 59.2% (n = 209) female) the prevalence of malnutrition was 7.6% (n = 27) and ‘risk of malnutrition’ was 28% (n = 99). At baseline, those who were malnourished had poorer quality of life scores, functional ability, were more frail, more likely to have been hospitalised or had a fall recently, had longer waiting times and were more likely to be discharged home from the ED than those who had normal nutrition status. At 30-days, those who were malnourished were more likely to have reported another hospital admission, a nursing home admission, reduced quality of life and functional decline than older adults who had normal nutrition status at the baseline ED visit. Differences between the MNA SF and 6-month outcomes were similar but not statistically significant.

Conclusion

Over one-third of older adults admitted to an Irish ED are either malnourished or at risk of malnourishment. Malnutrition was associated with a longer stay in the ED, functional decline, poorer quality of life, increased risk of hospital admissions and a greater likelihood of admission to a nursing home at 30 days.

Trial registration

Protocol registered in ClinicalTrials.gov, ID: NCT03739515, first posted November 13, 2018.

Assessing the Concurrent Validity and Interrater Reliability of Patient-Led Screening Using the Malnutrition Screening Tool in the Ambulatory Cancer Care Outpatient Setting

BACKGROUND

The prevalence of malnutrition in cancer patients is reported as high as 65%; however, malnutrition screening is often substandard. The Malnutrition Screening Tool (MST) has been validated for use by health care professionals to detect at-risk patients; however, there is a gap in the literature regarding validation of patient-led MST screening.

OBJECTIVE

The aim of the study was to assess the concurrent validity of patient-led MST against the Subjective Global Assessment (SGA) and the interrater reliability of patient-led MST against dietitian-led MST in patients attending ambulatory cancer care services for chemotherapy or supportive treatments.

DESIGN/PARTICIPANTS

A single-site diagnostic accuracy study of 201 patients between May and June 2017 attending the ambulatory cancer care setting at an Australian metropolitan tertiary hospital in Queensland.

MAIN OUTCOME MEASUREMENTS

The primary outcome measures were concurrent validity and interrater reliability of MST scores as determined by patients (patient-MST), dietitians (dietitian-MST), and SGA as completed by the dietitian.

STATISTICAL ANALYSIS

Concurrent validity of patient-led MST scores against the SGA was determined using specificity, sensitivity, positive predictive values, and negative predictive values. Interrater reliability of patient-MST and dietitian-MST was assessed using κ coefficient.

RESULTS

The ability of the patient-led MST scores (0 to 1 vs 2 to 5) to indicate nutrition status was found to have a sensitivity of 94% (95% CI 81% to 99%), a specificity of 86% (95% CI 79% to 91%), and an area under the receiver operating characteristic curve of 0.93 (95% CI 0.89 to 0.96). The positive predictive value was 59% (95% CI 45% to 71%), and the negative predictive value was 99% (95% CI 95% to 100%). A weighted κ of 0.83 (95% CI 0.82 to 0.87) between patient-MST and dietitian-MST was found.

CONCLUSION

Patient-led MST screening is a reliable and valid measure that can accurately identify ambulatory cancer care patients as at risk or not at risk of malnutrition.

Nutritional management of patients undergoing laparoscopic surgery for gastric cancer based on the concept of rapid rehabilitation

As a common malignant tumor, patients with gastric cancer (GC) are prone to malnutrition during the development and treatment of the disease. Fast track surgery (FTS), as a perioperative medical concept based on evidence-based medicine, plays an important role in nutrition management, including preoperative malnutrition screening and treatment, preoperative nutritional management, postoperative early oral feeding, accelerated promotion of gastrointestinal function recovery, and nutritional support. Based on a series of small sample studies, the safety and importance of FTS in laparoscopic nutrition management of GC are gradually emerging, but clinical implementation is difficult. This article will review the research progress of FTS in the field of laparoscopic nutrition management of GC in the past decade.

Similar health economic outcomes in low-risk and high-risk malnourished inpatients as screened by the Malnutrition Screening Tool after delivery of oral nutritional supplements

OBJECTIVE

The aim of this study was to determine whether modified low- and high-risk Malnutrition Screening Tool (MST) scores (2 versus >2, respectively) were independently predictive of health economic outcomes.

METHODS

We analyzed data from a recent nutrition-based quality improvement program (QIP) that prescribed daily oral nutritional supplements for all hospitalized adults at risk for malnutrition. In the original study, an electronic medical records-based MST was administered at the time of admission, and patients were classified as "low risk" or "high risk" for malnutrition based on MST scores (2 versus ≥2). We compared health economic outcomes for patients at low or high risk for malnutrition based on a modified score (MST = 2 versus >2, respectively), looking for between-group differences in length of stay (LOS) and unplanned 30-d readmissions. Analyses were additionally stratified by age (<65 versus ≥65 y of age).

RESULTS

Of the 1269 patients enrolled in the QIP, 413 (32.5%) had MST of 2 and 856 (67.5%) had MST >2. Mean LOS was 5.19 d (±4.78) for patients with MST 2 and 4.49 d (±4.69) with MST >2 (non-statistically significant between-group difference; P = 0.277). There were no significant differences in unplanned 30-d readmission rates (14% for low-risk and 17.1% for high-risk patients; P = 0.171). These findings remained statistically insignificant when the low- and high-risk MST score groups were further stratified by age.

CONCLUSIONS

Outcomes of hospitalized patients with MST 2 were not significantly different from those with an MST >2. This suggests that patients at both lower and higher risk for malnutrition (based on MST scores of 2 versus ≥3) were similar in terms of LOS and 30-d readmission rates. To avoid overlooking cases of malnutrition risk, the validated cutoff scores for the MST should be consistently implemented. Training that is consistent with the validated MST is recommended rather than attempting to reduce the case burden by "raising the bar" and attempting to classify patients with an MST = 2 as "low risk."