Nutritional status classification in the Department of Veterans Affairs

Identifying Critically Ill Veterans Who Require Nutrition Intervention: A Quality Improvement Study Comparing Nutrition Risk Tools

BACKGROUND

Identification of intensive care unit (ICU) patients who require nutrition intervention is crucial to initiating nutrition therapy. This prospective quality improvement study evaluated the Nutritional Risk Screening (NRS) 2002, Malnutrition Universal Screening Tool (MUST), and Nutrition Risk in Critically Ill (NUTRIC) score in comparison with the Veterans Administration Nutrition Status Classification (VANSC) tool to determine which best identified the need for nutrition intervention.

METHODS

A convenience sample of 150 ICU patients was evaluated using the VANSC, NRS 2002, MUST, and the NUTRIC score. The resultant score, need for nutrition intervention, and presence of malnutrition were recorded for patients. Interventions were defined as need for enteral or parenteral nutrition, nutritional supplements, or diet change. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Matthews Correlation Coefficient (MCC), F1 score, and accuracy to predict need for nutrition intervention were calculated for each screening tool.

RESULTS

Of the 150 patients, 49 (33%) required 1 or more nutrition interventions. The NRS 2002 (0.878) and VANSC (0.816) had the highest sensitivity. The NUTRIC (0.921) and VANSC (0.911) had the highest specificity. The VANSC (0.816) and MUST (0.687) had the highest PPV. The VANSC (0.911) and NRS 2002 (0.872) had the highest NPV. The VANSC (0.727) and MUST (0.528) had the highest MCC. The VANSC (0.816) and MUST (0.680) had the highest F1 score.

CONCLUSIONS

Trialing several tools to identify their efficacy and reliability individual setting may help determine the most appropriate tool to utilize for your patient population and specific goals.

Parenteral Nutrition Electrolyte Abnormalities and Associated Factors Before and After Nutrition Support Team Initiation

BACKGROUND

Studied since the 1940s, refeeding syndrome still has no universal definition, thus making comparison of studies difficult. Negative outcomes (eg, metabolic abnormalities) may occur with the use of specialized nutrition, such as parenteral nutrition (PN). Less than half of medical institutions have a nutrition support team (NST) managing PN. Interdisciplinary team management of PN may reduce negative outcomes of PN. The objective of this study was to show the value of the NST by measuring differences in PN variables, especially electrolyte abnormalities (EAs), before and after NST initiation at a large medical center and to identify factors associated with EAs among adult subjects receiving PN.

MATERIALS AND METHODS

During this retrospective study, computerized medical charts (N = 735) from 2007-2010 were reviewed for electrolyte changes (particularly potassium, magnesium, and phosphorus) the first 3 days following PN initiation in hospitalized adults. Changes in EAs with other variables were compared before and after NST implementation. Equivalent samples sizes were collected to better evaluate the impact of the team.

RESULTS

Following the implementation of the NST, fewer EAs were seen in PN patients (53%; χ2  = 10.906, P = .004); significantly less potassium, phosphorus, and magnesium intravenous piggyback supplementation (88.8% vs 94%; χ2  = 5.05, P = .026) was used; and mortality within 30 days of PN cessation was significantly less (12.7% vs 10.6%, P = .012).

CONCLUSION

Our study complements existing research, finding that an NST was associated with a decreased occurrence of EAs and mortality in the hospitalized adult receiving PN.

Association Between Malnutrition and Clinical Outcomes in the Intensive Care Unit: A Systematic Review [Formula: see text]

Malnutrition is associated with poor clinical outcomes among hospitalized patients. However, studies linking malnutrition with poor clinical outcomes in the intensive care unit (ICU) often have conflicting findings due in part to the inappropriate diagnosis of malnutrition. We primarily aimed to determine whether malnutrition diagnosed by validated nutrition assessment tools such as the Subjective Global Assessment (SGA) or Mini Nutritional Assessment (MNA) is independently associated with poorer clinical outcomes in the ICU and if the use of nutrition screening tools demonstrate a similar association. PubMed, CINAHL, Scopus, and Cochrane Library were systematically searched for eligible studies. Search terms included were synonyms of malnutrition, nutritional status, screening, assessment, and intensive care unit. Eligible studies were case-control or cohort studies that recruited adults in the ICU; conducted the SGA, MNA, or used nutrition screening tools before or within 48 hours of ICU admission; and reported the prevalence of malnutrition and relevant clinical outcomes including mortality, length of stay (LOS), and incidence of infection (IOI). Twenty of 1168 studies were eligible. The prevalence of malnutrition ranged from 38% to 78%. Malnutrition diagnosed by nutrition assessments was independently associated with increased ICU LOS, ICU readmission, IOI, and the risk of hospital mortality. The SGA clearly had better predictive validity than the MNA. The association between malnutrition risk determined by nutrition screening was less consistent. Malnutrition is independently associated with poorer clinical outcomes in the ICU. Compared with nutrition assessment tools, the predictive validity of nutrition screening tools were less consistent.

The department of veterans affairs nutritional status classification scheme allows for rapid assessment of nutritional status prior to autologous peripheral blood stem cell transplantation and identifies patients at high risk of transplant-related complications

The nutritional assessment of patients prior to autologous peripheral blood stem cell transplantation (APBSCT) is labor intensive. A simple method of nutritional assessment prior to APSCT would be extremely helpful, especially if this method could identify patients at high risk of transplant-related complications. The Department of Veterans Affairs (VA) developed a Nutritional Status Classification Scheme (NSCS) to identify nutritionally compromised inpatients rapidly and reliably. The objective of this study was to determine if the use of the VA-NSCS could be utilized as a tool for the evaluation of patients prior to APBSCT and to determine if this tool could be used to identify patients at high risk of transplant-related complications. The nutritional status of 128 patients who underwent APBSCT was assessed by a registered dietician, utilizing the VA-NSCS, upon admission to the hospital and prior to conditioning regimen. Patients with moderately compromised nutritional status pretransplantation experienced a higher incidence of infections, longer duration of diarrhea, and longer length of hospital stay when compared to patients with normal or mildly compromised nutritional status. Our study demonstrates that the VA-NSCS, a simple and inexpensive tool to assess nutritional status, was useful in determining the pretransplant nutritional status of patients with lymphogenous malignancies who underwent APBSCT. In addition, this method was able to identify patients at a higher risk of posttransplant complications. Future studies should be undertaken to determine the optimal method for the nutritional assessment of autologous stem cell transplant candidates.

Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol

OBJECTIVE

To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients.

DESIGN

Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU.

SETTING

The medical-surgical ICUs of two teaching hospitals.

PATIENTS

Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group.

INTERVENTION

Implementation of an evidence-based ICU nutritional management protocol.

MEASUREMENT AND RESULTS

Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007).

CONCLUSION

An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.

Malnutrition screening in hospitalised patients and its implication on reimbursement

BACKGROUND

Several studies have cited the incidence of malnutrition in hospitals, which is correlated to negative clinical outcomes, to be up to 60%. Data in Singapore, however, are scarce. Its impact on casemix funding is not known.

AIMS

The aims of the present study were to determine the prevalence of malnutrition, the predisposing risk factors and the impact of documentation and coding of malnutrition on casemix funding in a local population in Singapore.

METHODS

Patients admitted to selected wards over a 1-month period were screened for malnutrition. Those at risk were further assessed using subjective global assessment. Logistic regression was used to ascertain the impact of identified factors on malnutrition. Financial impact analysis of coding of malnutrition as a comorbidity was carried out and tested with Wilcoxon signed rank tests.

RESULTS

Six hundred and fifty-eight patients were eligible for screening. The overall prevalence of malnutrition in the selected wards was 14.7% (95% confidence interval (CI): 12.0-17.4%). Old age, the occurrence of cancer and the admitting unit were statistically significant in explaining the occurrence of malnutrition. Coding of malnutrition was found to significantly increase the complexity of 24 of 105 episodes (22.9%) of patient care as measured by expected cost weights (P < 0.001) and expected lengths of stay (P < 0.001). As a result, the expected financing for these 24 patients increased by 59.7%.

CONCLUSIONS

Malnutrition is prevalent in hospitalised medical and surgical patients. Certain clinical factors should heighten awareness and prompt detection for malnutrition. Coding for malnutrition impacts favourably on casemix funding for a subset of malnourished patients.

Introducing a nutrition screening tool: an exploratory study in a district general hospital

BACKGROUND

Concerns have been raised that patients' nutrition is a neglected aspect of care. Accordingly, 'nutrition screening tools' have been devised to ensure that all patients are assessed by nurses and, where appropriate, referred to dieticians. The tool adopted in our hospital was the 'Nursing Nutritional Screening Tool'.

AIM

To investigate the impact of this screening tool on: nutrition-related nursing documentation; patient care at mealtimes; dietician referral.

METHODS

This study was conducted on two similar general medical wards in a United Kingdom (UK) district general hospital, with the help of staff and patients (n = 175) admitted during two study periods, May 1999 and January 2000. Data were collected over 28 days before and after introduction of the screening tool on one of the wards. For both wards, in each stage of the study, data were collected b: review of patients' notes, non-participant observations of mealtimes. Frequencies of dietician referral and documentation of weight were compared by cross-tabulations and chi2 tests. Nine months later, the findings were discussed with ward sisters in a group interview.

FINDINGS

Introduction of the screening tool impacted on the process but not the outcomes of screening. Use of the screening tool increased the frequency of nutrition-related documentation: the proportion of patients with weights recorded increased on the intervention ward (P < 0.001), and decreased on the comparator ward. Frequency of dietician referral decreased on both wards, but differences were statistically insignificant. There was no observable change in patient care at mealtimes. The nurses in charge of the wards felt that introduction of the screening tool had raised awareness of nutrition-related care.

CONCLUSIONS

Meeting patients' nutritional needs is a complex aspect of care which may benefit from introduction of structured guidelines. However, the potential of screening tools to improve care is limited by diverse factors, which warrant further exploration.

Technical overview of a web-based telemedicine system for wound assessment

This report provides a technical overview of a Web-based telemedicine system for monitoring wounds in patients who do not have immediate access to the services of a consulting physician, including patients at home or in long-term-care facilities. Such a system would allow for the easy transmission and access of digital images of a patient's wounds and would allow multiple types of data required for comprehensive management of a patient's condition to be summarized and displayed. A store-and-forward method of data transmission was chosen for this project, rather than real-time videoconferencing, to limit the use of expensive technology and to maximize convenience for both the patient and the consulting physician. Under the store-and-forward technique, a clinician obtains wound data from the patient, then transmits these data to a Web site where the telemedicine physician can view data from multiple patients at his or her convenience.