A critical evaluation of the use of nutrition screening tools by nurses

Effectiveness of Food-Based Fortification in Older People. A Systematic Review and Meta-Analysis

BACKGROUND

Early intervention with nutritional support has been found to stop weight loss in older people malnourished or at risk of malnutrition. Enriched food could be a more attractive alternative to improve meals, than conventional oral nutritional supplements.

AIMS

To determine the effectiveness of food-based fortification to prevent risk of malnutrition in elderly patients in community or institutionalized elderly patients.

METHODS

A systematic review was conducted of randomized controlled trials, quasi-experimental, and interrupted time series including a longitudinal analysis.

PARTICIPANTS

Elderly patients who are institutionalized, hospitalized or community-dwelling, with a minimum average age of 65 years. All type of patient groups, with the exception of people in critical care, or those who were recovering from cancer treatment, were included.

INTERVENTION

Studies had to compare food-based fortification against alternatives. Studies that used oral nutritional supplementation such as commercial sip feeds, vitamin or mineral supplements were excluded. The search was conducted in Cochrane, CINAHL, PubMed, EMBASE, LILACS, and Cuiden. An independent peer review was carried out.

RESULTS

From 1011 studies obtained, 7 were included for the systematic review, with 588 participants. It was possible to perform meta-analysis of four studies that provided results on caloric and protein intake. Food-based fortification yielded positive results in the total amount of ingested calories and protein. Nevertheless, due to the small number of participants and the poor quality of some studies, further high quality studies are required to provide reliable evidence.

IMPLICATIONS FOR PRACTICE

Despite the limited evidence, due to their simplicity, low cost, and positive results in protein and calories intake, simple dietary interventions based on the food-based fortification or densification with protein or energy of the standard diet could be considered in patients at risk of malnutrition.

[Nutritional status assessment in Geriatrics: Consensus declaration by the Spanish Society of Geriatrics and Gerontology NutritionWork Group]

Ongoing population ageing is one of the factors influencing the increase in the prevalence of undernutrition, as elderly people are a vulnerable group due to their biological, psychological and social characteristics. Despite its high prevalence, undernutrition is underdiagnosed in the geriatric sphere. For this reason, the aim of this consensus document is to devise a protocol for geriatric nutritional assessment. A multidisciplinary team has been set up within the Spanish Society of Geriatrics and Gerontology (in Spanish Sociedad Española de Geriatría y Gerontología [SEGG]) in order to address undernutrition and risk of undernutrition so that they can be diagnosed and treated in an effective manner. The MNA-SF is a practical tool amongst the many validated methods for nutritional screening. Following suspicion of undernutrition, or after establishing the presence of undernutrition, a full assessment will include a detailed nutritional history of the patient. The compilation of clinical-nutritional and dietetic histories is intended to help in identifying the possible risk factors at the root of a patient's undernutrition. Following this, an anthropometric assessment, combined with laboratory data, will describe the patient's physical and metabolic changes associated to undernutrition. Currently, the tendency is for further nutritional assessment through the use of non-invasive techniques to study body composition in association with functional status. The latter is an indirect index for nutritional status, which is very interesting from a geriatrician's point of view. To conclude, correct nutritional screening is the fundamental basis for an early undernutrition diagnosis and to assess the need for nutritional treatment. In order to achieve this, it is fundamental to foster research in the field of nutritional geriatrics, in order to expand our knowledge base and to increasingly practice evidence-based geriatrics.

Feasibility of implementing routine nutritional screening for older adults in Australian general practices: a mixed-methods study

BACKGROUND

Nutrition screening in older adults is not routinely performed in Australian primary care settings. Low awareness of the extent of malnutrition in this patient group, lack of training and time constraints are major barriers that practice staff face. This study aimed to demonstrate the feasibility of including a validated nutrition screening tool and accompanying nutrition resource kit for use with older patients attending general practice. Secondary aims were to assess nutrition-related knowledge of staff and to identify the extent of malnutrition in this patient group.

METHODS

Nine general practitioners, two general practice registrars and 11 practice nurses from three participating general practices in a rural, regional and metropolitan area within a local health district of New South Wales, Australia were recruited by convenience sampling.

RESULTS

Four key themes were determined regarding the feasibility of performing MNA -SF: ease of use; incorporation into existing practice; benefit to patients' health; and patients' perception of MNA-SF. Two key themes related to the nutrition resource kit: applicability and improvement. These findings were supported by open ended questionnaire responses. Knowledge scores of staff significantly improved from baseline (52% to 66%; P < 0.05). Of the 143 patients that had been screened, 4.2% (n = 6) were classified as malnourished, 26.6% (n = 38) 'at risk' of malnutrition and 69.2% (n = 99) as well-nourished.

CONCLUSION

It is feasible to include the MNA-SF and a nutrition resource kit within routine general practice, but further refinement of patients' electronic clinical records in general practice software would streamline this process.

Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings

BACKGROUND

Given the prevalence of under-nutrition and reports of inadequate nutritional management of patients in hospitals and the community, nutritional screening may play a role in reducing the risks of malnutrition. Screening programmes can invoke costs to health systems and patients. It is therefore important to assess the effectiveness of nutritional screening programmes.

OBJECTIVES

To examine the effectiveness of nutritional screening in improving quality of care (professional practice) and patient outcomes compared with usual care.

SEARCH METHODS

We searched the following databases: CENTRAL (The Cochrane Library), MEDLINE, EMBASE and CINAHL up to June 2012 to find relevant studies.

SELECTION CRITERIA

Randomised controlled studies, controlled clinical trials, controlled before-after studies and interrupted time series studies assessing the effectiveness of nutritional screening were eligible for inclusion in the review. We considered process outcomes (for example patient identification, referral to dietitian) and patient outcomes (for example mortality, change in body mass index (BMI)). Participants were adult patients aged 16 years or over. We included studies conducted in different settings, including hospitals, out-patient clinics, primary care or long term care settings.

DATA COLLECTION AND ANALYSIS

We independently assessed the risk of bias and extracted data from the included studies. Meta-analysis was considered but was not conducted due to the discrepancies between the studies. The studies were heterogeneous in their design, setting, intervention and outcomes. We analysed the data using a narrative synthesis approach.

MAIN RESULTS

After conducting initial searches and screening the titles and abstracts of the identified literature, 77 full text papers were retrieved and read. Ultimately three studies were included. Two controlled before-after studies were conducted in hospital settings (one in the UK and one in the Netherlands) and one cluster randomised controlled trial was conducted in a primary care setting (in the USA).The study conducted in primary care reported that physicians were receptive to the screening intervention, but the intervention did not result in any improvements in the malnutrition detection rate or nutritional intervention rate. The two studies conducted in hospitals had important methodological limitations. One study reported that as a result of the intervention, the recording of patients' weight increased in the intervention wards. No significant changes were observed in the referral rates to dietitians or care at meal time. The third study reported weight gains and a reduction in hospital acquired infection rate in the intervention hospital. They found no significant differences in length of stay, pressure sores, malnutrition and treatment costs per patient between the two hospitals.

AUTHORS' CONCLUSIONS

Current evidence is insufficient to support the effectiveness of nutritional screening, although equally there is no evidence of no effect. Therefore, more high quality studies should be conducted to assess the effectiveness of nutritional screening in different settings.

The automated malnutrition assessment

OBJECTIVE

We propose an automated nutritional assessment algorithm that provides a method for malnutrition risk prediction with high accuracy and reliability.

METHODS

The database used for this study was a file of 432 patients, where each patient was described by 4 laboratory parameters and 11 clinical parameters. A malnutrition risk assessment of low (1), moderate (2), or high (3) was assigned by a dietitian for each patient. An algorithm for data organization and classification using characteristic metrics for each patient was developed. For each patient, the algorithm characterized the patients' unique profile and built a characteristic metric to identify similar patients who were mapped into a classification. For each patient, the algorithm characterized the patients' classification.

RESULTS

The algorithm assigned a malnutrition risk level for different training sizes that were taken from the data. Our method resulted in average errors (distance between the automated score and the real score) of 0.386, 0.3507, 0.3454, 0.34, and 0.2907 for the 10%, 30%, 50%, 70%, and 90% training sizes, respectively. Our method outperformed the compared method even when our method used a smaller training set than the compared method. In addition, we showed that the laboratory parameters themselves were sufficient for the automated risk prediction and organized the patients into clusters that corresponded to low-, low-moderate-, moderate-, moderate-high-, and high-risk areas. The organization and visualization methods provided a tool for the exploration and navigation of the data points.

CONCLUSION

The problem of rapidly identifying risk and severity of malnutrition is crucial for minimizing medical and surgical complications. These are not easily performed or adequately expedited. We characterized for each patient a unique profile and mapped similar patients into a classification. We also found that the laboratory parameters were sufficient for the automated risk prediction.

A systematized interdisciplinary nutritional care plan results in improved clinical outcomes

OBJECTIVE

This study investigated identification and treatment of patients at-risk for malnutrition and extended inpatient length of stay.

DESIGN

Data were collected retrospectively from the medical records for a period of 6 months. The records were reviewed for (1) adherence to RD recommendation, (2) decreasing serum albumin during hospital stay, (3) length of hospital stay, (4) readmission within 30 days, (5) age, (6) gender, (7) past medical history, (8) primary and secondary diagnoses, (9) the presence or absence of a diet order and (10) medications.

SUBJECTS AND PARTICIPANTS

Medical records were reviewed for diagnoses associated with nutrition-related complications. Patient's records were excluded for length of stay less than 4 days, or in-hospital death.

RESULTS

The mean LOS was 10 days shorter when the advice was followed (p=0.0074).

CONCLUSIONS

Patients at high nutritional risk have a shorter LOS and have fewer complications when the RD advice is followed.

The association between malnutrition and oral health status in elderly in long-term care facilities: a systematic review

OBJECTIVES

Malnutrition is a common problem in the elderly. It is not clear if oral health is associated to malnutrition in this population. The aim of this systematic review is to determine whether an association exists between oral health and malnutrition in the elderly in a long-term care facility.

DESIGN

Systematic review.

DATA SOURCE

Medline, Cochrane and Cinahl were systematically searched for to identify articles published between January 1985 and May 2011. Reference lists were checked for additional publications.

REVIEW METHODS

Publications were included if they explored the association between oral health status and malnutrition. As no consensus about terminology was found, a sensitive filter was developed. The methodological quality of the studies was assessed. Two independent reviewers performed all methodological steps.

RESULTS

Sixteen studies met the criteria for inclusion. Eleven studies used a multivariate approach; nine of these found an association between oral health status and malnutrition. Four studies found a relationship between masticatory problems and malnutrition. Five studies found an association between malnutrition and dental condition, number of oral problems, tongue alteration, problems with saliva flow, and candidiasis. Overall, the methodological quality of the studies was medium.

CONCLUSIONS

Tentative evidence indicates an independent association between oral health status and malnutrition in the elderly residing in a long-term care facility. Caution is needed for the interpretation of these results because of the absence of a gold standard to define and assess malnutrition and oral health status and the presence of methodological limitations throughout the studies.

Hospital malnutrition: prevalence, identification and impact on patients and the healthcare system

Malnutrition is a debilitating and highly prevalent condition in the acute hospital setting, with Australian and international studies reporting rates of approximately 40%. Malnutrition is associated with many adverse outcomes including depression of the immune system, impaired wound healing, muscle wasting, longer lengths of hospital stay, higher treatment costs and increased mortality. Referral rates for dietetic assessment and treatment of malnourished patients have proven to be suboptimal, thereby increasing the likelihood of developing such aforementioned complications. Nutrition risk screening using a validated tool is a simple technique to rapidly identify patients at risk of malnutrition, and provides a basis for prompt dietetic referrals. In Australia, nutrition screening upon hospital admission is not mandatory, which is of concern knowing that malnutrition remains under-reported and often poorly documented. Unidentified malnutrition not only heightens the risk of adverse complications for patients, but can potentially result in foregone reimbursements to the hospital through casemix-based funding schemes. It is strongly recommended that mandatory nutrition screening be widely adopted in line with published best-practice guidelines to effectively target and reduce the incidence of hospital malnutrition.

Early assessment of nutritional status in patients scheduled for colorectal cancer surgery

Nutritional support is important to optimize treatment outcomes in colorectal cancer surgery. Using retrospective review of patients' medical records, we sought to identify the kinds of nutritional problems patients with colorectal cancer reported on their first visit to the surgeon to support those at risk of malnutrition. After reviewing data from the Patient-Generated Subjective Global Assessment of Nutritional Status, patients had a supportive counseling meeting about nutrition with a nurse. Of the 153 patients, 65% were diagnosed with colon cancer and 35% with rectal cancer. Eighteen percent of those with colon cancer were overweight, and 12% were obese. Of those with rectal cancer, 10% were overweight, and 7% were obese. Weight loss was reported by 18% of the patients with colon cancer and by 12% of the patients with rectal cancer. To identify the patients who need nutritional support before colorectal cancer surgery, it is important to first identify the patients' nutritional status. When the focus is on surgery, it is possible that these problems are not mentioned if no questions are asked. Nutritional assessment at the outpatient department makes it possible to use the time lapse between examination and surgery to improve the nutritional status.

MUST scoring - a 'must' or a waste of nursing time?

Hospital malnutrition is a major clinical and public health problem, affecting at least 2 million people in the United Kingdom. The subject captures national attention and has provoked escalating efforts towards prevention (Banks, 2006). A significant number of patients admitted to hospital are either malnourished or at significant risk of becoming so. Malnutrition predisposes to disease, delays recovery from illness, and adversely effects wellbeing and clinical outcome. Attention to nutrition may be deficient due to the diffuseness of responsibility, other care priorities, and lack of staffing resources (Guenter et al, 1982).

An audit of nutritional care in a health board in Scotland

This article's aim is to describe the processes used and results found when conducting an audit of nutritional care within a health board area in Scotland. Nutritional standards and an audit tool were developed by a multidisciplinary team and all in-patient clinical areas took part. The results demonstrate that there is still a considerable amount of work that needs to be undertaken to ensure that patients are getting the most effective and efficient nutritional care and this article denotes some of the initiatives instilled to address areas of identified challenges.

An algorithm for the clinical assessment of nutritional status in hospitalized patients

Upon admission to hospital, 30–50% of patients either are or become malnourished. There is no generally accepted definition of malnutrition or guidelines on the best way to establish nutritional status. We consider it self-evident that the nursing staff have an important role in screening patients at risk of malnutrition on admission and thereafter at regular times. This is why we developed the nursing nutritional screening form (NNSF). The NNSF was tested by nurses, dietitians and clinicians, in pairs, to establish the extent of agreement in two phases on sixty-nine and forty patients. Later, the form was used in practice by nursing staff on five wards (334 patients). Based on the results of the NNSF, patients were referred to a dietitian. The dietitian established whether the patient was indeed at risk, or was actually malnourished, using a complete nutritional history. The degree of concurrence within pairs was reasonable to good. The same applied to the concurrence between nursing staff and dietitians, but concurrence between clinicians and nursing staff was less. In total, 334 patients were screened and sixty-nine of them were referred to the dietitian. It was established that 86% of the referred patients were potentially at risk of malnutrition or were malnourished. Without the NNSF, 39% (n27) of the patients referred to the dietitian would not have been referred, or would have been referred much later. The NNSF makes it possible for nurses to detect malnourished patients or patients at risk of malnutrition at an early stage of their hospitalization.

The assessment of older people's needs in care homes

In many countries there is a concern to improve assessment procedures for older people to avoid misplacement in nursing homes and ensure that rehabilitation takes place where possible. The study examined assessment documentation in 126 care homes in North West England. On a set of core domains for assessing need, the level of coverage varied considerably. The use of standardised scales was infrequent apart from those that measured risk of developing pressure sores. Some important key domains were infrequently mentioned on the assessment forms including mental health, pain, oral health and foot care. The most frequently covered items were the activities of daily living. There were clear differences in the assessment approaches employed in different types of home. The lack of inclusion of certain key health areas on some assessment forms suggests that the well-being and quality of life of some residents may be poorly addressed, and that further work is required for the standard of assessment in care homes to match that in community-based care.

Nutritional screening and assessment tools for use by nurses: literature review

AIM

This paper reports a literature review describing the range of published tools available for use by nurses to screen or assess nutritional status of patients/clients, and to examine whether the validity, reliability, sensitivity, specificity and acceptability of the tool have been investigated. Tools developed specifically for use with older adults are not considered in this review. A screening/assessment tool is described as a tool that uses a questionnaire-type format, contains more than one risk factor for malnutrition and gives an assessment of risk.

BACKGROUND

The incidence of malnutrition in people cared for by nurses is high and screening or assessment tools are often used to identify those with, or at risk of, malnutrition.

METHODS

A comprehensive literature review methodology was employed. A range of electronic databases was searched from 1982 to 2002. Search terms incorporating "nutrition", "screening", assessment, feeding, instrument, tool, validity, reliability, sensitivity and specificity were combined. Manual searches were also conducted.

RESULTS

Seventy-one nutritional screening/assessment tools were identified of which 35 were reviewed. Tools not reviewed included those which incorporated significant use of biochemical measures (8), included complex anthropometric measures (3), were concerned specifically with ingestion (4) or were designated for use with an older population (21). The tools reviewed use a wide variety of risk factors for malnutrition, varying from anthropometric measurements to socio-cultural aspects of eating behaviour. Some identify an action plan based on the score obtained. Many have not been subjected to validity and/or reliability testing and yet appear to be in use in clinical practice. The sensitivity, specificity and acceptability of the tools are often not investigated.

CONCLUSION

There are many published nutritional screening/assessment tools available for use by nurses to screen or assess the nutritional status of patients/clients. Many have not been subject to rigorous testing. Future work should consider a more standardized approach to the use of these tools.

Changing perspectives in the nutritional management of disease

There have been substantial changes in the nutritional management of many diseases in the last 20 years, which have been accompanied by a growing recognition of its importance. Many of the changes in clinical nutrition have been associated with the introduction of standards, clinical audit and the implementation of evidence-based practice, which has led to a re-evaluation of some established dietary interventions using a hierarchy-of-evidence approach. Although there are few randomised controlled trials on which to base such work, the examination of other, often less-robust, evidence has led to some traditional dietary interventions being modified. Examples in gastroenterology include the use of low-fat diets in gall bladder disease and the restriction of protein in hepatic encephalopathy, where the current evidence suggests that neither should be used routinely in clinical practice. Where therapeutic dietary restrictions are required, as with low-Na diets in ascites, there is very little information on how these restrictions influence total nutrient intake and, if intake is impaired, how the detrimental effects of an inadequate intake should be balanced with the therapeutic effects of restriction. Studies are required to ensure that nutritional interventions are not only effective but also free from undesirable side effects. The mode and timing of the delivery of nutritional support has also been re-evaluated and the benefits of early enteral feeding have been recognised. The delivery of dietary advice is a new area that is being considered, with practitioners in clinical nutrition using behaviour-change skills to facilitate optimum nutrition rather than simply providing patients with advice. For such developments to continue in clinical nutrition it is essential that all practice should be systematically evaluated and, where necessary, modified in the light of sound current research findings, and that gaps in our present knowledge base are identified and addressed.

Dietary needs for bone health and the prevention of osteoporosis

Osteoporosis is identified as a painful, disabling and disfiguring health deficit that is entirely preventable given early detection and reversal of the causes--one of which is deficiency of nutrients required for bone health. The notable examples of nutrients where deficiency is directly related to the onset of osteoporosis are identified as calcium and vitamin D. The reasons why deficiency occurs are analysed in this article and high-risk situations for deficiency identified and discussed. The use of phytooestrogens in dietary prevention of osteoporosis is explored to include analysis of foods containing phytooestrogens, the quantities required, and product variability. Given the increasing role of phytooestrogens in dietary prevention of osteoporosis, discussion in this section looks at the need for food labelling, including phytooestrogen content, so that consumers can make reasoned choices as to the quantities they require and the dietary sources from which this will be obtained.

The methodology of nutritional screening and assessment tools

BACKGROUND

The aim of this paper was to give a critical appraisal of the methodology of nutritional screening and assessment tools.

METHODS

A literature search identified 44 tools. Each tool was assessed in relation to details of its application, method of derivation and evaluation of its performance.

RESULTS

The findings indicate that tools were published with insufficient details regarding their intended use and method of derivation, and with an inadequate assessment of their effectiveness. An appraisal of these features judged that no one tool satisfied a set of criteria regarding scientific merit.

CONCLUSION

There is thus a need to ensure that nutritional screening and assessment tools are developed using procedures based on good design and sound statistical practice. This paper suggests that a unified approach using multivariate techniques could make a significant contribution to this process.

Nutritional awareness of critically ill surgical high-dependency patients

It has been recognized that malnutrition in hospital is a serious problem that may go undetected. There is growing evidence that early nutritional support in high-risk patients helps reduce postoperative complications; however, malnutrition is often diagnosed only once it is well established. This study showed that, both retrospectively and prospectively; there were no formal nutritional assessments of patients in a high-dependency unit (HDU), that time to feeding was generally within the recommended 5-7 day postoperative period, and that the most common form of supplementary feeding was total parenteral nutrition (TPN). Prospectively, the choice of supplementary feeding was dependent on the type of surgery and the individual patient's condition. Since this study was completed, a dietician has been allocated to the HDU and carries out formal nutritional assessments on a daily basis. Further research is required to assess the impact of the dietician on patient nutrition.