Approach to the Hospitalized Patient: Nutrition Care Process and Nutrition Screening

Results of a Screening Test• A = TRUE POSITIVE: – Screening test is positive and the individual has disease • B = FALSE POSITIVE: – Screening test is positive but the individual does

Approach to the Hospitalized Patient:

Nutrition Care Process and

Nutrition Screening

Nutrition Diagnosis

Nutrition Assessment

Nutrition Intervention

Nutrition Monitoring

and Evaluation

Screening

Nutrition Diagnosis

• Identify and label an existing

nutrition problem

• The nutrition professional is

responsible for treating this

problem

• The Academy of Nutrition and

Dietetics has a list of diagnoses

– These may or may not meet your

needs

– Some other aspect of health status

• This step includes both the planning

and the intervention

Nutrition Monitoring and

Evaluation

• Identify progress made

• Determine if goals and/or expected

outcomes are being met

• Must be relevant to the initial

diagnosis, intervention plan and

goals

Development of

Nutrition Care

Plan

Implementation of Nutrition Care Plan

Patient Re-assessment and Updating of Nutrition Care Plan

Termination of Therapy Patient Monitoring

Discharge Planning/Continuity

of Care

Continued Inpatient Care?

Not at Risk

Nutrition Care Algorithm

JPEN J Parenter Enteral Nutr 2011;35; 16-24

References to Consider

• Nutrition Care Process and Model Part 1: The 2008 Update

Journal of the American Dietetic Association 1117

2008;108:1113-• Nutrition Care Process Part II: Using the International

Dietetics and Nutrition Terminology to Document the

Nutrition Care Process Journal of the American Dietetic

Association 2008;108:1287-1293

• International Dietetics & Nutrition Terminology (IDNT)

Reference Manual: Standardized Language for the Nutrition Care Process, 3 rd Edition 2010

• Mueller C, Compher C, Druyan ME et al A.S.P.E.N Clinical

Guidelines: Nutrition screening, assessment, and

intervention in adults JPEN J Parenter Enteral Nutr

2011;35:16-24

Nutrition Screening

What is Screening

• WHO Definition

– The use of simple tests across a healthy population

in order to identify the individuals who have

disease, but do not yet have symptoms

• Acute Care Setting:

– The use of simple tests across a population in order

to identify the individuals who have disease, but do not yet have symptoms

• Screening does not diagnose illness

– Those who screen positive are sent on for further

assessment

What is the Purpose of Nutrition

Screening?

• Identifies patients at nutritional risk

• Identifies the need for further nutrition

assessment

• Predicts clinical outcome if the patient

does not receive nutritional intervention

• Predicts healthcare use

What is Nutrition Assessment

• Occurs after nutrition screening

• A systematic approach for

– Data collection

– Recording data

– Interpretation of that data

• Ongoing process

– A more detailed look at the patient’s condition

– Includes assessment and reassessment

• Allows the clinician to gather more information

and determine:

– If there truly is a nutritional problem

– The name of the nutritional problem

– The severity of the nutritional problem

Nutrition Screening vs Assessment

Nutrition Screening Nutrition Assessment

Intake • Recent changes in

intake

• Changes in specific nutrient intake

• Changes in energy intake

• Not usually included • Medical Diagnosis

• Impact of medical diagnosis on ability to meet needs

Nutrition focused physical

Accuracy of Screening Tool

• The accuracy of a screening test is

measured by its ability to:

– Correctly categorize people with preclinical

disease as “test positive”

– Correctly categorize people without

preclinical disease as “test negative”

– Three important measures

• Sensitivity and Specificity

• Positive and Negative Predictive Value

• Validity and Reliability

Results of a Screening Test

• A = TRUE POSITIVE:

– Screening test is

positive and the

individual has disease

• B = FALSE POSITIVE:

– Screening test is

positive but the

individual does NOT

have disease

• C = FALSE NEGATIVE:

– Screening test is

negative but the

individual has the

disease

• D = TRUE NEGATIVE:

– Screening test is

negative and the

individual does NOT

have disease

Disease Status

Positive Have Disease

Negative

-No Disease

Test Result:

Positive

for Disease

PV +

Negative

for Disease

PV - A+C B+D

Sensitivity Specificity

• Gives us information about the

test

• Definition:

– The probability of screening

positive when the disease is

present

• As the sensitivity of a test increases,

the screening test is more likely to correctly identify patients who HAVE disease

• Higher percentage of false positive

– Many people may be told they have

disease when they do not

Disease Status

Positive Have Disease

-Test Result:

Positive

for Disease

A

Negative

for Disease

C

A+C

Sensitivity

Sensitivity Example

• Example of a HIGHLY SENSITIVE

hypertension screening program:

– Criteria of risk

• The patient will screen positive for

hypertension if diastolic blood pressure is 90

mm Hg or higher – RESULT

• Many people WITHOUT hypertension would

screen positive

– HIGH false positive

– To make the test MORE sensitive:

• Decrease the criteria for diastolic blood pressure

from 90-88 mm HG

– Even more people WITHOUT hypertension would

screen positive

90 92 94 88

86

90 92 94 88

86

• Gives us information about the

test

– The probability of screening

negative if the disease is absent

• As the specificity of a test increases,

the screening test is more likely to correctly identify patients who do NOT have disease

• Low percentage of false positive

– Fewer people will be told they have

disease when they do not

Disease Status

Negative

-No Disease

Test Result:

Positive

for Disease

B

Negative

for Disease

D

B+D

Specificity

Specificity Example

• Example of a HIGHLY SPECIFIC

hypertension screening program:

– Criteria of risk:

• The patient will screen positive for

hypertension if diastolic blood pressure

is 88 mm Hg or higher – Result:

• Fewer people WITHOUT hypertension

would be screening positive

– LOW false positive

– To make the test MORE specific:

• Increase the criteria for diastolic

pressure from 88 to 100 mm Hg

– Even FEWER people WITHOUT

hypertension would screen positive

90 98 100 88

86

90 98 100 88

86

Sensitivity vs Specificity

• Sensitive Test Result

– Diastolic Blood Pressure:

88 mm Hg

– Patient screening result: You

HAVE hypertension

• High rate of false positive

• Specific Test Result

– Diastolic Blood Pressure: 100

mm Hg – Patient screening result: You HAVE hypertension

• Low rate of false positive

Many patients WITH

hypertension test positive

Many Patients WITHOUT hypertension test positive

Many patients WITH

hypertension test positive

Few Patients WITHOUT hypertension test positive

Predictive Value

• Refers to the interpretation of test

results

– Predictive Value Positive

– Predictive Value Negative

Predictive Value Positive

• The probability of having disease when the screen is

positive

• To increase predictive value POSITIVE:

– Increase specificity (by changing the criterion for positivity)

• An individual with a positive test will be more likely to HAVE disease

– Low false positive

– Positive for HTN move diastolic from 88 to 100

Disease Status

Positive Have Disease

Negative

-No Disease

Test Result:

Positive

for Disease

PV +

Predictive Value Negative

• The probability of NOT having disease when the screen is negative

• To increase predictive value NEGATIVE:

– Increase sensitivity (by changing the criterion for positivity)

• An individual with a positive screening will be less likely to HAVE

disease

– High false positive

– Negative for HTN move diastolic from 100 to 86

Disease Status

Positive Have Disease

Negative

-No Disease

Test Result:

Negative

for Disease

PV -

• Definition

– How well the screening tool

measures the problem

• A validated screening tool will be

appropriate for targeted:

• Populations

• Diseases

• Settings

Measuring Validity

• How sensitive is the test is in

detecting those individuals who

truly DO have the disease?

• How specific is the test is in

detecting those who truly DO NOT have disease?

• Ideally a screening test should be

highly sensitive and highly specific

• Reliability

– How consistently the tool measures the

problem

– The ability of a test to produce the same

results over and over again

• Reliable screening tool

– Will yield very similar results every time it is

used under given testing conditions

Criteria for Choosing Screening Tools

• Convenient to use

• Can be used by people with different

backgrounds

• Short & Fast to perform

– Less than 5 minutes

• Simple to use

– No calculations – No laboratory data

• Non Invasive

Nutrition Screening Tools for

Hospitalized Patients

• When choosing a nutrition screening tool, it is

important to identify what you are screening for

• Numerous validated screening tools are available

and appropriate for the hospitalized patient:

– Malnutrition Universal Screening Tool (MUST)

– Nutritional Risk Screening (NRS 2002)

– Short Nutritional Assessment Questionnaire (SNAQ)

– Malnutrition Screening Tool (MST)

– Subjective Global Assessment (SGA)

Malnutrition Universal Screening Tool

(MUST)

• Identifies adults who are:

– Malnourished – At risk of malnutrition – At risk of under nutrition – Obese

• Usefulness:

– Useful in a variety of settings

• Recommended Settings

– Primary care – Home care – Acute care – Long term care

Criteria of MUST

• Criteria used by MUST to determine the

overall risk of malnutrition

– Step 1: Body Mass Index (BMI)

– Step 2: Unintentional Weight Loss

– Step 3: Acute Disease Effect

• Positive Aspects

– MUST is linked to a generic care plan for the

treatment of patients at risk of malnutrition

• Negative Aspects

– Too difficult

• Must calculate BMI

Gut 2003;52:vii1-vii12 doi:10.1136/gut.52.suppl_7.vii1

Nutritional Risk Screening

Criteria of NRS 2002

• Criteria indicating the need for nutrition intervention:

– Impaired Nutritional status

– Severity of Disease

• Positive Aspects of NRS 2002

– Easy to use

– Nutrition care plan is indicated in all patients who are:

• Severely Malnourished or Severely Ill

• Moderately undernourished and mildly ill

• Mildly undernourished and moderately ill

– NRS 2002 is linked to an intervention plan

• Negative Aspects

– Requires subjective assessment of severity of illness

– Does not categorize the risk of malnutrition

Nutritional Risk Screening 2002

Impaired nutritional status Severity of disease

Mild

Score 1

Wt loss > 5% in 3 months OR

Food intake < 50-75% of normal requirement in preceding week

Mild Score 1

Hip fracture Chronic patients, in particular with acute complications: cirrhosis, COPD

Chronic hemodialysis, diabetes, malignant oncology

Moderate

Score 2

Wt loss > 5% in 2 months OR

BMI 18.5-20.5 + impaired general condition

OR Food intake < 25-50% of normal requirement in preceding week

Moderate Score 2

Major abdominal surgery Stroke

Severe pneumonia, malignant hematology

Severe

Score 3

Wt loss > 5% in 1 months (~15% in 3 month)

OR BMI < 18.5 + impaired general condition

OR Food intake <0-25% of normal requirement in preceding week

Severe Score 3

Head injury Bone marrow transplantation

Intensive care patients (APACHE

>10)

Score 1: Score 2

Score 1 + Score 2 = Total Score _

Nutr Clin Pract 2008;23:373-382

Short Nutritional Assessment

– Designed to be completed by the nurse upon

patient admission to the hospital

• Dietitian consulted if moderately or severely malnourished

• Recommended Settings:

– Hospital

Criteria of SNAQ

• Criteria to determine the overall need for

nutrition intervention:

– Did you lose weight unintentionally?

– Did you experience a decreased appetite over the last

month?

– Did you use supplemental drinks or tube feeding over

the last month?

• Positive Aspects of NRS 2002

– Quick & Easy to use

– Nutrition care plan is indicated in all patients who are:

• Moderately malnourished >2 but <3 points

• Severely Malnourished <3 points

• Negative Aspects

– Does not take into account severity of disease

http://www.fightmalnutrition.eu Accessed 3/4/12

Malnutrition Screening Tool (MST)

• Identifies malnourished individuals and

individuals at risk of becoming

malnourished

• Usefulness:

– Can be performed quickly

– Can be used by a people with different

backgrounds

– Recommended Settings:

• Hospitalized patients

Criteria of MST

• Criteria used by MST to determine the overall need for

nutrition intervention:

– Have you lost weight recently without trying?

• If yes, how much?

– Have you been eating poorly because of decreased appetite?

• Positive Aspects of MST

– Quick & Easy to use

– Nutrition care interventions can be prioritized by score

• Low risk: 0-1: Rescreen in 7 days

• Medium Risk: 2-3: Nutrition consult in 48-72 hours

• High Risk: 4-5: Nutrition consult in 24 hours

• Negative Aspects of MST

– Does not take into account severity of disease

http://www.ensurenutrition.com/static/cms_workspace/videos/MST.pdf Accessed 3/4/12

MST

Subjective Global Assessment

• Identifies moderately and severely

Subjective Global Assessment

• Criteria to determine the overall need for

Subjective Global Assessment

• Positive Aspects SGA

– Good when circulating protein may not be reliable

(volume overload)

• Negative Aspects of SGA

– Subjective assessment

– User must be trained on its use

– Does not recommend a specific nutrition care plan to be

implemented based on the final ranking of nutritional status

– Calculations necessary

– Highly dependent on patient report

– History must be available and accurate

A=Not at nutrition risk B=Low to Moderate nutrition risk

C=High nutrition risk

• Screening is the first step in identifying

nutrition problems

• Primary objective of screening is to

reduce morbidity and mortality from

disease through early detection and

treatment

• Screening tools should be convenient,

simple and quick to use

• A variety of validated nutrition

screening tools are available

• Charney P Nutrition Screening Vs Nutrition

Assessment: How Do They Differ? Nutr Clin Pract 2008;23:366-372

• Elia M, et al Considerations for screening

tool selection and role of predictive and

concurrent validity Curr Opin Clin Nutr

Metab Care 2011;14:425-433

• Mueller C, et al Nutrition Screening,

Assessment and Intervention in Adults

JPEN 2011;35 (1):16-24

• Anthony P Nutrition Screening Tools for

Hospitalized Patients Nutr Clin Prac 2008; 23:373-382

Overview of Hospital Diets

& Nutrition Intervention

Nutrition Intervention & Diet

Modification

• Therapeutic diets are based on a general

adequate diet modified as necessary

• Vary from normal as little as possible

• Recognize personal eating patterns and

Hospital Diets

• Designed to be nutritionally adequate within

the needs of the specific disease state

• Typically ordered by the physician

• In some institutions, dietitians have privileges

to write diet orders

• If not, the dietitian needs to work with the

physician to assure the pt receives the

correct diet modification

Typical Diet Orders

• “House” or “regular”

– No restrictions

• “Soft”

– Very vague diet order

– Generally no crunchy foods

– Foods that are easy to digest

• Liquid diets

– Clear liquidsFull liquids