Why Are Screening and Assessment Important?
Benefits of Nutritional Risk Screening and Assessment
Early diagnosis of disease-related malnutrition is the first step in effective management of this prevalent health care problem. In a comprehensive study, it was found that only 50 percent of malnourished patients were recognized in regular clinical practice.1 Severe malnutrition can be identified rather easily, whereas less severe states, particularly in patients with complex conditions, tend to become evident only in later stages of treatment.2 For this reason, mandatory screening using a validated nutritional risk screening tool is recommended for early identification and treatment of malnutrition. These validated nutrition risk screening tools have proven effective in identifying at-risk patients.3,4
Patient Benefits of Nutritional Risk Screenings
When nutritional risk screening is performed, the deleterious effects of disease-related malnutrition can be reduced or prevented. The benefits include:
- Faster wound healing5
- Fewer complications5,6,7,8,9
- Reduced number of infections5,7,8,10
- Shorter duration of mechanical ventilation9,10
- Shorter hospital stays6,11
- Faster mobilization and less convalescence6
- Better quality of life12
Early Detection is Critical to Enabling Good Clinical Nutrition
To counteract disease-related malnutrition and its consequences, timely identification of impaired nutritional status and quick response to start treatment are crucial for patients in nutritional risk groups. Today, only 50 percent of disease-related malnutrition cases worldwide were recognized in regular clinical practice.1,13
Good nutritional care is a vital part of patient management and includes:
- Proper screening of nutritional condition
- Decision on nutritional strategy
- Calculation of energy and nutrient requirements
- Decision on route of administration
- Tight monitoring of the nutritional therapy
- Competent complication management
Recommended Patient Screening Tools
Various screening tools have been designed to detect protein and energy under-nutrition in patients. These tools are also effective for predicting whether under-nutrition is likely to develop and/or worsen. The European Society for Clinical Nutrition and Metabolism (ESPEN) has set guidelines for nutritional risk screening of hospitalized patients14 suggesting the following tools to avoid unnecessary depletion:
- Nutritional Risk Screening 2002 (NRS 2002) for use in the hospital setting14
- Subjective Global Assessment (SGA) for use in the hospital setting15
- Malnutrition Universal Screening Tool (MUST) for use in the community14
- Mini-Nutritional Assessment (MNA) for use with elderly patients14
Generally, the most commonly used methods of predicting or identifying malnutrition are the screening of nutritional condition using NRS 2002, MUST or SGA, as well as the interpretation of biochemical parameters.
Each screening method has been recommended for different patient populations, care settings and age groups. Criteria for the selection of the appropriate tool also include validity and reliability of the method, predictive power, acceptability by patients and caregivers, and simplicity of use.4
The tools consider weight loss, body mass index, serum albumin levels, physical signs of malnutrition, age, and disease severity amongst the signs of disease-related malnutrition.16
Assessment is the second step of efficient nutritional management. It is a detailed, more specific and in-depth evaluation of the causes of malnutrition and the risk factors for nutrition and fluid deficiency.
The assessment should be performed by a nutritional expert (e.g. a dietitian, a clinician interested in nutrition, or a nutrition nurse specialist) or by a nutritional support team. Clinical judgment is essential to decide on the appropriate follow up. The completion of the assessment allows interventions which can lead to better outcomes.
- 1. a. b. Kruizenga HM, Van Tulder MW, Seidell JC et al. Effectiveness and cost-effectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr 2005;82:1082-1089.
- 2. Kruizenga HM, de Jonge P, Seidell JC et al. Are malnourished patients complex patients? Health status and care complexity of malnourished patients detected by the Short Nutritional Assessment Questionnaire (SNAQ). Eur J Intern Med 2006;17(3):189-194.
- 3. Tappenden KA, Quatrara B, Parkhurst ML et al. Critical role of nutrition in improving quality of care: an interdisciplinary call to action to address adult hospital malnutrition. JPEN 2013;37(4):482-487.
- 4. a. b. Van Bokhorst-de van der Schueren MA, Guaitoli PR, Jansma EP et al. Nutrition screening tools: does one size fit all? A systematic review of screening tools for the hospital setting. Clin Nutr 2014;33(1):39-58.5
- 5. a. b. c. Waitzberg DL. Efficacy of nutritional support: evidence-based nutrition and cost-effectiveness. Nestle Nutr Workshop Ser Clin Perform Programme 2002;7:257-271.
- 6. a. b. c. Correia MI, Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003;22(3):235-239.
- 7. a. b. Jie B, Jiang ZM, Nolan MT et al. Impact of nutritional support on clinical outcome in patients at nutritional risk: a multicenter, prospective cohort study in Baltimore and Beijing teaching hospitals. Nutrition 2010;26(11-12):1088-1093.
- 8. a. b. Kennedy JF, Nightingdale JM. Cost savings of an adult hospital nutrition support team. Nutrition 2005;21(11-12):1127-1133.
- 9. a. b. Heidegger CP, Berger MM, Graf S et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomized controlled clinical trial. Lancet 2013;381(9864):385-393.
- 10. a. b. Alberda C, Gramlich L, Jones N et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Int Care Med 2009;35(10):1728-1737.
- 11. Martin CM, Doig GS, Heyland DK et al. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170(2):197-204.
- 12. Ha L, Hauge T, Spenning AB et al. Individual, nutritional support prevents undernutrition, increases muscle strength and improves QoL among elderly at nutritional risk hospitalized for acute stroke: a randomized, controlled trial. Clin Nutr 2010;29(5):567-573.
- 13. NICE: National Collaborating Centre for Acute Care. Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition. Methods, evidence and guidance. London 2006.
- 14. a. b. c. d. Kondrup J, Allison SP, Elia M et al. ESPEN Guidelines for Nutrition Screening 2002. Clin Nutr 2003;22(4):415-421.
- 15. A.S.P.E.N. Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric care. JPEN 2002;26:1SA-138SA.
- 16. Mueller C, Compher C, Ellen DA et al. A.S.P.E.N. Clinical Guideline: Nutrition screening, assessment, and intervention in adults. JPEN 2011;35(1):16-24.