ORIGINAL ARTICLEComparison of tools for nutritional assessment and screening at hospital admission: A population study
Introduction
Hospitalized patients (20–62%) are either malnourished or at risk of malnutrition in developed counties.1, 2, 3 Malnutrition has been associated with higher rates of complications,4, 5 increased nosocomial infections,6 higher hospital costs,4, 7 higher mortality4, 8 and longer length of hospital stay (LOS).4, 8 Complications of malnutrition increase LOS, therapeutic hospital cost and ultimately the cost of patient rehabilitation.9 Thus, nutritional status should be evaluated.
There are wide discrepancies in the prevalence of poor nutritional status in the different studies10 and these depend not only on the population or type of institution studied, but also on the different diagnostic criteria used to define nutritional status.11 The first problem associated with the assessment of nutritional status is the terminology. Nutritional screening tools identify characteristics known to be associated with dietary or nutritional problems. Its purpose is to differentiate individuals who are at high nutritional risk or have poor nutritional status. Those patients considered at risk of nutritional depletion should be referred to specialists for nutritional assessment and intervention. The objective of nutritional assessment, on the other hand, is to accurately define nutritional status of the patient, define clinically relevant malnutrition and to monitor changes in nutritional status.12 Nutritional assessment usually includes anthropometric, dietary and biochemical measurements, clinical history, physical and other parameters.13
A number of nutritional screening and assessment tools have been developed to assess nutritional risk.14, 15, 16, 17 Each has advantages and disadvantages. The subjective global assessment (SGA) questionnaire18 is an accurate nutritional assessment tool that is a predictor of complications, such as infections and poor wound healing14 and is associated with longer LOS in severely malnourished patients.19 It is one of the best available tools to assess nutritional status, because it is patient centered, incorporates clinical history and physical examination, and has been demonstrated to be associated with patient outcome.20, 21, 22, 23 The nutritional risk index (NRI), developed by Veterans Affairs Total Potential Nutrition Cooperative Study Group,15 is a screening tool that was found to be a sensitive, specific and positive predictor for identifying patients with risk for complications following surgery. More recent nutritional screening tools are the malnutrition universal screening tool (MUST),16 developed by British Association for Parenteral and Enteral Nutrition (BAPEN) and the nutritional risk screening tool 2002 (NRS-2002),17 endorsed by the European Society for Clinical Nutrition (ESPEN). Although nutritional screening and assessment tools do not have the same goal, their comparison is of interest. True validity of a screening or assessment tool can only be discussed when its impact on clinical outcome has been proven. LOS is a relevant outcome parameter in terms of morbidity, and hospital cost. Although LOS has been criticized as an outcome parameter due to the many non-nutritional factors that influence it, it is an outcome measurement that integrates the role of main diseases and adverse effects of malnutrition, such as infection, poor wound healing and impaired functional status.23
The SGA was chosen as the reference method. The purpose of this population study (n=995) was to test the sensitivity and specificity of screening tools, i.e. NRI, MUST and NRS-2000 compared to nutritional assessment tools, i.e. SGA and to evaluate the association between nutritional risk determined by these screening or assessment tools and LOS.
Section snippets
Patients
All adult patients admitted to the hospital admission center for medical or surgical reasons and subsequently hospitalized were eligible for inclusion. Every 10th patient who met entry criteria was included in the study during a 3-month period (n=995). Two patients refused to participate. Exclusion criteria were edema, burns, peritoneal- or hemodialysis, rehydration perfusion and major cardio-respiratory resuscitation (n=61), because these conditions preclude the use of bioelectrical impedance
Results
Eighty-one percent of patients included in the study were hospitalized <10 days (Table 1). Fifteen percent were hospitalized >11 days. Patients hospitalized >11 days were significantly older and had lower weight and albumin and higher weight loss and percent body fat than patients hospitalized 1–10 days (Table 2). The proportion of male to female was not significantly different between patients hospitalized 1–10 and >11 days. Although all correlations were significant between anthropometric and
Discussion
Nutritional screening tools identify characteristics known to be associated with nutritional problems and differentiate individuals who are at high nutritional risk or have poor nutritional status. Nutritional assessment, on the other hand, defines nutritional status and clinically relevant malnutrition, and monitors changes in nutritional status.12
Medium and high nutritional risk was 25% by NRI, 28% by NRS-2002 and 37% by MUST, compared to 39% of patients being moderately or severely
Conclusions
A large percentage of patients were at medium or high nutritional risk (39% by SGA, 28% by NRS-2002 and 37% by MUST) at hospital admission. NRS-2002 had higher sensitivity and specificity than MUST or NRI, compared to SGA. There was a significant association between LOS and nutritional risk by NRS-2002, MUST and NRI and nutritional status by SGA. Nutritional risk or status can be determined by NRS-2002, MUST and SGA, respectively, in patients at hospital admission.
Conflict of interest statement
There is no conflict of interest or association with pharmaceutical/biotechnology companies or other associations of any of the authors. Nutrition 2000Plus is a public Foundation to promote “Good Nutrition” and funds nutrition research and publishes research results, trains physicians in nutrition, and organizes seminars on nutrition. C. Pichard (senior author) is the President of the Foundation.
Acknowledgements
We thank Jens Kondrup, MD for critical review of the manuscript. We are indebted to Pierre Guerini for retrieving the LOS data, the dietitians at the Geneva University Hospital and the staff of the Hospital Admission Center for their collaboration. The public Foundation Nutrition 2000Plus provided financial support for this work.
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