Screening nutrition care process

1. The Nutrition Care Process: Driving Effective
Intervention and Outcomes

2. Nutrition Care Process
♦ Process for identifying, planning for, and
meeting nutritional needs
♦ Malnutrition increases:
– morbidity
– length of hospital stay = more care
– mortality
– higher costs ($$$$$$$)

3. Relationship
Between
Patient/Client/Group
& Dietetics
Professional
-
Nutrition Diagnosis
 Identify and label problem
 Determine cause/contributing risk
factors
 Cluster signs and symptoms/
defining characteristics
Nutrition Assessment
 Obtain/collect timely and
appropriate data
 Analyze/interpret with
evidence - based standards

  Identify risk factors
  Use appropriate tools
and methods
  Involve
interdisciplinary
collaboration
Screening& Referral
System
Outcomes
Management Sys tem
  Monitor the success of the Nutrition Care
Process implementation
  Evaluate the impact with aggregate data
  Identify and analyze causes of less than
optimal performance and outcomes
  Refine the use of the Nutrition Care
Process
ADA NUTRITION CARE PROCESS AND MODEL
 Document
Nutrition Monitoring and
Evaluation
  Monitor progress
  Measure outcome indicators
  Evaluate outcomes
  Document
Nutrition Intervention
 Plan nutrition intervention
• Formulate goals and
determine a plan of action
 Implement the nutrition intervention
• Care is delivered and actions
are carried out
 Document
Document

4. Central Core of
Nutrition Care Model
The relationship
between the client &
the dietetics
professional(s)
– collaborative
– client-focused
– individualized

5. Outer Rings of
Nutrition Care Model
♦ Strengths brought to process by dietetics
professional
– dietetics knowledge
– skills of critical thinking, collaboration,
communication
– evidence-based practice
♦ Factors of external environment
– health care system, practice setting
– social support, economics, education level

6. ADA’s Nutrition Care
Process Steps
♦ Nutrition Assessment
♦ Nutrition Diagnosis
♦ Nutrition Intervention
♦ Nutrition Monitoring and Evaluation
For more information, access the ADA member page in the Quality
Management section. http://www.eatright.org/Member/83_12962.cfm

7. Nutrition Assessment
Components
♦ Gather data, considering
– Dietary intake
– Nutrition related consequences of health and disease
condition
– Psycho-social, functional, and behavioral factors
– Knowledge, readiness, and potential for change
♦ Compare to relevant standards
♦ Identify possible problem areas

8. Example of Nutrition Assessment
Content
Nutrition
assessment
what data
are most
effective for
identifying
clients’
nutrition
related
problem
of interest
Type of assessment
Content component
Nutritional adequacy
Fat and cholesterol intake
Trans fatty acid intake
Health status
Lipid profile
BMI
Waist circumference
What are the reliable
standards (ideal goals)?
• how well, how much,
how long
What type
of
assessment
data?

9. How do we get from Assessment to
Intervention?
Nutrition Diagnosis
A crucial element of
providing quality
nutrition care

10. Nutrition Diagnosis
Purpose
♦ Identify and label the nutrition problem
♦ Nutrition diagnosis
NOT medical diagnosis
♦ EXPLICIT statement of nutrition diagnosis
Note: Documentation is an on-going process that
supports all the steps in the Nutrition Care
Process

11. Nutrition Intervention
Purpose
♦ Plan and implement purposeful actions to address
the identified nutrition problem
– bring about change
– set goals and expected outcomes
– client-driven
– based on scientific principles and best available
evidence
Note: Documentation is an on-going process that
supports all the steps in the Nutrition Care Process

12. Nutrition Monitoring &
Evaluation
Purpose
♦ Determine the progress that is being made toward the
client’s goals or desired outcomes
Monitoring: review and measurement of status
at scheduled times
♦ Evaluation: systematic comparison with previous status,
intervention goals, reference standard
Note: Documentation is an on-going process that
supports all the steps in the Nutrition Care Process

13. Nutrition Screening
♦ Purpose: To quickly identify individuals
who are malnourished or at nutritional risk
and to determine if a more detailed
assessment is warranted
♦ Usually completed by DTR, nurse,
physician, or other qualified health care
professional
♦ At-risk patients referred to RD

14. Characteristics of Nutrition
Screening
♦ Simple and easy to complete
♦ Routine data
♦ Cost effective
♦ Effective in identifying nutritional
problems
♦ Reliable and valid

15. Nutrition Questionnaire

16. Nutrition Screening Tools
♦ Acute-care hospital or residential setting
♦ Perinatal service
♦ Pediatric practice
♦ Malnutrition Universal Screening Tool
(MUST)
♦ Nutrition Screening Initiative (NSI)

17. Food and Nutrient Intake Risk
Factors
♦ Calorie or protein, vitamin and mineral intake
greater or less than required
♦ Swallowing difficulties
♦ Gastrointestinal disturbances, bowel irregularity
♦ Impaired cognitive function or depression
♦ Unusual food habits (pica)
♦ Misuse of supplements
♦ Restricted diet
♦ Inability or unwillingness to consume food
♦ Increase or decrease in activities of daily living
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th
edition, p. 386

18. Psychological/Social Risk
Factors
♦ Language barriers
♦ Low literacy
♦ Cultural or religious factors
♦ Emotional disturbances associated with feeding difficulties
(e.g., depression)
♦ Limited resources for food preparation or obtaining food
or supplies
♦ Alcohol or drug addiction
♦ Limited or low income
♦ Lack of ability to communicate needs
♦ Limited use or understanding of community resources
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th
edition, p. 386

19. Physical Risk Factors
♦ Extreme age (adults >80 years, premature infants,
very young children)
♦ Pregnancy: adolescent, closely spaced, or three or
more pregnancies
♦ Alterations in anthropometric measurements,
marked overweight/ underweight for age, height,
both; depressed somatic fat and muscle stores
♦ NOTE: recent unintentional weight loss is more
predictive of morbidity/mortality than wt/ht status
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

20. Physical Risk Factors (cont)
♦ Chronic renal/cardiac disease, diabetes,
pressure ulcers, cancer, AIDS, GI
complications, hypermetabolic stress,
immobility, osteoporosis, neurological
impairments, visual impairments
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

21. Abnormal Laboratory Values
♦ Visceral proteins (albumin, prealbumin,
transferrin)
♦ Lipid profile (cholesterol, HDL, LDL,
triglycerides)
♦ Hemoglobin, hematocrit, other blood tests
♦ BUN, creatinine, electrolytes
♦ Fasting and PP blood glucose levels, A1C
Hammond KA. Assessment: Dietary and Clinical Data. In Krause, 12th edition, p. 386

22. Medications
♦ Chronic use
♦ Multiple and concurrent use
(polypharmacy)
♦ Drug-nutrient interactions

23. Joint Commission Standards Drive
Nutrition Screening in Health Care
Organizations

24. Nutrition Care Process: Screening
♦ The Joint Commission (TJC) requires
that nutritional risk be identified within
24 hrs in all hospitalized pts
♦ TJC also requires nutrition screening in
accredited ambulatory facilities
♦ Standards of Care protocols determines
process; evidence-based guidelines
♦ Use simple techniques, available info
♦ May be done by other than RD
♦ Usually simple form with targeted info

25. Standard PC.2.20:The hospital defines in
writing the data and information gathered
during assessment and reassessment
Elements of Performance
♦ The information...to be gathered during the initial
assessment includes the following, as relevant...:
– Each patient's nutrition and hydration status, as
appropriate
♦ The hospital has defined criteria for when
nutritional plans must be developed

26. Standard PC.2.120: The hospital defines in
writing the time frame(s) for conducting the
initial assessment(s).
Elements of Performance
♦ A nutritional screening, when warranted by the
patient's needs or condition, is completed within
no more than 24 hours of inpatient admission
– CAMH online version, 2006

27. Standards Relating to Nutrition
Assessment
Standard PC.2.130
♦ Initial assessments are performed as defined
by the hospital.
Standard PC.2.150
♦ Patients are reassessed5
as needed.
CAMH online version, 2006

28. Screening for Malnutrition in Acute Care
Settings
“The consensus of the committee is that while
screening for nutrition risk in the acute care
setting is crucial, the JCAHO requirement
that nutrition screening be completed within
24 hours of admission is not evidence-based
and may produce inaccurate and misleading
results.”
• Institute of Medicine, 1999

29. Commonly Used Criteria for Nutrition
Risk Screening-Acute Care
♦ Diagnosis
♦ Weight
♦ Weight change
♦ Need for diet
modification or
education
♦ Laboratory values (s.
albumin, cholesterol,
hemoglobin, TLC
♦ Problems with
chewing or
swallowing
♦ Diarrhea
♦ Constipation
♦ Food dislikes or
intolerance
Institute of Medicine, 1999

30. Nutrition Screening and Assessment Tool
Courtesy Carolinas Medical Center, Charlotte, N.C.

31. Prevalence of Nutrition Risk in
Acute Care
♦ The prevalence of nutrition risk will vary
depending on the population screened and
the criteria used for screening
♦ In published studies, prevalence of
malnutrition in hospitalized patients has
ranged from 12% to more than 50%
♦ There is little published data regarding
nutrition screening for other purposes

32. Malnutrition in Hospitalized Pts
Population Criteria Prevalence
Warnold et
al, 1984
Noncancer pts in
Sweden (n=215)
Wt loss, Wt/Ht,
s. alb, AMC
12%
Messner et
al, 1991
VA patients
(n=500)
s. alb, TLC, wt
loss
55%
Robinson et
al, 1987
Medicine pts
(n=100)
Wt loss, lab data,
anthropometrics
40%
Chima et al,
1997
Medicine pts
(n=173)
s. alb, wt loss,
wt/ht
32%
Thomas, et
al, 2002
Subacute pts
(837)
Lab data,
anthropometrics,
MNA score
29%

33. CNM Nutrition Screening Survey
Chima and Seher, 2007
♦ Blast email sent to 1668 members of the
Clinical Nutrition Management dietetic
practice group in May, 2007
♦ 522 usable surveys were returned, for a
response rate of 31%

34. Does Your Health Care Organization
Screen Patients for Nutrition Risk?
99
63
0
10
20
30
40
50
60
70
80
90
100
Inpatient (n=522) Ambulatory (n=345)
% of Respondents
(with accredited ambulatory clinics)

35. Screening in Acute Care

36. Who Has Primary Responsibility for
Nutrition Screening (Inpatient)?
6.5
74
83
68.5
17
10 8
5
0
10
20
30
40
50
60
70
80
90
Nursing Nutrition Other
1987 CNM survey
(n=46)
2003 CNM survey
(n=110)
2007 CNM (n=514)
*In the 1987 survey, only 60% of 77 respondents
reported admission nutrition screening
% of
Respondents

37. Criteria Used by Nursing in
Nutrition Screening (n=442)
Criterion N %
History of weight loss 418 95%
Poor intake pta 360 81%
Patient is on nutrition support 349 79%
Chewing/swallowing issues 333 75%
Skin breakdown 319 72%
Pregnant/lactating mother off OB 197 45%
Diagnosis 167 38%
Need for education 160 36%
Geriatric surgical patient 148 33%

38. Criteria Used by Nursing in
Nutrition Screening (n=442)
Criterion N %
Specific diet orders 105 24%
Food allergy 103 23%
NPO/Clear liquid in-house 84 19%
Weight for height criterion 75 17%
Age (premature or geriatric) 71 16%
Visceral proteins (albumin, PAB) 51 12%
Infant on concentrated formula 43 10%
Body mass index 38 9%
Other 111 25%

39. How Were Nursing
Screening Criteria Chosen?
0
10
20
30
40
50
60
70
Readily
Available
Easy to
Use
No Clinical
Expertise
Evidence
Based
Tested
and
Validated
Seem to
Work Well
TJC
Requires
It
% of
respondents
(n=442)

40. Where Are Nursing Screening
Results Documented in the MR?
0
10
20
30
40
50
60
70
Nursing Admitting
Assessment
Other Specific Form Computerized
Record
Interdisciplinary
Form
% of
Respondents
(n=442)

41. How Are + Nursing Screens
Communicated to Nutrition Staff?
0
10
20
30
40
50
60
70
80
90
Fax Phone Computer Other N/A
% of
Respondents,
n=438

42. If Nursing Screens, Do Nutrition
Staff Do a Secondary Screen?
57
43
0
10
20
30
40
50
60
Yes No
% of respondents
(n=441)

43. Why Do Nutrition Staff (NS) Do
Secondary Screening?
% n
NS screens identify patients missed
by NU screens
62% 158
Criteria used by NS may not
identify pts at nutrition risk
46% 117
NU screens may not be completed 50% 129
NU screens may be unreliable 34% 86
NS staff may not be notified of +
NU screens
46% 118
Other 24% 61

44. Characteristics of
Secondary Nutrition Screening
% n
Nutrition staff (NS) screens use
different data than NU
61% 156
Nutrition staff (NS) collect the
same data as NU
12% 30
NS utilize criteria that require
nutrition expertise
55% 139
Other 6% 14

45. Who Is Responsible for
Secondary Nutrition Screening?
0
10
20
30
40
50
60
70
Dietitians DTR BS Nutr Clerk Other
%of
Respondents
(n=256)

46. Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
Criterion N %
Diagnosis 223 86%
NPO/Clear in-house 192 74%
Patient on nutrition support 190 74%
Specific diet orders 161 62%
Visceral proteins (albumin, PAB) 158 61%
Chewing/swallowing issues 139 54%
Skin breakdown 137 53%
History of weight loss 136 53%
Weight for height criterion 119 46%

47. Criteria Used by Nutrition Staff in
Secondary Screening (n=258)
Criterion N %
Poor intake prior to admission 110 43%
Need for education 95 37%
BMI 93 36
Food allergy 89 35%
Geriatric surgical patient 83 33
Pregnant/lactating outside OB 79 31%
Age (premature or geriatric) 78 30%
Infant on concentrated formula 44 17%
Other 40 15%

48. Where Is Secondary Screening
Documented in the Medical Record?
15
28 28
23
5
0
5
10
15
20
25
30
Chart
Form
Computer Progress
Note
Not Doc Interd
Form
%of
Respondents
n=260

49. Criteria Used by Nursing/Nutrition to Identify
Patients at Nutrition Risk (Inpatient)
95
53
81
43
75
54
79
74 72
53
45
31
0
10
20
30
40
50
60
70
80
90
100
Wt Loss Poor Intake
PTA
Chewing/
Swallowing
EN/PN Skin Brkdwn Preg/
Lactating
% of Resp
Nursing Scrn
n= 442
% Resp
Nutrition
Screen
n=252

50. Criteria Used By Nursing/Nutrition to
Identify Patients at Nutrition Risk (Inpatient)
24
62
38
86
33 33 36 37
0
10
20
30
40
50
60
70
80
90
100
Spec Diets Dx Ger Surg Education
% Resp
Nursing Scrn
n=442
% Resp
Nutrition
Scrn n=252

51. Criteria Used By Nursing/Nutrition to
Identify Patients at Nutrition Risk
(Inpatient)
16
30
17
46
23
34
10
17 19
74
12
61
0
10
20
30
40
50
60
70
80
90
100
Age wt/ht Food
Allergy
Conc
Formula
NPO/Clr Visceral
Pro
% Resp
Nursing
Scrn
n=442
% Resp
Nutr
Scrn
n=252

52. How Many Levels of Risk Does
Your Screening System Include?
43
41
16
0
5
10
15
20
25
30
35
40
45
Two Three Four or More
% of Respondents
n=522

53. Has Your Inpt Screening System Been
Validated for Sensitivity/Specificity?
26
74
26
74
0
10
20
30
40
50
60
70
80
Sensitivity Specificity
Yes
No
% of respondents

54. How Well Do Inpt Screening Criteria
Effectively Identify Nutrition Risk?
71
34
15
54
1
8
13
4
0
10
20
30
40
50
60
70
80
All/Most of the
Time
Sometimes Half to Never n/a
Nutrition Staff
criteria
Nursing Staff
Criteria

55. Validation of Nutrition Screening Tools
in Acute Care
Criteria Population Comment
Kovacevich
et al, NCP
1997
Dx, intake,
IBW, Wt hx
Adult acute
care pts
n=186
Sensitivity 84.6%;
specificity 62.6 by
PAB. (Nearly full
page screen form)
Ferguson
M.
Nutrition 1
Jun 1999
Appetite,
unintentional
wt loss
Adult acute
care pts
n=408
(Australia)
High inter-rater
reliability (93-97%)
High sensitivity/
specificity vs SGA
Laporte M,
JNHA 1 Jan
2001
BMI + wt
loss
BMI +
albumin
Elderly
acute /LTC
n=142
(Canada)
Validity 60.5%-
93.1% vs RD
nutrition assessment

56. Validation of Nutrition Screening Tools
in Acute Care
Criteria Population Comment
Mezoff A.
Pediatrics 1
Apr 1996
Lngth/ht,
wt/ht %ile,
wt hx, dx, lab
data
PICU pts w/
RSV
High nutr risk
score associated
with poor
outcome; (nearly
full page form)
Burden ST.
J Hum Nutr
Diet 2001
BMI,
MUAC, wt
hx, intake vs
needs
100
med/surg/
elderly
hospital pts
(UK)
Sensitivity 78%;
specificity 52% vs
nutrition
assessment
(overestimates pts
at moderate risk)

57. Adult-Geriatric
Inpatient Screening Criteria at MHS
♦ 1. Pregnant or Lactating mother admitted to unit
other than antepartum or mother-baby
♦ 2. Significant unintentional weight loss >=10 lb. in
past 1-2 months
♦ 3 Patient DESIRES EDUCATION on a
therapeutic diet
♦ 4. Patient unable to take oral or other feedings
>=5 days prior to admission
♦ 5. Patient on enteral or parenteral feedings
♦ 6. Geriatric patient (80 years plus) admitted for
surgical procedure
♦ 7. Patient with skin breakdown (decubitus ulcer)

58. Infant-Child-Adolescent
Inpatient Screening Criteria at MHS
♦ 1. Recent weight loss
♦ 2. On special diet and NEEDS EDUCATION
♦ 3. Has feeding tube or on parenteral feedings
♦ 4. Diabetic
♦ 5. Receives high calorie feeds/concentrated
formula
♦ 6. Food allergy
♦ 7. Failure to thrive
♦ 8. Feeding problems/intolerance
♦ 9. Teen who is pregnant or lactating
♦ 10. Child being breast fed

59. MHS Adult Ambulatory Screen

60. MHS Peds Ambulatory Screen

61. MetroHealth Screening Prompt
Criteria in Peds Ambulatory Clinics
Children <2 Years
♦ <10 %ile weight/length
♦ >90 %ile weight/length
Children 2-18 Years
♦ < 10 %ile BMI/age
♦ >85 %ile BMI/age

64. Nursing Admission Screens: Most Common
Criteria MHMC (Feb 17-Mar 2, 2003)
8
39
13
25
23
8
6 5
0
5
10
15
20
25
30
35
40
EN/PN Wt Loss Intake Education Skin Preg/Lact Age Conc
Feeds
# of Pts, n=101

65. % of Positive Nutrition Screens Classified as
High Risk after Review (by Criterion)
100
70
82
53
61
17
0
0
10
20
30
40
50
60
70
80
90
100
EN Skin Intake Wt Education Age Preg/Lact
% of
Positive
Screens

66. Nutrition Screening at MetroHealth
♦ Consistent with national practice in terms of
criteria, procedures, and time frames
♦ With the exception of TJC-mandated
criteria, specificity ranges from 50-100%
♦ TJC-mandated criteria are poor predictors
of nutrition risk
♦ No data on sensitivity (e.g. what percentage
of at risk pts are we discovering?)

67. Issues in Nutrition Screening
♦ Most nutrition screening in acute and
ambulatory settings is done by staff other
than nutrition professionals
♦ Based on a national survey, identified at-
risk patients are referred to nutrition
professionals less than half the time

68. Issues in Nutrition Screening
♦ Much of the research that exists validates
more comprehensive nutrition screening tools,
e.g. MNA in the elderly
♦ Little research has been done to validate or
evaluate nutrition screening as it currently
exists in most acute care institutions: a
process using limited data obtained on
admission by nursing staff.
♦ There is no “gold standard” of nutrition status
that can be used as a benchmark

69. ADA Screening Evidence Analysis
Work Group
♦ Convened fall, 2007
♦ Will develop definitions and formulate
questions for evidence analysis regarding
nutrition screening

70. Members of Screening EAL Work
Group
♦ Chair: Pam Charney, PhD, RD, CNSD, consultant
♦ Vicki Castellanos, PhD, RD, Florida International
University, educator
♦ Cinda Chima, MS, RD, University of Akron,
educator
♦ Maree Ferguson, MBA, PhD, RD, Queensland,
Australia, clinical manager
♦ Nancy Nevin-Folino, MEd, RD, CSP, LD, FADA,
Children’s Hospital, Dayton, Oh, practitioner
♦ Judy Porcari, MBA, MS, RD, Clinical Manager
♦ Annalynn Skipper, PhD, RD, FADA, Consultant