September, 19th 2016 Liz Hudson MPH, RD Clinical Nutrition Screening, Subjective Global Assessment, and Intake assessment September, 19th 2016 Liz Hudson MPH, RD

Objectives Define and discuss the nutrition screening process for hospitalized patients Describe the steps and goals of a comprehensive nutrition assessment Subjective global assessment Review methods to assess dietary intake

Nutrition Screening: Differences in definitions “A process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated” -American Society for Parenteral and Enteral Nutrition (A.S.P.E.N) “The process of identifying patients, clients, or groups who may have a nutrition diagnosis and benefit from nutrition assessment and intervention by a registered dietitian (RD).” -Academy of Nutrition and Dietetics (The Academy) Quality Management Committee

Key considerations for nutrition screening Screening may be conducted in any practice setting as appropriate Tools should be quick, easy to use, valid, and reliable for the patient population or setting Tools and parameters are established by RDs, but the screening process may be performed by other personnel dietetic technicians, registered nurse, and other trained personnel Nutrition screening and re-screening should occur within an appropriate time frame for the setting The Joint Commission mandates nutrition screening within 24 hours of admission to an acute care center

Nutrition Screening Nutrition screening can be implemented to identify patients or clients with various nutrition diagnoses.  Most important function is to identify risk for malnutrition.  By identifying malnutrition risk early through nutrition screening, nutrition intervention can be implemented immediately Increased potential to improve health outcomes length of stay, readmission rates, and hospital costs In the absence of nutrition screening, malnutrition may be overlooked particularly in patients who fall within the traditional "healthy" weight range or who remain overweight even after losing significant amounts of weight

Other Considerations Complexity: If the tool requires calculations (eg, BMI, percentage weight loss) or is lengthy with many parameters, it is likely to be more time consuming and subject to error. Can result in a low compliance with screening Nutrition screening tools that are simple, quick, and easily completed by nonprofessional staff, patients, or family are preferred

Other considerations Patient population: Tools selected for clinical use should have been tested in patient populations similar to the ones where they will be applied Sensitivity: As screening is only the first step to identify people who require nutrition assessment, a screening tool needs to achieve a high sensitivity (i.e., identifies all at risk), even if this is at the expense of a high specificity (or false positives) , accurate identification of all patients who are malnourished (sensitivity) takes precedence over misclassifying well-nourished patients (specificity)

Other factors to consider… Who will perform screening? How can screening be incorporated into current procedures? What action will be taken for individuals identified as at risk?

Commonly Used Nutrition Screening Tools: Malnutrition Screening Tool (MST) Reliability measures the agreement between the results of the tool when administered by different users (inter-rater) or on different occasions (intra-rater). The Inter-rater reliability was measured by the kappa value, where a value of 0 indicates no agreement and 1 indicates perfect agreement. Based on the available evidence, the MST was the only tool shown to be both valid and reliable for identifying nutrition problems in acute care and hospital-based ambulatory care settings

Commonly Used Nutrition Screening Tools: Malnutrition Universal Screening Tool (MUST) The MUST was developed by the Malnutrition Advisory Group, a standing committee of the British Association for Parenteral and Enteral Nutrition (BAPEN) in 2003. It is a validated, evidence-based tool designed to identify adults who are malnourished or at risk of malnutrition. The tool has face validity, content validity, concurrent validity with a range of other screening tools, and predictive validity. In hospitals, MUST predicts length of hospital stay, discharge destination, and mortality after controlling for age. In community care, it predicts rate of hospital admissions and general practitioner visits, and shows that appropriate nutrition intervention improves outcome. The tool is internally consistent and reliable, with good reproducibility between healthcare providers It has been validated across care settings (ie, primary care, home care, acute care, long-term care), which has the benefit of allowing comparable nutrition screening data across care settings. Three criteria are used by MUST to determine the overall risk of malnutrition: body mass index (BMI), unintentional weight loss, and acute disease effect.

Nutrition Assessment First step in the nutrition care process: Nutrition Diagnosis Nutrition Intervention  Nutrition Monitoring & Evaluation It is defined as “a systematic method for obtaining, verifying, and interpreting data needed to identify nutrition-related problems and their causes and significance” – (JADA 2008) It is an ongoing, nonlinear, dynamic process that involves initial data collection as well as continual reassessment and analysis of the patient's/client’s status compared with specified criteria

Nutrition Assessment Provides the foundation for the nutrition diagnosis at the next step of the nutrition care process

Nutrition Assessment Nutrition assessment data are obtained from a variety of sources, including: Screening or referral form Patient/client interview Medical or health records Consultation with other caregivers, including family members Community-based surveys and focus groups Statistical reports, administrative data, and epidemiological studies

Nutrition Assessment: What data is included Food and nutrition-related history Assessment of nutritional adequacy (diet history) Anthropometric data (height, weight, BMI) Biochemical data Medical tests and procedures Nutrition-related physical examination findings Patient/client’s history (medical, social)

Nutrition Assessment Goal: Identify any specific nutrition risk(s) or clear existence of malnutrition 1. Identify individuals who require aggressive nutrition support 2. Restore or maintain an individual’s nutrition wellness 3. Identify appropriate medical nutrition therapy

A, B, C, D’s of Nutrition Assessment Anthropometric data Biochemical parameters Clinical/physical assessment Dietary history/assessment The above pieces comprise the ABCD’s of assessment

Tools for Assessment of Nutritional Status Subjective Global Assessment (SGA) validated nutrition assessment tool that correlates well with nutrition risk indices and other assessment data in hospitalized patients Mini Nutritional Assessment (MNA): reliable and quick method for evaluating nutritional status in older adults, >65 years old Evaluates independence, medication therapy, pressure ulcers, number of full meals consumed per day, protein intake, fruit and vegetable intake, fluid intake, mode of feeding, self-view of nutritional status, comparison with peers, mid-arm and calf circumferences http://www.mna-elderly.com/forms/MNA_english.pdf

Assessment of Medical/Health History Medical History Usually includes the following information: These histories shed light on nutritional concerns Chief complaint Present or past illness Current health Allergies Past or recent surgeries Family history of disease Psychosocial data Review of problems by body system from the patient’s perspective Alcohol and drug use Increased metabolic needs Increased nutrient losses Chronic disease Recent major surgery or illness Disease or surgery of GI tract Recent significant weight loss

Medication History Important because food and drugs can interact in many ways that affect nutrition status and drug therapy effectiveness Important to any nutrition assessment

Social History SES Ability to purchase food – then prepare it! Living alone Physical or mental handicaps Smoking, drugs, alcohol Lack of socialization at meals Unsuitable or unstable housing Maybe you need to teach them to count carbs and they cannot read!

Assessment of Dietary Intake The book states that balance between nutrient intake and nutrient requirements = nutrition status Infection, disease, fever, physiologic stress Nutrition Requirements Nutrient Intake FOOD INTAKE: Disease, SES, behavior, emotions, cultural pressures Growth Psychologic stress ABSORPTION: disease, physiologic stress, mechanical problems Body maintenance and well-being

Assessment of Dietary Intake Individual food intake is influenced by: Economic situation Eating behavior Emotional climate Cultural influences Effects of disease states on appetite Ability to acquire and absorb nutrients

Methods to Assessment Dietary Intake Diet History: one of the best means of obtaining dietary information reviews of an individuals usual patterns of food intake and the food selection variables that dictate food intake Specific information is important: see box 4-2 in book

Diet History Information Allergies, intolerances, food avoidances: gather information on foods being avoided, why they are being avoided, how long they have been avoided Appetite: Assess if good, poor, any changes Factors that affect appetitenot hungry? Early satiety? Taste changes? Attitude toward eating: Disinterest in eating? Irrational ideas about food, eating, body image

Diet History Information Chronic disease: Treatments, length of treatment time Dietary modifications: self-imposed or physician prescribed, date of modification Past nutrition and diet education: compliance, barriers to compliance Dental and oral health: problems with chewing, dry mouth, pain with eating Gastrointestinal Factors: frequency of problems, avoidance of specific foods swallowing difficulty, choking or food sticking Heartburn, gas, bloating Problems with nausea, vomiting, diarrhea, constipation: certain foods make it worse?

Diet History Information Home Life and Meal Patterns Who does the shopping, cooking? Ability to prepare foods? Socialization during meals

Assessment of Dietary Intake: Methods Retrospective: 24-hour recall Food Frequency Questionnaire (FFQ) Prospective/concurrent: Food Diary Calorie count (Nutrient Intake Analysis)

Retrospective Methods 24-hr recall Obtain information on the specific foods and amounts of foods consumed within the past 24 hours What are the pros and cons? Food Frequency Questionnaire Retrospective review of intake frequency (i.e. food consumed per day, per week, per month) Mostly utilized in research studies Not always practical in the inpatient setting Pros and cons? Pros: quick, easily done at the bedside Cons: inability to recall foods, may not be indicitive of typical intake or patterns, people might exaggerate low intakes and underreport high intakes of foods

Prospective/Concurrent Food Diary Documenting dietary intake as it occurs, often used in outpatient settings (3 days  2 weekday, 1 weekend day) Calorie Count Inpatient setting: information about actual intake is collected through direct observation or an inventory of foods eaten based on what remains on a patient’s tray (nurse, family, or dietetic tech record) Usually 3 days Nutritional supplements, snacks, or any supplemental nutrition support (EN or PN) should also be included Not easy to do, and should only be used in situations where nutrition support is being considered (starting or stopping)

Nutrition Assessment Components Review dietary intake for factors that affect health conditions and nutrition risk Evaluate health and disease condition for nutrition-related consequences Evaluate psychological, functional, and behavioral factors related to food access, selection, preparation, physical activity, and understanding of health condition

Nutrition Assessment Components Evaluate patient’s knowledge, readiness to learn, and potential for changing behaviors Identify the standards by which data will be compared Identify possible problem areas for making nutrition diagnoses

Critical Thinking in the Nutrition Assessment Observing for nonverbal and verbal cues that can guide and prompt effect interviewing methods Distinguishing between important and unimportant data

SGA video and handout