1. Identifying Malnourished Patients Focus on the Canadian Nutrition Screening Tool and Subjective Global Assessment

2. Nutrition Screening ≠
Nutrition Assessment

3. Better Practice…
Screening
At risk
Assessment

4. Nutrition Screening: What is it?
A process to identify an individual who is:
At risk of malnutrition (risk factors are present that impair intake and/or increase the body’s needs for nutrients and/or energy)
Malnourished
Likely to benefit from further nutrition assessment and treatment
It is a rapid and simple process conducted by admitting or front line staff, typically a nurse not a nutrition professional.
Nutrition screening identifies those may be on the continuum between malnutrition risk (risk factors are present that can lead to malnutrition) and overt malnutrition…nutrition risk or risk of malnutrition is the presence of risk factors that sufficiently impair food intake and that will change anthropometry, body weight, body function etc. (i.e., subclinical malnutrition) if they are not addressed. Overt malnutrition is identified when there is physical signs or other evidence of the functional deficit resulting from inadequate intake to meet the body’s needs.
At risk: Susceptibility to a disease or event e.g. Malnutrition, falls, etc.
Being at risk of malnutrition sounds less urgent than actually being malnourished...but, findings provide supporting evidence that “nutritional risk” should also be considered a serious health risk. (Bales 2001)
A.S.P.E.N / ADA EAL © 2012 / Chen et al / ADA 2003 / ESPEN 2008 / Reuben, 1995 /Mueller et al., 2011 / Kondrup et al., 2003 / Chen et al., 2001 4

5. Why screening is relevant…
Malnutrition has negative consequences
Treatment can improve malnutrition and consequent health outcomes
Malnutrition is prevalent enough that it makes sense to screen
Malnutrition is under-recognized outside of the dietetic/nutrition professional community
Laur & Keller, 2017 (unpublished)

6. Which Patients Receive a Dietitian Consult NUTRITION CARE IN CANADIAN HOSPITALS STUDY
Type of hospital, presence of diet technician, surgery vs. medical patient did not influence if a dietitian consult occurred
Only 1 of 18 hospitals had standardized screening program, not fully linked to dietitian referral
Dietitians saw 23% of patients, typically based on referral
45% of these patients were well nourished
36% had mild/moderate and 19% had severe malnutrition
75% of mild/moderate and 60% of severely malnourished patients were missed using a referral process
Nutrition screening can help make sure dietitians are seeing the RIGHT patients.
NOTE this analysis based on patients NOT receiving enteral or parenteral nutrition as 100% of these patients saw the dietitian
(Keller et al., Clin Nutr 2015)

7. Main considerations in selecting a screening tool
Easy
Front-line personnel can use
Uses existing personnel, processes
Inexpensive to collect on all clients
On electronic medical chart
Implemented as part of a general work-up
Data readily available
Appropriate for the setting in which it is to be used
Specific to the population

8. Canadian Nutrition Screening Tool (CNST)
Simple, easy to use, 2 question tool
These results indicate that screening can be readily and reliably completed by a nursing with minimal training.
Rigorously validated and tested for reliability in 3 Canadian hospitals using regular personnel (n=140).
Criterion validity: SE 73% & SP 86%;
Inter-rater reliability (n = 122): Kappa = 0.88; 95% CI ( )
Nursing personnel say that the CNST was easy to use
The criterion for validation was subjective global assessment completed by a dietitian. Many front-line nurses were involved in this study demonstrating that no specialized skill is required.
Laporte et al EJCN

9. Canadian Nutrition Screening Tool
CNST consists of two questions. A patient is considered at risk when both questions are YES. A single question being YES does not indicate any special treatment or consideration of risk. Note, unintentional weight loss is what is a risk. Intentional weight loss would be recorded as NO on the form. Note, low food intake can be due to poor appetite, or other barriers to food intake. Any of these reasons for low intake for MORE THAN a WEEK indicate risk and the answer is YES. If intake has been less than usual BUT for less than one week, the answer is NO.
Laporte et al EJCN

10. CNST: Implementation Introduce the CNST in the admission assessment
EMR facilitates the screening and referral process
Develop a referral process
If 2 YES answers with CNST → automatic referral to dietitian
Think about focusing on some specific wards initially…
Re-screening weekly during hospitalisation captures:
Inadequate food intake during admission
Weight loss during admission
Note: If Integrated Nutrition Pathway for Acute Care (INPAC) is implemented, monitoring of food intake replaces re-screening

11. Other Validated Nutrition Screening Tools (for hospital use)
Malnutrition Screening Tool (MST)
Simple Screening Tools (#1 & #2)
Mini Nutritional Assessment – Short Form (MNA-SF)
Nutritional Risk Screening (NRS 2002)
Malnutrition Universal Screening Tool (MUST)
Short Nutritional Assessment Questionnaire (SNAQ)
Some Challenges
Require detailed information
Time to complete
May be difficult to complete at first contact

12. 12

13. Principles of “Ethical Screening”
Target people in potential need of nutrition assessment and treatment
Identify nutrition problems and appropriate course of action (e.g. assessment, treatment)
Have a referral/treatment algorithm in place to promote appropriate and efficient referral
e.g. Integrated Nutrition Pathway for Acute Care
Include follow-up and monitoring post treatment
Ethical screening involves voluntary participation in a screening process.
It also includes a responsibility to:
1) Target people in need of nutrition assessment and treatment through the consistent use of a valid and reliable screening tool.
2) Provide those identified to be at risk with reasonable options for assessment and treatment.
3) Follow-up with these individuals to ensure that their nutritional needs are met with the intervention.
Keller HH. et al Nutrition Today.

14. I N P A C Keller et al, 2016 Nutrition Journal
Please see the INPAC training for additional details regarding this pathway.
Keller et al, 2016 Nutrition Journal

15. Purposes of Assessment
Confirm malnutrition
All screening tools will have false positives= people who triggered risk but are not malnourished
Clarify processes  inflammation and/or intake as root causes of wasting and weight loss
Identify potential reasons for poor food intake e.g. nausea, dysphagia, self-feeding difficulties
Identify intervention modes, best approaches
Monitor intervention success – compare to a baseline
Keller, H.H. Aging Well with Nutrition. Second Edition. 2009

16. Subjective Global Assessment (SGA)
SGA is the gold standard for diagnosing malnutrition in hospital.
SGA predicts a variety of nutrition related outcomes and this has been demonstrated in several studies worldwide
Trained professionals assess food intake, functional status, and body composition.
Note: Detailed information on SGA is provided in a separate presentation

17. Subjective Global Assessment: Components
History: Changes in dietary intake
Gastrointestinal and other symptoms that impair food intake/absorption
Functional capacity
Potential stress of disease and/or cachexia
Changes in weight over past 6 months
Trajectory of recent changes
Physical: Loss of subcutaneous fat: triceps, chest, trunk
Muscle wasting: deltoids, quadriceps, biceps, …
Edema: ankle, sacral, ascites; clarifies potential cause of weight changes
Detsky et al.1987 JPEN

18. SGA A (Well Nourished) OR no decrease in food intake
< 5% weight loss
no/minimal symptoms affecting food intake
no deficit in function
no deficit in fat or muscle mass OR
An individual with some criteria for SGA B or C but with recent adequate food intake; non-fluid weight gain; significant recent improvement in symptoms allowing adequate oral intake; significant recent improvement in function; and chronic deficit in fat and muscle mass, but with recent clinical improvement in function.
*In the elderly prominent tendons and hollowing is the result of aging and may not reflect malnutrition.

19. SGA B (Moderately Malnourished)
definite decrease in food intake
5% - 10% weight loss without stabilization or gain
mild/some symptoms affecting food intake
moderate functional deficit or recent deterioration
mild/moderate loss of fat and/or muscle mass OR
An individual meeting criteria for SGA C but with improvement (but not adequate) of oral intake, recent stabilization of weight, decrease in symptoms affecting oral intake, and stabilization of functional status.
*In the elderly prominent tendons and hollowing is the result of aging and may not reflect malnutrition.

20. SGA C (Severely Malnourished)
severe deficit in food/nutrient intake
> 10% weight loss which is ongoing
significant symptoms affecting food/nutrient intake
severe functional deficits OR
Recent significant deterioration obvious signs of fat and/or muscle loss.
*In the elderly prominent tendons and hollowing is the result of aging and may not reflect malnutrition.

21. Why should we use SGA? An example from the Nutrition Care in Canadian Hospitals study
SGA when adjusted for other covariates predicts
Length of stay (Allard et al., JPEN 2015)
As relevant as key predictors such as age, disease state for key health outcomes (Allard et al., JPEN 2015)
Only food intake and handgrip add to the predictive ability of SGA for the outcomes of length of stay and readmission (Jeejeebhoy et al., AJCN 2015)
Other objective indicators do not add to the predictive value of SGA (Jeejeebhoy et al., AJCN 2015)
SGA is the start of a comprehensive assessment, which will include other indicators and investigations to determine micronutrient malnutrition, cause of malnutrition etc.
An association that is significant when adjusted for other factors such as disease state, means that SGA itself has predictive power for the outcomes. This means that the effect of SGA is present when also considering age, disease and the other covariates that were included in the analysis.
SGA may not provide sufficient history to understand how to intervene with a patient. Further clinical history, biochemistry, anthropometry and assessment of eating risks such as dysphagia are typically included in a comprehensive dietetic assessment which is individualized to the patient.

22. Summary
Malnutrition is prevalent in hospital and detection and diagnosis are needed for treatment.
Screening ensures malnourished patients are not missed.
Screening ≠ Assessment
The Canadian Nutrition Screening Tool is a simple, reliable and valid tool consisting of two questions.
Screening should be followed by diagnosis and treatment if malnutrition is present.
SGA is the gold standard for diagnosing malnutrition in hospital.

23. Acknowledgements These slides were created and approved by:
Heather Keller
Celia Laur
Bridget Davidson
The More-2-Eat Education Group*
* Includes input from the UK Need for Nutrition Education/Innovation Programme (NNEdPro) Group
The More-2-Eat study was funded by the Canadian Frailty Network (known previously as Technology Evaluation in the Elderly Network, TVN), supported by Government of Canada through Networks of Centres of Excellence (NCE) Program

24. References
Allard, J.P., Keller, H.H., Teterina, A. Jeejeebhoy, K.N., Laporte, M., Duerksen, D. et al. Factors associated with nutritional decline in hospitalised medical and surgical patients admitted for 7 d or more: a prospective cohort study. BJN. 2015, 114(10), Allard JP, Keller H, Jeejeebhoy KN, Laporte M, Duerksen D, Gramlich L, Payette H, Bernier P, Vesnaver E, Davidson B, Terterina A, Lou W. Malnutrition at hospital admission: contributors and impact on length of stay. A prospective cohort study from the Canadian Malnutrition Task Force. J Parenter Enteral Nutrition. 2016;40(4): Detsky AS, Baker JP, Johnston N, Whittaker S, Mendelson RA, Jeejeebhoy KN. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr. 1987;11(1):8-13. Jeejeebhoy KN, Keller, HH, Gramlich L, Allard JP, Laporte M, Duerksen D et al. Nutritional assessment: comparison of clinical assessment and objective variables for the prediction of length of hospital stay and readmission. AJCN. 2015; doi: /ajcn Keller HH, McCullough J, Davidson B, Vesnaver E, Laporte M, Gramlich L, Allard J, Bernier P, Duerksen D, Jeejeebhoy K. The integrated nutrition pathway for acute care (INPAC): Building consensus with a modified delphi. Nutrition Journal. 2015;14(63). Keller HH, Allard JP, Laporte M, Davidson B, Payette H, Bernier P, Jeejeebhoy K, Dureksen DR, Gramlich L. Predictors of dietitian consult on medical and surgical wards. Clin Nutr. 2015;34(6): Keller HH. Aging Well with Nutrition. Second Edition Keller, H.H., Brockest, B., & Haresign, H. (2006). Building capacity for nutrition risk screening. Nutrition Today, 41[4], Laporte M, Keller H, Payette H, Allard JP, Duerksen DR, Bernier P, Jeejeebhoy K, Gramlich L, Vesnaver E, Teterina A. Validity and reliability of the new canadian nutrition screening tool in the ‘real-world’ hospital setting. Eur J Clin Nutr. 2015;69(5): Laur C, Keller HH. Making the Case for Nutrition Screening of Older Adults in Primary Care. Unpublished.