Providing the right nourishment

Nurses are being encouraged to embrace nutrition screening and to undertake research studies in this field, writes Annie May.

It is well recognised that malnourished patients recover more slowly from illness and experience more complications.

Yet, despite this, routine screening of hospital patients for nutrition risk early in their admission is not universal in Australia.

“Evidence shows that nutrition screening is obligatory as best practice and that it can benefit undernourished patients through early detection and treatment,” says Robyn Cant, senior research fellow at Monash University’s School of Nursing and Midwifery and author of the paper ‘Investing in patients’ nutrition: nutrition risk screening in hospital’, published in the recent issue of Australian Journal of Advanced Nursing.

But, she says, there is a lack of data about patients’ response to nutritional interventions and more research is required to determine the consequences of screening.

“Research is desperately needed to show how to improve patient outcomes and to demonstrate the best intervention strategies to use to replete malnourished patients,” Cant says.

According to the Dietitians Association of Australia, malnutrition is a major public health issue in Australia. Known as the silent epidemic, malnutrition is estimated to affect 35 to 43 per cent of patients in Australian hospitals.

“It has a devastating impact on quality of life and leads to poor medical outcomes, most of which are very expensive to manage, including: longer hospital stays; increased likelihood of being readmitted; increased risk of falls, infection and complication rates; a negative impact on the mental state in the elderly; and increased death rates,” says the DAA.

As a result, the association is calling for health professionals to be educated on how to identify, screen and referring those at risk.

Currently no standard or single quick measure can indicate presence of malnutrition. This demands a detailed patient assessment using physical examination and aspects of the medical history such as gastrointestinal symptoms and biochemistry. Assessment is usually carried out by a dietitian or a clinical nutrition nurse specialist.

A number of tools have been developed to screen patients for risk of malnutrition, each using several indices associated with characteristics of under-nutrition.

Some use objectively obtained criteria such as body weight, body mass index (BMI) or other anthropometric measures such as skin folds or arm circumference and/or biochemical measures. Others use subjective criteria such as reported weight loss and reported appetite change.

Three tools developed for hospital patients, and highlighted in Cant’s paper are the Malnutrition Screening Tool (MST), Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment.

The MST identifies adults who are at risk of malnutrition using subjective data and has been the focus of evaluation studies in Australia and overseas, writes Cant.

“It has a sensitivity of 93 per cent in identifying patients with a score of two as being at nutrition risk, with specificity of 93 per cent and is recommended as an easy to use tool for the screening of adult hospital patients.

“As it does not require a patient to be weighed it can be completed by a patient, carer, nurse or other health professional. “

Other nutrition screening tools valid for hospital patients are the Simplified Nutritional Assessment Questionnaire (SNAQ) and the Nutritional Risk Screening (NRS 2002).

Unlike the UK, Cant says there is no universal screening standard nor routine screening for malnutrition in most Australian hospitals and that there is evidence that competent screening practice is lacking.

A 2008 study highlighted in her paper on nurses views and practices on the use of screening tools found low rates of compliance in using both MST and MUST in several wards of three Melbourne hospitals.

Audit rates were 2 per cent to 61 per cent. After nurse education and staff support over four months, compliance improved to 41 to 70 per cent.

“Nurses found that use of the MST took ‘just a few seconds’ and the MUST longer as patients were weighed.”

Factors reported to limit the time nurses gave to screening include competing patient care tasks, nurses’ skill in use of the tool and acceptance of evidence based practice.

Cant points to a recent study of screening of 275 randomly selected acute care hospital patients in a tertiary Australian hospital showed that malnutrition was poorly documented. It found that only 15 per cent of malnourished patients were identified and correctly documented by dietitians as being malnourished in the medical history.

Cant recommends nurses should become skilled and expert in rapid nutrition risk screening of patients.

“In the absence of screening, however, nurses can assist data collection by use of simple measures. These include: recording the weight and height of patients on admission and any factors that impede nutrition such as chewing or swallowing difficulties, and lower cognitive function. Each of these is a risk factor for development of malnutrition.”

And again, more research is required.

“One way to facilitate this research is for nurses to embrace nutrition screening and to undertake research studies in this field. If this data were available, administrators may recognise both economic and patient centred benefits of investing in systematic nutrition screening,” says Cant.

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