Bedside nutrition assessment past, present, and future: a review of the subjective global assessment

Bedside nutrition assessment remains an essential skill for the practicing clinician to master as the nutrition status of our patients directly influences clinical outcomes and mortality rates. Dr Charles E. Butterworth Jr's initial report of malnutrition in hospitalized patients, the so-called "skeleton in the closet," riveted the medical community. Two other studies in the 1970s published prevalence rates of hospital malnutrition of 48% in adult medical patients and 50% in adult surgical patients. Even more disturbing, 75% of patients at risk for malnutrition on admission had worsening nutrition parameters during their hospitalization. These findings led to a search to find an integrated bedside nutrition assessment tool to identify malnutrition in hospitalized patients. Initially reported in 1982, The Subjective Global Assessment is an integrated tool that utilizes the clinical judgment of a practitioner to identify patients at risk of or with malnutrition. It is a clinically useful tool that can be applied at the bedside by the average practitioner. It is a simple, safe, and inexpensive tool allowing for widespread use by trained clinicians and remains the gold standard for new bedside assessment tools.     

Nutrition assessment, care, and considerations of ventricular assist device patients

A ventricular assist device (VAD) is an implantable mechanical device that is used to partially or completely replace the circulatory function of a failing heart. VADs may serve as a bridge to heart transplantation or as permanent circulatory assistance, also referred to as destination therapy. There is a paucity of information regarding the nutrition complications in VAD patients, and as such, little is presently known of the optimal means of nutrition assessment and management of these complex and often critically ill patients. In this review, a general overview of the VAD, comparisons of nutrition assessment measures, and strategies to meet the nutrition needs of these patients are provided using evidence-based information wherever possible. Because there is a lack of nutrition studies and assessment guidelines specifically for VAD patients, many of the guidelines for care of these patients are currently based on the information available for the care of patients with heart failure. Although the optimal measure to assess nutrition status remains poorly studied, a systematic, thorough nutrition assessment of patients with heart failure and heart transplant candidates prior to VAD placement appears to be important to identify those at nutrition risk and, with appropriate nutrition therapy, decrease their risk for morbidity and mortality. VAD patients with inadequate oral intake may require nutrition support to meet their nutrition needs; however, feeding the hemodynamically compromised patient provides additional challenges.     

Implementing frailty into clinical practice: We cannot wait

Geriatric medicine was implemented in many countries in the 1980s due to the discharge of many older adults with multiple pathologies, cognitive impairment and severe disabilities to emergency departments. In fact, at that time nobody was capable or wanted to care about these older adults with severe disabilities. For these reasons, most of the departments of geriatrics were created at that time. Most were based in sub-acute and long term care to take care of these patients. Since then, geriatric medicine has grown in many countries and now there are acute care units, day hospitals, mobile teams and memory clinics worldwide. However, today in most of these centers geriatric physicians are dealing with patients with already severe disabilities at a stage which is often not reversible. Almost 95% of the geriatric force is involved in care for already dependent older adults. We need, of course, to continue to take care of these individuals with severe disabilities, but moreover, we need to take care of the pre-frail and frail older adults. It is an absolute necessity if we want to prevent rapid disability in our aging population, and if we want to anticipate it to promote more efficient care. Pre-frail and frail older adults are those following the Fried criteria who have a sedentary life, an involuntary weight loss, low physical activity, exhaustion, low strength. If they have one of the Fried criteria, they are pre-frail; if they have 3 or more, they are frail. Frail older adults are more likely to become dependent, but today they are not really taken into consideration by our health care systems. We need, in collaboration with the family physicians, to take up this challenge. To do it we need a targeted, strong and sustained intervention. - Targeting the pre-frail and frail older adults. To do this we need a simple tool to be used by family practitioner and other health professionals to screen those at risk of being frail. The IANA tool (a simple 5 questions) recently validated by Morley et al. is a good example. Another example is the tool used in the Gerontopole Frailty Clinics. It is useful to keep the subjective assessment of the physician if we want to keep him/her involved in the interventional process. - Important Intervention: To have a real impact the intervention must be strong. To do this a complete geriatric assessment of the pre-frail and frail patients is necessary to be able to diagnose some age-related disease at a pro-dromal stage, where it is still possible to cure the patient: e.g., early stage of macular degeneration, glaucoma, hearing impairment, mild cognitive impairment, sarcopenia (8.9) or loss of mobility. It is also an opportunity to have this population benefit from new drug trials in prodromal Alzheimer's disease in an early stage of sarcopenia for example. The evaluation must use specific tools to do most accurate diagnosis of potential age related diseases. This assessment must include also social, health, economic and psychosocial assessment, as well as the evaluation of the deficit accumulation. - A sustained Intervention. Because the aging of this population will still increase, we need to have long-term and sustained intervention. Physical exercise, cognitive exercise, nutrition intervention, social services will be needed in association of the detection and treatment of age related diseases. A recent study showed that even in older frail persons with hip fracture, a sustained resistance exercise program for one year can improve outcomes. More standardization of these multi-domain interventions is an important domain for further research. We need to find a compromise between very strong interventions which will be accepted by few frail older adults and too light interventions usually not strong enough to have a real impact. - The I.A.G.G. (International Association of Gerontology and Geriatrics), http://www.iagg.info/ and the G.A.R.N. (IAGG Global Aging Research Network) http://garn-network.org/index.php have already taken and will take further initiative in this domain. They have pointed out the need to concentrate on aging-in-place to prevent premature nursing home placement. We really need to implement pre-frail and frailty in usual geriatric care worldwide. If we are able to recognize and treat frailty in our clinical practice, it will be a new area for geriatric medicine. At this time, we will be able to develop high level clinical research on biomarkers, imaging and new treatment approaches. Multi-domain or multimodal intervention will be most probably necessary. At the same time, some actions have to be implemented to prevent iatrogenic hospitalization if these frail older adults have to be hospitalized. This move of geriatric medicine in the pre-frail and frail will be cost effective and can give a new rebound for geriatrics, as recommended in a recent European intiatives.     

Comprehensive geriatric assessment recommendations: adherence of family practice residents

A study was performed to determine whether family practice residents followed recommendations made by a comprehensive geriatric assessment clinic. Of 109 consecutive consultations, 27 patients had follow-up visits with family practice residents who participated in the assessment and who subsequently served as their primary care physicians. Adherence of residents to 437 clinic recommendations was monitored for 90 days by medical record review. Although recommendations to begin or increase a medication were followed 85.4% of the time, residents followed recommendations to stop or decrease medications less than 65% of the time. Recommendations to order a specific laboratory test or x-ray examination were acted on 70.3% of the time. Preventive recommendations were followed only 54.3% of the time. Residents' adherence to team-based care plans varied widely by type of recommendation. Special efforts are needed to increase compliance with comprehensive geriatric assessment clinic recommendations, particularly those for preventive services.     

Nutrition assessment in long-term care.

Assessment of nutrition status is necessary in long-term care settings for both optimal patient care and to meet regulatory standards. Careful nutrition assessment leads to development of an individual plan of care to optimize nutrition status. Although the Minimum Data Set is mandated as the nutrition assessment tool in long-term care settings, published studies show that the use of the Minimum Data Set to assess nutrition status is problematic. Two types of nutrition assessment instruments have been developed. The first type aims to identify those at risk for malnutrition but is not used to diagnose clinical malnutrition, whereas the second type has been designed to diagnose malnutrition. A number of commonly used nutrition assessment tools have not been validated in long-term care populations. This review focuses on the available tools used in the long-term care setting and provides an overview of their characteristics and performance measures.     

Improving nutritional screening of hospitalized patients: the role of prealbumin

BACKGROUND: Limited resources prevent hospitals from having all patients formally evaluated by a nutrition expert. Thus, hospitals rely on nutrition-screening tools to identify malnourished patients. The purpose of this study was to determine the effectiveness of a nutrition-screening protocol, prealbumin (PAB), retinol binding protein (RBP), and albumin (ALB) in identifying malnourished hospitalized patients. METHODS: A nutrition screening protocol was prospectively used in medical and surgical patients and consisted of a nurse administering a questionnaire to patients and requesting formal evaluation by a registered dietitian (RD) only if nutritional issues were identified. Patients also had ALB, PAB, and RBP drawn, which were used to both screen and identify the malnourished. PAB, RBP, and ALB were compared as predictors of RD classification of patient nutritional status. RESULTS: The nutrition-screening protocol classified 104 of 320 patients (33%) as malnourished. However, 43% of the patients were not deemed at nutritional risk according to this protocol and therefore did not receive RD assessment. PAB was a significant predictor of RD-determined nutritional status (p < .05), whereas RBP and ALB were not. PAB screening/assessment identified 50% (162/320) of the patients as being malnourished. Notably, 50% of the patients (71 of 142) who were not evaluated by an RD were identified as malnourished using PAB criteria. The nutrition-screening protocol took 1.2 days longer to determine malnourishment compared with PAB (p = .0021). CONCLUSIONS: Use of screening questionnaires may miss or delay identification of malnourished patients. PAB screening/assessment may improve identification of those patients requiring nutrition intervention and thus enhance the care of hospitalized individuals.     

Developing a standard of care for patients at risk for long-term hospitalization

At one hospital, during 1 month, charts of patients whose length of stay was greater than or equal to 60 days were reviewed to determine current dietetics practice. Several areas that affect overall nutrition care were identified: consistent follow-through on recommendations, continuity of care, consistent protocol for addition of supplements, communication of results of calorie counts, and assessment of nutritional status over the course of hospitalization vs documentation on a particular day. A protocol was developed to provide weekly information about patient weight for ongoing nutrition assessment. A profile of patients at risk for increased length of hospital stay was developed using historical information. Patient age and diagnosis at the time of admission were the basis of the profile, which was incorporated into the screening program. A standard of care was designed to provide early, aggressive nutrition intervention to patients at risk. Clinical managers can follow the steps outlined to develop consistent nutrition care standards. Such standards can be incorporated into a quality improvement program to assess the effectiveness of the nutrition care methods and improve the quality of care provided.     

Implementation of functional assessment scales in geriatric practice: a feasibility study

AIM: A study was undertaken to evaluate the feasibility of functional assessment scales regarding completion rate and ability to document functional changes in geriatric rehabilitation patients. METHODS: Five functional assessment scales were implemented, and used on admission and discharge as part of standard care. RESULTS: Of 2,812 patients, 90 patients (3.2%) had no scales administered, 2,330 patients (82.9%) had between one and six scales administered and 392 (13.9%) had a complete data set (seven scales). The percentage of inpatients who were independent or almost independent in basic ADL functions improved from 30% to 60% during hospitalization; 53% had cognitive impairment, while 19% expressed depressive thoughts or depression on admission. CONCLUSION: Functional assessment scales were feasible in the clinical routine, gave important information on patients' functional status at baseline, and showed that patients improved their physical function considerably during hospitalization. Interdisciplinary teamwork and management affect the success of the implementation of assessment scales.     

Clinical specialization programs for dietitians: a needs assessment

This needs assessment was conducted to identify the perceived need for advancement and specialization through practicum programs in clinical dietetics. A questionnaire was developed and validated through a pilot study. It was mailed to a randomized sample of 950 dietitians (52%) registered with the ODA. Fifty two per cent responded, representing 27% of ODA members. Of those surveyed 89% were currently employed. The most current area of practice was clinical nutrition (55%) followed by foodservice (22%) and community nutrition (14%). Seventy two per cent of the respondents identified that they would consider enrolling in a specialized practicum. Most cited reasons for enrolling were increased knowledge/expertise (44%) and increased professional profile (25%). Areas of greatest interest were: nutrition assessment (9%), critical care/nutrition support (8%) and gerontology (7.5%). Sixty two per cent preferred the program to be offered part-time, 27% full-time and 9% were impartial. The most frequently cited length and cost per week for the program within specified part or full-time categories was: two weeks full-time (36.5%) at S200-299.00 (33%), four weeks full-time (25%) at S100-199.00 (31%) and two weeks part or full-time (23.5%) at S200-299.00 (57%). Desired ODA regions for program availability were: Toronto (34%), Kitchener/Waterloo/Hamilton (17.5%) and London (14%). Lastly, 92% of the respondents felt the program should be CDA and ODA approved and continuing education points be provided. These results indicate that dietitians are interested in pursuing professional self-development through specialized practicums.     

Creating a clinical nutrition registry: prospects, problems, and preliminary results

There is a tremendous gap in the information available to support the practice of hospital-based dietitians and to address the issue of how the risk of developing protein-energy malnutrition can be avoided in the majority of patients. This article describes the rationale and benefits of creating a nutrition registry of within-hospital clinical nutrition care. A nutrition registry is made up of observational data, collected on an ongoing basis, of nutritional interventions provided to hospitalized patients. It is the first step in data gathering to demonstrate the effectiveness of clinical nutrition interventions. The methods and preliminary results of a nutrition registry that was established at The University of Illinois Medical Center, Chicago, III, are presented. Using subjective global assessment, 55% (257 of 467) of patients at admission and 60% (280 of 467) of patients at discharge were moderately or severely malnourished. Patients that were normal nourished at admission and became moderately or severely malnourished had higher hospital charges ($40,329 for moderately malnourished patients, $76,598 for severely malnourished patients) than those that remained normal nourished ($28,368). This pattern held independent of admission nutritional status. Major challenges in implementation of a registry into the responsibilities of the staff dietitian are reviewed. The conclusion of this study is that nutrition registries can be established and will provide the much needed baseline data to document the impact of nutrition interventions on outcomes of medical care.     

Nutrition screening and assessment of anthropometry and bioelectrical impedance in the frail elderly: a clinical appraisal of methodology in a clinical setting

Nutrition screening is recommended to identify those at risk for malnutrition; nutrition assessment by anthropometry and impedance is widely used to indicate nutritional status but may be problematical in the frail elderly in nursing homes. Acceptability, availability, suitability and appropriate reference data influence clinical application of these measurements. In our study, nutrition screening and assessment methodology were evaluated in 46 nursing home residents, mean age 86.3 +/- 6.6 years, mean weight 66.1 +/- 12.9 kg, mean height 163.1 +/- 9.6 cm, and mean BMI 24.9 +/- 4.6 kg/m2. Significant correlations (P < 0.05) were found in all measures of body weight, BMI, body fatness and leanness. Interpretation of data by five different reference standards and cutoff points revealed wide variation in identification of malnutrition by anthropometry. Appropriate reference data for body lean and fatness are not yet available. Thus, population-specific methodology and reference standards are of crucial importance.     

Screening for nutrition risk in children: the validation of a new tool

Background: The importance of the early identification and management of nutritional risk is well established in adult and elderly hospital care. Numerous nutritional screening tools are available for adults, for example Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA) and NRS‐2002 (Kondrup et al., 2003). Currently there is no validated nutrition risk screening tool for use with children admitted to hospital in the UK. The aim of this study was to test the validity of a newly developed nutrition risk screening tool for children. Methods: All children (aged 2–17 years) admitted to the study wards (two medical, two surgical) over a 4 week period were screened using a newly developed, nurse administered paediatric nutrition screening tool (NST). The NST consisted of three elements – clinical diagnosis, nutritional intake and anthropometric measures. Each element was scored and children with an overall score of three or more were considered at nutritional risk. Of those screened, a sample (n = 89) were further assessed for full nutritional status by a registered dietitian. The full nutritional assessment consisted of a face‐to‐face interview obtaining dietary and social information, anthropometric measurements and retrieval of medical information from case notes. Data were analysed using chi‐square tests to compare groups within the sample and k statistic to compare agreement between the full nutritional assessment and NST. Full ethical approval was obtained prior to undertaking this study. Results: The majority of 89 participants were surgical admissions (58%), male (56%) and the mean (SD) age was 9.0 (4.5) years. Nutritional risk was identified in 21% of the sample using the NST, and in 20% of the sample by full nutritional assessment. The prevalence of nutritional risk was not significantly different between methods or between males and females (by either method), but was statistically higher (by both methods) in medical compared with surgical admissions (χ² = 18.426, P < 0.001; χ² = 7.139, P = 0.008 respectively). Compared to the full nutritional assessment, the NST demonstrated 72% sensitivity and 90% specificity and a k statistic (95% CI) of 0.599 (0.39, 0.81) ( Table 1 ).

Table 1. Agreement between full nutritional assessment and the nutrition screening tool (NST)

Impact of an Expansion of a Clinical Nutrition Curriculum on Pre-Clerkship Medical Students’ Perception of Their Knowledge and Skills Related to Performing a Nutritional Assessment

Learning how to provide nutritional counseling to patients should start early in undergraduate medical education to improve the knowledge, comfort, and confidence of physicians. Two nutrition workshops were developed for first-year medical students. The first workshop, co-led by physicians and registered dieticians, focused on obtaining nutrition assessments. The second workshop focused on the appropriate dietary counseling of patients with chronic kidney disease and cardiovascular risk. We surveyed students before workshop 1, after workshop 1, and after workshop 2 to assess their perceptions of the value of physician nutrition knowledge and counseling skills as well as their own comfort in the area of nutritional knowledge, assessment, and counseling. We found a significant improvement in their self-assessed level of knowledge regarding counseling patients, in their comfort in completing a nutritional assessment, and in their confidence in advising a patient about nutrition by the end of the first workshop. By the time of the second workshop five months later, students continued to report a high level of knowledge, comfort, and confidence. The implementation of clinical nutrition workshops with a focus on assessment, management, and counseling was found to be effective in increasing student’s self-assessed level of knowledge as well as their confidence and comfort in advising patients on nutrition. Our findings further support the previous assertion that clinical nutrition education can be successfully integrated into the pre-clerkship medical school curriculum.     

Teaching medical students the subjective global assessment

OBJECTIVE: Clinical nutrition assessment is a clinical skill not taught in many medical schools in North America. The purpose of this study is to determine whether second-year medical students can be taught to perform a nutritional Subjective Global Assessment (SGA). METHODS: In this study, second-year medical students were given a didactic session and a bedside demonstration of the SGA. Subsequently, they performed an SGA on unknown patients and classified those patients into one of three categories: A) well nourished, B) moderately malnourished, or C) severely malnourished. This was compared with the assessments of clinical dietitians and a physician. RESULTS: After this instruction, medical students correctly identified malnourished individuals. They were less accurate in their subclassification between mildly and severely malnourished individuals. The degree of agreement with clinical dietitians and a physician was fair (kappa = 0.34). CONCLUSIONS: With a multidisciplinary team of physicians and clinical dietitians, medical students can be taught the SGA in a 3h format. This is an important clinical skill that emphasizes the importance of clinical nutrition and may help identify malnourished individuals early in the course of their hospitalization.     

综合营养评估工具在心衰患者中的应用价值

目的 对心衰患者所采用的综合营养评估工具及应用价值进行综述，为我国心衰患者的营养相关研究提供理论基础。方法 以“营养”、“心力衰竭”、“nutrition”、“heart failure”等为关键词，查询PubMed、Web of Science、知网等数据库相关文献，综述材料。结果 对心衰患者运用的综合营养评估工具种类较多，各量表信效度较高，营养风险和营养不良检出率较好，但均为普适量表，测评内容不能与心衰患者的临床特征完全相符，开发针对心衰患者的营养评估工具处于起步阶段。结论 综合营养评估工具对心衰患者的营养评估效果较好，未来需要加强针对心衰患者营养量表的研究。     

Controlling hospital readmission of elderly persons living at home: a risk factor analysis

A large proportion of hospital stays stem from rapid readmission of elderly patients. These patients represent high cost users of inpatient care. Intervention in the hospital admission-readmission cycle may serve the interests of patients and payors alike. Data collected through comprehensive geriatric assessment can be useful in identifying those patients at high risk of readmission and who might benefit from more intensive in-hospital or post hospital attention. However, risk factors for readmission are largely unknown. We conducted a prospective study of elderly patients admitted to a metropolitan teaching hospital medical service and assessed by a geriatric team, to increase our knowledge of the factors associated with hospital readmissions. The most powerful predictor of hospital readmission within 6 months proved to be prior hospitalization. Attempts to reduce rehospitalizations in elderly patients must focus on those with prior recent hospitalizations.