Nutrition in Clinical Practice

Clinical Research Volume 23 Number 4

August 2008 417-423

Nutrition Risk Screening in Acute Care: 2008 American Society for

Parenteral and Enteral Nutrition
10.1177/0884533608321137
A Survey of Practice http://ncp.sagepub.com
hosted at
http://online.sagepub.com

Cinda S. Chima, MS, RD; Christin Dietz-Seher, MS; and

Susan Kushner-Benson, PhD
Financial disclosure: none declared.

The Joint Commissionaccredited acute care hospitals are staff screens (61%) used different data than nursing staff
required to screen patients for nutrition risk, but criteria and screens; 12% collected the same data as nursing staff.
procedures in use have not been described. The purpose of this Screening criteria most often used by nursing staff were a his-
study was to survey managers of clinical nutrition services in tory of weight loss (95%), poor intake prior to admission (81%),
acute care hospitals regarding procedures for screening for nutrition support (79%), chewing/swallowing issues (75%), and
nutrition risk. Members of the Clinical Nutrition Management skin breakdown (72%). Criteria most commonly used by nutri-
Dietetic Practice Group were surveyed using an e-mailed link to tion services staff were diagnosis (90%), nutrition support
an electronic survey. Of 1668 members contacted, 522 usable (81%), nothing by mouth (NPO)/clear liquid diet order (78%), vis-
surveys were completed (31%). Most respondents (84%) ceral proteins (71%), and specific diet orders (68%). Most
reported that nursing staff had primary responsibility for nutri- respondents had not formally evaluated their screening systems
tion screening; 10% used nutrition services staff; 4% used a for sensitivity or specificity. There is a need to further evaluate
computerized system. Where nursing staff did nutrition screen- the nutrition screening systems used in acute care hospitals in
ing (n = 441), 57% (n = 252) said that nutrition services staff do the U.S. (Nutr Clin Pract. 2008;23:417-423)
a secondary admission screen. Dietitians most often performed
secondary screens (70%), followed by dietetic technicians (16%), Keywords: nutrition assessment; nutrition therapy; nutrition
4-year-degreed staff (4%), and clerks (3%). Most nutrition services surveys; nutrition status; nutrition support

N
utrition screening is the collection of limited data The purpose of this study was to survey managers of
to identify individuals at nutrition risk who require clinical nutrition services in acute care hospitals regarding
nutrition assessment. It is a critical antecedent procedures used for screening of nutrition risk to answer
step in the nutrition care process.1 Screening takes place the following 3 research questions: (1) What procedures are
in healthcare delivery settings across the continuum of care. being used for screening for nutrition risk upon admission to
Healthcare organizations accredited by the Joint acute care hospitals? (2) What screening criteria are being
Commission are required to comply with its patient care used, why were they selected, and have they been validated
standards. Since 2003, hospital standards have required for sensitivity and specificity? (3) How well do the respon-
that all inpatients be screened for nutrition risk within 24 dents believe the systems are working in identifying patients
hours of admission.2 Although the time frame has been crit- at nutrition risk to those responsible for assessment?
icized as resource-intensive and not evidence-based,3 this
standard has prompted the implementation of nutrition
screening programs in accredited healthcare organizations.4 Methods
The Joint Commission standards provide latitude as
to screening procedures. Because there is no national con-
Subjects
sensus or gold standard regarding nutrition risk, screen-
ing practice and criteria vary. Little has been published Members of the Clinical Nutrition Management (CNM)
describing nutrition screening practices in healthcare Dietetic Practice Group (DPG) of the American Dietetic
institutions in the U.S. Association (ADA) are self-described managers who
direct clinical nutrition programs across the continuum of
From Family and Consumer Sciences, University of Akron, care.5 As such, they are often the people responsible for
Akron, Ohio. establishing policy regarding admission nutrition screen-
Address correspondence to: Cinda S. Chima, Family and ing. Currently, CNM has 1867 members, which comprises
Consumer Sciences, University of Akron, Schrank Hall South, the total population. The survey link was successfully sent
215G, Akron, Ohio 44325-6109; e-mail: cindachima@adelphia.net to 1668 working e-mail addresses (survey population).

417
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418 Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

Questionnaire Development Table 1. Demographics of Nutrition Services

Survey Respondents
Initial individual survey items were generated that aligned
with the 3 primary research questions, thus providing evi- n %
dence of the content validity of the Nutrition Screening
Dietetics/nutrition credentials
Survey (NSS).
Registered dietitian (RD) 517 99.04
Next, a pilot survey was conducted to evaluate the
Registered dietetic technician (DTR) 8 1.53
appropriateness of the questions and the clarity of the State license 232 44.44
wording. A hard copy of the NSS was administered to 114 Specialty certification, e.g., CNSD, CSR 139 26.63
attendees at the 2003 Clinical Nutrition Management Highest degree achieved
symposium,6 and participants were asked to write sugges- Associates degree 1 0.19
tions on the survey document. Bachelors degree 224 42.91
Survey items were revised based on feedback from the Masters degree 289 55.36
pilot, and an electronic instrument was developed using Doctoral degree 5 0.96
2-way survey software (Modern Mind Interactive [now Years of work experience
Validar Corporation], Seattle, WA). To evaluate the effi- Less than 5 24 4.60
5-10 73 13.98
cacy of the electronic data collection process, the NSS was
11-15 58 11.11
administered to members of the CNM DPG, with results
More than 15 367 70.31
reported elsewhere.4 Some respondents to the electronic Age, y
survey reported difficulty accessing the survey link. The 25 or under 2 0.38
Web portal was modified to address that problem. 26-35 75 14.37
Because 84% of respondents in this pilot reported that 36-45 108 20.69
nursing (NU) staff had primary responsibility for nutrition 46-55 230 44.06
screening, the survey was modified to focus on screening 56-65 94 18.01
methods used in interdisciplinary screening systems where 66 and older 4 0.77
NU staff perform the primary screen. Lastly, the NSS was Gender
evaluated by an expert in survey research who provided Male 11 2.11
Female 494 94.64
suggestions for the overall organization and structure of
Race
the NSS.
White/caucasian 471 90.23
Hispanic 8 1.54
Black/African American 7 1.34
Data Collection and Analysis Hospital size (occupied beds)
Permission was obtained from the ADA Practice Team and Less than 100 78 14.94
101-200 140 26.82
the CNM Executive Committee to e-mail the study link
201-300 119 22.80
to all CNM members with valid e-mail addresses. Subjects
301-400 56 10.73
were asked to give informed consent prior to proceeding with 401 or more 127 24.34
the survey. The study protocol was reviewed and approved by
the University of Akron Institutional Review Board. CNSD, certified nutrition support dietitian; CSR, certified
A link to the Web-based survey instrument was e-mailed specialist-renal.
with a cover letter to members of the CNM DPG who had
provided valid e-mail addresses. Two reminder e-mails copy. The response rate was consistent with other electronic
were sent at 2-week intervals. Descriptive statistics were surveys of health professionals.7-9 Demographics of the
compiled and summarized using Modern Mind Interactive study sample were comparable to that of the DPG overall
survey software. (data from ADA Practice Team). Ninety-seven percent of
respondents (507) reported having inpatient acute-care
beds at their institution; of those, 99% screened for nutri-
Results tion risk on admission.

Demographics
Demographics of respondents are in Table 1. Of 1668 CNM
Nutrition Screening Procedures
members contacted, 522 usable surveys were completed Most respondents (84%) reported that NU staff had pri-
(31%). Three surveys were discarded as unusable. Some mary responsibility for nutrition screening, while 10%
respondents (n = 21) had difficulty accessing the survey indicated that nutrition services staff (NS) was responsible.
electronically and elected to complete the survey in hard Four percent used a computerized system, e.g., a system

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 Survey of Nutrition Risk Screening in Acute Care / Chima et al 419

that automatically generates notification of at-risk Table 2. Admission Nutrition Screening

patients based on established criteria without human Criteria Used by Nursing Staff (NU) (n = 442) and
intervention. Nutrition Services (NS) Staff in Secondary
NU staff nutrition screening results were documented Nutrition Screening (n = 252)
in the nursing admission assessment/database (69%), com-
NU Screening NS Screening
puterized patient records (23%), and on interdisciplinary
forms (3%). Most respondents (96%) reported that hospital Criterion n % n %
policy required that screening be completed within 24
hours of patient admission, while 2% used a time frame of History of weight loss 418 94.57 136 52.71
24-48 hours. Online or computer systems were used to Poor intake prior to admission 360 81.45 110 42.64
Patient is on nutrition support 349 78.96 190 73.64
notify NS staff of positive screens (82%); others used
Chewing/swallowing issues 333 75.34 139 53.88
phones (5%), fax (2%), and other systems (10%). Skin breakdown 319 72.17 137 53.10
Of those who reported that NU staff has primary Pregnant/lactating mother 197 44.57 79 30.62
responsibility for nutrition screening (n = 441), 57% (n = 252) outside perinatal unit
stated that NS staff do a secondary admission screen. For Diagnosis 167 37.78 223 86.43
purposes of the survey, the secondary screen was defined Need for education 160 36.20 95 36.82
as part of the admission screening process adjunctive to NU Geriatric surgical patient 148 33.48 84 32.56
screening, and not a means of triaging referred patients or Specific diet orders 105 23.76 161 62.40
a separate screen completed at a later time on patients Food allergy 103 23.30 89 34.50
deemed low risk on admission. NPO/clear liquid in-house 84 19.00 192 74.42
The most common reasons for secondary screening Weight for height criterion 75 16.97 119 46.12
Age (premature or geriatric 71 16.06 78 30.23
were that NS screens identify patients missed by the NU
patient)
screen (62%); NU screens may not be completed (50%); Visceral proteins (albumin, 51 11.54 158 61.24
NS staff may not be notified of positive NU screens (46%); prealbumin)
criteria used in NU screens may not effectively identify Infant on concentrated formula 43 9.73 44 17.05
patients at nutrition risk (46%); and NU screens may be Body mass index 38 8.60 93 36.05
unreliable (34%). Other 111 25.11 40 15.05
Most NS screens (61%) used different data than NU
screens, and 55% stated that NS criteria require nutrition
expertise. Twelve percent reported that NS staff collect the
same data as NU staff. Dietitians were most often respon-
Secondary Admission Screening Criteria by
sible for secondary screens (70%), followed by dietetic Nutrition Services
technicians, registered (DTRs) (16%), 4-yeardegreed staff See Table 2 for a summary of criteria used by NS staff
(4%), and clerks (3%). to do secondary screenings. Reasons for selecting NS
The results of NS screening was documented in the screening criteria were availability (57%), documentation
progress notes (28%), in a computerized patient record in the literature as an indicator of nutrition risk (54%),
(28%), in a specific chart form or sticker (15%), or was not and ease of use (38%). Thirteen percent of respondents
documented (23%). Forty-three percent of respondents clas- indicated that screening criteria used by NS staff had
sified patients into 2 levels of nutrition risk, e.g., at-risk or not been formally tested and validated at their institution;
at risk; 41% used 3 levels; and 16% used 4 or more levels. 46% stated the criteria had been informally tested and
appeared to work well.
Primary Admission Screening Criteria by
Nursing Staff Functionality of Screening Systems
See Table 2 for a summary of diagnostic criteria used by NU Respondents were asked their opinions regarding the
staff in admission screening for nutrition risk. The most functionality of the screening systems currently in use.
common considerations in choosing NU screening criteria Communications issues around interdisciplinary screen-
were that they dont require clinical expertise (70%), are ing systems were identified. A minority of respondents
easy to use (65%), readily available (59%), well documented (38%) said that positive screens were communicated to
in the literature as an indicator of nutrition risk in acute them by other departments all or most of the time, while
care (48%), and required by The Joint Commission (39%). 11% reported they were rarely or never notified.
While only 11% stated that the criteria had been formally Seventy-one percent of respondents felt that NS
tested and validated in their setting, 40% said they had been screening criteria effectively identified patients at nutri-
informally tested through use and appeared to work well. tion risk all or most of the time, while only 34% felt that

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420 Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

NU screening criteria did so. Seventy-eight percent of including nutrition history, unintentional weight loss, per-
respondents said that screening timeframes were met all cent of ideal body weight, diet order, diagnosis, serum albu-
or most of the time, while 89% said assessment time min level, and total lymphocyte count. The algorithm
frames were met all or most of the time. demonstrated good interrater reliability among dietitians
and dietetic technicians.
In Chimas 2003 pilot survey of attendees at the CNM
Discussion symposium (n = 114), 74% reported that NU staff had
primary responsibility for admission screening, while 17%
Only a few small studies of limited quality have been pub- reported that NS staff had primary responsibility.6
lished regarding nutrition screening practices in use in Based on the limited data available, the screening
the U.S. In 1987, the CNM DPG published results of a process has changed significantly during the past 2 decades
members survey regarding inpatient nutrition screening partly as the result of regulatory changes. Specific screening
practices.10 The survey was distributed to 1200 members tools and criteria sets have been evaluated for effectiveness
through the DPG newsletter, with only 77 surveys in identifying patients at nutrition risk in acute healthcare
returned. In this limited sample, only 60% said their hos- settings. Some studies have focused on the use of labora-
pital did admission nutrition screening. Most screening tory tests, visceral proteins in particular.18-20 Laboratory
was done by registered dietitians (69%) and dietetic tech- tests often weigh heavily in multifactorial nutrition screen-
nicians (55.8%); registered nurses (RNs) rarely performed ing systems.21 More recent studies have identified discor-
screening (6.5%). Prior to the change in standards in dance between visceral protein measurements and clinical
1996, some patients were screened by nutrition assistants evaluations such as Subjective Global Assessment (SGA).22
within 72 hours of admission,11 and by dietetic technicians Although serum hepatic protein concentrations are strongly
within 48 hours of admission.12 predictive of morbidity and mortality, in acute care set-
Chima and colleagues evaluated the ability of a screen- tings, they are more reflective of severity of illness than
ing system to predict length of stay, hospital costs, and dis- nutrition status.23,24
charge status of medicine service patients.13 Screening was Beck and Ovesen reviewed evidence regarding the
done by dietitians and dietitic technicians. Criteria relationship between body mass index (BMI) and weight
included weight for height, laboratory data, history of loss in the elderly patients and nutrition risk, concluding
weight loss, and need for nutrition support. Patients iden- that criteria used in younger populations may miss at-risk
tified as being at nutrition risk had significantly higher elderly patients.25 Other researchers have studied the
length of stay, hospital costs, and need for postacute care relationship between commonly used nutrition markers
than low-risk patients. This may have been a function of and validated nutrition screening or assessment tools
severity of illness rather than nutrition status. like the Mini Nutritional Assessment (MNA; Nestl
In 1996, a screen used by dietitians for critically ill Nutrition, Vevey, Switzerland) and SGA administered by
children with respiratory syncytial virus was evaluated. various members of the healthcare team.26-28
Criteria included anthropometrics, disease history, diet In the U.K., the Malnutrition Universal Screening Tool
history, and laboratory data. Patients determined to be at (MUST) for adults has been developed as a rapid screening
high nutrition risk were found to have significantly poorer tool for adults in acute care and community settings.29-31
outcomes than those not at high risk.14 Schwartz reported MUST uses BMI, weight loss history, and expected lack of
on a preadmission nutrition screening system incorpo- intake for >5 days. It has been shown to predict mortality
rated into critical pathways for specific diagnoses such as and length of hospital stay even when weight and height
hip and knee surgery.15 This system improved patient out- cannot be measured.30
comes by leading to increasing patients dietary intakes Little has been published in the U.S. regarding the
prior to planned admissions, reducing hospitalization validity or effectiveness of admission nutrition screening
length of stay, and enhancing patient satisfaction. done by NU staff as it occurs in most healthcare facilities.
In 2003, after the Joint Commission standards incor- A review by Jones32 of 44 nutrition screening tools
porated the 24-hour time frame, Heller described inpatient intended for diverse settings and patient populations con-
and outpatient nutrition screening procedures in a pedi- cluded that none were published with sufficient details
atric hospital.16 Patients were initially screened by NU staff regarding development and proper application, nor did
using diagnostic criteria. Dietitic technicians followed up they provide an adequate assessment of their effective-
within 48 hours with a more comprehensive screen that ness. Few systems were intended for use by nurses caring
included diagnoses, feeding and GI concerns, and anthro- for hospitalized patients.
pometrics. Outpatient screening used appearance, weight A 2005 literature review by Green and Watson evalu-
and weight changes, and nutrition support criteria. ated 35 nursing nutrition screening/assessment tools used
Hiller and coworkers evaluated a nutrition status clas- in healthcare and community settings; 11 had published
sification system used in the Department of VeteransAffairs evidence of testing in hospital populations for some aspect
for validity and reliability.17 The system used 7 criteria, of validity, reliability, specificity, and sensitivity. Of those,

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 Survey of Nutrition Risk Screening in Acute Care / Chima et al 421

3 studies were done in the U.S.33 Further, there is little evi- affected by who performs it, even when the same criteria are
dence at present that nutrition screening positively affects used. Pattison and coworkers evaluated a subjective screening
patient outcomes.34 tool for use in elderly hospitalized patients.38 Physical
Kovacevich et al described a hospital admission nutri- measurements (triceps skinfold, arm muscle circumfer-
tion screening system that incorporated elements of the SGA ence, and percent ideal body weight <80% standard) were
and other factors into the NU admission assessment.35 The used as the gold standard. Nurses and dietitians scored
instrument was evaluated for nurse-nutritionist repro- patients in 5 areas (clinical condition, body weight, dietary
ducibility and validity as compared with serum prealbumin intake, ability to eat, and mental condition). Most (85%) of
levels. There was 97% agreement between the 2 raters. the undernourished patients were correctly classified by
Using prealbumin concentration as the standard, the tool the dietitian; only 58% were correctly identified by the
sensitivity was 85%, and specificity 63%. The researchers nurse. There was no agreement between scores from the
excluded patients with diabetes, renal or liver failure, pres- dietitian and nurse in any of the 5 scoring categories. It
ence of an acute phase response, and active inflammatory may be that a subjective tool requires greater content expert-
disease in order to avoid non-nutrition influences on preal- ise than an objective scoring system.
bumin. This reduced the generalizability of the results. In the U.K., McCall and Cotton evaluated a nursing
Elmore and coworkers compared a subjective screen- nutrition assessment tool for testretest reliability, inter-
ing system with an abbreviated tool using serum albumin rater reliability, and concurrent and construct validity.39
level, total lymphocyte count, and percent weight loss This tool included ratings of mental condition, weight,
using a comprehensive nutrition assessment as the stan- restrictions on intake, appetite, ability to eat, gut func-
dard.36 The abbreviated nutrition screen showed better tion, treatment condition, and pressure sores. Patients
sensitivity and specificity than the subjective screening were evaluated by 2 nurses and by a dietitian. The tool
method. This may be because the elements used in the yielded consistent assessments over time, but there was
abbreviated screening system were also used in the more consistent disagreement between the nurse and dietitian
extended nutrition assessment. ratings, particularly for more subjective elements.
In an Australian study, Ferguson et al developed a mal- Reilly et al developed and evaluated a nutrition risk
nutrition screening tool (MST) for hospitalized adults using score, including weight-for-height standards (growth chart
the SGA as the gold standard.37 The questions with the high- or BMI) appetite, ability to eat/retain food, and medical
est sensitivity and specificity in predicting SGA were ques- stress factor.40 In this small study, reproducible scores
tions regarding appetite and recent unintentional weight were obtained between dietitians; results of screening by
loss. These were incorporated into the final tool, which had a nurses and dietitians correlated well.
sensitivity and specificity of 93%. Subjects identified as being
at risk for malnutrition based on the MST had a significantly
longer length of stay than low-risk individuals. Conclusion
In the current survey, respondents were not asked
specifically about their use of validated nutrition screen- Hospitalized individuals are at risk for malnutrition
ing tools such as the MST and MUST, as the intent was caused by disease, surgeries, and injuries that increase
to identify individual screening criteria in common use. nutrition needs, treatments that affect nutrition status,
When given the opportunity to identify additional screen- and poor intake. Accreditation standards require nutrition
ing parameters in an open-ended question, no respondent screening of all hospitalized patients, and 99% of survey
named any of the validated tools. respondents reported that they screen for nutrition risk on
However, respondents reported that individual crite- admission. Thus, considerable time, effort, and resources
ria used in the validated tools were in common use in NU are devoted to nutrition screening in acute care health
screens, for example, history of weight loss (95%), and facilities in the U.S. and elsewhere. However, there is lit-
poor intake/appetite prior to admission (81%). BMI was tle published data suggesting that the systems in use are
not often used in NU screens (9%), but was more com- effective in terms of specificity, sensitivity, and construct
monly used in NS screens (36%) possibly because it validity. Most respondents to this survey had not evalu-
requires calculation and evaluation. ated the sensitivity and specificity of the screening tools
Additionally, in this study, a majority of respondents used. Of necessity, criteria were chosen based on avail-
thought the NS screening criteria identified patients at ability and ease of use rather than evidence of validity.
nutrition risk most or all of the time, but only about one- Many of the respondents to this survey expressed a lack
third of the respondents felt that the NU criteria were effec- of confidence in the process if not the criteria. Further,
tive in identifying risk. It may be that respondents exert there is limited evidence that nutrition screening
more control over the development and use of NS screen- improves patient outcomes. There is a need to evaluate
ing systems, and thus felt more confident in the results. whether the systems in use are working and to identify
Beyond process issues such as completion and com- best practices in identifying patients who require focused
munication of results, results of nutrition screening can be nutrition care.

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422 Nutrition in Clinical Practice / Vol. 23, No. 4, August 2008

This is challenging for a number of reasons. Many of 6. Chima CS. Nutrition screening practices in healthcare organiza-
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