Nutrition Screening Practices in Health Care Organizations: A Pilot Survey
Cinda Chima, MS, RD, LD
PDF attachment Screening Figures available here.
Introduction
Nutrition screening is the collection of limited data to identify individuals at nutritional risk who require nutrition assessment. It has been identified as a critical antecedent step in the Nutrition Care Process (1). Nutrition assessment is the evaluation of comprehensive data using evidence-based standards, usually followed by nutrition diagnosis and intervention for persons at nutrition risk (1). Screening takes place in health care delivery settings across the continuum of care. While some health care organizations have had nutrition screening programs in place for decades, in recent years the process has been dramatically affected by changes in regulatory requirements and accreditation standards.
Health care organizations accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) are required to comply with its patient care standards. This includes accredited acute care hospitals, long term care facilities, home care providers, ambulatory centers, and subacute programs. Since 1996, hospital standards have required that all inpatients be screened for nutritional risk within 24 hours of admission (2). The ambulatory, home care, and subacute standards also require that clients who require nutrition assessment be identified.
Although the mandated time frame has been criticized as resource-intensive and not evidence-based (3), this standard has prompted the implementation of nutrition screening programs where none existed before. It has also driven the screening criteria used and re-allocated responsibility for doing the screening. Many nutrition departments are not staffed to meet the requirement for universal screening within a narrow time window seven days a week. In some institutions responsibility for the collection of nutrition screening data has been shifted to nursing staff. In others, the process has been automated, using diagnostic, demographic, anthropometric, and laboratory data reports to identify patients who require further evaluation. Because the JCAHO standards provide latitude in establishing screening criteria and assessment time frames, and because there is no national consensus regarding what constitutes nutrition risk, screening practice and criteria vary. There has been little data published describing nutrition screening practices in health care institutions in the U.S.
The purpose of this pilot study was to test a survey instrument to be used to identify nutrition screening practices and criteria in current use in health care institutions in the United States.
Methods
A pilot survey was conducted using a convenience sample of 230 attendees at the Clinical Nutrition Management (CNM) Dietetic Practice Group Symposium in Charleston, S.C. in March, 2003. The survey instrument was developed following a review of the literature and tested with members of the Executive Committee of the Clinical Nutrition Management Dietetic Practice Group (DPG).
The survey was introduced at a general session of the practice group meeting. Attendees who were managers or providers in health care delivery settings were encouraged to complete the survey and return it to a central location. Participants were reminded about the survey several times during the meeting. The investigator encouraged attendees to participate by offering to share a summary of the results of the survey with all attendees who returned a questionnaire and provided contact information.
Data were analyzed and descriptive statistics summarized using Microsoft Excel 97.
Results
A total of 114 usable surveys were returned, for a response rate of 50%. Responding hospitals and care facilities ranged from <100 beds to >400 beds. All respondents screened inpatient admissions for nutritional risk. Of those facilities that offered ambulatory services (n=99), 72% reported screening in ambulatory areas.
Inpatient Screening
Nursing staff had primary responsibility for nutrition screening (data collection and identification of persons meeting risk criteria) in 74% of responding facilities, nutrition staff in 17%, and other staff/systems in 8%. A paper form was used to document screening by 64% of respondents, a computer record by 26%, and a combination system by 6%. Nutrition staff were notified of positive screens via computerized or online systems (64%), fax/phone/other (21%) or a paper form (3%). Twelve per cent reported there were no outside staff involved.
Consistent with JCAHO requirements, 96% of respondents used a time frame of less than 24 hours from admission to complete the initial screen. Assessment time frames varied, some keyed to the admission, and some to notification of a positive screen (Figure 1). Some respondents used different time standards depending on the risk level of the patient or the nursing unit or service.
Eight criteria for nutritional risk were used by at least half of respondents. They included a history of weight loss, current nutrition support, skin breakdown, specific diagnoses, poor intake, modified diets, geriatric surgical patients, and pregnant and lactating women (Figure 2). The last two criteria were included explicitly in the intent of the JCAHO Care of Patients standard TX.4 (2) at the time the survey was done. Other common criteria included NPO/clear liquid diets, a need for education, low visceral protein levels, weight-related or Body Mass Index (BMI) standards, food allergy, or an order for concentrated infant formula, generally given to babies with growth issues.
Ambulatory Screening
Of respondents who screened in ambulatory settings (n=72), 70% screened for nutritional risk in the Emergency Department (ED), 60% in “high risk” clinics such as radiation therapy or medical oncology, and 40% in primary care areas. Thirty per cent of respondents screened for nutritional risk in all ambulatory clinics.
The most common criteria used in ambulatory screening included weight change, a need for education, chewing/swallowing problems, lab results, and comparison of weight against a standard, for example, BMI or growth charts (Figure 3).
Identified Issues
The most common concern about the screening process reported by respondents was the notification/referral process. Only 41% of respondents reported that at-risk inpatients were referred to them all or most of the time, 20% received referrals half the time, and 40% less than half the time or never. When asked what they would change about the process, most who responded mentioned the referral/notification process or expressed a desire to automate the system.
In the ambulatory setting, only 25% of respondents reported receiving referrals all or most of the time, 17% received them half the time, and 58% less than half the time or never. It must be remembered that there is no regulatory requirement that at risk patients be referred to nutrition personnel, since nutrition care is an interdisciplinary process, and the physician may elect to manage nutrition issues himself. However, organizations are expected to adhere to their own policies and procedures.
Respondents were most confident regarding those elements of the screening/assessment process they controlled themselves (Figure 4). Particularly in the inpatient area, respondents believed their nutrition criteria effectively identified patients at nutritional risk, that they met their assessment time frames, and that nutrition intervention achieves positive outcomes during the hospital stay. In the ambulatory arena, respondents demonstrated less confidence in the criteria used and outcomes achieved.
The two reasons identified by respondents as most important in selecting a screening indicator was that it was well documented in the literature as an indicator of nutritional risk, and that JCAHO requires it.
Discussion
There is a voluminous body of literature regarding nutrition screening criteria and outcomes in various populations (4, 5). However, there is little research documenting current nutrition screening practice or to support the effectiveness of nutrition screening as it currently exists in most health care systems, that is, screening done by nursing staff using simple and accessible criteria.
Part of the problem is a lack of consensus regarding the purpose of nutrition screening and a common definition of nutritional risk. Some associate nutritional risk with risk of malnutrition. Other clinicians identify patients who need nutrition education, or patients whose diet orders require clarification. Still others define nutritional risk indicators by their ability to predict poor medical or surgical outcomes. Further, there is no accepted “gold standard” of nutritional status against which various screening systems can be benchmarked. This is particularly true in health care settings, where disease, disability, and therapies introduce confounding variables.
There have been dramatic changes in the screening process over the past two decades. In 1987, the CNM DPG published results of a survey of its members regarding inpatient nutrition screening practices (6). The survey was distributed to 1200 members through the DPG newsletter, with 77 surveys returned. Only 60% of respondents reported they had an admission screening system in place. Most screening was done by RDs (69%) and dietetic technicians (55.8%). RNs rarely performed screening (6.5%).
Prior to the change in standards in 1996, patients were screened by nutrition assistants within 72 hours of admission (7) and by dietetic technicians within 48 hours of admission (8).
In the mid 90s, the author and colleagues evaluated the ability of a screening system then in place to predict length of stay, hospital costs, and discharge status of medicine patients (9). Screening was done by dietitians and diet technicians. Criteria included weight for height, laboratory data, history of weight loss, and need for nutrition support. Patients identified as at risk had significantly higher length of stay, hospital costs, and need for post-acute care than low-risk patients.
In 1996, a screen used by dietitians for critically ill children with respiratory syncytial virus was evaluated. Criteria included anthropometrics, disease history, diet history, and lab data. Patients screened at high risk were found to have significantly poorer outcomes. (10)
In 2003, after the JCAHO standards incorporated the 24-hour time frame, Heller described inpatient and outpatient nutrition screening procedures in a pediatric hospital. Patients were initially screened by nursing staff using diagnostic criteria. Diet technicians followed within 48 hours with a more comprehensive screen that included diagnoses, feeding and gastrointestinal concerns, and anthropometrics (11). Outpatient screening utilized appearance, weight and weight changes, and nutrition support criteria.
Much of the research regarding validity and results of nutrition screening methods in health care facilities have utilized indicators not readily available for routine admission screening and does not reflect nutrition screening as it exists in health care today.
Applications
Despite the paucity of literature validating the screening systems currently in use in health care institutions in the U.S., clinicians can take steps to assure that their practice and criteria reflect the evidence that exists while meeting regulatory standards. Availability of a data element is necessary but not sufficient for its selection as a screening criterion. A more comprehensive survey using a nationwide sample of clinical nutrition managers should be undertaken. The research basis for each element of the screening process should be evaluated.
In the 2004 JCAHO hospital standards, nutrition assessment is housed under the broader assessment standards (12). However, the Elements of Performance still include the requirement that nutrition screening be completed within 24 hours of a patient admission. While meeting this standard has been challenging over time, its inclusion has mandated that nutrition status is addressed in the admission process, has assured the allocation of resources to this issue, and has encouraged an interdisciplinary process in the identification of patients who need nutrition care.
Cinda Chima is Assistant Professor of Nutrition and Dietetics at the University of Akron. Cinda can be contacted at csc19@uakron.edu.
References
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