Development and validation of 3-Minute Nutrition Screening (3-MinNS) tool for acute hospital patients in Singapore

It is important to detect and treat malnutrition in hospital patients so as to improve clinical outcome and reduce hospital stay. The aim of this study was to develop and validate a nutrition screening tool with a simple and quick scoring system for acute hospital patients in Singapore. In this study, 818 newly admitted patients aged above 18 years old were screened using five parameters that contribute to the risk of malnutrition. A dietitian blinded to the nutrition screening score assessed the same patients using the reference standard, Subjective Global Assessment (SGA) within 48 hours. The sensitivity and specificity were established using the Receiver Operator Characteristics (ROC) curve and the best cutoff scores determined. The nutrition parameter with the largest Area Under the ROC Curve (AUC) was chosen as the final screening tool, which was named 3-Minute Nutrition Screening (3-MinNS). The combination of the parameters weight loss, intake and muscle wastage (3-MinNS), gave the largest AUC when compared with SGA. Using 3-MinNS, the best cutoff point to identify malnourished patients is three (sensitivity 86%, specificity 83%). The cutoff score to identify subjects at risk of severe malnutrition is five (sensitivity 93%, specificity 86%). 3-Minute Nutrition Screening is a valid, simple and rapid tool to identify patients at risk of malnutrition in Singapore acute hospital patients. It is able to differentiate patients at risk of moderate malnutrition and severe malnutrition for prioritization and management purposes.

Nutrition screening and risk factors prior to chemotherapy in cancer patients 65 years and older

Background The largest proportion of cancer patients are aged 65 years and over. Increasing age is also associated with nutritional risk and multi-morbidities—factors which complicate the cancer treatment decision-making process in older patients. Objectives To determine whether malnutrition risk and Body Mass Index (BMI) are associated with key oncogeriatric variables as potential predictors of chemotherapy outcomes in geriatric oncology patients with solid tumours. Methods In this longitudinal study, geriatric oncology patients (aged ≥65 years) received a Comprehensive Geriatric Assessment (CGA) for baseline data collection prior to the commencement of chemotherapy treatment. Malnutrition risk was assessed using the Malnutrition Screening Tool (MST) and BMI was calculated using anthropometric data. Nutritional risk was compared with other variables collected as part of standard CGA. Associations were determined by chi-square tests and correlations. Results Over half of the 175 geriatric oncology patients were at risk of malnutrition (53.1%) according to MST. BMI ranged from 15.5–50.9kg/m2, with 35.4% of the cohort overweight when compared to geriatric cutoffs. Malnutrition risk was more prevalent in those who were underweight (70%) although many overweight participants presented as at risk (34%). Malnutrition risk was associated with a diagnosis of colorectal or lung cancer (p=0.001), dependence in activities of daily living (p=0.015) and impaired cognition (p=0.049). Malnutrition risk was positively associated with vulnerability to intensive cancer therapy (rho=0.16, p=0.038). Larger BMI was associated with a greater number of multi-morbidities (rho =.27, p=0.001. Conclusions Malnutrition risk is prevalent among geriatric patients undergoing chemotherapy, is more common in colorectal and lung cancer diagnoses, is associated with impaired functionality and cognition and negatively influences ability to complete planned intensive chemotherapy.

Validity and reliability of nutrition screening administered by nurses

Background: Nutrition screening is usually administered by nurses. However, most studies on nutrition screening tools have not used nurses to validate the tools. The 3-Minute Nutrition Screening (3-MinNS) assesses weight loss, dietary intake and muscle wastage, with the composite score of each used to determine risk of malnutrition. The aim of the study was to determine the validity and reliability of 3-MinNS administered by nurses, who are the intended assessors. Methods: In this cross sectional study, three ward-based nurses screened 121 patients aged 21 years and over using 3-MinNS in three wards within 24 hours of admission. A dietitian then assessed the patients’ nutritional status using Subjective Global Assessment within 48 hours of admission, whilst blinded to the results of the screening. To assess the reliability of 3-MinNS, 37 patients screened by the first nurse were re-screened by a second nurse within 24 hours, who was blinded to the results of the first nurse. The sensitivity, specificity and best cutoff score for 3-MinNS were determined using the Receiver Operator Characteristics Curve. Results: The best cutoff score to identify all patients at risk of malnutrition using 3-MinNS was three, with sensitivity of 89% and specificity of 88%. This cutoff point also identified all (100%) severely malnourished patients. There was strong correlation between 3-MinNS and SGA (r=0.78, p<0.001). The agreement between two nurses conducting the 3-MinNS tool was 78.3%. Conclusion: 3-Minute Nutrition Screening is a valid and reliable tool for nurses to identify patients at risk of malnutrition.

Validity and reliability of 3-minute nutrition screening (3-MinNS)performed by nurses on oncology and surgical patients

Background Nutrition screening is usually administered by nurses. However, most studies on nutrition screening tools have not used nurses to validate the tools. The 3-Minute Nutrition Screening (3-MinNS) assesses weight loss, dietary intake and muscle wastage, with the composite score of each used to determine risk of malnutrition. The aim of the study was to determine the validity and reliability of 3-MinNS administered by nurses, who are the intended assessors. Methods In this cross sectional study, three ward-based nurses screened 121 patients aged 21 years and over using 3-MinNS in three wards within 24 hours of admission. A dietitian then assessed the patients’ nutritional status using Subjective Global Assessment within 48 hours of admission, whilst blinded to the results of the screening. To assess the reliability of 3-MinNS, 37 patients screened by the first nurse were re-screened by a second nurse within 24 hours, who was blinded to the results of the first nurse. The sensitivity, specificity and best cutoff score for 3-MinNS were determined using the Receiver Operator Characteristics Curve. Results The best cutoff score to identify all patients at risk of malnutrition using 3-MinNS was three, with sensitivity of 89% and specificity of 88%. This cutoff point also identified all (100%) severely malnourished patients. There was strong correlation between 3-MinNS and SGA (r=0.78, p<0.001). The agreement between two nurses conducting the 3-MinNS tool was 78.3%. Conclusion 3-Minute Nutrition Screening is a valid and reliable tool for nurses to identify patients at risk of malnutrition.

Nutrition screening and assessment in Parkinson's disease : a comparison of methods

Background & Aims Nutrition screening and assessment enable early identification of malnourished people and those at risk of malnutrition. Appropriate assessment tools assist with informing and monitoring nutrition interventions. Tool choice needs to be appropriate to the population and setting. Methods Community-dwelling people with Parkinson’s disease (>18 years) were recruited. Body mass index (BMI) was calculated from weight and height. Participants were classified as underweight according to World Health Organisation (WHO) (≤18.5kg/m2) and age specific (<65 years,≤18.5kg/m2; ≥65 years,≤23.5kg/m2) cut-offs. The Mini-Nutritional Assessment (MNA) screening (MNA-SF) and total assessment scores were calculated. The Patient-Generated Subjective Global Assessment (PG-SGA), including the Subjective Global Assessment (SGA), was performed. Sensitivity, specificity, positive predictive value, negative predictive value and weighted kappa statistic of each of the above compared to SGA were determined. Results Median age of the 125 participants was 70.0(35-92) years. Age-specific BMI (Sn 68.4%, Sp 84.0%) performed better than WHO (Sn 15.8%, Sp 99.1%) categories. MNA-SF performed better (Sn 94.7%, Sp 78.3%) than both BMI categorisations for screening purposes. MNA had higher specificity but lower sensitivity than PG-SGA (MNA Sn 84.2%, Sp 87.7%; PG-SGA Sn 100.0%, Sp 69.8%). Conclusions BMI lacks sensitivity to identify malnourished people with Parkinson’s disease and should be used with caution. The MNA-SF may be a better screening tool in people with Parkinson’s disease. The PG-SGA performed well and may assist with informing and monitoring nutrition interventions. Further research should be conducted to validate screening and assessment tools in Parkinson’s disease.  

A novel, automated nutrition screening system as a predictor of nutritional risk in an oncology day treatment unit (ODTU)

Purpose Paper-based nutrition screening tools can be challenging to implement in the ambulatory oncology setting. The aim of this study was to determine the validity of the Malnutrition Screening Tool (MST) and a novel, automated nutrition screening system compared to a ‘gold standard’ full nutrition assessment using the Patient-Generated Subjective Global Assessment (PG-SGA). Methods An observational, cross-sectional study was conducted in an outpatient oncology day treatment unit (ODTU) within an Australian tertiary health service. Eligibility criteria were as follows: ≥18 years, receiving outpatient anticancer treatment and English literate. Patients self-administered the MST. A dietitian assessed nutritional status using the PGSGA, blinded to the MST score. Automated screening system data were extracted from an electronic oncology prescribing system. This system used weight loss over 3 to 6 weeks prior to the most recent weight record or age-categorised body mass index (BMI) to identify nutritional risk. Sensitivity and specificity against PG-SGA (malnutrition) were calculated using contingency tables and receiver operating curves. Results There were a total of 300 oncology outpatients (51.7 % male, 58.6±13.3 years). The area under the curve (AUC) for weight loss alone was 0.69 with a cut-off value of ≥1 % weight loss yielding 63 % sensitivity and 76.7 % specificity. MST (score ≥2) resulted in 70.6 % sensitivity and 69.5 % specificity, AUC 0.77. Conclusions Both the MST and the automated method fell short of the accepted professional standard for sensitivity (~≥80 %) derived from the PG-SGA. Further investigation into other automated nutrition screening options and the most appropriate parameters available electronically is warranted to support targeted service provision.

Improving the performance of nutrition screening through a series of quality improvement initiatives

Background Nutrition screening identifies patients at risk of malnutrition to facilitate early nutritional intervention. Studies have reported incompletion and error rates of 30-90% for a range of commonly used screening tools. This study aims to investigate the incompletion and error rates of 3-Minute Nutrition Screening (3-MinNS) and the effect of quality improvement initiatives in improving the overall performance of the screening tool and the referral process for at risk patients. Methods Annual audits were carried out from 2008-2013 on 4467 patients. Value Stream Mapping, Plan-Do-Check-Act cycle and Root Cause Analysis were used in this study to identify gaps and determine the best intervention. The intervention included 1) implementing a nutrition screening protocol, 2) nutrition screening training, 3) nurse empowerment for online dietetics referral of at-risk cases, 4) closed-loop feedback system and 5) removing a component of 3-MinNS that caused the most error without compromising its sensitivity and specificity. Results Nutrition screening error rates were 33% and 31%, with 5% and 8% blank or missing forms, in 2008 and 2009 respectively. For patients at risk of malnutrition, referral to dietetics took up to 7.5 days, with 10% not referred at all. After intervention, the latter decreased to 7% (2010), 4% (2011) and 3% (2012 and 2013), and the mean turnaround time from screening to referral was reduced significantly from 4.3 ± 1.8 days to 0.3 ± 0.4 days (p < 0.001). Error rates were reduced to 25% (2010), 15% (2011), 7% (2012) and 5% (2013) and percentage of blank or missing forms reduced to and remained at 1%. Conclusion Quality improvement initiatives are effective in reducing the incompletion and error rates of nutrition screening, and led to sustainable improvements in the referral process of patients at nutritional risk.

A simple nutrition screening tool for paediatric inpatients

Background: Pediatric nutrition risk screening tools are not routinely implemented throughout many hospitals, despite prevalence studies demonstrating malnutrition is common in hospitalized children. Existing tools lack the simplicity of those used to assess nutrition risk in the adult population. This study reports the accuracy of a new, quick, and simple pediatric nutrition screening tool (PNST) designed to be used for pediatric inpatients. Materials and Methods: The pediatric Subjective Global Nutrition Assessment (SGNA) and anthropometric measures were used to develop and assess the validity of 4 simple nutrition screening questions comprising the PNST. Participants were pediatric inpatients in 2 tertiary pediatric hospitals and 1 regional hospital. Results: Two affirmative answers to the PNST questions were found to maximize the specificity and sensitivity to the pediatric SGNA and body mass index (BMI) z scores for malnutrition in 295 patients. The PNST identified 37.6% of patients as being at nutrition risk, whereas the pediatric SGNA identified 34.2%. The sensitivity and specificity of the PNST compared with the pediatric SGNA were 77.8% and 82.1%, respectively. The sensitivity of the PNST at detecting patients with a BMI z score of less than -2 was 89.3%, and the specificity was 66.2%. Both the PNST and pediatric SGNA were relatively poor at detecting patients who were stunted or overweight, with the sensitivity and specificity being less than 69%. Conclusion: The PNST provides a sensitive, valid, and simpler alternative to existing pediatric nutrition screening tools such as Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), Screening Tool Risk on Nutritional status and Growth (STRONGkids), and Paediatric Yorkhill Malnutrition Score (PYMS) to ensure the early detection of hospitalized children at nutrition risk.

Prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting length of hospital stay, readmission, cost of hospitalisation and mortality : a cohort study

Background: It is important to identify patients who are at risk of malnutrition upon hospital admission as malnutrition results in poor outcomes such as longer length of hospital stay, readmission, hospitalisation cost and mortality. The aim of this study was to determine the prognostic validity of 3-Minute Nutrition Screening (3-MinNS) in predicting hospital outcomes in patients admitted to an acute tertiary hospital through a list of diagnosis-related groups (DRG). Methods: In this study, 818 adult patients were screened for risk of malnutrition using 3-MinNS within 24 hours of admission. Mortality data was collected from the National Registry with other hospitalisation outcomes retrieved from electronic hospital records. The results were adjusted for age, gender and ethnicity, and matched for DRG. Results: Patients identified to be at risk of malnutrition (37%) using 3-MinNS had significant positive association with longer length of hospital stay (6.6 ± 7.1 days vs. 4.5 ± 5.5 days, p<0.001), higher hospitalisation cost (S$4540 ± 7190 vs. S$3630 ± 4961, p<0.001) and increased mortality rate at 1 year (27.8% vs. 3.9%), 2 years (33.8% vs. 7.2%) and 3 years (39.1% vs. 10.5%); p<0.001 for all. Conclusions: The 3-MinNS is able to predict clinical outcomes and can be used to screen newly admitted patients for nutrition risk so that appropriate nutrition assessment and early nutritional intervention can be initiated.

Validating adult and paediatric nutrition screening and assessment tools in Vietnamese language in two acute hospital in Ho Chi Minh City, Vietnam

Despite being commonly prevalent in acute care hospitals worldwide, malnutrition often goes unidentified and untreated due to a lack in the implementation of a nutrition care pathway. The aim of this study was to validate nutrition screening and assessment tools in Vietnamese language. After converting into Vietnamese, Malnutrition Screening Tool (MST) and Subjective Global Assessment (SGA) were used to identify malnutrition in the adult setting; and the Paediatric Nutrition Screening Tool (PNST) and paediatric Subjective Global Nutritional Assessment (SGNA) were used in the paediatric setting in two acute care hospitals in Vietnam. This cross-sectional observational study sampled 123 adults (median age 78 years [39–96 years], 63% males) and 105 children (median age 20 months [2–100 months], 66% males). In adults, nutrition risk and malnutrition were identified in 29% and 45% of the cohort respectively. Nutrition risk and malnutrition were identified in 71% and 43% of the paediatric cohort respectively. The sensitivity and specificity of the screening tools were: 62% and 99% for the MST compared to the SGA; 89% and 42% for the PNST compared to the SGNA. This study provides a stepping stone to the potential use of evidence-based nutrition screening and assessment tools in Vietnamese language within the adult and paediatric Vietnamese acute care setting. Further work is required into integrating a complete nutrition care pathway within the acute care setting in Vietnamese hospitals.

Nutrition screening in long-term care facilities : an evaluation of the methodological quality of available instruments

A variety of nutrition screening instruments have been developed and implemented for identifying the risk of undernutrition among community and hospitalized older adults. Despite the high prevalence of undernutrition amongst older adults in long-term care, few screening instruments have been developed or evaluated in this setting. This review aims to evaluate the validity, reproducibility and feasibility of nutrition screening instruments developed for use, or described as being used, with older adults in long-term care. Ten publications encompassing nine independent nutrition screening tools were identified using electronic databases and manual searches of reference lists. The Mini Nutritional Assessment-Short Form (MNA-SF) was the most widely evaluated nutrition screening instrument and met the requirements for a valid instrument (sensitivity and specificity >0.9) for use in the long-term care setting. Modified versions of the MNA for use in China and South Africa also demonstrated acceptable levels of sensitivity and specificity. Other nutrition screening instruments were found to have variable levels of sensitivity and specificity and while some demonstrated levels consistent with the MNA-SF, only two were evaluated across more than one study population, Body Mass Index (BMI)+weight loss and BMI+albumin. These same instruments reported the highest levels of inter-rater and test-retest reproducibility, although this was only tested in one other instrument (Chinese Nutrition Screen -modified MNA). In conclusion, it is evident from this review that further work in this area is needed. Based on validity, reproducibility and feasibility it appears that BMI+weight loss is the most suitable nutrition screening instrument for use in the long-term care setting at this time. MNA-SF is promising; however, there is currently no data for inter-rater or test-retest reproducibility in the long-term care setting.

A simple nutrition screening tool for hemodialysis nurses

Objective : To assess the reliability of a nurse-performed nutrition screening tool (NST) for hemodialysis (HD) patients to identify nutritionally at-risk patients.

Design : Tool reliability assessment.

Setting and Participants : The setting was nine non-hospital private (n = 3) and public (n = 6) HD units in Australia (two rural and seven metropolitan). Participants were 112 HD patients.

Results : A total of 112 HD patients (male = 65, female = 47) from 9 non-hospital HD units in Australia (seven metropolitan and two rural) were screened with the NST and the outcome of dietitian referral compared with Standard Dietitians Assessment. The mean age of patients was 57.6 years. Overall, the NST showed a sensitivity of 0.84 (range, 0.71 to 0.94; P < .05) and a specificity of 0.9 (range, 0.82 to 0.98; P < .05). The NST was more sensitive (sensitivity, 0.93 [range, 0.87 to 0.99; P < .05]) and was more specific for men (specificity, 0.92 [range, 0.85 to 0.99; P < .05]). Specificity was very strong in metropolitan patients (specificity, 0.94 [range, 0.87 to 1.01; P < .05]).

Conclusions : The tool was more sensitive and specific than the NST previously reported by the same investigators. The tool is particularly specific in that it screens those patients not requiring dietitian intervention. The use of this tool may benefit HD units that do not have on-site or regular dietetic support to prioritize patients needing dietitian intervention.

Nutrition screening by nurses in dialysis

Aims and objectives : To determine whether a nurse-completed dialysis nutritional screening tool improves referral rates for nutritional support and compare nutrition sensitive biochemical indices, mortality rates and patient-centred quality of life outcomes between referred and non-referred dialysis patients.

Background : People with chronic kidney disease requiring dialysis are nutritionally at risk. Nutrition screening has been shown to identify dialysis patients who are nutritionally at risk to refer to dietitian expertise.

Design : Prospective cluster-randomised control trial.

Methods : Monthly nurse-completed nutrition screening was completed for six consecutive months using a validated four-item instrument measuring weight change, serum phosphate, serum potassium and appetite. Participants (n = 81) were haemodialysis patients from four satellite haemodialysis centres in one Australian metropolitan health service. Primary outcome measure was rate of referral to dietetic services for nutrition support for intervention vs. control groups at six months. Secondary outcome measures were blood pressure, biochemical indices and mortality for referred vs. non-referred patients at six and nine months, and generic and dialysis-specific quality of life for referred vs. non-referred at nine months was examined.

Results : There were three times as many dietetic referrals in the intervention group than in the control group (26·3 vs. 9·3%). Serum phosphate increased significantly more in the referred patients than the non-referred patients. There were no clinically significant changes between groups in quality of life, blood pressure, mortality rates or other biochemical indices at either six or nine months.

Conclusion : Nurse-completed nutritional screening can lead to appropriate dietetic referrals for nutritional support by nutritional expert clinicians.

Relevance to clinical practice : This study is the first to demonstrate that monthly systematic nurse-completed nutritional screening can facilitate appropriate dietetic referrals that may lead to increased nutritional care for people in satellite dialysis centres.