Nutrition risk screening is the first step in identifying patients at risk for malnutrition. Screening is also the first step of the Integrated Nutrition Pathway for Acute Care (INPAC) and ensures that detection of all malnourished (medical and surgical) patients occurs within 24 hours of admission.
What screening tool should I use? (expand +/-)
We recommend Canadian Nutrition Screening Tool (CNST) (pdf) because it is:
- Short (only 2 questions)
- Easy to use
- Valid and reliable for the acute care setting
- Questions can be asked of family or friends
- Does not need to be completed by a nutrition professional
- Nurses agree it is easy to include in their admission assessment
A 'Yes' answer to both questions indicates that the patient is at nutritional risk and requires further assessment to diagnose malnutrition.
Who should ask the screening questions and when? (expand +/-)
When planning the screening process, talk to staff about who should ask the questions, and when they should be asked. Having screening questions included in the existing nursing admission forms can be the simplest option. Nursing staff have said it was not hard to ask two more question and were more likely to ask the questions when they knew it connected to an action that benefited the patient.
The CNST questions can be easily embedded in the current admission forms. Others who interact with the patient within a few hours of admission (e.g. diet technician) could also complete nutrition screening.
Adherence and sustainability of screening may be increased by adding this tool to an electronic medical record (EMR). If adding the questions into an existing form/EMR is not possible right away, adding a separate page to the admission pack may be an option. This method typically requires more reminders for staff to ask the questions.
How will screening connect to assessment? (expand +/-)
When a patient is screened at risk, referral for assessment to diagnose malnutrition is always needed. All screening tools tend to over-identify risk for malnutrition, so assessment is essential.
Referrals that can be automated through an EMR can help ensure that this important step of referral for diagnosis after screening occurs. Other ways of ensuring follow through with a positive screen include education on:
• The importance of screening
• The importance of following through with a referral to the dietitian
• What is a positive screen for risk
• How to make a referral to a dietitian
• When not to screen and to go directly to a referral
Other strategies for getting screening into regular practice are:
• Make it easy to refer at risk patients by providing instructions or contact information for unit dietitian with the screening questions
• Provide check boxes and other reminders on assessment forms to promote accountability (e.g. initials for those who completed steps)
• Work with staff who conduct the screening to find out what would make the process easier
• Audit screening completion and feed back those results to the staff
• Celebrate successes when screening adherence is high
What are some practice models for screening? (expand +/-)
The following chart provides an overview of the models tested by More-2-Eat study hospitals. Consider these as examples as to how the process of screening and referral can be tailored to your hospital or unit.
|Where are the screening questions?||How is the RD notified?|
|Nurses||Admission paper-based form with RD referral instructions included on the form||Referral to RD (phone or paper based)|
|RD or Diet Tech checks the admission forms for positive screen; referral to RD as appropriate|
|Nurses||Admission form (electronic)||Electronic referral to dietitian or another clinician to complete SGA|
|Diet Clerk/ Technician||CNST form used when diets, preferences and other pertinent information collected from patients.||Diet clerk/technician leaves paper CNST in RD mailbox. Tracks risk on patient spreadsheet.|
Remember: the goal is to have all admitted/transferred patients screened, and where necessary, their nutritional status is assessed using the subjective global assessment (SGA). Anyone who is trained, particularly the registered dietitian (RD) or a diet technician (DT), can do SGA to diagnose malnutrition.
Comparison of nutrition screening tools
A review of the various nutrition screening tools and how they compare in terms of validation and reliability testing
Nutrition Screening Poster
An example of a poster to inform staff about nutrition screening using the CNST.
Example of CNST in an Admission Database
This is an example of how a hospital can integrate CNST into their admission database.
Identiftying Malnourished Patients
This is a PowerPoint presentation regarding the identification of malnutrition, including use of CNST.
Embedding Screening into Practice: A Step-by-Step Guide to Implementing Change
Acknowledgment: The ideas and resources included on this page are provided in part by the hospitals involved in the More-2-Eat project.