Screening

Goals of Screening

The goal of nutrition screening is to identify patients within 24 hours of admission who are malnourished and/ or at risk of nutritional deterioration. Screening is the first step in the pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC), and allows for early identification of patients who need further assessment and who may benefit from nutrition interventions to prevent further nutrition deterioration, reduce severity of complications of disease, accelerate recovery and reduce burden on the health system ^1,2.

a. Who and When to Screen

• Children aged 1 month to 18 years admitted to hospital, excluding critical care 
• Within 24 hours of admission

b. What screening tool should I use?

Numerous nutritional screening tools exist for use in the mixed group of hospitalized children^3-13. When selecting the proper tool for clinical use it is important to think about the purpose of screening, who will be the users, and what the setting is (including diseases and age groups).

For use in Canadian pediatric hospitals and P-INPAC, the following criteria were considered:

• Quick and easy to administer
• Able to be completed by health care professionals with no background in nutrition assessment
• No reliance on interpretation of anthropometric measures or growth standards
• Validated in general pediatric hospital populations

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Pediatric Nutritional screening Tools used in P-INPAC

P-INPAC recommends the use of a validated pediatric malnutrition screening tool, such as STRONGkids (A)¹⁴ or PNST (B) ¹⁵. These 2 tools have previously been used in studies in the Canadian setting^{16, 17}.

A. Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGkids)¹⁴

This nutritional screening tool was developed in the Netherlands to be performed within 24 h of admission in children aged 1 month to 18 years. It is comprised of questions covering 4 areas and does not include actual measurements.

 LINK TO TOOL

Areas covered:

1. Subjective clinical assessment
2. High risk disease
3. Nutritional intake and losses
4. Weight loss or poor weight gain

Risk levels are then assigned by point totals: 0 = low risk, 1-3 = medium risk, and 4-5 = high risk.

• For P-INPAC it is advised to use 4-5 points (high risk) as the cut-off for labeling a child at risk with need for further assessment 
• The tool can be completed by nursing staff or any health care professional as part of the admission process 
• It takes < 5 minutes to complete 

B. Pediatric Nutrition Screening Tool (PNST)¹⁵

This screening tool was developed in Australia and aims to identify hospital inpatients at nutritional risk. The tool consists of four simple questions to assist in the clinical diagnosis of patients up to 16 years.

 LINK TO TOOL WEBPAGE

 LINK TO TOOL

Areas Covered: 

1. Nutritional intake
2. Unintentional weight loss
3. Poor weight gain
4. Looking underweight

Nutrition screen is positive in case of “yes” to at least 2 questions. There is no classification into moderate or high risk.

• For P-INPAC it is advised to use a positive screen for labeling a child at risk with need for further assessment
• Can be completed by any health care professional as part of the admission process, do not need an expertise in nutrition assessment
• Takes < 3 minutes to complete

Other Pediatric Malnutrition screening Tools:

There are other validated nutritional screening tools available for general pediatric hospital patients.  These tools, including links and references are described HERE.

There are also malnutrition screening tools available for specific age groups, settings and diseases. References that describe these studies can be found HERE.

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c. Who should ask the screening questions and when? 

Can be completed by any health care professional (doctors, nurses, support staff etc). The majority of hospitals would have nurses perform the screening questions during their admission process.

d. How will screening connect to assessment?

Assessment of children that screen “at risk” is an important step in the P-INPAC pathway. Screening tools identify risk that must be confirmed by assessment, so patients with a positive screening should undergo further assessment in the form of SGNA.

A registered dietitian (RD) can complete SGNA and further assessments to identify and diagnose malnutrition. The RD can ensure those most at risk are properly identified and treated.

In order to ensure malnutrition screens are done well, education must be done with the healthcare professionals conducting the screening about:

• Importance of screening
• Defininition of a positive screen
• Importance of involving the RD
• Process of referring to a RD

e. How to implement the use of a screening tool?

Implementation is: 

• Bringing together key stakeholders to determine the best screening tool for your facility. Key stakeholders include: physicians, registered dietitians (and other relevant nutrition support staff), nursing staff, clinical managers, EMR programmers, clinical educators, and other relevant staff at your facility
• Determine which screening tool you use, make sure it is simple and user friendly for better uptake
• Involve the educators or choose staff to conduct roll out and education for the screening tool. When doing education, include real examples that are relevant to the specific wards as to why this screening tool is being implemented
• Educate nursing, physician and dietetic staff on the screening tool
• If possible, make the screening tool a part of the initial nursing assessment (many screening tool questions are already apart of their initial assessment which makes it easier for nursing staff to complete)
• Once education is completed, have champions (dietetic or nursing staff) on each ward who continue to keep motivation high for completing the screening tools and serve as resources for questions/concerns around the screening tool
• Complete audit and feedback to ensure that screening is being done accurately and completely
• Provide plenty of support throughout the implementation process – celebrate successes and obtain plenty of continued feedback on how to make the process run more smoothly and effectively

Various Practice Models for Implementation of Screening

Who Screens?	Where are the Questions?	How is the RD notified?
Nurses	Initial Nursing Assessment (electronic)	Electronic referral to RD to complete full assessment
Nurses	Initial Nursing Assessment (electronic)	First a review by physician and then a referral to RD by physician
Nurses	Paper admission form (with instructions on how to contact RD w/positive screen)	Nursing calls RD  - OR -  RD (or DA) reviews the paper admission form and completes full assessment

f. How can Electronic Medical Records be utilized to facilitate screening?

An Electronic Medical Record (EMR) provides the opportunity to hardwire nutrition screening and other P-INPAC care elements into the workflow of clinicians.In addition, EMRs provide the opportunity to aggregate data on nutrition screening and evaluate compliance with the nutrition care pathway¹⁹.

It is essential to understand what the EMR offers in terms of tools available to assist with nutrition screening.Specifically, consider whether the following tools are available in the EMR:

• Clinical Decision Support to assist health professional with completing the screening tool questions
• Mandatory completion of screening questions (also referred to as hard stops)
• Automatic referral to RD triggered when positive screen occurs

Work with other health disciplines and the EMR implementation team to determine whether the tools are appropriate to implement in your care setting and ensure that they are feasible for each discipline’s workflow¹⁹.

g. Click for Pediatric Malnutrition Screening References

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P-INPAC Pathway Screening Assessment Treatment Implementation