Subjective global assessment (SGA) - Diagnosing Malnutrition

Subjective global assessment (SGA) (http://www.nutritioncareincanada.ca/sites/default/uploads/files/SGA%20Tool%20EN%20colour_2017(1).pdf) is the gold standard for diagnosing malnutrition. It is also recommended by CMTF for triaging nutrition care. SGA is a simple bedside method used to diagnose malnutrition and identify those who would benefit from nutrition care. It provides an accurate diagnosis in 10 minutes. SGA has been validated in a variety of patient populations and is used extensively worldwide to diagnose malnutrition. The SGA assessment includes:

• Changes in recent food/fluid intake
• Weight change
• Gastrointestinal symptoms and other reasons for low intake
• Physical exam for wasting of muscle and fat

Dietitians or other trained professionals should conduct SGA within 24 hours of screening a hospital patient as ‘at risk’. SGA should also be used when nutrition risk screening is not possible or necessary for some patients (e.g. those with delirium, dementia, high risk conditions such as trauma, pressure ulcers or SIRS, language difficulties or receiving enteral or parenteral nutrition or recently transferred from critical care). In these cases, SGA should be automatically completed to rule out malnutrition, preferably on the first day of admission. When developing your screening and assessment process for triaging patients, make sure that staff knows the process (i.e. automatic referral) and what to do for these patients who cannot be screened.

The SGA score triages patients into SGA A, B or C. Within INPAC, the routes of care for each level are:

• SGA A (well nourished): Despite screening at nutrition risk, SGA A patients do not require further advanced or specialized care.
• SGA B (mild/moderate malnutrition): It is left to the discretion and clinical expertise of the professional doing the SGA to determine if a more comprehensive nutrition assessment is required to determine cause of malnutrition, potential micronutrient deficiency, or other investigations that could change the treatment plan.
• SGA C (severe malnutrition): Patients should receive a more comprehensive assessment.

The following are tips to facilitate detection and treatment of malnutrition using SGA.

• When the SGA is completed, it is more efficient to immediately continue with the comprehensive nutrition assessment for all SGA C patients, and if deemed appropriate, for SGA B patients.
• Develop a plan for standardized follow up of patients. This plan is especially relevant to SGA B patients who may be put on advanced care strategies and do not receive a comprehensive assessment automatically.
• To promote efficiency, SGA B patients can be followed by a diet technician or other nutrition staff member.
• At the point of identifying malnutrition, consider what strategies can be put in place immediately for SGA B and C patients and order these (e.g. medpass, food preferences).
• Medpass (small amount of oral nutritional supplement provided by nursing) is a common strategy used for all SGA B and C patients.