文档库 最新最全的文档下载
当前位置:文档库 › NRS2002

NRS2002

NRS2002
NRS2002

Clinical Nutrition (2003)22(4):415–421r 2003Elsevier Ltd.All rights reserved.doi:10.1016/S0261-5614(03)00098-0

SPECIAL ARTICLE

ESPEN Guidelines for Nutrition Screening 2002

J.KONDRUP ,n S.P .ALLISON,y M.ELIA,z B.VELLAS,z M.PLAUTH y

n

Rigshospitalet University Hospital Copenhagen,Denmark,y Queen’s Medical Centre,Nottingham,UK,z University of Southampton,Southampton,UK,z University Hospital Centre,T oulouse,France,y Community Hospital Dessau,Germany (Correspondence to:JK,Nutrition Unit^5711,Rigshospitalet University ,9Blegdamsvej,2100Copenhagen,Denmark)

Abstract?Aim:T o provide guidelines for nutrition risk screening applicable to di?erent settings (community,hospital,elderly)based on published and validated evidence available until June 2002.

Note :These guidelines deliberately make reference to the year 2002in their title to indicate that this version is based on the evidence available until 2002and that they need to be updated and adapted to current state of knowledge in the future.In order to

reach this goal the Education and Clinical Practice Committee invites and welcomes all criticism and sugges-tions (button for mail to ECPC chairman ).r 2003Elsevier Ltd.All rights reserved.

Key words:Nutritional Assessment;malnutrition;hos-pital;community

Background

About 30%of all patients in hospital are under-nourished.A large part of these patients are under-nourished when admitted to hospital and in the majority of these,undernutrition develops further while in hospital (1).This can be prevented if special attention is paid to their nutritional care.Other features of the patient’s primary disease are screened routinely and treated (e.g.dehydration,blood pressure,fever),and it is unacceptable that nutritional problems causing signi?cant clinical risk are not identi?ed.Neglect is also beginning to have medico-legal consequences,since an increasing number of cases of nutritional neglect are being brought to the courts.There is every reason,therefore,for hospitals and healthcare organizations to adopt a minimum set of standards in this area.

However,the lack of a widely accepted screening system which will detect patients who might bene?t clinically from nutritional support is commonly seen as a major limiting factor to improvement.

It is the purpose of this document to give simple guidelines as to how undernutrition,or risk for develop-ment of undernutrition,can be detected,by proposing a set of standards which are practicable for general use in patients and clients within present healthcare resources.Purpose of screening

The purpose of nutritional screening is to predict the probability of a better or worse outcome due to nutritional factors,and whether nutritional treatment

is likely to in?uence this.Outcome from treatment may be assessed in a number of ways:

1.Improvement or at least prevention of deterioration in mental and physical function

2.Reduced number or severity of complications of disease or its treatment.

3.Accelerated recovery from disease and shortened convalescence.

4.Reduced consumption of resources, e.g.length of hospital stay and other prescriptions.The nutritional impairment identi?ed by screening should therefore be relevant to these aims and outcomes and may vary according to circumstances,e.g.age or type of illness.In the community,undernutrition,with or without chronic disease,may be the primary factor determining the mental or physical function of an individual,whereas in hospital or in a nursing home,disease factors assume a greater importance with disease-associated undernutrition assuming an important albeit secondary role.Screening in the community can therefore be focused primarily on nutritional variables based on the results of semi-starvation studies such as those of Ancel Keys and his colleagues in 1950(2).In hospitals,other aspects of disease need to be considered in combination with purely nutritional measurements in order to deter-mine whether nutritional support is likely to be bene?cial.Randomized controlled trials of nutritional support in particular disease groups may therefore provide important evidence on which to base our criteria of nutritional risk.Methodological considerations

The usefulness of screening tools can be evaluated by a number of methods.The predictive validity is of major importance,i.e.that the individual identi?ed to be at

415

risk by the method is likely to obtain a health bene?t from the intervention arising from the results of the screening.This can be obtained in various ways,as described for the individual screening tools below.The screening tool must also have a high degree of content validity,i.e.considered to include all relevant components of the problem it is meant to solve.This is usually achieved by involving representatives of those who are going to use it in the process of designing the tool.It must additionally have a high reliability,i.e little inter-observer variation.It must also be practical, i.e.those who are going to use the tool must?nd it rapid,simple and intuitively purposeful.It should not contain redundant information,https://www.wendangku.net/doc/754917665.html,rmation about vomiting or dysphagia is unnecessary when dietary intake is part of the screening.The etiology of reduced dietary intake belongs to asssessment(see below)or is incorporated into the nutrition care plan.Several other aspects of evaluating screening tools are described in an analysis of44nutritional screening tools(3). Finally,a screening tool should be linked to speci?ed protocols for action, e.g.referral of those screened at risk to an expert for more detailed assessment and care plans.

Screening leads to nutritional care

Hospital and healthcare organizations should have a policy and a speci?c set of protocols for identifying patients at nutritional risk,leading to appropriate nutritional care plans:an estimate of energy and protein requirements including posssible allowance for weight gain,followed by prescription of food,oral supple-ments,tube feeding or parenteral nutrition,or a combination of these.It is suggested that the following course of action be adopted.

1.Screening This is a rapid and simple process

conducted by admitting staff or community health-care teams.All patients should be screened on admission to hospital or other institutions.The outcome of screening must be linked to de?ned courses of action:

a.The patient is not at risk,but may need to be

re-screened at speci?ed intervals,e.g.weekly

during hospital stay.

b.The patient is at risk and a nutrition plan is

worked out by the staff.

c.The patient is at risk,but metabolic or

functional problems prevent a standard plan

being carried out.

d.There is doubt as whether the patient is at risk.

In the two latter cases,referral should be made to an expert for more detailed assessment.

2.Assessment.This is a detailed examination of

metabolic,nutritional or functional variables by an expert clinician,dietitian or nutrition nurse.It is

a longer process than screening which leads to an

appropriate care plan considering indications, possible side-effects,and,in some cases,special feeding techniques.It is based,like all diagnosis, upon a full history,examination and,where appropriate,laboratory investigations.It will in-clude the evaluation or measurement of the func-tional consequences of undernutrition,such as muscle weakness,fatigue and depression.It involves consideration of drugs that the patient is taking and which may be contributing to the symptoms,and of personal habits such as eating patterns and alcohol intake.It includes gastrointestinal assessment, including dentition,swallowing,bowel function, etc.It necessitates an understanding of the inter-pretation of laboratory tests,e.g.plasma albumin which is more likely to be a measure of disease severity than of malnutrition per se.Calcium, magnesium and zinc levels may be important,and in some cases laboratory measurement of micro-nutrient levels may be appropriate.

3.Monitoring and outcome.A process of monitoring

and de?ning outcome should be in place.The effectiveness of the care plan should be monitored by de?ned measurements and observations,such as recording of dietary intake,body weight and function,and a schedule for detecting possible side-effects.This may lead to alterations in treatment during the natural history of the patient’s condition.

https://www.wendangku.net/doc/754917665.html,munication.Results of screening,assessment

and nutrition care plans should be communicated to other healthcare professionals when the patient is transferred,either back into the community or to another institution.When patients are transferred from the community to hospital or vice versa,it is important that the nutritional data and future care plans be communicated.

5.Audit.If this process is carried out in a systematic

way,it will allow audit of outcomes which may inform future policy decisions.

Although this document will focus mainly on the process of screening,this cannot be considered in isolation and must be linked to the pathway of care described above.

Components of nutritional screening

Screening tools are designed to detect protein and energy undernutrition,and/or to predict whether under-nutrition is likely to develop/worsen under the present and future conditions of the patient/client.Therefore, screening tools embody the following four main principles:

1.What is the condition now?Height and weight allow

calculation of body mass index(BMI).Normal range 20–25,obesity430,borderline underweight18.5–20, undernutrition o18.5.In cases where it is not possible

416ESPENGUIDELIN ES

to obtain height and weight,e.g.in severely ill patients,

a useful surrogate may be mid-arm circumference,

measured with a tape around the upper arm midway between the acromion and the olecranon.This can be related to centiles of tables for that particular population,age and sex.1BMI may be less useful in growing children and adolescents,and in the very elderly.Nevertheless,the BMI provides the best generally accepted measure of weight for height.

2.Is the condition stable?Recent weight loss is obtained

from the patient’s history,or,even better,from previous measurements in medical records.More than5%involuntary weight loss over3months,is usually regarded as signi?cant.This may reveal undernutrition which was not discovered by1.,e.g.

weight loss in obesity,and may also predict further nutritional deterioration depending on3and4.

3.Will the condition get worse?This question may be

answered by asking whether food intake has been decreased up to the time of screening,and if so by approximately how much and for how long.Con-?rmatory measurements can be made of the patient’s food intake in hospital or by food diary.If these are found to be less than the patient’s requirements with normal intake,then further weight loss is likely.

4.Will the disease process accelerate nutritional deteriora-

tion?In addition to decreasing appetite,the disease process may increase nutritional requirements due to the stress metabolism associated with severe disease

(e.g.major surgery,sepsis,multitrauma),causing

nutritional status to worsen more rapidly,or to develop rapidly from fairly normal states of(1–3)above. Variables1–3should be included in all screening tools,while4is relevant mainly to hospitals.In screening tools,each variable should be given a score, thereby quantifying the degree of risk and allowing a direct link to a de?ned course of action.

Screening tools recommended by ESPEN

The community:MUST for adults(see appendix)

The purpose of the MUST system is to detect under-nutrition on the basis of knowledge about the associa-tion between impaired nutritional status and impaired function(5).It was primarily developed for use in the community,where serious confounders of the effect of undernutrition are relatively rare.

Evaluation.The predictive validity of MUST in the community is based on previous and new studies of the effect of semi-starvation/starvation on mental and physical function in healthy volunteers concurrent validity with other tools,and utilisation of health care resources.The new series of studies describe the impair-ment of function as a results of various extents of weight loss,with various rates of weight loss,from various initial nutritional statures(low or high BMI)(6).

It has been documented to have a high degree of relia-bility(low inter-observer variation)with a k=0.88à1.00. Its content validity has been assured by involving a multidisciplinary working group in its preparation.Its practicability has been documented in a number of studies in different community regions in the UK(5)(Table1). The tool has recently been extended to other health care settings,including hospitals,where again it has been found to have excellent inter-rater reliability,concurrent validity with other tools,and predictive validity(length of hospital stay,mortality in elderly wards,and discharge destination in orthopaedic patients).

The hospital:NRS-2002(see appendix)

The purpose of the NRS-2002system is to detect the presence of undernutrition and the risk of developing undernutrition in the hospital setting(4).It contains the nutritional components of MUST,and in addition,a grading of severity of disease as a re?ection of increased nutritional requirements.It includes four questions as a pre-screening for departments with few at risk patients. With the prototypes for severity of disease given,it is meant to cover all possible patient categories in a hospital.A patient with a particular diagnosis does not always belong to the same category.A patient with cirrhosis,for example,who is admitted to intensive care because of a severe infection,should be given a score of 3,rather than1.It also includes old age as a risk factor, based on RCTs in elderly patients(4)(Table2). Evaluation.Its predictive validity has been documented by applying it to a retrospective analysis of128RCTs of nutritional support which showed that RCTs with patients full?lling the risk criteria had a higher likelihood of a positive clinical outcome from nutritional support than RCTs of patients who did not ful?ll these criteria (4).In addition,it has been applied prospectively in a controlled trial with212hospitalized patients selected according to this screening method,which showed a reduced length of stay among patients with complications in the intervention group(when adjusted for occurrence of operation and death).2Its content validity was maximized by involving an ESPENad hoc working group under the auspices of the ESPENEducational and Clinical Practice Committee in the literature based validation.It has also been used by nurses and dietitians in a2years’implementation study in three hospitals (local,regional and university hospital)in Denmark(7),

1Data on simultaneous measurements of BMI and mid-arm circum-ference have not been published in a form that allows comparison of cut-off points for these measurements.An analysis of RCTs,in which

mean values BMI were given together with mean values of mid-arm circumference,suggested that a mid-arm circumference o25cm corresponds to a BMI o20.5(4).The data did not allow for distinguishing between lower cut-off points for BMI.2The trial was completed in April2002and a manuscript is in preparation by N.Johansen et al.A copy is available upon request (kondrup@rh.dk)

CLINICAL NUTRITION417

which indicated that staff and investigators seldomly disagreed about a patient’s risk status.Its reliability was validated by inter-observer variation between a nurse,a dietitian and a physician with a k=0.67.Its practicability was shown by the?nding that99%of750newly admitted patients could be screened.The incidence of at-risk patients was about20%(7).

The elderly:MNA

The purpose of MNA is to detect the presence of undernutrition and the risk of developing undernutrition among the elderly in home-care programmes,nursing homes and hospitals.The prevalence of undernutrition among the elderly may reach signi?cant levels(15–60%) under these circumstances(8).The screening methods mentioned above will detect undernutrition among many elderly patients,but for the frail elderly the MNA screening is more likely to identify risk of developing undernutrition,and undernutrition at an early stage, since it also includes physical and mental aspects that frequently affect the nutritional status of the elderly,as well as a dietary questionnaire.It is in fact a combination of a screening and an assessment tool,since the last part of the form(not reproduced here)is a more detailed exploration of the items in the?rst part of the form. Evalution.The predictive validity of MNA has been evaluated by demonstrating its association with adverse health outcome(9),social functioning(10),mortality (11,12)and a higher rate of visits to the general practitioner(13).In a randomized trial of elderly at risk according to MNA,those given oral supplements increased body weight,but not grip strength(14),and in another similar(but small)randomized trial of elderly in a nursing home,the intervention group increased dietary intake but no functional or clinical outcome data were reported(15).The content validity has not been reported.The reliability(inter-observer variation)was estimated,with a k=0.51(8).The MNA takes o10min to complete and its practicability has been shown by its use in a large number of studies,see(8).

Children

A universally accepted screening tool for children is not yet available(although guidelines are in preparation under the Chairmanship of Professor Bert Koletzko, Munich).It is already standard practice among paedia-tricians to maintain height and weight charts,allowing calculation of growth velocity which is high-sensitive to nutritional status.Pubertal development is also im-paired during undernutrition.

Other screening systems

In their recent guidelines,the ASPENboard of directors stated that no screening system has been validated with respect to clinical outcome(16).They also suggested that,in the absence of an outcomes validated approach,a combination of clinical and biochemical parameters should be used to assess the presence of malnutrition. They suggest using the subjective global assessment,SGA (17),which classi?es patients subjectively on the basis of data obtained from history and physical examination, since this system has been validated in several ways other than with respect to clinical outcome,e.g.inter-observer variation.However,the lack of a direct connection between the observations and the classi?cation of patients leaves the tool more complex and less focused than desired for rapid screening purposes.

An analysis of a total of44screening tools for use in hospital and the community(3)indicated that tools were published with insuf?cient details regarding their intended use and method of derivation,and with an inadequate assessment of their effectiveness.No one tool satis?ed a set of criteria regarding scienti?c merit. The present recommendations by ESPENmay share some of these short-comings,but in view of the massive neglect of nutritional problems in health institutions, and the explicit lack of generally accepted screening tools,the predictive validity given above is considered suf?cient to provide a practical and reasonable ap-proach in the light of present knowledge.These recommendations may need to be modi?ed in the light of future experience.

Predictive validity vs meta-analyses of treatment

The predictive validity reported here needs to be commented upon in relation to recent meta-analyses, or systematic reviews.Such analyses suggest that nutritional support by the enteral or oral route improves functional capacity and clinical outcome,and reduces length of stay and mortality,e.g.(18,19).In a recent meta-analysis of studies employing parenteral nutrition (20),it was pointed out that there are inadequate data to assess the ef?cacy of parenteral nutrition in patients who are severely undernourished,who have highly catabolic disease processes,or who cannot be provided with enteral nutrition for several weeks.These are in fact the patients who most commonly receive supportive par-enteral nutrition now-a-days,and for ethical reasons, there will probably not be randomized trials available in the future either.The majority of studies available deal with the grey area of patients who are less under-nourished/not undernourished and/or are mildly–mod-erately catabolic.With these studies at hand,it was dif?cult to identify clinical conditions where parenteral nutrition would be clinically effective(20).However,the literature analysis mentioned above(4)suggests that parenteral nutrition is clinically effective in studies of patients who rather more than just ful?ll the criteria for being nutritionally at risk.

Furthermore,nutrients known to be essential for healthy humans are also essential for patients,and therefore the required documentation is not to con?rm

418ESPENGUIDELIN ES

the essentiality of nutrients among patients,but rather to de?ne when a certain form of nutritional support is more bene?cial than leaving the patient to develop nutritional de?ciences.Therefore,meta-analyses and systematic reviews of nutritional support are too simplistic,if performed by analogy with treatment using a new drug.Finally,a nutritional care plan in most cases will involve food,oral supplements,tube feeding and parenteral nutrition,often used interchangeably in the same patient,whereas the majority of randomized trials,and meta-analyses,have dealt with studies of single modality treatments.The predictive validity of a screen-ing tool therefore cannot be directly based on meta-analyses available at present.References

1.McWhirter J P,Pennington C R.Incidence and recognition of malnutrition in hospital.BMJ 1994;308:945–948

2.Keys A,Brozek J,Henschel A et al.The Biology of Human Starvation.Minneapolis:University of Minnesota Press;1950:703–748&819and 918

3.Jones J M.The methodology of nutritional screening and assess-ment tools.J Hum Nutr Diet 2002;15:59–71

4.Kondrup J,Rasmussen H H,Hamberg O et al.Nutritional Risk Screening (NRS 2002):a new method based on an analysis of controlled clinical trials.Clin Nutr 2003;22:321–336

5.Malnutrition Advisory Group (MAG).MAG—guidelines for Detection and Management of Malnutrition.British Association for Parenteral and Enteral Nutrition,2000,Redditch,UK

6.Elia M.Personal communication

7.Kondrup J,Johansen N,Plum L M et al.Incidence of nutritional risk and causes of inadequate nutritional care in hospitals.Clin Nutr 2002;21:461–468

8.Vellas B,Guigoz Y,Garry P J et al.The Mini Nutritional

Assessment (MNA)and its use in grading the nutritional state of elderly patients.Nutrition 1999;15:116–122

9.Beck A M,Ovesen L,Osler M.The ‘Mini Nutritional Assessment’(MNA)and the ‘Determine Your Nutritional Health’Checklist (NSI Checklist)as predictors of morbidity and mortality in an elderly Danish population.Br J Nutr 1999;81:31–36

10.Griep M I,Mets T F,Collys K et al.Risk of malnutrition in

retirement homes elderly persons measured by the ‘mini-nutritional assessment’.J Gerontol A Biol Sci Med Sci 2000;55:M57–https://www.wendangku.net/doc/754917665.html,pan B,di Castri A,Plaze J M et al.Epidemiological study

of malnutrition in elderly patients in acute,sub-acute and long-term care using the MNA.J Nutr Health Aging 1999;3:146–15112.Gazzotti C,Albert A,Pepinster A et al.Clinical usefulness of the

mini nutritional assessment (MNA)scale in geriatric medicine.J Nutr Health Aging 2000;4:176–81

13.Beck A M,Ovesen L,Schroll M.A six months’prospective follow-up of 65+-y-old patients from general practice classi?ed according to nutritional risk by the Mini Nutritional Assessment.Eur J Clin Nutr 2001;55:1028–1033

https://www.wendangku.net/doc/754917665.html,uque S,Arnaud Battandier F,Mansourian R et al.Protein-energy oral supplementation in malnourished nursing-home residents.A controlled trial.Age Ageing 2000;29:51–56

15.Beck A M,Ovesen L,Schroll M.Home-made oral supplement as

nutritional support of old nursing home residents,who are

undernourished or at risk of undernutrition based on the MNA.A pilot trial.Aging Clin Exp Res 2002;14:212–215

16.ASPENBoard of directors.Guidelines for the use of parenteral,

enteral nutrition in adult and pediatrc care.J Parenter Enteral Nutr 2002;26:9SA–12SA

17.Detsky A S,McLaughlin J R,Baker J P et al.What is subjective

global assessment of nutritional status?J Parenter Enteral Nutr 1987;11:8–13

18.Potter J,Langhorne P,Roberts M.Routine protein energy supple-mentation in adults:systematic review.BMJ 1998;317:495–50119.Stratton R J,Green C J,Elia M E.Disease Related Malnutrition:

An Evidence-based Approach to Treatment.CAB International,Oxford,UK,2003

20.Koretz R L,Lipman T O,Klein S.AGA technical review on

parenteral nutrition.Gastroenterology 2001;121:970–1001

Can be adapted for special circumstances (e.g.when weight and height cannot be measured or when there are ?uid disturbances)using speci?ed alternative measurements including subjective criteria.It also identi?es obesity (BMI 430kg/m 2).

Appendix

Malnutrition Universal Screening Tool (MUST)for adults

CLINICAL NUTRITION 419

420ESPENGUIDELIN ES

Nutritional Risk Screening(NRS2002)

CLINICAL NUTRITION421 r

相关文档