NRS2002 Screening, Notas de estudo de Nutrição

Baixe NRS2002 Screening e outras Notas de estudo em PDF para Nutrição, somente na Docsity! Clinical Nutrition (2003) 22(4): 415–421 r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/S0261-5614(03)00098-0 SPECIAL ARTICLE ESPENGuidelines for Nutrition Screening 2002 J. KONDRUP,n S. P. ALLISON,yM. ELIA,z B.VELLAS,zM. PLAUTHy nRigshospitalet University Hospital Copenhagen, Denmark, yQueen’sMedical Centre, Nottingham, UK, zUniversity of Southampton, Southampton, UK, zUniversity Hospital Centre,Toulouse, France, yCommunity Hospital Dessau, Germany (Correspondence to: JK, Nutrition Unit^5711, Rigshospitalet University, 9 Blegdamsvej, 2100 Copenhagen, Denmark) Abstract3Aim: To provide guidelines for nutrition risk screening applicable to di¡erent settings (community, hospital, elderly) based on published and validated evidence available untilJune 2002. Note:These guidelines deliberately make reference to the year 2002 in their title to indicate that this version is based on the evidence availableuntil 2002 and that theyneed tobeupdatedandadapted to current state of knowledge in the future. Inorder to reach this goal the Education andClinical Practice Committee invites andwelcomes all criticism and sugges- tions (button for mail to ECPC chairman). r 2003 Elsevier 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 significant clinical risk are not identified. 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 benefit 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 influence 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 identified 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 beneficial. 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 identified to be at 415 risk by the method is likely to obtain a health benefit 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 find it rapid, simple and intuitively purposeful. It should not contain redundant information, e.g. information 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 of 44 nutritional screening tools (3). Finally, a screening tool should be linked to specified 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 specific 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 defined courses of action: a. The patient is not at risk, but may need to be re-screened at specified 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 defining outcome should be in place. The effectiveness of the care plan should be monitored by defined 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. 4. Communication. 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, obesity 430, borderline underweight 18.5–20, undernutritiono18.5. In cases where it is not possible 416 ESPEN GUIDELINES the essentiality of nutrients among patients, but rather to define when a certain form of nutritional support is more beneficial than leaving the patient to develop nutritional deficiences. 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 & 819 and 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–M63 11. Compan 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: 146–151 12. 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 AM, Ovesen L, Schroll M. A six months’ prospective follow- up of 65+-y-old patients from general practice classified according to nutritional risk by the Mini Nutritional Assessment. Eur J Clin Nutr 2001; 55: 1028–1033 14. Lauque 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. ASPEN Board 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: 495–501 19. 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 OVERALL RISK OF UNDERNUTRITION 0 LOW 1 MEDIUM 2 or more HIGH ROUTINE CLINICAL CARE OBSERVE TREAT Repeat screening Hospital - every week Care Homes - every month Community - every year for special groups, e.g. those >75 y Hospital - document dietary and fluid intake for 3 days Care Homes (as for hospital) Community - Repeat screening, e.g. from <1 mo to >6 mo (with dietary advice if necessary) Hospital - refer to dietitian or implement local policies. Generally food first followed by food fortification and supplements Care Homes (as for hospital) Community (as for hospital) (i) BMI (kg/m2) 0 20.0 1 = 18.5-20.0 2 18.5 (i i) Weight loss in 3-6 months 0 = 5% 1 = 5-10% 2 10% (i ii) Acute disease effect Add a score of 2 if there has been or is likely to be no or nutritional intake for > 5 days Add scores ≥ ≤ ≤ ≥ Can be adapted for special circumstances (e.g. when weight and height cannot be measured or when there are fluid disturbances) using specified alternative measurements including subjective criteria. It also identifies obesity (BMI430 kg/m2 ). Appendix Malnutrition Universal Screening Tool (MUST) for adults CLINICAL NUTRITION 419 Table 1 Initial screening Yes No 1 Is BMI o20.5? 2 Has the patient lost weight within the last 3 months? 3 Has the patient had a reduced dietary intake in the last week? 4 Is the patient severely ill ? (e.g. in intensive therapy) Yes: If the answer is ‘Yes’ to any question, the screening in Table 2 is performed. No: If the answer is ‘No’ to all questions, the patient is re-screened at weekly intervals. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Table 2 Final screening Impaired nutritional status Severity of disease (E increase in requirements) Absent Normal nutritional status Absent Normal nutritional requirements Score 0 Score 0 Mild Score 1 Wt loss 45% in 3 mths or Food intake below 50–75% of normal requirement in preceding week Mild Score 1 Hip fracture* Chronic patients, in particular with acute complications: cirrhosis*, COPD*. Chronic hemodialysis, diabetes, oncology Moderate Score 2 Wt loss 45% in 2 mths or BMI 18.5 – 20.5 + impaired general condition or Food intake 25–60% of normal requirement in preceding week Moderate Score 2 Major abdominal surgery* Stroke* Severe pneumonia, hematologic malignancy Severe Score 3 Wt loss 45% in 1 mth (415% in 3 mths) or BMI o18.5 + impaired general condition or Food intake 0-25% of normal requirement in preceding week in preceding week. Severe Score 3 Head injury* Bone marrow transplantation* Intensive care patients (APACHE410). Score: + Score: =Total score Age ifZ70 years: add 1 to total score above =age-adjusted total score Score Z3: the patient is nutritionally at-risk and a nutritional care plan is initiated Score o3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. NRS-2002 is based on an interpre-tation of available randomized clinical trials. A nutritional care plan is indicated in all patients who are quirement is increased, but can be covered by oral diet or supplements in most cases. *indicates that a trial directly supports the categorization of patients with that diagnosis. Diagnoses shown in italics are based on the prototypes given below. (1) severely undernourished (score=3), or (2) severely ill (score=3), or (3) moderately undernourished + mildly ill (score 2 +1), or (4) mildly undernourished + moderately ill (score 1 + 2). Score=2: a patient confined to bed due to illness, e.g. following major abdominal surgery. Protein requirement is substantially increased, but can be covered, although artificial feeding is required in many cases. Nutritional risk is defined by the present nutritional status and risk of impairment of present status, due to increased requirements caused by stress metabolism of the clinical condition. Prototypes for severity of disease Score=3: a patient in intensive care with assisted ventilation etc. Protein requirement is increased and cannot be covered even by artificial feeding. Protein breakdown and nitrogen loss can be significantly attenuated. Score=1: a patient with chronic disease, admitted to hospital due to complications. The patient is weak but out of bed regularly. Protein re- Nutritional Risk Screening (NRS 2002) 420 ESPEN GUIDELINES A Has food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 0=severe loss of appetite 1=moderate loss of appetite 2=no loss of appetite B Weight loss during last months? 0=weight loss greater than 3 kg 1=does not know 2=weight loss between 1 and 3 kg 3=no weight loss C Mobility? 0=bed or chair bound 1=able to get out of bed/chair but does not go out 2=goes out D Has suffered physical stress or acute disease in the past 3 months? 0=yes 2=no E Neuropsychological problems? 0=severe dementia or depression 1=mild dementia 2=no psychological problems F Body Mass Index (BMI) [weight in kg]/[height in m]2 0=BMI less than 19 1=BMI 19 to less than 21 2=BMI 21 to less than 23 3=BMI 23 or greater Screening score (total max. 14 points) 12 points or greater Normal—not at risk - no need to complement assessment 11 points or below Possible malnutrition - continue assessment Initial Screening in Mini Nutritional Assessment (MNAr) for the elderly CLINICAL NUTRITION 421