EAL

NSCR: Quick and Easy Nutrition Screening Tools: Adult Patients in Acute and Ambulatory Care Settings (2009)

Citation:

Study Design:

Class:

- Click here for explanation of classification scheme.

Quality Rating:

Research Purpose:

To design and validate a simple scoring system for screening patients for risk of nutritional depletion
To evaluate the suitability of this Nutrition Risk Score (NRS) as a potential screening tool for nursing staff to assess the risk of nutritional depletion of all patients on admission and during their hospital stay.

Additionally, the authors aimed to promote a multidisciplinary approach to clinical nutrition and increase awareness of the importance of assessing nutritional status.

Inclusion Criteria:

To validate the NRS: Two consecutive hospital admissions to each of ten medical and surgical specialties
To evaluate the use of the NRS by nursing staff as a nutrition screening tool: Hospital inpatients from ten medical and surgical specialties.

Exclusion Criteria:

None listed.

Description of Study Protocol:

Recruitment

Both study groups consisted of hospital inpatients.

Design and Statistical Analysis

Study Group One:
- 20 patients were evaluated by ten dietitians, each dietitian evaluated four patients and each patient was assessed by two different dietitians
- At each assessment, the dietitians calculated the patient's NRS, performed a validated Nutrition Risk Index (NRI) and provided their own clinical impression of the patient's nutritional depletion
- The NRS included points for weight loss, BMI (percentile charts for children), ability to eat and retain food and a stress factor for injury or illness
- The NRI was taken from a previously written paper and listed as validated
- 40 assessments were made in total
- The relationship between scores was evaluated with Spearman's rank correlation test by comparing actual scores obtained with either the NRS or the validation scoring system rather than final risk catagories. The significance of these correlation coefficients was determined using the T-test.
- Each time the NRS was used it was also assigned a separate score for ease of use; how this was determined is not explained
Study Group Two:
- 12 dietitians assessed 153 hospitalized patients using the NRS over the course of five days
- Dietetic referrals, nursing interventions and monitoring nutritional status at the ward level was noted
- Three qualified ward nurses also assessed 19 of the patients and the results were compared with those obtained by the dietitian

Data Collection Summary:

Timing of Measurements

Study Group One:
- The NRS, the validated NRI and the clinical impression were completed on the same day
- The time period between consecutive admissions is not stated
Study Group Two:
- All assessments using the NRS were completed within a five-day period
- The timing of the assessments completed by nurses is not specified.

Description of Actual Data Sample:

Initial N

Study Group One: 20 patients at two consecutive admissions
Study Group Two: 150 hospital inpatients were selected; it also notes 153 patients were assessed. No explanation is given for the three-patient difference. This was 18% of the inpatient population.

Attrition (Final N)

Same as the initial N for both Groups One and Two.

Age

Study Group One: Mean age 56.4 years, range of six weeks to 79 years
Study Group Two: Mean age 55.9 years, range of 8.5 months to 92 years.

Other relevant demographics:

Study Group One: Inpatients from ten medical and surgical specialties, not further specified
Study Group Two: Inpatients from ten medical and surgical specialties, the proportion of the sample taken from each specialty was chosen to correspond to the annual total admissions to that specialty in the previous year. 17 percent of the patients chosen were from pediatrics.

Location:

Birmingham Heartlands Hospital, Birmingham, UK.

Summary of Results:

Study Group One:
- The NRS obtained by two different dietitians fell into the same risk category for all 20 patients with a correlation coefficient of 0.91 (P<0.001) for the actual scores
- In 85% of the assessments, patients fell into the same category of risk using the NRS or NRI. The correlation coefficient was 0.68 (P<0.001) for the actual scores.
- In 93% of the assessments, patients fell into the same category of risk using the NRS or the dietitian's clinical impression. The correlation coefficient was 0.83 (P<0.001).
Study Group Two:
- 74% of the NRS done by the nurse and the dietitian were the same with a correlation coefficient of 0.80 (P<0.001). When scores were different, the nurses put the patient in a higher risk category than the dietitian.
- All moderate and high-risk patients were detected by the nursing staff
- 64% of the patients in the moderate nutrition risk category and 30% of the patients in the high nutrition risk category had no nutritional intervention to prevent a deterioration in nutritional status.

Other Findings

Study Group One: Ease of use scores indicate that the NRS was easy to complete, but no further analysis is given.
Study Group Two: 50% of patients scored low risk, 24% scored moderate risk and 26% scored high risk.

Author Conclusion:

The NRS was successfully validated against the two other assessment methods described, was easy to use and appropriate for nurses to use on a wide variety of patients.

Hospital staff awareness of nutritional status and its implications was increased.

Funding Source:

University/Hospital:

Birmingham Heartlands Hospital, Birmingham UK

Reviewer Comments:

The NRS scoring to determine low, moderate or high risk was not explained
Timing of the two consecutive admissions was not explained
Adults and children were both included but not separated out when tool was validated
It is unclear who was providing the interventions (nursing or the dietitian), when the NRS score was determined and what exactly the interventions were
Nurses only performed 19 assessments out of the 153 patients selected
Sample for Group Two indicates 150 patients were selected, but 153 patients were assessed
How the ease of use score is derived is not explained and may be subjective.

Quality Criteria Checklist: Primary Research
Relevance Questions
	1.	Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)	N/A
	2.	Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?	N/A
	3.	Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?	N/A
	4.	Is the intervention or procedure feasible? (NA for some epidemiological studies)	N/A

Validity Questions
1.	Was the research question clearly stated?		Yes
	1.1.	Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?	Yes
	1.2.	Was (were) the outcome(s) [dependent variable(s)] clearly indicated?	Yes
	1.3.	Were the target population and setting specified?	Yes
2.	Was the selection of study subjects/patients free from bias?		No
	2.1.	Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?	No
	2.2.	Were criteria applied equally to all study groups?	Yes
	2.3.	Were health, demographics, and other characteristics of subjects described?	No
	2.4.	Were the subjects/patients a representative sample of the relevant population?	???
3.	Were study groups comparable?		???
	3.1.	Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)	No
	3.2.	Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?	???
	3.3.	Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)	Yes
	3.4.	If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?	N/A
	3.5.	If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)	N/A
	3.6.	If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?	Yes
4.	Was method of handling withdrawals described?		N/A
	4.1.	Were follow-up methods described and the same for all groups?	N/A
	4.2.	Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)	N/A
	4.3.	Were all enrolled subjects/patients (in the original sample) accounted for?	N/A
	4.4.	Were reasons for withdrawals similar across groups?	N/A
	4.5.	If diagnostic test, was decision to perform reference test not dependent on results of test under study?	N/A
5.	Was blinding used to prevent introduction of bias?		Yes
	5.1.	In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?	N/A
	5.2.	Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)	Yes
	5.3.	In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?	N/A
	5.4.	In case control study, was case definition explicit and case ascertainment not influenced by exposure status?	N/A
	5.5.	In diagnostic study, were test results blinded to patient history and other test results?	N/A
6.	Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?		N/A
	6.1.	In RCT or other intervention trial, were protocols described for all regimens studied?	N/A
	6.2.	In observational study, were interventions, study settings, and clinicians/provider described?	N/A
	6.3.	Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?	N/A
	6.4.	Was the amount of exposure and, if relevant, subject/patient compliance measured?	N/A
	6.5.	Were co-interventions (e.g., ancillary treatments, other therapies) described?	N/A
	6.6.	Were extra or unplanned treatments described?	N/A
	6.7.	Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?	N/A
	6.8.	In diagnostic study, were details of test administration and replication sufficient?	N/A
7.	Were outcomes clearly defined and the measurements valid and reliable?		Yes
	7.1.	Were primary and secondary endpoints described and relevant to the question?	Yes
	7.2.	Were nutrition measures appropriate to question and outcomes of concern?	Yes
	7.3.	Was the period of follow-up long enough for important outcome(s) to occur?	N/A
	7.4.	Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?	Yes
	7.5.	Was the measurement of effect at an appropriate level of precision?	Yes
	7.6.	Were other factors accounted for (measured) that could affect outcomes?	Yes
	7.7.	Were the measurements conducted consistently across groups?	Yes
8.	Was the statistical analysis appropriate for the study design and type of outcome indicators?		Yes
	8.1.	Were statistical analyses adequately described and the results reported appropriately?	Yes
	8.2.	Were correct statistical tests used and assumptions of test not violated?	Yes
	8.3.	Were statistics reported with levels of significance and/or confidence intervals?	Yes
	8.4.	Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?	N/A
	8.5.	Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?	Yes
	8.6.	Was clinical significance as well as statistical significance reported?	Yes
	8.7.	If negative findings, was a power calculation reported to address type 2 error?	N/A
9.	Are conclusions supported by results with biases and limitations taken into consideration?		No
	9.1.	Is there a discussion of findings?	Yes
	9.2.	Are biases and study limitations identified and discussed?	No
10.	Is bias due to study's funding or sponsorship unlikely?		Yes
	10.1.	Were sources of funding and investigators' affiliations described?	Yes
	10.2.	Was the study free from apparent conflict of interest?	Yes