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FROM THE ACADEMY

Differentiating Malnutrition Screening and


Assessment: A Nutrition Care Process
Perspective

HE ACADEMY OF NUTRITION
and Dietetics (Academy) supports nutrition screening as
the rst step to identify patients at nutritional risk who would
benet from seeing a registered dietitian nutritionist (RDN).1 Nutrition
screening is a supportive task that triggers the entry of a patient into the
Academys Nutrition Care Process
(NCP), a standardized process to identify nutrition-related problems and
provide appropriate intervention.
However, nutrition screening and
nutrition assessment are terms often
used interchangeably in the literature
and in practice despite their differences. This could lead to confusion.1
The different functions of nutrition
screening and assessment in the
context of malnutrition are the focus
of this narrative.
In 1995, The Joint Commission
mandated that all patients be screened
for nutrition risk to determine whether a
patient would benet from a full nutrition assessment.2 Screening must be
done within 24 hours of admission to an
acute care facility. The Academy supports
this approach3 as do the American Society for Parenteral and Enteral Nutrition
(A.S.P.E.N.) and the European Society for
Parenteral and Enteral Nutrition.4-6
However, The Joint Commission does
not mandate the tool or criteria to be

This article was written by Lindsey B.


Field, MS, RDN, LD, Abbott Nutrition
Malnutrition Research Fellow at the
Academy of Nutrition and Dietetics/
Academy of Nutrition and Dietetics
Foundation, Chicago, IL; and Rosa K.
Hand, MS, RDN, LD, director of the
Dietetics Practice Based Research
Network, Academy of Nutrition and
Dietetics, Chicago, IL.
2212-2672/Copyright 2015 by the
Academy of Nutrition and Dietetics.
http://dx.doi.org/10.1016/j.jand.2014.11.010
Available online 9 January 2015

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used for nutrition screening, which leads


to wide variation in methods used between sites.7
The Academy denes nutrition
screening as the process of identifying
patients, clients, or groups who may
have a nutrition diagnosis and benet
from nutrition assessment and intervention by a registered dietitian.8
Similarly, A.S.P.E.N., an interdisciplinary
organization whose members span
the health care continuum (registered
nurses [RNs], RDNs, pharmacists, physicians, scientists, and other nutrition
support health professionals) dene
nutrition screening as a process to
identify an individual who is malnourished or who is at risk for malnutrition
to determine if a detailed nutrition assessment is indicated.9 In contrast, the
longer, more detailed nutrition assessment process identies (diagnoses) a
nutrition problem and recommends
an intervention. Simply, screening
determines risk of a problem and
assessment determines presence of a
problem.

NUTRITION SCREENING IN THE


CONTEXT OF MALNUTRITION
Malnutrition is estimated to affect 30% to
50% of adult hospital patients
in the United States,10 but only 3.2%
of these patients are discharged
with a diagnosis of malnutrition.11
Therefore, many patients are either
well-nourished on admission to the
hospital and malnutrition develops during their stay,12 are malnourished when
they are admitted and are overlooked, or
both. It is well-documented that
malnourished patients have worse outcomes compared to well-nourished patients, including increased length of
hospital stay, number of readmissions,
decreased function and quality of life,
increased mortality, and higher health
care costs.13-15 Pressure ulcers are twice
as likely to develop in malnourished
hospital patients compared with well-

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

nourished patients,16 and the risk of


surgical site infections is three times
higher.17 Use of an inappropriate
screening tool (one that has not been
validated or has been validated in a
different population) negatively inuences patient care and risks misdiagnosis (or missed diagnosis) of nutritionrelated problems. Other risks include
wasting resources, such as clinician time
and health care dollars, and most
importantly, poor patient outcomes.
Therefore, identication and treatment
of these patients through an appropriate
screening and assessment process is a
critical concern to health care providers,
patients and families, hospital administrators, and third-party payers.

CLINICAL DOCUMENTATION IN
PRACTICE: ACADEMY
NUTRITION CARE PROCESS
In 2003 the Academy adopted the
Nutrition Care Process and Model
(NCP), a standardized process for
nutrition and dietetics practitioners to
use critical thinking and decisionmaking skills to address nutritionrelated problems and provide quality
care.1 The NCP, updated in 2008,18
consists of four steps to be done in
sequence: (a) Nutrition Assessment,
(b) Nutrition Diagnosis, (c) Nutrition
Intervention, and (d) Nutrition Monitoring and Evaluation. These four steps
have corresponding standardized terminology, called the NCP Terminology
(NCPT), that supports consistent use of
language in documentation of nutrition
care. Nutrition screening is a supportive task that triggers the entry of a
patient into the NCP.

Nutrition Screening
Nutrition screening identies patients
who need to be seen by an RDN.
Screening is most often completed by
someone other than a nutrition and
dietetics practitioner (eg, nurse), and
2015 by the Academy of Nutrition and Dietetics.

FROM THE ACADEMY


does not require formal nutrition
training. In fact, a recent survey showed
that in 86% of facilities, nurses conduct
the screening.7 Screening should be
quick, simple, valid (sensitive and specic), reliable, and done regularly to
capture changes in risk.8,19 As part of
the nutrition care planning process, The
Joint Commission also mandates regular
re-screening of patients, including those
who were not at nutritional risk on
admission. For both initial and rescreening, The Joint Commission leaves
specic policies and procedures to the
discretion of each facility. Therefore,
between facilities, there is variation
in who completes the screening, what
tool is used, and when re-screening is
required.

Nutrition Assessment
The Academy denes nutrition assessment as the process to obtain, verify,
and interpret data needed to identify
nutrition-related problems, their causes, and signicance.20 A nutrition
assessment provides the foundation for
the other three steps of the NCP by
providing information for determining
the nutrition diagnosis and also for
understanding the cause of the diagnosis (ie, the etiology), and should be
done by a trained nutrition professional.
An understanding of the etiology helps
the RDN determine the most feasible
and effective intervention to implement
for resolution of the diagnosis.
Assessment information/data are
organized into ve categories: (a) food/

nutrition-related history; (b) anthropometric measurements; (c) biochemical data, medical tests, and
procedures;
(d)
nutrition-focused
physical ndings; and (e) client/patient history.20 Single nutrition assessment ndings alone do not warrant a
nutrition diagnosis; rather, they are
collectively used in the documentation
of a nutrition diagnosis and etiology
and help to direct nutrition intervention and identify outcomes to monitor.
The clinician identies signs and
symptoms (assessments) to support
each diagnostic term dened in the
NCPT. Groups of assessments that are
commonly used together and are validated may be referred to as diagnostic
tools. Examples of diagnostic tools for
malnutrition are the Subjective Global
Assessment21 (SGA) and the Malnutrition Clinical Characteristics (MCC).22

WHAT MAKES NUTRITION


SCREENING AND ASSESSMENT
TOOLS VALID?
Before a nutrition screening tool is
implemented in a health care setting, it
is important to determine if the tool
has been validated.23 Tools may be
validated in a general population or
in a specic subgroup and may be
designed to identify general nutrition
concerns or a specic risk, such as risk
of malnutrition. To test the validity of
screening or assessment tools, the tool
in question is tested against a gold
standard (reference standard) that

identies one group of individuals who


have the disease and another group of
individuals who do not have the disease or condition. Some gold standards
include a biopsy, angiography, autopsy,
lab test result, or a diagnostic tool (such
as SGA). A new assessment tool would
generally be compared with an existing
assessment tool that has been validated (convergent validity). Similarly,
screening tools are generally validated
in one of two ways: (a) the new
screening tool is tested against a valid
screening tool (convergent validity), or
(b) the new screening tool is tested
against a valid assessment tool (predictive validity).
A valid screening tool will have high
sensitivity (patients identied as at risk
of malnutrition are generally malnourished) and a high specicity (patients
not at risk are in fact well-nourished).24
See Figure 1 for relevant denitions
and how to calculate sensitivity and
specicity. Screening tools attempt to
identify risk and the need for further
testing (assessment) rather than a
denite diagnosis. Therefore, it is most
important to not miss people who may
have the disease; false negatives must
be avoided, whereas false positives can
be accepted in screening. In assessment, the balance between sensitivity
and specicity is more nuanced and
must be based on any risk that could be
incurred by treating an individual who
does not have the disease.
Ideally, a valid tool will be 100%
sensitive and specic, meaning that all

Term

Denition

Example

Sensitivity

The proportion of subjects with disease in whom a test


is positive. Also called positive in disease.
SensitivityTrue Positive/(True PositiveFalse Negative)

A patient who is identied as at risk on the


screening tool is likely to also be
malnourished.

Specicity

The proportion of subjects without the disease being tested


for in whom a test is negative. Also called negative in health.
SpecicityTrue Negative/(True NegativeFalse Positive)

A patient who is identied as not at risk


on the screening tool is likely to also be
well-nourished.

Positive predictive
value (PPV)

The probability that a person with a positive test result


has the disease being tested for.
PPVTrue Positive/(True PositiveFalse Positive)

The likelihood that a patient who is found to


be malnourished according to a new nutrition
assessment tool is malnourished when
measured by a gold standard existing tool.

Negative predictive
value (NPV)

The probability that a person with a negative test result


does not have the disease being tested for.
NPVTrue Negative/(True NegativeFalse Negative)

The likelihood that a patient who is found to be


well-nourished according to a new nutrition
assessment tool is well-nourished when
measured by a gold standard existing tool.

Figure 1. Common measurements used when testing the validity of a nutrition screening or assessment tool as compared to a gold
standard.
May 2015 Volume 115 Number 5

JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

825

FROM THE ACADEMY


patients screened will correctly be
identied as at risk for malnutrition
(sensitivity) or not at risk for malnutrition (specicity). This is generally
not considered realistic; therefore, it is
important to balance false positives
and negatives.
Figure 2 illustrates the properties of a
valid nutrition screening tool modeled
after the Malnutrition Screening Tool

(MST).24 Because of the sensitivity


(93%) of the MST, it is highly probable
that a malnourished patient will be
identied as at risk during screening. In
an ideal situation, these at-risk patients
would be assessed by an RDN and most
would be diagnosed with malnutrition
(as evidenced by the large number
of patients in the upper left box
[true positive] in Figure 2). After a

malnutrition diagnosis, patients would


receive nutrition interventions aimed
at resolving the diagnosis. However, if a
screening tool with low sensitivity was
used instead, malnourished patients
might not be identied as at risk
(increasing the number of patients in
the lower left box [false negative] in
Figure 2) and an RDN would be less
likely to be consulted to see the

Registered Dietitian Nutritionist (RDN)


Assessment Positive for Malnutrition

RDN Assessment Negative for


Malnutrition

Screening
Result
Positive

True Positive: Number of patients who are


correctly classied as malnourished
(n1,568)
 Screening tool identies the patient
at risk for malnutrition.
 RDN completes full nutrition assessment as part of the Nutrition
Care Process (NCP).
 RDN diagnoses patient as malnourished, patient receives appropriate nutrition intdervention and
monitoring/evaluation.
 Ideally, better patient outcomes
than a malnourished patient who
did not receive an intervention.

False Positive: Number of patients


misclassied as being malnourished
(n588)
 Screening tool identies the
patient at risk for malnutrition.
 RDN completes full nutrition
assessment as part of the NCP.
 RDN does not diagnose the
patient as malnourished, the
patient is well-nourished.
 While assessing a well-nourished
person, the RDN could have spent
time assessing an at-risk patient.
 Patient should be rescreened for
risk of malnutrition regularly
throughout hospital stay.

Positive Predictive Value


1,568 (True Positive)/
1,568 (True Positive)588
(False Positive)73%

Screening
Result
Negative

False Negative: Number of patients


misclassied as being well-nourished
(n124)
 Screening tool does not identify
the patient at risk for malnutrition.
 RDN does not complete a nutrition
assessment. However, if the RDN
had completed an assessment
(such as in a validation study), the
RDN would have diagnosed the
patient as malnourished.
 The patient is likely to have poor
outcomes: Increased number of
readmissions, length of stay, mortality, and health care costs, and decreased function and quality of life.
 Patient should be rescreened for
risk of malnutrition regularly
throughout hospital stay.

True Negative: Number of patients


correctly classied as being wellnourished (n7,720)
 Screening tool does not identify
the patient at risk for
malnutrition.
 RDN is not consulted, no nutrition assessment is completed. If
the assessment had been
completed, the RDN would have
identied no nutrition problems
(well-nourished).
 No additional nutrition intervention is required.
 Patient should be rescreened for
risk of malnutrition regularly
through hospital stay.

Negative Predictive Value


7,720 (True Negative)/
7,720 (True
Negative)124 (False
Negative)98%

Sensitivity
1,568 (True Positive)/1,568 (True
Positive)124 (False Negative)93%

Specicity
7,720 (True Negative)/7,720)(True
Negative)588 (False Positive)93%

Figure 2. 22 illustration of sensitivity and specicity based on the Malnutrition Screening Tool for 10,000 patients when compared
with a gold standard assessment tool. The bullets describe the hypothetical clinical scenario of patients with each combination of
screening and assessment results.
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May 2015 Volume 115 Number 5

FROM THE ACADEMY


patient, decreasing the likelihood of a
nutrition intervention. In the second
situation, the patient is more likely to
be readmitted to the hospital, have an
increased mortality rate and higher
health-care costs, have decreased
function and quality of life, and have a
longer length of stay compared with a
malnourished patient13-15 who enters
the NCP and receives a nutrition
intervention.25
Equally important to sensitivity and
specicity are predictive values, which
answer the questions: if the test is
positive, how likely is it that the patient
has the disease? (Positive Predictive
Value [PPV]) or how likely is it that
the patient who tests negative for the
disease is disease free? (Negative
Predictive Value [NPV]). This is particularly important when nutrition
screening is done by a non-nutrition
practitioner who alerts the RDN to atrisk patients. Depending on their condence in the predictive value of the
initial screening tool (and facility policy), RDNs may rescreen, by their own
choice or based on department policy.
For example, if the tool has a 50% PPV,
only 50% of patients who are identied
as at risk during screening will actually
be malnourished when assessed by
the RDN (increasing the number of
patients in the upper right box [false
positives] in Figure 2). This inaccuracy
may cause the RDN to feel the need to
rescreen to narrow the list of patients
from a large group who were identied
as at risk to those who are more likely
to be at risk and, therefore, benet
from a consultation and medical
nutrition therapy. Similarly, an RDN
may need to rescreen when a tool with
a low NPV is used because this tool
may overlook patients at risk for
malnutrition. The example from
Figure 2 illustrates a tool with a high
PPV and NPV. Therefore, RDNs using
this tool can feel condent that their
screening correctly identies the patients who are in need of a complete
assessment (ie, those who screen positive are likely to be malnourished and
those who screen negative are unlikely
to be malnourished).

Assessment Tools Confused for


Screening Tools
SGA is often used in studies as the gold
standard (reference standard) when
determining the validity of nutrition
May 2015 Volume 115 Number 5

screening tools.24,26 Although SGA was


originally developed as a screening
tool to assess risk for poor surgical
outcome,21 it actually functions as
a nutrition assessment tool. The SGA
uses history (weight change, dietary
intake change, gastrointestinal symptoms, functional capacity, diseases related to nutritional requirements) and
physical exam (loss of subcutaneous
fat, muscle wasting, edema, and ascites) to determine a patients nutritional
status. Patients are diagnosed as wellnourished (A classication), moderately malnourished (B classication), or
severely malnourished (C classication). Although SGA is a validated
nutrition assessment tool across many
disease states,27,28 survey results of
health-based professionals in the
United States found that some providers continue to use this assessment
tool for screening.7,23
Among adult hospitalized patients,
SGA is an inappropriate nutrition
screening tool for three reasons. First,
screening, by denition, is the process
of identifying patients who are at risk
for malnutrition and would benet
from seeing an RDN. The scientic
literature supports the validity of SGA
to diagnose patients as well-nourished
or malnourished (making a diagnosis
rather than determining risk). Second,
SGA requires gathering information
from the medical chart, a patient
interview, and a brief physical exam.
Although it is not a lengthy tool, it does
not meet the denition of simple,
quick, and performed by any health
professional without formal training in
nutrition. Third, SGA is better at classifying patients as malnourished or
well-nourished and is not sensitive
enough to detect acute changes in
nutritional risk usually found during
the screening process.29

WORKING WITH NON-DIETETICS


PRACTITIONERS TO
UNDERSTAND NUTRITION
SCREENING
Screening methods vary substantially
among facilities. To best use resources,
only validated screening tools should be
used. Using a validated tool may improve
resource utilization by helping nutrition
and dietetics practitioners feel more
comfortable with other health professionals completing the screening step
and thus decreasing double screening.

Screening is not a one-time process but


must be repeated throughout an admission because risk levels can change.
Screening and assessment serve
different and complimentary roles. The
ultimate goal is to identify patients at risk
for malnutrition and notify an RDN to
complete a full assessment and diagnose
malnutrition, if present.
Lack of acceptance or understanding
of nutrition screening by other health
professionals could be due to differences in screening denitions across
professions. According to the US Preventive Service Task Force, screening
tests are dened as those preventive
services in which a test or standardized
examination procedure is used to
identify patients requiring special
intervention30 (ie, procedures performed to detect disease in persons
who have no symptoms or signs [are
asymptomatic or pre-symptomatic]).
However, this is usually not feasible in
nutrition screening; rather, the clinician is looking for early signs and
symptoms that a disease may be present. Consider the difference between
screening for breast cancer, in which
mammography is used to identify
possible malignancies prior to the patient feeling any lumps, and screening
for malnutrition, in which symptoms
such as weight loss may already be
present. In the future, nutrition may
move closer to other medical professions as the use of presymptomatic
biomarkers increases and advances.
However, with the move toward
asymptomatic identication of disease,
the risk to those with false screening
tests often increases, and care must be
taken to ensure that earlier identication truly means better outcomes.
Improving patient care and outcomes
begins with identifying at-risk patients.
RDNs can educate patients, families,
administrators, and other health care
practitioners about the goals and processes of valid nutrition screening to
increase the provision of necessary dietetics services. The NCP supports this
multidisciplinary approach to notify
dietetics practitioners to provide
appropriate intervention to improve
patient outcomes, provide quality care,
and decrease wasted resources.

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AUTHOR INFORMATION
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
Full salary support for L. B. Field is through an educational grant from Abbott Nutrition to the Academy of Nutrition and Dietetics; however,
Abbott Nutrition had no control over the content or publication of this article. R. K. Hand has no conict of interest to report.

FUNDING/SUPPORT
There was no funding for this article.

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