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Perspectives in practice

Perspectives pour la pratique

Availability of Nutrition Screening Parameters


In New Brunswick Hospitals and Nursing Homes

ISABELLE CAISSIE, MSc, LITA VILLALON, PhD, RD, FDC, NATALIE CARRIER, PhD, RD, cole des sciences des aliments, de
nutrition et dtudes familiales, Universit de Moncton, Moncton, NB; MANON LAPORTE, MSc, RD, CNSC, Rseau de la
sant Vitalit Health Network Hpital Rgional Campbellton, Campbellton, NB

ABSTRACT

Rsum

We explored the availability of parameters for a nutrition


screening system among elderly people in New Brunswick (NB)
health care facilities. Patients aged 65 or older were asked to
participate in the study; each participant had been admitted to
one of four hospitals or lived in one of six nursing homes. Availability of nutrition screening parameters (weight, height, weight
change, serum albumin level, appetite, and food intake record)
was assessed by auditing the participants medical charts.
When data were not available, the feasibility of obtaining them
was determined. Additional data related to nutrition screening
were also obtained. In total, 421 participants were recruited for
the study: 140 (33.2%) who lived in nursing homes and 281
(66.8%) who were in hospitals. Parameters needed to conduct
nutrition screening, such as weight upon admission, were available for 83.6% of participants; usual weight was available for
43.0%, height for 86.0%, and serum albumin level for 47.5%.
Our findings show that basic parameters for nutrition screening
are available, and that implementation of a nutrition screening
system is feasible for patients in NB health care facilities.

Nous avons valu la disponibilit de paramtres permettant


de mettre en place un systme de dpistage nutritionnel chez
les ans frquentant les tablissements de soins de sant
au Nouveau-Brunswick (N.-B). Des patients gs de 65ans et
plus, admis dans lun des quatre hpitaux ou rsidant dans
lun des six centres dhbergement et de soins de longue dure,
ont t sollicits pour ltude. La disponibilit des paramtres
de dpistage nutritionnel (poids, taille, changement de poids,
niveau dalbumine srique, apptit et apport alimentaire) a t
value par la consultation des dossiers mdicaux des patients.
En labsence de certains paramtres, la possibilit de les obtenir
a t vrifie. Dautres informations sur le dpistage nutritionnel ont galement t obtenues. Au total, 421sujets ont t
recruts: 140 (33,2%) rsidents de centres dhbergement
et 281 (66,8%) patients hospitaliss. Les paramtres requis
pour le dpistage, par exemple le poids ladmission, taient
disponibles dans 83,6% des dossiers. Le poids habituel tait
disponible dans 43,0% des dossiers, la taille dans 86,0% et le
niveau dalbumine srique dans 47,5%. Nos rsultats dmontrent que les paramtres de dpistage de base sont disponibles
et que la mise en uvre dun systme de dpistage nutritionnel
dans les tablissements de soins de sant du N.-B. est ralisable.

(Can J Diet Pract Res. 2012;73:35-39)


(DOI: 10.3148/73.1.2012.35)

(Rev can prat rech ditt. 2012;73:35-39)


(DOI: 10.3148/73.1.2012.35)

Introduction
Malnutrition is prevalent among elderly hospitalized and nursing home populations, varying from 25% to 65% (1-8). Numerous consequences are related to malnutrition, such as increased
morbidity, mortality, and infection (2,9-14). Recognizing and
treating malnutrition therefore are important. Different organizations, especially in Europe, have raised this issue and emphasized the importance of nutrition screening in hospitals and
nursing homes (15-17). The goal of screening is to identify people who may be malnourished or at risk for malnutrition (18).
The British Association for Parenteral and Enteral Nutrition
(BAPEN) recommends that nutrition screening be conducted
upon a patients admission and repeated weekly in hospital patients and monthly in nursing home residents (19).
Several nutrition screening tools have been developed and
validated (1,8,20-24). Most of these require data on current
weight, usual weight, and height to determine body mass index
(BMI) and estimate weight change (1,8,20,22,24). Appetite (21),
food intake (20,22,24), and serum albumin level (1,8) are also
parameters included in certain tools.

Screening tools should be simple and brief enough that admission staff can use them (2,12,25), and specific tasks, such as
measuring height and weight upon admission, should be assigned (26-28). Patients determined by screening to be at high
risk should have a nutrition assessment and receive appropriate
nutrition care (8,29).
Although the importance of nutrition screening in hospitals
and nursing homes is well documented, the availability of common nutrition screening parameters is not well known.

PURPOSE
We explored the availability of nutrition screening parameters
among people aged 65 or older in New Brunswick (NB) health
care facilities. Specific objectives were to determine the availability of nutrition screening parameters and to identify barriers limiting the availability of these parameters. This study is
Phase 2 of a feasibility study on the establishment of a nutrition
screening system in NB health care facilities. Phase 1 is described
elsewhere (30).
Canadian Journal of Dietetic Practice and Research Vol 73 No 1, Spring 2012

35

Perspectives in practice
Perspectives pour la pratique
Table 1
Number of participants, by health care facility, language, and type of unit
Hospitals (n=281)
Unit
LTC
GRE
AC
Surgery
Medicine
Oncology
Total

Nursing homes (n=140)

Francophone

Anglophone

Smalla

23
23

16.3
16.3

30
30

21.4
21.4

10

39
47
9

27.7
33.3
6.4

25
55

17.9
39.3

141

100

140

Francophone

100

Total

Anglophone

Largeb

Smalla

60

10

Largeb

60

193
53

64
102
9

70

70

421

AC = acute care; GRE = geriatric and rehabilitation evaluation; LTC = long-term care
a
Small nursing home = fewer than 60 beds
b
Large nursing home = 60 or more beds

METHODS

Design
Four of the five hospitals that participated in Phase 1 of the
studyagreed to participate in Phase 2. A random sample ofsix
nursing homes (three French and three English) was selected
from the 31 homesparticipating in Phase 1. Participating hospitals and nursing homes wererepresentative geographically, in
size and by language.
From June 2008 to September 2009, we recruited elderly
patients requiring acute care (AC) or long-term care (LTC)
and those who were in geriatric and rehabilitation evaluation
(GRE) units of the following establishments: Hpital rgional
Dr-Georges-L.-Dumont (302 beds), Moncton Hospital (400
beds), Hpital rgional de Campbellton (166 beds), and Saint
John Regional Hospital (524beds). In addition, elderly residents
were recruited from the following participating nursing homes:
Kenneth E. Spencer Memorial Home (200 beds), Foyer la Villa
du Repos (126beds), Foyer de Dalhousie (105beds), Kiwanis
Nursing Home (70 beds), Salvation Army Lakeview Manor
(50 beds) and Foyer St-Thomas de la Valle de Memramcook
Inc (30beds). Cognitively intact participants and legal guardians of cognitively impaired participants were required to sign
an informed consent form.
The research protocol was approved by the ethics committee of the Facult des tudes suprieures et de la recherche de
lUniversit de Moncton, and the research and ethics boards of
the four hospitals and representatives of the six nursing homes.
Data collection
In hospitals, elderly patients admitted to AC units were recruited
within 48hours of admission. In nursing homes, LTC units, and
GRE units, subjects were randomly selected from a list of eligible
patients. Once informed consent forms were signed, data on
screening parameters were obtained from participants medical
charts. Data were collected by a trained research assistant (a graduate nutrition student with research ethics and data collection
training) during on-site visits. In each hospital, approximately
50 subjects in AC units, 15 subjects in GRE units, and 15 sub36

jects in LTC units were recruited. In nursing homes, 10 residents


(for homes with fewer than 60 beds) to 30 residents (for homes
with 60 or more beds) were recruited. The research assistant verified whether nutrition screening parameters (e.g., current and
usual weight, height, serum albumin level, appetite, and meal
fractions consumed) were available. If not, the research assistant
determined the feasibility of obtaining them from nursing staff.
Data specific to each establishment were also gathered, including
availability of upright and chair scales, who conducted screening,
how screening was conducted, and whether nutrition screening
parameters were entered into electronic patient records.
Statistical analysis
All data collected were organized by categories. Each hospital
and nursing home had its own individual category. Data collected were entered into a spreadsheet, using Microsoft Office
Excel 2007 for Windows XP (Microsoft Corporation, Redmond,
WA, 2007). Descriptive statistical analyses were used to represent the presence or absence of different screening parameters
accurately. Statistical variance analyses, as well as Pearsons chisquare tests, were performed using SPSS version 17.0 (SPSS Inc.,
Chicago, IL, 2009) to determine if statistical differences existed
between the presence of parameters in each hospital and nursing home. The chi-square level of significance was set at p<0.05.

RESULTS
In total, 281 (66.8%) hospital patients and 140 (33.2%) nursing
home residents participated in the study. Fifty percent of participants were from French settings, and the other 50% were from
English settings (Table 1). Among hospitalized participants,
41.6% (175) were from AC units, while 12.6% (53) were from
LTC units and 12.6% (53) from GRE units.
Table 2 presents study participants sociodemographic and
medical characteristics. Slightly more women (54.4%) than
men (45.6%) participated in the study (p=0.004). Women were
somewhat older (mean age, 81.9) than men (mean age, 79.6)
(p=0.001); women who resided in nursing homes were older
than those in hospitals (p=0.005). Significantly more partici-

Revue canadienne de la pratique et de la recherche en dittique Vol 73 n 1, printemps 2012

Perspectives in practice
Perspectives pour la pratique
Table 2
Study participants sociodemographic and medical characteristics
Characteristic
Sex
Female
Male
Age (years)
Female
Male
Total
Cognitively intact
Yes
No
a

Total (n=421)

Hospitals (n=281)

Nursing homes (n=140)

54.4%
45.6%

51.6%
48.4%

60.0%
40.0%

0.103
0.103

81.89 8.60a
79.57 7.26a
80.83 8.09a

80.87 9.12a
79.25 7.23a
80.10 8.33a

83.59 7.32a
80.08 7.03a
82.31 7.40a

0.005
0.204
0.004

66.3%
33.7%

78.6%
21.4%

41.4%
58.6%

0.000
0.000

Mean standard deviation

pants were cognitively intact in hospitals (78.6%) than in nursing homes (58.6%) (p<0.001).
Table 3 provides data on the availability of nutrition screening parameters by type of establishment and by language.
Weight was entered into the medical chart upon admission for
more than 75% of participants (74.0% in hospitals and 96.0%
in nursing homes). In most facilities, nursing staff who entered
weights in patients medical charts specified how the weight was
obtained (i.e., whether it was measured or reported). Weight
had been directly measured for 86.0% of participants and reported by the patient or estimated by nursing staff for 14.0%.
For participants (16.4%) whose weight had not been recorded
upon admission, nursing staff were asked to weigh them within
48 hours. After 48 hours, only 41.0% of these had been weighed.
The most common reason given for not weighing participants
was a lack of time (50%, n=20). Other reasons were that patients
were too weak (20%, n=8), that patients had a hip or pelvic fracture (20%, n=8), that patients had a sore leg (5%, n=2), and

that weight already was being measured every month in nursing


homes (5%, n=2).
Usual weight was recorded in 43.0% and height in 86.0% of
participants. However, not all medical charts specified whether height was measured or self-reported. After we asked head
nurses of units how they normally obtained heights, we determined that 46.8% of heights were measured and 53.2% were
self-reported.
Significant differences were observed between French and
English hospitals and nursing homes when documented weight
(p<0.001), height (p<0.001), and normal weight (p=0.010)
were compared. Serum albumin level was measured upon admission for 47.5% of participants, and no significant differences
were found between hospitals and nursing homes (p=0.606).
However, a significant difference was observed between hospitals and nursing homes (p<0.001) for documented appetite and
meal fractions consumed. Appetite was documented for 62.6%
of hospitalized patients and 82.9% of nursing home residents,

Table 3
Nutrition screening parameters available in hospitals and nursing homes, by language
Hospitals (n=281)

Total (n=421)

Francophone
Parameter
Weight documented
Height documentedb
Usual weight documented
Albumin documented
Albumin <28
Albumin 28-35
Albumin >35
BMI <21
BMI 21-23
BMI 24-30
BMI >30
Appetite
Meal fractions consumed
b

Nursing homes (n=140)

Anglophone

Francophone

pa

Anglophone

352
363
181
200
21
97
82
50
73
167
53
292
304

83.6
86.2
43.0
47.5
5.0
23.0
19.5
11.9
17.3
39.7
12.6
69.4
72.2

106
131
72
64
9
37
18
17
20
66
18
64
124

75.2
92.9
51.1
45.4
6.4
26.2
12.8
12.1
14.2
46.8
12.8
45.4
87.9

110
107
45
67
8
28
31
17
24
42
15
112
114

78.6
76.4
32.1
47.9
5.7
20.0
22.1
12.1
17.1
30.0
10.7
80.0
81.4

66
56
34
31
3
22
6
6
12
27
11
48
26

94.3
80.0
48.6
44.3
4.3
31.4
8.6
8.6
17.1
38.6
15.7
68.6
37.1

69
68
30
38
1
10
27
10
17
32
9
68
40

98.6
97.1
42.9
54.3
1.4
14.3
38.6
14.3
24.3
45.7
12.9
97.0
57.1

0.000
0.000
0.010
0.606
0.000
0.000
0.000
0.002
0.002
0.002
0.002
0.000
0.000

BMI = body mass index


a
p<0.000 when French and English subjects are compared by type of facility
b
Measured or reported

Canadian Journal of Dietetic Practice and Research Vol 73 No 1, Spring 2012

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Perspectives in practice
Perspectives pour la pratique
Table 4
Nutrition screening parameters and/or tools and screening practices, by type of facility
Characteristic
Scale
Upright
Chair
Nutrition screening
Internal form
Screening tool
Other
Who does screening
Nursing staff
Dietitian
Diet technician
Time for screening
5 minutes
10 minutes
20 minutes
Parameters in computera
BMI in computerb

Total (n=27)

Hospitals (n=21)

Nursing homes (n=6)

96.3%
85.2%

95.2%
81.0%

100%
100%

0.586
0.247

3.7%
22.2%
74.1%

28.6%
71.4%

16.7%

83.3%

0.015
0.015
0.015

14.8%
70.4%
14.8%

19.0%
62.0%
19.0%

100%

0.197
0.197
0.197

70.4%
14.8%
14.8%
66.7%
51.9%

62.0%
19.1%
19.1%
71.4%
61.9%

100%

50.0%
16.7%

0.197
0.197
0.197
0.326
0.050

BMI = body mass index


a
Head nurses were asked if the parameters (height, weight, etc.) were entered into a computer program by the nursing staff.
b
The research assistant looked at the computer program to see if BMI was calculated automatically.

while meal fractions were documented for 84.7% of hospitalized


patients and 47.1% of nursing home residents. With the data
available, BMI was calculated for 81.5% of participants. The average BMI was 25.935.82kg/m2. The simple screening tool #1
included in Babineau et al.s study led 44% of participants to be
classified as at high nutritional risk (8).
Table 4 presents nutrition screening parameters and/or tools
and screening practices by type of facility. An upright scale was
available in nearly all hospital units (95.2%, n=20) and in all
nursing homes (100%, n=6) (p=0.586); 80.9% (n=17) of hospital units had chair scales, compared with 100% (n=6) of nursing
homes (p=0.247). Valid nutrition screening tools were used only
in hospital settings, and with only 28.6% of participants. Most
nursing homes (83.3%, n=5) used anthropometric and biochemical parameters (weight loss over time, BMI, albumin level)
to detect risk, and only 16.7% (n=1) used an internal screening
form. A dietitian did nutrition screening in all nursing homes
(n=6), and took about five minutes to complete it. In hospitals,
dietitians conducted screening most of the time (62%, n=13);
nurses or diet technicians each did the screening 19% (n=4)
of the time. Nurses and diet technicians took 10 to 20 minutes
to complete the screening. Fifty percent of nursing homes and
71.4% of hospitals had computerized systems that enabled them
to access screening parameters electronically. Body mass index
was calculated automatically in patients electronic charts in
16.7% of nursing homes and 61.9% of hospital units.

DISCUSSION
European researchers have investigated the availability of certain
nutrition screening parameters in hospitals and nursing homes
(15,28,31,32). In United Kingdom (UK) hospitals, audits of
weighing practices over five years showed that the percentage of
patients being weighed on admission rose from 37.5% in 1998
38

to 59.6% in 2003 (31). Another UK survey and audit indicated


that 49% of patients were routinely weighed upon admission
to hospital, compared with 98% in care home settings (which
included nursing homes) (15). Height was recorded in only 28%
of hospital patients, but in 71% of those in care home settings
(15). In a Scandinavian hospital, weight was measured upon admission in 45% of patients (28). Weight was measured in up to
82.9% of those in Dutch health care facilities (32). Most of these
percentages of weight and height measurements are lower than
those gathered in our study. A recent pilot survey that the international nutritionDay project conducted in Canada showed that
52% of patients were weighed upon admission to hospitals and
79% were weighed when a weight measurement was requested
(33). Again, these Canadian results are lower than ours, as we
found that 74% of hospitalized patients weights were available
in medical charts. However, we were not as successful at obtaining weights upon request (41%).
Measured and self-reported weights have been found to be
highly correlated in older adult populations (34), even among
cognitively impaired elderly people (35). On the other hand, a systematic overestimation of recalled height has been observed (34).
The BMI values derived from measured and self-reported weight
and height are also highly correlated (34,35). Payette et al. indicated that self-reported height and weight data can be used as a valid
screening tool for undernutrition risk (35). However, Kuczmarski
et al. indicated that failure to measure height and weight can result
in subsequent misclassification of overweight status (34).
According to staff reports, the main factor limiting the availability of screening parameters was a lack of time to weigh patients. Also observed were underutilization of screening tools,
nursing staffs limited involvement in the screening process, low
availability of BMI in electronic medical records, and improper
recording of usual weight.

Revue canadienne de la pratique et de la recherche en dittique Vol 73 n 1, printemps 2012

Perspectives in practice
Perspectives pour la pratique
Study limitations
A study limitation was our inability to determine whether participants weights and heights were accurate. In addition, information on admission was difficult to obtain for some nursing home
residents, especially if they had lived in the home for a long time.

RELEVANCE TO PRACTICE
Our study and the nutritionDay pilot project (33) are among the
first in Canada to highlight the availability of nutrition screening parameters. Our findings show that basic parameters for nutrition screening are available upon admission in approximately
75% of cases. We also observed that collaboration with nursing
staff is necessary for gathering these parameters. Better access
to computerized systems for screening was also indicated. With
all these elements in place, a standardized approach to nutrition
screening with the implementation of a valid and simple nutrition screening tool will be possible.
Acknowledgements
This project was supported by Le Rseau de recherche interdisciplinaire sur la sant des francophones en situation minoritaire
au Canadaand theFacult des tudes suprieures et de la recherche de lUniversit de Moncton.
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