The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN)

doi:10.1016/j.clnu.2004.02.003

Clinical Nutrition

Volume 23, Issue 5, October 2004, Pages 1104-1112

https://doi.org/10.1016/j.clnu.2004.02.003 Get rights and content

Abstract

Background & aims: Nutrition screening tools (NST) identify individuals who are malnourished or at risk of becoming malnourished and who may benefit from nutritional support. The aims of this study were to design, pilot and evaluate a NST based on four nutritional parameters (weight, height, recent unintentional weight loss and appetite) recommended by the British Association for Parenteral and Enteral Nutrition as the minimum required to identify patients with nutritional problems.

Methods: A dietitian assessed the nutritional status of 100 patients admitted to the general medical wards. Results from the study were used to design a NST. The concurrent validity of the screening tool was then assessed, by comparing it with a nutritional assessment by an experienced dietitian in 100 patients admitted to acute medical and elderly care wards. The inter-rater reliability of the screening tool was also assessed using three nurses and 26 acute medical patients.

Results: All four nutritional parameters were required to identify all at-risk patients. There was good agreement between the screening tool and the dietitian's assessment (κ=0.717) and inter-rater reliability was reasonable (mean κ=0.66).

Conclusion: The screening tool was valid and reliable in identifying medical patients at risk of malnutrition and was quick and simple to use.

Introduction

Malnutrition in hospital was identified as a significant problem more than 20 years ago1., 2. yet recent literature suggests that up to 40% of patients in hospital may be malnourished and that many become more malnourished during their hospital stay.³ While there is evidence that malnutrition is associated with increased morbidity and mortality and as a result, increased length and cost of hospital stay,4., 5., 6., 7., 8. an increasing number of studies have shown the benefits of timely and appropriate nutritional intervention, especially in those identified as at nutritional risk.9., 10., 11., 12., 13.

The King's Fund Report “A positive approach to nutrition as treatment”¹⁴ concluded that one reason why the problem persists is that malnourished patients and those who are at risk of becoming malnourished are not readily recognised by medical and nursing staff. As a result, many patients who could benefit from nutritional intervention remain untreated. To aid the identification of malnourished patients, the British Association for Parenteral and Enteral Nutrition (BAPEN) recommends that all patients should be routinely screened on admission to hospital, at regular intervals throughout their stay and during outpatient and GP appointments.¹⁵ Nutrition screening using a validated tool is one method by which at risk patients may be identified by health care professionals with little training in nutrition.

The role of a nutrition screening tool (NST) is to aid in the identification of patients who are currently malnourished or who are at risk of becoming malnourished, in order that they might be referred for further assessment and nutritional intervention, if appropriate. Screening tools should support, but never replace, clinical judgement. They are not designed to assess the nutritional status of patients, establish the severity of undernutrition or the reasons for poor status; they are there simply to indicate that a patient has actual or potential nutritional problems and requires further investigation. Screening tools should therefore be quick and easy to use, easy to interpret and acceptable to the patient and health care professionals. Any screening tool should be valid, i.e. should measure what it is intended to measure, reproducible, i.e. identify malnourished and at risk patients and reliable, i.e. different observers should obtain the same results on the same patients.

In 1995, a report by a BAPEN Working Party concluded that health care workers were not routinely screening patients on admission to hospital and made recommendations to address the issue.¹⁶ Four questions and two measurements were proposed as the minimum required for identifying patients with nutritional problems and possibly requiring referral for specialist nutrition advice (BAPEN4) (see Box 1). Neither a scoring system nor an action plan was described in the original paper. Since interpretation of the answers to the questions and the decision to take appropriate action require specialist nutritional knowledge, the BAPEN recommendations were of limited clinical use to non-specialist health care professionals.

Section snippets

Aims

The aims of this study were to design, pilot and evaluate a NST based on the BAPEN4. Thus, the first aim was to design a NST based on the BAPEN4, incorporating both a score and an action plan to enable non-specialist health care professionals to take appropriate action in those patients identified as at nutritional risk. This is described in Study 1. The second aim was to assess the concurrent validity of the NST by comparing it with a nutritional assessment by an experienced dietitian. This is

Study 1

The objectives of this study were to record the number of patients with positive responses to the BAPEN4, to classify these patients’ nutritional risk using a full nutritional assessment by an experienced dietitian and to use these results to devise a scoring system for a screening tool based on the BAPEN4.

The study took place in spring 1998 on 127 consecutive patients admitted to the acute medical and elderly care wards at St. Thomas’ Hospital. This was the maximum feasible sample with the

Study 1

Twenty-seven (21%) patients were not assessed either because they were discharged or died before assessment, or were unable or unwilling to comply (Table 1).

Clinical characteristics of the remaining 100 patients are shown in Table 2. Results of the nutritional assessment and the BAPEN4 questions are shown in Table 3. Thirty-eight (93%) patients considered to be at medium or high nutritional risk reported recent unintentional weight loss. Thirty-three (80%) of the medium and high-risk patients

Discussion

This study demonstrates that it is possible to design and use a NST based on the BAPEN4 questions. Compared to a full nutritional assessment by a dietitian, the tool developed in this study was valid and reliable in the majority of acute medical and elderly care patients within 72 h of hospital admission. Nurses who used the tool reported it was easy to use and quick to administer. When used correctly, the NST identified patients requiring a more detailed nutritional assessment.²⁴

The tool was

Acknowledgements

The authors would like to thank the nursing and medical staff on the acute medical and elderly care wards at St. Thomas’ Hospital for their help in the completion of this project, in particular Dr. Nigel Bateman, Consultant Physician (Respiratory Medicine), Dr. Finbarr Martin, Consultant Physician (Elderly Care) and Jane Corser (Nurse Manager). The authors are grateful for the statistical advice provided by Prof. Sue Chinn, Department of Public Health Medicine, King's College, London.

Funding: A

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Original ArticleThe development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN)

Abstract

Introduction

Section snippets

Aims

Study 1

Study 1

Discussion

Acknowledgements

Lancet

Clin Nutr

Clin Nutr

Clin Nutr

Am J Clin Nutr

Clin Nutr

Nutrition

Clin Nutr

Protein status of general surgical patients

J Am Med Assoc

Incidence and recognition of malnutrition in hospital

Br Med J

Cost-effectiveness of nutritional support

J Parenter Enteral Nutr

Economic impact of malnutritiona model system for hospitalised patients

J Parenter Enteral Nutr

Impact of nutritional status on DRG length of stay

J Parenter Enteral Nutr

Original Article
The development, validation and reliability of a nutrition screening tool based on the recommendations of the British Association for Parenteral and Enteral Nutrition (BAPEN)