Abstract
Background: Malnutrition is an underdiagnosed condition that is highly prevalent in hospitalised patients and has adverse effects on health outcomes. Inconsistent use of malnutrition screening tools in hospitals results in fewer patients receiving dietetic support. To date, no studies in New Zealand, and few worldwide, have explored the differences in malnutrition screening, diagnosis, and dietetic treatment between hospital wards.
Objective: To compare 1. Malnutrition screening rates; 2. Prevalence of malnutrition; 3. Dietetic treatment plans; and 4. Post-discharge dietetic input in adult inpatients at risk of malnutrition in Southland Hospital. Differences were then analysed according to whether patients were admitted to the medical, surgical or rehabilitation ward.
Design: Newly admitted inpatients to selected wards within Southland Hospital, New Zealand were recruited for a cross-sectional observational study, between August and October 2021. For Phase One, nurse completed malnutrition screening within 48 hours of admission were audited using the Malnutrition Screening Tool (MST). Phase Two included malnutrition assessment of patients at risk of malnutrition, identified in Phase One. Data included the Subjective Global Assessment form; anthropometric measures (body mass index, mid upper arm circumference, tricep skinfolds, and handgrip strength); body composition using bioelectrical impedance analysis; and 24-hour food intake using patient recall and digitally captured plate waste methodology. Patient follow up data was collected 30 days post-discharge and included length of hospital stay, readmission and mortality rate.
Results: Of 195 patients included in Phase One, 24 patients participated in Phase Two (50% females, 77.5% 65 years). In Phase One, nurse’s malnutrition risk was significantly lower in patients admitted to the surgical ward compared to those in the medical or rehabilitation wards (3.5% vs 58.4% and 58.1%, p < 0.005). Of all the patients screened on admission, 21.5% were at risk of malnutrition, as assessed by the student dietitian. An MST score of 2 corresponded with a malnutrition diagnosis, with 81.8% of patients identified as at risk of malnutrition being malnourished. Compared to surgical and medical patients, patients admitted to the rehabilitation ward were more likely to be at risk of malnutrition (29% vs 16.1% and 24.7% ); be malnourished (12.9% vs 10.3% and 6.5%); and receive at least one dietetic intervention (66.7% vs 59.3% and 48%) compared to medical and surgical patients. Malnourished patients (Phase 2 n = 18 of 24) were more likely to be referred to a dietitian (30.8% vs 0%) and receive nutrition related discharge planning (68% vs 0%), but a shorter length of hospital stay (7.8 vs 6.5 days) compared to well-nourished patients. Albeit the very small sample size limits the interpretation and power of the study. Hospital documentation of malnutrition was only documented for one malnourished patient (5.6%). Within 30 days post-discharge, malnourished patients were more likely to be readmitted (76.9% vs 40%) and had a higher mortality rate (75% vs 25%) in comparison to well-nourished patients.
Conclusion: High prevalence of patients at risk for malnutrition amongst all wards suggests malnutrition screening and treatment are inadequate in Southland hospital. The association between MST scores 2 and malnutrition diagnosis, in addition to nurse’s low malnutrition screening rates and sub-consequently few dietitian referrals, shows further education is warranted. Education regarding malnutrition screening and prompt referral to dietitians is required to prevent the development, and increased severity, of malnutrition. District Health Boards are recommended to enforce the practice of malnutrition screening through policy change to optimise patient’s nutritional status.