The Graz Malnutrition Screening (GMS): a new hospital screening tool for malnutrition

Regina E Roller, Doris Eglseer, Anna Eisenberger, Gerhard H Wirnsberger, Regina E Roller, Doris Eglseer, Anna Eisenberger, Gerhard H Wirnsberger

Abstract

Despite the significant impact of malnutrition in hospitalised patients, it is often not identified by clinical staff in daily practice. To improve nutritional support in hospitals, standardised routine nutritional screening is essential. The Graz Malnutrition Screening (GMS) tool was developed for the purpose of malnutrition risk screening in a large hospital setting involving different departments. It was the aim of the present study to validate the GMS against Nutritional Risk Screening (NRS) and Mini Nutritional Assessment-short form (MNA-sf) in a randomised blinded manner. A total of 404 randomly selected patients admitted to the internal, surgical and orthopaedic wards of the University Hospital Graz were screened in a blinded manner by different raters. Concurrent validity was determined by comparing the GMS with the NRS and in older patients (70+ years) with the MNA-sf additionally. According to GMS, 31·9 or 28·5% of the admitted patients were categorised as at 'risk of malnutrition' (depending on the rater). According to the reference standard of NRS, 24·5% of the patients suffered from malnutrition. Pearson's r values of 0·78 compared with the NRS and 0·84 compared with the MNA showed strong positive correlations. Results of accuracy (0·85), sensitivity (0·94), specificity (0·77), positive predictive value (0·76) and negative predictive value (0·95) of GMS were also very high. Cohen's κ for internal consistency of the GMS was 0·82. GMS proves to be a valid and reliable instrument for the detection of malnutrition in adult patients in acute-care hospitals.

Keywords: Adults; ESPEN European Society for Clinical Nutrition and Metabolism; GMS Graz Malnutrition Screening; Hospital nutrition; IT information technology; MNA-sf Mini Nutritional Assessment-short form; Malnutrition; NRS Nutritional Risk Screening; Risk screening; SGA subjective global assessment.

Figures

Fig. 1
Fig. 1
The Graz Malnutrition Screening (GMS) risk translated into English language. Items 1–3 are obtained from nursing staff. Item 4, which includes rating of disease, is completed by physicians. A total score of more than 3 points indicates ‘risk of malnutrition’. Information is gathered in the hospital software. In terms of positive screening, information is transferred to dietitians and assessment is performed and clinical nutritional intervention is started whenever indicated. ICD, International Classification of Diseases.
Fig. 2
Fig. 2
The Graz Malnutrition Screening consists of five different scoring categories.
Fig. 3
Fig. 3
Prevalence of risk of malnutrition among all patients in different age groups tested with three screening tools used by different teams in a blinded manner. Differences between scores of different screening tools were not statistically significant. GMS 1, Graz Malnutrition Screening Rater 1 (); GMS 2, Graz Malnutrition Screening Rater 2 (); NRS, Nutritional Risk Screening Rater 3. , Nutritional Risk Screening Rater; , Mini Nutritional Assessment.
Fig. 4
Fig. 4
Percentage of patients identified to be at risk for malnutrition using the Graz Malnutrition Screening (GMS) and the Nutritional Risk Screening (NRS, ). GMS 1 (), Graz Malnutrition Screening Rater 1; GMS 2 (), Graz Malnutrition Screening Rater 2; NRS, Nutritional Risk Screening Rater 3. All data are grouped for wards of assignment.

References

    1. McWhirter JP & Pennington CR (1994) Incidence and recognition of malnutrition in hospital. Br Med J 308, 945–948.
    1. Kyle UG, Pirlich M, Schuetz T, et al. (2003) Prevalence of malnutrition in 1760 patients at hospital admission: a controlled population study of body composition. Clin Nutr 22, 473–481.
    1. Pirlich M, Schutz T, Kemps M, et al. (2003) Prevalence of malnutrition in hospitalized medical patients: impact of underlying disease. Dig Dis 21, 245–251.
    1. Pirlich M, Schutz T, Norman K, et al. (2006) The German hospital malnutrition study. Clin Nutr 25, 563–572.
    1. Stratton RJ, Hackston A, Longmore D, et al. (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92, 799–808.
    1. Westergren A, Lindholm C, Axelsson C, et al. (2008) Prevalence of eating difficulties and malnutrition among persons within hospital care and special accommodations. J Nutr Health Aging 12, 39–43.
    1. Lochs H, Allison SP, Meier R, et al. (2006) Introductory to the ESPEN guidelines on enteral nutrition: terminology, definitions and general topics. Clin Nutr 25, 180–186.
    1. Müller M, Compher C, Druyan ME, et al. (2011) A.S.P.E.N. clinical guidelines, nutrition screening, assessment, and intervention in adults. JPEN J Parenter Enteral Nutr 35, 16–24.
    1. Joint Commission on Accreditation of Healthcare Organizations (2007) Comprehensive Accreditation Manual for Hospitals. Chicago, IL: Joint Commission on Accreditation of Healthcare Organizations.
    1. Jensen GL (2006) Inflammation as the key interface of the medical and nutrition universes: a provocative examination of the future of clinical nutrition and medicine. JPEN J Parenter Enteral Nutr 30, 453–463.
    1. Jensen GL, Mirtallo J, Compher C, et al. (2010) Adult starvation and disease-related malnutrition: a proposal for etiology-based diagnosis in the clinical practice setting from the International Consensus Guideline Committee. JPEN J Parenter Enteral Nutr 34, 156–159.
    1. Kondrup J, Johansen N, Plum LM, et al. (2002) Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr 21, 461–468.
    1. Bavelaar JW, Otter CD, van Bodegraven AA, et al. (2008) Diagnosis and treatment of (disease related) in-hospital malnutrition: the performance of medical and nursing staff. Clin Nutr 27, 431–438.
    1. Meijers JMM, Schols JMGA, van Bokhorst-de van der Schueren MAE, et al. (2009) Malnutrition prevalence in The Netherlands: results of the annual dutch national prevalence measurement of care problems. Br J Nutr 101, 417–423.
    1. Llido LO (2006) The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000–2003. Clin Nutr 25, 91–101.
    1. Mowe M, Bosaeus I, Rasmussen HH, et al. (2008) Insufficient nutritional knowledge among health care workers? Clin Nutr 27, 196–202.
    1. Mowe M, Bosaeus I, Rasmussen HH, et al. (2006) Nutritional routines and attitudes among doctors and nurses in Scandinavia: a questionnaire based survey. Clin Nutr 25, 524–532.
    1. Persenius MW, Hall-Lord ML, Bååth C, et al. (2008) Assessment and documentation of patients’ nutritional status: perceptions of registered nurses and their chief nurses. J Clin Nurs 17, 2125–2136.
    1. Liang X, Jiang ZM, Nolan MT, et al. (2009) Nutritional risk, malnutrition (undernutrition), overweight, obesity and nutrition support among hospitalized patients in Beijing teaching hospitals. Asia Pac J Clin Nutr 18, 54–62.
    1. Ferguson M, Capra S, Bauer J, et al. (1999) Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 15, 458–464.
    1. Detsky AS, McLaughlin JR, Baker JP, et al. (1987) What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr 11, 8–13.
    1. Kondrup J, Rasmussen HH, Hamberg O, et al. (2003) Nutritional Risk Screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 22, 321–336.
    1. Rubenstein LZ, Harker JO, Salva A, et al. (2001) Screening for undernutrition in geriatric practice: developing the Short-Form Mini Nutritional Assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 56, 366–377.
    1. Vellas B, Villars H, Abellan G, et al. (2006) Overview of the MNA-its history and challenges. J Nutr Health Aging 10, 456–465.
    1. Aapro M, Arends J, Bozzetti F, et al. (2014) Early recognition of malnutrition and cachexia in the cancer patient: a position paper of a European School of Oncology Task Force. Ann Oncol 25, 1492–1499.
    1. Ikizler TA, Cano NJ, Franch H, et al. (2013) Prevention and treatment of protein energy wasting in chronic kidney disease patients: a consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int 84, 1096–1107.
    1. Maharshi S, Sharma BC & Srivastava S (2015) Malnutrition in cirrhosis increases morbidity and mortality. J Gastroetnerol Hepatol 30, 1507–1513.
    1. Caccialanza R, Palladini G, Klersy C, et al. (2014) Malnutrition at diagnosis predicts mortality in patients with systemic immunoglobulin light-chain amyloidosis independently of cardiac stage and response to treatment. JPEN J Parenter Enteral Nutr 38, 891–894.
    1. Collins PF, Elia M & Stratton RJ (2013) Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology 18, 616–629.
    1. Rahman A, Jafry S, Jeejeebhoy K, et al. (2015) Malnutrition and cachexia in heart failure. JPEN J Parenter Enteral Nutr (Epublication ahead of print 29 January 2015).
    1. Sura L, Madhavan A, Carnaby G, et al. (2012) Dysphagia in the elderly: management and nutritional considerations. Clin Interv Aging 7, 287–298.
    1. European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel (2014) Prevention and Treatment of Pressure Ulcer: Clinical Practice Guideline (accessed December 2015).
    1. Jyrkkä J, Enlund H, Lavikainen P, et al. (2011) Association of polypharmacy with nutritional status, functional ability and cognitive capacity over a three-year period in an elderly population. Pharmacoepidemiol Drug Saf 20, 514–522.
    1. Landis JR & Koch GG (1977) The measurement of observer agreement for categorical data. Biometrics 33, 159–174.
    1. Ljungqvist O & de Man F (2009) Undernutrition – a major health problem in Europe. Nutr Hosp 24, 368–370.
    1. Elia M & Russell C (editors) (2009) Combating malnutrition: recommendations for action. Report from the Group on Malnutrition, BAPEN, Redditch.
    1. Sorensen J, Kondrup J, Prokopowicz J, et al. (2008) EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 27, 340–349.
    1. Action Group A3 of the European Partnership on Active and Healthy Aging of the European Commission (2015) Nutrilive: testing and implementing an integrated approach to nutrition: from assessment to personalized interventions. (accessed March 2015).
    1. Correia MI, Hegazi RA, Higashiguchi T, et al. (2014) Evidence-based recommendations for addressing malnutrition in health care: an updated strategy from the feed M.E. Global Study Group. J Am Med Dir Assoc 15, 544–550.
    1. Kondrup J, Allison SP, Elia M, et al. (2003) ESPEN guidelines for nutrition screening 2002. Clin Nutr 22, 415–421.
    1. Persson MD, Brismar KE, Katzarski KS, et al. (2002) Nutritional status using mini nutritional assessment and subjective global assessment predict mortality in geriatric patients. J Am Geriatr Soc 50, 1996–2002.
    1. Velasco C, García E, Rodríguez V, et al. (2011) Comparison of four nutritional screening tools to detect nutritional risk in hospitalized patients: a multicentre study. Eur J Clin Nutr 65, 269–274.
    1. Young AM, Kidston S, Banks MD, et al. (2013) Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition 29, 101–106.
    1. Raslan M, Gonzalez MC, Dias MC, et al. (2010) Comparison of nutritional risk screening tools for predicting clinical outcomes in hospitalized patients. Nutrition 26, 721–726.
    1. Roubenoff R, Roubenoff RA, Preto J, et al. (1987) Malnutrition among hospitalized patients. A problem of physician awareness. Arch Intern Med 147, 1462–1465.
    1. Mowe M, Bavelaar JW, Otter CD, et al. (2008) Diagnosis and treatment of (disease-related) in-hospital malnutrition: the performance of medical and nursing staff. Clin Nutr 27, 431–438.
    1. Tangvik RJ, Guttormsen AB, Tell GS, et al. (2012) Implementation of nutritional guidelines in a university hospital monitored by repeated point prevalence surveys. Eur J Clin Nutr 66, 388–393.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren