Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care

Abstract

Nutrition & DieteticsVolume 66, Issue s3 p. S1-S34 Free Access Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care First published: 14 December 2009 https://doi.org/10.1111/j.1747-0080.2009.01383.xCitations: 145AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat EXECUTIVE SUMMARY Malnutrition is a major international and Australian health problem, which continues to be unrecognised and therefore, untreated. It is both a cause and a consequence of ill health across many patient groups and healthcare settings. Malnutrition interferes with patients' ability to benefit from health treatments and affects every domain of their well-being. Additionally, it increases society's healthcare costs. This paper, ‘Evidence based practice guidelines for nutritional management of malnutrition in adult patients across the continuum of care’, has been developed to gather the best available evidence for detecting malnutrition and managing it with nutritional interventions. The Guideline Steering Committee hopes to influence health care providers and especially dietitians to increase capacity within Australia to implement affordable detection systems, such as routine malnutrition screening. It is expected that the guidelines will provide a framework for evidence-based nutritional assessments and increase access to appropriate patient-focussed treatments for affected adults that are timely and occur both within and across hospital and primary care sectors. These guidelines are based on an agreed and rigorous process undertaken by the Steering Committee, and in accordance with the Dietitians Association of Australia (DAA) performance standards. They have resulted from the voluntary contribution of a collaboration of dietitians with clinical and research expertise across a range of practice settings. The process involved a systematic search of the literature, an assessment of the strength of the evidence, consultation with key stakeholders and the development of evidence-based statements and practice tips that may help to guide clinical practice and improve patient experience and health outcomes in Australian healthcare sectors for malnourished adults. The dissemination and implementation of the recommendations of the guidelines will be supported by the DAA. SUMMARY OF EVIDENCE-BASED RECOMMENDATIONS The guideline recommendations have been graded using the National Health and Medical Research Council (NHMRC) classifications for grades of recommendation1, which are as follows: Level A Body of evidence can be trusted to guide practice. Level B Body of evidence can be trusted to guide practice in most situations. Level C Body of evidence provides some support for recommendation(s) but care should be taken in its application. Level D Body of evidence is weak and recommendation(s) must be applied with caution. 1. Nutrition screening Clinical question 1a. What is the prevalence of malnutrition and is it a problem? Evidence-based recommendations The prevalence of malnutrition is high worldwide (including in Australia) in all healthcare settings, yet is largely under-recognised and under-diagnosed resulting in a decline in nutritional status. Therefore, it is recommended that healthcare professionals are informed that malnutrition is associated with adverse clinical outcomes and costs. NHMRC Grade of recommendation: A Malnutrition should be identified, treated and action taken to reduce the prevalence in Australian healthcare settings and in community-dwelling adults. NHMRC Grade of recommendation: B Clinical question 1b. Should there be routine screening for malnutrition and if so where and when should malnutrition screening occur? Evidence-based recommendations Routine screening for malnutrition should occur in the acute setting to improve the identification of malnutrition risk and to allow for nutritional care planning. NHMRC Grade of recommendation: B Routine screening for malnutrition should occur in the rehabilitation, residential aged care and community settings to improve the identification of malnutrition risk and enable nutritional care planning. NHMRC Grade of recommendation: D Clinical question 1c. What screening process can be used to identify adults at risk of malnutrition? Evidence-based recommendations Use a valid malnutrition screening tool appropriate to the population in which it is to be applied. NHMRC Grade of recommendation: B 2. Nutrition assessment Clinical question What nutrition assessment processes can be used to diagnose malnutrition in adults? Evidence-based recommendations Use a valid nutrition assessment tool appropriate to the population in which it is to be applied. NHMRC Grade of recommendation: B 3. Nutrition goals, interventions and monitoring Clinical question 3a. In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition goals, for optimal client, clinical and cost outcomes? Evidence-based recommendations Aim to prevent decline/improve nutritional status and associated outcomes in adults with malnutrition or at risk of malnutrition. NHMRC Grade of recommendation: A Clinical question 3b. What are the appropriate interventions for prevention and treatment of malnutrition in adults? Evidence-based recommendations Nutrition interventions can improve outcomes. Consideration should be given to the healthcare setting, resources, patient/client goals, requirements and preferences. NHMRC Grade of recommendation: B–C Clinical question 3c. What are appropriate monitoring and outcome measures to demonstrate improved patient, clinical and cost outcomes? Evidence-based recommendations Choose standardised measures which change in a clinically meaningful way to demonstrate the outcomes of nutrition interventions. NHMRC Grade of recommendation: not applicable 1 INTRODUCTION 1.1 Purpose and scope The purpose of these guidelines is to provide health care professionals, especially dietitians with evidence based recommendations supporting the identification and nutritional management of malnourished adults. The ‘Evidence Based Practice Guidelines for Nutritional Management of Malnutrition in Adult Patients across the Continuum of Care’ focus on the identification and treatment of malnutrition in the acute, rehabilitation, residential aged care, and community settings. Although there are other international guidelines which address malnutrition,2,3 it was determined that gaps existed in these guidelines which warranted addressing and it was perceived that there would be a benefit in exploring the evidence base with respect to the Australian context. Malnutrition is defined as ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/ body form (body shape, size and composition) and function and clinical outcome’.4 For the purpose of these guidelines malnutrition refers solely to protein-energy under-nutrition despite the definition given above which encompasses both under- and over-nutrition. In developed countries the increasing prevalence of obesity and its resultant health consequences has contributed to the lack of recognition of under-nutrition. For nutritional treatment of obesity the reader is referred to the ‘Best Practice Guidelines for the Treatment of Overweight and Obesity in Adults’ endorsed by the Dietitians Association of Australia.5 The outcomes of the implementation of these evidence based guidelines will achieve the following anticipated benefits for adults with malnutrition or at risk of malnutrition: • Improved access to ethical, effective and efficient patient care by developing and implementing relevant patient-centred protocols and pathways appropriate to the healthcare setting. • Correct diagnosis of malnourished patients increasing recognition of the impact of this disease/ condition on patients and health service. • Improved patient experience and health outcomes for identified adults. • A skilled Dietitian workforce playing a key role in addressing adult malnutrition across healthcare settings by continuing advocacy of the Dietitians Association of Australia. • Advocacy for appropriate and adequate food services; eating environments; staff resources and policy. • Capacity building in Australian health and human services for preventing, recognising and treating malnutrition by the entire health workforce and health policy makers. 1.2 Methods 1.2.1 Guideline framework In developing these Guidelines the American Dietetic Association's Nutrition Care Process (NCP)6 has been used to define the clinical questions for the systematic review. The NCP framework incorporates a standardised process and language as part of a conceptual model to guide and document nutrition care and patient outcomes.6 The framework includes nutrition assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation.6 This NCP framework has recently been adopted by the DAA. A trigger event initiates where and how the patient is identified for nutrition care.7 This trigger event may include nutrition screening. Since malnourished adults are often not recognised and thus fail to have access to the Nutrition Care Process, the ‘trigger event’ has been added to the Guideline framework. This NCP including the trigger event is illustrated in Figure 1.7 Figure 1Open in figure viewerPowerPoint American Dietetic Association Nutrition Care Process and Model7. Reproduced with the permission of Elsevier. • Nutrition screening describes the process of identifying clients with characteristics commonly associated with nutrition problems who may require comprehensive nutrition assessment and may benefit from nutrition intervention. These Guidelines refer to malnutrition screening which is used to identify those who may be malnourished or at risk of malnutrition. • Nutrition assessment is a comprehensive approach to gathering pertinent data in order to define nutritional status and identify nutrition-related problems. The assessment often includes patient history, medical diagnosis and treatment plan; nutrition and medication histories, nutrition related physical examination including anthropometry, nutritional biochemistry, psychological, social, and environmental aspects. • Nutrition diagnosis is a clinical judgement based on data collected during the assessment phase. The set of nutrition diagnoses derived from the assessment data will give direction to prioritising treatment goals and intervention strategies. The nutrition diagnosis uses standardised terminology which identifies and labels the actual occurrence, or risk of developing nutrition problems that dietitians treat independently. A nutrition diagnosis is written in PES format that states the problem (P) or nutrition diagnosis, the aetiology (E) or risk factors/ causes and the signs and symptoms (S) or measurable adverse nutrition status.8 • Nutrition intervention is designed to address a nutrition problem or aetiology of the nutrition diagnosis. Nutrition interventions aim to change nutrition-related behaviour, risk factors, environmental aspects or characteristics of health status. • Nutrition monitoring is the review and assessment of a patient's status at a scheduled follow-up point with regard to the nutrition diagnosis, intervention plans/ goals, and outcomes. • Outcome evaluation is the systematic comparison of current findings with previous status, intervention goals, or reference standards. Outcomes which can be used to show the effectiveness of nutrition interventions can be grouped into direct nutrition outcomes, clinical and health status outcomes, patient-centred outcomes, and health care utilisation and cost outcomes.9 1.2.2 Literature appraisal and collation Developing the literature search strategy and clinical questions Relevant clinical questions were developed for components of the Nutrition Care Process (Figure 1). A systematic literature review of studies was designed to address the clinical questions using appropriate search terms and methodologies. Three searches were written for the Medline Database using the OVID search engine and then modified to suit Embase and CINAHL databases. The Cochrane Database of Systematic Reviews was searched for all papers relating to malnutrition. The searches were limited to the English language and studies involving humans. Limits were added which excluded tutorials, editorials, news, letters and comments. Articles not reported in full (abstract only) were also excluded. Preliminary inclusion and exclusion criteria were defined by agreement of the Steering Committee and included in the search methodology where applicable. Please refer to Appendix 1 for the detailed search strategy. The clinical questions were as follows: 1 Criteria for screening and referral systems (Figure 1): What is the best method for identification of adults with malnutrition or at risk of malnutrition for improved patient, clinical and cost outcomes? 2 Nutrition assessment (and Nutrition Diagnosis) (Figure 1): Which specific measures best reflect nutritional status or change in nutritional status in adults with malnutrition or at risk of malnutrition, for the diagnosis of malnutrition, can be altered by nutritional intervention, and are associated with improved patient, clinical and cost outcomes? 3 Nutrition intervention; Nutrition monitoring and evaluation (Figure 1): a) What are the nutrition goals for adults with malnutrition or at risk of malnutrition for improved patient, clinical and cost outcomes? b) In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition interventions, to optimise nutritional status for improved patient, clinical and cost outcomes? c) In adults with malnutrition or at risk of malnutrition, how will nutrition interventions be monitored for improved patient, clinical and cost outcomes? All searches were conducted to August 2006. For the first two clinical questions databases were searched from inception of the databases whereas the final question (Q3) was from 1996. The searches returned a total of 3987 titles and abstracts for review. In response to the large number of abstracts retrieved, the Steering Committee made some modifications to manage the literature appraisal as follows: The search for the nutrition screening tool section was modified to focus on the main recommendations from the Jones review in 200610 of 44 nutrition screening and assessment tools describing literature until the year 2000 and also any identified relevant articles of screening tools with level III-2 evidence or higher to support their use published after 2000. Ninety-six articles were identified published between January 2000 and November 2008. Since August 2006 modifications have been made to the clinical questions. A newly devised question has been added to determine whether malnutrition is a problem in Australia (prevalence) and question 1 has been split into parts to enhance the focus of the evidence based statements. Diagnosis was removed from the clinical questions when the International Statistical Classification of Diseases and Related Health Problems 10th Revision Australian Modification (ICD-10-AM) criteria for diagnosing malnutrition was released.11 Consequently the new ICD-10-AM diagnostic criteria for malnutrition has been included in the document as a Nutrition Assessment practice tip. Please refer to Table 1 for the final clinical questions. Table 1. Final Guideline clinical questions Nutrition Care Process Clinical questions which informed the systematic search Nutrition Screening Q1a) What is the prevalence of malnutrition and is it a problem? 1b) Should there be routine screening for malnutrition and if so where and when should malnutrition risk screening occur? 1c) What screening process can be used to identify adults at risk of malnutrition? Nutrition Assessment and Nutrition diagnosis Q2. What nutrition assessment processes can be used to identify malnutrition in adults? Nutrition goals (a) Q3a) In adults with malnutrition or at risk of malnutrition, what are the appropriate nutrition goals, for optimal client, clinical and cost outcomes? Nutrition interventions (b) Q3b) What are the appropriate nutrition interventions for prevention and treatment of malnutrition in adults? Nutrition monitoring and evaluation (c) Q3c) What are appropriate monitoring and outcome measures to demonstrate improved patient, clinical and cost outcomes? For question 1a evidence was extracted from Stratton's comprehensive review of studies until 2003 investigating the prevalence and consequences of malnutrition.12 A literature search was then conducted to identify international reviews between 2003 and 2008 as well as all published papers which investigated malnutrition prevalence in an Australian or New Zealand population. The literature identified in the searches for the initial clinical questions along with the literature attained from the additional clinical question (question 1a) was then appraised for the guidelines. Seventy-eight papers (including the Stratton review) met the inclusion criteria (refer to Table 2) for question 1a and b.12 In addition to the Jones 2006 review,10 41 papers published between January 2000 and November 2008 met the inclusion criteria for the screening tool part of the question (question 1c). For question 2, twenty-five papers were assessed as meeting the inclusion criteria and included an assessment tool measured against a means of confirming validity. One hundred and four papers were assessed as meeting the inclusion criteria for question 3 and retrieved for full appraisal. Thus, a total of 249 papers were reviewed for the guidelines. Table 2. Inclusion and Exclusion Criteria Inclusion criteria Exclusion criteria Protein-energy malnutrition Non-English language Undernutrition Children/ Paediatrics Energy deficiency Specific Vitamin Deficiencies (e.g. Vitamin D) Protein deficiency Specific Mineral Deficiencies (e.g. Magnesium) Adults Eating Disorders (anorexia or bulimia) Medical Nutrition Therapy Cystic Fibrosis Measurements of Nutrition Status (eg biochemistry, anthropometry) Coeliac Disease Screening for Protein-Energy Malnutrition Obesity surgery (Gastric bypass/ bands) Assessments of Nutrition status (e.g. Assessment tools) Liver Disease Nutrient intakes Renal disease and Chronic Kidney Disease Nutrition interventions(a) Dialysis and Haemodialysis Nutrition monitoring Hereditary protein deficiency disorders Complications, mortality and morbidity relating to malnutrition Non-Systematic reviews/opinions/viewpoints Unspecified nutritional deficiency Non-Western Countries Critical care Crohns Disease Alcoholism Alcoholism if malnutrition is vitamin related Prevalence data only Cancer Screening tools with ≥2 parameters for the screening section only HIV (a) Note: if nutrition interventions included an exercise component, these studies were included in the guidelines, however pharmaceutical interventions are not specifically addressed in these Guidelines. HIV, Human Immunodeficiency Virus. A minimum of two Steering Committee members independently assessed the titles and abstracts using the inclusion and exclusion criteria (Table 2) before retrieving the full article. Criteria were added when the reviewers commenced assessing the literature and determined further criteria were needed to ensure the scope of the guidelines remained focussed. Additional criteria exclude conditions and diseases which were already the subject of other DAA evidence based guidelines or were alternate, potentially co-existing mechanisms for protein-energy malnutrition such as sarcopenia or cachexia (please refer to existing DAA endorsed evidence based practice guidelines: Evidence Based Practice Guidelines for Nutritional Management of Patients Receiving Radiation Therapy,13 Cancer Cachexia,14 Chronic Kidney Disease,15 and Australasian Clinical Practice Guideline for Nutrition in Cystic Fibrosis.16) Tables were developed to collate the evidence for screening, assessment, intervention, monitoring and evaluation. Evidence was categorised by health care setting and patient characteristics as described in Table 3. Table 3. Definitions used for collating evidence based statements Setting/ Demographic Definition for the purpose of collating the evidence based statements Acute Care Acute Care is defined as services occurring within an acute care hospital Rehabilitation Rehabilitation is defined as services by a multidisciplinary team with the goal of reducing disability by improving task-oriented behaviour.17 Rehabilitation settings include both inpatient and ambulatory settings. Residential Aged Care Residential Aged Care is defined as services for aged people who can no longer be assisted to stay in their home.18 Residential aged care settings involve both low (hostel) and high care (nursing home). Community Community is defined as free living adults with or without assistance from community services. Across settings Across settings is used to describe evidence which involved participants or analysis in two or more of the above settings. Older adult Groups of study participants had a mean age over 60 years. Note: Literature describing the setting as ‘sub-acute’ was reviewed closely and reported according to the setting for which the participants were most aligned. In most cases these were the acute and rehabilitation settings. 1.2.3 Rating the evidence The strength of the evidence was assessed using the level of evidence rating system recommended by the ‘National Health and Medical Research Council (NHMRC) additional levels of evidence and grades of recommendations for developers of guidelines-Pilot Program’ (Appendix 2).1 NHMRC level of evidence of rating scheme is provided for various types of studies including: intervention; diagnosis; prognosis; aetiology; and screening (Appendix 2). • Aetiology study criteria were used for clinical questions 1a and 1b • Diagnostic studies were used for clinical questions 1c and 2 • Intervention studies were used for clinical questions 3 a), b) &c) In all cases the evidence was ranked by two independent reviewers. Any disagreements between reviewers were handled by a third independent reviewer. This evidence then informed the evidence based statements. Only articles assessed as providing the highest level of evidence were included in the evidence based statements. However, with respect to the evidence base in the Australian and New Zealand populations, this evidence is also presented, where available, in addition to the higher level evidence from international studies. Unfortunately no New Zealand studies were located. This approach was supported by Dietitian stakeholder consultation in May 2008. Articles identified to be the same level of evidence but reporting inconclusive findings have been noted. Articles were excluded if they reported inconclusive findings and were reviewed as being of a lower level of evidence than articles supporting the evidence based statement. Some articles were assigned two levels of evidence. This was to demonstrate the difference between findings generated from analyses performed within (Level IV) and between group (Level II-III-3). If no evidence was returned during the search this was identified as ‘no evidence located’ in the evidence based statements. The grades of recommendations were then formulated from the evidence based statements. The five components that are considered in judging the body of evidence to apply a grade of recommendation according to the NHMRC classification are the volume of evidence, consistency of the results, potential clinical impact of the proposed recommendation, and the generalisability of the body of evidence to the Australian health care context (Appendix 2).1 The grades of recommendation are: Level A Body of evidence can be trusted to guide practice. Level B Body of evidence can be trusted to guide practice in most situations. Level C Body of evidence provides some support for recommendation(s) but care should be taken in its application. Level D Body of evidence is weak and recommendation(s) must be applied with caution. A process of decision making to deal with any conflict arising between members of the Steering Committee was agreed upon. If one or more Steering Committee members were in disagreement with the majority then these Committee members were requested to seek additional information to support their position. If the conflict was unable to be resolved at this point then the process was for the Steering Committee to seek advice from an independent expert. 1.2.4 Development of the practice tips Whilst evidence based statements are objective interpretations of available evidence, ‘practice tips’ were developed by the Committee where there was insufficient high level evidence from the literature to support an evidence based statement, but enough low level evidence and/or ‘expert opinion’ to provide a statement of support for a practice approach. The practice tips contained within these Guidelines acknowledge the diversity of settings and age related target groups and are often an extension to relevant evidence based statements in order to provide further detail or clarification. In all cases, the practice tips have required consensus by all members of the Committee and external reviewers. The Committee also recommends that evidence based recommendations and practice tips contained in this document are read in conjunction with relevant complementary guidelines. Some examples include the National Institute for Health and Clinical Excellence (NICE) Nutrition support in adults,3 European Society of Parenteral and Enteral Nutrition (ESPEN) guidelines on adult enteral nutrition19 and the stroke guidelines.20,21 The development process for these other Guidelines allowed recommendations based on both formal and informal consensus methods using expert opinion when there was an absence of scientific literature. 1.3 Consultation process At the DAA 26th National Conference in 2008, a formative consultation with dietitians was sought on: relevant content, ease of use, clarity of recommendations, organisational barriers and whether or not these guidelines would be used in practice. The feedback provided by the ninety five participants indicated that the majority of dietitians understood the Guideline development process; found that the Guideline format and structure were easy to follow; that the overall objectives were clear and that the evidence based recommendations were specific and unambiguous. Participants strongly agreed that they would use the Guidelines as part of their everyday practice. Most agreed that the Guidelines would help to bridge the gap between research and practice and that the Guidelines would result in the anticipated benefits claimed. Specific feedback on improvements to the document were considered by the Committee and incorporated as appropriate. For example, a range of DAA endorsed evidence based practice guidelines, were reviewed and cross referenced with the current document where relevant. These included; Evidence based practice guidelines for nutritional management of radiation therapy,13 cancer cachexia,14 chronic kidney disease15 and cystic fibrosis.16 The Committee decided that it was also important to include information on disease states such as cancer, renal disease and (Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome ) HIV/AIDS in order to answer question 1a. ‘What is the prevalence of malnutrition and is it a problem?’. However, these diseases are not referred to in later questions; instead reference is made to the above guidelines. Further, where participants identified gaps in the literature in the intervention section, additional studies were located including studies published after the final date of the systematic search. A list of barriers to the implementation of the Guidelines in workplaces across the continuum of care were identified by workshop participants in 2008. Another workshop was held at the DAA 27th National Conference in 2009 which focussed on addressing the barriers to implementation previously identified. This body of work is discussed under Applicability. As part of the DAA guideline development process, these Guidelines have been independently reviewed by experts and assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) instrument.22 Modifications to these Guidelines have been undertaken in response to this review. Since the Steering Committee acknowledge that dietitians do not act alone in either the detection or treatment of malnourished patients, it was considered important to consult with a wide range of health professionals and consumers of health services. The March 2008 version was circulated by DAA on b