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                                          UNIVERSITARIA CAREGGI (FLORENCE, ITALY)

           Masini Maria Luisa                                Casini Alessandro                        Meacci Ciardi Duprè Catia
              AOU Careggi                                      AOU Careggi                                  AOU Careggi
             Florence, Italy                                   Florence, Italy                             Florence, Italy
            +39-055-7949061                                  +39-055-7946106                              +39-055-7947892                        

             Surrenti Calogero                               Bedogni Giorgio
               AOU Careggi                                Liver Research Center
              Florence, Italy                                Basovizza, Italy
             +39-055-7949061                                +39-040-3757840

Good practices and ergonomic solution.                                     2. METHODOLOGY

KEYWORDS                                                                   The aim of this study was twofold: 1) to assess the prevalence and
Malnutrition, hospitals, epidemiology, screening.                          incidence of malnutrition at the Azienda Ospedaliero-
                                                                           Universitaria Careggi and, 2) to evaluate the accuracy of
1. INTRODUCTION.                                                           nutritional screening performed by nurses as compared to
Malnutrition is a common cause and consequence of illness,
especially in older people (1,2). Malnutrition affects the function        In a pilot study aimed at identifying the most suitable screening
of every organ system, increases the risk of infection, extends            test for AOUC, we compared the nurse vs. dietitian accuracy of
hospital stay and increases costs. In European and US hospitals,           MUST and NRS-2002 in a sample of 118 consecutive patients
an average of 30% of patients are malnourished. Despite the                (5,6). As a result of this study, we choose MUST as the screening
frequency of malnutrition, it is undiagnosed in most patients.             tool because simpler to compile and less prone to errors.
Many scientific bodies recommend that screening tools be                   A sample size of 720 patients was chosen for the study
implemented and regularly employed in hospitals but this                   hypothesizing a frequency of malnutrition of 0.30 to be assessed
suggestion is rarely followed.                                             with a 95% confidence interval from 0.27 to 0.33.

The Council of Europe has identified 5 factors contributing to             Patients were enrolled at 5 medical and 4 surgical wards of
hospital malnutrition in Europe: 1) dilution of responsibility as          AOUC. They were randomly selected in number of about
nutritional assistance is concerned; 2) lack of adequate training of       16/month per ward using a computer-generated-list.
health care providers; 3) lack of knowledge of patient’s
preferences and objectives; 4) lack of cooperation among different         Within 24 hours from admission of the patients, the nurses
health care operator and, 5) lack of interest about nutrition from         measured weight, height, arm circumference (left), calculated
health              care             administrators             (3).       BMI, and compiled MUST. Within 48 hours from admission, the
                                                                           dietitians performed the same measurements made by the nurses
In line with the available evidence, nutritional support is a              plus those of triceps and subscapular skinfold and recumbent
neglected problem at the Azienda Ospedaliero-Universitaria                 weight if standard weight could not be measured. The same
                                                                           procedure was repeated at patients’ discharge.
Careggi (AOUC, Florence, Italy). Our clinical charts do report the
diagnosis of undernutrition only in a very small number of cases.
                                                                           3. RESULTS
Even more important, our charts do not report simple data from
clinical history and physical examination which are essential to           662 (92%) of 720 planned patients were enrolled into the study
diagnose undernutrition. These data are weight, height,                    and 132 nurses and 11 dietitians took part to the study.
involuntary weight loss, difficulty at eating, and quantity of food
consumed during the hospital stay. This is a problem because, as           However, only 499 MUST were compiled in their entirety by both
pointed out by the World Health Organization, “Anthropometry is            nurses and dietitians at admission and 259 at discharge. Moreover,
the single, most universally applicable, inexpensive, and non-             only 222 MUST were compiled in their entirety by dietitians and
invasive method to asses the size, proportions and composition of          nurses at both admission and discharge.
the human body. Moreover, since body dimensions at all ages
reflect the overall health and welfare of individuals and                  The prevalence and incidence of malnutrition calculated from the
populations, anthropometry may be used to predict performance,             available MUST are given in Table 1.
health and survival” (4).

                                                                          5. REFERENCES
Table 1. Prevalence and incidence of malnutrition
                  Prevalence-      Prevalence-                            1. Lean M, Wiseman M. Malnutrition in hospitals. BMJ 2008, Feb
                   admission        discharge                             9;336(7639):290.
                                                      (n = 222)
                    (n = 499)       (n = 259)
                                                                          2. Corish CA, Kennedy NP. Protein-Energy undernutrition in
                                                                          hospital in-patients. Br J Nutr 2000, Jun;83(6):575-91.
                   N       D        N        D        N        D
                                                                          3. Dougherty D, Bankhead R, Kushner R, Mirtallo J, Winkler M.
MUST ≥ 1                                                                  Nutrition care given new importance in JCAHO standards. Nutr
                  28%     32%     26%      25%      16%      10%
(“survey”)                                                                Clin Pract 1995, Feb;10(1):26-31.
                  16%     18%     13%       8%       6%       2%          4. Beck AM, Balknäs UN, Fürst P, Hasunen K, Jones L, Keller U,
                                                                          et al. Food and nutritional care in hospitals: How to prevent
                                                                          undernutrition--report and guidelines from the council of Europe.
Taking dietitians as the gold standard, the true positive rate and        Clin Nutr 2001, Oct;20(5):455-60.
the true negative rate of nurses in detecting a MUST ≥ 2 were
                                                                          5. Stratton RJ, Hackston A, Longmore D, Dixon R, Price S,
0.70 and 0.95 respectively. This corresponds to a positive
                                                                          Stroud M, et al. Malnutrition in hospital outpatients and
likelihood ratio of 14.3 and to a negative likelihood ratio of 0.3.
                                                                          inpatients: Prevalence, concurrent validity and ease of use of the
4. CONCLUSIONS                                                            'malnutrition universal screening tool' ('MUST') for adults. Br J
                                                                          Nutr 2004, Nov;92(5):799-808.
The prevalence of malnutrition (MUST ≥ 1) at admission in the
AOUC was around 30%, in line with available estimates.                    6. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z, Ad Hoc
Importantly, nearly half of the patients were severely                    ESPEN Working Group. Nutritional risk screening (NRS 2002):
malnourished (MUST ≥ 2).                                                  A new method based on an analysis of controlled clinical trials.
                                                                          Clin Nutr 2003, Jun;22(3):321-36.
On the basis of the admission data, AOUC nurses can screen
malnutrition using MUST with virtually no false negatives (5%)
but with some false positives (30%).

The prevalence of malnutrition at discharge remains high, in line
with available evidence. Nonetheless, these data must be taken
with caution because they were obtained only in a subsample of

The incidence of malnutrition between admission and discharge is
not negligible, especially taking into account the mean recovery
time of 8 days. Nonetheless, these data must be taken with caution
because they are available only in a subsample of patients.

After this study, we created an ad hoc group in order to assess the
best strateg to control hospital malnutrition inside AOUC. The
Italian Association of Dietitians (ANDID) collaborated with the
Centre for Clinical Risk Management and Patient Safety of the
Tuscany Region to the development of a protocol of “Good
Clinical Practice” protocol aimed at treating and preventing
undernutrition. Such protocol was enacted by the Government of
the Tuscany Region on February 25, 2008.


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