A generic tool for nutritional information transfer should accommodate current screening and diagnostic criteria
A recent issue of the British Journal of Nutrition contains a paper by Berger et al. (Reference Berger, Egiseer and Eisenberger1) that describes a Delphi process to develop a tool for the documentation and transfer of nutritional information within healthcare systems. The authors point out that although malnutrition is highly prevalent in European healthcare (and elsewhere) nutritional information is usually not included in medical information transfer systems. The initial approach to develop this tool was to capture the essential nutritional information; first from the core expert group’s review of the literature, and then through a Delphi process using invited nutrition experts from sixteen European countries. Finally, feasibility of the tool was evaluated through a questionnaire completed by forty-eight randomly selected primary health and hospital-based physicians from a limited area of Austria. The overall response rate was 58 %. The resulting nutritional documentation (NDoc) tool contains thirty items distributed under three themes, that is, nutritional assessment, nutritional diagnosis/intervention and artificial nutrition. It is suggested that the tool should be integrated in the computerised medical record system on a global scale.
This initiative is worthwhile and could help to secure and improve nutritional (and medical) care. As currently conceived, the NDoc tool appears to be adapted mainly for the needs of primary care physicians, whereas there are also dietitians and nurses working in primary care that have needs for somewhat different nutritional information. However, initiatives to address such needs do not preclude the current effort. The third step in the Delphi process, that is, relying on primary care and hospital physicians to decide which information is of practical utility, may have resulted in the NDoc tool being inconsistent with the most recent knowledge about screening and diagnosis of malnutrition. For example, assessment of muscle mass, incorporation of aetiological criteria like decreased food intake and the presence of inflammation could have been incorporated. Moreover, instruments and variables used to screen for malnutrition risk and to diagnose malnutrition vary regionally, so a tool with the ambition to be feasible globally has to be able accommodate such variations.
Recently a global initiative was launched with the objective to harmonise the diagnosis of malnutrition, that is, The Global Leadership Initiative on Malnutrition (GLIM), representing four major societies in the field of clinical nutrition, that is, the American Society of Parenteral and Enteral Nutrition (ASPEN), The European Society of Clinical Nutrition and Metabolism (ESPEN), Federacion Latinoamericana de Terapia Nutricional, Nutricion Clinica Y Metabolismmo (FELANPE) and the Parenteral and Enteral Nutrition Society of Asia (PENSA)(Reference Cederholm, Jensen and Correia2, Reference Jensen, Cederholm and Correia3). In summary, the GLIM criteria of malnutrition include three phenotypic criteria (weight loss, low BMI, reduced muscle mass) and two aetiological criteria (reduced food intake/malabsorption, disease burden/inflammation). Malnutrition is diagnosed when at least one phenotypic criterion is combined with at least one aetiological criterion. All the suggested GLIM criteria/nutritional variables are present in most of the existing approaches for screening and diagnosis of malnutrition. We therefore recommend that any tool that is intended for documentation and transfer of nutritional information between care givers contains these GLIM variables so that a basis for malnutrition diagnosis is provided and appropriate intervention and care may be undertaken. The NDoc tool could be easily modified to incorporate such an approach.
The third theme of the NDoc tool is unfortunately entitled Artificial Nutrition, where information on recommended nutritional treatment, for example, oral supplementation, enteral and parenteral nutrition, is provided. During the work with the ESPEN Guidelines on Nutritional Terminology and Definitions(Reference Cederholm, Barazzoni and Austin4), it became clear that experts around the world wanted to exchange the negatively loaded terminology Artificial Nutrition with the more neutral concept of Medical Nutrition. For further testing of the NDoc tool this terminology is recommended.
In conclusion, the NDoc tool for documentation and transfer of nutritional information between care givers represents an important initiative to improve quality of care. We recommend that the tool in its present form should be updated to include information that reflects current knowledge and consensus, and should be used as a template that can be readily updated to accommodate developing evidence, knowledge and relevant consensus documents.
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A generic tool for nutritional information transfer should accommodate current screening and diagnostic criteria
A recent issue of the British Journal of Nutrition contains a paper by Berger et al. (Reference Berger, Egiseer and Eisenberger1) that describes a Delphi process to develop a tool for the documentation and transfer of nutritional information within healthcare systems. The authors point out that although malnutrition is highly prevalent in European healthcare (and elsewhere) nutritional information is usually not included in medical information transfer systems. The initial approach to develop this tool was to capture the essential nutritional information; first from the core expert group’s review of the literature, and then through a Delphi process using invited nutrition experts from sixteen European countries. Finally, feasibility of the tool was evaluated through a questionnaire completed by forty-eight randomly selected primary health and hospital-based physicians from a limited area of Austria. The overall response rate was 58 %. The resulting nutritional documentation (NDoc) tool contains thirty items distributed under three themes, that is, nutritional assessment, nutritional diagnosis/intervention and artificial nutrition. It is suggested that the tool should be integrated in the computerised medical record system on a global scale.
This initiative is worthwhile and could help to secure and improve nutritional (and medical) care. As currently conceived, the NDoc tool appears to be adapted mainly for the needs of primary care physicians, whereas there are also dietitians and nurses working in primary care that have needs for somewhat different nutritional information. However, initiatives to address such needs do not preclude the current effort. The third step in the Delphi process, that is, relying on primary care and hospital physicians to decide which information is of practical utility, may have resulted in the NDoc tool being inconsistent with the most recent knowledge about screening and diagnosis of malnutrition. For example, assessment of muscle mass, incorporation of aetiological criteria like decreased food intake and the presence of inflammation could have been incorporated. Moreover, instruments and variables used to screen for malnutrition risk and to diagnose malnutrition vary regionally, so a tool with the ambition to be feasible globally has to be able accommodate such variations.
Recently a global initiative was launched with the objective to harmonise the diagnosis of malnutrition, that is, The Global Leadership Initiative on Malnutrition (GLIM), representing four major societies in the field of clinical nutrition, that is, the American Society of Parenteral and Enteral Nutrition (ASPEN), The European Society of Clinical Nutrition and Metabolism (ESPEN), Federacion Latinoamericana de Terapia Nutricional, Nutricion Clinica Y Metabolismmo (FELANPE) and the Parenteral and Enteral Nutrition Society of Asia (PENSA)(Reference Cederholm, Jensen and Correia2, Reference Jensen, Cederholm and Correia3). In summary, the GLIM criteria of malnutrition include three phenotypic criteria (weight loss, low BMI, reduced muscle mass) and two aetiological criteria (reduced food intake/malabsorption, disease burden/inflammation). Malnutrition is diagnosed when at least one phenotypic criterion is combined with at least one aetiological criterion. All the suggested GLIM criteria/nutritional variables are present in most of the existing approaches for screening and diagnosis of malnutrition. We therefore recommend that any tool that is intended for documentation and transfer of nutritional information between care givers contains these GLIM variables so that a basis for malnutrition diagnosis is provided and appropriate intervention and care may be undertaken. The NDoc tool could be easily modified to incorporate such an approach.
The third theme of the NDoc tool is unfortunately entitled Artificial Nutrition, where information on recommended nutritional treatment, for example, oral supplementation, enteral and parenteral nutrition, is provided. During the work with the ESPEN Guidelines on Nutritional Terminology and Definitions(Reference Cederholm, Barazzoni and Austin4), it became clear that experts around the world wanted to exchange the negatively loaded terminology Artificial Nutrition with the more neutral concept of Medical Nutrition. For further testing of the NDoc tool this terminology is recommended.
In conclusion, the NDoc tool for documentation and transfer of nutritional information between care givers represents an important initiative to improve quality of care. We recommend that the tool in its present form should be updated to include information that reflects current knowledge and consensus, and should be used as a template that can be readily updated to accommodate developing evidence, knowledge and relevant consensus documents.