Nutritional Assessment Procedures

Nutritional markers are most effectively used in a comprehensive screening and ongoing evaluation program that help in making decisions about nutritional support. The following provides an algorithm for the most effective use of these markers in conjunction with other parameters.

Adapted from Brugler, DiPrinzio, and Bernstein 1999

The generalized algorithm presented above applies to medical patients; certain special patient classes should be assessed based on the chart below:

Nutritional Assessment: Special Cases

Provided as a courtesy by Robert G. Martindale, MD, PhD

Ongoing assessment performed according to the algorithm should demonstrate significant improvement over time. In particular, the prealbumin level should increase with aggressive nutrition support at a rate of 1 to 2 mg/dL per day, until the patient reaches the acceptable range. If this doesn't occur, other markers should be used to evaluate the possibility of complications, including infection and anastomatic breakdown.

The Value of Visceral Protein Testing

Rapid identification of malnutrition in hospitalized patients and the resultant treatment intervention has been shown in recent studies to optimize patient outcomes and reduce the cost of care (Brugler 2002).

In a recent study by Brugler et al., abnormal levels of prealbumin together with normal or abnormal levels of albumin were associated with higher hospital costs and worsened health outcomes. The following graph depicts the costs for the total care of patients in relation to their prealbumin and albumin levels. Of the four categories, category II showed (Brugler 2002):

• The highest mean cost for total care
• The highest mean complication rate during hospitalization (0.5 complications/patient)
• The highest readmission rate (19.4% readmitted in 31 days)
• The highest percentage of patients receiving registered dietician care (77.4%)

Category I = Normal ALB/Normal Prealbumin
Category II = Abnormal ALB/Abnormal Prealbumin
Category III = Normal ALB/Abnormal Prealbumin
Category IV = Abnormal ALB/Normal Prealbumin

Categories III and IV also demonstrated higher costs of hospital care when compared to category I, indicating the usefulness of albumin and prealbumin as independent markers for identifying patients with malnutrition.

Visceral proteins, such as prealbumin, C-reactive protein and retinol-binding protein, have shorter half-lives than albumin; therefore, because they are more reactive to physiological changes in the body, they may be more valuable in identifying malnutrition earlier.

Rural American Hospitals

The benefit of visceral protein testing is not limited to urban or even suburban facilities. Healthcare professionals are also starting to recognize how rural hospitals can benefit from these useful markers of malnutrition.

One protocol for visceral protein testing was developed for Native Americans in an Indian Health Services hospital, designed to enhance the detection of malnutrition. (Bickford/2000) The goal—devise a system that integrates observation (patient histories) with automation (visceral protein testing). These separate entities would work together to more accurately and rapidly identify malnourishment, and would ease the time constraints of registered dieticians in Native American hospitals.

Diagnosis consists of two points of evaluation. The first is a 1-month baseline collection of data on all consecutively admitted, adult, nonmaternity patients identified to be at moderate or severe risk for malnutrition. The second is 2 weeks of automated testing of the visceral proteins, prealbumin, C-reactive protein and retinol-binding protein. Continuous therapy and monitoring is warranted until patients are discharged (Bickford/2000).

The treatment algorithm adopted by this Native American hospital can be enlarged by clicking here.

Visceral Protein Testing Algorithm

Current statistics still associate malnutrition with a 25% morbidity rate and a 5% mortality rate, along with prolonged LOS. The rapid identification of patients who would benefit most from nutrition restoration during hospitalization is the key to (Bickford 2000):

• Improved patient outcomes
• Reducing the cost of care
• Maximizing care reimbursement
• Fulfilling regulatory requirements

Much education is still required to bring an overall awareness of the problems associated with malnutrition to this type of isolated society, and there is a distinct need for increased staffing and higher salaries to bring about improvement in the quality of healthcare (Bickford 2000).

For additional information on the nutritional assessment of patients with malnutrition, click here.