Are Dietitians Documenting Malnutrition Based on Subjective Global Assessment Category?
Publication: Canadian Journal of Dietetic Practice and Research
15 November 2018
Abstract
Purpose: This study reports on dietitian use of the Nutrition Care Process Terminology (NCPT) diagnosis of malnutrition based on Subjective Global Assessment (SGA).
Methods: Nutrition assessment reports for adults in medical, surgical, and cardiac units in 13 Canadian hospitals were retrospectively examined for a 6-week period in 2014. Reports with a SGA and NCPT diagnosis were included regardless of why the patient was seen by the dietitian.
Results: Of the 932 nutrition assessment reports, 857 (92%) included an SGA. Based on SGA, the prevalence of mild to moderate malnutrition (SGA B) and severe malnutrition (SGA C) was 53.4% (n = 458) and 10.0% (n = 86), respectively. When categorized as severely malnourished, the most common NCPT diagnoses were “malnutrition” (n = 55, 72.4%), “inadequate oral intake” (n = 11, 14.5%), and “inadequate protein-energy intake” (n = 10,13.1%). Among those with SGA B and C, the assignment of the NCPT malnutrition diagnosis was 19.8% (n = 95).
Conclusions: Dietitians play a key role in the prevention, identification, and treatment of malnutrition in the hospitalized patient and are well positioned to take a leadership role in improving its documentation. Ongoing audits, staff support, and training regarding NCPT use may improve the application of the malnutrition diagnosis. Future research examining dietitian barriers to using the malnutrition diagnosis would be valuable.
Résumé
Objectif. Cette étude porte sur l’utilisation par les diététistes du diagnostic de malnutrition de la terminologie du processus de soins en nutrition (TPSN) sur la base de l’évaluation globale subjective (ÉGS).
Méthodes. Les rapports d’évaluation nutritionnelle de patients adultes provenant des unités médicales, chirurgicales et cardiaques de 13 hôpitaux canadiens ont été examinés de manière rétrospective pour une période de six semaines en 2014. Les rapports comprenant une ÉGS et un diagnostic TPSN ont été inclus, peu importe la raison pour laquelle le patient était suivi par un ou une diététiste.
Résultats. Parmi les 932 rapports d’évaluation nutritionnelle consultés, 857 (92 %) comprenaient une ÉGS. Sur la base de l’ÉGS, la prévalence d’une malnutrition légère à modérée (ÉGS B) et d’une malnutrition aiguë (ÉGS C) était de 53,4 % (n = 458) et de 10,0 % (n = 86), respectivement. Lorsque caractérisés de malnutrition aiguë, les diagnostics TPSN les plus fréquents étaient « malnutrition » (n = 55, 72,4 %), « apport oral insuffisant » (n = 11, 14,5 %) et « apport protéino-énergétique insuffisant » (n = 10, 13,1 %). Parmi les patients ayant reçu une ÉGS B ou C, l’attribution du diagnostic de malnutrition TPSN était de 19,8 % (n = 95).
Conclusions. Les diététistes jouent un rôle clé dans la prévention, l’identification et le traitement de la malnutrition chez les patients hospitalisés et sont en bonne position pour assumer un rôle de leader dans l’amélioration de sa documentation. Des audits ainsi que le soutien et la formation du personnel concernant l’utilisation de la TPSN pourraient contribuer à améliorer la mise en application du diagnostic de malnutrition. De futures recherches examinant les obstacles pour les diététistes à l’utilisation du diagnostic de malnutrition seraient profitables
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Fianancial support: None.
Conflicts of interest: The authors declare no conflicts of interest.
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Published In
Canadian Journal of Dietetic Practice and Research
Volume 80 • Number 2 • June 2019
Pages: 91 - 94
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Version of record online: 15 November 2018
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© 2019.
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Liz da Silva MS, RD, Christina Edmunds MS, RD, Talise Grossman BSc, RD, Lynn Kelly BSc, RD, Cathryn Nattrass BSc, RD, and Delara Saran MS, RD. 2019. Are Dietitians Documenting Malnutrition Based on Subjective Global Assessment Category?. Canadian Journal of Dietetic Practice and Research.
80(2): 91-94. https://doi.org/10.3148/cjdpr-2018-038
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