Natalie Ranelli

DIET 4470
28 May 2021
CQI Project 
Continuous Quality Improvement Project
Manchester Memorial Hospital, Manchester, CT

Identification of Problem and Study Rationale:

Malnutrition is a risk factor that can greatly impact patient’s clinical outcomes, their
quality of life, overall function and autonomy. In recent studies, malnutrition risk in the US was
identified in 1 in 3 patients. In addition, patients with reduced meal intake experienced an
increased mortality risk. (Sauer et al 2019) Identifying the patients at risk for malnutrition is
crucial to initiate timely and appropriate nutrition support. A firmly established method used in
many clinical settings are nutrition risk screening tools. These tools are often simple, and when
performed systematically during the hospital admission process can provide a quick and efficient
method to detect patients at risk. Patients with increased nutrition risk would subsequently be
included in a more detailed nutrition assessment to further identify and quantify nutrition issues.
(Reber et al 2019).
In discussion with Heather Gill, Clinical Nutrition Manager at Manchester Memorial
Hospital, the importance of screening tools was emphasized. Currently, there is no specific
nutrition related screening tool used on admission. If there was a quick and effective,
standardized way that nurses or other hospital staff could screen and identify patients at risk on
admission, there would be many potential benefits to the dietitians and patients. Adequate and
early implementation of nutrition support is related to improved health outcomes including
reduced length of stay, a decrease in mortality, decreasing other potential severe complications
that would create an improvement in patient quality of life. (Reber et al 2019). Currently, there is
a daily and elaborate screening process that takes place where the dietitians have to chart review
each patient and compare to a list of criteria. From there, if a patient was identified, a full
nutrition assessment would take place. This is a time consuming process and although this
additional screening may be necessary due to some criteria not being reflected in the
standardized tools, having an initial screening tool in place could eliminate some of the
additional steps. Having a standardized screening and assessment tool would create a more
structured care cascade for hospitalized patients.
There are many nutrition risk screening tools available, for the purpose of this project, the
top three, most common tools- Malnutrition Screening Tool (MST), Malnutrition Universal
Screening Tool (MUST), and Nutrition Risk Screening (NRS) were compared. Patients were
chosen from the list of patients used in the 1st quarter evaluations and were screened using each
of these tools to figure out which tool is most effective. The criteria each screening tool uses, the
strengths and weaknesses, effectiveness, and ease of use will be described in this project. 

Measurable Indicators:
To accurately assess and compare the reliability of these screening tools, the following criteria
was compared:
1. If the screening tool identified the patient as high risk and the patient was subsequently
diagnosed with malnutrition.
2. How often the screening tool triggered patients for full nutritional assessment.
 3. Reasons why a screening tool would or wouldn’t trigger a patient for a full nutrition
assessment such as low BMI or decreased appetite, compared to why a clinical dietitian
triggered the patient

Data Collection:
The list of patients was provided, the Clinical Nutrition Manager used these patients in her first
quarter evaluations. The patient’s charts were reviewed and then each individually screened
using the three different tools. The reason the clinical dietitian triggered the patients and if they
meet GLIM criteria for malnutrition was also recorded in the attached Excel table to test the
accuracy and benefit of the different screening tools.
To assess if these patients would be triggered on any of the screening tools, the following data
was measured and recorded:
1. Anthropometrics: Body weight, weight loss (both % and pounds), and BMI. Low BMI is
an indicator of chronic malnutrition.
2. Appetite and oral intake: including if the patient is acutely ill and if there was likely no
oral intake for a period of 5 days and what percentage of reduced intake.
3. Severity of Disease: certain screening criteria required severity of illness, and the more
severe a condition is the higher risk a patient would be.
4. Age: if the patient is older than 70, some screening tools place the patients at higher risk.

Data Analysis 
Please see the attached Excel document which was utilized to record the collected data
and perform statistical analysis to obtain results from the dataset. Each patient is listed in column
A, column B indicates if the patient met GLIM criteria for malnutrition, green patients did not
meet malnutrition criteria while red patients did. Column C indicates which criteria the dietitian
triggered the patient for a full nutritional assessment. Each screening tool’s criteria is
subsequently broken down.
The Malnutrition Screening Tool (MST) tool seen in columns D-F, uses a point system
for weight loss, increasing points depending on how many pounds the patient lost and points for
if the patient has a decreased appetite. The MST tool divides risk by low, moderate, and high
risk. Low risk patients are highlighted in green. According to the MST for low risk patients, if
length of stay exceeds 7 days, then patients are rescreened and seen as needed. Moderate risk
patients highlighted in yellow, and high risk patients highlighted in red, these patients should be
seen within 24-72hrs depending on risk and nutrition interventions should be rapidly
implemented. It should be noted that MST does not take into account BMI status
The Malnutrition Universal Screening Tool (MUST), columns G-J, assess patients BMI,
a lower BMI putting patients at higher nutrition risk, the tool assesses weight loss by percentage,
and if patients are acutely ill and there has been or is likely no nutritional intake for 5 or more
days. Patients are then scored at low (green), medium (yellow), or high (red) risk. According to
MUST standards, low risk patients received routine clinical care and repeat weekly screenings as
needed. Medium risk patients are in the “observe” category, and high risk patients are meant to
be treated by a dietitian immediately and monitored regularly.
The Nutrition Risk Screening (NRS), columns K-N, asks a more detailed series of
questions. If the patient meets any of the following criteria: BMI <20.5, lost weight, reduced
intake, or is severely ill, they are then fully screened. Depending on their impaired nutrition
status, severity of disease, and age the score is calculated. Greater or equal to three puts the
patient at nutritional risk and a nutrition care plan should be initiated. If a patient scores less than
3, they receive weekly repeat screening.
A total of 224 patients were screened and recorded. 106 patients did not meet criteria for
malnutrition, 188 patients met criteria for malnutrition. (Table 1) Most common criteria for
triggering a nutritional assessment (Table 2 and Chart 1) includes a BMI <18.5 (51 patients,
23%), wounds (44 patients, 19.5%), weight loss (39 patients, 17%), and
nausea/vomiting/diarrhea (33 patients, 15%).
Of the patients that met criteria for malnutrition, they were always identified by at least
one of the screening tools. Of the 118 patients that met for malnutrition, 88 times (75%) all three
screening tools triggered these patients at high nutritional risk. There are 30 instances (25%)
where at least one tool did not identify a high risk patient who met for malnutrition. The MST
missed 29 patients, meaning it was able to trigger 75% of the patients that met criteria for
malnutrition. MUST only missed one patient, meaning it was able to identify 99% of the patients
who met criteria for malnutrition. And NRS only missed one patient as well, identifying 99% of
patients at risk for malnutrition. (Table 3.)
Addressing the high rate of patients not meeting nutritional risk by MST standards: 25 of
the 29 times MST missed patients was related to a low BMI. The MST does not take into
account BMI. Low BMI is used in GLIM criteria (Appendix A) to diagnose malnutrition without
needing additional weight loss or loss of appetite. When excluding patients with a low BMI
being the diagnosing criteria for malnutrition, MST only missed 4 patients, meaning it identified
96% of patients who met criteria for malnutrition. When MST is paired with an additional BMI
calculation, the percent of patients that would meet criteria increases by 21%.
The MST triggered 24 additional patients that did not meet criteria of malnutrition,
MUST triggered 33 additional patients, and NRS triggered an additional 38 patients that did not
meet criteria. The MST triggered a nutritional assessment 4 times where no other screening tools
did, the MUST also triggered 4 patients alone where no other screening tools did, while the NRS
triggered a nutritional assessment for 15 patients when no other screening tool did. (Table 4).

Table 1: Patient Count

Malnutrition # of Patients %
No 106 47%
Yes 118 53%
TOTAL: 224

Table 2: Criteria for Triggering a Nutritional Assessment

Criteria Count %
BMI <18.5 51 23%
Wounds 44 19.5%
Weight Loss 39 17%
N/V/D 33 15%
Poor PO Intake 23 10%
Low Albumin 11 5%
Cancer 9 4%
Intubated/Sedated 4 1.8%
PO supplement 2 0.8%
 SLP Eval 2 0.8%
NPO/CL x 5 days 2 0.8%
Dysphagia 2 0.8%
Tube Feed PTA 1 0.4%
DKA 1 0.4%
TOTAL 224

Chart 1: Screening Criteria Frequency

Screening Criteria Frequency

poor PO intake
1% 1% 0% 1% N/V/D
4% 10% Wounds
BMI <18.5
intubated/sedated
17%
15% low alb
TF PTA
1% Dysphagia
0% weight loss
5% Cancer
Po supplement
2% 20%
SLP eval
DKA
23% NPO/CL x 5 days

Table 3: Incidences patients not triggered but met criteria for malnutrition
Times patients not triggered and met for malnutrition
# times MST missed: 29 25%
#times MST missed, excluding low BMI pts 4 3%
     
# times MUST missed 1 1%
     
#times NRS missed 1 1%

Table 4: Incidences tools triggered additional patients or triggered patients no other tools did
Times triggered additional patients or alone
# times MST triggered alone 4 # additional pts MST triggered 24
# times MUST triggered alone 4 # additional pts MUST triggered 33
# times NRS triggered alone 15 # additional pts NRS triggered 38
Discussion of Results:
Through the data collected and the methods compared there are clear pros and cons to
each tool, and their strengths and weaknesses were identified.
For MST, this tool only assessed weight loss and eating poorly. It does not take into
account low BMI which makes up the largest criteria for triggering a nutritional assessment.
However, that aside, MST still identified a large portion of patients that met criteria for
malnutrition. In addition, it had the lowest number of additional patients triggered and had very
few times where it was the only tool to trigger patients. Arguably, it is the simplest of the three
tools. Addressing weight loss simply as pounds lost, not as a percentage, which is easy for
patients and hospital staff to record and having a precise, clear answer to eating poorly makes the
tool easy to use. In the admission physical assessment used currently, BMI is already calculated
when height and weight is recorded.
For MUST, it does take into account BMI at multiple nutrition risk levels, and percent
weight loss. Calculating percent weight loss adds additional steps for hospital staff to assess
usual weight and weight loss. It also factors in oral intake, however phrased as “acutely ill and
there has been or is likely to be NO nutritional intake for greater or equal to 5 days” is usually
rare. According to a chart review of 224 patients and if patients have decreased intake, was rarely
NO intake for more than 5 days. Only 11 patients (<5%) met this criteria. However, MUST had
high accuracy triggering patients who met criteria for malnutrition. MUST triggered a sightly
higher number of additional patients compared to MST, but not as many and NRS. And it
triggered the same number of patients alone as MST. Both MUST and MST have differential
rankings of low, moderate, and high nutrition risk which creates levels of priority for patients to
be seen.
The NRS tool has multiple steps, making it more detailed but also more time consuming
for hospital staff to complete. It encompassed the most criteria that is helpful in diagnosing
malnutrition including low BMI, weight loss, reduced intake, severity of illness and age.
Similarly, to MUST it was able to trigger all of the patients but one who met criteria for
malnutrition. Despite high accuracy, it was the least selective tool, triggering the highest number
of additional patients and triggering the most patients that neither MUST or MST identified as
nutritional risk. Not having built in rankings for risk level is a downside of this method and
contributes to why a large number of patients are triggered.

Suggested Remedies:
Suggested remedies that can be concluded from this analyzed data set would be to utilize
a nutrition screening tool to have earlier identification of patients at nutritional risk. Certain
patients must be seen by dietitians according to hospital policy including patients with wounds or
low Braden score, but a screening tool would help identify patients with weight loss or decreased
appetite. The MST is the simplest tool, and the easiest to complete for busy hospital staff. Pairing
the MST screening tool with a BMI calculation, would provide an efficient way to identify
patients at risk without adding too many additional patients that may not need to have a full
nutritional assessment immediately but also ensuring the ones that do need to be treated
immediately by a dietitian are being identified.
In addition, the results seen in this group of patients was reiterated by studies in which
the MST has high agreement, validity, and reliability (Ferguson et al 1999). There are many
considerations when adding an extra step to staff’s duties including complexity. A tool that is too
complex would be time consuming, increase errors, and may have a low compliance. MST
combines a selective tool that is easy to use and understand, and has a high reliability to identify
patients at risk for malnutrition. The second best tool was MUST, with high rates of reliability
with the drawback of slightly more complexity. And finally, the NRS would be the least helpful
tool in this setting with the highest completely and the least amount of selectivity.
In conclusion, any screening tool would benefit the clinical dietitians workload and
increase the chance that high risk patients are quickly identified. For this setting, the Malnutrition
Screening Tool (MST) when paired with a BMI calculation is the easiest and most efficient tool
that would provide the best results to ensure that a nutritional assessment takes place.

Appendix 1: GLIM Criteria for Malnutrition

References:
Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition -
A consensus report from the global clinical nutrition community. Clin Nutr.
2019;38(1):1-9. doi:10.1016/j.clnu.2018.08.002

Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition

screening tool for adult acute hospital patients. Nutrition. 1999;15(6):458-464.
doi:10.1016/s0899-9007(99)00084-2

Reber E, Gomes F, Vasiloglou MF, Schuetz P, Stanga Z. Nutritional Risk Screening and
Assessment. J Clin Med. 2019;8(7):1065. Published 2019 Jul 20.
doi:10.3390/jcm8071065

Sauer AC, Goates S, Malone A, et al. Prevalence of Malnutrition Risk and the Impact of
Nutrition Risk on Hospital Outcomes: Results From nutritionDay in the U.S. JPEN J
Parenter Enteral Nutr. 2019;43(7):918-926. doi:10.1002/jpen.1499