BACKGROUND44% of spinal cord injured (SCI) patients

are at risk of undernutrition on admission to hospital.(1)

The Spinal Nutrition Screening Tool (SNST-1)(2) is a disease specific nutrition screening tool.

It is a validated method of identifying people with a SCI who are at risk of malnutrition(1).

Following modification of SNST-1 to SNST-2 the reliability and validity

of the new tool needs to be investigated.

OBJECTIVEThe aim of the study was to test validity of the modified SNST-2

ConclusionMalnutrition is common in patients with SCI.

The SNST-2 is an acceptable (valid and reliable) nutrition screening tool.

It can be used to identify patients with SCI who are at risk of malnutrition.

Further investigation is warranted to test its predictive validity.

This was a convenience sample.

It may not be a true reflection of the risk of malnutrition in people with SCI in the rehabilitation setting.

Guidance notes would aid uniformity and consistency in completion of SNST-2

There is a need to develop a weight management pathway to prevent

and treat overweight and obesity.

METHODBaseline clinical data was collected in a

SCI rehabilitation centre in the Republic of Ireland. This included:

• Anthropometric data • SNST-1 score • SNST-2 score

The validity of SNST-2 was tested by:I. Comparison with the previously validated SNST-1 (2) to assess concurrent validity

II. An additional SNST-2 was completed by the research dietitian to assess inter and

intra-rater reliability.III. Agreement was tested using

Cohen’s - statistics.(3)

RESULTSThe SNST-2 had “substantial agreement” with

SNST-1 (k: 0.888, 95% CI: 0.781-0.995).

The SNST-2 had substantial reliability (inter-rater reliability: dietitian vs nurse, k: 0.695, 95% CI:0.522-0.868).

The dietitian using SNST-2 was superior to nurses in sensitivity (95.2% v 87.9%) and negative predictive value (88.5%v 68%).

Validation of the modified Spinal Nutrition Screening Tool(SNST-2) in patients with Spinal Cord Injuries

Lorna O’Connor1, Eimear Smith1, Sajimon Cherian1, Siobhan Carrigg1 & Samford Wong2

1National Rehabilitation Hospital, Dublin, Ireland.2 National Spinal Injuries Centre, Stoke Mandeville Hospital, Alysebury, UK.

100

90

80

70

60

50

40

30

20

10

0

48.3%

51.7%

BMI>25kg/m2 BMI<25kg/m2

BMI

100

90

80

70

60

50

40

30

20

10

0

NUTRITIONRISK

27.6%

Nutrition and dietetic department, SMH, Buckinghamshire NHS Trust 2008

Nutritional Screening Tool for SCI patients to be completed by nursing staff Patient name Hospital number Est. Pre-injury Height Weight Body Mass Index (See ready reckoner chart) Date completed ____________________ Score

Weight History

0

No weight loss

1

Some unintentional weight loss. BMI 19-21

3

Moderate unintentional weight loss. BMI 16-18

4

Marked unintentional weight loss. BMI <16

Age

1 18-30yrs

2 31-60yrs

3 over 60yrs

4 under18yrs

Level of SCI

1 S1-S5

2 L1-L5

3 T1-T12

5 C1-C8

Other

medical conditions

0 None

1 Chronic condition

E.g. diabetes/substance abuse

2 Acute Trauma

Fractures/Head Injury 3

Infection/Post injury surgical intervention

4 Requires ventilation

5 Requires ventilatory

support with tracheostomy

Skin

Condition

0 Intact

1 Red mark or Grade 1

2

Superficial skin damage or Grade 2

3

Full thickness skin damage or Grade 3

5

Deep multiple pressure ulcers or Grade 4/5

Diet

0 Normal diet and fluids

1 Parenteral or enteral

nutrition

2 Modified texture diet +/-nutritional supplements

3 Nil by Mouth

Appetite

0 Good

1 Poor, > ½ left

2 Not accepting food & drink

or unable to eat

3* Vomiting and diarrhoea

Ability to eat

1 Able to eat independantly

2 Requires some help

3 Needs to be fed

TOTAL=

Score each risk factor, using highest score if more than one is relevant.

Total these row scores to obtain Initial Score and record risk level

Risk level 0-10 = Low 11-15 = Moderate >15 = High Nutrition and dietetic department, SMH, Buckinghamshire NHS Trust 2008

* Investigate cause and treat. Please repeat nutritional screening while in St Andrews / St Patrick

Date Recorded estimated weight

Risk of malnutrition Low/Moderate/High

Action taken E.g. daily build up or hot evening meal

Refer to dietitian (tick and date) Signature

Patients who are NBM for >5 days or require NG/PEG/TPN/PN feeding should automatically be referred to the Dietitian.

Ensure that patient is on the correct menu i.e. liquidised/soft (using coded menu or by contacting catering) and able to eat meal provided (suitable position and utensils). If appropriate, thickened fluids given as per SALT recommendations.

Score Action Low risk

Record risk in patient’s notes and any actions taken during your shift.

Monitor Patients’ intake for 3 days, if no improvement, continues to eat < ½ plated meals. Encourage menu choices indicated with an “E” Order hot evening meal. Give build-up soups/ shakes between meals using full cream milk. Order extra foods e.g. puddings, cheese and biscuits, roll and butter.

Moderate Record risk in patient’s notes and any actions taken during your shift.

Implement suggestions for low risk, in addition Consider hot evening meal (from bone santé menu), patient’s MRN number to record in ward diary (if bed bound patient) Offer Ensure Plus/ Enlive Plus 1-2 a day between meals. Ensure patient can open and reach supplement. Try different flavours. Enure plus creme should be used if the patient requires thickened fluids or a soft/liquidised diet.

High Risk Record risk in patient’s notes and any actions taken during your shift.

Implement suggestions for low and moderate risk. Refer to the Dietitian using email or appropriate form (internal mail) providing the patient’s name, DOB, hospital number, ward, diagnosis, consultant, and reason for referral and name of referrer. If referral is urgent e.g. TPN, NGT or PEG phone dietitians on x5775 [the dietitian will then collect completed referral form on the ward].

Spinal Nutritional Screening Tool Complete all boxes on admission and action as indicated by score

Estimated/reported Weight (kg)

Estimated/reported Height (m)

Body Mass Index (BMI) (use BMI chart to calculate)

Score each risk factor, using highest score if more than one is relevant. Total up column scores to obtain final score and record below.

Transfer total score overleaf and choose appropriate action plan according to identified risk category

Weight Loss / BMI (in last 3 months)

Age (yrs)

Level of SCI

Other Medical Conditions

Skin Conditions Diet Intake Ability to Eat

0

“Minimal” (under 5%)†

BMI ≥22.5 kg/m2

1

18-30

1

S1-S5

0

None

0

Intact

0

Normal diet and fluids or established

NG/PEG feed

0

Eating all meals or

tolerating full enteral feed

0

Not applicable as on NG/PEG feed

1

“Some” (5-10%)†

BMI 18.5 to 22.5 kg/m2

2

31-60

2

L1-L5

1

Chronic conditions eg. Pain /

substance abuse

1

Grade 1 ulcer

1

Introductory NG/PEG

feed

1

Under half meal or

NG/PEG feed tolerated

0

Able to eat independently

3

“Moderate” (11-15%)†

BMI 16.5 to 18.4 kg/m2

3

Over 60

3

T1-T12

2

Acute trauma eg. head injury/

fractures

2

Grade 2 ulcer

2

Modified texture diet

2

Minimal diet, or enteral feed

2

Requires some help

4

“Marked” (over 15%)

BMI <16.4 kg/m2

4

Under 18

5

C1-C8

3

Within 1 week of surgery/ ongoing

infection

3

Grade 3 ulcer

3

Nil by mouth for more than

5 days

3*

Vomiting and diarrhoea or not tolerating NG/PEG feed

3

Needs to be fed

4

Ventilated (non-invasive)

5

Grade 4 ulcer

† Calculate % weight loss and BMI

(Choosing highest score)

5

Fully ventilated with tracheostomy

* Investigate cause and treat

Date Column Score

Column Score

Column Score

Column Score

Column Score

Column Score

Column Score

Column Score

TOTAL SCORE

Patient’s Name

NHS No DOB

Complete table below to update nutritional risk scores and document weight changes Date Total

Score

Risk (L/M/H)

Latest Weight Actual/ Estimate

Weight Change (+/- kg)

Variance and Comments

Referred to Dietitian

Review Date

Nurse’s Signature

Follow local action plan according to risk score. Document actions in nursing notes. Score Risk Action Plan 10 and under

Low Rehab

Encourage healthy food and drink choices Monthly weight if possible Assist with feeding if needed Repeat score monthly

Monthly weight if possible Repeat score monthly

Low Acute

Encourage appropriate menu choices If eating less than half meals complete 3 day food chart and offer 2 nutritional supplements / sip feeds* a day If no improvement in eating refer to Dietitian

Weekly weight if possible Repeat score weekly

11-15

Moderate Rehab and Acute

Encourage appropriate menu choices Assist with feeding if needed Complete 3 day food chart. Implement “Red Tray” Replace missed meals with nutritional supplements / sip feeds * a day If no improvement in eating refer to Dietitian

Weekly weight if possible Repeat score weekly

Above 15

High Rehab and Acute

Encourage high energy / protein menu choices Assist with feeding if needed Complete 3 day food chart. Implement “Red Tray” Replace missed meals with nutritional supplements a day as prescribed by Doctor or Dietitian Refer to Dietitian

Weekly weight if possible Repeat score weekly

Patients N.B.M. for over 5 days or requiring NG/PEG feeding need automatic referral to Dietitian. If “out of hours” Feeding Regimes For The Prevention of Refeeding Syndrome guidance is available on …………. *Supplement Drinks; If the patient has diabetes monitor blood glucose levels and refer to Dietitian and Diabetes Advisor. If the patient has renal problems monitor bloods closely and refer to Dietitian and Medical Team. If too much weight is being gained or BMI above 30; 1) Give patient “Why Weight Matters” diet sheet, 2) Suggest patient attends “drop-in” weight clinic to monitor weight trend and 3) Offer referral to Dietitian. PLEASE RING EXT …….. TO FORMALLY REFER PATIENTS TO DIETITIAN FROM NUTRITIONAL SCREENING

Validation of the modified Spinal Nutrition Screening Tool (SNST-2) in patients with Spinal Cord Injuries

Lorna O’Connor 1, Eimear Smith1, Sajimon Cherian1, Siobhan Carrigg1 & Samford Wong2

1National Rehabilitation Hospital, Dublin, Ireland.2 National Spinal Injuries Centre, Stoke Mandeville Hospital, Alysebury, UK.

1: Wong S et al (2012) Brit J Nutr 108, 918-923.

2, Wong S et al (2012) Eur J Clin Nutr; 66, 382-387,

3:Landis JR & Koch GG (1977) Biometrics33, 159-174.

References*

44% of spinal cord injured (SCI) patientsare at risk of undernutrition on admissionto hospital.(1)

The Spinal Nutrition Screening Tool2(SNST-1) is a disease specific nutritionscreening tool.

It is a validated method of identifyingpeople with a SCI who are at risk ofmalnutrition.

Following modification (i.e. SNST-2), it’sreliability and agreement with thepreviously validated and published tool(SNST-1) needs to be assessed

Baseline clinical date was collectedin a SCIrehabilitation centre in the Republic ofIreland.This included:Anthropometric dataSNST-1 scoreSNST-2 score.

The validity of SNST-2 was tested by:I. comparison with the previously

validated SNST-1 (2) to assessconcurrent validity

II. an additional SNST-2 was completedby the research dietitian to assess inter-and intra-rater reliability.

III. agreement was tested using Cohen’s κ-statistics.(3)

Background

Objective

Method

Conclusion

Malnutrition is common in patients with SCI.

The SNST-2 is acceptable (valid and reliable) nutrition screening tool.

It can be used to identify patients with SCI who are at risk of malnutrition.

Further investigation is warranted to test its predictive validity.

This was a convenience sample.

It may not be a true reflection of the of malnutrition in people with SCI in the rehabilitation setting.

Guidance notes would aid uniformity and consistency in completion of SNST

Highlighted a need to develop a weight management pathway to prevent and treat overweight and obesity.

Results

Nutrition RiskAt risk of Malnutrition

Nutrition Risk 27.60% 72.40%

27.60%

72.40%

NUTRITION RISK

The SNST-2 had “substantial agreement” with SNST-1 (κ: 0.888, 95% CI: 0.781-0.995).

The SNST-2 had substantial reliability (inter-rater reliability: dietitian vs nurse, κ: 0.695, 95% CI: 0.522-0.868).

The dietitian using SNST-2 was superior to nurses in sensitivity (95.2% v 87.9%) and negative predictive value (88.5%v 68%).

Acknowledgement:The authors would like to thank the patients and staff from the Spinal Cord System of Care Programme at the National Rehabilitation Hospital, Dun Laoghaire, Co Dublin, Ireland for facilitating the study. We would like to thank Anthony Twist, Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, UK and Philippa Bearne, Salisbury District Hospital, Salisbury, UK fordevelopment of the SNST-1

0102030405060708090

100

BMIBMI<25 kg/m2 48.3BMI>25kg/m2 51.7

51.7

48.3

BMIBMI>25kg/m2 BMI<25 kg/m2

• 35.9% Female• N=89• Median Age: 54 years

(18-90)• 48.8% with

Tetraplegia

The aim of the study was to test validity of the modified SNST-2

SNST-2 (Nurse) SNST-2 (Dietitian)SNST-1 Low Medium High At risk Low Medium High risk At risk

Low 58 2 0 2 60 1 0 1Medium 8 13 0 3 19 0High 0 1 3 0 0 4At-risk 8 17 3 23Sensitivity 87.9% 95.2%Specificity 89.5% 95.8%PPV 96.7% 98.4%NPV 68% 88.5%κ 0.679 0.89495% CI 0.508 to 0.851 0.791 to 0.996

PPV: positive predictive value; NPV: negative predictive value

1: Wong S et al (2012) Brit J Nutr 108, 918-923.2: Wong S et al (2012) Eur J Clin Nutr; 66, 382-387,3: Landis JR & Koch GG (1977) Biometrics 33, 159-174.

The authors would like to thank the patients and staff from the Spinal Cord System of Care Programme at the National Rehabilitation Hospital, Dun Laoghaire, Co Dublin, Ireland for facilitating the study. We would like to thank Anthony Twist, Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, UK and Philippa Bearne, Salisbury District Hospital, Salisbury, UK

References:

Acknowledgement:

SNST-1 SNST-2 SNST-2

N=8948.8% with tetraplegiaMedian age : 54 years (18-90)35.9 % female , 63.1 % male.