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“Is malnutrition screening by nurse practitioner using albumin levels more accurate in diagnosing malnutrition in patients ages 70 and older compared with a routine physical exam for early detection and treatment of malnutrition.”

Evaluation plan Outline

Introduction and Background

Malnutrition can weaken the immune system and increase health risks among older adults whose risk is higher than their younger counterparts. Malnutrition is a health condition characterized by eating insufficiently, lack of the right nutrients in the body, or failure to absorb and use food that one eats by the body. As such, malnutrition screening is vital in older adults to ensure proper measures are taken to combat their nutritional status. Such should be conducted using appropriate screening tools like measuring albumin levels, routine physical examination, and malnutrition universal screening tool, among others (Young et al., 2013).  While older adults have a high prevalence of long-term health conditions, they more vulnerable to malnutrition, and treating this condition can improve quality of life, general health status, and reduce healthcare costs. The study will take place at the Bassano Health Center in Canada.

Evaluation Plan Goal

Using the albumin levels and routine physical exam to detect and treat malnutrition are the primary screening tools used to assess nutrition status in older adults. Evaluating the validity and accuracy of the two methods over each other is critical to determine the most appropriate for older adults at risk of malnutrition.  The purpose of this evaluation plan is to compare which approach is more accurate in malnutrition screening between using albumin levels and routing physical examination in diagnosing malnutrition in patients aged 70 and above. The performance of the two tools will be assessed on their criterion validity and the estimated malnutrition risk.

Resources needed for the Evaluation

The population of study:  Patients of 70 years and above with chronic illnesses who had been admitted in the hospital at a specific time between May 2017 and April 2019 (Kirsch et al., 2020)

• Consent forms – to obtain permission for malnutrition screening from the patients or their relatives
• Malnutrition screening tools – the tools include serum albumin testing kit and Short Nutritional Assessment Questionnaire to conduct a routine physical examination.
• Hospital outcomes – to evaluate in-hospital death, infection, and hospital stay for longer days (LOS), obtained from electronic patients’ records: Hospital infection, in this case, refers to infections acquired and diagnosed while at the hospital stay (Onokayeigho, 2019).
• SPSS statistical software – to compare data results.

Program activities (List (bullet points) and describe the activities to be undertaken

• The patients will sign the consent form, while those cognitively impaired will have their forms signed by close relatives.
• For routine physical examination (Short Nutritional Assessment Questionnaire), the following information will be assessed (Young et al., 2013).
• The patient or relative will be asked questions regarding the dietary intake to assess the quality. Such will help to understand the cooking methods, portion sizes, and eating patterns, and drinks taken (Young et al., 2013).
• A recent decrease in food intake due to loss of appetite or chewing difficulties – to indicate future development course and the probability of the condition worsening.
• Weight loss in the last months – to assess weight loss greater than 3 kg, the patient does not know, weight loss between 1 and 3kgs or no weight loss reported. To indicate historical development and assess the stability of the condition.
• Mobility level – is the patient bed or chair bound, is the patient able to rise out of bed or chair but cannot go out, or the patient can go out.
• Disease severity which could prompt deterioration of the nutritional condition. Such will be coded as ICU – acute (A) and non-acute (B)
• Blood samples will be obtained and tested in the clinical laboratory to determine albumin levels.
• Determining body mass index which indicates disease risk.

Measuring variables (how the Evaluation will be measured)

The patients will be defined at malnutrition risk if the following conditions are present:

• If body mass index (BMI) is estimated at <18.5 kg/m²
• If the albumin concentration is (p<0.001), the patient is at high risk
• Weight loss of >10% in recent months.

Moderate risk patients will be identified as those with:

• Bodyweight loss of 5-8% in the last six months
• A cut off point BMI of >60 (Power et al., 2018).

Importantly to note, patients with the acute illness have low concentrations of albumin with the high risk of malnutrition and hence;

• BMI of <18.5kg/ m² indicates an underweight patient
• BMI of 18.5 – 25 kg/ m² shows an average patient
• BMI of >25kg/ m² indicates an overweight patient.

A low level of albumin may be a result of recent chronic disease or inflammation and may temper with the malnutrition screening results. If either of the screening tools indicates the presence or absence of malnutrition condition independently, it is preferred as the more accurate as of the other. The assumed consensus is that average albumin level should range between 35 and 50 g/l (3.5 – 5.0 g/dl) (Onokayeigho, 2019).

Targeted outputs (highlight the targeted outputs)

The targeted outputs in this evaluation plan are mean and standard deviation (SD) of albumin values and routine physical exam results. To assess the accuracy of each screening tool for malnutrition, the results of the variables will be recorded in the following table.

Short-term patient outcomes

The evaluation plan entails determining both short and long term patient outcomes. Some of the short-term outcomes include:

• To determine the length of hospital stay for patients at risk of malnutrition and record comorbidities.
• Assess the albumin levels within 24 hours of admission.
• To assess the stability of the body mass index in the last 48 hours.
• To determine the predictive validity of each tool for the length of stay in malnutrition patients.
• To predict long term mortality within four days.

In this case, the patients with a BMI score of >3 will be recommended for special nutrition care (Power et al., 2018).

Long-term patient outcomes

The long-term outcomes include:

• To determine long-term health conditions imposed by the risk of malnutrition
• To determine the death rates of patients whose albumin levels were boosted compared to those whose physical examination was regulated.
• To assess the changes in BMI for the last six months.
• Assess the rate of body weight loss in the last four months.
• Determine the possibility of any chronic diseases that could increase the risk malnutrition
• To assess the effectiveness of a particular tool in determining the patients’ nutritional status.
• To determine the effectiveness of a screening tool in predicting the clinical outcomes of a patient
• To assess how a particular instrument is effective in determining nutrition status in older adults than the other (Dwyer et al., 2019).

Conclusion

The evaluation plan seeks to compare the accuracy of using albumin levels and routine physical examination for early detection and treatment of malnutrition in older patients. The assessment is based on patients admitted to Bassano Health Center between 2017 and 2019. The electronic records will be used to obtain patient information.  Comparing the accuracy of both short and long-term outcomes provides the basis to assess the accuracy of one screening method over the other. Nonetheless, considerations will be made for patients with chronic diseases while using the albumin screening tool.

References

Dwyer, J. T., Gahche, J. J., Weiler, M., & Arensberg, M. B. (2019). Screening Community-Living Older Adults for Protein Energy Malnutrition and Frailty: Update and Next Steps. Journal of Community Health, 1-21.

Kirsch, R., Matthews, K., & Williams, V. (2020). Using Global Criteria to Detect Malnutrition: Application in the Disease States. Nutrition in Clinical Practice, 35(1), 85-97.

Onokayeigho, E. (2019). Older Adults and Health Maintenance (1). The Catholic Voyage: African Journal of Consecrated Life, 10(1).

Power, L., Mullally, D., Gibney, E. R., Clarke, M., Visser, M., Volkert, D., … & MaNuEL Consortium. (2018). A review of the validity of malnutrition screening tools used in older adults in community and healthcare settings–A Manuel study. Clinical Nutrition ESPEN, 24, 1-13.

Young, A. M., Kidston, S., Banks, M. D., Mudge, A. M., & Isenring, E. A. (2013). Malnutrition screening tools: comparison against two validated nutrition assessment methods in older medical inpatients. Nutrition, 29(1), 101-106.