Improving Early Assessment of Malnutrition in Hospitalised Patients; Prealbumin versus Routine Clinical Assessment

The aim of this research is to investigate whether the introduction of Prealbumin (PAB) screening within the hospital setting will improve identification of malnourished patients compared to current assessment of malnutrition. Routine clinical assessment: The Malnutrition Universal Screening Tool (MUST) was implemented into admission documentation at Waitakere and North Shore Hospitals in 2006. Various other clinical assessment practises for malnutrition still continue, but are not formalised into the patient care pathway. Methodological Procedures: The study will be conducted in two phases. The first observing routine clinical care, the second observing results of introducing the obligatory laboratory test. The standard clinical documentation has the MUST score as part of the Admission-to-Discharge Planner card, which is completed at first by the admitting doctor. Once transferred to the ward the nursing process should involve the completion of a second MUST score sheet. A score of 2 or more should generate a referral, which can be by any clinician, to the Nutrition Services for a formal nutritional assessment. Each ward has its own allocated Dietitian based there, and they use the PG-SGA to assess malnutrition.Through out the study the ward dietitians will record the following data set: NHI number; date admitted, ward, date referred to nutrition services, who referred, what screening tool triggered referral (MUST, PAB or other); MUST score, PAB level, Patient Guided Subjective Global Assessment (PG-SGA) score; subjective assessment as whether malnourished or not; degree of malnutrition (subjective) Mild/moderate/severe; whether discharged before being seen. Phase 1:No alteration will be made to routine malnutrition screening presently performed at North Shore Hospital. Patients admitted to North Shore Hospital Wards; Acute Medical 3 and 10,Acute Surgical 4 and 8, Acute Orthopaedic ward 7 over four weeks of February as baseline measure. Phase 2:All patients who have blood tests taken on admission to North Shore Hospital routinely have their remaining plasma stored for a further 24 hours. All patients admitted to North Shore Hospital Wards; Acute Medical 3 and 10,Acute Surgical 4 and 8, Acute Orthopaedic ward 7 4th March to 3rd April. Patients newly admitted to the test wards will be identified from the Patient Information System (PIMS). The plasma samples of these patients will be removed from storage and tested for PAB, Retinol Binding Protein and Transferrin. The PAB results will be immediately posted on the hospital patient result portal, Concerto. Abnormal results appear in red and already have the automatic message appearing on the screen when the result is opened; ”A low prealbumin may indicate a failure of hepatic synthesis as a result of malnutrition, hepatic injury or inflammation, or be due to loss of protein as in protein loosing enteropathy. A referral to the ward dietitian is appropriate". Patients who have not had a serum albumin measured will also have that tested and displayed on Concerto. Results of RBP and Transferrin will not be displayed on Concerto, but recorded for later analysis. If complete blood counts have been taken lymphocyte count result will be noted, but if Complete blood count (CBC) has not been taken within the previous 24 hours extra blood will not be drawn for this. Laboratory methods:An aliquot of plasma, from lithium heparin blood taken routinely at admission, will be stored at 4 degrees C. PAB will be clinically determined by immunoturbidimetric test at North Shore hospital. The normal reference range for prealbumin is 0.2- 0.3 g/L. Albumin normal reference range 38-52g/L 1-70 years and 36-50g/L >70 years. Transferrin reference range is 2.4-3.6 g/L.