A Pilot Study To Compare Nutrition Screening Tools: Customized Nutrition Screening Tool for Burn Patients (Nstb) and Malnutrition Universal Screening Tool (Must)

SUMMARY

Nutrition screening is an initial procedure in which the risk of malnutrition is identified. It plays a role in and can incur costs to health systems and patients. A customized nutrition screening tool for burn patients (NSTB) was formulated and the nutritional risk score of 22 patients from a burn unit in Bahrain using NSTB and MUST was compared. The samples selected were adult patients aged 18 years or over; pregnant and mentally retarded patients were excluded. Mean age of the total sample was 29.40, and 90.9% were male. Mean BMI was 26.96. The mean and SD for NSTB was 2.18±1.65, and for MUST 2.0±0.0. A difference in the nutritional screening risk score of the same group of patients was observed. In the MUST group, 100% patients were classified as high risk, while in the NSTB group 50% patients were classified as high risk, 36.36% as moderate risk and 13.63% as low risk respectively. The variability of the risk score in the NSTB group helps prioritize the patients based on high, medium, and low risk, whereas MUST categorizes all patients as high risk. A unique screening tool for burns will be more effective in determining risk patients due to tailor-made characteristics. Even though the data sample is small, the difference gives scope for extensive study.

Introduction

According to the National Institutes of Health, nutrition is the science that interprets the interaction of nutrients and other substances in food in relation to maintenance, growth, reproduction, health and disease of an organism. It includes food intake, absorption, assimilation, biosynthesis, catabolism and excretion.¹ With proper nutrition, specific symptoms can be avoided, consequences delayed, and health outcomes improved. Adequate nutrition is essential in preventing malnutrition or degenerative diseases, and achieving overall wellbeing. It is one of the vital components of a burn patient’s treatment. Severe burn injury can increase the metabolic rate of a patient up to two times their regular metabolic rate. These unique factors of burn patients demand attention in the nutrition care process. Therefore, inclusion of the nutrition aspect in the multidisciplinary approach to the treatment of burns is crucial. The Joint Commission mandated in 1995 that nutrition screening be undertaken within 24 hours of hospital admission, followed by a complete nutrition assessment if an at-risk patient was identified during the screening.² Nutrition screening identifies patients at risk of malnutrition upon admission, which can incur costs to health systems and patients.³ This study aims at developing and comparing a unique and appropriate tool for the burn unit.

The role of nutrition in burns is very important. According to Harbin and Nosin, the hypermetabolic responses to burns are more severe and persistent than to any other trauma.⁴ It further states that the severity of hyperdynamic, hypercatabolic response is related to total burn surface area (TBSA). The pathophysiology of burn has two phases - the ebb phase and flow phase where the intervention approach also changes accordingly.⁵ In the nutrition care process (NCP), nutritional screening helps predict the likelihood of a better or worse outcome due to nutritional factors and whether nutritional therapy is likely to affect it. It enables to recognize patients who are prone to malnutrition so that early dietary intervention can be applied. The majority of screening techniques include four fundamental questions: recent weight loss, recent food intake, current BMI, and disease severity.⁶ In the case of burn injuries, due to pain or trauma the patient cannot provide history, and relatives are frequently unavailable at the time of admission. Secondly, existing tools fail to include burn-specific variable risk factors such as total burn surface area, type of burn, area of the burn and delayed admission from time of burn to make it more appropriate for the burn population. Hence, a nutrition screening tool specific for burns was developed.

Current studies for nutrition screening in burns patients do not have sufficient data; a recent prospective cross-sectional study by Bang et al. compared the nutritional risk in pediatric burn patients using three different pediatric nutritional screening tools: STRONG kids, PYMS and the STAMP tool. They found a significant difference in nutritional risk score using the three different nutritional risk screening tools.⁷ As per another study published by Ortiz et al., a nutrition screening tool - nutrition risk in critically ill (NUTRIC) - was used for severely burnt patients on a mechanical ventilator in the ICU. They found that only in the group with a high NUTRIC score was there an increased caloric intake (per 20% increase) associated with lower mortality and faster time to discharge alive.⁸ The NUTRIC tool cannot be applied to all burn patients, but only to the burn ICU patient population. In patients with burn injury, nutritional risk should be assessed in conjunction with nutritional status and is not only related to preexisting nutritional status but also to factors that can impair patients’ ability to receive and utilize nutrients during their hospital stays, such as the severity of the burn, their age, and complicating conditions such as inhalation injury and organ dysfunction. The degree of inaccuracy is more in burn injury because of excessive fluid losses from wound and nitrogen excretion.⁹ According to Hart et al. (2000), the five most important variables affecting the extent of the catabolic response to severe burn were admission weight, percentage of TBSA burned, metabolic rate expressed as a percentage of projected metabolic rate, the time elapsed between burn and any procedures like primary excision, and burn sepsis.¹⁰ Extensive published literature on the development and clinical use of a standard burn injury-specific nutritional screening tool is lacking.

Hence, the primary objective of this pilot study was to design and validate a burn-injury specific nutrition screening tool. The second objective of the study was to compare the nutritional risk score of burn patients using the newly developed tool with that of a standard nutrition risk screening tool (MUST).

Materials and methods

The study was conducted at the Burn Unit of the Bahrain Defence Force Military Hospital between November 2015 to February 2017. The study was approved by the Ethics Committee of the hospital (Ethics Approval number- BDF/R&REC/2016-85). The Burn Unit of the BDF hospital consists of 12 beds (4 ICU and 8 ward). Patients admitted to the burn unit from November 2015 to February 2017 were included in this pilot study. The study population included burn patients older than 18 years, and excluded patients with mental disability and pregnant women.

Development of the nutrition screening tool

The Burn Unit of the hospital was newly established in February 2015, hence the dietetics department of the hospital decided to create a nutrition screening tool to prepare nutrition protocol for the burn unit, which would be equally applicable for burn patients in the burn ICU and the burn ward. The review of literature for developing the screening tool was collected by the dietetics department from the British Burn Association,¹¹ ANZBA Australian and New Zealand Burn Association,¹² and South African burn nutrition guidelines.¹³ Also journals and international policies of burn associations were taken into consideration to include risk factors unique to burn patients associated with nutrition. We followed the guidelines of the published study by Skipper et al. for designing and validating our screening tool.¹⁴ As per the study guidelines, the nutrition screening tool should be quick and easy to finish within 10 minutes. It should have the option to be completed by 1^st contact healthcare staff (treating nurse), and validated by comparing with a reliable or established screening tool. Moreover, the result should include only adults and the tool should be applied in the hospital setting. The number of participants should be more than 20. The tool was named nutrition screening tool for burn patients (NSTB).

Validation of the tool

The developed tool was sent for objective evaluation by burn specialist health professionals such as plastic surgery consultant, nursing director, nursing supervisors, and senior dieticians. Changes were made according to their recommendations, and the final draft consisted of 15 risk factors, including general and burn-specific factors. It was resubmitted for final approval by the burn unit team. The final approved version of the tool was used for this study (Table I).

Table I.

NSTB screening tool

Patient’s name:
Patient’s number:
Diagnosis:
% of burn:
Weight:
		Date of admission
S. No	Risk factors	Risk screening preference
1	Adult more than >20% TBSA	YES	NO
2	Adult >10% TBSA full-thickness burn	YES	NO
3	Patient with burns on face or hand	YES	NO
4	Patient with inhalation injury	YES	NO
5	Patient with concomitant trauma	YES	NO
6	Patient with preexisting medical disorders	YES	NO
7	Patient with delayed medical care after the incident	YES	NO
8	Patient with chemical or electrical burns	YES	NO
9	Patient with prior history of malnourishment	YES	NO
10	Patient with a poor appetite for more than 3 days	YES	NO
11	Patient with a history of nausea, vomiting, and diarrhea	YES	NO
12	Patient with dysphagia	YES	NO
13	Patient with a history of anemia	YES	NO
14	Patient with enteral or parenteral feed	YES	NO
15	Patient with unintentional weight loss more than 10% for past 3 months	YES	NO
Total Score

Implementation of the tool

The tool was introduced in the burn unit (ICU and the ward) after an orientation lecture. A series of lectures were given to the whole burn unit team; the topics covered were the importance of nutrition, nutrition screening in burns, introduction and implementation of the new tool (NSTB). Separate orientation classes were conducted for nurses in different batches to cover all the shifts as they are the patients’ first contact staff. It was explained to them that the screening tool should be filled in within 24 hours of admission. In the event the score is high risk, they should initiate an electronic report and, at the same time, call the assigned dietitian for nutritional intervention. If the patient falls under moderate risk, they should keep a 24-hour dietary recall form to monitor closely for three days. A few nurses were asked to fill out the checklist to see if there were any difficulties in filling out the tool.

Comparison of NSTB and MUST tools

A pilot study was done using the NSTB and MUST to compare the results. We chose the MUST screening tool as a comparator to our tool because it is one of the most widely used standard nutrition screening tools, as evident from the result of a published systemic review study of 32 nutrition screening tools, which showed that only MUST showed fair criterion on validity while the others did not score well.¹⁵ The Journal of Clinical Medicine published an article stating that Nutrition Risk Screening (NRS 2002) and MUST are reliable tools compared to others.¹⁶ Currently, MUST is the standard tool used in BDF hospitals, so it was chosen for the comparison. The data were collected on an excel sheet with gender, age, anthropometric data, and nutritional risk score. Both tools, MUST and NSTB, were used to evaluate the nutritional risk for the same set of patients to compare the difference in score.

Results

The guidelines for designing and validating the nutrition screening tool were applied as follows. We were able to finish within 10 minutes. An assigned nurse completed the NSTB tool within the first 24 hours for all patients then it was verified by the dietitian, and validated by comparing with the MUST - a standard nutrition screening tool. The samples included were adults and the number of participants was more than 20.

In this study, a set of adult patients from the Burn Unit comprising the Burn ICU and burn ward of the Bahrain Defence Hospital were screened using both nutrition screening tools - MUST (n=22) and NSTB (n=22). 59% of the total patients (N=13) were from the Burn ICU and 41% (N=9) were from the burn ward, as shown in Fig. 1. The total burn surface area (TBSA) ranged from minimum 5% TBSA to maximum 60% TBSA, as shown in Fig. 2. Statistical analysis was done by Microsoft Excel, the continuous data were expressed as mean and SD, and the qualitative data as numbers and percentages. The mean age of the total sample was 29.4, and the mean BMI was 26.96, as shown in Table II. The mean and SD for risk score by NSTB is 2.62+1.64, and for MUST it is 2.0+0, as shown in Table III. Both tools’ scores were plotted in a graph to see the difference, as shown in Fig. 3.

Fig. 1.

Number of patients in burn ICU and burn ward

Fig. 2.

Total burn surface area for patients

Table II.

Demographic characteristics of patients (n=22)

Demographic details	Value
Male	20 (90.9%)
Female	2 (9.1%)
Age (years)	29.40±10.04
Height (cm)	170.3±10.0
Weight (kg)	77.07±15.47
BMI (kg/m2)	26.96±3.39
Continuous data expressed as mean± SD

Table III.

Score comparison of MUST and NSTB patients

Score	MUST (n=22)	NSTB (n=22)
Mean score	2.0±0.0	2.18±1.65
(Min, Max)	2	(0-5)

Fig. 3.

Line graph of comparative score of NSTB and MUST screening tool

100% (N=22) patients in the MUST group were classified as high risk, but in the NSTB group there was variation in risk score. Out of the total 22 patients in the NSTB group, 50% (N=11) patients were classified as high risk, 36.36% (N=8) as moderate risk, and 13.63% (N=3) as low risk.

Discussion

Adequate nutritional support is the cornerstone of burn care from the initial stages to the conclusion of rehabilitation. Nutritional and metabolic complications associated with burn injuries necessitate the deployment of complementary interventions early. While several aspects of nutrition therapy are similar in significant burns and other critical care conditions, the pathophysiology of burn injury and its important endocrine, inflammatory, metabolic and immune alterations require specific nutritional interventions.¹⁷ Coffey et al. stated that total body surface area burns and depth of burns and co-morbid variables should be addressed in nutritional therapy to prevent secondary problems, promote wound healing, decrease lean body mass loss, and shorten hospital stay.¹⁸ The demand for factors specific to burn injury is an integral aspect of assessment and should be included in the screening. A nutrition screening tool will aid in identifying patients who are malnourished or at risk of malnutrition, allowing intervention to be organized accordingly. In the case of burn admissions, most of the time more than one patient is admitted at the same time, especially during a fire disaster. It would be helpful to implement a tool that can categorize patients into high, moderate and low risk at such crucial times so that nutritional intervention can be prioritized for high risk patients. It was observed that samples in our study when screened with MUST appeared to be high risk, but when screened with NSTB were either moderate or low risk and these samples were discharged in less than 10 days. Two of the patients had inhalation burns only so were in the ICU for observation and later got discharged within four days, as shown in Fig. 4. A study by Omidvari et al. stated that the use of a nutritional screening tool in the treatment protocol made staff more aware of factors related to nutrition, and they started recording the patient’s weight and other related details better.¹⁹ Clinicians need to understand how the tools have been validated and which population and care facility they are designed for, to determine if a particular tool is suitable for their institute and disease condition.⁸ There is no study stating that a nutritional screening tool is not a necessity in the nutrition care process. Therefore, high-quality studies are needed in the future to establish that it is valuable and that every specialized unit can modify a checklist for screening based upon unique factors. A study on nutritional guidelines of the BBA, EBA, DVG etc. burn associations showed a big gap in methodological issues that could improve in the future to enhance nutrition support for severely burned patients.²⁰ A similar study by Michelle Cork also stated that extensive research is needed to develop nutrition management guidelines for adult burn patients.²¹ The need was felt in our burn unit to establish a more accurate nutrition care process by developing a burn-specific nutrition screening tool. Moreover, it was observed in our burn unit that due to the nutrition screening policy, nurses were more keen and aware of the nutritional aspect of burns. It helped with teamwork, more efficient burn care practice among professionals, and better patient care quality. The NSTB tool can be implemented on multiple burn units in the future to assess its accuracy and to update with feedback from various burn centers.

Fig. 4.

Patients with inhalation burn and cutaneous burn

Conclusion

The study results indicated that the NSTB customized screening tool was more appropriate for categorizing burn patients as high, medium, and low risk. This segregation can help nursing staff and dieticians to prioritize patients in a resource constraint setting and in the event of mass casualties. The primary difference observed between the two tools is that NSTB considers burn-specific factors such as type of burn, total burn TBSA, burn etiology, location of burns, and other factors specific to nutrition like comorbidity, dysphagia, etc. In contrast, the existing tools do not capture these burn-specific factors. As per the factors mentioned above, it was considered that a nutrition screening tool for burns would provide better ascertainment of categorization of patients as high, moderate, and low risk, which is missing in MUST, and it gives scope for extensive study in future.

Limitations

The study, being a pilot study, included a lower number of patients; hence the study result cannot be concluded to establish the large-scale clinical applicability of the tool. An extensive multicenter study involving a larger patient population can help to confirm the validity of the NSTB tool. The number of risk factors listed in the NSTB tool is 15, but they can be shortened to reduce the time to complete the nutrition screening. Thus, work is in progress to categorize the elements which can be put together to save more time.