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Original Paper
Ann Nutr Metab 2012;61:65–69
DOI: 10.1159/000338967
Nutritional Screening Model in Tertiary
Medical Unit in Croatia
Tajana Pavic a Neven LJubicic a Sanja Stojsavljevic a Zeljko Krznaric b
a Division of Gastroenterology and Hepatology, Department of Internal Medicine, Clinical Hospital Center Sisters
of Mercy, and
b Division of Gastroenterology, Department of Internal Medicine, University Hospital Center Zagreb,
Zagreb , Croatia
nutritional risk and the majority of them does not receive
nutritional support. More ef fort is needed to implement nu-
tritional standards in daily clinical practice.
Copyr ight © 2012 S. Karger AG, Ba sel
Introduction
Recognition of malnutrition in hospitalized patients
remains a significant component of inpatient care with
vast clinical and economic consequences. Multiple stud-
ies over many years have reported that the prevalence of
hospital malnutrition ranges from 20 to 50%
[1] . Despite
its high prevalence, which varies according to the meth-
odological, demographic and socioeconomic factors
[2] ,
malnutrition often remains undetected and untreated,
mostly due to the poor awareness and insufficient knowl-
edge of the attending hospital staff
[3] . Considering the
fact that nutritional care routines in Europe still remain
poor, one of the recently published conclusions of the Nu-
trition Day Audit Team was that establishment of proper
nutritional risk screening is an important starting point
for improving nutritional care in many European hospi-
tals
[4] . Nutritional screening has not been a part of the
daily routine in Croatian hospitals, nor was it included in
Key Words
NRS 2002 ⴢ Malnutrition ⴢ Nutritional screening ⴢ
Malnutrition, hospital
Abstract
Background/Aims: Malnutrition of hospitalized patients is
often undetected and untreated due to poor awareness and
insufficient knowledge of the attending hospital staff. Nutri-
tional screening has not been part of the daily routine in Cro -
atian hospitals. Our aim was to implement nutritional screen-
ing as part of the routine medical examination and to assess
the nutritional risk at admission for all hospitalized patients.
Methods: All patients hospitalized in departments of inter-
nal medicine in ter tiar y hospit als in Cro atia were scre ened at
entry using the Nutrition Risk Screening 2002 (NRS 2002). Re-
sults: Between October and December 2010, 1,696 patients
were screened and analyzed (948 males and 748 females).
329 (19.4%) had an NRS 2002 score 6 3 and were considered
to be at nutritional risk. An NRS 2002 score 6 3 was identified
as a significant predictor of the length of hospital stay (beta
coefficient = 0.06, p = 0.027) and fatal outcome (OR = 6.18,
p ! 0.001). Only 32.8% of malnourished patients received
some nutritional support. Conclusions: Every fifth patient
hospitalized in a general medical department in Croatia is at
Recei ved: January 10, 2012
Accepted a fter revision: April 20, 2012
Publish ed online: July 24, 2012
Tajana Pavic
Division of Gastroenterology and Hepatology, Department of Internal Med icine
Cli nical Hospital Center Sisters of Merc y
Vinogradska cesta 29, HR–10000 Zagreb (Croatia)
Tel. +385 1 3787 111, E-Mail tajana.pavic
@ gmail.com
© 2012 S. Ka rger AG, Basel
0250–6807/12/0611–0065$38.00/0
Accessible online at:
www.karger.com/anm
Pavic /LJubicic /Stojsavljevic /Krznaric
Ann Nutr Metab 2012;61:65–69
66
health care policies involving other medical institutions.
Until now, there has been no data about the prevalence of
malnutrition in the patient population admitted to ter-
tiary medical units in Croatia. Our aim was to implement
nutritional risk screening as part of the routine medical
examination for all patients admitted to a medical de-
partment in a general university-affiliated hospital in
Croatia. The other objective is to assess the nutritional
risk at admission for all hospitalized patients using the
simple Nutritional Risk Screening tool 2002 (NRS 2002),
as recommended by the European Society for Clinical
Nutrition and Metabolism (ESPEN) for use in hospital
settings
[5] . Most importantly, we aimed to sensitize the
medical community in Croatia and regional countries to
nutritional issues and highlight the need for proper nu-
tritional interventions despite limited health care fund-
ing.
Materials and Methods
Our program began in April 2010 after a staff meeting and a
presentation about the problem of malnutrition in a hospital set-
ting which included the introduction of the screening tool NRS
2002. During a 6-month period educational activities were held
on each of 8 divisions (gastroenterology a nd hepatology, hematol-
ogy, cardiology, nephrology, endocrinology, immunology and
pulmonology, intensive care unit and intensive cardiac care unit)
at the Department of Internal Medicine in the Clinical Hospital
Center Sisters of Mercy, Zagreb, Croatia, regarding different as-
pects of NRS 2002, measurement of height, weight and body mass
index (BMI). Special attention was given to this subject and pre-
sentations continued to be held for interns and residents on each
ward to assure accurate collection of medical data. From 1 Octo-
ber 2010, all hospitalized patients were screened for nutritional
risk using NRS 2002 within 24 h of admission.
This study includes results of the first 3 months of monitor-
ing
– all patients hospitalized from the 1 October to 31 December
2010 were included in the study. Patients admitted to day care
units or for observation after endoscopic or other invasive proce-
dures were excluded. Body weight was measured in light clothes
with a portable electronic scale (Seca, Germany), and height was
measured with a portable stadiometer (Seca 220 telescopic mea-
suring rod). Weight and height were used to calculate BMI
(kg/m
2 ).
For bedridden patients in whom exact measurements
could not be obtained, BMI was approximated according to the
mid upper arm circumference. If the mid upper arm circumfer-
ence was less than 23.5 cm, BMI was estimated to be less than 20
[5] . Nutritional risk screening was assessed using the NRS 2002
[6] . T his nutritional risk s core has been validated to identi fy those
patients who are likely to benefit from nutritional support. The
risk is calculated by adding the Nutritional Score of 0–3 to the
Disease Severity Score of 0–3 plus a score of 1 for patients of 70
yea rs or older. Patients with a score of 3 or more points were con-
sidered at nutritional risk and were eligible for nutritional sup-
port.
Statistical Analyses
Data distribution was analyzed with the Smirnov-Kolmogo-
rov test and appropriate parametric tests according to the ob-
tained results. Patient characteristics were given as means, stan-
dard deviations and proportions of categorical variables. Com-
parisons of quantitative data between the two groups were
performed by the independent t test, and differences in frequen-
cies were compared by Pearson 2 test. p values ! 0.05 were con-
sidered significant. The linear regression model was used for the
prediction of the length of the hospital stay. The normality of dis-
tribution was previously checked with the Kolmogorov-Smirnov
test. In some cases when standard deviation is rather high com-
pared to mean, median and corresponding interquarti le range are
better markers for distribution description. After having done
this ( lengt h of hospital st ay media n: 9 days, IQR: 5–12 days), it was
obvious that the median is similar to the mean value. We also
ma de a n a na lysis wi th t he log-tra nsf orm ed l eng t h of hos pit al stay,
and there were no major differences compared to the previous
analysis. Data were analyzed using statistical package IBM SPSS
Statistics release 19.0.0.1 (www.spss.com, Chicago, Ill., USA).
R e s u l t s
A total of 2,115 patients were admitted to the Depart-
ment of Internal Medicine during the 3-month period, and
1,696 patients were screened and analyzed (948 men and
748 women). Those who were admitted to day care units,
who were hospitalized briefly for observation after an in-
vasive procedure, or had missing data for any other reason
were not analyzed. 1,114 patients (65.7%) were admitted as
emergency cases. 909 (53.6%) patients were older than 65
years. Overall mortality rate was 5.3%. Mean length of stay
during investigation time was 9.4 days (SD 6.1). When as-
sessed according to BMI only 2.9% of patients were classi-
fied as malnourished according to the WHO recommen-
dations
[7] (BMI ! 18.5). On the other hand, 36.9% patients
were classified as overweight (BMI 1 25) and 25.2% of pa-
tients were found to be obese (BMI 1 30). The main char-
acteristics of the patients are given in table1 .
The screening tool NRS 2002 demonstrated that out of
1,696 patient, 329 (19.4%) were at nutritional risk at the
time of hospital admission. Most of these patients (55.3%)
were classified as having normal weight according to the
BMI (18.5–25). The nutritional risk frequency according
to the age groups is presented in figure 1 . Regarding the
leading diagnosis, the highest prevalence of malnutrition
in absolute number was found in gastroenterological and
pulmonary patients ( fig.2 ). When assessed relatively
within each subspecialty, pulmonary (42.7%), nephrolog-
ical (37%), hematological (36.5%) and gastroenterological
(22.2%) patients were found to be at g reater r isk of malnu-
trition. In the group of patients with nutritional risk, sig-
Nutritional Screening Ann Nutr Metab 2012;61:65–69
67
nificantly more had malignant compared to benign dis-
ease (45.6 vs.15.4%, p ! 0.001). Patients with nutritional
ri sk exhibited a longer le ngt h of hospital stay compared to
patients who were not at risk (mean 9 vs. 11.5 days, SD 5.5
vs. 8.2; p ! 0.001). The linear regression model identified
independent predictors of the length of hospital stay: NRS
2002 6 3 (beta coefficient = 0.06, p = 0.027), older age
(beta coefficient = 0.06, p = 0.015), malignant disease
(beta coefficient = 0.11, p ! 0.001) and emergency hospital
admission (beta coefficient = 0.23, p ! 0.001) ( table 2 ).
NRS 2002 score 6 3 was also identified as a significant
predictor of fatal outcome (OR = 6.18, p ! 0.001) ( table3 ).
Tab le 1. Patients’ characteristics according to NRS 2002
NRS 2002 <3 NRS 2002 ≥3
Total, n 1,367 329
Age, years 61.9815.4 72.2813.9
Gender (M/F), n 780/587 168/161
Weight, kg 82.3817.8 68.9816.3
Height, cm 171.389.2 168.9814.5
BMI 27.985.4 23.285.6
Subspecialty, n
Gastroenterology
Pulmonology
Cardiology
Nephrology
Hematology
Endocrinology
Angiology
Other
394 (28.8%)
103 (7.5%)
514 (37.6%)
66 (4.8%)
59 (4.3%)
98 (7.2%)
104 (7.6%)
29 (2.1%)
112 (34.0%)
77 (23.4%)
42 (12.8%)
39 (11.9%)
34 (10.3%)
9 (2.7%)
8 (2.4%)
8 (2.4%)
<45
4.0%
NRS 2002 ≥3 (%)
0
Age (years)
10
20
30
40
50
60
70
80
90
45–64
19.2%
≥65
76.8%
Fig. 1. Prevalence of patients with NRS ≥ 3 according to the ad-
mitting diagnosis.
Gastroenterology 34.0
010 20
Prevalence of patients with NRS ≥3 (%)
30 40
Pulmonology 23.4
Cardiology 12.8
Nephrology 11.9
Hematology 10.3
Endocrinology 2.7
Angiology 2.4
Other 2.4
Fig. 2. Prevalence of patients with NRS ≥ 3 according to the ad-
mitting diagnosis.
Tab le 2 . Predictors for duration of hospital stay: linear regression
Parameter Standardized
coefficients
beta
t p 9 5.0% CI for
beta
lower
bound
upper
bound
BMI 0.00 0.02 0.987 –0.05 0.05
NRS ≥3 0.06 2.22 0.027 0.11 1.79
Age 0.06 2.43 0.015 0.00 0.04
Malignancy 0.11 4.60 <0.001 1.19 2.95
Emergency admission 0.23 9.24 <0.001 2.32 3.57
CI = Confidence interval.
Tab le 3 . I ndependent risk factors for fatal outcome of hospitaliza-
tion identified by logistic regression
Parameter OR p 9 5% CI
lower
bound
upper
bound
Age 1.03 0.002 1.01 1.06
LOH 0.92 0.002 0.88 0.97
Malignancy 1.37 0.319 0.74 2.56
Emergency admission 14.44 <0.001 3.44 60.52
BMI 1.02 0.528 0.97 1.06
NRS ≥3 6.18 <0.001 3.45 11.07
OR = Odds ratio; CI = confidence interval; LOH = length of
hospital stay.
Pavic /LJubicic /Stojsavljevic /Krznaric
Ann Nutr Metab 2012;61:65–69
68
During this period only 32.8% of patients with an ap-
parent indication for nutritional intervention received
some kind of nutritional support, half of them (14.9%)
apparently being severely malnourished (BMI ! 16).
Discussion
Nutritional risk screening, representing an essential
first step in the structured process of nutrition care
[6] , is
not part of the routine in most European hospitals
[8] .
The Committee of Ministers of the Council of Europe
adopted a resolution on Food and Nutrition Care in Hos-
pitals in November 2003, recommending a wide range of
measures regarding implementation of nutritional care
in hospitals starting with nutritional risk screening
[9] .
NRS 2002 defines nutritional risk by the present nutri-
tional status, and risk of impairment of the present status
due to the increased requirements caused by disease-re-
lated stress metabolism. The predictive validity of NRS
2002 has been documented by applying it to a retrospec-
tive analysis of 128 randomized controlled trials, show-
ing benefit from nutritional support
[10] and two pro-
spective controlled trials
[11, 1 2] . Until now, nutrition
screening in Croatia has not been a part of a routine med-
ical examination. Consequently, no epidemiological data
have been available on the prevalence of malnutrition in
the adult general population requiring hospitalization.
The popu lat ion i nclude d in th is s tudy, hospita lized in the
largest department in the second-largest medical center
in the Croatian capital, is, in our view, a good representa-
tive of the general status in Croatian hospitals. The ter-
tiary health care network in Croatia includes six univer-
sity hospitals which manage the majority of all patients,
although not necessarily the most difficult ones. The uni-
versity hospital, in which this study was undertaken, cov-
ers an area of approximately 300,000 inhabitants. Al-
though one has to take into account regional differences
and specifics of each medical specialty, the results of a
general medical department with a large number of hos-
pitalized patients per year (with geriatric and oncology
patients within 8 divisions mentioned earlier), such as
ours, reflects adequately the incidence of disease-related
malnutrition among medical patients in Croatian hospi-
tals. According to NRS 2002, the prevalence of malnutri-
tion on admission to the hospital in our study was 19.4%.
This agrees with previous findings that a significant pro-
portion of hospitalized patients are undernourished or at
nutritional risk at admission
[13 –19] . According to an-
thropometric measurements McWhirter and Penning-
ton [13] found that 40% of surgical and nonsurgical pa-
tients were undernourished on admission, and Edington
et al.
[15 ] reported a 20% incidence of malnutrition which
was associated with an increased length of hospital stay.
In a comparative study by Naber et al.
[14] prevalence of
malnutrition in nonsurgical hospitalized patients at ad-
mission was 45% according to Subjective Global Assess-
ment (SGA), 57% according to the Nutritional Risk Index
and 62% according to the Maastricht Index; the severity
of malnutrition in the patients predicted the occurrence
of complications during their hospital stay. In the Ger-
man hospital malnutrition study malnutrition was re-
ported in 27% of patients according to SGA and associ-
ated with an increased length of hospital stay; higher age,
malignant disease and major comorbidity were found to
be independent risk factors
[16] . Three studies assessed
malnutrition on admission by NRS 2002. A large Turkish
study reported an incidence of 15% in the overall hospital
patient population
[17] . The results of the Swiss study on
32,837 patients admitted to internal medical depart-
ments detected an incidence of 18.2%, which resembles
most our study criteria and results
[18] . In an interna-
tional multicenter study in 26 hospital departments
32.6% of patients were defined as ‘at risk’ by NRS 2002
and had more complications, higher mortality and longer
lengths of stay tha n ‘not at risk’ patients. The authors con-
cluded that components of NRS 2002 are independent
predictors of poor clinical outcome
[19] . Our results (34%
of malnourished gastroenterological patients) support lo-
cal data on gastroenterolog y inpatients in a tertiar y med-
ical unit in Zagreb in which malnutrition, using the SGA,
was reported in 38.6% of patients
[20] . It is well known
that advanced age predisposes institutionalized subjects
to nutritional deficits
[21] . Our findings indicate that nu-
tritional risk increases with age. In those who were under
65 years of age the risk was found in 7.8%, while in those
over 65, nutritional risk was detected in 22.2%.
Not surprisingly, higher BMI was found to lower the
odds for malnutrition; nevertheless, this fact has to be
taken cautiously. BMI has been used to estimate an excess
or deficit in body weight, but it lacks precision in mea-
surement of body composition, which has been shown to
be clinically important in many contexts
[22] . Another
condition associated with obesity is sarcopenia, which
combines the health risks of obesity and depleted muscle
mass in a predominantly elderly population
[23, 24] . In
our population obesity showed no independent predic-
tive value for short-term survival.
NRS 2002 proved to be a simple, practical and reliable
screening method. During the initial training period,
Nutritional Screening Ann Nutr Metab 2012;61:65–69
69
only a few participants (mainly physicians and nurses)
were familiar with the NRS 2002; nevertheless, all were
able to implement successfully the screening tool in their
everyday practice. The nutritional-risk assessment train-
ing has become a part of the obligatory intern and resi-
dent educat ion in our institution. Emphasis shou ld be put
on the fact that nutritional screening has not only been
part of a study, but it has been implemented as a routine
procedure, in the hope that other institutions in Croatia
will also adopt it, based on our experience. The fact that
only 32.8% of patients assessed as being at nutritional risk
received nutritional support underlines the necessity for
further sensitization of medical staff regarding this prob-
lem and proves the importance of the goals achieved; one
of them is the introduction of the NRS 2002 screening
tool as a standard measure in the assessment of patient
medical status.
Conclusion
Every fifth patient hospitalized in a general medical
department in Croatia is at nutritional risk but only a
third of them receive nutritional support. Implementa-
tion of nutritional risk screening as a routine should be
the first step towards improving the awareness of medical
professionals regarding necessary nutritional interven-
tions.
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