BACKGROUND 44% 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. OBJECTIVE The aim of the study was to test validity of the modified SNST-2 Conclusion Malnutrition 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. METHOD Baseline 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) RESULTS The 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’Connor 1 , Eimear Smith 1 , Sajimon Cherian 1 , Siobhan Carrigg 1 & Samford Wong 2 1 National 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 NUTRITION RISK 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 * 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/m 2 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/m 2 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/m 2 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/m 2 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 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 Assist with feeding if needed 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 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 1 Medium 8 13 0 3 19 0 High 0 1 3 0 0 4 At-risk 8 17 3 23 Sensitivity 87.9% 95.2% Specificity 89.5% 95.8% PPV 96.7% 98.4% NPV 68% 88.5% κ 0.679 0.894 95% 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=89 48.8% with tetraplegia Median age : 54 years (18-90) 35.9 % female , 63.1 % male.