Adult Malnutrition Screening & Nutrition Intervention Pathway

Why Screening Matters

Malnutrition affects up to 30% of adults admitted to hospital and is linked to higher infection rates, longer stays, increased readmissions, and mortality. Early detection through systematic screening enables timely nutrition interventions, improves outcomes, and reduces healthcare costs.

Screening Tools

Several validated instruments are available. The most widely used in acute and community settings are:

• MUST (Malnutrition Universal Screening Tool) suitable for all adult settings; uses BMI, weight loss, and acute disease effect.
• Mini Nutritional Assessment Short Form (MNASF) designed primarily for older adults.
• Subjective Global Assessment (SGA) a clinicianbased tool that incorporates medical history and physical exam.

Whichever tool is chosen, it must be applied within 24hours of admission or first contact, repeated at regular intervals (e.g., weekly in hospital, every 36months in community), and recorded in the patients medical record.

Screening Process

Nutrition Assessment

When a patient is flagged as medium or high risk, a registered dietitian (RD) or nutrition support clinician conducts a comprehensive assessment, including:

1. Detailed dietary history (24hour recall, food frequency).
2. Anthropometry (weight, height, midupper arm circumference, skinfolds).
3. Biochemical data (albumin, prealbumin, CRP, electrolytes).
4. Clinical assessment (muscle mass, edema, functional status).
5. Identification of barriers (cognitive, financial, cultural).

The outcome is a nutrition diagnosis (e.g., Inadequate protein intake) and a set of measurable nutrition goals.

Intervention Pathway

1. Goal Setting

Goals should be Specific, Measurable, Achievable, Relevant, and Timebound (SMART). Typical objectives include:

• Achieve 5% weight gain in 24weeks for underweight patients.
• Increase protein intake to 1.2g/kg body weight/day.
• Maintain serum albumin within normal range.

2. Choose the Intervention Modality

Interventions are tiered according to severity:

• Dietary counseling education on food choices, meal planning, and portion sizes.
• Oral nutritional supplements (ONS) highenergy, highprotein drinks or fortified foods.
• Enteral nutrition (EN) tube feeding when oral intake is insufficient or unsafe.
• Parenteral nutrition (PN) intravenous feeding for patients with nonfunctional GI tract.

3. Implement the Plan

Key steps include:

1. Prescribe the chosen modality in the EHR with clear dosage and duration.
2. Provide written and verbal instructions to the patient/caregiver.
3. Coordinate with nursing, pharmacy, and food services to ensure delivery.
4. Monitor tolerance (e.g., GI symptoms, aspiration risk).

4. Monitoring & Evaluation

Reassessment occurs at predetermined intervals (usually weekly in hospital, monthly in community):

• Weight & BMI
• Intake records (calories, protein)
• Blood markers (if indicated)
• Functional outcomes (handgrip strength, walking distance)

If goals are not met, intensify the intervention or refer to a specialist nutrition support team.

5. Discharge Planning & Continuity of Care

Before discharge, the RD provides a documented nutrition care plan that includes:

• Recommended diet and supplement regimen.
• Followup appointments (outpatient dietitian, primary care).
• Community resources (meal delivery services, support groups).

Clear handover communication prevents gaps in care and reduces readmission risk.

Roles & Responsibilities

Quality Improvement & Auditing

To sustain an effective pathway, institutions should monitor performance indicators such as:

• Screening compliance rate (% of eligible patients screened within 24h).
• Referral timeliness (average time from highrisk screen to dietitian assessment).
• Intervention uptake (percentage of prescribed ONS actually consumed).
• Clinical outcomes (average length of stay, readmission rates, mortality).

Data are reviewed monthly by a multidisciplinary nutrition committee, and corrective actions (training, protocol tweaks) are implemented as needed.

Key TakeHome Messages

• Screen all adult patients early and repeat regularly.
• Use a validated tool (MUST, MNASF, or SGA) and act on medium/high risk scores.
• Prompt, individualized nutrition assessment guides the choice of intervention.
• Document every step in the EHR and communicate across the MDT.
• Monitor progress, adjust the plan, and ensure smooth transition at discharge.

Further Reading

For detailed guidelines, see:

• British Association for Parenteral and Enteral Nutrition (BAPEN). Guidelines for Nutrition Support.
• European Society for Clinical Nutrition and Metabolism (ESPEN). Clinical Nutrition Guidelines.
• Academy of Nutrition and Dietetics. Nutrition Care Process.