老師 : 陳慧君老師學生 : 郭雅婷 陳冠恩

報告日期 : 2012/12/28

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Purpose

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In order to improve validity of NTUH nutrition screen tool, the first purpose of this project was to compare the difference of high-risk rate for malnutrition between international nutritional screening tools and NTUH nutrition screening tool used currently. Then, the second purpose was to evaluate the sensitivity and specificity of NTUH tool.

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Materials and

Methods

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Total subjects : 41 patients (16 men ， 25 women)

Duration: 2012/9/20 ~ 2012/11/1

Timing : Admission within 24 hours

Condition :Age > 18 y

The ward types: From

5Materials & Methods

Family Medicine 6A

Internal Medicine gastrointestinal

13A

Cancer (Breast cancer) ＆

surgical gastrointestinal 8A

Digestive tract 13B

Nutritional screening tools:

(1) Malnutrition Universal Screening Tool

(MUST)

(2) Nutritional Risk Screening 2002

(NRS 2002)

(3) NTUH malnutrition screening tool.

6Materials & Methods

Overall risk of malnutrition is established as presented in Table 1.

7Materials & Methods

放一張 MUST 篩檢表的圖

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Nutritional intervention

Nutritional risk is established according to the rating in Table 1.

9Materials & Methods

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If total score ≧3Nutritional

intervention

1. 疾病類別 2. 進食量 <50% or NPO≧ 3 days Diarrhea : 3 次 / 日 ≧ 3 days BMI < 18 or BMI > 30 病人自覺 1mo 內體重有無下降 3. 項目≧ 2

直接放圖講解

11Materials & Methods

If Score ≧ 2

Select the disease

To judgment the patient's condition

Nutritional intervention

Table 1. Malnutrition cut-points12

Screening tool Points Nutritional Status/risk

Malnutrition Universal Screening Tool

(MUST)

0 Low risk of malnutrition

1 Medium risk malnutrition

2 High risk of malnutrition

Nutritional Risk Screening 2002(NRS 2002)

0 No risk

1-2 Low risk

3-4 Medium risk

≧ 5 High risk

NTUH malnutrition screening tool

0-1 No risk

≧ 2 High risk

Materials & Methods

Nutritional intervention

Since there is no gold standard for patients we decided to calculate a combined index as a reference tool.

Malnutrition Cut-point: if the patient is evaluated at risk of

malnutrition according to at least two out of three pre-mentioned tools, this patient was categorized as malnutrition in the combined index classification.

13Materials & Methods

chi squared test:

It is used to compare malnutrition rate between different nutritional screening tools.

14Materials & Methods

The combined index was considered the criterion of true malnutrition.

nutritional tool

combined index

A √ √

B √

C √

D

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specificity = D

(C+D)

sensitivity =A

(A+B)

Malnutrition patients by both the nutritional tool and the combined index

Malnutrition patients by both the nutritional tool and the combined indexMalnutrition by the combined index but

not from the nutritional toolMalnutrition by the combined index but

not from the nutritional toolMalnutrition by the nutritional tool but

not by the combined indexMalnutrition by the nutritional tool but

not by the combined index Not malnutrition either by the nutritional screening tool or by the combined index Not malnutrition either by the nutritional screening tool or by the combined index

Result

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Table 2.

Evaluated data N =41

Sex

Men

Women

Age

(mean ± SD )

Age 65y≧BMI (kg/m2)

(mean ± SD )

16 ( 39% )

25 ( 61% )

62.1 ± 15.2

19 ( 46.3% )

22.3 ± 3.3

17Patient characteristicsResults

疾病名稱 人數 百分比糖尿病慢性腎病惡性腫瘤COPD

中風合併吞嚥困難肝硬化消化道手術嚴重腦部創傷骨髓移植髖骨骨折其他

12

3

26

1

1

5

2

0

0

0

0

29.3%

7.3%

63.4%

2.4%

2.4%

12.2%

4.9%

0.0%

0.0%

0.0%

0.0%

18Table 3. Cause of Admission

N = 41 NRS 2002 MUST NTUH Combined index

營養不良人數( 百分比 )

10

(22.0%)b

11

(26.8%) b

5

(12.2%) a

8

(19.5%)

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Table 4.

NRS 2002 ＆ MUST

NRS 2002 ＆ NTUH

MUST ＆ NTUH

P value 0.716 0.004 0.017

Results

P 值 < 0.05 具有顯著的差異

病床種類 人數 營養不良人數 百分比

6A 10 6 14.6%

7B 1 0 0.0%

8A 18 2 4.8%

13A 7 0 0.0%

13B 5 0 0.0%

Total 41 8

20Results

人數 營養不良人數

百分比

過輕 ( < 18.5) 7 4 9.8 %

適中 (18.5 ~ 23.9) 20 3 7.3%

過重 ( 24 ~ 26.9 ) 13 1 2.4%

肥胖 ( >27 ) 1 0 0%

Total 41 8

21Results

敏感度 : NRS 2002 > MUST > NTUH

精確度 : NRS 2002 > NTUH > MUST

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NRS2002 MUST NTUH

敏感度 80 72 62.5

精確度 94 91 92

Results

Discussion

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1. 造成台大篩檢表營養不良篩檢率偏低的因素有哪些 ?

(1)評估項目裡未將疾病嚴重度列入分數計算中。

(2)與其他篩檢表比較下發現 , 病人或家屬對於 < 體重下降 > 較無自覺 !

(3)因為 NTUH 表中的 4 項篩選結果在 NRS2002 和MUST 中都占有比較多的分數 , 可是 NTUH 須同時符合 2 項以上才歸類於營養不良 , 所以營養不良率會偏低。

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2. 建議增加哪些項目來提升台大營養篩檢表的敏感度和精確度 ?

A: (1) 將各項疾病嚴重度列入評分 ( 如下頁範例 )

(2) 建議將 < 病人自覺最近 1 個月內體重有無明顯變化 > 改為

→1 個月內體重下降幅度 (≦5% , 5-10% , ≧10%) 給予不同程度的分數。

(3) 若將需營養介入的判定點由≧ 2 項改為≧ 1 項 , 則營養不良篩檢率便會接近 NRS2002 與 MUST 。

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各項疾病嚴重度評分表 – NTUH版

嚴重度 疾病嚴重度

輕度(1 分 )

糖尿病、慢性腎病、肝硬化、髖骨骨折、慢性阻塞性肺癌、惡性腫瘤

中度(2 分 )

消化道手術、中風合併吞嚥困難

重度(3 分 )

嚴重腦部創傷、骨髓移植

參考自 NRS 2002 疾病嚴重度評分表

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3. 為何 13A 和 13B 的營養不良率為 0 ?

A: 抽樣人數不足

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總人數 營養不良人數 年齡 > 65 歲 BMI

6A 10 674.1 ± 20.5 90% 21.5

8A 18 251.8 ±

8.3 11% 22.6

13A 7 066.7 ± 16.7 43% 22.6

13B 5 074.0 ± 11.7 80% 23.5

4. 評估病人營養風險時判斷的優先順序 ? ( 例 :BMI / 體重流失 ( 幾個月內 ?) / 進食

量 )

A: 以嚴重度高者為優先評分標準

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嚴重度 BMI 體重流失 進食量

輕度 >20.53 個月內體重流失 > 5

%50 – 75 %

中度 18.5 – 20.5 2 個月內體重流失 > 5

%25 – 50 %

重度 < 18.5 1 個月內體重流失 > 5

%< 25 %

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