Development, validation and implementation of a program to detect malnutrition with NRS-2002 screening tool in patients of the oncology and hematology service

Background: Hospital malnutrition is an increasingly prevalent situation, which involves both an increase in health costs, a decrease in the life quality of those who suffer from it, and greater morbimortality. Nutritional screening is essential to detect malnutrition early and avoid these complications. Methods: NRS-2002 was performed on all patients admitted to the oncohaematology service, followed by the complete nutritional assessment (VN) to check its validity, which is repeated weekly to determine the degree of malnutrition during the hospital stay. Data were summarized using mean (standard deviation) and median (1st, 3rd quartile) for numerical variables, and absolute frequency (relative) for qualitative variables. To measure agreement between the two diagnoses, Cohen's Kappa was calculated for each visit. The level of association between the variables was measured using the Goodman and Kruskal measure. Results: 573 patients were admitted to the oncohaematology service, of which: 34.4% malnutrition, 44.7% risk of malnutrition and 20.9% good nutritional condition, on admission to hospital according to the NRS-2002. In patients admitted for more than a week, NRS-2002 was performed weekly and found that, upon discharge, they suffered: 34.4% malnutrition, 50.8% risk of malnutrition and 14.76% good nutritional status; also 12.3% worsen their nutritional status, 68.9% maintain it and only 18.9% improve it. 78.8% of patients with longer admissions require a VN. Conclusions: Our results suggest that the NRS-2002 is a simple and effective method for early malnutrition detection. It's important a nutritional monitoring during the hospitalization period, because the patients are susceptible to worsening of their nutritional status.


Introduction
The World Health Organization describes hospital malnutrition (HM) as a potential but preventable medical complication that influences the outcome of treatments. Hospitalized patients with malnutrition are more likely to prolong their hospital stay, as it is associated with an increased incidence of infections and delayed wound healing, among other consequences 1 . The European Association for Parenteral and Enteral Nutrition defines it as a state that leads to loss of muscle and fat mass, which can cause a decrease in mental and physical functional capacity, as well as a worse response to diseases, which is caused by a decrease in intake and/or assimilation of nutrients 2 . In addition, in cancer patients, immune suppression can usually be caused by malnutrition, surgical trauma, and the tumor's own immunosuppressive capacity 3 .
In the ill patient, malnutrition is more precisely called disease-related malnutrition (DRM) since both the disease and the relevant treatment are the main etiopathogenic factors 4 . DRM is damage caused by the stimulation of systemic inflammation by an underlying disease 2 . It is a multifactorial problem, involving both the disease and its associated factors and the problems resulting from hospitalization.
Furthermore, malnutrition has a direct effect on the evolution of the disease, since it has consequences for different organs and systems, worsening the evolution of the patient, increasing morbidity and mortality, reducing their quality of life, and, as a consequence, increasing health expenditure 4,5,6 . The DRM affects 30 million people in Europe and involves 170 billion euros per year.
In Spain, 1.7 million adults are at risk of malnutrition 7 .
The Global Leadership Initiative on Malnutrition (GLIM) recently convened experts from leading clinical nutrition societies to standardize the definition of malnutrition and diagnostic criteria for malnutrition. They define undernutrition as: "phenotypic criterion (loss of body weight, low body mass index (BMI) or reduced muscle mass) associated with an etiological criterion (reduced food intake/assimilation or inflammation/burden of disease)" 8 . likelihood of an unfavourable prognosis" and "to identify subjects who may benefit from nutritional treatment" 17 .
More specifically, in cancer patients, the importance of early detection of malnutrition, through appropriate screening implemented and validated in the hospital service, is reflected in facts such as that an early nutritional intervention could restore energy balance and improve the outcome of cachexia 18 .

Nutritional Risk Screening 2002 (NRS-2002):
Nutritional screening system recommended by ESPEN for inpatients. First, an initial screening is performed, which consists of 4 questions that are answered with yes or no (TABLE 1) 19,20,21 . According to the answers: If the answer is NO to all 4 questions, the test is repeated at weekly intervals.
If the answer is YES to any of the questions, the screening in Table 2 is performed: the final screening test is completed, which assesses the nutritional status and severity of the disease (TABLE 2).
In the final screening test, the patient is classified according to nutritional status and severity of the disease, with each score from 0 to 3, absent to severe, respectively. Both columns are then added together and a point is added if the patient is >70 years old. If the total sum is >3 points, there is nutritional risk, so nutritional support is necessary. On the other hand, if it is <3 points, since there is a probability of entering a risk situation throughout the admission, it is recommended to carry out the NRS-2002 weekly to avoid a case of malnutrition in the future.
The NRS-2002 screening test allows normonutrition patients to be discarded more quickly, as no anthropometric measurements are required, which is a great advantage. It is a test with high sensitivity, but low reproducibility 13,21 .
Although, according to another study, some other test such as PG-SGA seems more appropriate for identifying malnutrition in gynecological cancer patients 22 , our intention was to develop, validate and implement a screening tool throughout the oncohaematology service in a third level hospital, regardless of the type and location of the tumour. SAMPLE AND SAMPLING: 6 The nutritional screening test NRS-2002 and NA was performed on 573 patients, with an inclusion period of one year (June 2017-August 2018), 372 men (64.92%) and 201 women (35.08%), with an average age of 59.46 years, ranging from a minimum of 16 years to a maximum of 93 years, and a median age of 61 years. The oncology and haematology service was chosen for the pioneering implementation of the nutritional screening test and therefore for the study, because patients admitted to these areas are at very high risk of suffering from malnutrition, both on admission and during their stay in hospital. In addition, they are patients with a high time of admission, so it is easier to observe their evolution.
With regard to this study, the NA was performed in all cases, independently of the nutritional screening test, in order to assess its usefulness, as well as its efficiency and effectiveness.
Firstly, the computer support was designed, using a clinical management system for hospital patients, Orion Clinic, specifically through direct access to the Dietetics programme created to carry out the nutritional screening test.
Once the nutritional screening is done, an alert is generated to the nutrition service by means of a list that indicates the test score corresponding to each patient.

NUTRITIONAL SCREENING:
The nutritional screening test is the NRS-2002.
If the final test is positive (>3 points), an alert will be generated to the hospital's nutrition service and the NA will be performed.
Through this assessment, malnutrition is diagnosed and classified according to its degree of severity.
Finally, when malnutrition is diagnosed, the doctor in charge and the nutrition and endocrinology service will be informed so that they can take the necessary measures to prevent or treat HM.

COMPLETE NUTRITIONAL ASSESSMENT:
NA is performed when the nutritional screening test concludes that the patient is at risk of malnutrition or undernutrition. In this study, all patients are tested to ensure that the nutritional screening was performed correctly.
NA consists of anthropometric, biochemical, dietary, and clinical indicators of the patient.
Firstly, the personal data are completed, such as age, sex and the pathology he suffers from. These data are noted in the patient's medical history.
Secondly, the anthropometric assessment is performed, where we ask the usual weight; we weigh and measure the height, the triceps skinfold (TSF) and the mid-arm circumference (MAC); finally, we calculate the weight loss rate (WLR), the BMI and the mid-arm muscle circumference (MAMC).
Unintentional WLR as a form of nutritional depletion is commonly seen in aging, cancer, and many chronic diseases 23 .
Once all the data are complete, we compare the PT, CB and PMB data in the percentile table and observe in which percentile our patients are and, therefore, the type of malnutrition and protein depletion they suffer. In our study we measured body mass, height, TSF and MAC. With these data we have calculated the BMI and the MAMC with the International Society for the Advancement of Kinanthropometry method (ISAK) 24 .
The biochemical evaluation is extracted from the daily analyses carried out by the doctor in charge.
Urine samples may offer a valid alternative or a complementary addition to serum for nutritional metabolism analyses in large-scale clinical and epidemiological studies 25 .
In our study we looked at creatinine, lymphocyte and glomerular filtrate data because they are the only nutritionally relevant data that appear in all daily analyses.
With regard to the dietary indicators, first of all, the type of diet is observed and a 24-hour record is made, asking the patient or the accompanying person how much food was ingested at each intake.
The dietary indicators give information on both the amount of requirements covered and the composition of the diet. Something to keep in mind, since, for example, a lower intake of protein can be associated with more nausea 26 , and because although the foods consumed by patients with advanced cancer correspond largely to the typical foods consumed by healthy people 27 , it is the amounts that will determine to a greater extent the percentage of requirements covered.
The kilocalories and grams of protein of each intake are calculated and added up, calculating the total contribution in the diet. If the patient has any type of supplementation, either oral or by tube, the total intake is noted and calculated. The percentage of covered needs, both in terms of kilocalories and proteins, is then calculated using the following formula: (see Formula

Results
The agreement during visit 1 is moderate, with a value k=0.57, increasing progressively in visits 2, 3 and 4 to considerable agreement, with k-values of 0.63, 0.70 and 0.72 respectively ( In addition, patients with longer admissions (>1 week) were re-evaluated weekly. 68.86% of patients maintained their nutritional status throughout their stay in hospital, with no improvement or worsening: they remained at normal nutritional status, risk of malnutrition and undernutrition from the time they were admitted to hospital (7.38%, 31.97% and 29.51% respectively). On the other hand, 18.86% of patients improve their nutritional status upon discharge from hospital: they go from risk of malnutrition to normonutrition and from malnourished to risk of malnutrition (7.38% and 11.48% respectively). Finally, 12.3% of patients worsen their nutritional status during their stay in hospital: they go from normonutrient to risk of malnutrition and from risk of malnutrition to malnourished (7.38% and 4.92% respectively).
It can be seen that, of the 68.86% of patients who maintain their nutritional status, 61.48% are at risk of malnutrition or undernutrition, requiring a NA. If we add to this the 12.3% of patients who worsen their nutritional status during their hospital stay, we conclude that 73.78% of the total patients who are admitted to hospital for more than one week require a NA, and, if necessary, extra nutritional support.
We can see that, at hospital discharge, 34.43% are malnourished, 50.83% at risk of malnutrition and 14.76% with good nutritional status, so that 85.26% of patients need some kind of extra nutritional support.
If we apply the GLIM criteria, we have found that 100% of the patients present an inflammatory load due to the tumour disease they suffer, as well as 26% of the patients ingest ≤50% of the energy requirements for >1 week and 82.4% of the patients ingest ≤100% of the requirements for > 2 weeks. 100% of patients meet at least 1 aetiological criterion. On the other hand, with regard to the phenotypical criteria, 55.1% of the patients present a weight loss greater than 5%, 23.4% of the patients present BMI <20 Kg/m 2 and 54% of the patients with admissions greater than a week's duration present a decrease in muscle mass measured by the MAMC. 72.3% of the patients present at least 1 phenotypic criterion and 100% of the patients present at least 1 etiological criterion, so it is concluded that 72.3% of the patients studied present malnutrition according to GLIM criteria.

Discussion
Gutiérrez et al. conducted a study with a sample of 247 patients hospitalized in a second level hospital, finding that 42% of the patients were at risk of malnutrition in the first 24 hours after admission. In addition, they concluded that there was a significant association between nutritional risk and decreased food intake in the last week, as well as severity of illness, age and gender. On the other hand, a decrease in food intake increased the probability of presenting a nutritional risk by 6.67 In the implementation phase, they studied 1123 patients, finding that 19% were at risk of malnutrition according to the nutritional screening test. Of these, 77% were >70 years old. 27% had higher scores in the section on alteration of nutritional status, 27% in the section on severity of disease and 40% in both sections equally. 25% of the patients at risk according to the NRS-2002 were readmitted in less than 30 days and the mortality rate was 5%. On the other hand, in the consolidation phase, they studied 2527 patients: 15% were at nutritional risk. 73% were > 70 years old 35   On the other hand, the Global Subjective Assessment method (GSA) was also used by Moriana et al. to detect malnutrition in a third-grade hospital in Valencia, obtaining that 50% of the 197 patients studied were malnourished. The average stay of malnourished patients was longer than that of patients at risk of malnutrition and normonutrients, 13.5, 12.1 and 6.97 days respectively. The GSA correlated significantly with anthropometric and biochemical parameters of malnutrition 40 .
Sremanakova et al. assessed the risk of malnutrition in 727 patients hospitalized after a stroke using the MUST screening test, of the 1101 admitted to this service, meaning that only 66% of the patients were examined. Of these, 78.5% were at low risk of malnutrition, while 4.1% and 17.4% were at medium or high risk of malnutrition, respectively, which adds up to 21.5% of patients at medium to high risk of malnutrition and who should be monitored nutritionally, as they are more likely to have longer hospital stays and a higher risk of mortality (10.9% and 3.5%, respectively). Significantly, and despite the low prevalence of risk of malnutrition in these patients, almost 1/3 of the patients were not evaluated 41 .
Almasaudi et al. studied 363 patients undergoing surgery for colorectal cancer, assessing their nutritional status by means of the MUST test. The 21% of the patients presented medium-high nutritional risk. They found significant associations between the MUST test and subcutaneous adiposity, visceral obesity and skeletal muscle index. As well as longer hospital stay and shorter survival 42 .
For all these reasons, the importance of implementing a nutritional screening test that detects the DRM early when the patient is admitted to hospital has been sufficiently demonstrated.
As far as we know, our study is the first to show that the NRS-2002 nutritional screening test is a useful, valid and highly applicable tool for the early detection of malnutrition and, therefore, to act quickly, avoiding possible complications in an oncohaematology service in a third level hospital.