Early Nutrition Intervention

10 Oncology Nutrition Connection Summer 2010 The 7th Vital Sign: Implementing a Malnutrition Screening Tool at a Community Cancer Center Rhone M. Levin, MEd, RD, CSO, LD Oncology Dietitian St. Luke s Health System, Mountain States Tumor Institute Introduction There is no question that nutrition is a fundamental component in the care and treatment of oncology patients. Data demonstrate that an adequate nutritional status improves healing and recovery after surgery and other cancer treatments, tolerance to treatment, and even the response to treatment in some cancer types (1). Early oncology nutrition intervention, nutrition counseling, and appropriate provision of oral supplementation results in positive patient outcomes and is cost effective (2). Research supports the value of early intervention; the later oncology nutrition care is started, the more difficult it is to modify or improve a patient s nutritional status (3). Even mild weight loss is a predictive factor for malnutrition, and should be aggressively treated (4). Weight loss correlates with decreased performance status in a majority of tumor categories (5), and those who develop malnutrition are at increased risk for treatment delays, treatment complications, more frequent hospitalizations, and reduced key outcomes including quality of life (6). Yet, many cancer centers continue to care for oncology patients with limited or inadequate Registered Dietitian time (7). Malnutrition in Cancer Patients: Don t Ask, Don t Tell Over the past two decades, oncology treatment has moved primarily to the outpatient setting (8). As a result, oncology patients access to registered dietitians has changed. Cancer patients in outpatient settings do not have access to routine nutrition screening required by The Joint Commission (formerly JCAHO) for inpatients (9). A paradigm exists that if you don t ask about malnutrition, it isn t happening. Cancer center staff may perceive it is difficult to use RD services due to restricted hours or time delays between referral and patient consultation. This can lead cancer center staff to refer patients only when severely malnourished, thus providing crash and burn nutrition intervention, the least effective and most time consuming form of intervention. A negative cycle can develop: late identification of malnutrition increases risk of adverse effects of treatment and lowers quality of life, increases nutrition needs, and inhibits response to treatments. This negative cycle, when combined with lack of oncology RD time, makes it more difficult to obtain positive outcomes from nutrition intervention. Early Nutrition Intervention Incorporating a malnutrition screening tool into global oncology care is a comprehensive method to identify patients early in their nutritional decline (10). The malnutrition screening process should trigger appropriate referral to the oncology nutrition (RD) specialist, who can then implement Medical Nutrition Therapy before significant decline in nutritional status occurs. Oncology patients often experience a lengthy period of treatment and healing, which can lead to predictable side effects as well as unpredictable road blocks to adequate nutrition (11). By routine application of a malnutrition screening tool, staff are able to catch the moment when a patient is no longer able to compensate for the barriers the cancer or a cancer treatment s side effects impose (12). Proactive referral at the right time leads to effective use of oncology dietitian time and is more likely to protect nutritional status and patient quality of life. Nutrition screening for oncology outpatients is recommended by the American Dietetic Association (ADA): All patients diagnosed with or undergoing treatment for cancer should have a baseline nutrition screening to identify nutritional risks and deficits. (13). The Association for Parenteral and Enteral Nutrition (ASPEN) and the Oncology Nursing Society (ONS) support this position (14 16). Screening tools should be easy to use, standardized, rapid, noninvasive, and costeffective (17). The tool must be capable of identifying cancer patients who are malnourished, and those at risk of becoming malnourished. The ADA Evidence Analysis Library provides a comparison of parameters measured in several oncology screening tools (18). The ONS critically evaluated and recommended three malnutrition screening tools in 2007: Patient Generated Subjective Global Assessment (PG SGA) includes 17 data points and contains both screening and assessment criteria; Mini Nutrition Assessment (MNA) includes 18 data points and contains both screening and assessment criteria; and the Malnutrition Screening Tool (MST) includes 2 data points and is a pure screening tool (19). The 7th Vital Sign: Screening for Malnutrition Malnutrition screening addresses an important and often overlooked component of a cancer patient s quality of life (18). Implementing a malnutrition screening tool follows the same pattern as pain screening, the national effort that encouraged medical facilities to routinely inquire about and treat pain. Screening for pain became known as the 6th vital sign, following temperature, pulse, respiration, blood pressure, and

Oncology Nutrition Connection Volume 18 No. 3 11 oxygenation. The effort to recognize pain assessment as a component of vital signs addressed the significant impact that untreated pain has on quality of life. Just as importantly, routine malnutrition screening across the continuum of oncology treatment should become the 7th vital sign. A Community Cancer Center St. Luke s Health System is a community hospital system with hospital-based and freestanding cancer centers, called the Mountain States Tumor Institute (MSTI), located across Idaho. Food and Nutrition Services recognized that oncology patients at MSTI benefited from nutrition interventions provided by Registered Dietitians, but were unable to fully staff each site with an oncology trained dietitian. Over a two year period they worked to enhance oncology nutrition services and justify increased RD time. The Challenge Food and Nutrition Services primary goal was to define excellence in the oncology nutrition program and to provide consistent oncology nutrition services across all MSTI sites, within the setting of budget constraints amid an economic downturn. Usual Practices at Mountain States Tumor Institute Prior to initiating routine malnutrition screening, the oncology dietitians offered services to all patients, and no fees were charged for nutrition time. Two RDs job shared the largest clinic in order to provide daily nutrition services, and one RD covered 3 smaller centers, providing on-site nutrition service at least one day per week and phone consultation as needed. Staff worked to meet the needs of patients, focusing most of their efforts on high-risk diagnoses: head and neck, GI tract, Pediatric, hematopoietic cell transplantation, and concomitant treatment. Referral was by physician, NP, and RN, self-referral, or interdisciplinary rounds. On admission, a patient assessment and history included questions from the MST, however no further malnutrition screening occurred. Patients were offered a pre-treatment education program entitled Treatment Learning Class or TLC. The session included a discussion of treatment regimens, management of common side effects, and a general nutrition lecture. Each patient received the National Cancer Institute Eating Hints booklet as a resource. RDs spent a significant amount of time tracking their patients, checking in with them, monitoring their progress and charts, trying to catch the moment when a patient experienced nutritional decline and weight loss. Referrals were hit and miss, thus surveillance was obligatory and time consuming, with the net effect of being able to see fewer patients within the time constraints. The Community Cancer Center Clinics The Mountain States Tumor Institute is comprised of two large facilities (Boise and Magic Valley) and 3 smaller sites called Western sites (Meridian, Nampa, and Fruitland). A malnutrition screening tool was implemented at 4 of the sites (Boise and Western sites). The four clinics are geographically separated, but patients may receive treatments and supportive care from any of the clinics. Staff and patients travel distances to provide and access oncology care. At the time the malnutrition screening tool was implemented, three of the clinics were using electronic medical record MOSAIQ, while one clinic was still using a paper chart. (Continued on next page) The Answer Excellence in an oncology nutrition program was defined as: Use of a malnutrition screening tool appropriate for oncology populations Screening for malnutrition or risk for malnutrition, routinely and consistently, across all diagnoses and treatment regimens Access to an RD trained in oncology, ideally board certified or working toward certification (Certified Specialist in Oncology Nutrition or CSO credential) Use of Medical Nutrition Therapy Development of a culture of nutrition : cancer center staff members are trained and aware of the impact nutrition has on the healing process; and are encouraged and expected to refer patients who have nutrition concerns to the RD Staffing and Patient Categories Total Number of new MSTI patients: 2008 Boise, Meridian, Fruitland, Nampa Data 2078 (increase of 5% per year projected growth) Number of patients considered 725 (35%) Nutritional High Risk by diagnosis Number of medical oncologists / 9 medical oncologists pediatric medical oncologists 3 pediatric medical oncologists Number of radiation oncologists / 4 radiation oncologists number of radiation treatment machines 5 radiation treatment machines Number of gynecological oncologists 2 Number of nurse practitioners 5 Number of RD FTE for oncology services 2007-2008: 0.6 and some consulting hours 2008-2009: 1.5 2009-2010: 1.6 Number of RD FTE for oncology services 2010-2011: 2.2 proposed for next budget year

12 Oncology Nutrition Connection Summer 2010 Choosing a Screening Tool A literature search was performed, and validated oncology malnutrition screening tools were compared. To encourage acceptance of a screening tool into a busy clinic, the tool needed to be quickly and easily performed. The MST was chosen as the model. It is comprised of two components, one of which (weight) was already collected prior to each physician visit. The RDs developed a simplified version to reduce effort required by clinic staff, resulting in a screening tool with two components: the question have you been eating poorly because of a decreased appetite? and an evaluation of weight change. Any decrease in appetite, combined with any amount of weight loss, was considered a positive screen and required referral to the oncology dietitian. Staff Concerns The oncology nutrition staff agreed that patients would benefit from routine malnutrition screening, and acknowledged that the current system did not refer all patients early in their nutritional decline. Staff was concerned about managing additional workload generated by the malnutrition screening tool. After defining practices, staff agreed that chart review would be adequate intervention for some patients, while some nutrition assessments would be deferred if necessary. Staff also voiced concern about the validity of a simplified MST. Other screening tools have included assessment portions, which help identify patients with urgent needs and offers the ability to prioritize patient care for the RD. However, time constraints with nursing staff reduced the likelihood of implementation of any malnutrition screening tool that was cumbersome, lengthy, or time consuming. While the simplified MST might generate referrals that were false positives, the expertise and training of oncology dietitians would allow them to quickly identify patients who required a full nutrition assessment. We decided to use the easy and quick (simplified MST) screening tool and have the RD finish the screen by reviewing the chart before proceeding to a nutrition assessment (if indicated). This resulted in a collaborative screening process, one that depended on the nursing service to initially screen patients for criteria indicative of nutrition risk, but also depended on the RD, with her/his specialized nutrition expertise, to complete the screening. Oncology nutrition staff recognized that use of a malnutrition screening tool would eventually relieve them from the usual surveillance practices regarding patient weights and tolerance of treatment. This trade off would allow additional RD time to complete nutrition referral screening. Additionally, management recognized that nutrition intervention time required to address minor problems or mild side effects is significantly less than waiting until a nutrition issue has progressed and needs become more demanding. This was presented as a more effective use of RD time, and a means to enhance services to oncology patients. This also fulfilled a facility goal to seek out methods to work more efficiently while improving patient care. Clinic Approval A proposal was developed to collect data and analyze statistics pertinent to benefits of nutrition services in oncology patients as well as the effectiveness of malnutrition screening. After being approved by clinic administration, Champions were sought from all disciplines to review the proposal and identify potential barriers to success. The proposal was presented at clinical practice meetings and operations councils, and received feedback and approval from all sites. Procedures were developed, incorporating staff input. Information Technology was involved to update the electronic medical record. The Procedure The Clinical Assistant Personnel or CAP staff (certified nursing assistants) would apply the malnutrition screening tool at each doctor visit, when vital signs were obtained. The procedure was named the 7th vital sign to remind staff of the additional step in gathering data. CAPs would integrate appetite question as a part of a natural conversation at the time vital signs were collected and weight obtained. CAPs documented the answer to the appetite question in the electronic medical record, and if there was both a weight loss and decrease in appetite the CAP would send an electronic referral entitled weight loss screen to the dietitian. A training PowerPoint presentation was developed and presented at all sites for CAPs. Staff, including the CAPS, were educated about the significance of malnutrition in the oncology patient, allowed to ask questions about nutrition and the procedure, and encouraged to buy in to the process. A date was set for implementation. The Process or The Test A one-day data collection was completed to retrospectively assess the effect of using a malnutrition screening tool in the clinic. It was estimated that an additional 15% of patients would be referred to the RD on that day. Data collection: Initially, we were most interested in collecting data regarding the total number of new referrals generated by the malnutrition screening tool. Electronic referrals, as well as completion dates, were counted automatically. We tracked the total number of referrals by site, and subtracted the number of patients we were already following. We also documented the work that was deferred. Initial performance improvement data indicated an average increase in referrals to the RD of 40.5%. This did not mean the work load for full nutrition assessment and nutrition intervention was up 40.5%, but the surveillance of patients was nearly doubled. This data was used to request additional FTE hours. Lessons Learned and Things We Did Not Expect. Patients expressed appreciation for increased oncology nutrition surveillance and contact. Many patients considered to be at low risk for malnutrition in treatment had

Oncology Nutrition Connection Volume 18 No. 3 13 episodes of decreased appetite and weight loss that triggered a referral for nutrition intervention. We were able to document significant volumes of malnutrition that were present but had previously remained unaccounted. In retrospect, we would have benefited from a more comprehensive data collection prior to implementation, to fully recognize the volume of referrals that would ensue. Use of the electronic medical record (EMR) at the 4th MSTI site occurred soon after implementation of the malnutrition screening tool, which added to a stressful learning process. We observed variable application of the malnutrition screening tool by staff, requiring retraining and follow up. New awareness of patient difficulties with eating and malnutrition caused some staff to become alarmed, resulting in frequent and immediate requests for dietitian intervention. Some CAP and nursing staff felt a need to spend time addressing nutrition issues for patients instead of just referring patients to the RD. It was described as opening a can of worms. Some staff needed confirmation that this was exactly why we were collecting this information, and it was ok to just send the referral to the RD. Independently, the clinics began recording heights and weights in metric units the same month the malnutrition screening tool was implemented, which led to stress and lack of compliance with the new procedure. Development of a shortened nutrition assessment form in the EMR prior to implementing the malnutrition tool would have reduced the amount of RD time spent on documentation. Future Goals The oncology dietitians recognize the value that nutrition services add to the cancer center. Our goal is to continue to grow oncology nutrition services by supporting group education; offering survivorship classes and cancer prevention classes; providing community presentations on nutrition and cancer; and publishing monthly updates in a patient oriented e-newsletter. We also plan to continue to develop a culture of nutrition through formal and informal education of nursing, radiation therapists, physicians, and administrators via inservices, grand rounds, lunch and learns, sharing of pertinent nutrition related research articles, as well as the inclusion of nutrition discussions at tumor boards. Lastly, due to the geographic challenges, and limited RD presence on site at some clinics, we are implementing enhanced communication centers utilizing technology such as Skype, fax and teleconferencing equipment. These telephone booths for patients will allow the RD and other support services to provide personable intervention from a distance, while the patient is available on site at their clinic. Interview with Valerie Robenstein, RD, CSO, LD, Oncology Dietitian at MSTI What was your main concern regarding the implementation of a malnutrition screening tool at MSTI? I was concerned I would become overwhelmed by the increase in numbers of patients that needed to be seen. The fact that patients would be identified as needing RD intervention, but could not be added to an already overfilled schedule was stressful. I knew we needed to count referrals to show the need for more hours, but it was challenging. I knew I needed to let go of this. Estimated time to process the weight loss referrals? We estimate that about 50% of the patients require only a review of their chart, about 10 minutes per patient including documentation of the service. The rest may need phone contact, or even full nutritional assessment, which takes about 45 minutes per person. We have not yet given up all of the tracking and weight surveillance of high risk patients. Eventually, that change will free up more time for patient care. Were there any surprising referrals? I have had a couple of consults that I wouldn t have anticipated any nutrition concerns based on diagnosis or treatment regimen. What lessons have the RDs learned about implementing a malnutrition screening tool? Timing is important. But, I m not sure there is ever a good time. We needed to start it before budget proposals were initiated to give us the data to justify more FTEs. It may have been easier if we had some kind of nutrition assessment form already created in the EMR, to speed documentation. Also, we need to continue with nutrition education and encourage consistent use of the malnutrition screening tool with the staff. Some of our staff float in and out of CAP positions, and need reminders. What are the benefits you have seen? I have been surprised at the change in attitude from staff members. Some CAPS expressed concern that we were adding more to the work load than we actually were. Many CAPS have come to me and said that now they are used to it, it is nothing to ask about appetite and send a referral accordingly. I feel more comfortable knowing that all patients are being routinely assessed for malnutrition, and no one will fall through the cracks. Rhone Levin can be reached at levinr@slhs.org References: 1. Lammersfeld CA, Vashi PG, Gupta D, Grutsch JF, Burrows JL, Becker JD, Lis CG. 2003 ASCO Annual Meeting: The impact of changes in nutritional status on survival in advanced colorectal cancer. Proc Am soc Clin Oncol. 22:2003 (abstr 1251). Available at: http://www.asco. org/ascov2/meetings/abstracts?& vmview=abst_detail_view&confid=23& abstractid=101143. Accessed 7/17/10. 2. Isenring EA, Bauer JD, Capra S. Nutrition support using the American Dietetic Association Medical Nutrition Therapy protocol for radiation oncology patients improves dietary intake compared with standard practice. J Am Diet Assoc. 2007; 107(3):404 412. 3. Houge K, Jonnalagadda SS. Does nutrition intervention in cancer patients impact cost savings? Oncology Nutrition Connection. 2006;14(2):17 18. (Continued on next page)

14 Oncology Nutrition Connection Summer 2010 4. Berger V, Le Morzadec C, Cellier P, Tuchais C, Devla R, Pabot Du Chatelard P, Jadaud E, Lortholary A, Maillart P. 2003 ASCO Annual Meeting: Predicting malnutrition in cancer patients. Proc Am Soc Clin Oncolol 22:2003 (abstr 3046). http://www.asco.org/ascov2/meetings /Abstracts?&vmview=abst_detail_view &confid=23&absabstrac=102552. Accessed 7/17/10 5. Dewys WD, Begg C, Lavin PT. Prognostic effect of weight loss prior to chemotherapy in cancer patients. American Journal of Medicine. 1980;68:491 497. 6. Andreye HJ, Norman A, Oates J, Cunningham D. Why do patients with weight loss have a worse outcome when undergoing chemotherapy for gastrointestinal malignancies? European Journal of Cancer. 1998;34(4):503 509. 7. Jacobsen M. Getting the word out: Nutrition counseling improves outcomes. Oncology Nutrition Connection. 2006; 14(2):1,5 7. 8. Erskine J, Perrett J. Prevalence of nutrition screening in ambulatory cancer patients and its relationship to nutrition intervention: A pilot study. Oncology Nutrition Connection. 2006; 14(4):1,4 6,24 25. 9. The Joint Commission. Nutrition, Functional, and Pain Assessments and Screens. Available at: http://www.joint commission.org/accreditationprograms /Hospitals/Standards/09_FAQs/PC/ Nutritional_+Functional_Pain_+ Assessments.htm. Accessed 7/17/10. 10. Davies M. Nutritional screening and assessment in cancer-associated malnutrition. European Journal of Oncology Nursing. 2005;9(supplement 2):S64 S73. 11. Wojtaszek CA, Kochis LM, Cunningham RS. Nutrition impact symptoms in the oncology patient. Oncology Issues. 2002;17(supplement 2 M/A):S15 S16. 12. Ottery FD. Supportive nutrition to prevent cachexia and improve quality of life. Seminars in Oncology. 1995; 22:98 111. 13. American Dietetic Association Nutrition Care Manual. Available at: http://nutrition caremanual.org/content.cfm?ncm_ content_id=83966. Accessed 7/15/10. 14. August DA, Huhmann MB, and ASPEN Board of Directors. A.S.P.E.N. Clinical Guidelines: Nutrition support guidelines during adult anticancer treatment and in hematopoietic cell transplantation. Journal of Parenteral and Enteral Nutrition. 2009;33;472 500. 15. Oncology Nursing Society. Available at : http://onsopcontent.ons.org/toolkits/ evidence/clinical/pdf/nutritiontools.pdf Accessed 7/17/10. 16. Kubrak C. Jensen L. Critical evaluation of nutrition screening tools recommended for oncology patients. Cancer Nursing. 2007;30(5):E1 E6. 17. Leuenberger M, Kurmann S, Stanga Z. Nutritional screening tools in daily clinical practice: the focus on cancer. Supportive Care in Cancer. 2010;18 (supplement 2):17 27. 18. The American Dietetic Association Evidence Analysis Library. Available at: http://www.adaevidencelibrary.com/ topic.cfm?cat=4305. Accessed 7/17/10. 19. Oncology Nursing Society. Available at: http://www.ons.org/research/pep/ media/ons/docs/research/measurement/ nutritional-status.pdf. Accessed 7/17/10. 20. Marin C, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clinical Nutrition. 2007;26(3):289 301.