Elsevier

Clinical Nutrition

Volume 30, Issue 4, August 2011, Pages 430-435
Clinical Nutrition

Original Article
Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS) in hospital practice

https://doi.org/10.1016/j.clnu.2011.01.015Get rights and content

Summary

Background & aims

Nutritional screening in paediatric inpatients is important. However, there is a lack of validated screening tools for this population. In this study the development of a nurse administered paediatric malnutrition screening tool is described and its performance evaluated.

Methods

The Paediatric Yorkhill Malnutrition Score (PYMS) rate BMI, weight loss, dietary intake and predicted effect of the current condition on nutritional status, with a score of 0–2 for each element. Patients with total score of 2 or more are referred for dietetic review. A four month pilot phase was conducted in three medical and one surgical wards of a tertiary hospital and the general paediatric ward of a district general hospital. Performance of the tool was assessed by auditing completion rates, yield, impact on dietetic workload, and by evaluating dietitians’ feedback.

Results

1571 patients (72% of admissions) were screened of whom 158 (10%) scored at high risk. Non-screened children were younger and had a shorter length of hospital stay. Of the 125 patients who scored at high risk, between the 2nd and 4th month of the pilot, 66 (53%) were assessed by a dietitian of whom 86% were judged to be at true risk of malnutrition and 50% of these were new to the dietetic service. Dietetic workload did not increase significantly during the pilot phase although the proportion of referrals from the acute receiving wards increased. Dietitians’ feedback was positive, with recognition that PYMS identified patients at risk of malnutrition who may not have otherwise been referred.

Conclusions

Nutrition screening by nurses using the new PYMS score is feasible for paediatric inpatients, identifies children at risk of malnutrition and uses available resources efficiently.

Introduction

While disease associated malnutrition is a common problem in paediatric hospitals, it often remains undetected and untreated1, 2, 3 with significant potential impact on patient’s health4, 5, 6, 7 and health expenditure.8 Thus identification of children at risk of malnutrition should be an important part of any program for providing optimal hospital care. This has been highlighted in recent national guidelines which state that all patients should be screened for risk of malnutrition on admission and periodically during hospital stay.9

Anthropometry and growth charts have traditionally been used to assess growth and to screen for chronic undernutrition, but this will not identify children in the early stages of malnutrition or those at risk of deterioration as a result of an acute medical condition. In addition, plotting data is time consuming for nurses and requires training. It has been proposed that nutritional screening tools may be more appropriate to identify nutritional risk and could be utilised by ward nursing staff.10 These are usually presented as a questionnaire proforma outlining factors that put patients at high malnutrition risk, and a number of such screening tools have been developed for adults.7, 11, 12 However these tools are inappropriate for children and validated paediatric screening tools are scarce.

In paediatrics four validated tools have been developed to date: The first of these, the Subjective Global Nutritional Assessment (SGNA) for children, as proposed by Secker and Jeejeebhoy,13 is a comprehensive nutritional assessment method rather than a rapid screening tool. The other two are shorter screening tools; one assesses pain, disease condition and food intake in the hospital and has been validated in a tertiary hospital in France.14 The other, the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) has been developed in the UK for use by the nursing staff, although detailed validation data is as yet not available and it has so far only been described in abstract form.15 STAMP uses a comparison of weight and height centiles, recent changes in nutritional intake, and the impact of disease diagnosis on nutritional status. A recent Dutch tool which combines subjective clinical assessment, high risk disease, nutritional intake and weight loss was developed for use by paediatricians and therefore may not be suitable for nursing use.16

While seeking a tool for use by nursing staff in our tertiary children’s hospital we considered STAMP and the French tool which were available at the time, but while the STAMP tool was attractive, none appeared to fully meet the needs of our hospital population, leading us to develop our own: the Paediatric Yorkhill Malnutrition Score (PYMS). We have demonstrated elsewhere that PYMS has acceptable levels of sensitivity and specificity compared to full dietetic assessment and to have a more useful profile than other screening tools already in use.17 In this paper we describe the process of developing the tool and how it functioned as performed by nursing staff in day to day practice.

Section snippets

Development of the Paediatric Yorkhill Malnutrition Score

A multidisciplinary health professional team (medical, dietetic, nursing, academic, practice development staff) developed a screening tool that would fulfil the following criteria:

  • a.

    To identify the majority of children (≥1 years) at the highest risk of malnutrition (sensitive) whilst not misclassifying too many patients at low risk.

  • b.

    To be quick and easy to use at ward level using information regularly collected on admission by nursing staff.

  • c.

    To be feasible to integrate in regular hospital admission

Audit of completion rates

Between 23rd June and 28th October 2008, 2174 children were admitted to the 5 pilot wards (Table 1). Of these patients 1571 (72.3%) were screened, with a higher proportion screened in the TPH [TPH n = 1208 (73.7%) vs. DGH n = 363 (68%), p = 0.011]. Screened patients came from a variety of medical and surgical specialties (Table 2). In the TPH only, those children who were not screened were significantly younger and had a shorter length of hospital stay than those who were screened (Table 1).

Discussion

Screening for malnutrition risk on hospital admission is recommended as an integral part of patient’s standard care. While an ideal tool identifies the majority of children at risk of malnutrition and does not misclassify those at low risk, assessment of its performance in a clinical setting is essential before introducing it for routine use. In a previous study we have reported the results of assessing the diagnostic validity of the PYMS, which demonstrated its usefulness as a screening tool.

Conclusions

Regular clinical use of PYMS appears to be feasible in a DGH and TPH, producing a high yield of patients at risk of malnutrition and without requiring significant increase in staffing levels or workload.

Statement of authorship

All authors have made substantial contributions to all of the following: (1) the conception and design of the study, or acquisition of data, or analysis and interpretation of data, (2) drafting the article or revising it critically for important intellectual content, (3) final approval of the version to be submitted. KG designed the study, undertook the main research activities, conducted data analysis, drafted the manuscript; IM contributed to the research activities and revised the

Conflicts of interest

None to declare.

Acknowledgements

The authors of the study would like to acknowledge the contribution of Mr Toby Mohammed, Dr Graham Stewart, Ms Christina McGuckin on the development of the PYMS and the hospital auxologist Ms Wendy Paterson for providing training to the nursing staff. They are particularly grateful to the nursing and dietetic departments at the Royal Hospital for Sick Children, Yorkhill, Glasgow, and the Royal Alexandra Hospital, Paisley. The project was funded by the National Health Service Greater Glasgow &

References (19)

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