Improving the performance of nutrition screening through a series of quality improvement initiatives

Nutrition screening identifies patients at risk of malnutrition to facilitate early nutritional intervention, yet incompletion and error rates of 30%-90% have been reported for commonly used screening tools. The effect of a series of quality improvement initiatives in improving the referral process and the overall performance of the 3-Minute Nutrition Screening (3-MinNS) tool was assessed for patients at National University Hospital (Singapore) at risk for malnutrition.

Annual audits were carried out from 2008 through 2013 on 4,467 patients. Performance gaps were identified and addressed through interventions, including (1) implementing a nutrition screening protocol, (2) nutrition screening training, (3) nurse empowerment for online dietetics referral of at-risk cases, (4) a closed-loop feedback system, and (5) removing a component of 3-MinNS that caused the most errors without compromising its sensitivity and specificity.

Nutrition screening error rates were 33% and 31%, with 5% and 8% blank or missing forms, in 2008 and 2009, respectively. For patients at risk of malnutrition, referral to dietetics took up to 7.5 days, with 10% not referred at all. After the interventions, nonreferrals decreased to 7% (2010), 4% (2011), and 3% (2012 and 2013), and the mean turnaround time from screening to referral was reduced significantly from 4.3 +/- 1.8 days to 0.3 +/- 0.4 days (p < .001). Error rates were reduced to 25% (2010), 15% (2011), 7% (2012), and 5% (2013), and the percentage of blank or missing forms was reduced to and remained at 1%.

Quality improvement initiatives were effective in reducing the incompletion and error rates of nutrition screening and led to sustainable improvements in the referral process of patients at nutritional risk.