From screening to strategy: a multidisciplinary nutrition pathway to combat hospital acquired malnutrition

doi:10.15406/jaccoa.2025.17.00625

Journal of

eISSN: 2373-6437

Anesthesia & Critical Care: Open Access

Mini Review Volume 17 Issue 3

From screening to strategy: a multidisciplinary nutrition pathway to combat hospital acquired malnutrition

Khaled Sewify,¹

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Ahmed Abutaleb,¹ Abdulah Almulhem,¹ Wael Gomaa,¹ Shamini Segerun,² Ruena Cartin,² Simi Bindhumon,³ Khloud AlOtabi,³ Omar Alzuwayed,⁴ Yousef Sewify⁵

¹Critical Care Department, King Fahad Military Medical Complex, Kingdom of Saudi Arabia
²Nursing Department, King Fahad Military Medical Complex, Kingdom of Saudi Arabia
³Nutrtion Department, Prince Sultan Medical College, Kingdom of Saudi Arabia
⁴Pharmacy Department, King Saud Hospital, Kingdom of Saudi Arabia
⁵Airport Department, Sydney Kingsford Smith Airport, Australia

Correspondence: Khaled Sewifty, Critical Care Department, King Fahad Military Medical Complex (KFMMC), Dhahran 31932, Saudi Arabia

Received: June 14, 2025 | Published: June 24, 2025

Citation: Sewify K, Abutaleb A, Almulhem A, et al. From screening to strategy: a multidisciplinary nutrition pathway to combat hospital acquired malnutrition. J Anesth Crit Care Open Acces. 2025;17(2):87-89. DOI: 10.15406/jaccoa.2025.17.00625

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Abstract

Hospital-acquired malnutrition (HAM) represents an under-recognized condition which negatively impacts recovery time and survival rates and extends hospital stays for patients. This study describes the creation and execution of a structured evidence-based Nutrition Support Pathway which combines the Malnutrition Universal Screening Tool (MUST) with a dedicated Nutrition Care Team (NCT) and an advanced Nutrition Support Professional Team (NSPT). The proposed protocol establishes standardized procedures for identifying at-risk patients and their subsequent referral and intervention process to enhance both patient outcomes and care efficiency. The pathway proved successful in a tertiary care hospital and now serves as a model for wider implementation.

Abbrevation

BMI, body mass index; MUST, Malnutrition Universal Screening Tool; NCT, Nutrition Care Team; NSPT, Nutrition Support Professional Team; NSTs, Nutrition Support Teams

Introduction

Hospitalized patients face widespread and often undiagnosed malnutrition problems especially in intensive care and surgical units because these patients experience fast nutritional decline. The admission rate of malnutrition exceeds 30% and hospital patients experience worsening nutritional status because of insufficient food intake and metabolic stress and delayed nutritional support.¹ The condition known as hospital-acquired malnutrition (HAM) leads to higher patient morbidity and delayed wound healing and extended mechanical ventilation and increased infection rates and longer hospital stays.

The European Society for Clinical Nutrition and Metabolism (ESPEN) and the American Society for Parenteral and Enteral Nutrition (ASPEN) have established evidence-based guidelines that support early nutritional support yet its implementation in clinical practice remains inconsistent.^2,3The barriers to implementation include the absence of standardized screening tools, insufficient training, competing clinical priorities, and unclear pathways for escalation.

Our institution created a Nutrition Support Pathway as a solution to these gaps. The initiative used validated screening protocols together with interprofessional collaboration and defined escalation criteria to provide timely appropriate nutrition care. The following article describes the pathway development process and its components and results which serve as a model for other healthcare organizations to implement.

Pathway framework and screening protocol (As shown in Figure 1)

Figure 1 Nutrition Support Flow Chart.

The Malnutrition Universal Screening Tool (MUST) (as shown in Table 1) serves as a validated tool for nutritional screening of all patients upon admission according to ESPEN and ASPEN guidelines.^1,2 The MUST tool assesses three key factors which include BMI measurements and weight loss without intent and the impact of acute disease on food consumption for at least five days.

Step	Parameter	Criteria	Score
1. BMI score	Current Body-Mass Index (kg m⁻²)	≥ 20 (> 20 if ≥ 65 yr)	0
		18.5 – < 20	1
		< 18.5	2
2. Weight-loss score	Unintentional Weight Change in last 3–6 mo	< 5 %	0
		5 – 10 %	1
		> 10 %	2
3. Acute-disease effect score	Patient acutely ill and has had or is likely to have no nutritional intake for > 5 days	Yes	2
		No	0
4. Overall risk of malnutrition	Add scores from Steps 1–3	0	Low Risk
		1	Medium Risk
		≥ 2	High Risk

Table 1 Malnutrition Universal Screening Tool (MUST) — Adult Scoring & Action Tables

A must score of:

0 indicates Low Risk — routine clinical care
1 indicates Medium Risk — observe dietary intake and reassess
≥ 2 indicates High Risk — triggers immediate referral to the dietitian and activation of the Nutrition Care Team (NCT).

Nutrition Care Team (NCT)

The NCT comprises the primary physician, in-unit clinical dietitian, primary and charge nurse. Upon activation:

The dietitian performs a comprehensive nutritional assessment
A tailored nutritional management plan is initiated
Patients are monitored for improvement or deterioration

If the patient fails to respond to standard dietary interventions or presents complex nutritional needs, referral is escalated to the Nutrition Support Professional Team (NSPT).⁴

Referral criteria to the NSPT

According to institutional policy, patients are referred to the NSPT based on the following criteria:

At least one of the following:

High risk for malnutrition based on The Malnutrition Universal Screening Tool (MUST).
At risk of malnutrition or already malnourished based on dietician assessment.

Additionally at least one of the following factors should be present:

High risk for refeeding syndrome according to NICE guidelines criteria (as shown in Table 2).⁴
Not tolerating Enteral Nutrition for past 1 week.
Total Parenteral Nutrition requirement is justified.
High Risk Pre-operative patients with anticipated post-op deficits.
Long ICU stay, extensive burns, or trauma.
Complex feeding strategy is needed to improve patient’s nutritional status.

Risk Category	Criteria
High risk if any one of the following is present:	• BMI < 16 kg/m²
	• Unintentional weight loss > 15% in the last 3–6 months
	• No nutritional intake for > 10 days
	• Low baseline levels of potassium, phosphate, or magnesium
High risk if any two or more of the following are present:	• BMI < 18.5 kg/m²
	• Unintentional weight loss > 10% in the last 3–6 months
	• No nutritional intake for > 5 days
	• History of alcohol misuse or use of insulin, chemotherapy, antacids, or diuretics

Table 2 NICE Guidelines – Criteria for High Risk of Refeeding Syndrome

Team roles and advanced management

The NSPT includes a senior nutrition intensivist, senior clinical nutritionist, clinical pharmacist, and senior nutrition nurse (All are experts and certified in nutrition):

Intensivist: leads decision-making and treatment protocol.
Dietitian: calculates nutrient requirements and feeding strategy.
Pharmacist: compounds sterile TPN and reviews drug-nutrient interactions.
Nurse: monitors feeding access and tolerance and coordinates care.

Interdisciplinary discussions occur regularly through Enteral/Parenteral Nutrition Committee meetings.⁵

Nutritional therapy is reassessed within 24–48 hours post-referral with frequent follow up till patient's improvement then will be referred back to nutrition care team.

Discussion

A structured Nutrition Support Pathway has shown its effectiveness in managing hospital-acquired malnutrition through a systematic and multidisciplinary approach. The pathway uses validated screening protocols together with streamlined communication and tiered escalation to improve nutrition care delivery for critically ill and complex medical patients. The MUST tool enables early screening to detect nutritional risks when patients first enter the healthcare system.¹ The NCT enables quick coordination and dietetic assessment through its integration while the NSPT provides a specific pathway for managing high-risk or non-responding cases. The pathway enhances accountability through defined team roles and response timelines which support evidence-based nutritional goal adherence.

The 2024 ESPEN Guidelines on Clinical Nutrition in Hospitalized Patients now support this approach by recommending the creation of multidisciplinary nutrition support teams (NSTs) to coordinate nutritional interventions.⁶ The ESPEN guidelines state that NSTs must consist of at least a physician with clinical nutrition expertise and a registered dietitian and a nurse with nutrition care knowledge and a pharmacist who will work together as described in this study.⁶ These teams have been proven to enhance patient nutrition levels while decreasing hospital-acquired infections and leading to better patient results.

Furthermore, ESPEN 2024 explicitly identifies early identification and escalation to expert teams as a core priority for malnutrition prevention, particularly in high-risk populations such as ICU, surgical, and oncology patients.⁶ The guidelines endorse care models that embed screening tools like MUST into admission protocols and recommend institutional policies for referral to advanced support teams when oral or enteral intake fails to meet targets.⁶

The pathway enables better documentation and audit readiness and compliance with accreditation standards for nutritional safety and quality. The pathway promotes learning between different disciplines and develops a practice culture that focuses on nutrition. The model works well for different institutional sizes including regional hospitals with restricted specialist access. The success of this initiative depends on continued training programs and leadership backing and the integration of the pathway into electronic medical record systems. The pathway visibility and adherence can be improved through the implementation of alerts and standardized forms and reassessment prompts. The importance of patient and family involvement in nutrition planning needs to be strengthened as part of a complete approach. The initiative supports worldwide initiatives to establish nutrition as a fundamental hospital care indicator while demonstrating the strategic importance of interdisciplinary models for preventing malnutrition.

Clinical implications and outcomes

The structured multidisciplinary pathway follows international guidelines to decrease ICU-related malnutrition risks and standardize nutritional therapy initiation.^3,6 The pathway enables earlier intervention and decreases refeeding complications while providing standardized care delivery across teams.

Conclusion

The care model uses validated screening (MUST) and structured team workflows and targeted referral criteria to provide a replicable method for optimizing nutrition in critically ill patients. The approach supports best practice and integrates nutritional therapy as a fundamental component of ICU care.

Acknowledgments

The authors thank the entire multidisciplinary team members for their dedication to improving patient care, and the administration of King Fahd Military Medical Complex for their support of this quality improvement initiative.

Author Contribution

KS: Conceptualization, Data curation, Formal Analysis, Investigation, Methodology, Software, Validation, Visualization, Writing–original draft, Writing–review and editing.

AA: Conceptualization, Data curation, Formal Analysis, Methodology, Project administration, Software, Validation, Visualization, Writing–review and editing.

AA: Conceptualization, Formal Analysis, Funding acquisition, Methodology, Project administration, Software, Visualization, Writing–review and editing.

WG: Conceptualization, Methodology, Supervision, Writing–review and editing.

SS: Conceptualization, Methodology, Project administration, Resources, Supervision, Writing–review and editing.

RC: Conceptualization, Methodology, Supervision, Writing–review and editing.

SB: Conceptualization, Methodology, Supervision, Writing–review and editing.

OA: Conceptualization, Writing–review and editing.

YS: Writing–review and editing.

Conflicts of interest

The authors declare no conflicts of interest related to this case report.

Funding statement

This research received no specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Ethics approval statement

This article followed the ethical standards of the institution where it took place. Formal ethical approval was taken as per the policies of the reporting institution.