ORIGINAL ARTICLE Validity and reliability of the new Canadian Nutrition Screening Tool in the ‘real-world’ hospital setting M Laporte 1 , HH Keller 2 , H Payette 3 , JP Allard 4 , DR Duerksen 5 , P Bernier 6 , K Jeejeebhoy 7 , L Gramlich 8 , B Davidson 9 , E Vesnaver 10 and A Teterina 4 BACKGROUND/OBJECTIVES: Nutrition screening should be initiated on hospital admission by non-dietitians. This research aimed to validate and assess the reliability of the Canadian Nutrition Screening Tool (CNST) in the ‘real-world’ hospital setting. SUBJECTS/METHODS: Adult patients were admitted to surgical and medical wards only (no palliative patients). Study 1—Nutrition Care in Canadian Hospitals (n = 1014): development of the CNST (3 items: weight loss, decrease food intake, body mass index (BMI)) and exploratory assessment of its criterion and predictive validity. Study 2—Inter-rater reliability and criterion validity assessment of the tool completed by untrained nursing personnel or diet technician (DT) (n = 150). Subjective Global Assessment performed by site coordinators was used as a gold standard for comparison. RESULTS: Study 1: The CNST completed by site coordinators showed good sensitivity (91.7%) and specificity (74.8%). Study 2: In the subsample of untrained personnel (160 nurses; one DT), tool’s reliability was excellent (Kappa = 0.88), sensitivity was good (490%) but specificity was low (47.8%). However, using a two-item (‘yes’ on both weight change and food intake) version of the tool improved the specificity (85.9%). BMI was thus removed to promote feasibility. The final two-item tool (study 1 sample) has a good predictive validity: length of stay (P o0.001), 30-day readmission (P = 0.02; X 2 5.92) and mortality (P o0.001). CONCLUSIONS: The simple and reliable CNST shows good sensitivity and specificity and significantly predicts adverse outcomes. Completion by several untrained nursing personnel confirms its utility in the nursing admission assessment. European Journal of Clinical Nutrition (2015) 69, 558–564; doi:10.1038/ejcn.2014.270; published online 17 December 2014 INTRODUCTION Malnutrition is common in acute care hospitals throughout the developed world, 1 and Canadian hospitals are not an exception. 2–4 Various organizations have identified nutrition screening as an initial strategy to treat malnutrition, with some visionaries mandating this step in the hospital setting. 5–8 In acute care hospitals, it should be a rapid and simple process conducted by admitting staff, 6 busy nurses or other relevant professionals, 9 whereas nutritional assess- ment requires professional judgment by a dietitian 10,11 and is hugely more time-consuming. Efficacy of nutrition screening lies in the validity, reliability and feasibility of the tool used. 12 Over the past two decades, much work has been done in the development and validation of nutrition screening tools for hospital use. 13–19 When looking at the criterion validity of these tools, many showed sensitivity and specificity values over 70%, which is considered as the prerequisite for an adequate tool performance. 20 However, most of these tools present bias in their validation process, leading to inflated validation results (Table 1). Speci fic flaws include the following: (1) the validity was assessed in the same population in which the tool was developed; 2,14 (2) the same rater completed the tool and performed the criterion nutritional assessment in the same patients; 14,20–26 and (3) the screening was conducted by trained researchers, 14,25–27 dietitians 20,21,23,24 or trained nursing personnel. 18,19–21,24,28–31 Moreover, not many screening tools have been validated with completion by nutrition assistants/diet technicians (DTs), 13,22,28 a viable alternative to nursing for this process. Inter-rater reliability often includes only few trained raters. 13,14,18,19,21,24 As a result, validity and inter-rater reliability of these tools is unknown in the ‘real-world’ setting where it is completed at hospital admission by any number of busy nursing personnel who have no training in nutrition screening. To be feasible for use in all patients, a screening tool must be simple (few items; taking o5 min 32 ), preferably including data documented in electronic medical records (EMRs). 33 Weight loss, 13–19 food intake 14–19 and body mass index (BMI) 13,15–17 are items consistently included in the tools. However, interpretation of these items can present limitations. Weight, BMI and weight loss are challenging to collect. The quantitative (amount or percen- tage) of weight loss is also difficult to obtain. It was reported that patients know whether or not they had lost weight, but recalling weight before the loss or estimating the amount of lost weight is difficult. 21 Moreover, a time frame for weight loss needs to be specified, as well as clarifying whether this is unintentional weight loss, 34 as these are essential components to determine the extent of risk. No tool examines these two components of weight loss, without relying also on the difficulty to collect the estimation of the absolute amount of weight lost in a specific time 1 Clincal Nutrition Department, Vitalité Health Network, Campbellton Regional Hospital, Campbellton, New Brunswick, Canada; 2 Schlegel-UW Research Institute for Aging, University of Waterloo, Waterloo, Ontario, Canada; 3 Research Center on Aging, Health and Social Services Centre, University Institute of Geriatrics of Sherbrooke, University of Sherbrooke, Sherbrooke, Québec, Canada; 4 Department of Medicine, University Hospital Network, University of Toronto, Toronto, Ontario, Canada; 5 Department of Medicine, St-Boniface Hospital, University of Manitoba, Winnepig, Manitoba, Canada; 6 Jewish General Hospital, Montréal, Québec, Canada; 7 Department of Medicine, St Michael’s Hospital, Toronto, Ontario, Canada; 8 Department of Medicine, University of Alberta, Alberta Health Services, Edmonton, Alberta, Canada; 9 Canadian Malnutrition Task Force, Canadian Nutrition Society, Toronto, Ontario, Canada and 10 University of Guelph, Guelph, Ontario, Canada. Correspondence: M Laporte, Clinical Nutrition Department, Vitalité Health Network, Campbellton Regional Hospital, 189 Lily Lake Road, P.O. Box 880, Campbellton, New Brunswick E3N 3H3, Canada. E-Mail manon.laporte@vitalitenb.ca Received 19 August 2014; revised 24 October 2014; accepted 14 November 2014; published online 17 December 2014 European Journal of Clinical Nutrition (2015) 69, 558 – 564 © 2015 Macmillan Publishers Limited All rights reserved 0954-3007/15 www.nature.com/ejcn