Review Article J Clin Nutr 2016;8(1):2-10 pissn 2289-0203 ㆍ eissn 2383-7101 http://dx.doi.org/10.15747/jcn.2016.8.1.2 입원환자의영양검색도구 설은미 1,2, 주달래 1,3, 이혁준 1,4,5 서울대학교병원 1 영양집중지원팀, 2 간호본부, 3 급식영양과, 4 위장관외과, 5 서울대학교의과대학외과학교실 Eunmi Seol 1,2, Dal Lae Ju 1,3, Hyuk-Joon Lee 1,4,5 1 Nutritional Support Team, 2 Department of Nursing Service, 3 Department of Food Service and Nutrition Care, 4 Division of Gastrointestinal Surgery, Seoul National University Hospital, 5 Department of Surgery, Seoul National University College of Medicine, Seoul, Korea Malnutrition is a common problem in hospital settings. A poor nutritional status has been associated with higher rates of infection, poor wound healing, longer hospital stays, and higher hospital costs. Therefore, early recognition and timely treatment of malnutrition is vital. To identify malnourished individuals or those at risk of becoming malnourished, selecting and validated a uniform screening tool is clearly an important issue. Both the Nutritional Risk Screening-2002 (NRS-2002) and Malnutrition Universal Screening Tool (MUST) are recommended by the European Society for Parenteral and Enteral Nutrition (ESPEN) for a hospital setting. For older patients, the Mini Nutritional Assessment (MNA) is the recommended tool. Short Nutrition Assessment Questionnaire (SNAQ) and Malnutrition Screening Tools (MST) are brief and simple screening tools that use self-reported queries of variables that include weight loss and poor appetite. On the other hand, many of those require considerable time and labor to administer and may not be highly applicable to a Korean population. In Korea, most hospitals use a computerized nutritional screening system with a self-developed nutrition screening index. The variables for the tools, which are based on each hospital setting, include the objective data available in the patient's medical records and limited information collected from the nursing admission questionnaire. The application of different tools hampers any comparison of the malnutrition prevalence between different settings and patients groups. In addition, the absence of a widely accepted malnutrition screening tool hinders both effective recognition and the treatment of malnutrition. Therefore, the development of uniform and valid screening tools and effective nutritional support programs for Korean malnourished patients is needed. Key Words: Malnutrition, Nutritional screening, Hospital 서 론 Received Apr 7, 2016; Revised Apr 18, 2016; Accepted Apr 18, 2016 Correspondence to Hyuk-Joon Lee Department of Surgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-1957, Fax: +82-2-766-3975, E-mail: appe98@snu.ac.kr Conflict of interest: None. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 병원에입원하는환자의 20% 50% 가영양불량위험요인을가지고있고, 그중약 75% 가입원기간중영양불량이악화된다고한다. 1,2 영양불량은질병치료지연, 감염률, 합병증발생률, 사망률을증가시키고재원기간을늘려결과적으로의료비용을상승시킨다. 3 영양불량환자에서발생가능한이러한문제점을해결하고, 적절한영양지원을시행하기위하여국내 외병원에서는영양집중지원팀 (Nutrition Support Team, NST) 을조직하여운영하고있다. NST는각병원에서활동하는의 c 2016, The Korean Society for Parenteral and Enteral Nutrition. All Rights Reserved.
사, 간호사, 약사, 영양사로이루어진다학제팀으로국내에는 2014년 8월 집중영양치료료 (Therapy by Nutrition Support Team) 수가화적용이후 NST 활동에대한관심이증가되어현재 2차및 3차의료기관을중심으로설치 운영되고있다. 3 집중영양치료를위해서는입원환자의정확한영양상태평가및영양불량환자의선별 관리가필요한데, 이를위하여각병원에서는영양검색도구 (nutritional screening tool) 를사용하여초기영양평가를실시하고있다. 초기영양평가시 Nutrition Risk Screening-2002 (NRS-2002) 와같이임상영양관련학회를중심으로전문가들의의견이반영된영양검색도구를개발한후병원간일관된도구를사용하는것이바람직하겠지만, 국내의경우각병원의상황에맞게자체개발된다양한도구를사용하고있는실정이다. 이에본종설은국내병원의영양검색도구현황을알아보고이들의문제점에대하여고찰하고자한다. 본론 1. 영양검색도구 (Nutritional screening tools) 유럽정맥경장영양학회 (European Society for Parenteral and Enteral Nutrition, ESPEN) 의정의에따르면, 영양검색이란영양불량이있거나영양불량위험이있는환자를간단한도구를사용하여빠른시간내에분류하는과정 이다. 4 실제로영양검색은인력과자원이제한된임상에서환자의영양문제를진단하고, 영양관리가필요한환자들을우선적으로선별하여개인에게맞는적절한영양치료를적용함으로긍정적인임상결과를기대하게한다. 4-6 이러한이유로미국의 JCAHO (Joint Commission for Accreditation of Healthcare Organization) 에서는입원후 24시간이내에영양검색을실시할것을권고하고있고, 우리나라에서도의료기관인증평가제도를통해모든입원환자에대해초기영양평가 ( 영양검색 ) 를실시하고, 그결과를근거로영양불량위험환자에대한영양관리를하도록하고있다. 7,8 영양검색에사용될수있는영양평가지표로는키, 체중변화, 피하지방및체단백질량측정을포함한신체계측치 (anthropometry assessment), 생화학적검사결과, 환자의임상상태, 식사력등이있다. 6 이러한다양한영양평가지표중어떤지표를사용할것인가에대한부분은여전히논란이많지만, 환자의영양상태를평가하기위해서는단일지표가아닌다양한지표를사용하여종합적으로고려할필요가있겠다. 6,9 한편, 분별력있는영양검색을시행하기위해서는간단하고실용적이며신뢰도와타당도가검증된영양검색도구를선택하는것이무엇보다중요하다. 10 Kruizenga 등 11,12 이시행한연구 에따르면부적절한도구를이용한영양검색은영양불량위험환자의선별을어렵게만든다고하였고, Rasmussen 등 13 이시행한연구에서도부적절한도구를이용한영양검색이영양지원의주요한방해요인이된다고하였다. 이와같이영양검색및영양검색도구선택에대한중요성이인식됨에따라약 20년전부터영양검색도구개발을위한움직임이활발하게이루어졌고, 지금까지다양한도구가개발되어사용되고있다. 14 현재타당성을인정받아세계적으로많이사용되고있는표준화된영양검색도구로는 NRS-2002, Malnutrition Universal Screening Tool (MUST), Mini Nutritional Assessment (MNA), Short Nutritional Assessment Questionnaire (SNAQ), Malnutrition Screening Tool (MST) 등이있고각영양검색도구에대한자세한내용은다음과같다. 1) Nutrition Risk Screening-2002 (NRS-2002) Kondrup 등 2 에의해개발된 NRS-2002는체질량지수 (body mass index, BMI), 체중감소및섭취량변화에근거한환자의영양상태, 진단명에의한질병의중증도, 나이 3가지요소를바탕으로영양불량위험정도를분류하고그에맞는영양지원을시행하도록설계된영양검색도구이다 (Table 1). NRS-2002는영양평가지표로진단명을사용하기때문에질병의중증도에따른영양요구량차이를반영할수있어보다포괄적인범위의환자에게적용가능하다는장점이있다. 15 본도구의타당도는 128개의무작위전향적임상시험 (randomized controlled trials) 연구의후향적분석 (retrospective analysis) 을통하여검증되었고, 분석결과 NRS-2002를통해선별된환자들에게영양지원을시행하였을때영양지원기대비율이 1.7배상승하는효과를나타냈다고하였다. 2 이는입원환자 212명을대상으로시행한연구에서본도구로선별된환자군에게영양지원을적용하였을때재원일수와합병증발생률이감소하였다는것과유사한결과이며, 4 26개병원의입원환자 5,051명을대상으로 Sorensen 등 16 이시행한연구결과및 314 명의위장관수술환자를대상으로한 Guo 등 17 의연구결과와도유사하였다. Kyle 등 18 이시행한또다른연구에서는병원입원환자 955명을대상으로다양한영양검색도구를선택하여각각초기영양평가를시행한후영양불량환자선별정도를 Subjective Global Assessment (SGA) 와비교하여도구의타당도를검증하였다. 초기영양평가를위하여 MUST, Nutritional Risk Index (NRI), NRS-2002가영양검색도구로사용되었고, 연구결과 NRS-2002가다른도구에비하여높은타당도를보였으며, 이러한결과는재원일수와밀접한상관관계를보였다. 18 본도구는간호사, 영양사, 의사를대상으로확인했을때 Volume 8, Number 1, April 2016 3
Eunmi Seol, et al. Table 1. Nutritional Risk Screening-2002 (NRS-2002) Initial screening Yes No 1. Is BMI<20.5? 2. Has the patient lost weight within the last 3 months? 3. Has the patient had a reduced dietary intake in the last week? 4. Is the patient severely ill? (e.g., in intensive therapy) Yes: If the answer is Yes to any question, the screening in final screening is performed. No: If the answer is No to all questions, the patient is re-screened at weekly intervals. If the patient e.g., is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Final screening Impaired nutritional status Severity of disease Absent Normal nutritional status Absent Normal nutritional requirements Score 0 Score 0 Mild score 1 Weight loss >5% in 3 mo or food intake below 50% 75% of normal requirement in preceding week Mild score 1 Hip fracture, chronic patients, in particular with acute complications: cirrhosis, COPD, chronic hemodialysis, diabetes, oncology Moderate score 2 Severe score 3 Weight loss >5% in 2 mo or BMI 18.5 20.5+ impaired general condition or food intake 25% 60% of normal requirement in preceding week Weight loss >5% in 1 mo (>15% in 3 mo) or BMI 18.5+impaired general condition or food intake 0% 25% of normal requirement in preceding week in preceding week Moderate score 2 Severe score 3 Score: + Score: =total score Age 70 years: add 1 to total score above =age-adjusted total score Major abdominal surgery, stroke, severe pneumonia, hematologic malignancy Head injury, bone marrow transplantation, intensive care patients (APACHE>10) Score 3: the patient is nutritionally at-risk and a nutritional care plan is initiated. Score <3: weekly rescreening of the patient. If the patient e.g. is scheduled for a major operation, a preventive nutritional care plan is considered to avoid the associated risk status. Modified from the article of Kondrup et al. Clin Nutr 2003;22(4):415-21. 4 BMI = body mass index; COPD = chronic obstructive pulmonary disease; APACHE = acute physiology and chronic health evaluation. 67% 의재연성을나타냈고, 많은연구를통하여입원환자의 95% 이상에서적용가능하다는결과를보였다. 16,18,19 이러한연구결과를바탕으로최근국내에서도규모가큰대학병원을중심으로 NRS-2002를영양검색도구로도입하기위한노력을기울이고있다. 하지만, NRS-2002를비롯한기존의영양검색도구는외국환자들을대상으로개발되었기때문에우리나라에그대로적용하기에적합하지않을가능성이크다. 20 뿐만아니라, 영양검색을위하여체중감소및섭취량변화에대한자세한정보확인이필요해보다많은인력과시간투입이요구되고, 질병의중증도분류를위한진단명코드화가어렵다는점에서국내병원에그대로적용하기에는한계가있다. 15 2) Malnutrition Universal Screening Tool (MUST) MUST는영국정맥경장영양학회 (British Association for Parenteral and Enteral Nutrition) 에의해개발된영양검색도구로 BMI, 비의도적인체중감소, 급성질병에의한증상정도에따라환자의영양상태를저위험군, 중증도위험군, 고위험군으로분류하여각자의영양상태에맞는영양지원을계획하도록 설계된도구이다 (Fig. 1). 21 King 등 22 과 Wood 등 23 이시행한연구에서본도구를이용한영양검색은재원일수, 사망률, 퇴원형태와밀접한상관성이있음이나타나도구의타당도가검증되었고, 영국의다양한보건의료계에있는의사, 간호사를대상으로확인한결과 80.9% 의재연성을나타낸바있다. 하지만, MUST 역시평가항목중하나인급성질병에의한증상정도를추론하기가애매하여임상적으로적용하기에어려움이있다. 3) Mini Nutritional Assessment (MNA) MNA는 ESPEN에서외래및입원, 요양기관등의환경에있는노인환자의영양불량위험정도를파악하기위하여만들어진영양검색도구로신체계측치 ( 신장, 체중, BMI, 상박부둘레, 장딴지둘레, 최근 3개월간의체중감소여부 ), 식사력 ( 식사횟수, 단백질섭취, 과일및채소섭취, 식사량변화여부, 수분섭취, 식사형태 ) 등을포함하는총 18개의항목으로구성된도구이다. 본도구의타당도는 21개의임상연구에등록된 14,149명의환자를대상으로한메타분석을통해서검증되었는데, 그결 4 Journal of Clinical Nutrition
Fig. 1. Malnutrition Universal Screening Tool (MUST). Reused from the article of Kondrup et al. Clin Nutr 2003;22(4):415-21. 4 BMI = body mass index. 과 MNA score를기준으로시행한영양지원은긍정적인임상적결과를도래할뿐아니라사망률, 재원기간, 퇴원형태및병원비용과밀접한상관관계를나타냈다고하였다. 또한, 급격한체중변화와혈청알부민변화가나타나기전에환자의영양불량위험정도에대한파악이가능하다는연구결과에따라 MNA 는영양검색도구뿐아니라, 영양평가도구 (nutritional assessment tools) 로도많이사용되고있다. 하지만, 영양검색도구로임상에 MNA를적용하기에는조사해야하는항목이지나치게많고, 환자에게적용하기복잡하다는점을고려할때, 인력과시간이한정되어있는국내병원실정상사용에어려움이있다고생각된다. 24 4) Short Nutritional Assessment Questionnaire (SNAQ) SNAQ는 Kruizenga 등 11 에의해개발되었고, 비의도적인체중변화, 식욕, 구강영양보충제품섭취또는경관급식여부를포함하는 3가지변수만을이용하여영양불량위험이있는환자를선별해내는도구로비교적간단하고쉬운영양검색도구이다. 297명의입원환자를대상으로시행한연구에서본도구를이용해선별된영양불량환자에게조기에영양지원이적용되는경우재원일수및의료비용감소에효과가있음이나타나도구의타당도가검증된바있다. 하지만, SNAQ 도구의타당성검증은 BMI에의해서만시행되었을뿐향후환자의임상적결과를고려하지않았다는점에서병원영양검색도구로사용하는데한계가있다. 12 Volume 8, Number 1, April 2016 5) Malnutrition Screening Tool (MST) MST는 Ferguson 등 25 에의해개발된도구로영양학적기본질문들을조사한뒤영양평가도구인 SGA를예측할수있는질문들을정리하여만든영양검색도구이다. 식욕과최근비의도적인체중감소를포함하는 2가지변수만을이용하여영양불량환자를선별할수있어 SNAQ와함께비교적빠르고, 간단하고쉽게사용가능하다는장점이있다. 입원환자 408명을대상으로시행한연구에서본도구를적용하여영양검색을한결과재원일수를예측하는데밀접한상관성이있는것으로나타났고, 사용자간 93% 97% 의재연성을보였다. 25 2. 국제학회에서제안하는영양검색도구의사용가이드라인다양한영양평가지표를포함한영양검색도구의사용가이드라인은대표적으로 ESPEN과 American Society for Parenteral and Enteral Nutrition (ASPEN) 에서제시하고있는데, 특히 ESPEN에서는 2002년가이드라인을통해임상적상황에맞는영양검색도구사용을권장하고있다. 병원입원환자의경우영양검색과정에진단명을고려한 NRS-2002를사용하여초기영양평가를시행한후, 영양지원여부를결정하도록권고하고있고, 지역사회의경우 MUST를, 노인환자의경우 MNA를사용하도록하고있다. 4 한편, ASPEN에서는 2010년 Nutritional Support Core Curriculum을통해영양검색도구사용가이드라인을제시하였다. 우선적으로급성 만성, 외래와같은현재환자건강상태 5
Eunmi Seol, et al. 를고려하여영양검색시기를결정하고, 초기영양평가시체중변화, 영양지원과거력, 섭취량변화를확인하여그결과에따라환자의영양불량정도를고위험군, 저위험군으로분류한후, 영양평가및영양지원을결정하도록권고하고있다 (Fig. 2). 5 3. 국내병원영양검색도구 2014년국내상급종합병원과전국분포종합병원을대상으로시행한임상영양현황설문조사결과에따르면전체 99개병원 ( 상급종합병원 35개, 종합병원 64개 ) 중 77개 (77.8%) 의병원에서초기영양검색을시행하고있고, 특히상급종합병원의경우 97% 에해당되는것으로나타났다. 전체병원중 81.8% 의병원에전산화시스템이구축되어있었고, 대부분의병원 ( 상급종합병원 91.4%, 종합병원 96.8%) 은각병원상황에맞게자체 개발된영양검색도구를이용하고있었다. 또한, 영양검색도구에사용되는지표를확인한결과, 병원유형에관계없이혈중알부민 (albumin) 이가장많은비중을차지하였고, 그외에총림프구수 (total lymphocyte count, TLC), 표준체중백분율, 나이, BMI, 체중변화, 진단명, 식사력, 섭취량변화순서인것으로조사되었다. 26 한편, 2012년대한외과대사영양학회에서학회등록병원을중심으로영양지원현황에대하여조사한결과, 전체 35개의병원중 32개의병원 (91.4%) 에서초기영양검색을실시하고있었고, 그중대부분의병원 (76.9%) 에서는입원환자전체를대상으로영양검색을시행하고있었다. 또한, 전체병원중 74.3% 의병원에영양검색도구가있다고하였고, 그중 NRS-2002를포함한표준화된영양검색도구를사용하고있는병원은 14개병 Fig. 2. Nutritional screening and assessment reprinted from Nutritional Support Core Curriculum, ASPEN 2010. 6 Journal of Clinical Nutrition
원 (53.8%) 이었으며, 그외 12개병원 (46.1%) 은각병원의실정에맞게자체개발된도구를사용하고있었다. 27 이러한조사결과를바탕으로볼때, 국내병원에서도영양검색및영양검색도구의중요성에대한인식이증가함에따라, 경험이많은대학병원을중심으로영양검색도구자체개발및개발된도구의타당도검증을위해노력을기울이고있음을알수있다. 따라서규모가큰국내대학병원을중심으로각병원에서자체개발하여사용중인영양검색도구를확인해보고자한다. 1) 서울대학교병원영양검색도구 (Seoul National University Hospital-Nutrition Screening Index, SNUH-NSI) 서울대학교병원은 1,782개의병상규모를가진의료기관으로병원실정에맞게자체개발된 SNUH-NSI 도구를사용하여전체입원환자를대상으로입원후 24시간이내에영양검색을실시하고있다. SNUH-NSI의영양평가지표는총 11개의항목으로, 단일지표가아닌입원시체중변화유무, 식욕상태, 소화기장애에대한환자의주관적인진술과입원전 2주이내가장최근에시행된혈중알부민수치 (serum-albumin), 혈중총콜레스테롤수치 (serum-cholesterol), TLC, 헤모글로빈수치 (hemoglobin), C-반응성단백질 (C-reactive protein) 등의생화학적검사결과, 입원첫날의식사형태, 연령, BMI를포함한다양한지표로구성되어있다 (Table 2). SNUH-NSI의영양평가지표에해당되는각각의항목은그성격에따라서영양불량의중증도를반영하는정도가다르다. 따라서영양불량에미치는영향력의경중을반영하여 R1, R2, R3 세가지로구분하고, 각위험항목의조합에따라영양불량고위험군 (P1), 중증도위험군 (P2), 저위험군 (P3) 으로분류하여영양상태에맞는영양지원이이루어지도록설계되었다. 영양검색에사용되는 11가지영양평가지표중대부분은병원내자동검색시스템을이용하여정보수집이가능하도록되어있기때문에인력과자원이제한적인임상현장에서사용하기에비교적실용적이라고생각된다. 본도구는위절제수술환자 174명을대상으로 SNUH-NRI 및 NRS-2002를이용하여영양검색을시행한후, 그결과를 Patient Generated-Subjective Global Assessment (PG-SGA) 를통한심층영양평가결과와비교하여도구의타당도를검증하였다. 그결과, SNUH-NSI ( =0.498), NRS-2002 ( = 0.439) 모두 PG-SGA의심층영양상태평가결과와보통 (moderate) 의일치도를보여영양검색도구로적합함을확인하였고, 이러한연구결과는수술후합병증발생률과밀접한상관관계가있음을나타냈다. 28,29 서울대학교병원에서는 2014년 6월부터 2015년 5월까지, 1년동안병원에입원한 18세이상성인환자, 총 69,716건을대상으로입원시초기영양평가자료를전자의무기록 (electronic medical records) 을통하여수집하고, 그내용을분석하였는데그결과영양불량고위험군에속하는환자는전체입원환자중 18% (12,649건) 에해당되는것으로나타났다. 입원시 SNUH-NSI 를통한평가결과, 영양불량저위험군 (P3) 환자의재원기간 (6.1 일 ) 에비해영양불량고위험군 (P1) 환자의재원기간 (11.9일) 이유의하게높게나타났고, 중환자실입실, 경장및정맥영양투여비율이유의하게높았다. 또한, 재원기간동안의사망률을비교해보면영양불량저위험군환자의사망률은 0.14% 인데반하여영양불량고위험군환자의사망률은 5.9% 로나타났다. Table 2. Seoul National University Hospital-Nutrition Screening Index (SNUH-NSI) Variable R1 R2 R3 Appetite Bad - Normal/good Change of weight Yes - No Difficulty in digesting - Yes No Diet type Fluid diet Soft blended diet or NPO Normal regular diet Serum-albumin (g/dl) <2.8 2.8 3.3 3.3 Serum-cholesterol (mg/dl) - <130 130 Total lymphocyte count (cells/mm 3 ) <800 800 1,500 1,500 Hemoglobin (g/dl) - Male <13.0 Male 13.0 Female <12.0 Female 12.0 C-reactive protein (mg/dl) - >1 1 Body mass index (kg/m 2 ) <18 or 25 18 25 Age (y) - >75 75 Status of malnutrition P1; High risk group of malnutrition; (more than 2 of R1) or (1 of R1 and more than 2 of R2) P2; Medium risk group of malnutrition; (1 of R1) or (more than 2 of R2) P3; Low risk group of malnutrition; the others R = risk factor; NPO = nothing by mouth. Volume 8, Number 1, April 2016 7
Eunmi Seol, et al. Table 3. Selected nutritional screening tools Institute Title of nutritional screening program Contents (a) Yonsei University Gangnam Severance Hospital (b) National Cancer Center (c) Seoul National University Bundang Hopital Nutritional Risk Screening Tool (NRST) Malnutrition Screening Tool for Cancer patients (MSTC) Nutrition Screening Index (NSI) NRST=albumin 1+age 2.5+Hct % 1.5+TLC 2* (*Coding: albumin <3.5 g/dl: 1, 3.5 g/dl: 0; age >65 y: 1, 65 y: 0; Hct <37%: 1, 37%: 0; TLC <1,800 cells/mm 3 : 1, 1,800 cells/mm 3 : 0) MSTC scoring= 0.116+(1.777 intake change)+(1.304 ECOG)+ (1.568 wt change)+( 0.187 BMI), P=exp(MSTC)/{1+exp(MSTC)} NSI=age 1+BMI 1.5+albumin 2+TLC 1.5* (*Coding: age >65 y: 1, 65 y: 2; BMI <18.5 kg/ m 2 : 1, 18.5 kg/ m 2 : 2; albumin <3.5 g/dl: 1, 3.5 g/dl: 2; TLC <900 cells/mm 3 : 1, 900 cells/mm 3 : 2) Hct = hematocrit; TLC = total lymphocyte count; BMI = body mass index; ECOG = Eastern Cooperative Oncology Group; wt = weight; exp = exponential function. 2) 강남세브란스병원영양검색도구 (Nutritional Risk Screening Tool, NRST) 강남세브란스병원은 810개의병상규모를가진의료기관으로다양한병명을가진환자의신속한영양불량평가를위하여성인입원환자 424명의자료를이용하여영양검색도구인 NRST 를개발하였다. NRST 도구개발및평가는 NRST 구성요소선정, NRST scoring scheme의탐색, NRST 평가의기준점설정, NRST의임상결과예측력재확인의 4단계과정을통해실시되었고, 영양평가지표로는 serum-albumin, 나이, hematocrit 수치, TLC가사용되었다. 본도구의 scoring scheme은 Table 3의 (a) 에제시되어있고, 측정결과 3.5점이상인경우영양불량위험군으로분류하였다. 도구의타당도는성인입원환자 142명을대상으로 NRST와 NRS-2002를통한초기영양평가결과를비교하여검증된바있고, NRST를이용한영양평가는재원일수, 합병증여부, 사망률, 질병예후를비롯한환자의임상적결과에대하여만족할만한예측력을가지는것으로나타났다. 14 한후, 그결과를 PG-SGA와비교하여검증된바있고, 이러한결과는합병증발생률, 재원일수, 삶의질과밀접한상관관계가있는것으로나타났다. 30 4) 분당서울대학교병원영양검색도구 (Nutrition Screening Index, NSI) 분당서울대학교병원은 1,328개의병상규모를가진의료기관으로, 환자의영양상태를최대한정확하게예측할수있는영양검색지표개발을위하여 PG-SGA를수행하여환자의영양상태를판정하고, 이결과를환자의현재영양상태를평가하는기준지표로삼아 NSI를개발하였다. 나이, BMI, serum-albumin, TLC의 4가지항목을 PG-SGA 결과를예측할수있는항목으로분류하였다. NSI scoring은 Table 3의 (c) 에제시되어있고, 측정값이 8.75 이하인경우영양불량고위험군으로분류하였다. 본도구의타당도는 20세이상성인환자 201명을대상으로영양상태와임상정보를조사한후 PG-SGA를수행하여환자의영양상태를판정하고그결과를비교하여검증되었다. 31 3) 국립암센터영양검색도구 (Malnutrition Screening Tool for Cancer patients, MSTC) 국립암센터는 605개의병상규모를가진의료기관으로, 2009 년암환자에게특화된영양검색도구인 MSTC를개발하였다. MSTC의영양평가지표는섭취량변화, ECOG (Eastern Cooperative Oncology Group) performance scale, 체중변화, BMI를포함하고, MSTC scoring은 Table 3의 (b) 에제시되어있다. 측정결과 P>0.13194인경우영양불량위험군으로 P 0.13194인경우영양불량비위험군으로분류하여영양지원을시행하도록설계되었다. 본도구의타당도는입원암환자 1,472명을대상으로 MSTC를이용하여초기영양평가를시행 결론 영양불량은질병치료지연, 감염률, 합병증발생률, 사망률, 재원기간, 의료비용의상승과밀접한상관관계를보인다. 따라서환자의영양문제를진단하고, 영양관리가필요한환자들을우선적으로선별하여개인에게맞는적절한영양치료적용을목표로하는영양검색및영양검색도구의중요성이증가하고있다. 현재외국에서개발되어세계적으로많이사용되고있는표준화된영양검색도구로는 NRS-2002, MUST, MNA, SNAQ, MST 등이있다. 이들은많은연구를통해서타당성을인정받았지만, 외국인환자를대상으로개발되었기때문에우리나라 8 Journal of Clinical Nutrition
입원환자에게적용하기에적합하지않을가능성이많고, 인력과시간이한정된국내병원실정상각각의도구를그대로도입하여사용하기에는어려움이있다. 이러한이유로국내많은병원에서는각병원의실정에맞게영양검색도구를개발하여사용하고있다. 병원의상황에맞게자체개발된영양검색도구는각병원환자군특성에따라영양불량위험도를민감하게반영할수있는영양평가지표를도구에포함시킬수있고, 병원내자동전산화시스템을이용한정보파악및환자의영양상태를모든의료진이쉽게접근하여공유할수있도록한다는장점이있다. 하지만, 병원별다양한도구를사용하는것은환자의영양불량평가에대한병원간의데이터공유를힘들게해정보호환을어렵게하고, 이것은결과적으로병원간에일관성있는영양지원을방해하는요인이된다. 또한, 집중영양치료료수가화적용후관심이증대되고있는 NST의운영방안결정, 향후 NST 가이드라인정립및환자영양상태개선을위한병원간일관된조치를취하기어렵게만든다. 따라서이러한문제점을해결하고병원간일관된도구를이용한영양검색을유도하기위하여학회차원에서현장의실정과전문가들의의견이반영된사용하기쉽고간편한영양검색도구의개발이필요하다고생각된다. REFERENCES 1. Norman K, Pichard C, Lochs H, Pirlich M. Prognostic impact of disease-related malnutrition. Clin Nutr 2008;27(1):5-15. 2. Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working Group. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003;22(3):321-36. 3. Cooper C, Brierley ER, Burden ST. Improving adherence to a care plan generated from the Malnutrition Universal Screening Tool. Eur J Clin Nutr 2013;67(2):174-9. 4. Kondrup J, Allison SP, Elia M, Vellas B, Plauth M; Educational and Clinical Practice Committee, European Society of Parenteral and Enteral Nutrition (ESPEN). ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003;22(4):415-21. 5. American Society for Parenteral and Enteral Nutrition. (A.S. P.E.N.) Board of Directors and Clinical Practice Committee. Definition of terms, style, and conventions used in A.S.P.E.N. Board of Directors-approved documnets [Internet]. Silver Spring:American Society for Parenteral and Enteral Nutrition; 2010 [cited 2016 Apr 1]. Available from: http://www. nutritioncare. org/ Clinical_Practice_Library. 6. Lee RD, Nieman DC. Nutritional assessment. 3rd ed. Boston: McGraw-Hill;2003. 7. Joint Commission on Accreditation of Healthcare Organizations. Comprehensive accreditation manual for hospitals. Chicago, IL:Joint Commission on Accreditation of Healthcare Organizations;2007. 8. KOIHA. Ministry for Health, Welfare and Family Affairs. 2014 Korea Institute for Health Care Accreditation (Version 2.0). Seoul:KOIHA;2014. 9. Hur H. Nutrition screening and assessment of patients for malnutrition. J Korean Soc Parenter Enter Nutr 2013;5(1):2-9. 10. Neelemaat F, Meijers J, Kruizenga H, van Ballegooijen H, van Bokhorst-de van der Schueren M. Comparison of five malnutrition screening tools in one hospital inpatient sample. J Clin Nurs 2011;20(15-16):2144-52. 11. Kruizenga HM, Van Tulder MW, Seidell JC, Thijs A, Ader HJ, Van Bokhorst-de van der Schueren MA. Effectiveness and costeffectiveness of early screening and treatment of malnourished patients. Am J Clin Nutr 2005;82(5):1082-9. 12. Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de van der Schueren MA. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 2005;24(1):75-82. 13. Rasmussen HH, Kondrup J, Ladefoged K, Staun M. Clinical nutrition in danish hospitals: a questionnaire-based investigation among doctors and nurses. Clin Nutr 1999;18(3):153-8. 14. Han JS, Lee SM, Chung HK, Ahn HS, Lee SM. Development and evaluation of a Nutritional Risk Screening Tool (NRST) for hospitalized patients. Korean J Nutr 2009;42(2):119-27. 15. Yun OH, Lee GH, Park YJ. Development of a simplified malnutrition screening tool for hospitalized patients and evaluation of its inter-methods reliability. J Nutr Health 2014; 47(2):124-33. 16. Sorensen J, Kondrup J, Prokopowicz J, Schiesser M, Krähenbühl L, Meier R, et al; EuroOOPS study group. EuroOOPS: an international, multicentre study to implement nutritional risk screening and evaluate clinical outcome. Clin Nutr 2008;27(3): 340-9. 17. Guo W, Ou G, Li X, Huang J, Liu J, Wei H. Screening of the nutritional risk of patients with gastric carcinoma before operation by NRS 2002 and its relationship with postoperative results. J Gastroenterol Hepatol 2010;25(4):800-3. 18. Kyle UG, Kossovsky MP, Karsegard VL, Pichard C. Comparison of tools for nutritional assessment and screening at hospital admission: a population study. Clin Nutr 2006;25(3):409-17. 19. Kondrup J, Johansen N, Plum LM, Bak L, Larsen IH, Martinsen A, et al. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr 2002;21(6):461-8. 20. Ruiz-López MD, Artacho R, Oliva P, Moreno-Torres R, Bolaños J, de Teresa C, et al. Nutritional risk in institutionalized older women determined by the Mini Nutritional Assessment test: what are the main factors? Nutrition 2003;19(9):767-71. 21. Malnutrition Advisory Group (MAG). MAG-Guidelines for Volume 8, Number 1, April 2016 9
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