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Universal Procedures for Food Security Screening – Adult/Pediatric/Neonatal – Emergency Department/Inpatient/Ambulatory

Universal Procedures for Food Security Screening – Adult/Pediatric/Neonatal – Emergency Department/Inpatient/Ambulatory - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


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Universal Procedures for Food Security
Screening – Adult/Pediatric/Neonatal –
Emergency Department/
Inpatient/Ambulatory
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY .......................................................................................................................3
SCOPE ................................................................................................................................................4
METHODOLOGY .................................................................................................................................5
DEFINITIONS ......................................................................................................................................6
INTRODUCTION .................................................................................................................................6
RECOMMENDATIONS .........................................................................................................................6
Screening ............................................................................................................................................... 6
Patient Education and Referral ............................................................................................................. 7
Monitoring ............................................................................................................................................ 8
Staff Training ......................................................................................................................................... 8
Special Considerations .......................................................................................................................... 9
UW HEALTH IMPLEMENTATION ........................................................................................................ 10
APPENDIX A. EVIDENCE GRADING SCHEME(S) ................................................................................... 13
REFERENCES .................................................................................................................................... 14
Contact for Content:
Name: Cassie Vanderwall, MS, RDN, CD, CDE, CPT – Clinical Nutrition
Phone Number: (608) 890-8528
Email Address: CVanderwall@uwhealth.org
Contact for Changes:
Name: Lindsey Spencer, MS – Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
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2
Guideline Author:
Cassie Vanderwall, MS, RDN, CD, CDE, CPT – Clinical Nutrition
Coordinating Team Members:
Susan Ehrlich, MD – General Pediatrics
Anne Gargano Ahmed, HungerCare Coalition
Kathy Chambers, Director - Patient and Family Connections
Barb Liegel, Director- Nursing & Coordinated Care
Kristine Moses, RN – General Pediatrics
Lisa Nackers, Clinical Psychologist – TAC Specialty Clinics
Alisa Sunness, RDN, CDE – Health Education
Margaret Eich, MS, RDN, CDE - Ambulatory
Lisa Davis, MS, RDN – Clinical Research Unit
Review Individuals/Bodies/Implementation Team:
Sandra Vergenz, RN, BSN - Nursing Informatics
Amber Canto, Wisconsin Nutrition Education Program (WNEP) State Coordinator
Megan Neuman, MD – General Pediatrics and Adolescent Medicine
Megan Waltz, MS, RDN, CD – Culinary and Clinical Nutrition Services, Director
Robin Crist – Clinical Nutrition, Manager
Emily Wallace, MS, RDN, CNSC - Clinical Nutrition, Manager
Patient and Family Advocacy Council (PFAC) – American Family Children’s Hospital (AFCH)
Leanne Hammerschmitt – Clinic Manager, AFCH Specialty Clinics
Anne Moseley – Director of Pediatric Nursing
Jennifer Cullen – Director, UW Health Ambulatory Operations
Elizabeth Kolk - Adult Ambulatory Clinic Manager
Wendy Adams – Director, UW Health Clinical Operations
Ann Malec - Director, Medical Nursing
Tracey Abitz – Director, Surgical Nursing
Dina Geier – Business Operations Manager, Emergency Department
Maria Brenny-Fitzpatrick – Director, Transitional Care
Rachel Nalwa – Nursing Clinic Manager
Mary Vasquez – Clinic Manager
Deb Brausen –Adult Specialty Clinics, Vice President
Laura Brunner – Nursing Specialist
Tracey Abitz – Surgical Nursing, Director
Rachel Edwards – Nursing Manager
Rena Doyle – Inpatient, Nurse
Brandon Stiefel – Inpatient, Nurse
Windy Smith – Nursing, Manager
Val Mack – Nursing, Manager
Clara Wittman – Emergency Services, Nursing
Julie Lechelt – Outcomes, Manager
Beth Boyle – Social Work and Spiritual Care, Manager
Megan Webber – Nursing Education Specialist
Clair Novak – Senior Clinical Systems Analyst
Scott Guetzlaff - Clinical Systems Analyst
Katelynn Berel – Clinical Systems Analyst
Ryley O’Brien – Clinical Content Facilitator
Committee Approvals/Dates:
Nutrition Committee (Last Periodic Review: 03/23/2017)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 04/27/2017)
Release Date: April 2017 | Next Review Date: April 2020
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Executive Summary
Guideline Overview
This guideline provides indications and recommendations for implementing and maintaining a
universal food security screening procedure to facilitate the identification of patients with food
insecurity.
Key Practice Recommendations
The present Clinical Practice Guideline (CPG) provides recommendations to standardize the
screening of patients for food security in the inpatient, emergency department, and ambulatory
settings for neonatal, pediatric and adult populations. The key recommendations include:
1. Within all settings- inpatient, emergency department and ambulatory- a qualified health care
provider should screen patients/caregivers to determine if they have or are at risk for food
insecurity.1-8 (UW Health GRADE High quality evidence, strong recommendation)
2. All qualified and interested health care providers should receive training on how to
approach, implement and monitor food security utilizing the food security screening
questions and procedure. 9-10 (UW Health GRADE High quality evidence, strong recommendation)
3. All patients/caregivers who answer “often true” or “sometimes true” to one or both of the
validated two-question food security screening questions, or screen positively for food
insecurity, should be offered additional resources based on their residential location.1-8, 10-12
(UW Health GRADE High quality evidence, strong recommendation)
4. All patients/caregivers who screen positively for food insecurity should be automatically
referred to supporting services for additional education on local food-related resources.1-8, 10-
11
(UW Health GRADE Moderate quality evidence, weak/conditional recommendation)
5. All patients who screen positively for food insecurity according to the UW Health Universal
Food Security Screening procedure should be identified for monitoring food security status
at all in-person patient encounters.1-8, 10-13 (UW Health GRADE High quality evidence, strong
recommendation)
Companion Documents
1. Standards of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory Clinical
Practice Guideline
2. UW Health Prevention and Management of Obesity – Pediatric – Ambulatory Clinical
Practice Guideline
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Scope
Disease/Condition(s): Food Insecurity is the “uncertain or limited access to enough food for an
active and healthy life” as assessed by a validated food security survey.11 Food insecurity is not
equivalent to hunger. Hunger is “an individual-level physiological condition that may result from
food insecurity. 14
Clinical Specialty: Primary Care, Nursing, Inpatient Care, Clinical Nutrition Services, Health
Education, Health Psychology, Psychiatry, Social Work, Case Management, Emergency
Department, Patient Resources
Intended Users: Medical Assistant, Nursing, Physician, Case Management, Social work
Objective(s): To provide evidence-based recommendations and guide practice in screening
patients/caregivers for food security so patients may be appropriately managed and cared for by
a UW Health practitioner and supported upon discharge by external resources and community
partners where and when they are needed.
Target Population:
ξ Any adult or pediatric patient (independent of age) seen within the inpatient, emergency
department or ambulatory settings at UW Health qualifies for screening for food security.
ξ Any adult patient/caregiver or pediatric patient (independent of age) who screens
positively for food insecurity.
Interventions and Practices Considered:
ξ Universal screening process for identifying food insecurity.
ξ Referral workflow for consult to social work services and case management for further
assessment, intervention, and documentation at every positive in-person patient
encounter screening. See Appendix B for ordering procedures.
ξ Referral process to community resources local to the patient’s residence.
ξ Patient education workflow and scripting (Appendix C), including provision of Do you
need food for you or your family? UW Health Patient Resources hand-out (Available in
English and Spanish).
ξ Workflow and scripting for monitoring and follow-up of food security (Appendix D).
Major Outcomes Considered:
ξ Ensures that all patients within UW Health are universally screened for food security.
ξ Directs patients with food insecurity to community resources and programs in interest of
patient safety and optimal patient care.
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Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.
Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Recognition of Potential Health Care Disparities:
Food insecurity is associated with many factors including poverty, unemployment and
underemployment, as well as family dynamics such as children in immigrant families, families
headed by single women, families with less education, and families experiencing parental
separation or divorce.1
Food insecurity is a perilous public health issue that impacts several domains of health for
patients and families in all communities. In 2015, 12.7% households in the United States were
identified as living in food insecure households without consistent access to adequate food;
these households included 13.1 million or nearly 17% of all children. This was an improvement
in food insecurity since 2014, partially due to increasing screening and intervention efforts
nation-wide.15 Ref
In the validation study for the Hunger Vital Sign™ by Children’s HealthWatch. Households that
affirmed food insecurity were more likely to be in fair or poor health, to have been hospitalized,
report depressive symptoms, and to have children at risk for developmental delays.16
Identification of patients and families with food insecurity is the first step in the process and
without a formal screening process, practitioners may not be able to tell who is food insecure.17
These patients should also be referred to community resources, such as 211, and/or social work
and/or case management for support. It is also critical to monitor and document food security
status and track interventions that address food insecurity over time.17
The objective of this guideline is to implement universal workflow for food security screening in
all patients seen at UW Health in an effort to overcome and prevent health care disparities and
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combat societal inequalities and inequities related to access to “enough food for an active,
healthy life” 14 – Food insecurity.
Definitions
The following definitions are verbatim from the U.S. Department of Agriculture (USDA)
Economic Research Service for Food Security in the U.S.14
Food Security is defined as assured “access by all people at all times to enough food for an
active, healthy life” and at a minimum the “ready availability of nutritionally adequate and safe
foods and the assured ability to acquire acceptable foods in a socially acceptable manner.”
Food Insecurity is defined as “uncertain or limited access to enough food for an active and
healthy life for all household members.” 14 Families may be considered food insecure if they:
ξ Experience anxiety about having enough food in the house.
ξ Have to purchase lower quality, lower variety, or less desirable food.
ξ Have to eat less or less often.
Introduction
Health inequities are avoidable inequalities in health between groups of people. Social and
economic conditions- and their effects on people’s lives- determine their risk of illness and their
actions taken to prevent them from becoming ill and/or seeking treatment for present illnesses.
Given that health is transmitted by social factors, to make the greatest impact on population
health, there is a great need to close the gap on inequities and address the root causes of
health.14, 18 Food insecurity can have serious health effects across the lifespan and has been
shown to increase the risk of developing and/or not taking action to prevent, manage, or treat a
variety of health conditions and disease states. Therefore, the medical community recognizes
the need to address the broader social determinants of health, including food security, at all
clinical touch-points.
Recommendations
Screening
Many national societies, including the American Academy of Pediatrics [AAP] Task Force on the
Family (2015) and American Diabetes Association (2017), are beginning to recognize the
potential effects of food security on overall health and development of chronic disease.1,19 The
AAP recommends extending the responsibilities of the provider to include screening,
assessment, and referral of parents for social problems that “can adversely affect the health and
emotional or social wellbeing of their child.” 1, 20-22 The literature also illustrates a correlation of
several triggers, or predictors of food insecurity, including:
ξ Sarcopenia and Falls in older adults 23-24
ξ Recent residential move 22-23
ξ Loss of employment 22-23
ξ Sequential hospital readmissions 22-26, 28-29
ξ Living in a household with an adult who has multiple chronic conditions 27
While food insecurity has been associated with many factors and multiple conditions, it is
important to note that there are no conclusive predictors of food insecurity and thus universal
screening is necessary. Early identification of food insecurity via screening questions has the
potential to influence the prevention and treatment of illness.1, 16, 28
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Screening questions should be universal and independent of setting and population within UW
Health. However, the workflow may differ according to setting. Within all settings- inpatient,
emergency department and ambulatory- a qualified health care provider should screen
patients/caregivers to determine if they have or are at risk for food insecurity.1-8 (UW Health
GRADE Moderate quality evidence, strong recommendation) A 2-question food security screening
tool, known as the Hunger Vital Sign™, has been validated for use in pediatric and adult
populations and has shown to be both specific and sensitive among low-income families.16
UW Health Food Security Screening, known as Hunger Vital Sign
For each of the following statements, please tell me which one is “often true”, “sometimes true”,
or “never true” for the past 12 months, that is since last [name of current month].
1. We (I) worried whether our food would run out before we (I) got money to buy more.
2. The food that we (I) bought just didn’t last and we (I) didn’t have money to get more.
POSITIVE SCREEN: All patients/caregivers who answer “often true” or “sometimes true” to one
or both of the validated two-question food security screening questions should be considered a
positive screen.
Patient Education and Referral
All patients/caregivers who screen positively for food insecurity should be automatically referred
to supporting services for additional education on food-related local resources.1-8, 10-11 (UW Health
GRADE Moderate quality evidence, weak/conditional recommendation) These resources should work
to address a patient’s mental health, stress, tiredness, worry, any strained familial relations, as
well as overt food-related or nutritional difficulties.29 Providers and clinical staff should answer
any questions or concerns, work to decrease stigma associated with not having enough food,
and may explore common barriers to utilizing food resources.
Reducing food insecurity via utilization of community and national programs can decrease a
patients’ risk of hospitalization, development of chronic disease, and behavioral and emotional
problems. All patients should be offered resources, including information about local food
pantries, based on their residential location.1-8,10-12 (UW Health Low quality evidence, strong
recommendation)
National Programs
1. Supplemental Nutrition Assistance Program (SNAP, formerly the Food Stamp Program)
2. Special Supplemental Nutrition Program for Women, Infants and Children (WIC)
3. The Child and Adult Care Food Program (CACEP)
4. National School Lunch and School Breakfast Programs
5. Summer Food Service Programs
6. The Emergency Food Assistance Program (TEFAP)
Wisconsin
1. Emergency Department Hunger Care Coalition Resources
2. Pediatrics Food Insecurity Hunger Care Coalition Resources
3. WIC- Wisconsin
4. Feeding America- Wisconsin
5. Second Harvest Food Bank of Southwestern Wisconsin
a. 2-1-1 Helpline. 2-1-1 is three-digit phone number that connects people with free and
confidential information and referral services. 2-1-1 provides callers with access to
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resources such as food pantries and meal sites, bill payment assistance, housing
search assistance, support groups, and community clinics. 2-1-1 is free, available
every hour of every day, can assist in 140 languages, and is accessible in every
community in Wisconsin.
b. FoodShare
c. Summer Food Service Program (SFSP)
d. Mobile Pantries
6. Hunger Task Force of Milwaukee
7. Dane County Food Pantry List
8. Home Health United Meals on Wheels
9. Independent Living, Inc. Meals on Wheels
Monitoring
All patients who screen positively for food insecurity should be identified for monitoring upon
follow-up visits and admissions. 1-8, 10-13 (UW Health GRADE High quality evidence, strong
recommendation) By monitoring the Hunger Vital Sign and thus a patient’s food security status
over time, healthcare providers can improve the overall health of their patients by seeing
through the recommended support services and interventions, as well as, identified barriers to
improving food insecurity. Health care systems can also report these data to public health
entities for more global monitoring.
Staff Training
Screening questions are only as effective as the training that accompanies the implementation.
Quality training on food security screening has the potential to significantly increase utilization of
the tool, identification of at-risk patients, as well as, increasing appropriate referrals to
resources.1-8, 10, 28
All qualified health care providers appointed to screen patients should receive training on how to
approach, implement and monitor food security utilizing the food security screening questions
and procedure. 8-9 (UW Health GRADE High quality evidence, strong recommendation) Suggested
questions are outlined below (Table 1) to support providers and clinical staff in approaching
conversations around food security with sensitivity while also asking probing questions to
identify specific stressors, coping strategies, and utilization of resources. 30-32
Table 1. Suggested Questions to Identify Potential Stressors
Potential
Stressor(s) Factors to Consider Suggested Question(s)
Medication cost Cost of medications may make it difficult to buy food
“Cost of medications can sometimes mean less money
to spend on food. Before I prescribe this medication for
you/your child, what concerns do you have, if any?”
Cost of living
Overall increase of cost of
living including energy, food,
child care, health costs may
compete with money for food
“Have you applied for SNAP benefits? You know, more
than half of all Americans get SNAP benefits at some
point in their adult life.”
Special diet
Therapeutic diets and/or
supplements can impact the
family food budget
“The supplemental drink I am prescribing for you/your
child today can be expensive. Before I make any
recommendations, I would like to get your permission
to discuss how things might impact your family food
budget.”
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Special Considerations
Food insecurity may involve a trade-off between purchasing more expensive nutritious food and
less expensive energy- and carbohydrate-dense processed foods.19 Higher food insecurity has
been associated with consuming more total calories, more fat and sugar, and a diet that is lower
in fruits and vegetables. Non-nutritional consequences, including low physical activity and
higher emotional and psychological stress, have also been correlated with food insecurity.29,33
As a result, food insecurity can have negative health effects across the lifespan and has been
shown to increase the risk of developing and/or not taking action to prevent or treat the
following:
ξ Low birth weight 22
ξ Poor maternal health 22, 34-35
ξ Anemia 34-36
ξ Diabetes 11, 19, 25, 37-38
ξ Hypertension 24-25, 39-40
ξ Congestive heart failure 40-41
ξ Obesity40
ξ Asthma41-42
ξ Mental illness43-44
There is also suggestive evidence that adults are often faced with difficult choices between
purchasing food and medication, especially among older adults, which results in sub-optimal
treatment and management of chronic diseases including cardiovascular disease, diabetes and
hypertension.19, 22-23, 35, 37 Providers should consider modifying care advice and interventions,
especially in patients with chronic conditions, based upon the availability of food or balance of
budgeted financial costs. (UW Health Low quality evidence, weak/conditional recommendation) For
example, children and adolescents with food insecurity are more likely to be iron deficient, and
supplementation may be necessary.1 Patients with diabetes may require alternative medication
recommendations or targets for glycemic control. Glipizide may be considered in patients with
diabetes and food insecurity on a sulfonylurea, due to its relatively short half-life and ability to be
taken immediately before meals (obviating the need to plan meals to an extent that may not be
attainable for patients with food insecurity).19 For patients on insulin, short-acting insulin
regimens delivered by a pen may be preferred due to their ability to be delivered immediately
after food consumption (whenever food becomes available).19
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UW Health Implementation
Potential Benefits:
ξ Standardization of the screening questions to assess food security throughout the
inpatient, emergency department and ambulatory care settings.
Potential Harms:
ξ If the screening questions and procedures are not implemented and delivered in a
sensitive manner, it may increase feelings of social stigmatization and anxiety.
Qualifying Statement:
This clinical practice guideline provides indications and evidence-based recommendations for
implementing and maintaining a universal food security screening workflow to facilitate the
identification of patients with food insecurity in a sensitive manner, in order to, reduce the health
risk associated with food insecurity and provide assistance and benefits for UW Health
patients/caregivers.
Pertinent UW Health Policies & Procedures
1. None identified.
Patient Resources
The following materials should be provided to the patient and family if they screen positively for
food insecurity:
1. Emergency Department Hunger Care Coalition Resources
2. Pediatrics Food Insecurity Hunger Care Coalition Resources
3. 2-1-1 Helpline. 2-1-1 is three-digit phone number that connects people with free and
confidential information and referral services. 2-1-1 provides callers with access to
resources such as food pantries and meal sites, bill payment assistance, housing search
assistance, support groups, and community clinics. 2-1-1 is free, available every hour of
every day, can assist in 140 languages, and is accessible in every community in
Wisconsin.
Supplemental Patient Resources
1. HFFY 588: Healthy Eating Habits After Age 65 (includes links to Senior Farmers' Market
Nutrition Program, Supplemental Nutrition Assistance Program, Meals on Meals)
2. Social Work Services Food and Clothing Resources
3. Feeding America Food Banks Serving Wisconsin
2-1-1 can also provide information on the Summer Food Service Program, which provides
free, nutritious meals and snacks to help children age 18 and under get the nutrition they
need throughout the summer months (June – August) when they are out of school. Patients
can also visit http://www.211wisconsin.org/ for more information
4. FoodShare Helpline. FoodShare Wisconsin (SNAP/food stamps) is a nutrition assistance
program that provides money for groceries on a Quest (EBT) card. Patients can call 1-877-
366-3635 or visit www.GetAQuestCard.org
5. WIC (Women, Infants and Children) . WIC is a supplemental nutrition and health program for
pregnant and post-partum women, infants, and children less than 5 years of age. WIC helps
families buy specific foods for good health, supports breastfeeding, and provides information
on nutrition, feeding, and offers community resources. There is no citizenship requirement
for WIC. Local WIC offices can be reached by calling the Maternal and Child Health Hotline
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at 1-800-722-2295 or visiting https://www.dhs.wisconsin.gov/wic/wic-offices.htm to find the
area WIC office closest to the patient.
6. FoodShare/Quest Card Online Application
7. Second Harvest Food Bank of Southern Wisconsin
8. Aging & Disability Resource Centers
9. Community Action Coalition for South Central Wisconsin
10. Hunger Task Force of Milwaukee
11. Feeding America
12. Jefferson County Food Assistance Resources brochure
13. Independent Living Evening Meals on Wheels
14. Home Health United Meals on Wheels
15. Dane County Food Pantry List
External Resources
For the Healthcare Professional-
1. HungerCare Food and Nutrition Screening Algorithm
2. Wisconsin FoodShare: includes income eligibility information, link to online application, and
list of foods that may be purchased with Quest card.
3. HungerCare Coalition Provider Resources
4. Wisconsin Women Infants and Children (WIC) eligibility
National Hunger Organizations
1. Feeding America
2. The Food Research and Action Center (FRAC)
3. USDA Supplemental Nutrition Assistance Program (SNAP)
Guideline Metrics
1. Proportion of patients screened within the inpatient setting.
2. Proportion of patients screened within the emergency department.
3. Proportion of patients screened within the ambulatory setting.
4. Proportion of patients who screened positively for food insecurity by clinical environment.
Implementation Plan/Clinical Tools
1. Guideline will be posted on U-Connect in a dedicated location for Clinical Practice
Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter and the
Department of Culinary and Clinical Nutrition Services weekly newsletter.
3. Notice will communicated via the following departments’ listservs:
a. Department of Family Medicine
b. Department of Psychology
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c. Department of Psychiatry
d. Department of Social Work
e. Department of General Pediatrics and Adolescent Medicine
f. Department of Culinary and Clinical Nutrition Services
g. Department of Emergency Medicine
h. Department of Case Management
4. Links to this guideline will be updated and/or added in Health Link or equivalent tools. This
may include smart set, e-referral, or consult order with specific questions.
Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.
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Appendix A. Evidence Grading Scheme(s)
Figure 1. GRADE Methodology adapted by UW Health
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.
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References
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3. Holben DH & Myles W. Food insecurity in the United States: its effect on our patients.
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4. Garg A, Boynton-Jarrett R, Dworkin PH. Avoiding the Unintended Consequences of
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Copyright © 2017 Univ ersity of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 04/2017CCKM@uwhealth.org