MUST and BAPEN Nutrition Screening Week 2010. Liz Evans Nutrition Nurse Specialist Buckinghamshire Healthcare NHS Trust. Chair National Nurses Nutrition Group Council Member British Association of Enteral and Parental Nutrition.

Why Nutritional Screening? Nutritional screening is key to identifying those at risk of malnutrition and monitoring the progress of people who have been identified as malnourished” Improving Nutritional Care. A Joint Action Plan form the Department of Health and Nutrition Summit Stakeholders. Dept of Health 2007

Why MUST? In 2003 there were well over 50 published nutrition screening tools in clinical use. They took anything from 2 minutes to 30 minutes to complete. Many had not been tested for reliability and validity and lacked evidence base. Several different tools could be in use in the same hospital.

Confusion reigned. Nutrition screening – refers to a rapid, general evaluation to detect significant risk of malnutrition and to undertake a clear plan of action. Nutritional assessment is a more detailed, more specific and more in – depth evaluation of nutritional status by an expert so that specific dietary plans can be implemented ( Malnutrition Action Group the MUST report 2003). 4

Characteristics of a good screening tool. Should be easy to understand. Easy and quick to complete. Reliable, valid and evidence based. Should be relevant to different clinical conditions and care settings. Linked to a care plan. Should AID rather than replace clinical judgement. The same tool should be used to screen patients at risk of malnutrition as they move from one healthcare setting to another.

What is MUST? MUST’ is a five-step screening tool to identify adults, who are malnourished, at risk of malnutrition (undernutrition), or obese. It also includes management guidelines which can be used to develop a care plan. Developed in 2003 by the Malnutrition Action group - a sub group of BAPEN ( British Association of Parental and Enteral Nutrition) Intended to be universal – i.e in all acute and community settings Aimed to be quick and user friendly. 6

So what is MUST? Malnutrition Universal Screening Tool 7

Malnutrition Universal Screening Tool 8

Step 1 Aim: Determine BMI category score Need to obtain: - Weight - Height 9

Step 2 Aim: Determine unplanned weight loss score Need to: - Establish patients usual weight - Establish weight loss over previous 3-6months 10

Step 3 Aim: Establish acute disease effect score Need to: - Determine if patient is acutely ill - Establish if there has been no nutritional intake or likelihood of no intake for more than 5 days 11

Step 4 Aim: Obtain overall malnutrition risk score Need to: - Add scores from steps 1-3 - OR subjectively establish risk score 12

Step 5 Aim: Implementation of appropriate action plan Need to: - Obtain and follow MUST action plan - Know when to refer to a dietitian 13

Care plans Can be adapted to local policy Should be disseminated to members of the multidisciplinary team and across healthcare settings as patient between secondary and primary healthcare.

When should it be used? Routinely for patients admitted to hospitals and care homes New patients attending GP surgeries. In those over 75 years old Vulnerable groups

Nutrition Screening Week 2010 Third of a series of weeks commissioned by BAPEN. Previously Autumn 2007 and summer 2008 The survey was carried out from12-14th January 2010 reflecting the prevalence of ‘malnutrition ’during the winter. Reporters from 185 hospitals, 148 care homes and 20 mental health units in the UK completed a general questionnaire and an anonymous patient/client questionnaire as part of a national audit on nutritional screening using criteria based on the ‘Malnutrition Universal Screening Tool ’(‘MUST’) in all care settings. Data was collected on patients during the first three days of admission to hospitals and acute mental health units, and on residents admitted to care homes and long stay/rehabilitation mental health units in the previous six months.

Key points 1 There was a higher prevalence of malnutrition in patients admitted to hospital found in this survey. Nutritional screening policies vary between and within healthcare settings and so malnutrition continues to be under- recognised and under –treated. MUST was the most commonly used screening tool in all care settings. In some settings no screening tools were being used and/or no training on nutritional screening was being provided.

Key points 2 There was a lack of awareness of standards relating to weighing scales in all settings although centres that were aware knew that scales should be regularly calibrated. Whilst nutritional screening is linked to care planning in most institutions, this is not routinely followed through into discharge planning. Much of the ‘malnutrition’ present on admission to institutions originates in the community.

Combating Malnutrition – Recommendations for Action (BAPEN 2009) Public expenditure on disease related malnutrition in the UK in 2007 was estimated at 13 billion ( 80% of which was in England). At any given point in time more than three million people in the UK are either malnourished or at risk of malnutrition. The vast majority of these are living in the community. However hospital care provides a vital opportunity to identify malnutrition and initiate treatment.

Key Findings Screening for malnutrition as recommended by national bodies, is still not being carried out routinely by hospitals, care homes and primary care settings. One of the obstacles is the lack of suitable and accurate equipment to implement it. The education and training needs of health, housing and social care professionals are not being met in the area of nutritional care. Commissioners are not holding providers to account for delivering nutritional care due to the lack of guidance. Existing regulatory systems –across both health and social care providers – need review and improvement.

Incentives Requirements to conduct nutritional screening should be included in the Quality and Outcomes Framework of the GP contract. The importance of nutritional care should be reflected in the system of Payment by Results, both for secondary and primary care. The Department of Health should also consider including a serious instance of poor nutritional care in their list of “Never Events”.

Effective regulation. From April 2010 when full registration with CQC commences, health and social care providers will be obliged to undertake nutritional screening. All large health care providers should have a nominated individual at board level responsible and accountable for the delivery of effective nutritional care within their organisation. The Royal College of General Practitioners accreditation scheme should reflect the importance of ensuring that GP’s screen their patients for malnutrition, as per NICE guidance.

Effective Commissioning. Prioritise malnutrition in the planning of local services by including malnutrition indicators. The Dept of Health should issue guidance pioneered successfully in diabetes care that can demonstrate how an individual’s nutritional care needs should be identified and then managed between primary and secondary care providers and social care providers.

How can nurses make a difference? Trusts need to employ more Nutrition Nurse Specialists with the knowledge to push forward changes and educate staff. Senior nurses at board level should make nutritional care a priority and support protected mealtimes and mandatory nutrition training. Ward routines should be re assessed to ensure that patients are given the help they need at all times, not just lunchtime.

District nurses should be encouraged to undergo training in nutritional screening for their patients. Nursing managers should have nutrition and hydration as a quality and safety indicator as part of their performance review. Nursing managers should ensure that all their nursing staff understand that feeding and hydration are as important as infection control and cleaning.

However all this is pointless if we do not…. Listen to our patients and their carers and families. Work together across all care boundaries. Acknowledge mistakes and demonstrate how we can improve.

And finally… food for thought. Good nutritional care is a team effort. It is the responsibility of.. Nurses Dietitians Doctors. Pharmacists Speech therapists Physiotherapists Catering staff Managers……BUT also…

Patients and their friends and families.