BACKGROUND: A significant proportion of patients admitted to hospital are at risk of malnutrition.
AIM: This study aimed to audit use of the Malnutrition Universal Screening Tool (MUST).
METHOD: A core project group set up a pilot to trial the tool’s use, followed by full implementation in an acute hospital. Two audits were then carried out.
RESULTS AND DISCUSSION: The first audit revealed a significant increase in dietetic referrals as a result of using the tool, indicating an increase in the number of patients identified as at risk of malnutrition. The second audit showed continued improvements in carrying out nutritional screening.
CONCLUSION: This study shows that all patients should be screened on admission for malnutrition and appropriate treatment should be initiated.
Bernadette McWilliams, SEN, RGN, ACNS, is deputy ward manager, Mid-Ulster Hospital, County Derry, Northern Ireland.
Nutrition is essential for life, and is as vital as medication and other types of treatment. It is every individual nurse’s responsibility to maintain patient safety by developing effective, evidence-based practice and leadership at all levels.
Good nutrition, hydration and enjoyable mealtimes can dramatically improve older people’s health and well-being. It is unacceptable that in some institutions there is a failure to provide support at mealtimes for those who need it and a lack of good-quality, attractive and nutritious food – this constitutes a lack of respect for patients’ dignity (Department of Health and Nutrition Summit Stakeholder Group, 2007).
Nutrition is an essential part of patient care that is often neglected or overlooked. For most people, nutritional needs are met by an adequate diet but some patients are unable to meet their requirements (Box 1).
Box 1. Examples of patients who are unable to meet adequate nutritional requirements
Maintaining the nutritional state of patients who are in hospital is a fundamental aspect of care. However, the Audit Commission (2001) cited studies demonstrating that up to 40% of adult patients are either admitted to hospital with malnutrition, or become malnourished during their stay.
Malnutrition can be defined as a state of nutrition in which a deficiency, excess or imbalance of energy, protein or other nutrients, including minerals and vitamins, causes measurable adverse effects on a person’s body function and clinical outcome (Royal College of Physicians, 2002).
About 5% of the UK population are thought to be underweight, and it is estimated that approximately two million people are malnourished at any one time. Malnutrition can, and does, affect anyone in society (Gregory et al, 1990) but the most vulnerable groups include those with long-term conditions, older people, those recently discharged from hospital, and those who are poor or socially isolated. Malnutrition is both a cause and consequence of disease – it predisposes people to, and delays recovery from, illness.
Age concern (2006) argued that it is a ‘national scandal’ that six out of ten older people are at risk of becoming malnourished, or their situation deteriorating, in hospital. Patients who are malnourished stay in hospital longer, are three times more likely to develop complications during surgery, and have a higher mortality rate than those who are well fed (Age Concern, 2006).
Essence of care
The importance of nutrition was highlighted by the Essence of Care initiative (Modernisation Agency, 2003). In Northern Ireland, this initiative was led by the Chief Nursing Officer at the Department of Health, Social Services and Public Safety and taken forward in partnership with Northern Ireland Practice and Education Council for Nursing and Midwifery. It features benchmarks that cover eight areas of care, one of which focuses on food and nutrition.
Each area includes an overall patient-focused outcome and a number of factors that need to be considered to achieve this outcome. Within food and nutrition, two factors relate to screening: one on screening and assessment and the other on implementation of care. We recognised that we needed to implement a nutritional screening tool for inpatients.
The issue of malnutrition has been highlighted by a number of recent reports. Age Concern (2006) suggested that up to 14% of older people aged over 65 in the UK are malnourished; four out of ten older people admitted to hospital are malnourished on arrival.
A number of factors influence patients’ nutritional state. These may include a patient’s inability to eat, ongoing medical problems and issues with the food itself. The government has recognised these problems, and The NHS Plan (DH, 2000) included food in hospitals as a major area for improvement. This document set out how increased funding and reform aim to redress geographical inequalities, improve service standards and extend patient choice.
Hospital food is an essential element of patient care. Good food can encourage patients to eat well, aiding their recovery from surgery or illness. The Better Hospital Food Programme (NHS Estates, 2001) aimed to ensure the consistent delivery of food that is safe, high-quality, nutritious, well presented and served at a time that is convenient for patients.
The Council of Europe’s (2003) Resolution ResAP(2003)3 on Food and Nutritional Care in Hospitals published 10 key characteristics of good nutritional care in hospitals. Two of these relate to the MUST tool:
- All patients are screened on admission to identify malnutrition or those at risk of it. All patients are re-screened weekly;
- All patients have a care plan, which identifies their nutritional care needs and how they are to be met.
Following research carried out by Age Concern (2006), The Daily Telegraph featured an article suggesting that older patients who were vulnerable were starving in hospital because nurses did not have time to help them eat (Hall, 2006). However, the British Association for Parenteral and Enteral Nutrition (BAPEN) (2006) argued: ‘Doctors and nurses in hospital cannot tackle malnutrition on their own. It must be tackled where it starts – in the community – where one in eight older people are affected.’
NICE (2006) published a clinical guideline to help NHS staff identify patients who were malnourished or at risk of malnutrition. The guidance sets out the appropriate nutrition support that such patients should receive. In short, NICE recommends that:
- All hospital inpatients should be screened on admission and all outpatients at their first clinic appointment; this should involve weight and height measurement and BMI calculation;
- Nutrition support should be considered in people who are malnourished, that is, with a BMI of <18.5, or have had unintentional weight loss of more than 10% within the last 3–6 months;
- Nutrition support should be considered in people at risk of malnutrition, as defined by poor or no oral intake for more than five days;
- All acute hospital trusts should employ at least one specialist nutrition support nurse and establish a nutrition steering committee;
- All practitioners directly involved in patient care should receive education and training, relevant to their post, on the importance of providing adequate nutrition.
It is well known that many patients suffer from malnutrition while in hospital. However, the prevalence of malnutrition in hospitals is based on data collected over 10 years. In response to this, BAPEN undertook a prospective national survey of nutrition across both hospital and community settings (BAPEN, 2007a). The study showed the overall risk of malnutrition is 28%, irrespective of patients’ care settings. In general, risk increases significantly with age. BAPEN (2007b) then launched a new web-based information resource, Organisation of Food and Nutrition Support in Hospitals (available for download free of charge at www.bapen.org.uk), whose purpose is to help senior staff ensure the appropriate infrastructure, processes and resources are in place for good nutritional care.
Further guidance came from the DH and Nutrition Summit Stakeholder Group – the key priority for action 3 in Improving Nutritional Care (DH and Nutrition Summit Stakeholder Group, 2007) recommended: ‘All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients.’
The MUST tool
BAPEN’s Malnutrition Advisory Group launched the malnutrition universal screening tool (MUST) in 2003, in response to national concerns about the issue in hospitals. An accompanying report to launch the tool examined the need to screen for malnutrition in clinical practice, set out the criteria that needed to be fulfilled and described the development and use of the tool for adults (Malnutrition Advisory Group, 2003).
I was keen to oversee MUST’s implementation, following consultation with interested nursing staff. The key elements that needed to be addressed were weight loss/recent starvation, and current BMI and likely future changes. The scoring system showed whether a patient was low, medium or high risk.
I was identified as the project leader to implement the MUST tool. It is a validated nutritional screening tool, which may be applied to each patient admitted to hospital, with the goal of targeting any patient, regardless of age, who may be at risk of malnutrition. This problem does not only affect older people – although the risk of older people being malnourished is higher than that for younger people, many younger patients are also at significant risk.
This research project aimed to:
- Pilot the screening tool based on guidelines set out by the Malnutrition Advisory Group;
- Identify people at risk, according to the tool’s scoring system;
- Develop a care plan for patients at medium and high risk within the tool;
- Provide weekly, accurate documentation of nutritional status by recording each patient’s weight and BMI on their care plan;
- Ensure prompt referral to dietetic department and speech and language department;
- Promote evidence-based practice and deliver quality care to all patients.
Initially, a core group was established involving a cross-section of disciplines, such as nursing, catering, hotel/domestic services, dietetics, and speech and language. All members of the group had equal standing and all opinions were listened to and discussed. The group used Essence of Care guidelines and agreed best practice using the specific indicators for each area, as set out by the Modernisation Agency (2003). A scoring system was used to establish best/worst practice, with A being worst practice and E depicting best practice. The Essence of Care document features a total of 10 factors relating to food and nutrition, but only two are directly relevant to the ‘MUST’ tool:
- Screening and assessment to identify patients’ nutritional needs;
- Planning, implementation and evaluation of care for those patients who require a nutritional assessment.
The group discussed these factors and the care that needed to be implemented. An action plan was devised, delivered and re-evaluated to ensure care was being delivered at an optimum level. The group then agreed on the design of the core care plan that was to be incorporated into the screening tool, and also agreed an agenda. We sought views regarding documentation and implementation of the MUST tool through questionnaires. These posed questions on several aspects of care, for example:
- Was a screening tool available within the hospital setting?
- Were patients weighed routinely on admission?
- Where were patients’ weight measurements recorded, and was a BMI recorded?
- Were patients offered an adequate choice of meals?
- Other areas were also covered, such as resources, catering, availability of food out-of-hours and patient/family views.
The group audited the questionnaires and the core care plan was then revised on several occasions in consultation with all disciplines involved, ensuring evidence-based care was being delivered to a high standard. The group made several changes to the original care plan, including first-line nursing action of patients at medium risk, such as giving them high-calorie snacks, full cream milk if their condition allowed, a leaflet on ‘how to improve your appetite’, and generally trying to cater for their likes and dislikes.
A pilot scheme was set up in one ward initially and comments were sought from staff members about the MUST tool’s effectiveness. As with any pilot scheme, there were problems at the beginning – these were identified and addressed. Protected mealtimes were implemented in the pilot ward, with discussion with all disciplines, especially medical staff, as this was a particularly popular time to carry out a ward round.
The project group then arranged training for all staff in the hospital site. This was in the form of rolling sessions lasting approximately 30 minutes. These were facilitated by the project leader and the dietetic department. All staff are now trained in the use of the screening tool.
Every ward in the hospital is now using the screening tool. The results of the initial audit are outlined below. However, not everyone with a BMI of <18.5 is at high risk – some of these may be perfectly healthy and have a normally low BMI. This is why it is important to use all aspects of the tool accurately.
These are the main findings:
- 200 patients were screened initially, using the MUST tool;
- Ages of patients ranged from 16–98 years;
- All specialities were involved;
- A total of 163 dietetic referrals were made in a six-month period;
- There was a rise of 30–40% in dietetic referrals;
- A third (n = 65, 33%) of these patients were found to be at high risk of malnutrition, that is, with a BMI of <18.5;
- 18 patients (9%) were at medium risk of malnutrition;
- 117 patients (59%) were at low risk of malnutrition.
Every patient was screened for nutritional status on admission. Previously a dietetic referral was carried out if a patient’s Braden score was ≤18, or if there was obvious weight loss or concern. The tool’s implementation saw a significant increase in dietetic referrals and, therefore, an increase in the number of patients who were at risk of malnutrition being identified.
As a result of the increase in dietetic referrals, the trust has employed extra dietetic staff in the form of students to assist the two full-time dietitians. A more recent audit carried out from August 2006 to May 2007 continued to show an improvement in levels of nutritional screening. The results showed:
- 256 patients were screened on admission;
- 99 patients (39%) were referred to the dietitian;
- The table below outlines the results.
All patients are re-screened weekly and their weight is recorded on the core care plan, which is readily available for all staff to see. At the time of writing we noted a steady improvement in patients’ weight gain. However, an audit would need to be carried out to gather accurate data.
Changes to practice
The following were implemented at ward level:
- Protected mealtimes in all wards;
- The ward routine was altered to enable a quieter environment for patients at mealtimes;
- All staff gave assistance to those who needed it;
- Food was made available out of hours;
- Improved choice of menu for patients, with ethnic and kosher meals available;
- Introduction of high-calorie snacks and leaflets on ‘how to improve your appetite’;
- Introduction of food charts and core care plans;
- Confirmation of roles and responsibilities of all staff;
- Prompt dietetic referrals within a 24-hour period;
- Accurate documentation monitoring nutritional status;
- Raising staff awareness of the importance of recording a patient’s weight, height, BMI, risk category, risk score, recent nutritional status and overall health, on admission;
- Stressing the importance of cooperation between all disciplines, and prompt/relevant referrals.
The above changes show that staff are implementing the MUST tool efficiently and effectively, but there are some areas that need to be addressed and implemented. These include keeping the project’s momentum going, maintaining staff interest in the tool and, most importantly, monitoring and addressing the nutritional status of all patients, regardless of age or gender.
The initiative brought about a vast improvement in the identification of patients at risk of malnutrition, and care delivery is continually improving. It was relatively inexpensive to implement, as meetings were held during normal working hours – the main cost was typing the draft copy/final copy and photocopying the tool for use in all wards. MUST has also proved to be beneficial for all patients, easy to use and measurable in terms of patient care and satisfaction.
As with any new initiative or change to practice, some problems are bound to arise. Fortunately these could be solved with the cooperation and commitment of all disciplines.
The tool’s implementation was a new initiative that required commitment, time, energy and support from colleagues and management. The problems encountered were:
- Managing time, and arranging dates and times for future meetings;
- Ensuring protected time for project leader;
- Maintaining the momentum;
- Securing staff engagement with the new initiative – it is well known that people are often wary of change;
- Agreeing on the final draft of the care plan, such as how much emphasis was placed on the nursing/dietetic/catering input. With compromise and understanding all disciplines agreed with the final document;
- Implementing the action plan within the timescale set by the group;
- Being unable to implement areas identified within the action plan, such as changing the current design of wards to enable a dining room to be created, changing patients’ mealtimes or having catering facilities at night. These were areas that could not be altered completely, but alternative arrangements were put in place;
- Having limited secretarial support – this could cause delays in implementing changes to practice;
- Implementing protected mealtimes – this could be problematic, ensuring all disciplines adhered to the times set and did not carry out unnecessary duties;
- Ensuring the MUST tool was recorded accurately and consistently in all areas of the hospital, and continually auditing its effectiveness.
The MUST tool is now implemented in all areas of the hospital successfully. Use of the tool is audited every six months, and all wards are visited regularly to ensure it is being implemented accurately. It has proven to be invaluable in identifying patients at risk of malnutrition or undernutrition. Dietetic referrals continue to increase and nutritional status is treated as a result.
Previously, nutritional status was recognised by the patient’s general condition, Braden score, appearance and eating habits. Now, a tool is used to assist all staff in detecting malnutrition in patients who previously may have been missed. The tool is also a guide for new staff, enabling them to follow specific guidelines and implement quality care.
One area that should also be discussed when devising a screening tool is the issue of multiculturalism, as there are many different cultures and planning menus could prove problematic.
All hospitals should have a nutritional screening tool in place, as it safeguards patients and identifies areas of practice that may require changing. Change can be frightening and time consuming, but it can also be extremely satisfying and heartening to see patients receive the care they rightly deserve.
The following recommendations are suggestions to ensure best practice:
- All hospital trusts should have a nutrition working group;
- Every ward should identify members of staff to act as link nurses for food and nutrition;
- Gain support and commitment from all disciplines to ensure successful implementation of the screening tool;
- Protected mealtimes should be implemented in all areas, and signs clearly displayed to inform visitors and staff;
- Red-tray system or alternative should be implemented to identify patients at high risk of malnutrition;
- Staff need to be aware of their roles and responsibilities regarding nutrition;
- All patients should be screened;
- Improve patients’ choice of meals and ensure adherence to Better Food Programme guidelines;
- Ensure prompt referrals (within 24 hours of admission) to dietetic department;
- Frequent auditing should be carried out to ensure quality care;
- Staff should be encouraged to take ownership of the screening tool to ensure accurate documentation.
It is the responsibility of all hospital trusts to implement, evaluate and audit their core care plan and the MUST tool. However, the aim should remain unchanged: all patients should be screened on admission for malnutrition and treatment should be initiated and delivered to the highest possible standard.
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British Association for Parenteral and Enteral Nutrition (2007b) BAPEN launches web-based information resource Organisation of Food and Nutritional Support in Hospital (OFNoSH). www.bapen.org.uk
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