Findings from a national survey show that malnutrition is still under-recognised
In this article…
- Details of a national nutrition screening survey
- Why malnutrition is a growing problem
- How nurses can address the issue in hospitals and the community
Carolyn Best is nutrition nurse specialist, Winchester and Eastleigh Healthcare Trust, and communications officer for the National Nurses Nutrition Group.
Best C (2011) Malnutrition needs identifying in the community. Nursing Times; 107: 22, early online publication.
A recent survey found that in the UK, more than one in three adults are malnourished on admission to hospital or care homes, and one in five are malnourished on admission to mental health units. The Nutrition Screening Week report supported by the British Association of Parenteral and Enteral Nutrition was conducted to establish the prevalence of malnutrition in the UK. Data was collected from hospitals, care homes and mental health units. Empowering healthcare staff to recognise existing skills they have in this area and ensuring reporting mechanisms are used and followed up may help to tackle malnutrition in individuals.
Keywords: Nutrition, Nutritional screening tools, Malnutrition
- This article has been double-blind peer reviewed
A recent survey has revealed disturbing levels of malnutrition in hospitals and other health and social care settings, and suggested much of this was present on admission. The Nutrition Screening Week (NSW) report is the third in a series of four national nutrition screening surveys in the UK supported by the British Association of Parenteral and Enteral Nutrition (BAPEN, 2011). The purpose of the surveys is to capture information on rates of malnutrition and screening through all four seasons.
The first audit was undertaken in September 2007 (autumn), the second in July 2008 (summer) and this, the third audit in January 2010 (winter). In addition to the information collected from the UK in the previous two surveys, the third also included data from hospitals and care homes in the Republic of Ireland (ROI).
In total, 185 hospitals, 148 care homes and 20 mental health units in the UK, and 29 hospitals and 17 care homes in the ROI took part in the survey. The data collected focused on patient information for the first three days of admission to hospitals and acute mental health units, and on residents admitted to care homes and long-stay or rehabilitation mental health units in the previous six months.
Findings specific to the UK
Much of the “malnutrition” present on admission to institutions originated in the community, with more than one in three adults being malnourished on admission to hospital or care homes and one in five on admission to mental health units in the UK. Most of those affected were in the high-risk category. This was a higher recorded level of malnutrition than in the previous two NSW surveys.
The Malnutrition Universal Screening Tool (MUST) was the most commonly used screening tool in all settings (BAPEN, 2004). However, in some centres no screening tools were being used and no training on nutritional screening was provided. There was also a lack of awareness of standards relating to weighing scales in all settings.
While nutritional screening is linked to care plans this is not routinely followed through into discharge planning.
Findings specific to the ROI
Nutritional screening policies and practice varied between and within healthcare settings. While all centres involved had access to nutrition and dietetic services most hospitals had no screening policy in place or access to a nutrition support team. Nutritional screening tools were not used in all hospitals but where screening was undertaken, MUST was the most commonly used tool. All care homes used a nutritional screening tool.
There was a lack of awareness of standards relating to weighing scales in all settings and no area recorded having specific standards relating to weighing scales. Nutritional screening was linked to care plans in about half of hospitals in the survey, but this was not routinely followed through into discharge planning. All care homes linked the results of nutritional screening to care plans.
Implications for nursing
The National Institute for Health and Clinical Excellence (2006) has stated all inpatients should be screened on admission and all outpatients at their first clinic appointment. Screening should then be repeated weekly for inpatients and when there is clinical concern for outpatients. People in care homes should be screened on admission and when there are clinical concerns.
Nurses are usually responsible for completing a nutritional screening tool in hospital because screening is often part of the admission assessment. However, simply completing a screening tool and recording a risk score will not be enough to manage a patient’s poor nutritional state.
As the NSW 2010 survey showed, MUST is the commonly used screening tool, and this includes recommendations for nursing actions. Nurses need to be confident they can safely implement a series of actions at ward level that will benefit patients before referring them to other health professionals. Implementing nutritional action plans early in patients’ admissions means corrective measures can begin promptly.
However, as the NSW 2010 report shows, many patients being admitted to hospital are already malnourished, so identifying and managing the problem ideally needs to be addressed by community services (BAPEN, 2011)The report highlighted that nutritional screening policies and practice vary between and within healthcare settings, so malnutrition continues to be under-recognised and under-treated. When MUST was first developed it was intended for use across all healthcare settings (BAPEN, 2004). If used in this way screening scores could be transferred between primary and acute care, giving a clear record of patients’ nutritional status and risk of malnutrition. However, as yet, in many areas this tends not to happen.
Although the NSW survey does not explore malnutrition in the community, earlier studies suggested there was evidence of malnutrition in 10% of the general population (Elia, 2003). Elia and Russell (2009) reported at any point in time, three million people were at a high risk of malnutrition in the UK, with the majority (93%) living in the community. They suggested that without action, the burden of malnutrition would rise, because of the ageing population and increase in long-term conditions.
Looking at this issue, the European Nutrition Health Alliance (ENHA, 2006) stated that addressing malnutrition in the community would be a complex task and that the NHS or government alone would be insufficient to tackle the problem. The alliance suggested that tackling malnutrition should involve “an effective delivery chain that cuts across the domains of multiple national and local public agencies, the private, and the non-profit sector”.
In its report Older People Living in the Community, the Scottish Government recognised that malnutrition could be prevented or treated by implementing appropriate nutrition screening and management in the community. However, the report admitted that current use of screening and nutritional management was limited and that the cost-effectiveness of nutritional screening in the community and its impact on outcomes were not known (Scottish Government, 2009).
In 2006, NICE stated that all health professionals directly involved in caring for patients in both acute and primary care should receive education and training relevant to their post on the importance of providing adequate nutrition. This is possibly another area that needs attention, but with the financial constraints currently being imposed on health services, nursing staff will find it difficult to access training.
Recognising the prevalence of malnutrition in the community does not guarantee that anything is being done to improve the situation. All health professionals have a responsibility to patients in their care. While screening programmes are not streamlined, visually assessing and reporting on concerns regarding patients’ nutritional state can be done fairly easily, for example by recognising that their clothes are looser or that prepared food is not being eaten. If health professionals were empowered to recognise the skills they already have and reporting mechanisms were used and followed up, this could go some way to addressing the issue.
One area where work is being done to address the issue of nutrition screening in the community is the County Durham and Darlington Community Health Services, which has developed a training package called Focus on Undernutrition (FoU). Rachael Masters, team lead dietitian for FoU says the aim of project is to ensure the timely detection and treatment of undernourished patients, and appropriate prescribing of nutritional supplements. FoU promotes the use of MUST in a variety of settings by providing support and accredited training on identifying and treating undernutrition. The training is standardised throughout all health and social care settings in the county to ensure seamless patient care, and is linked to regional Commissioning for Quality and Innovation (CQUIN), social service commissioning frameworks, clinical policy and care pathways. There is a great deal of interest in this initiative and it will be interesting to review its success in the next year or so.
Meanwhile, to complete the seasonal cycle hospitals, care homes and mental health units across the UK have just finished collecting data for the final NSW survey for spring and we look forward to looking at those findings and to seeing how they can help us to address malnutrition in the UK. NT
British Association for Parenteral and Enteral Nutrition (2011) Nutrition Screening Survey in the UK and Republic of Ireland in 2010. A Report by the British Association for Parenteral and Enteral Nutrition. Worcester: BAPEN.
British Association for Parenteral and Enteral Nutrition (2004) Malnutrition Universal Screening Tool. The MUST Itself.
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Elia M, Russell CA (2009) Combating Malnutrition: Recommendations for Action: A Report From the Advisory Group on Malnutrition. Worcester: BAPEN.
European Nutrition Health Alliance (2006) Malnutrition Among Older People in the Community: Policy Recommendations for Change. A UK Policy Report by: The European Nutrition for Health Alliance and (BAPEN)British Association for Parenteral and Enteral Nutrition. London: ENHA.
National Institute for Health and Clinical Excellence (2006) Nutrition Support for Adults. Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Clinical Guideline 32. London: NICE.
The Scottish Government (2009) Older People Living in the Community - Nutritional Needs, Barriers and Interventions: a Literature Review Online.