VOL: 103, ISSUE: 38, PAGE NO: 30-31
Jean Bell, MSc, BSc, RN
Jean Bell is research nurse, Dumfries and Galloway NHS health board(2007) Nutritional screening during hospital admission. www.nursingtimes.net ...
AbstractBell, J. (2007) Nutritional screening during hospital admission. www.nursingtimes.net
BACKGROUND: This article reports on a study on whether the mandatory requirements of NHS Quality Improvement Scotland's (QIS) (2003) clinical standard 2 on nutritional care in hospital were being achieved. This standard, which covers assessment, screening and care planning, requires the mandatory nutritional screening of patients within 24 hours of admission into Scottish hospitals and the implementation of a nutritional care plan where necessary. The standard also recommends constant patient evaluation/reassessment and a discharge plan.
AIM: To investigate if the mandatory requirements of NHS QIS standard 2 were achieved and to identify the issues affecting nurses' compliance with the standard.
METHOD: The study consisted of three stages: a casenote audit, which compared emergency medical with elective surgical patients; a nursing staff questionnaire; and two focus groups to investigate if the requirements of the standard were being met.
RESULTS: Few nurses were aware of the NHS QIS standard 2 and only 26& of surgical and medical patients were screened according to it.
CONCLUSION: There is a need to introduce a different validated and reliable nutritional screening tool. Further staff education is needed on nutrition.
This article, part 2, looks at the results in detail. Part 1 looked at background and methodology.
The study consisted of three stages: a case note audit, a nursing staff questionnaire and two focus groups to investigate if the mandatory requirements of the standard were being met.
Case note audit
Demographics of sample
The case note audit looked at 100 randomly selected case notes of admitted patients, 50 medical emergency and 50 surgical elective patients.
The case note audit found that on average 26% of patients were nutritionally screened. In addition the study found:
- The age of patients whose case notes were reviewed ranged from 18 to 95 years;
- The average age was 70 years for medical and 64 years for surgical patients;
- 37 (74%) medical patients were over 60;
- 33 (66%) surgical patients were over 60.
Length of stay
- The average stay was similar for both medical and surgical patients and was 13 and 14 days respectively;
- The length of stay ranged from 7 to 30 days for medical patients;
- For surgical patients it was 7-75 days for surgical patients.
The surgical patients were expected to be in hospital for a shorter period of time than medical patients, as they have their surgery, recover and are discharged. However, complications and poor health conditions post-theatre that required high-dependency and intensive care nursing prolonged their stay.
The case note audit found that on average 26% of patients were nutritionally screened:
- Some 22% of surgical patients were nutritionally screened;
- Nearly a third (30%) of medical patients were nutritionally screened;
- The majority of medical patients (88%) were admitted via the medical admissions ward with 31% screened;
- Some 50% of surgical patients were admitted via the admission lounge and only 18% were screened. The remaining 50% were admitted directly to the surgical wards and 4% were screened.
The general population is living longer but with more combined chronic long-term illnesses/conditions (Economics of Health Care, 2004).The figures from the study show two-thirds of all local hospital admissions were aged 60 and over and a quarter of these were aged 75 and over. However, the case note audit found that only 36% of patients from this age group (over 60) were nutritionally screened.
Referral to dietitian
Only 2% of both medical and surgical patients were referred to the dietitian.
- There was no documented evidence of patients being screened again after seven days in either setting; however, two surgical patients were screened again following transfer to other ward areas.
- Multiple transfers were not uncommon;
- Only 12% of the total sample remained in their admission ward;
- Some 54% were transferred once, 17% twice and 17% were transferred three or more times (two patients were transferred six times).
Questionnaire and focus group findings
There was a wide range of nursing experience within the chosen sample of 206 returned questionnaires. Nearly half (47%) had over 10 years' experience and 39% had five or fewer year. The majority (95%) of respondents have only ever used the current nutritional screening tool. Some 27% of staff were aware of the standard being assessed. The focus group medical nurses present felt few nursing staff were aware that QIS standard 2 was a standard for nutrition.
There was a consensus that improving communication links with community nurses/dietitians could help the nutritional condition of older patients before admission for surgery. One participant said:
'You can get an elderly patient coming in who isn't fit for surgery due to poor nutrition. It would help if they were pre-assessed by community nurses and started on food supplements prior to admission, and surgery could be delayed until their nutrition had improved, making them fitter for surgery.'
Nutritional screening tool
Only 27% stated that they always completed the screening tool, 35% only completed it sometimes and 12% never completed it. Some staff commented that the current tool was not very good. This may be why some nurses do not complete the screening tool. Perry (1997) confirmed nurses' need to find a screening tool that is simple to use and acceptable for patients. The majority of the focus group agreed every surgical patient was automatically nutritionally screened on admission to the ward using the standard nutritional screening tool and was referred to the dietitian when required. The nurses agreed clinical judgement was used and for young, fit and healthy patients who were admitted for short periods of time, post-operation care was more important.
Comments from participants included the following:
'I think you have to work through the admission process but it is not always required.'
'Everyone is screened but sometimes it is a paper exercise.'
'Depends whether elective trauma or minor.'
'Not done for young patients for minor procedures.'
'I did it off the top of my head, by looking at the patient.'
'Only if nutrition is highlighted as a problem on admission.'
Non-completion of the nutritional screening tool
The most common reason identified by almost a third of staff for not completing the screening tool was a lack of time. The second reason was a change in the patient's condition. Questionnaire responses for not completing the nutrition screening tool ranged fromrole differences to a lack of awareness as to whose role it is to screen patientsExamples of comments included: 'Usually done in a admission unit,' and 'Night duty hours - tends to be left for day staff.'
There were prioritisation issues, such as 'In our ward there are more acute emergencies to deal with', as well as education issues: 'Never knew what it was.'
Passing on information
One nurse spoke of how the information gathered from the screening tool is only useful if passed on to other members of the multidisciplinary team. The present nutritional screening tool is used across the medical wards but could be revised to includetick boxes for repeat screening.The rehabilitation ward uses different paperwork.
Repeat screening after seven days in hospital
Similarly to the case note audit, few staff - 3% always and 11% usually - screen patients again after seven days in hospital. The surgical focus group members admitted that repeat screening could be missed and the medical group felt it ideally should be carried out at each mealtime.
Responses included comments such as: 'Don't know how to', 'Forgot', 'I'll put my hand up, this is where we fall down, by not always reassessing'. Nutritional screening is still seen as the dietitian's role by some nursing staff.
All medical focus group staff screen patients transferred from other wards, using the nutritional chart on the Waterlow scale, observing what the patient is eating and using clinical judgement, with referral to the dietitian when required. They admitted that sometimes this was not completed on admission due to pressure of work and extra paperwork. The nutritional screening score is recorded in the nursing kardex and nutritional care plan. Staff commented:
'You should be reassessing every mealtime virtually, and we do that without thinking. It's not conscious thinking, it's something you do.'
'We take information from the patient and family and watch them on the ward to come to the nutritional score. We reassess everyone whether it has been done on admission or not.'
Repeat screeningafter transfer to another ward
The findings of the case note audit and questionnaire showed patients were not screened again on transfer to another ward, which could indicate valuable information had been omitted from patients' care. The nurses agreed nutritional repeat screening does not occur at a set time, but patients are reassessed at every mealtime, with information passed on verbally to the following shift to observe potential problems.
'Every one of our patients has nutritional screening done on transfer to our ward.'
'In a busy ward it is just another piece of paper for them to fill in at the end of a day and they are taking 30 admissions a day, you know I can see why bits of paper don't get done. It is the same with us if we take five transfers from the admission ward, along with our paperwork, not every bit of paper will get completed but that doesn't mean to say that someone is not screening the patients.'
Nutritional care plans
Only a quarter of respondents used a nutrition care plan always or usually. The majority (75%) used one sometimes or never. Comments included: 'Don't know much about care plans' and 'Work night shift'.Surgical wards do not have a current care plan and three of the medical wards have different ones. The nurses from intensive care and surgical high-dependency units use care plans for parenteral and enteral nutritional support feeding.
'We have nutritional care plans, we take bloods off in the morning, and, say the potassium levels are low, pharmacy will add extra to the feed to match it up.'
The orthopaedic staff use integrated care pathways (ICPs), which incorporate daily nutritional screening and care plans.
'We use ICPs which is basically a tick box for nutritionally stable, which is nurse assessed, and we would go on that if the person hasn't been referred when they first come in, if they have obviously deteriorated and develop sort of prolonged post-op nausea, we will refer them back to the dietitian.'
The focus group staff were undecided whether or not a generic care plan would be useful. The surgical nursing staff felt a generic care plan would be large and difficult to use to cover every specialty.
'Every specialty area is different and has its own needs. Certainly we are all surgical wards, but my patients' needs are surgical and different from an orthopaedic ward and a gynaecology ward.'
The medical nurses felt a generic care plan could be used.
'Care plans can be generic - most of what we use is generic, very few are individualised - every ward uses printed versions.'
Nurses' nutritional knowledge
Nearly half the staff (46%) agreed they were suitably informed and knowledgeable about patients' nutrition. However, 72% of staff would like to know more about nutritional issues for hospital inpatients, which gives amixed message. Focus group staff felt their knowledge of nutrition and screening was adequate, as the dietitian gives advice and information when required.
'I think the basic knowledge is absolutely fine, and nobody wants to be a nutritionist or dietitian.'
However, all staff agreed nutritional training might benefit consultants and surgical team members, as participants felt they appear to be slow at initiating nutritional support for patients.
'I often think consultants can be quite slow. For people that have major operations and for two or three days it's OK to have a saline/glucose drip, after which they may relapse and you then begin to wonder, well, they have major surgery and what replacement are they getting, but you sometimes think they can be a bit slow, they kind of pooh-pooh it.'
Nurses also felt that patients and relatives have a better knowledge of nutrition.
'Nutrition is in the media these days and people are quite knowledgeable anyway. They will come and say to you they are only ordering vegetables and no meat or soup and nothing else.'
Access to dietitians
All staff had daily access to a dietitian, pharmacist and other members of the multidisciplinary team, which enabled them to work closely to nutritionally support patients.
'The dietitian in our ward is excellent and normally if she is not there, someone else covers for her, plus our pharmacist is very hot on nutrition as well, so like my team they work very close together.'
'We don't have any issues or problems, as the dietitian attends the multidisciplinary meetings, so she knows the patients.'
Staff have access to a dietitian Monday to Friday. Supplements are available from the kitchen outside this time. Any nutritional problems occurring over the weekend were dealt with by nursing staff, dietetic cook or the dietitian on Monday.
Starting nutritional support
Participants start nutritional support following discussions with nursing staff, dietitian and the consultant.
'We call the dietitian or the doctor if we discover an underweight patient. Their bloods can show a protein and albumin deficiency indicating they may have not been eating or drinking, and their family indicate there is no food, nothing in the house, the fridge is empty.'
One nurse spoke of her experience on her ward of the successful 'Protected mealtimes' pilot.
'We had a trial for two months - it was spot on, and once the word got through that you can't come into the ward at meal times it worked. Patients got peace.
'We have tried to keep it on but we still get emergencies at mealtimes, and visitors now are the worst offenders - when they are told it is mealtime and they can't come in, they go off in the huff. We have medically ill patients and this system would be very helpful, especially for stroke feeding - we welcome visitors who come in to help feed patients.
'But it can be other visitors who come in that put off patients whose nutritional status is poor, because they don't feed well as they physically can't and they sit there with a towel and the food does go everywhere and they get embarrassed and to have visitors in there is not on - it's enough for that patient to put their knife and fork down and not eat, and that happens.'
Awareness of QIS food, fluid and nutrition standard 2
Some 54 (27%) of respondents were aware of the standard. Comments from the questionnaire stated: 'Heard of it via media', 'Have heard of staff going on a course' and 'Would like to know more'.
The nurses agreed ward HCAs were key members of the nutritional team.
'Our staff will also tell you if the patients have not touched a meal or their water and are aware of the patients' likes and dislikes. They would know if they can't eat or if they need [to be] fed.'
'Yes, they mainly dish out the meals and if you have not got observant auxiliaries you are in trouble.'
The results from the case note audit showed what was actually happening in relation to nutritional patient care. It suggested few patients are nutritionally screened; 15 medical and 11 surgical patients (26%) were actually screened [ok?].Seventy-two of the 100 patients were over 60 years of age, of which 26 were nutritionally screened (36%).However, in practice there appears to be daily informal, undocumented screening of patients' nutritional condition.
The answers given by the nursing staff to the questionnaire produced a different perspective than the case note audit. The focus groups allowed for further probing of staff which identified they were aware of the factors surrounding nutritional screening and gave the general consensus that nutritional screening was happening but not being documented in case notes. Conducting the study over the three stages has gathered more in-depth information, which confirms the rationale for the multi-dimensional approach to the data collection.
These are to ensure compliance with NHS QIS clinical standards for food, fluid and nutritional care in hospitals, standard 2.
The nutritional screening findings from the case note audit, nursing staff questionnaire and focus groups suggest several recommendations, which appear to be achievable with staff education and all members of the multidisciplinary team working together. These are as follows:
- Staff need to be aware of NHS QIS standard 2;
- Aim for 100% nutritional screening of patients within 24 hours of admission to hospital, to promote consistency with the standard;
- To comply with the mandatory requirements of the standard, the MUST [in full] tool should be introduced, as this is the nutritional screening tool of choice. It is validated and reliable and has a comprehensive training package available for nurses;
- Record the nutritional screening score in medical notes, to ensure staff are aware the patient has been screened;
- Nutritionally at-risk patients should be referred to a dietitian as soon as is practicable;
- Nursing staff attitudes towards nutritional screening need to change. Staff need to be aware of the potential poor outcome for patients if they become severely undernourished;
- Improve training on the use of the nutritional screening tool for all staff who have contact with patients, to ensure potential and actual nutritional problems can be identified quickly;
- A generic care plan should be devised and introduced (following adequate staff training on how to complete it);
- Fluid and food charts must be used for all patients, so that mealtime input can be monitored more efficiently;
- Discharge plans which include nutritional status must be drawn up on admission and reassessed before discharge to ensure patients' nutritional status is maintained once discharged;
- Management should consider the reintroduction of protected mealtimes to provide patients with a dedicated period of low ward activity to enjoy their meals without disruption;
- Using different coloured tray for at-risk patients to highlight to all staff their special needs, such as assistance with feeding or their mealtime input monitored;
- Nutrition should be given a higher profile to increase awareness of the standard, with yearly updates for all members of the multidisciplinary team, to maintain nutrition's high profile by reminding staff of the problems of under-nutrition;
- There is a need for champions, facilitators or a nutritional link member of staff on each ward, or a ward nutrition coordinator to facilitate the nutritional care of all patients, to raise the profile of nutrition and have a designated point of contact for training updates;
- Improve nutritional advice available at outpatient clinics, to identify potential problems of under-nutrition before the patient is admitted for surgery and correct the problem, which if untreated may cause complications for the patient or surgery cancellation.
For these recommendations to be effective there is a need to build on the findings of this study. The study's findings should be disseminated to all nursing and management staff. Practice facilitators, champions or link nurses are needed as a ward point of contact to maintain good communication links.
A strategic and structured approach to implementation requires planning and a timescale for action. There is a demand for a repeat audit and regular feedback to staff on performance to ensure uniform interpretation and implementation.
Although the response rate for the questionnaire was good (64%), it would have been interesting to discover why 36% chose not to take part. This poses the question: would the findings be different if more nurses had replied? In addition, why did six staff return blank questionnaires, when it would have been easier not to reply at all? Some staff commented that the current nutritional screening tool was unsuitable for purpose. This may be the reason why staff do not use it and possibly why some staff did not return the questionnaire.
The wording of the questionnaire, which asked for: always, usually, sometimes and never replies, may have affected nurses' answers. This was to prevent yes/no answers as they could have been construed as threatening. Some of the replies may be what the respondent thought the investigator was looking for. However, using the mixed method of data collection allowed for further exploration of the findings.
The presence of two nurse managers at the surgical focus group may have been daunting and intimidating for the less experienced ward staff, who may have felt unable to express their true thoughts and ideas.
Recommendations for future research
NHS QIS standard 2 is relatively new and no previous data exploring the issues identified in this study, such as awareness and compliance, is available. Further research is required in these areas, including work to identify the barriers to full implementation of the standard.
I have identified a number of suggestions for improving nutritional screening, such as the introduction of a different screening tool, protected meal times and coloured trays. Further research is required to discover which of these is most effective.
A larger longitudinal study is needed to explore whether nutritional care planning and screening tools are having an impact on patient health. This would provide a further dimension by investigating long-term compliance, patient outcomes and readmission rates.
Government bodies and professional groups have recognised that some patients may not be receiving adequate nutrition and at-risk patients may not be suitably screened while inpatients in hospital. Some patients may be discharged from hospital in a worse nutritional state than when they entered. It is predicted the decline in nutritional status could be largely prevented or treated with appropriate screening, assessment and management.
The key aims of this study were to investigate compliance with the mandatory requirements ofNHS QIS clinical standards for food, fluid and nutritional care in hospitals standard 2. The documented evidence of this study currently indicates that this hospital is not meeting the mandatory requirements of NHS QIS standard 2. It appears only slightly more than a quarter of patients admitted into hospital locally are being routinely nutritionally screened. Patients are not screened again on transfer to another ward, after being in hospital for seven days or more and care plans are not used. This nutritional study is important in raising nursing and management staff awareness of the issues surrounding NHS QIS standard 2. The study provides valuable information, which can be built on to improve patient nutritional health.
A lack of clarity in roles and responsibilities, with some nurses assuming others have carried out screening, seems to indicate that nurses' perception of what is happening is not what is actually being carried out. A constantly changing nursing role is putting pressure on nurse time, and so limiting their capacity to provide basic nursing care such as nursing assessment. Nurses are individually responsible for their own actions; they appear to be nutritionally screening patients and referring them to dietitians on the basis of intuition rather than the documented results of a screening tool.
All staff require training to be aware of the mandatory requirements of NHS QIS standard 2. Non-compliance with standard 2 may be due to the nurses' perception that the current nutritional screening tool is not user-friendly, with a lack of completion time due to increasing paperwork.
Clinical factors do combine with environmental factors influencing dietary intake. More emergency medical admissions were nutritionally screened on admission than surgical elective patients. Slightly more patients were screened after 24 hours in hospital and only a third of patients over 60 years were screened. The case note audit identified that 26% of patients were nutritionally screened, while the nurses' questionnaire found 27% of nurses were aware of NHS QIS standard 2 and the same number of nurses always nutritionally screened patients on admission to hospital.
The implications of these findings are significant for patients, nurses, clinicians and management. There is a pressing need to review the nutritional assessment of all patients admitted into hospital locally, to meet the NHS QIS clinical standards in food, fluid and nutritional care in hospitals standard 2.
In order to comply with NHS QIS standard 2, management and the dietetic department have now introduced a region-wide protected mealtimes policy, the MUST tool with nutritional training, a red tray alert system, a nutritional care plan and nutritional discharge planning. An audit will be carried out in the near future to assess whether the implementation of the new nutritional aids are being used and the resulting effects on patient care.
Economics of Health Care (2004) www.oheschools.org
NHS Quality ImprovementScotland (2003) Clinical Standards: Food, Fluid and Nutritional Care in Hospitals. Edinburgh: NHS Quality Improvement Scotland.
Perry, L. (1997) Nutrition: a hard nut to crack. An exploration of the knowledge, attitudes and activities of qualified nurses in relation to nutritional nursing care. Journal of Clinical Nursing; 6: 4, 315-324.
The dissertation from which this article was developed was supervised by Dr Valerie Blair, Senior Lecturer School of Health Studies, Bell College, Hamilton.