Issue 128 malnutrition nutritional screening

COVER STORY

MALNUTRITION: NUTRITIONAL SCREENING AT THE NHS ‘FRONT DOOR’ - A REVIEW Penny Doyle Registered Dietitian Buckinghamshire Healthcare NHS Trust (BHT) at Stoke Mandeville Hospital (SMH), Aylesbury Penny has worked part-time for BHT for 20 months as a REACT dietitian and has had previous NHS roles within West Hertfordshire including elderly rehabilitation, GP clinics and FODMAP groups.

She is a member of the BDA Specialist Group for Older People and the BDA Freelance Group.

Penny is author of four health cookbooks.

REACT (Rapid Emergency Assessment and Care Team) is a multidisciplinary team operating at the ‘front door’ of busy Stoke Mandeville Hospital serving over 48,000 inpatients and 219,000 outpatients a year. Penny’s unique post was created in 2016 with the aim of providing nutritional support to a team of physiotherapists, OTs, SLTs, nurses, social workers and HCAs assessing new admissions to Assessment and Observation Unit (AOU), Short stay ward and A&E. The philosophy of REACT is to limit unnecessary hospital stays, facilitate earlier and safer discharges and prevent readmissions by multidisciplinary working. Whilst Penny is aware of similar NHS dietetic roles that are split between the Acute and Community, she is not aware of other roles that are solely hospital based.

She would, therefore, love to hear from other departments who have experience of comparable roles to discuss all aspects, including nutritional screening.

Twenty months into her role at REACT, Penny reflects on the challenges of obtaining useful nutritional screening at the dynamic, ‘front door’ of a busy Acute hospital.

The Malnutrition Universal Screening Tool (MUST) is the BHT tool on Acute wards, but compliance on Acute admissions and short stay wards could be improved, which would more readily identify suitable patients for intervention. If you would like to get in touch with Penny regarding this article, please email penny.doyle@buckshealthcare.nhs.uk.

Malnutrition is a large problem within the NHS and nutritional screening data has demonstrated that malnutrition remains a significant public health issue in both hospitals and the community.

The British Association of Parenteral and Enteral Nutrition (BAPEN) cites that more than 10% of those aged over 65 years are at medium to high risk of malnutrition and amongst residents in care homes as many as 40% could be suffering from malnutrition,1 which can rise to 60% amongst those in hospital.2 Even obese people can become malnourished when acutely unwell and will show symptoms of lethargy, poor concentration, altered mood and poor physical status. We

know that in both the under- and overweight, malnutrition and loss of weight are associated with falls, increased infection risk, worse surgical outcomes and loss of independence.

Primarily through the work of BAPEN, it is no surprise to fellow dietitians that malnutrition is often unrecognised and untreated in hospitals (both in- and out-patients), nursing homes and in the community.

This is a great cause for concern for healthcare professionals, national www.NHDmag.com October 2017 - Issue 128

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References 1. Wright C. CN Focus 2012;4(3):17-19. 2. Sharma M et al. Colorectal Disease 2013;15: 885-891. 3. Data on file. 4. Malnutrition Advisory Group (MAG) 2011.Malnutrition Universal Screening Tool. www.bapen.org.uk/pdfs/must/must_full.pdf. Accessed September 2016. *Of those who were at medium or high risk of malnutrition at baseline, 67% were at low risk of malnutrition on study completion.

All information correct at the time of print. December 2016

Stoke Mandeville Hospital (SMH) currently uses MUST which should be completed within 24 hours of admission . . . and which identifies patients at risk of undernutrition and who might benefit from nutrition support either with or without input from a dietitian. organisations and colleges, UK government departments, and the Council of Europe.

Nutritional screening, which is the focus of this article, refers to a rapid, general, often initial evaluation undertaken by nurses, medical or other staff, to detect significant risk of malnutrition and to implement a clear plan of action, such as simple dietary measures, or referral for expert advice.1 NICE advises that there are conflicting views on the value of nutritional screening in any setting, and there is no clear evidence as to whether screening in primary care or the wider community is really beneficial, or how it should be carried out - a Guideline Development Group (GDG) is taking this forward.3 In the meantime, and mindful of my remit to reduce undernutrition risk to BHT patients, accurate nutritional screening was always going to be a big part of my plan.

However, I am too encouraged and grateful for the key role that other ‘nutrition savvy’ health professionals play in helping to identify suitable patients. My REACT colleagues in all disciplines have proved helpful and supportive by encouraging MUST screening, but also simply by promoting excellent communication about a patient’s background, weight, and oral intake and sharing this appropriately in MDT and ward meetings.

MUST IN BUCKINGHAMSHIRE HEALTHCARE

Stoke Mandeville Hospital (SMH) currently uses MUST which should be completed within 24 hours of admission, following Buckinghamshire Healthcare NHS Trust (BHT)

policy and which identifies patients at risk of undernutrition who might benefit from nutrition support either with or without input from a dietitian. BHT process is that dietitians are only asked to see patients with scores of 2 or more who have ongoing weight loss, and/ or who are more complex patients, e.g. with dysphagia, diabetes or other diagnoses, though in practice many more are referred.

Local MUST training to Ward staff (RGNs, HCAs and Housekeepers) is provided by ward dietitians and also by some Nutrition Link Nurses (NLNs) where possible; SMH is also lucky to have an experienced Nutrition Specialist Nurse who provides annual training to NLNs and Housekeepers. The aim, in line with BAPEN advice, is that all staff can help identify patients who may benefit from input by a dietitian either in hospital or in the community. My REACT colleagues (HCPs and HCAs) have also proved supportive and willing to promote MUST scoring by ward staff (this score is including in the ‘Single Joint Assessment’ paperwork) and also in referring patients for dietetic assessment.

Annual BHT audit of MUST in 2016 looked at records of 301 patients over 22 wards (including SMH, Wycombe Hospital and three rehabilitation wards at Amersham Hospital) and indicated poor compliance of nutritional screening in SMH short stay and assessment wards. At a snapshot in time, the audit measured parts of all five steps of MUST including % completion of patient MUST forms in nursing notes, which included patient’s www.NHDmag.com October 2017 - Issue 128

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Date of preparation: August 2017 Job code: EN01293

MALNUTRITION weight, height, BMI score, weight loss score, acute disease effect score and total risk score.3 The audit also looked at whether MUST plans (0, 1 or 2) were correctly instigated and if repeat screening had taken place weekly.

A CASE FOR SUBJECTIVE MUST?

Subjective MUST – three questions Answering ‘Yes’ to one or more question indicates raised nutrition risk and can help assign a score to patients for whom weight/ height is not readily available.

• Clinical impression: does the patient look like they have a low BMI (note MUAC can be used to estimate this)?

• Does the patient look like they’ve had unplanned weight loss, e.g. loose rings or clothing and/or report recent limited food intake?

• Acute disease effect, i.e. Is their condition likely to limit their intake for five days or more, e.g. dysphagia, delirium?4

Unfortunately, this (and previous) audits have identified that some Acute admissions don't always receive screening within the first 24 hours of admission. Ward managers are aware of this and are keen to address this by enabling further staff training, but have also queried the applicability of MUST in this setting.

Patient turnover and clinical pressures are high, patients often staying in AOU <23 hours, though usually up to three to four days on short ARE THERE OTHER TOOLS FOR NUTRITIONAL stay wards. Lack of staff time and knowledge, SCREENING AT THE ‘FRONT DOOR’? clinical pressures and limited knowledge The difficulties in completing MUST in Acute about weight, height admissions/short stay or diet history, are all wards (SMH wards), as The difficulties in completing contributing factors with in any setting, should which many dietitians be addressed, as factors MUST in Acute admissions/ will resonate. However, contributing could include short stay wards (SMH I believe that we should limited understanding continue to support ward of benefit, time and wards), as in any setting, staff and also encourage opportunity. Acute Team should be addressed, use of ‘Subjective’ MUST dietitians, as good leaders, as factors contributing (see below), which should need to help overcome be valued equally, not as barriers which could could include limited a lesser tool. Subjective include training, improved understanding of benefit, MUST can also be quickly paperwork, adequate completed at bedside by equipment, e.g. scales and time and opportunity. any trained member of measures, and awareness the care team and can be of alternatives, e.g. equally useful in initiating a MUST care plan (1 Subjective MUST. Naturally, this will also lead to or 2) which is the crux of what we’re trying to consideration of other screening tools and whilst achieve. I would also argue that answering the this search wasn’t exhaustive, ones that I found three questions outlined below is a reasonable of interest included SNAQ (Short Nutritional part of the ‘receiving’ ward’s role in helping Assessment Questionnaire) and SGA (Subjective initiate good communication with family, carers Global Assessment). and other professionals. Ambulance crews In 2013, a large Dutch study5 concluded are usually excellent sources of information that the validity of both MUST and SNAQ is and, if relevant information is frequently insufficient for hospital outpatients, which communicated, it will become commonplace is possibly the most closely matched setting for all. for my REACT work and so is interesting to Nutrition assessment is key to any patient’s consider: 2,236 outpatients over a number of treatment and can start in the most basic form hospitals and departments were screened using by visual assessment at the time of a patient’s SNAQ and MUST to compare tools in this emergency admission. setting, and whilst SNAQ identified too few www.NHDmag.com October 2017 - Issue 128

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MALNUTRITION patients as undernourished, MUST identified too many. It was suggested that this is due to the MUST score’s weighting of acute disease effect; patients may well be misinterpreting this, so being classified as ‘high risk’ even with normal BMI and no known weight loss. By comparison, SNAQ’s underestimation can be most likely explained by the large number of patients who were classified as undernourished based on a low BMI. SNAQ was designed for inpatients for whom unintentional weight loss is measured and doesn’t include BMI, so would be missed. This study, therefore, advises simply to measure body weight, height and inquire about weight loss to determine undernutrition in hospital outpatients. However, a study by University Hospital Southampton NHS Trust in conjunction with Southampton University, published a study which used SNAQ to conclude that poor appetite was common among the older hospitalised women and was associated with a higher risk of poor healthcare outcomes.6 SGA is marketed as ‘a simple bedside method of assessing the risk of malnutrition and identifying those who would benefit from nutritional support’.7 It was founded by some international medics in 2004 and is validated in some settings including surgical, oncology and dialysis and ICU patients. SGA establishes predictive malnutrition risk using medical history and some physical measurements, but having briefly reviewed supporting literature, it strikes me as being more complex to train and

execute than MUST, so is not suitable for ‘front door’ screening.

SUMMARY

Whilst nutritional screening tools are helpful, BAPEN 1 acknowledges that ‘there is no gold standard for the assessment of nutritional status, and no tool can replace a clinician’s judgment in interpreting information obtained from history, physical examination, anthropometric measurements and laboratory’. This resonates well with me as I find that liaison with my colleagues has been a very powerful tool in helping to identifying patients at risk. BAPEN also advises that screening should be repeated at regular intervals and that the same tool should be used to screen patients as they move from one healthcare setting to another.

For the moment, therefore, I will continue to promote the use of MUST, using Subjective as needed, partly because it remains the most validated, user-friendly tool and is relatively easy to train, but also because it is widely used in the community and change would require a whole Trust review.

In the future, and maybe initiated by this article, I hope to liaise with other departments and consider other tools, possibly even something bespoke for REACT, to help identify the most suitable patients for dietetic input. Do write to me with your comments and feedback via email: penny.doyle@buckshealthcare.nhs.uk.

References: 1 MUST Nutritional Screening of Adults - a multidisciplinary responsibility. BAPEN Executive Summary (June 2012) 2 Development of a screening tool for assessing risk of undernutrition for patients in the community. Journal Human Nutrition & Dietetics (1998); 11 323-330 3 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. NICE CG 32- 2006 4 MUST Explanatory Booklet; BAPEN (2011). ISBN 978-1-899467-71-6 5 Leistra et al (2013). Validity of nutritional screening with MUST and SNAQ in hospital outpatients. Eur J Clin Nut 2013 6 Pilgrim et al (2015). Measuring Appetite with the Simplified Nutritional Appetite Questionnaire identifies hospitalised older people at risk of worse health outcomes. Journal of Nutrition Health and Ageing (2015) 7 www.subjectiveglobalassessment.com

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