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Volume 7.18 - 2nd November 2017

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

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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. 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 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.

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Increase calorie intake by 55% IN ADDITION TO NORMAL diet2 HAVE 92% COMPLIANCE OF THE PRESCRIBED DAILY AMOUNT3 Reduce ‘MUST’ scoreS IN 67% OF PATIENTS*3,4

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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

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Local MUST training to Ward staff (RGNs, clinical pressures and limited knowledge about HCAs and Housekeepers) is provided by ward weight, height or diet history, are all contributing dietitians and also by some Nutrition Link factors with which many dietitians will resonate. Nurses (NLNs) where possible; SMH is also However, I believe that we should continue to lucky to have an experienced Nutrition Specialist support ward staff and also encourage use of Nurse who provides annual training to NLNs ‘Subjective’ MUST (see below), which should be and Housekeepers. The aim, in line with BAPEN valued equally, not as a lesser tool. Subjective advice, is that all staff can help identify patients MUST can also be quickly completed at bedside who may benefit from input by a dietitian either by any trained member of the care team and can in hospital or in the community. My REACT be equally useful in initiating a MUST care plan colleagues (HCPs and HCAs) have also proved (1 or 2) which is the crux of what we’re trying to supportive and willing to promote MUST scoring achieve. I would also argue that answering the by ward staff (this score is including in the three questions outlined below is a reasonable ‘Single Joint Assessment’ paperwork) and also in part of the ‘receiving’ ward’s role in helping referring patients for dietetic assessment. initiate good communication with family, carers Annual BHT audit of MUST in 2016 looked at and other professionals. Ambulance crews are records of 301 patients over 22 wards (including usually excellent sources of information and, if SMH, Wycombe Hospital and three rehabilitation relevant information is frequently communicated, wards at Amersham Hospital) and indicated poor it will become commonplace for all. compliance of nutritional Nutrition assessment screening in SMH short is key to any patient’s The difficulties in completing stay and assessment wards. treatment and can start At a snapshot in time, in the most basic form MUST in Acute admissions/ the audit measured parts by visual assessment at short stay wards (SMH of all five steps of MUST the time of a patient’s including % completion emergency admission. wards), as in any setting, of patient MUST forms Subjective MUST – three should be addressed, in nursing notes, which questions as factors contributing included patient’s weight, Answering ‘Yes’ to one or height, BMI score, weight more question indicates could include limited loss score, acute disease raised nutrition risk and understanding of benefit, effect score and total risk can help assign a score to score.3 The audit also patients for whom weight/ time and opportunity. looked at whether MUST height is not readily plans (0, 1 or 2) were available. correctly instigated and if repeat screening had • Clinical impression: does the patient look like taken place weekly. they have a low BMI (note MUAC can be used to estimate this)? A CASE FOR SUBJECTIVE MUST? • Does the patient look like they’ve had Unfortunately, this (and previous) audits have unplanned weight loss, e.g. loose rings or identified that some Acute admissions don't clothing and/or report recent limited food always receive screening within the first 24 intake? hours of admission. Ward managers are aware • Acute disease effect, i.e. Is their condition of this and are keen to address this by enabling likely to limit their intake for five days or further staff training, but have also queried the more, e.g. dysphagia, delirium?4 applicability of MUST in this setting. Patient turnover and clinical pressures are ARE THERE OTHER TOOLS FOR NUTRITIONAL high, patients often staying in AOU <23 hours, SCREENING AT THE ‘FRONT DOOR’? though usually up to three to four days on short The difficulties in completing MUST in Acute stay wards. Lack of staff time and knowledge, admissions/short stay wards (SMH wards), as Copyright © 2017 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

NHD CPD eArticle in any setting, should be addressed, as factors contributing could include limited understanding of benefit, time and opportunity. Acute Team dietitians, as good leaders, need to help overcome barriers which could include training, improved paperwork, adequate equipment, e.g. scales and measures, and awareness of alternatives, e.g. Subjective MUST. Naturally, this will also lead to consideration of other screening tools and whilst this search wasn’t exhaustive, ones that I found of interest included SNAQ (Short Nutritional Assessment Questionnaire) and SGA (Subjective Global Assessment). In 2013, a large Dutch study5 concluded that the validity of both MUST and SNAQ is insufficient for hospital outpatients, which is possibly the most closely matched setting for my REACT work and so is interesting to consider: 2,236 outpatients over a number of hospitals and departments were screened using SNAQ and MUST to compare tools in this setting, and whilst SNAQ identified too few 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

Volume 7.18 - 2nd November 2017

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, BAPEN1 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 Copyright © 2017 NH Publishing Ltd - All rights reserved. Available for printing and sharing for the use of CPD activities for personal use. Not for reproduction for publishing purposes without written permission from NH Publishing Ltd.

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Questions relating to: Malnutrition: nutritional screening at the NHS ‘front door’ - a review. Type your answers below, download and save or print for your records, or print and complete by hand. Q.1

What are the symptoms of malnutrition in the obese and elderly?

Q.2

Describe the role of nutritional screening in the management of malnutrition.

Q.3

What is the advice from BAPEN on screening for malnutrition in both hospital and the community settings?

Q.4

Explain the contributory factors that make it difficult for appropriate screening to take place.

Q.5

What is Subjective MUST?

Q.6

Describe the factors that can improve nutritional screening in hospitals.

Q.7

Explain the different outcomes of a MUST and SNAQ comparison study and the concluding advice given.

Q.8

Outline why the author of this article promotes the continued use of MUST.

Please type additional notes here . . .