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Type and Title of Submission


Title:

Implementing nutritional screening in care homes

Description:

Peterborough PCT in collaboration with Nutricia have devised and implemented a new training programme, with the aim of implementing the NICE guidelines on nutritional screening in care homes. The programme is designed to teach care homes how to recognise and monitor residents for signs of under-nutrition using the Malnutrition Universal Screening Tool (MUST), and to take appropriate action and treat at risk residents.

Category:

Clinical

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG32 - Nutrition support in adults

Category(s) that most closely reflects the nature of the submission:

Implementation policy

Is the submission industry-sponsored in any way?

Yes
Nutricia worked collaboratively with Peterborough PCT dietitians and Older Peoples specialist team, to support the process of developing, setting up and implementing an education programme to tackle under-nutrition in local care homes.


Description of submission


Aim

Under-nutrition, is widely recognised as a significant burden for the NHS, currently costing the NHS in excess of 7.3 billion a year, three times the amount it costs to tackle obesity [1]. Across the UK 30% of care home residents are at risk of under nutrition [2]. This is particularly important in this group of vulnerable individuals as it can be detrimental clinically, impairing quality of life and delaying recovery from illness. The aim of the project was to implement NICE guidance surrounding nutritional screening through an education and training programme for care homes, in order to appropriately identify and manage under-nutrition which in turn may reduce overall NHS burden and be of benefit to the care home residents. An education programme was designed to teach care home staff about the importance of nutrition and how practically to recognise and monitor residents for signs of under-nutrition using the Malnutrition Universal Screening Tool [3] ('MUST'). Staff were trained to take appropriate action to treat at risk residents, and follow up training and monitoring was undertaken. In order to evaluate the effectiveness of the education programme an audit before and after implementation was undertaken. [1]. Elia, M, et al (2005). The cost of disease related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. Redditch, UK, BAPEN. [2]. Elia, M. (2007). Nutrition Screening survey and audit of adults on admission to hospital, care homes and mental health units. Redditch, UK, BAPEN. [3]. Elia M (2003). Screening for malnutrition: a multidisciplinary responsibility. Development and use of the 'Malnutrition Universal Screening Tool' ('MUST') for adults. Malnutrition Advisory Group, BAPEN. http://www.bapen.org.uk/must_tool.html

Objectives

1. Implement NICE guidance for nutrition support in care homes in order to generate local data on prevalence of malnutrition, and develop local policies for the detection and treatment of malnutrition. 2. Increase screening for malnutrition in care homes and use of appropriate care plans for nutrition support. 3. Disseminate information to GPs, other health professionals to highlight the importance of screening and appropriate treatment.

Context

Peterborough PCT has a process for implementing NICE guidelines and the dietetic service was required to produce an action plan in response to this guidance. The dietetic service was already working with care homes and had good relationships with care home managers. As a result, it was decided to prioritise the implementation of MUST in care homes. Prior to implementation of the education package, with the support of Nutricia staff, we gathered baseline data by undertaking an audit of all 19 care homes in Peterborough PCT. This audit assessed the current level of screening (including documentation of nutrition information), use of nutrition support and current level levels of malnutrition. It also assessed levels of equipment available (e.g. weighing scales) to ensure they were adequate to allow screening to occur in each care home. The aims of this baseline audit were: 1. To highlight the amount of nutrition information currently documented 2. To screen residents and understand local prevalence of malnutrition 3. To identify if nutrition support is used appropriately 4. To check that equipment is available for screening. Following the baseline audit, the education package was implemented into 6 care homes, 3 nursing homes, and 3 residential care homes, as a pilot. An evaluation of the process was undertaken by audit, pre and post implementation.

Methods

1. Implement NICE guidance for nutrition support in care homes in order to generate local data on prevalence of malnutrition, and develop local policies for the detection and treatment of malnutrition. Care homes where the education program was implemented now comply with NICE guidance. This programme will now we rolled out to all care homes in Peterborough. An audit of 703 care home residents showed that: - Screening, was undertaken using a variety of tools, which are difficult to interpret. - The prevalence of 'at risk' individuals was 32%, which was higher in nursing (38%) than residential homes (25%) (p<0.01). - 68% of 'at risk' residents were receiving no form of nutrition support. Care plans were developed and agreed locally. A standard care plan for each category, low, medium and high were used, these included both dietary advice and recommendations about oral nutritional supplements depending on severity of risk. These care plans were essential for the successful implementation of screening and treatment of under nutrition. 2. Increase screening for malnutrition in care homes and use of appropriate care plans for nutrition support. Before the project began just over half of the residents were routinely screened, after the education program, all residents were screened and had increased documentation of nutritional status. 100% of staff felt the training session improved their awareness of nutrition and were able to implement the correct nutritional care plan. There was an increased use of appropriate care plans for nutrition support following the education programme. 3. Disseminate information to GPs, other health professionals to highlight the importance of screening and appropriate treatment. Following the implementation of MUST and appropriate care planning, healthcare use was reduced compared to the period before implementation. Results will be shared with commissioners in the PCT including GPs.

Results and evaluation

The satisfaction of care home staff and success of the education programme and implementation of MUST has been evaluated. The pilot care homes have been regularly visited and monitored monthly, to provide any follow up training they needed, and to provide on site support. This was key to the success of the project. The implementation of this training program using MUST led to: - increased documentation - increased number of residents screened - increased use of appropriate care plans - increased carer knowledge of malnutrition and appropriate action - compliance with NICE guidance The initial baseline audit has been published in abstract form (Cawood et al 2008), and we plan to write up the data for full publication later this year. Dissemination to date has included: - Symposia presentation at 'PCT Live' annual conference (Oct 2007) - Symposia presentation at 'The British Dietetic Association' annual conference (June 2008) - Abstract in Journal Human Nutrition and Dietetics (August 2008) - Summary in Dietetics Today supplement (August 2008) - News report and DVD for NHS Alliance national conference (Oct 2008) AL Cawood, A Smith, J Dalrymple-Smith, R Bolch, S Pickles, S Church, RJ Stratton (2008). Prevalence of malnutrition and use of nutritional support in Peterborough Primary Care Trust. JHND; 21, P384

Key learning points

- Use a project planning approach; require structure and timelines for the implementation, training and evaluation. - Involve all stakeholders who will be part of the project at the beginning (particularly local GPs) so all are aware of project requirements - Identify a local champion at each care home who can be a point of contact and assist on site with ongoing training and promotion of MUST. - Be aware of the needs of local care home staff e.g. English not first language and implications of this for training programmes and training resources which may need adapting accordingly. - Ensure regular follow-up visits are made after initial training to reinforce the key messages. - Ensure time is taken for standardised care plans to be integrated and implemented in the care homes appropriately. - Be realistic in terms of the time required to ensure the information is embedded within some care homes, as enthusiasm and interest varies across care homes. - Ensure that post implementation, a monitoring system is established to ensure best practice is sustained. - Share results with key stake holders to promote the improved health care outcomes, appropriate prescribing & cost effectiveness of interventions.

Contact Details

Name:Alison Smith
Job Title:Specialist Dietitian
Organisation:Peterborough Community Services
Address:Peterborough PCT, Older People's Specialist Team, 1st Floor Winchester Place, Thorpe Rd
Town:Peterborough
Postcode:PE3 6AP
Phone:01733 882115/466625
Email:alison.smith@peterboroughpct.nhs.uk

 

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This page was last updated: 29 September 2008

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.