Quality statement 1: Screening for the risk of malnutrition

Quality statement

People in care settings are screened for the risk of malnutrition using a validated screening tool.

Rationale

Malnutrition has a wide-ranging impact on people's health and wellbeing. Screening for the risk of malnutrition in care settings is important for enabling early and effective interventions. It is important that tools are validated to ensure that screening is as accurate and reliable as possible.

Quality measure

Structure: a) Evidence of local arrangements to ensure that people in care settings are screened for the risk of malnutrition using a validated screening tool.

b) Evidence of local arrangements to ensure that screening for the risk of malnutrition is carried out by health and social care professionals who have undertaken training to use a validated screening tool.

c) Evidence of local arrangements to ensure that care settings have access to suitably calibrated equipment to enable accurate screening to be conducted.

Process: a) The proportion of people in care settings who are screened for the risk of malnutrition using a validated screening tool.

Numerator – the number of people in the denominator who are screened for the risk of malnutrition using a validated screening tool.

Denominator – the number of people in a care setting.

b) The proportion of people admitted to hospital who are re-screened weekly for the risk of malnutrition.

Numerator – the number of people in the denominator who are re-screened weekly for the risk of malnutrition.

Denominator – the number of people admitted to hospital.

c) The proportion of people in care home settings who are screened monthly for the risk of malnutrition.

Numerator – the number of people in the denominator who are screened monthly for the risk of malnutrition.

Denominator – the number of people in community care settings.

Outcome: a) Incidence of people at risk of malnutrition.

b) Prevalence of risk of malnutrition.

What the quality statement means for each audience

Service providers ensure systems are in place to screen people in the appropriate context (see definitions) for the risk of malnutrition using a validated screening tool.

Health and social care professionals ensure they screen people in their care (see definitions for settings) for the risk of malnutrition using a validated screening tool.

Commissioners ensure they commission services with local arrangements for screening in the appropriate care settings (see definitions) for the risk of malnutrition using a validated screening tool.

People admitted to hospital, attending an outpatient clinic for the first time or having care in a community setting are offered checks for their risk of malnutrition (not getting enough calories and nutrients, such as protein and vitamins, to meet the body's needs) using an accurate and reliable tool.

Source guidance

NICE clinical guideline 32 recommendations 1.2.2, 1.2.3 (key priorities for implementation), 1.2.4 and 1.2.5.

Data source

Structure: a), b) and c) Local data collection.

Process: a)

i) Local data collection. Acute hospitals, care homes and mental health trusts can review historical data on screening rates by reviewing the previous findings of the annual national nutrition screening survey conducted by the British Association for Parenteral and Enteral Nutrition (BAPEN).

ii) Department of Health Essence of Care benchmarks for food and drink, best practice indicators for factor 7 (screening and assessment) include measures for screening on admission to hospital, care homes and on registration with GP surgeries.

b) Local data collection

c) Local data collection

Outcome: a) and b) Local data collection.

Definitions

Care settings and eligibility

The term 'settings' refers to any care setting where there is a clinical concern about risk of malnutrition. These include the following, as set out in NICE clinical guideline 32.

  • All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and for outpatients if there is clinical concern.

  • Screening should take place on initial registration at general practice surgeries and when there is clinical concern. Screening should also be considered at other opportunities (for example, health checks, flu injections).

  • People in care homes on admission or where there is clinical concern. The topic expert group (TEG) advised that screening should be repeated monthly for people in this setting, or sooner if there is clinical concern.

  • The TEG, based on their expert opinion and professional practice advised that community settings include domiciliary care and local authority day care services and should have protocols for conducting screening when a person first accesses services.

  • Hospital departments who identify groups of patients with a low risk of malnutrition may opt out of screening these groups. Opt-out decisions should follow an explicit process via the local clinical governance structure involving specialists in nutrition support.

Clinical concern

Screening should be carried out when there is clinical concern, for example, if the person has unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose-fitting clothes or prolonged intercurrent illness.

Validated screening tool

As set out in NICE clinical guideline 32 recommendation 1.2.6: 'Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this'.

A validated tool should be used to conduct the screening to support accuracy and consistency within and between settings. The TEG agreed that a validated tool is a tool for which there is evidence that it has been tested to ensure that:

  • it measures what it is intended to measure

  • its measurements are reproducible.

  • it is user friendly

  • it has been developed by a multidisciplinary group.

The term 'screening' is not used here to refer to a national screening programme such as those recommended by the UK National Screening Committee.

Equality and diversity considerations

Nutritional screening should be available to everyone for whom it is appropriate, including people who are unconscious, sedated, unable to speak or communicate (because of language problems or because of their condition), and those who cannot be weighed or have their height measured. Some screening tools (such as MUST) cater for all of these people.