Shared learning database

Published date:
January 2012

Our new approach to audit was going to be very different in order to effectively drive improvement. Every ward would be required to participate in repeated monthly audits with feedback shared at all levels.

The message had gone out across the entire trust: Nutrition screening using the Malnutrition Universal Screening Tool (MUST) was a 'MUST do' for everyone and we MUST do better. The findings would highlight our weakness. It was a bumpy journey. Then the findings enabled good practice to be rewarded where screening and care planning was improving month on month. Wards became eager to demonstrate their compliance.

High targets were set by our Trust board who took a vested interest every month without fail to scrutinise and challenge the results. Wards began to shine as their monthly compliance, with MUST screening for every patient, rose impressively.

Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

The overall aim of this initiative was to improve the identification and treatment of malnutrition risk in adults through the clinical audit process by:
1) A trust wide multi-disciplinary approach.
2) Assessing our compliance with the trust malnutrition policy based on NICE CG32 through the development of on-line data collection and electronic analysis.
3) Providing smart cost-effective and efficient ways of reporting the identification and treatment of malnutrition risk on a trust wide basis for the adult inpatient hospital population
4) To use a regular data collection strategy to identify trends and areas of good and bad practice enabling focussed actions, turning weaknesses into strengths.

Authors: P. Norman(1), J. Barton(2), E.R. Walters(3), H. Warwick(3), 1:Clinical Effectiveness Manager, University Hospital Southampton NHS Foundation Trust, SO16 6YD 2:Associate Director of Nursing and Patient Experience, University Hospital Southampton NHS Foundation Trust, SO16 6YD, 3: Department of Nutrition and Dietetics, University Hospital Southampton NHS Foundation Trust, SO16 6YD. For the purposes of this abstract the focus will be on two key standards from the NICE guidance however the audit has collected and produced more data than we are able to report within the confines of the abstract:

The trust's policy for treatment of malnutrition in adults is based upon the NICE clinical guideline 32: nutritional support in adults

NICE CG32 (excerpt 1.2.2 page 13)
"All hospital inpatients on admission and all outpatients at their first clinic appointment should be screened. Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients".

NICE CG32 (excerpt Appendix D, Audit criterion)
"A clear process should be established for documenting the outcomes of screening (that is, 'nutritional risk score') and the subsequent actions (that is, 'nutritional care plan') taken if the patient is recognised as malnourished or at risk of malnutrition".

The main objectives were therefore to improving the identification and treatment of malnutrition risk in adults by succeeding in reaching the following:
1) Improving compliance with nutritional screening within 24 hours of admission to reach a target of 95%.
2) Improving compliance with evidence of nutrition care plans for patients at malnutrition risk.
3) Improve compliance with re-screening patients who were inpatients for longer than 7 days.
4) Providing data for the purposes of reporting internally and externally to the organisation.

Reasons for implementing your project

Since 2006 our Trust has had a policy for identifying and treating malnutrition risk in adults using the malnutrition universal screening tool (MUST). Monitoring compliance has proved challenging, being a large hospital (1100 beds) with high patient turnover. 'Snapshot' audits across the trust proved time consuming and did not provide trust wide assurance. The 'hawthorne effect' was experienced with planned audits, where practice temporarily improved during the audit period. Nutrition is a top priority for the trust, and a more robust approach to monitoring identification and treatment of patients with malnutrition risk was needed.

An online audit questionnaire and reporting system was developed to demonstrate compliance with trust policy using Snap software. The audit was initially planned to be monthly for at least 6 months with February 2011 being the pilot month when the presence of a nutrition care plan for medium and high risk patients was identified at 53% (n=62). The pilot phase identified nutritional screening within 24 hours of admission was 81% (n=398). Each ward area was asked to continue to submit a monthly audit of 10 patients, with data entered by nursing staff directly into the on-line questionnaire, minimising data transfer work and reducing errors. A monthly summary report provides compliance data at both ward and trust level. Validation of results is possible as patient hospital numbers are included in the audit data.

The trust wide approach enabled us to combine our resources across the organisation and pool together the data. Opportunities arose to benchmark against other areas. Cost savings arising from identifying people at risk of malnutrition are well documented and include increased complications, reduced survival, greater hospital admission rates, increased length of stay and reduced quality of life. Addressing the issues is cost effective and benefits the patients by reducing morbidity and mortality.

How did you implement the project

An on-line audit tool was developed using Snap audit software (Appendix A, pg 1-2)
Sample:10 cases per ward area per month, GICU A and GICU B-10 cases, Admissions unit-0 cases.

Sampling technique: Purposive sampling. Not applicable means:
a) Patient receiving end of life care
b) It was documented in the notes 'there was no intent to treat malnutrition'
c) Screened at pre-assessment within one week prior to assessment.
Exceptions: None. Audit type & data source: A concurrent audit of patients notes

Communication and leadership: Initially the associate director of nursing communicated details of the audit to all matrons for cascading on to their clinical leaders on each ward. The audit was also communicated in core brief. This was followed up by additional support at the nutrition link nurse training days, via emails and on the ward support from the project team and clinical dietitians.

Achievement of the 95% MUST nutrition screening (within 24 hours) target was dependent on high level support within the organisation, monthly progress monitoring, involvement of all wards and accountability for results.

A serious approach to the trust's top Patient Improvement Framework (PIF) priority supported by A) Leadership-see email examples of communication in Appendix A (pages 4,5). B) Accountability at ward level sits with the Matrons C) Snap e-Results viewer-free technology enabling regular data access D) Clinical Quality Dashboard-portal for communicating key targets E) Staff knowing who the leaders are and ensuring they are approachable (example 3 page 5) F) Continuous communication to reflect upon the results and review the findings making appropriate modifications to the audit tool as required G) A multi-disciplinary team approach was essential.

Monthly data publication (charts, tables etc.)-see Appendix A (page 12) is quick to complete including import of cases using Snap e-Results viewer software.

Key findings

When the 95% target set for screening within 24 hours was not reached, further investigation highlighted an outlier. Data before the outlier is extrapolated is shown in Graph 1 Appendix>
The audit findings showed that the Acute medical unit (AMU) admitted 30% of all cases. Other wards contributed a maximum of 3% each of the overall admissions. Compliance with screening was consistently lower on AMU than other areas therefore it was declared an outlier. In the last quarter of 2011, a decision was made to enlist a dedicated matron to engage with staff, working with them to raise awareness of the standards and improve compliance and also to understand what the barriers were. Graph 2 Appendix A, shows for the last quarter compliance has reached the 95% target after extrapolation of outlier. The audit helped to improve compliance and reach the target set by the Trust board at the start of the audit.

Graph 3, Appendix A shows compliance on AMU increased from 73% to 82%.

The details in Graph 4, Appendix A shows improved numbers of at risk patients with nutrition plan.

Graph 5, Appendix A shows repeat screening improved from 83% to 89%.

The overall impact of undertaking the audit was to improve the rate of screening upon admission by approximately 10% as shown in Table 1, appendix A.

1) Improved compliance with evidence of nutrition care plans for patients at malnutrition risk by 44% from 53% (n=62) in February 2011 to 97% (n=65) by December 2011.
2) Improved compliance with re-screening patients who were inpatients for longer than 7 days from 83% (n=187) in February 2011 to 89% (n=142) by December 2011.
3) The data has provided results required for the purposes of reporting internally and externally to the organisation.

Key learning points

1) Ward moves/name changes may be encountered
2) Disbelief-many data queries in the early stages
3) Confusion-almost everyone was confused by 'current (auditing) ward' and 'Admitting ward'
4) Perseverance needed-we nearly abandoned the project after the first quarter due to poor compliance and ongoing challenges
5) Approach: Training / explanations / approachable team keeping open line of communication
6) Change to data collection proforma (audit tool)

Change: The data collection proforma (audit tool) was edited to add an information section to the bottom of it stating all of the following:
a) The admitting ward is NOT necessarily the 'current (auditing) ward'
b) Other wards could submit data for patients admitted to your ward
c) 'Admitting ward' is used to show the results for the table showing 'MUST scores to be assessed within 24 hours of admission'
d) 'Current (auditing) ward' is used to show the results for 'Appropriate nutrition plan for medium/high risk patients'
e) revised instructions for auditors.

In January 2012 two further changes were agreed to improve clarity over question 7 for auditors. The addition of question 23 would a better understanding of the possible reasons for any non-compliance with screening within 24 hours of first admission, through using the MUST scoring tool.

1) Replaced
Q7 Was a MUST score documented on the day of, or within 24 hours of admission to first admitting ward? With:

Q7 Was a MUST score documented within 24 hours of admission? (this could be first admitting ward e.g. AMU, Surgical admissions unit, direct admission - OR ward patient was transferred to if within 24 hours of admission)

2) Addition of a question, to the end of the audit proforma to ask: If No to Question 7, why was there no MUST risk assessment within 24 hours?

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Tertiary care
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