Walsall Healthcare NHS Trust
Malnutrition is common across nursing, care and residential home settings. Without continued staff training and resident screening using Malnutrition Universal Screening Tool (MUST), malnutrition would have been unrecognised and untreated. The audit also showed that identifying and appropriately treating malnutrition could potentially reduce health care costs, as well as inappropriate prescribing of ONS.
Guidance the shared learning relates to:
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
Malnutrition is common among older people in nursing and care homes. It is frequently unrecognised and is often under-treated in the UK(2). Malnutrition costs an estimated £13 billion in the UK(3). It is recommended that all patients admitted to a nursing or care home, be screened for malnutrition(2). Despite this, there remains little information on the prevalence of malnutrition in this population. Malnutrition has a negative impact on a patient's health, and in turn this has cost implications for the NHS. Therefore identifying and appropriately treating malnutrition can avoid knock-on healthcare complications and inflated costs.
The aim of this study was to establish the prevalence of malnutrition in older people in nursing, care and residential homes using the 'Malnutrition Universal Screening Tool' (MUST) (1), (2), (3). The study also aimed to determine how many residents were appropriately prescribed oral nutritional supplements (ONS), and by whom.
1. Elia M (2003) The 'MUST' report. Nutritional screening for adults: a multidisciplinary responsibility. Redditch, UK, BAPEN.
2. NICE Guideline (2006). Nutrition support in adults. Clinical guideline 32.
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. 4. To ensure the appropriate prescribing of oral nutritional supplements (ONS)
Reasons for implementing your project
The homes initially trained were identified by the inappropriate referrals received by the Clinical Community Dietitian. The reason for referral was 'losing weight' and sometimes no other information was included. Dietitians require weight record, height and a MUST score to make a nutritional assessment. The Clinical Community Dietitian approached Walsall's local Nutricia Sales Executive, and together with his help with resources and introduction letters, the initiative commenced in October 2009.
The homes were then approached by the Clinical Community Dietitian were the initiative was introduced and explained what the training day entailed. The managers then agreed on a date which was ideal for their staff to attend.
Prior to the training day, we gathered information from the managers of each home. This information gave us insight into the current level of screening (including documentation of nutrition information), use of nutrition support (i.e. who prescribed ONS for residents and the reason for doing this), 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.
All resources were provided by Nutricia.
Six monthly follow ups were done at the homes that were trained.
Staff were trained to use the Malnutrition Universal Screening Tool ('MUST'), which is clinically validated and meets NICE guidance on screening.
How did you implement the project
630 residents (mean age 82; 72% female) from 17 nursing, care, residential and mental health homes (5 nursing homes, 5 care homes, 6 residential homes and 1 mental health centre) were screened for malnutrition using 'MUST' from January 2010 to June 2011. The screening was carried out by the clinical community dietitian and Nutricia Nurse, as well as staff trained on the use of MUST. 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. 58% (364 residents) were screened as being low risk, 17% (105 residents) were screened as medium risk and 24% (150 residents) were screened as high risk. The mean BMI for each risk group was as follows: low risk (25.9kg/m2), medium risk (20.1kg/m2) and high risk (17.5kg/m2). Homes were the training was implemented now comply with NICE guidance. This training initiative is being rolled out to all nursing, care and residential homes in Walsall. 2. Increase screening for malnutrition in care homes and use of appropriate care plans for nutrition support.17% (105 residents) were screened as medium risk and 24% (150 residents) were screened as high risk. Only 32 (13%) of the 255 'at risk' residents were known to the dietitian. Before the initiative began many of the homes residents were not routinely screening their residents. After the training initiative, all residents were screened and had increased documentation of nutritional status. 3. Disseminate information to GPs, other health professionals to highlight the importance of screening and appropriate treatment. Following the 'MUST' screening, these 46 residents who were on inappropriately prescribed ONS were able to stop. These residents were no at risk of malnutrition. Appropriate dietary advice was given to the staff on management of these residents, and also to re-screen according to care plans.
Table: Percentage of screened residents receiving supplements and the source of the prescription:
Low risk Medium risk High risk
Hospital 5(0.8%) 0(0%) 9(1.5%)
GP 10(1.6%) 12(2.0%) 15(2.4%)
Dietitian 10(1.6%) 9(1.5%) 32(5.2%)
From the table, 17% of residents in the care homes taking supplements,only 8% were being monitored and reviewed by a dietician.15 low risk and 12 medium risk residents had been prescribed ONS, either when discharged from hospital and from the GP.These residents were not being monitored.The 10 low risk and 9 medium risk residents known to the dietitian were able to stop the ONS prescribed. After the 'MUST' screening, these 46 residents who were on ONS were able to stop.Appropriate dietary advice was given to the staff on management of these residents,and also to re-screen according to care plans. Malnutrition is common in the nursing, care and residential homes studied i.e. 41% of residents (17% medium and 24% high risk). 13% of residents on ONS were at risk of malnutrition according to 'MUST' (3.5% medium risk, 9.0% high risk).Most of the residents with malnutrition did not receive ONS or dietetic input for oral nutritional support.Residents in the homes studied were inappropriately prescribed ONS without further review. (Table):2.4% of low risk residents on ONS prescribed by either the hospital or GP,2.0% of medium risk residents on ONS prescribed by the GP. This study shows that malnutrition is common (41%) across nursing,care and residential home settings.Without continued staff training and resident screening using 'MUST', malnutrition would have been unrecognised and untreated.The study also showed that identifying and appropriately treating malnutrition could potentially reduce health care costs, as well as inappropriate prescribing of ONS. See attached abstract on re-screening after 6 months to provide any follow up needed in 6 pilot homes.
Key learning points
Commence with a project plan; have 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 'link' nurse at each home who can be a point of contact and assist on site with ongoing training and promotion of MUST. 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 homes appropriately. Be realistic in terms of the time required to ensure the information is embedded within some 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. This initiative received a Patient Safety Award in 2010 and was also nominated for the prestigious pF Award for Cross-functional Partnership Working in 2010.
The work was also submitted to BAPEN 2010 and accepted as an oral communication and poster. The work was submitted for the MNI Grant 2011, as well as BAPEN 2011.
Clinical Community Dietitian
Walsall Healthcare NHS Trust
Is the example industry-sponsored in any way?
Nutricia worked collaboratively with Walsall's clinical community dietitian to support the process of developing, setting up and implementing an initiative to tackle under-nutrition in local nursing, care and residential homes.