Results in a SNAP
A MUST for effective
compliance monitoring?
Emily Walters, Chief Dietitian
A brief history...
Launch of policy for Malnutrition in Adults (2006)
–
–
–
–
–
–
Information on intranet
Hard copies of MUST paperwork for wards
Senior nurse briefings
Ward-based teaching
Nutrition Link Nurse training days
MUST score for inpatient referrals to Dietitian
Audit 2007 Southampton General Hospital
• Most nurses felt that “MUST” was important
• Three quarters believed that ‘all or most’
patients on their ward were routinely screened
BUT…
– 14 % screened within 24 hours of admission
– 31 % screened within 7 days
– 81 % of patients at risk of malnutrition had been
missed
Steps to support change included...
• Trust prioritisation of nutrition
- nutrition is 1 of 7 key patient safety areas
• External interest e.g. CQC
• A Trust champion with power to change practice
e.g. Associate Director of Nursing
• Individuals required to take ownership and
responsibility e.g. Matrons, Ward Managers
• Links with other initiatives e.g. infection control
team, catering red trays
Compliance remained variable – why?
• Competing pressures
• No central reporting or consequences of noncompliance unlike other areas e.g. hand hygiene
• A need for formal monitoring within the Trust if
the policy is to compete with other agendas?
• MUST within 24 hours admission and
evidence of care plans for ‘at risk’ patients
became a KPI with central monitoring
Monitoring compliance
• How to monitor compliance?
– Large organisation - time consuming to audit
– Small ‘snapshot’ audits across the trust did not
provide trustwide assurance
– The ‘hawthorne effect’ was experienced with
planned audits
• How were others monitoring compliance?
Introducing SNAP!
Developing the audit using SNAP
• SNAP software was used to create an
online audit questionnaire and reporting
system
• Who was involved?
– Associate Director Nursing
– Clinical Effectiveness Manager
– Chief Dietitian
• What did we need to know?
• What would be useful to know?
SNAP audit questions
• Baseline data – month, area auditing,
auditor
• MUST within 24 hours admission?
• MUST category?
• MUST score correct?
• Nutrition care plan for those ‘at risk’?
• Repeat score?
Monthly Inpatient MUST Audit 2011
TARGET: ANTS TO AUDIT AT LEAST 10 SETS OF NOTES (Including KARDEX) PER WARD EACH MONTH
- sample from 2 bays (results will be reported at ward level via the dashboard)
- TO BE INPUTTED BY 28TH OF EVERY MONTH
Q1
Auditor's name:
Q2
Month of the year audited:








January 2011
February 2011
March 2011
April 2011




May 2011
June 2011
July 2011
August 2011
September 2011
October 2011
November 2011
December 2011



January 2012
February 2012
March 2012
Q3 Patient's hospital number
Q4
Current Ward:


AMU


C Neuro
E3
D Neuro


E4



Clinical
Decisions U

D2

E5 Colorectal





CCU
D3
Eye Unit
F1




F8 Stroke Unit
D5
D6




E7 Urology
CICU
CSSU




G5
G6





C4

D7

F2

G7



C6


D8


F3


G8
Bramshaw
CHDU
C7
D4
E2
E8
F4
F5
F6 Emerg
Admit
F7
F9 closed
G9


GICU A

C5 Isolation
Ward
MHDU
GICU B
NICU
SHDU
Stanley
Graveson
Respiratory
centre
SNAP audit process
• Each ward submits a monthly audit of 10
patients
• Data entered by nursing staff directly into the online questionnaire
– minimising data transfer work
– 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.
Did wards participate?
Number patients audited for compliance with malnutrition risk policy
Mar-12
Feb-12
Jan-12
Dec-11
Nov-11
Oct-11
Sep-11
Aug-11
Jul-11
Jun-11
May-11
Apr-11
Mar-11
Feb-11
2010
2009
0
100
200
300
Number patients
400
500
Example of data report
MUST score documented within 24 hours of first admission? by Ward or department that originally admitted the patient to hospital
89%
AMU (131)
Bramshaw (10)
Clinical Decisions U (-)
CCU (16)
CHDU (10)
CICU (1)
CSSU (11)
C4 (-)
C6 (10)
C7 (3)
C Neuro (6)
D Neuro (14)
D2 (11)
D3 (8)
D4 (5)
D5 (-)
D6 (-)
D7 (-)
D8 (3)
E2 (-)
E3 (11)
E4 (1)
E5 Colorectal (6)
E7 Urology (4)
E8 (-)
Eye Unit (4)
F1 (-)
F2 (9)
F3 (9)
F4 (10)
F5 (5)
F6 Emerg Admit (24)
F7 (1)
F8 Stroke unit (1)
F9 closed (-)
G5 (1)
G6 (-)
G7 (-)
G8 (-)
G9 (-)
GICU A (4)
GICU B (1)
IC5 Isolation Ward (7)
MHDU (5)
NICU (8)
SHDU (3)
Stanley Grav eson (7)
Respiratory centre (2)
C3 (2)
0%
11%
100%
100%
100%
100%
100%
100%
100%
100%
93%
100%
100%
100%
1%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
92%
8%
100%
100%
100%
25%
75%
100%
100%
100%
100%
100%
86%
14%
50%
50%
100%
5%
10%
15%
20%
25%
30%
35%
40%
Yes
45%
50%
No
55%
60%
65%
70%
75%
80%
85%
90%
95% 100%
Did a KPI & monthly
trustwide auditing make
a difference to policy
compliance?
2011 Trust wide MUST nutrition screening % compliance, all wards
100%
90%
88%
90%
90%
89%
87%
92%
91%
86%
83%
81%
79%
80%
70%
60%
Yes
50%
No
Target
40%
30%
20%
10%
D
be
r(
38
ec
e
m
m
ov
e
N
0)
8)
be
r(
35
(3
92
er
ob
O
ct
m
be
)
0)
r(
34
37
8
ep
te
S
A
ug
us
t(
(3
6
ly
Ju
ne
Ju
)
7)
6)
(3
4
4)
(3
1
M
ay
8)
32
pr
il
(
A
ch
M
ar
Fe
br
ua
ry
(3
(3
7
5)
98
)
0%
Improved use of nutrition care plans for ‘at risk’ patients
Q13 X Q2 Nutrition plan in place for medium and high risk patients
100%
63
97%
90%
45
83%
80%
29
76%
52
75%
Yes
32
73%
70%
41
80%
40
70%
29
67%
42
72%
36
64%
60%
33
53%
50%
29
47%
40%
20
36%
14
33%
30%
No
17
30%
12
27%
17
25%
9
24%
20%
16
28%
10
20%
9
17%
10%
12
20
h
ar
c
M
br
u
20 ary
12
Fe
Ja
nu
20 ary
12
O
ct
o
20 be
11 r
m
20 be
11 r
Se
pt
e
01
1
Au
gu
s
t2
11
20
Ju
ly
20
Ju
ne
20
1
ay
M
ril
Ap
1
20
11
11
20
h
ar
c
M
br
u
20 ary
11
Fe
Ja
nu
20 ary
11
11
Month of the year audited
N
ov
em
20 be
11 r
D
ec
em
20 be
11 r
2
3%
0%
Repeat screening improved from 83% to 89% (Feb–Dec 2011)
Q14 X Q2 Repeat screening for for patients in hospital for longer than 7 days
100%
141
95%
90%
149
93%
Yes
153
88%
151
85%
155
83%
80%
173
94%
131
85%
111
83%
126
89%
136
88%
118
79%
70%
60%
50%
40%
30%
20%
32
21%
32
17%
22
17%
26
15%
10%
No
24
15%
20
12%
8
5%
19
12%
16
11%
11
7%
11
6%
Month of the year audited
12
20
h
ar
c
M
br
u
20 ary
12
Fe
Ja
nu
20 ary
12
N
ov
em
20 be
11 r
D
ec
em
20 be
11 r
O
ct
o
20 be
11 r
m
20 be
11 r
Se
pt
e
01
1
t2
gu
s
Au
Ju
ly
20
11
11
20
Ju
ne
20
1
ay
M
ril
Ap
1
20
11
11
20
h
ar
c
M
br
u
20 ary
11
Fe
Ja
nu
20 ary
11
0%
What other information?
Divisional data example
Div A
Number audited with MUST
within 24 hours
Number with category
% with category
Div B
Div C
48
163
10
Div D
119
47
98%
161
99%
10
118
100%
99%
Total
340
336
99%
MUST score components
Percentage Number patients
with score
with score
BMI score correct
97%
355/365 patients
Weight loss score
90%
328/365 patients
Acute disease score 93%
341/365patients
Data analysis to identify trends
• Acute medical unit (AMU) admitted
approximately 30% of all cases in the
audit.
• Other wards contributed a maximum of 3%
each of the overall admissions.
2011 Trust wide MUST nutrition screening % compliance, all wards
100%
90%
88%
90%
90%
89%
87%
92%
91%
86%
83%
81%
79%
80%
70%
60%
Yes
50%
No
Target
40%
30%
20%
10%
D
be
r(
38
ec
e
m
m
ov
e
N
0)
8)
be
r(
35
(3
92
er
ob
O
ct
m
be
)
0)
r(
34
37
8
ep
te
S
A
ug
us
t(
(3
6
ly
Ju
ne
Ju
)
7)
6)
(3
4
4)
(3
1
M
ay
8)
32
pr
il
(
A
ch
M
ar
Fe
br
ua
ry
(3
(3
7
5)
98
)
0%
2011 Trust wide MUST nutrition screening % compliance, all wards (excluding N/A and
ourlier: AMU)
120%
100%
93%
85%
91%
88%
85%
93%
92%
89%
97%
95%
94%
80%
Yes (%)
60%
No
Target
40%
20%
D
be
r(
26
ec
e
m
m
ov
e
N
1)
0)
be
r(
26
(2
66
er
ob
O
ct
m
be
)
2)
r(
24
25
7
pt
e
Se
Au
gu
s
t(
(2
5
ly
Ju
ne
Ju
)
6)
8)
(2
3
8)
(2
2
M
ay
0)
24
ril
(
Ap
ch
M
ar
Fe
br
ua
ry
(2
(2
7
5)
73
)
0%
Compliance on AMU increased from 73% to 82%
(Feb – Dec 2011)
Line Chart showing AMU's trend for documenting MUST scores within the first 24 hours of admission to hospital
(based on ward patient was first admitted to - excluding N/A cases)
90%
Yes
80%
87
81%
69
80%
91
73%
70%
99
82%
89
80%
99
83%
79
81%
99
79%
72
73%
62
70%
64
64%
60%
50%
40%
36
36%
30%
26
30%
34
27%
26
27%
No
20%
17
20%
27
21%
22
20%
21
19%
19
19%
22
18%
20
17%
10%
Month of the year audited
m
2 0 be
11 r
ec
e
D
m
2 0 be
11 r
ov
e
N
O
ct
o
2 0 be
11 r
m
2 0 be
11 r
ep
te
S
ug
2 0 us
11 t
20
ly
Ju
A
11
11
Ju
ne
20
20
11
M
ay
A
pr
il
2
01
1
11
20
ch
M
ar
ru
2 0 ar
11 y
eb
F
Ja
nu
20 ary
11
0%
Percentage of patients with a documented MUST score within 24
hours admission
100
90
80
Percentage
70
60
Feb-11
50
Mar-12
40
30
20
10
0
Trustwide
Trust excluding AMU
AMU
Impact of SNAP audit on MUST score
within 24 hours admission
• 13% improvement Trust wide
• 81% Feb 2011 to 94% March 2012
• 12% increase Trust wide without AMU
• 85% Feb 2011 to 97% March 2012
• 16% increase on AMU
• 73% Feb 2011 to 89% March 2012
Summary of key findings
• A ‘trustwide’ approach needed
• Key leaders identified and available for support
• KPI set with central monitoring
• SNAP made monthly trustwide audits possible
• SNAP provides data for clinical quality dashboard
• SNAP e-results viewer (free to all areas) enables
everyone to see results at their desk top
• SNAP data helps identify training needs
Identification and treatment of malnutrition risk
has improved as a result of using SNAP