MUST and BAPEN Nutrition
Screening Week 2010.
Liz Evans Nutrition Nurse Specialist Buckinghamshire
Healthcare NHS Trust.
Chair National Nurses Nutrition Group
Council Member British Association of Enteral and
Parental Nutrition.
Why Nutritional Screening?
Nutritional screening is key to identifying those at
risk of malnutrition and monitoring the progress
of people who have been identified as
malnourished”
Improving Nutritional Care. A Joint Action Plan form the
Department of Health and Nutrition Summit Stakeholders.
Dept of Health 2007
Why MUST?
• In 2003 there were well over 50 published
nutrition screening tools in clinical use.
• They took anything from 2 minutes to 30
minutes to complete.
• Many had not been tested for reliability and
validity and lacked evidence base.
• Several different tools could be in use in the
same hospital.
Confusion reigned.
• Nutrition screening – refers to a rapid, general
evaluation to detect significant risk of malnutrition
and to undertake a clear plan of action.
• Nutritional assessment is a more detailed, more
specific and more in – depth evaluation of nutritional
status by an expert so that specific dietary plans can
be implemented ( Malnutrition Action Group the
MUST report 2003).
Characteristics of a good screening
tool.
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•
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Should be easy to understand.
Easy and quick to complete.
Reliable, valid and evidence based.
Should be relevant to different clinical conditions and
care settings.
• Linked to a care plan.
• Should AID rather than replace clinical judgement.
• The same tool should be used to screen patients at
risk of malnutrition as they move from one
healthcare setting to another.
What is MUST?
• MUST’ is a five-step screening tool to identify adults,
who are malnourished, at risk of malnutrition
(undernutrition), or obese. It also includes
management guidelines which can be used to
develop a care plan.
• Developed in 2003 by the Malnutrition Action group
- a sub group of BAPEN ( British Association of
Parental and Enteral Nutrition)
• Intended to be universal – i.e in all acute and
community settings
• Aimed to be quick and user friendly.
So what is MUST?
• Malnutrition
• Universal
• Screening
• Tool
Malnutrition Universal Screening Tool
Step 1
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•
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Aim: Determine BMI category score
Need to obtain:
Weight
Height
Step 2
•
•
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Aim: Determine unplanned weight loss score
Need to:
Establish patients usual weight
Establish weight loss over previous 3-6months
Step 3
•
•
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Aim: Establish acute disease effect score
Need to:
Determine if patient is acutely ill
Establish if there has been no nutritional
intake or likelihood of no intake for more than
5 days
Step 4
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•
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Aim: Obtain overall malnutrition risk score
Need to:
Add scores from steps 1-3
OR subjectively establish risk score
Step 5
• Aim: Implementation of appropriate action
plan
• Need to:
- Obtain and follow MUST action plan
- Know when to refer to a dietitian
Care plans
• Can be adapted to local policy
• Should be disseminated to members of the
multidisciplinary team and across healthcare
settings as patient between secondary and
primary healthcare.
When should it be used?
• Routinely for patients admitted to hospitals
and care homes
• New patients attending GP surgeries.
• In those over 75 years old
• Vulnerable groups
Nutrition Screening Week 2010
• Third of a series of weeks commissioned by BAPEN.
• Previously Autumn 2007 and summer 2008
• The survey was carried out from12-14th January 2010
reflecting the prevalence of ‘malnutrition ’during the winter.
• Reporters from 185 hospitals, 148 care homes and 20 mental
health units in the UK completed a general questionnaire and
an anonymous patient/client questionnaire as part of a
national audit on nutritional screening using criteria based on
the ‘Malnutrition Universal Screening Tool ’(‘MUST’) in all care
settings.
• Data was collected on patients during the first three days of
admission to hospitals and acute mental health units, and on
residents admitted to care homes and long stay/rehabilitation
mental health units in the previous six months.
Key points 1
• There was a higher prevalence of malnutrition in
patients admitted to hospital found in this survey.
• Nutritional screening policies vary between and
within healthcare settings and so malnutrition
continues to be under- recognised and under –
treated.
• MUST was the most commonly used screening tool
in all care settings. In some settings no screening
tools were being used and/or no training on
nutritional screening was being provided.
Key points 2
• There was a lack of awareness of standards relating
to weighing scales in all settings although centres
that were aware knew that scales should be regularly
calibrated.
• Whilst nutritional screening is linked to care planning
in most institutions, this is not routinely followed
through into discharge planning.
• Much of the ‘malnutrition’ present on admission to
institutions originates in the community.
Combating Malnutrition –
Recommendations for Action (BAPEN
2009)
• Public expenditure on disease related malnutrition in
the UK in 2007 was estimated at 13 billion ( 80% of
which was in England).
• At any given point in time more than three million
people in the UK are either malnourished or at risk of
malnutrition. The vast majority of these are living in
the community.
• However hospital care provides a vital opportunity to
identify malnutrition and initiate treatment.
Key Findings
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Screening for malnutrition as recommended by national bodies,
is still not being carried out routinely by hospitals, care homes
and primary care settings.
One of the obstacles is the lack of suitable and accurate
equipment to implement it.
The education and training needs of health, housing and social
care professionals are not being met in the area of nutritional
care.
Commissioners are not holding providers to account for delivering
nutritional care due to the lack of guidance.
Existing regulatory systems –across both health and social care
providers – need review and improvement.
Incentives
• Requirements to conduct nutritional screening should
be included in the Quality and Outcomes Framework
of the GP contract.
• The importance of nutritional care should be reflected
in the system of Payment by Results, both for
secondary and primary care.
• The Department of Health should also consider
including a serious instance of poor nutritional care in
their list of “Never Events”.
Effective regulation.
• From April 2010 when full registration with CQC
commences, health and social care providers will be
obliged to undertake nutritional screening.
• All large health care providers should have a
nominated individual at board level responsible and
accountable for the delivery of effective nutritional
care within their organisation.
• The Royal College of General Practitioners
accreditation scheme should reflect the importance
of ensuring that GP’s screen their patients for
malnutrition, as per NICE guidance.
Effective Commissioning.
• Prioritise malnutrition in the planning of local
services by including malnutrition indicators.
• The Dept of Health should issue guidance pioneered
successfully in diabetes care that can demonstrate
how an individual’s nutritional care needs should be
identified and then managed between primary and
secondary care providers and social care providers.
How can nurses make a difference?
• Trusts need to employ more Nutrition Nurse Specialists
with the knowledge to push forward changes and
educate staff.
• Senior nurses at board level should make nutritional
care a priority and support protected mealtimes and
mandatory nutrition training.
• Ward routines should be re assessed to ensure that
patients are given the help they need at all times, not
just lunchtime.
• District nurses should be encouraged to undergo
training in nutritional screening for their patients.
• Nursing managers should have nutrition and
hydration as a quality and safety indicator as part of
their performance review.
• Nursing managers should ensure that all their
nursing staff understand that feeding and hydration
are as important as infection control and cleaning.
However all this is pointless if we do
not….
• Listen to our patients and their carers and
families.
• Work together across all care boundaries.
• Acknowledge mistakes and demonstrate how
we can improve.
And finally… food for thought.
• Good nutritional care is a team effort. It is the responsibility
of..
• Nurses
• Dietitians
• Doctors.
• Pharmacists
• Speech therapists
• Physiotherapists
• Catering staff
• Managers……BUT also…
• Patients and their friends and families.