Appendix A
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:




February 2011
March 2011
April 2011
Q3
Patient's hospital number
Q4
Current Ward:
Q5
Q6


AMU

June 2011
July 2011
August 2011



September 2011
October 2011
November 2011
January 2012
February 2012
March 2012
December 2011
_________________
C Neuro


E3
D Neuro
E4


Clinical
Decisions U

D2

E5 Colorectal





CCU
D3
F1




F8 Stroke Unit
D6




E7 Urology
CSSU




G6





C4

D7

F2

G7



C6


D8


F3


G8
Bramshaw
CHDU
CICU
C7
D4
D5
E2
E8
Eye Unit
F4
F5
F6 Emerg
Admit
F7
F9 closed
G5


GICU A

C5 Isolation
Ward
MHDU
GICU B
NICU
SHDU
Stanley
Graveson
Respiratory
centre
G9
Ward or department that originally admitted the patient to hospital:


AMU


C Neuro


E3
D Neuro
E4



Clinical
Decisions U

D2

E5 Colorectal





CCU
D3
F1




F8 Stroke unit
D6




E7 Urology
CSSU




G6





C4

D7

F2

G7



C6


D8


F3


G8

Bramshaw
CHDU
CICU
C7
D4
D5
E2
E8
Eye Unit
F4
F5
F6 Emerg
Admit
F7
F9 closed
G5


GICU A

IC5 Isolation
Ward
MHDU
GICU B
NICU
SHDU
Stanley
Graveson
Respiratory
centre
C3
G9
What was the patient's length of stay in hospital?
Less than or =7
days

8-14 days


15-21 days
More than 21 days
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)

Q8




May 2011



Q7




January 2011
Yes


No
N/A
You have answered N/A - please give the reason below:

Patient on LCP

Screened at pre-assessment within one week
prior to admission
1

Q9
Q10
You have answered there was NO MUST score documented within 24 hours of admission. Within
how many days of admission to ward was the first MUST score documented?


2 days


5 days
6 days


8 days
3 days

4 days

7 days

10 days

1 medium
Yes
Yes

Yes

Admission <7 days
No

No
4-6 high
No
No
Patient on LCP

Yes
Upon admission

N/A

It was documented there was
'No intent to treat
malnutrition'
No
Not
Applicable



Q20

No


weights or measurement inaccuracies
Other: please
____________________
speficy
No

Yes

You have indicated the MUST score calculation

Yes
Was an Acute disease effect score documented?

No
Weekly
Yes
Was a Weight loss score documented?

Q21


Yes
Q17 Was the patient weighed?
Q19

3 high
Was a BMI score documented?

Q18

2 high
You have answered N/A - please give the reason for N/A below:

Q16

Was a MUST score repeated weekly?

Q15
0 low
Is there evidence of an appropriate nutrition care plan for medium or high risk?

Q14
Not documented at
all during inpatient
stay
Was the MUST category documented?

Q13
>10 days
Was the MUST score calculation correct?

Q12


9 days
You have answered Yes a MUST score was documented upon admission. Please indicate the
MUST score UPON ADMISSION, for this patient:

Q11
It was documented there was 'No intent to
treat malnutrition'
Is there any documented evidence in the notes or KARDEX, of referral to nutrition and dietetics?



Yes
Not applicable
No
Q22
Auditor's comments:
Q23
If No to Question 7, why was there no MUST risk assessment within 24 hours?

Acuity

Transfer within 24 hours of
admission

Not known
Q24 Click on data icon and select today's date
please
_________________
2
TIPS FOR READING YOUR RESULTS
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'
To view your results: Email IT support and request that Snap e-Results Viewer is installed
on your PC (you will be required to include your PC configuration number) - Once
installed, click on the Snap e-Results viewer icon, go to file and 'open'. Use the browser to
find this file path: O:\Corporate\CE-eResults Viewer\MUST. Each month a batch of tables
and charts is refreshed and saved as 'overall results' and 'specific month' results. Once
you open the file you want to view, use the green arrows at the top of the e-Results Viewer
to turn the pages and see the results.
3
SUBJECT: Communication and leadership with technology.
Achievement of the 95% MUST nutrition screening (within 24 hours) target set at the start of
the audit has been 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





Compliance being driven at the highest levels (see examples 1 and 2 emails below)
Accountability at ward level sits with the Matrons
Snap e-Results viewer – free technology enabling regular data to all clinical areas
Clinical Quality Dashboard (CQD) – portal for communicating key targets to the
organisation
Staff knowing who the leaders are and ensuring they are approachable to query data and
support for training and staff education (example 3)
Example 1
From: Associate Director of Nursing
Sent: 11 July 2011 19:31
To: Matrons
Cc: DHN; MUST Team
Subject: MUST Audit results June 2011
(ON BEHALF OF DIETICIAN LEAD FOR MUST)
Dear Colleagues,
Please find attached the breakdown of MUST audit data for June 2011. As you are aware,
this information is available on Snap viewer but we have agreed to circulate monthly for the
next few months whilst everyone secures access to Snap viewer via IT (a simple process as
previously explained by Clinical Effectiveness Manager).
We are working on setting up divisional reports for the audit data this month and Clinical
Effectiveness Manager has helpfully done some further work to this today - I have noticed a
couple of wards in the wrong divisions, so if you cannot see yours please check all the other
divisions in case it is miss-allocated - we will of course correct this for next month's report.
The main messages from this report are that overall, we achieved 87% compliance for
MUST screening within 24 hours and 68% for appropriate MUST care plans being in
place. This is a slight deterioration on May's results, which may not be statistically significant
but means we did not reach our target of 95% MUST compliance within 24 hours by end of
June 2011.
I would be grateful if you would action the following:
1) Review MUST audit submissions with your Ward Leaders and their ANTs, with a view to
making all areas compliant with the requisite 10 audits in July.
2) Review with ANTs and ward leaders the areas which have not achieved 100% compliance
with MUST screening within 24 hours and which are non compliant for appropriate care plans
- the PIF target for this is 90%.
(Both metrics will be available on the CQD (Dashboard) in July.
3) Let me know if you feel 10 audits may not be achievable in any clinical area and the
reason why.
The Chief Dietitian and I will be meeting on her return from leave to review the report, so if
you would like us to consider any changes please do let me know.
With kind regards,
Associate Director of Nursing (Patient Experience)
Southampton University NHS Trust
4
Example 2
From: Associate Director of Nursing
Sent: 20 September 2011 20:41
To: Divisional Leads
Cc: Director of Nursing; MUST Team
Subject: August 2011 MUST Audit results
Dear Colleagues,
Please find attached the MUST audit results for August 2011. I have highlighted wards and
departments who have met the targets for returns, screening and care plans in green and
those who have not met in yellow. Please note the following:
Good practice:
* Division D was the only division to meet the 24 hour must screening target at 96% (Div A
81%, Div B 86% and Div C 89%)
* C6, AMU, F6, Cardiac and T&O care groups met or exceeded the submission target of 10,
with Neuro and Gynae not far behind.
* 100% screening in G5, C6, E8, F6, IDU, Cardiac units, E3, D4, F1, F2, F3, F4, and S.G
Areas for focussed improvement this month
* Surgery, Cancer and Emergency medicine (D and G level wards ) all had very low audit
submission rates
* Nil submissions for; F7; D5, F9, G6, G8, D2
* 24 hour screening to be increased in: C4, D3, E5, GICU, AMU, D6, D7, C and D Neuro
As per discussions at Nursing and Midwifery Group, the Director of Nursing and I will arrange
to meet the following ward's leaders and matrons over the next couple of week or so to
discuss progress with improvement plans.
Div A - D3
DIv B - G7/8 and D5/7
Div D - F8
Please do not hesitate to contact me if you have any queries.
With kind regards,
Associate Director of Nursing (Patient Experience)
Example 3
When problems have been highlighted the matrons are contacted by the associate director
nursing. The nursing staff then met with the Chief Dietitian (part of the project team) to look
at practical issues and problems and work out solutions. It was important to avoid blame and
provide support, assistance and encouragement.
5
RESULTS
The chart below shows the steady improvement across the organisation for screening
malnutrition risk within 24 hours of admission. The 95% target was not reached but further
investigation of the data highlighted an outlier. Data before the outlier is extrapolated is
shown in Graph 1 below:
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%
0%
Fe
ua
br
ry
(3
)
98
ar
M
ch
7
(3
5)
A
3
il (
pr
)
28
ay
M
1
(3
4)
Ju
ne
4
(3
6)
Ju
ly
6
(3
7)
Au
8
37
t(
s
gu
S
)
te
ep
be
m
34
r(
0)
ct
O
ob
e
2
39
r(
N
)
em
ov
35
r(
e
b
D
8)
em
ec
38
r(
e
b
0)
6
The outlier
The audit findings showed that the Acute medical unit (AMU) admitted 30% of all cases in
the audit. 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 below shows
that in the last quarter compliance has reached the trust-wide target after the outlier has
been extrapolated. The audit has helped to improve compliance and reach the target set by
the Trust board at the start of the audit.
2011 Trust wide MUST nutrition screening % compliance, all wards (excluding N/A and
ourlier: AMU)
120%
100%
93%
85%
88%
85%
93%
91%
89%
97%
95%
92%
94%
80%
Yes (%)
60%
No
Target
40%
20%
be
r(
26
D
ec
e
m
m
ov
e
N
1)
0)
)
be
r(
26
(2
66
ob
O
ct
m
be
er
r(
24
2)
)
25
7
pt
e
Se
Au
gu
s
t(
(2
5
Ju
ly
ne
6)
8)
(2
3
8)
Ju
0)
(2
2
M
ay
24
ril
(
Ap
ch
M
ar
Fe
br
ua
ry
(2
(2
7
5)
73
)
0%
7
Graph 3: Compliance on AMU increased from 73% to 82%.
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%
89
80%
99
82%
99
79%
79
81%
99
83%
72
73%
62
70%
64
64%
60%
50%
40%
36
36%
30%
26
30%
34
27%
26
27%
No
20%
17
20%
22
20%
21
19%
27
21%
22
18%
19
19%
20
17%
10%
20
ly
Ju
Au
g
2 0 us
11 t
Se
pt
em
2 0 be
11 r
O
ct
o
2 0 be
11 r
N
ov
em
20 ber
11
D
ec
em
20 ber
11
11
11
Ju
ne
20
20
11
M
ay
Ap
ril
2
01
1
11
20
ch
M
ar
br
u
20 ary
11
Fe
Ja
nu
20 ary
11
0%
Month of the year audited
8
Graph 4: The details in the graph below shows improved numbers of at risk patients with
nutrition plan.
Q13 X Q2 Nutrition plan in place for medium and high risk patients
100%
63
97%
90%
45
83%
80%
29
76%
Yes
32
73%
70%
41
80%
52
75%
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
M
ar
c
br
u
20 ary
12
Fe
Ja
nu
20 ary
12
O
ct
o
20 be
11 r
m
20 be
11 r
pt
e
01
1
Se
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
N
ov
em
20 be
11 r
D
ec
em
20 be
11 r
2
3%
0%
Month of the year audited
9
Repeat screening improved from 83% to 89% as shown in Graph 5 below:
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%
12
20
M
ar
ch
br
u
20 ary
12
Fe
N
ov
em
20 be
11 r
D
ec
em
20 be
11 r
Ja
nu
20 ary
12
01
1
Se
pt
em
20 be
11 r
O
ct
o
20 be
11 r
t2
gu
s
Au
Ju
ly
20
11
11
Ju
ne
20
1
20
1
ay
M
Ap
ril
2
01
1
11
20
h
ar
c
M
br
u
20 ary
11
Fe
Ja
nu
20 ary
11
0%
Month of the year audited
10
Evaluation:
The overall impact of undertaking the audit was to improve the rate of screening upon
admission by approximately 10% as shown in Table1 below
Clinical area
February 2011
December 2011
% improvement
Trust wide
81%
91%
10%
Trust wide (excluding
AMU)
85%
94%
9%
AMU
73%
83%
10%

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.

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.

The data has provided results required for the purposes of reporting internally and
externally to the organisation.
11
Example of monthly reporting
1.
Compliance with submitting monthly MUST audits
All clinical areas are required to submit 10 patient audits each month with the exception of
GICU A and B (5 each) and AMU (10 per area = 30 submissions)
Table 1: Compliance with submitting monthly MUST audits (Dec 2012)
Compliance for
submitting audits
Clinical area
AMU, BWU, CSSU, CHDU, CCU, D2, D3, D4, D5, D7, D8, E3, E7,
100% compliant
E8, F1, F2, F3, F4, F6, F7, F8, G6, G8, GICU A, IC5, SG
<100% compliant
C7, D6, E5, Eye Unit, F5, G5, GICU B, SHDU
Non-compliant
CDU, CICU, D Neuro, E2, E4, F9, G7, G9, MHDU, NICU, RSDU*
(*RSDU requested to be included in MUST audit)
Graph 1: Compliance with audit submission (December 2011)
Number of responses submitted by current ward
AMU
Bramshaw
Clinical Decisions
U
CCU
CHDU
CICU
CSSU
C4
C6
C7
C Neuro
D Neuro
D2
D3
D4
D5
D6
D7
D8
E2
E3
E4
E5 Colorectal
E7 Urology
E8
Eye Unit
F1
F2
F3
F4
F5
F6 Emerg Admit
F7
F8 Stroke Unit
F9
G5
G6
G7
G8
G9
GICU A
GICU B
C5 Isolation Ward
MHDU
NICU
SHDU
Stanley Graveson
Respiratory centre
0
34
12
10
10
10
10
10
3
10
11
10
11
21
8
10
10
14
9
10
10
8
10
10
10
10
8
10
10
10
8
10
10
6
4
10
6
10
5
10
15
20
25
30
35
12
2.
Screened using MUST within 24 hours admission
Screened using MUST within 24 hours admission by admitting ward
Overall Trust compliance December 2011:
91%
(380 patients audited)
Trust compliance without AMU December 2011:
94%
(261 patients audited)
AMU compliance December 2011:
83%
(119 patients audited)
Table 2: Screened using MUST within 24hrs admission by admitting ward per
Division
Division A
Division B
Division C
Division D
Total audited
53
177
11
129
Number
screened
% screened
44
154
10
127
83%
87%
91%
98%
13
Graph 3: Screened using MUST within 24hrs admission by admitting ward
(Ward gaps due to area having no direct admissions of patients audited.)
MUST score documented within 24 hours of first admission? by Ward or department that originally admitted the patient to hospital
AMU (119)
Bramshaw (11)
Clinical Decisions U (-)
CCU (11)
CHDU (9)
CICU (-)
CSSU (8)
C4 (9)
C6 (7)
C7 (2)
C Neuro (5)
D Neuro (4)
D2 (12)
D3 (12)
D4 (7)
D5 (-)
D6 (2)
D7 (-)
D8 (4)
E2 (10)
E3 (15)
E4 (-)
E5 Colorectal (2)
E7 Urology (1)
E8 (1)
Eye Unit (8)
F1 (11)
F2 (8)
F3 (12)
F4 (10)
F5 (5)
F6 Emerg Admit (32)
F7 (-)
F8 Stroke unit (10)
F9 (1)
G5 (-)
G6 (-)
G7 (-)
G8 (-)
G9 (-)
GICU A (7)
GICU B (-)
IC5 Isolation Ward (9)
MHDU (-)
NICU (3)
SHDU (6)
Stanley Graveson (7)
Respiratory centre (-)
C3 (-)
0%
83%
17%
91%
9%
100%
100%
100%
100%
100%
50%
50%
100%
100%
100%
100%
100%
100%
100%
90%
93%
10%
7%
50%
50%
100%
100%
100%
100%
100%
100%
100%
40%
60%
94%
6%
100%
100%
43%
57%
100%
67%
33%
100%
86%
14%
5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Yes
No
14
3.
Number patient weighed
Patients weighed (%)
Upon adm ission
Weekly
0%
10%
20%
30%
Yes (451)
4.
85
13
86
10
40%
50%
No (63)
60%
70%
80%
90%
2
4
100%
Not Applicable (15)
Correct Score
MUST score correct:97%* (328 / 339 patients with a MUST score)
BMI score correct:
96%
(369/383 patients)
Weight loss score:
93%
(357/383 patients)
Acute disease score: 93%
(355/383 patients)
*Inaccurate weight or measurement cited as the cause of incorrect scores in all cases.
Table 3: MUST score category documented by admitting ward per Division
Division A
Division B
Division C
Division D
Total with
44
154
10
127
Number
screened
% screened
44
154
10
127
83%
87%
91%
98%
15
5.
Repeat screen for patients admitted >7 days
Length of admission of patients audited
7 day admission:
62% patients audited (237 patients)
>21 day admission:
11% patients audited (43 patients)
Repeat screen
Repeat screen indicated on >7 day admission:
146 patients
Repeat screen not clinically indicated:
4 patients
Repeat MUST should have been documented in:
142 patients
Evidence of repeat screen documented in 89% (126 patients)
16
Was a M UST score
repeated weekly?
Base
Base
Yes
No
142
126
89%
16
11%
1
1
100%
-
1
1
100%
-
Current Ward:
AMU (1)
Bram shaw (1)
Cl i ni cal Deci si ons U
(-)
CCU (-)
CHDU (1)
CICU (-)
CSSU (1)
C4 (7)
C6 (6)
C7 (1)
C Neuro (2)
D Neuro (-)
D2 (1)
D3 (5)
D4 (2)
D5 (14)
D6 (4)
D7 (9)
D8 (5)
E2 (-)
E3 (4)
E4 (-)
E5 Col orectal (5)
E7 Urol ogy (3)
E8 (5)
Eye Uni t (2)
F1 (1)
F2 (8)
F3 (6)
F4 (1)
F5 (5)
F6 Em erg Adm i t (-)
F7 (5)
F8 Stroke Uni t (7)
F9 (-)
G5 (4)
G6 (7)
G7 (-)
G8 (7)
G9 (-)
GICU A (2)
GICU B (3)
C5 Isol ati on Ward
(2)
MHDU (-)
NICU (-)
SHDU (-)
Stanl ey Graveson
(5)
Respi ratory centre ()
-
-
-
-
-
-
1
-
-
-
1
100%
-
1
1
100%
7
6
86%
1
14%
6
5
83%
1
17%
1
1
100%
-
2
2
100%
-
-
-
-
-
1
1
100%
5
3
60%
2
2
100%
14
12
86%
2
14%
4
3
75%
1
25%
9
9
100%
-
5
5
100%
-
4
-
4
100%
-
2
40%
-
-
5
5
100%
-
3
3
100%
-
5
5
100%
-
2
1
50%
1
1
100%
-
8
8
100%
-
6
6
100%
-
1
1
100%
-
5
5
100%
-
-
1
50%
-
-
5
4
80%
1
20%
7
7
100%
-
-
4
4
100%
7
4
57%
7
-
3
43%
-
-
4
57%
3
43%
-
-
2
2
100%
-
3
3
100%
-
2
2
100%
-
-
-
-
-
-
-
-
-
-
5
-
5
100%
-
-
17
18
6.
MUST score on admission
Actual MUST score upon admission (counts)
100.0%
90.0%
279
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
26
20
15
4
0.0%
0 low
1 medium
2 high
3 high
4-6 high
19
7.
Evidence of care plans for patients identified as being at malnutrition risk from
MUST score
17% patients audited identified as being at malnutrition risk: (65/380 patients)
Overall Trust compliance for evidence of care plan for ‘at risk’ patient = 97% (63patients)
Appropriate nutrition care plan in place for medium and high risk patients - by Ward or department that AUDITED
100%
AMU (4)
Bramshaw (-)
Clinical Decisions U (-)
CCU (3)
CHDU (3)
CICU (-)
CSSU (-)
C4 (6)
C6 (-)
C7 (-)
C Neuro (1)
D Neuro (-)
D2 (-)
D3 (5)
D4 (2)
D5 (2)
D6 (-)
D7 (1)
D8 (2)
E2 (-)
E3 (-)
E4 (-)
E5 Colorectal (3)
E7 Urology (2)
E8 (2)
Eye Unit (-)
F1 (-)
F2 (1)
F3 (2)
F4 (1)
F5 (-)
F6 Emerg Admit (-)
F7 (-)
F8 Stroke Unit (2)
F9 (-)
G5 (2)
G6 (1)
G7 (-)
G8 (2)
G9 (-)
GICU A (2)
GICU B (3)
C5 Isolation Ward (8)
MHDU (-)
NICU (-)
SHDU (4)
Stanley Graveson (1)
Respiratory centre (-)
0%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
5% 10% 15% 20% 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100%
Yes
No
20