Registered Charity No: Registered Charity No: Nutrition screening: why bother Adapted presentation originally prepared by: Christine Russell RD Hon Treasurer BAPEN British Association for Parenteral and Enteral Nutrition

Registered Charity No: BAPEN Multi-disciplinary charity dedicated to raising awareness and standards of nutritional care Founded in 1992 – “A Positive Approach to Nutrition as Treatment” Kings Fund Centre Report Increasing focus on nutritional care and status of all consumers of health & social care ‘Malnutrition Universal Screening Tool’ (‘MUST’) 2003 Health Economic Report 2005

Registered Charity No: King’s Fund Centre Report (1992) “ only when the assessment of every patient’s nutritional status has become routine will the full benefits of nutrition treatment be realised”

Registered Charity No: Defining malnutrition No universally accepted definition but the following has been suggested: “ A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body structure and function and on clinical outcome”

Registered Charity No: Causes of malnutrition Multifactorial! Clinical – associated with disease leading to problems such as nausea and vomiting, pain, malabsoprtion, infections, difficulty eating and swallowing, confusion, medication… Important changes to the body with ageing Lifestyle – accessibility shops, finances, cultural, living conditions, bereavement, depression, cooking ability and knowledge

Registered Charity No: Prevalence of malnutrition % underweight adults (BMI<20kg/m 2 ) living freely in the community, hospital & residential accommodation Elia/MAG 2003 General population: England 5.2% Scotland 5.5% Wales 5.0% Patients in the community: Major surgery previous 6 wks >10.6% Chronic diseases 12.2% Residential accommodation: In UK >65 yrs 16.0% In Scotland >65yrs 29.0% Hospital: 13-40%

Registered Charity No: Prevalence of malnutrition on admission (BAPEN NSW07) Hospitals Overall28% ( 22% high risk, 6% medium risk) Acute hospitals27% Community hospitals29% Care Homes Overall30% (20% high risk, 10% medium risk) Nursing homes35% Residential homes22% Mental Health Units Overall19% (12% high risk, 7% medium risk) Acute units31% Long stay/rehab.21%

Registered Charity No: Consequences of malnutrition Increased morbidity Increased length of stay Increased dependency Increased mortality Increased costs of care

The Malnutrition Carousel 28% of patients admitted to hospital are malnourished Up to 70% of patients discharged from hospital weigh less than on admission More GP visits Home Hospital More hospital admissions Longer stay More support post- discharge More likely to be discharged to Care Homes

Registered Charity No: Why screen for malnutrition? Malnutrition is frequently unrecognised and untreated Malnutrition costs health and social care ≥£7.3b/year Effective management of malnutrition improves clinical outcome and reduces costs Regular screening is the only way that malnourished individuals can be identified and appropriate action taken Recommended / required by various bodies e.g NICE, NHSQIS, Council of Europe, Care Commissions

Who to screen & when? In Hospital – on admission In Care – on admission & monitor as appropriate In the Community – on registering with a GP & at Annual Check for 75 years +

Registered Charity No: Definitions Nutritional screening Rapid, simple general procedure done at first contact with subject to detect risk of malnutrition, done by nurses, doctors or other HCWs Nutritional assessment Detailed, more specific in depth evaluation of subject’s nutritional status, done by those with nutritional expertise

Registered Charity No: ’ How to screen? Establish screening policy Use a validated tool One that is quick and easy to use Establish care plans Identify resources Educate and train staff Audit practice NICE Guidance and Scottish Standards based on ‘MUST’

Registered Charity No: ’ The ‘Malnutrition Universal Screening Tool’ (‘MUST’)

Malnutrition Universal Screening Tool

Registered Charity No: ’ Screening as part of the patients journey Where is he/she now? BMI an indication of current nutritional status Where has he/she come from? i.e past history Recent weight loss Where is he /she going? i.e likely clinical course Acute disease effect

Registered Charity No: Step 1: BMI Obtain weight and height Calculate BMI or use BMI chart provided to get score Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained

Registered Charity No: BMI Score >20 kg/m kg/m 2 1 <18.5 kg/m 2 2 >30 kg/m 2 ( obese ) 0

Registered Charity No: Unintentional weight loss over 3-6 months <5% body weight: normal intra-individual variation 5-10% body weight: of concern –decrease in voluntary physical activity –increase in fatigue –less energetic >10% body weight: of significance –changes in muscle function –disturbances in thermoregulation –poor response or outcome to surgery and chemotherapy

Registered Charity No: Step 2: Weight loss score Indicates acute or recent-onset malnutrition Score <5% body weight: % body weight: 1 >10% body weight: 2

Registered Charity No: Step 3: Acute disease effect Patients who are acutely ill AND have had or are likely to have no nutritional intake for more than 5 days Most likely to apply to patients in hospital Add 2 to score

Registered Charity No: Step 4: Overall risk of malnutrition Total of scores from Steps 1, 2 and 3 Document score 0 = Low risk 1 = Medium risk 2 or more = High risk

Registered Charity No: Registered Charity No: ’ The old ones are the best “It is not for the sake of piling up miscellaneous information or curious facts but for the sake of saving life and increasing health and comfort” F Nightingale 1859

Registered Charity No: Care plan Set aims and objectives Agree management of those at risk Treat underlying conditions Improve nutritional intake Monitor and review Reassess subjects at nutritional risk as they move through care settings

It’s not…

Registered Charity No: In summary We should bother to screen because: Malnutrition in UK is common and costs ≥£7.3billion Screening identifies those at risk, enabling early intervention. Screening is simple and quick to do and recommended / required by various bodies Working together helps overcome barriers