Registered Charity No: Malnutrition in the UK: the importance of nutritional screening Christine Russell Chair BAPEN’s Nutrition Screening Week

Overview Understand the meaning of ‘malnutrition’ Appreciate the prevalence of malnutrition in UK Understand the causes and consequences of the problem Understand the difference between screening and assessment. Use of the ‘Malnutrition Universal Screening Tool’ (‘MUST’) and e-learning module Importance of care planning

BAPEN Multi-disciplinary charity committed to raising awareness of malnutrition and its impact on health & social care budgets and resources, personal experiences and health outcomes in order to improve nutritional care Practical screening tool – ‘MUST’ Financial statistics- health economics /cost of malnutrition in UK Audit data – British Artificial Nutrition Survey (BANS) Nutrition Screening Surveys – hospital, care, mental health, sheltered housing Policy recommendations & action working with Governments & statutory agencies ‘Patient’ & consumer group opinions Campaigning & communicating

What is malnutrition ? Literally means “bad” nutrition which can mean over nutrition or under nutrition No internationally agreed criteria to define malnutrition

Proposed definition of malnutrition “ 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” (Elia/ MAG 2003) Here we will focus on under-nutrition

Causes of Malnutrition Multi-factorial! Clinical – associated with disease leading to problems such as nausea and vomiting, pain, malabsorption, infections, difficulty eating and swallowing, confusion, medication… Ageing process -important changes to the body occur Lifestyle –access to shops, finances, cultural, living conditions, bereavement, depression, cooking ability and knowledge

Effects of under-nutrition on organ function Immunity – Increased risk of infection Hypothermia Impaired gut integrity and immunity Renal function - loss of ability to excrete Na & H 2 O Decreased cardiac output Ventilation - loss of muscle & hypoxic responses Psychology – depression & apathy Anorexia Loss of strength liver fatty change, functional decline necrosis, fibrosis Impaired wound healing

Consequences of malnutrition Increased risk of admission into hospital Increased complications and dependency Increased length of stay in hospital Increased cost of care Increased mortality More likely to be discharged into care home Increased risk of being re-admitted post discharge from hospital

The Cost of Obesity & ‘malnutrition’ Costs to NHS in 2007 ~£4.2 billion/year Costs of ‘malnutrition’ in 2007 ≥£13 billion/ year (Costs exclude the consequences of obesity or under-nutrition)

Groups at risk Individuals with acute or chronic conditions Those recently discharged from hospital Older people Malnutrition can be exacerbated by: Poverty Social isolation Substance misuse Religious / cultural beliefs / practices if not adequately considered when in care

Percentage of people aged 65+ at medium/high risk of malnutrition North England 19.4% Central England 12.3% South England 11.3% Source: further analysis of 1998 NDNS Survey data Wales 11%

BAPEN’s National Nutrition Screening Weeks: September 2007, July 2008, January 2010 and April 2011 To establish current prevalence /risk of malnutrition on admission to hospital, care homes and mental health units in UK General questionnaire re nutritional care Data collection forms based on ‘MUST’ criteria

28-34% patients admitted to hospital were at risk – most patients being at high risk 18-20% patients admitted to mental health units % residents admitted to care homes in previous 6 mths were at risk

Prevalence in other care settings ≥10 -20% in outpatients- high in patients with COPD 12-14% in sheltered housing ~25% in patients receiving care at home

Need to identify the problem as early as possible Much malnutrition originates in the community Hospitals provide an ideal opportunity to Identify the problem If unchecked the problem can spiral and get progressively worse

The Malnutrition Carousel 28-34% of patients admitted to hospital are at risk of malnutrition 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

Why screen for malnutrition? Malnutrition is not always visible, is more common than you think and costs health and social care ≥£13b/year At any one time, more than 3 million adults in UK are at risk 93% live in the community & 2% are in hospital where ~1 in 3 are at risk on admission Older people and those with chronic conditions are particularly at risk Help people stay independent and well in their own home as long as possible & reduce the need for admission into hospital

Why screen for malnutrition? Effective management of malnutrition reduces the burden on health & care resources 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 Quality Commission, Nutrition Action Plan

NICE recommendations- Who to screen & when? In Hospital – on admission, repeat weekly. Outpatients: if clinical concern In Care – on admission & if clinical concern In the Community – on registering with a GP & at other times e.g health checks, flu jabs

What is clinical concern? Unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, impaired swallowing, altered bowel habit, loose fitting clothes or prolonged inter-current illness. (NICE 2006)

What is screening and how can we do it?

Nutritional screening “Rapid, simple, general procedure done at first contact with subject to detect risk of malnutrition, done by nurses, doctors or other care workers” (Elia/ MAG 2003) Complementary to and part of nurse assessment

Nutritional assessment “ Detailed, more specific in depth evaluation of subject’s nutritional status, done by those with nutritional expertise ” ( Elia/ MAG 2003 )

‘Malnutrition Universal Screening Tool’ (‘MUST’) A simple 5 step validated tool for use by all care workers in all care settings: Step 1-height and weight to obtain BMI Step 2- recent unintentional weight loss Step 3- effect of acute disease Step 4- overall score / category of risk Step 5- management guidelines

‘Malnutrition Universal Screening Tool’ (‘MUST’)

“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” The old ones are the best F Nightingale 1859

Care plan Set aims and objectives Treat underlying conditions Improve nutritional intake in line with local policy Monitor and review Reassess subjects at nutritional risk as they move through care settings Include nutritional information in discharge communications

Implementation of nutritional screening Education and training of those involved Audit of practice Resources available: – Local workshops/lectures/workbooks – E-learning

‘ MUST ’ e-learning Developed in partnership with NHS Greater Glasgow and Clyde

‘ MUST ’ e-learning For healthcare staff working in hospital – Causes and consequences malnutrition – How to screen using ‘MUST’ – Online assessment – Optional reporting system Hosted on secure server Accessible via internet from work or home SCORM compliant version in development

‘MUST’ e-learning Community module now available Healthcare staff working in – Primary Care – Care Homes

‘MUST’ e-learning Link to Hospital module: