1. Malnutrition Universal Screening Tool (MUST) Gill Cuffaro Senior Lecturer - Dietetics University of Hertfordshire
What is nutritional screening
Why screen patients
The MUST tool - what is it?
The MUST tool – how can it be used?

2. March 2004 - Sip Feed Audit Appropriate Prescribing Compliance
Monitoring
Food First

3. WATFORD AND THREE RIVERS PCT
GUIDELINES FOR THE IDENTIFICATION OF ADULT COMMUNITY PATIENTS AT RISK OF MALNUTRITION IN
WATFORD AND THREE RIVERS PCT
Produced by: Community Nutrition and Dietetic Department &
Medicines Management
September 2005

4. Guidelines Screening Tool - MUST Nutritional Support Pathway
First line dietary advice sheets
Training to Primary Care Staff

5. Nutrition support in adults
National Institute for Health and Clinical Excellence (NICE) Clinical Guidence 32 February 2006
Nutrition support in adults
Oral nutrition support, enteral tube feeding and parenteral nutrition

6. AIM:
To improve the practice of nutrition support by providing evidence and information for all healthcare professionals, patients and carers so that malnutrition whether in hospital or the community is recognised and treated by the best form of nutrition support at the appropriate time.

7. WHAT IS NUTRITIONAL SCREENING?
It is a rapid, simple, general procedure done at first contact with patient to detect risk of malnutrition or to identify malnutrition.
It can be carried out by all health care professionals

8. GROUPS AT RISK OF MALNUTRITION
Sick, frail elderly
Cancer
Chronic neurological conditions i.e MND, MS
Stroke
Acute/chronic pain
Chronic respiratory disorders i.e COPD
Chronic inflammatory bowel disease
HIV / AIDS

9. WHAT IS MALNUTRITON? No universally accepted definition but it
Can be defined as:
‘ A state in which a deficiency of nutrients such as energy, protein, vitamins and minerals causes measurable adverse effects on body composition, function or clinical outcome’
(NICE guideline – Nutritional support in adults, February 2006)

10. CONSEQUENCES OF MALNUTRITION
Evidence that malnourished patients:
Visit their GP more often
Need more prescriptions
Have more hospital admissions and longer stays
Have an increased morbidity and mortality
Have a reduced quality of life

11. WHY SCREEN FOR MALNUTRITION?
Malnutrition is frequently unrecognised and untreated
Effective management of malnutrition reduces the burden on healthcare and care resources
Regular screening is the only way that malnourished individuals can be identified and appropriate action taken

12. All hospital inpatients on admission
Screen:
All hospital inpatients on admission
All outpatients at their first appointment
All people in care homes on admission
All people on registration at GP surgeries
And upon clinical concern
Clinical concern includes, unintentional weight loss, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothes, or prolonged intercurrent illness

13. Consider screening at other opportunities ie
Consider screening at other opportunities ie. health checks, flu injections
Repeat screening weekly for inpatients and when there is clinical concern for all
Screening should be carried out by healthcare professionals with appropriate skills and training
Screening should assess BMI (Body Mass Index) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired nutrient intake. The Malnutrition Universal Screening Tool (MUST), for example, may be used to do this

14. WHAT IS MUST ? Malnutrition Universal Screening Tool
5 step tool used to identify adults who are malnourished or a risk of malnutrition
A validated tool across various settings including Care Homes, Hospital wards, Outpatient Clinics and General Practice
Quick and easy to use and give reproducible results
Useful for patients in whom height and weight are difficult to obtain as it includes alternative measures and subjective criteria which are given to obtain BMI ( Body Mass Index )

15. COMPONENTS OF MUST
A flow chart showing 5 steps to use for screening and management
BMI chart
Weight loss tables
Alternative measurements

16. Step 1: BMI SCORE Obtain weight and height
Calculate BMI or use BMI chart provided
Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained
SCORE

17. Step 2: Weight Loss Score (Unplanned weight loss over 3-6 months)
Note unplanned weight loss and refer to tables
SCORE

18. Step 3: Acute Disease Effect
Patients who have had or are likely to have no nutritional intake for more than 5 days
Most likely to apply to patients in hospital
SCORE

19. Step 4: Overall Risk of Malnutrition
Add up scores from Steps 1, 2 and 3
Document score
0 = Low risk
1 = Medium risk
2 or more = High risk

20. Alternative measurements Estimating Height from ulna length

21. Estimating BMI from mid upper arm circumference (MUAC)
BMI Category
Estimating BMI from mid upper arm circumference (MUAC)
If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2
If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2

22. MUST SCREENING TOOL – How do we use it?
MUST measurements
Case Studies
Feedback

23. MUST Measurements Estimation
Estimate how tall your partner is……………………………………......
Estimate how much your partner weighs……………………………….
What is your partners estimated BMI?………………………………….
(do not tell them your estimation until you have recorded their reported measurements below)
Reported
Ask your partner how tall they think they are………………………….
Ask your partner how much they think they weigh……………………
What is your partners reported BMI?…………………………………..
Actual
Measure your partners height……………………………………………
Weigh your partner………………………………………………………..
What is your partners actual BMI?………………………………………
Mid Upper Arm Circumferance (MUAC)
Measure your partners MUAC…………………………………………..
What is their BMI range using MUAC?
Ulna Length
Measure your partners Ulna length………………………………………
How tall are they using ulna length measurements?
Compare this to their actual height………………………………………

24. CASE STUDY D – Primary Care
69 year old man living at home with his wife, has rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea
Height: 1.73m
Previous weight: 71kg (2 months ago when weighed at GP Surgery)
Current weight: 69kg
Is patient at low, medium or high risk of malnutrition?
What would be your action plan?

25. CASE STUDY E – Primary Care
38 year old lady living at home with regular visits during the day from Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less
Height: ulna length 24.0cm
Previous weight: 62kg (6 months ago at OP clinic)
Current weight: 57kg
Is patient at low, medium or high risk of malnutrition?
What would be your Action Plan?

26. CASE STUDY F – Primary Care
89 year old man admitted to hospital after a fall at home and whilst an inpatient he contracted c.diff infection. Two months later he has been discharged, he still has diarrhoea but it is improving with treatment.
Height: 6’ 0” (estimated)
Weight: 56kg (estimated)
Previous weight: 65kg (before admission)
Is patient at low, medium or high risk of malnutrition?
What would be your Action Plan?

27. ANSWERS

28. CASE STUDY D - ANSWERS
69 year old man living at home with his wife, has rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea
Height: 1.73m
Previous weight: 71kg (2 months ago when weighed at GP Surgery)
Current weight: 69kg
Is patient at low, medium or high risk of malnutrition?
Low Risk
What would be your action plan?
Repeat MUST monthly due to constipation, nausea and some weight loss
Balanced diet advice sheet, for a regular meal pattern and adequate fobre intake
Give and discuss fluid advice sheet

29. CASE STUDY E - ANSWERS
38 year old lady living at home with regular visits during the day from Carers. She has MS and is wheelchair bound. She reports that for the last 6 months she has been experiencing difficulties swallowing and has been eating less
Height: ulna length 24.0cm
Previous weight: 62kg (6 months ago at OP clinic)
Current weight: 57kg
Is patient at low, medium or high risk of malnutrition?
Medium risk
What would be your Action Plan?
Repeat MUST monthly due to weight loss
Refer to Speech and Language therapist
Food and fluid chart
Give and discuss Making More of your food advice sheet

30. CASE STUDY F - ANSWERS
89 year old man admitted to hospital after a fall at home and whilst an inpatient he contracted c.diff infection. Two months later he has been discharged, he still has diarrhoea but it is improving with treatment.
Height: 6’ 0” (estimated)
Weight: 56kg (estimated)
Previous weight: 65kg (before admission)
Is patient at low, medium or high risk of malnutrition?
High Risk
What would be your Action Plan?
Start food and fluid chart
Give and discuss Making More of Your Food advice sheet
Start sip feeds 2 per day for initial period of 2 weeks using Guide to Nutritional Sip feed advice sheet
Refer to Dietitian for urgent review