Malnutrition screening among elderly people in a community setting: a best practice implementation project

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1 Malnutrition screening among elderly people in a community setting: a best practice implementation project Dana Craven APD 1 Zachary Munn PhD 2 Clint Moloney PhD 3 Melissa Taylor RN BNurs 3 1. Community and Aged Care Dietitian, Anglicare Southern Queensland, Sunshine Coast 2. Senior Research Fellow, The Joannna Briggs Institute, School of Translational Health Science, Faculty of Health Sciences, The University of Adelaide 3. University of Southern Queensland Primary Contact Dana Craven DCraven1@usc.edu.au Key Dates Commencement date: July 2013 Completion date: December 2013 Executive Summary Background The prevalence of malnutrition in older adults within the community is high and presents a major cost to the health care system. Overlooking malnutrition is concerning because this is an aspect of health care that greatly impacts on quality of life. Community care based organizations are in the ideal position to address this issue. The implementation of routine malnutrition screening amongst community care clients may assist with improving the nutritional status of individuals within the community and subsequently assist with achieving better health outcomes. Objectives To promote evidence based practice in relation to the nutritional management of malnutrition for Anglicare clients in the community. doi: /jbisrir Page 433

2 Methods An organizational audit was conducted across four service Zones within the Anglicare Sunshine Coast branch. The method was in accordance with the Joanna Briggs Institute s Practical Application of Clinical Evidence System and Getting Research into Practice tools. A three phase process of change was followed using a baseline audit, feedback and re-audit cycle to implement evidence based practice. Results The baseline audit revealed poor compliance with malnutrition screening and implementation of action plans. Following the implementation phase there was significant improvement in compliance across all criteria. Conclusions Overall this implementation project has been a great success. It has achieved the aim of promoting evidence based practice in relation to nutritional management of malnutrition. Follow-up audit data indicates malnutrition screening of new clients at admission occurred almost 100% of the time compared to 50% at baseline. Keywords community, elderly, malnutrition, MST, nutrition screening. Background Worldwide the number of older people is growing. 1 In Australia 3.1 million people are aged 65 years and over, with most living in private dwellings. Of these one in five require assistance with basic daily care and activities. 2 Active and healthy ageing can be affected by a number of contributors, including nutritional status. 1 Across all settings, including acute hospital, rehabilitation, residential aged care facilities and community settings (i.e. individuals living freely in their own homes) malnutrition (defined as under nutrition) is prevalent. 3 Recent studies have reported the prevalence of malnutrition in the community setting ranges between 10-30%. 3 Malnutrition occurs for many reasons, and is both a cause and result of ill health. 3,4 In Australia, malnutrition in older adults presents a major cost to the health care system. 3 Therefore overlooking or failing to treat malnutrition is concerning because this is an aspect of health care that greatly impacts on quality of life. As the prevalence of malnutrition in older adults within the community is high, community based organizations are in the ideal position to address this. The implementation of routine malnutrition screening amongst community care clients may assist with improving the nutritional status of individuals within the community and subsequently assist with achieving better health outcomes. 3,5 Evidence based recommendations from the National Health and Medical Research Council (NHMRC) state that malnutrition should be identified in the community setting. The NHMRC also recommends doi: /jbisrir Page 434

3 that treatment and action should take place in order to reduce prevalence of malnutrition in community dwelling adults. 3 Anglicare Southern Queensland is a not-for-profit organization committed to social and community welfare issues and aged and community care needs. Services provided by the Sunshine Coast Branch include nursing, allied health, personal care, domestic assistance, social support, in-home respite and Pastoral care. The majority of service provision is funded by HACC (Home and Community Care) and most clients are 65 years or older. One of the goals of home health care provided by Anglicare is to enable the elderly to maintain their independence and grow older in the comfort of their own homes. Currently the branch has over 1000 clients distributed across a large geographical area (>3000km 2 ) divided into four service Zones. Nutrition and Dietetics is a relatively new service to this Branch and there is currently one part time Dietitian servicing the whole of the Sunshine Coast branch. Typically a referral for nutrition care is provided to the Dietitian by another health care professional or in some cases clients may self refer. Often the referral process can be triggered by a particular event or process such as disease, unintentional weight loss or changes in appetite. overlooked, particularly malnutrition. 3 However, in many cases nutrition may be Nutrition screening is a process that can identify clients at risk of malnourishment. The American Society for Parenteral and Enteral Nutrition define nutrition screening as a process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated. 6 Nutritional screening is a quick process that can be completed by anyone using a simple tool. Various screening tools have been validated according to the setting. 3 Validated tools for the community setting include the Mini Nutritional Assessment Short-Form (MNA-SF) and, the Malnutrition Universal Screening Tool (MUST). 3 Currently at Anglicare Sunshine Coast there is no formal process of nutrition screening using a validated tool. As this is not in adherence with the current best available evidence, it was decided to implement malnutrition screening as a best practice implementation project for the Joanna Briggs Institute (JBI) Clinical Fellowship program. Objectives The overall aim was to promote evidence based practice in relation to the nutritional management of malnutrition for Anglicare clients in the community. Specifically, the aims of this project were: 1. To audit current practice regarding compliance with the best available evidence regarding malnutrition screening in the community. 2. Incorporate malnutrition screening into the standard admission process. 3. To implement a dietetic referral system to enable nutrition care planning. doi: /jbisrir Page 435

4 Methods The method was in accordance with the JBI Practical Application of Clinical Evidence Systems (PACES) and Getting Research into Practice (GRIP) tools. This online tool follows a three phase process of change using a baseline audit, feedback and re-audit cycle to implement evidence based practice. The implementation project was conducted across all four service Zones, and therefore an organizational audit was conducted. This method enabled comparison between compliance with best practice across the four Zones. The project was conducted over a four month period from July 2013 to November The project was registered as a Quality Improvement Activity within the Branch. Formal ethics committee approval was not indicated as there was no direct patient contact by auditors. Phase 1 Using the evidence summary for Nutritional Screening: Community Settings, 7 the following audit criteria were created, which represent the best available evidence on this topic: A validated screening tool is used to identify clients at risk for malnutrition. New clients are screened at admission. The screening tool has been completed accurately. Action plans are initiated when at risk patients for malnutrition are identified. It was decided to use the Malnutrition Screening Tool (MST) 8 for this project. The MST is a valid and reliable malnutrition screening tool for adult acute hospital patients. 8 Although the MST is not currently validated in the community setting, 3 it was used because it is already incorporated in the admission documentation used by Anglicare. The MST is located within the Health Behaviors Profile section of the Ongoing Needs Assessment (ONI) (refer Appendix 1). The MST has two questions and provides a total score. A total score of two or greater indicates the patient is at risk of malnutrition. A client who scores two or higher should be referred to the Dietitian for nutrition assessment. A retrospective baseline chart audit was conducted by the project leader to determine current compliance with the audit criteria. Twenty client charts were randomly selected from each of the four Zones (total 80 charts). Each chart was assessed to determine compliance with four audit criteria, outlined as follows: Criterion 1: A validated screening tool is used to identify clients at risk for malnutrition. All charts that had an MST completed met this criterion as the MST was the only tool available within the admission paperwork. If screening was not completed this option was scored N/A. N/A was used rather than No because No may imply that a non-validated screening tool was used Criterion 2: New clients are screened at admission. If the MST was completed (regardless of accuracy) this criterion was met. doi: /jbisrir Page 436

5 Criterion 3: The screening tool has been completed accurately. Both questions on the MST must have been completed and a total score entered in order for this criterion to be met. Criterion 4: Action plans are initiated when at risk patients for malnutrition are identified. If the score was 2 the chart was checked to locate a referral to the Dietitian. As paperwork is not always entered into the chart this was cross checked with the Dietician s referral spreadsheet. This master spreadsheet tracks and manages all Dietetic referrals received. If there was no evidence of a referral this criterion was not met. Results were recorded manually over a four week period and the data entered into the JBI PACES program by the project leader. Phase 2 Due to time constraints, baseline audit results were not presented to stakeholders prior to commencing Phase 2. However it had previously been identified by the project leader that malnutrition screening compliance was poor. This led to project endorsement and support from the Branch Manager and other senior staff. Prior to implementation of nutrition screening, the project leader met individually with relevant stakeholders to discuss the implementation process and to identify potential barriers. Stakeholders included the Branch Manager, a senior Clinical Nurse and the Allied Health Team Leader. The JBI Getting Research into Practice (GRIP) tool was utilized to assist this process and to inform the development of strategies (Table 3). A pathway for the management of malnutrition was developed by the Dietitian (refer Appendix 2) that outlined required action based on MST score. All twelve Registered Nurses (RN) and ten Allied Health (AH) staff members who perform client admissions attended an education session regarding malnutrition screening. This was facilitated by the project leader on 31 st July for RNs and 7 th August for AH staff. Staff who were not present at these sessions were ed the information and followed up individually by the project leader. The education sessions provided an overview of the issue of malnutrition in the community, instructions on how to complete the MST accurately and the referral process. Information handouts and how to guides were provided to all staff. It was noted that client s whose score indicate malnutrition risk may decline dietetic referral. The project leader requested that staff advise when this occurs. Phase 3 A follow-up retrospective chart audit was conducted by the project leader to compare compliance with the audit criteria. Clients admitted to Anglicare Sunshine Coast between 1 st August and 30 th November were selected. It was expected to audit twenty new admissions per zone to match the baseline audit, however new admissions during this time period were lower than anticipated. The number of follow up audits per zone are shown in Table 1. doi: /jbisrir Page 437

6 Table 1 Number of charts audited in Phase 1 and Phase 3 by Zone Number of Charts Number of Charts Zone Baseline (Phase 1) Follow Up (Phase 3) Difference New admissions were identified by running a client report in the Anglicare client management system Procura. The audit was completed online by the project leader by accessing the Health Behavior Profile section in Procura, the organization s system for client management, for each client. Charts were assessed as per the Phase 1 baseline audit for each criterion. Results Baseline Audit For the baseline audit, the frequency of each criterion is shown in Table 2. The compliance rates (%) are shown in Figures 1-4. Table 2 Frequency of criteria in baseline audit Criteria Frequency Zone 1 (n=20) Zone 2 (n=20) Zone 3 (n=20) Zone 4 (n=20) Total (n=80) Yes A validated screening tool is used to identify clients at risk for malnutrition. No N/A Yes Action plans are initiated when at risk patients for malnutrition are identified. No N/A Yes New clients are screened at admission. No N/A Yes The screening tool has been completed accurately. No N/A doi: /jbisrir Page 438

7 Figure 1 Baseline compliance against audit criteria Zone 1 Figure 2 Baseline compliance against audit criteria Zone 2 Figure 3 Baseline compliance against audit criteria Zone 3 Figure 4 Baseline compliance against audit criteria Zone 4 Across all criteria, Zone 4 performed highest overall. As expected, all Zones were 100% compliant with Criterion 1. Zone 4 displayed 50% compliance for Criterion 2, with the remaining three Zones reaching 0% compliance. Zone 4 was highest for Criterion 3 at 80% followed by Zone 3 at 45%, Zone 1 at 40% and Zone 2 at 35%. Zone 1 was highest at 88% for Criterion 4 followed by Zone 4 at 75%, Zone 2 at 71% and Zone 3 at 67%. doi: /jbisrir Page 439

8 Strategies for GRIP Barriers, strategies, resources and outcomes identified are presented in Table 3. Table 3 GRIP Implementation Barriers Strategies Resources Outcome Malnutrition screening Incorporate screening Staff time Decided to use existing not currently used as into standard admission MST located in Core standard practice process Assessment tool ONI. Provide education to Staff time Project leader attended clinical staff who perform admissions on how to complete the MST How To Guide Team leaders (CN, AH Leader) team meetings to educate staff. Develop and implement Dietitian Pathway developed. pathway for Dietetic referral based on screening score Handout Copies provided to all staff. Staff not compliant with Discuss with CN to Staff time CN reinforced to all completing section of admission paperwork confirm with staff Communication staff that completion is required component of that contains MST admission paperwork at this time. Poor knowledge Dietetic referral Staff time Staff are aware of role regarding impact of malnutrition and management of those at risk guidelines provided in management pathway Handout Discussion at meeting and examples of screening and dietetic referral process for those with scores 2 Staff do not attend Follow up via and Staff time Contacted all staff not meetings phone call present Client with score 2 Client has right to Staff time Potential future declines assessment nutrition refuse. refusal Staff to note Data collection research project All strategies were implemented as outlined in the GRIP table. doi: /jbisrir Page 440

9 Follow-up Audit Criteria frequency for the follow-up audit is shown in Table 4. The compliance rates (%) are shown in Figures 5-8. Table 4 Frequency of criteria in baseline audit Criteria Frequency Zone 1 (n=20) Zone 2 (n=13) Zone 3 (n=17) Zone 4 (n=16) Total (n=66) Yes A validated screening tool is used to identify clients at risk for malnutrition. No N/A Yes Action plans are initiated when at risk patients for malnutrition are identified. No N/A Yes New clients are screened at admission. No N/A Yes The screening tool has been completed accurately. No N/A Figure 5 Percentage compliance with best practice for audit criteria of baseline and follow up audits Zone 1 doi: /jbisrir Page 441

10 Figure 6 Percentage compliance with best practice for audit criteria of baseline and follow up audits Zone 2 Figure 7 Percentage compliance with best practice for audit criteria of baseline and follow up audits Zone 3 Figure 8 Percentage compliance with best practice for audit criteria of baseline and follow up audits Zone 4 doi: /jbisrir Page 442

11 Overall, Zone 4 demonstrated highest compliance across all four Criteria. There was no change for Criteria 1 across all four Zones. For Criteria 2 there was a 40% increase for Zone 1, 67% increase for Zone 2, 50% increase for Zone 1 with Zone 4 remaining stable. There was an increase for Criteria 3 for all four Zones. Zones 1 and 2 reached 100% compliance followed by Zone 4 at 94% (18% increase) and Zone 3 at 88% (96% increase). Criteria 4 saw an increase in error for Zones 1 (15%) and 2 (13%), however accuracy increased for Zones 3 (13%) and 4 (16%). Figure 9 Percentage compliance with best practice for audit criteria of baseline and follow up audits: all zones aggregated Across all Zones there was no change in compliance for Criteria 1 and 4. However, the largest increases in compliance were for Criteria 2 and 3. Collectively malnutrition screening occurred 95% of the time upon admission compared to 50% at the baseline. Action plans also saw a considerable increase from 11% at baseline to 50% at follow-up. Discussion Overall the implementation of malnutrition screening of clients has been successful. This is evidenced by near 100% compliance across all four Zones for audit Criterion 3 (new clients are screened at admission). Zones 1 and 2 achieved 100% compliance, with Zones 3 and 4 performing screening 88% and 94% of the time. The highest change was for Zone 3 which almost doubled the amount of screening between pre- and post-implementation audit. Action plan implementation (Criterion 2) also increased across Zones 1-3 and remained stable for Zone 4 at 50%. It was interesting to note that some clients declined nutrition assessment. In the case where a client declined Dietetic referral, this was recorded as a positive value for the criteria. The reasons varied and this requires further investigation as to why. Additionally further investigation may be required regarding clients who score 2 on the MST but are not obviously malnourished, for example someone who appears overweight or obese. Also it is likely that some action plans were attempted but declined and not communicated to the project leader. It was interesting to note that Criterion 4 (the screening tool has been completed accurately) decreased for Zones 1 and 2. It would be expected that after training and with reference materials for completing doi: /jbisrir Page 443

12 the tool that this would increase. The audit revealed that the inaccuracy occurred by failure to complete question 2 of the MST. This requires follow up with staff and if necessary further education provided to ensure accuracy. However it should be noted that the sample size was small and a 15% decrease across 20 charts represents a small number (3) of clients. Although the audit was conducted across four Zones, trends cannot be attributed to particular staff members. The RNs do not work in one dedicated Zone; their run is dictated by client need. It should also be noted that all post audit charts were completed by RNs and none by AH members. This is due likely to a reduction of new admissions during this project period. Therefore it is not clear at this time if AH staff are compliant with the audit criteria. It should be noted that the follow up audit was conducted online using the online client management system Procura. Therefore it is likely that there may be some error between the handwritten chart documentation and its transferral to the system, such as the second score being accidentally omitted. Unfortunately time constraints and geographical location of charts across four Zones did not allow for physical chart audit for the follow-up cycle. Moving forward, the results of this audit will be presented to all clinical staff. Re-education regarding tool completion will be provided where needed and feedback from staff regarding the project and the results collected. The end goal is to achieve 100% compliance. Periodic chart auditing will be conducted to ensure this is occurring and to identify any new barriers. Conclusion Overall this project has been successful and has achieved the aim of promoting evidence based practice in relation to nutritional management of malnutrition. Malnutrition screening of new clients at admission is occurring almost 100% of the time. The initiation of action plans has greatly improved across the Zones. More work is required to improve the accuracy of tool completion and this will be discussed with staff for feedback. Further research is necessary to establish why nutrition treatment may be declined by an individual when flagged at risk of malnutrition after nutrition screening. Conflict of Interest Nil identified. Acknowledgements Funding for this fellowship was received by the Department of Social Services: Teaching and Research Aged Care Services (TRACS); Aged and Community Care Education and Research Training project between Anglicare Southern Queensland and the University of Southern Queensland. I would like to thank my fellow staff members at Anglicare, in particular Caroline Bell CN and all the wonderful RNs I work with every day. Thank you to my AH team for your interest and support. Thank you to our fabulous administration team in particular Tina Kennedy and Catherine McKay. Also thank you to Clint Maloney and Melisa Taylor from USQ and the team at JBI, especially Zac Munn for your input and patience. Thank you to Prof Liz Isenring for answering my questions and generously giving me your time. Finally, a thank you to the other Fellows who experienced this journey with me. doi: /jbisrir Page 444

13 References 1. World Health Organization. Nutrition for older persons: a growing global challenge. [Internet]. C2013 [cited 2013 Oct 13]. Available from: 2. Australian Bureau of Statistics. Population by age and sex, regions of Australia, 2012 (cat. no ). [updated 2013 Aug 29; cited 2013 Oct 13]. Available from: OpenDocument#PARALINK2 3. Dietitians Association of Australia. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet. 2009; 66 (Suppl. 3): S1 4. Blaikley, C. Mind the hunger gap: a review of malnutrition in the community. Br J Community Nurs. 2012:S Leggo M, Banks M, Isenring E, Stewart L Tweeddale M. A quality improvement nutrition screening and intervention program available to home and community care eligible clients. Nutr Diet 2008;65: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Board of Directors and Clinical Practice Committee. Definition of terms, style, and conventions used in A.S.P.E.N. Board of Directors approved documents. American Society for Parenteral and Enteral Nutrition [Internet] [cited 2013 Jul 11]. Available from: 7. Munn Z. Nutritional Screening: Community Settings. Joanna Briggs Institute COnNECT+. 9/7/ Ferguson M, Capra S, Bauer J, Banks M. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15: doi: /jbisrir Page 445

14 Appendix 1: Health Behaviors Profile doi: /jbisrir Page 446

15 Appendix 2: Anglicare Sunshine Coast Pathway for Management of Malnutrition Anglicare Sunshine Coast Pathway for Management of Malnutrition August The Malnutrition Screening Tool (MST) is located within the Health Behaviors Section of the ONI. Complete this tool upon admission. 2. Use the flowchart below to determine course of action based on MST score. LOW RISK MST score = 0-1 MODERATE RISK MST Score = 2 HIGH RISK MST Score = 3-5 No recent weight loss and no nutrition impact symptoms. Client unlikely to be at risk of malnutrition. Eating poorly and/or recent weight loss of <2kg. Client is at risk of malnutrition. Eating poorly and recent weight loss of >2kg. Client is at high risk of malnutrition. Subsequent visits any changes (e.g. illness, wounds) - rescreen Refer to Dietitian. Refer to Dietitian. Generating the Referral: Prefer to receive referrals electronically i.e. scan the Allied Health Referral form. If referral related to MST note this in the Comments/Reason for Referral section of form, for example, MST Score = 2. Referrals will be prioritized based on the score and associated nutrition impact factors. doi: /jbisrir Page 447

16 Correctly Completing the Tool Applies to the last six months If unsure, ask if they suspect they have lost weight e.g. clothes or rings are looser, dentures may be looser. For example, less than three quarters of usual intake. Are they eating poorly because of any reason? Not always just chewing or swallowing problems, could be depression, unnecessary dietary restrictions, etc. Add up values and refer to flow chart to determine course of action doi: /jbisrir Page 448