National Update on Malnutrition

National Update on Malnutrition Dr Trevor Smith Consultant Gastroenterologist University Hospital Southampton BAPEN Executive Officer Chair, British Artificial Nutrition Survey

British Association for Parenteral and Enteral Nutrition A multi-disciplinary charity committed to raising awareness of malnutrition and the options for nutritional treatment, along with the impact on health outcomes, resource utilization, and health & social care budgets. B A P E N Malnutrition Matters

Malnutrition = medium + high risk MUST score 4 annual screening weeks 2007-11 2/3 of hospitals had a nutrition team 661 hospitals 34,699 patients 28% malnourished on admission to hospital

BAPEN NSW Data

474 care homes 3971 adults 35% malnourished

BAPEN Care Home report

Prevalence and consequences of malnutrition in the UK PRIMARY CARE hospital dependency GP visits prescription costs HOME General population (adults) BMI <20kg/m 2 : 5% BMI <18.5kg/m 2 : 1.8% Elderly: 14% Prevalence of malnutrition SHELTERED HOUSING 10-14% of tenants HOSPITAL 28% of admissions CARE HOMES 30-42% of recently admitted residents SECONDARY CARE complications length of stay readmissions mortality

Complications of abdominal operations for malignant disease Meguid et al. Am J Surg 1988 100 90 80 70 60 50 40 30 20 10 0 Complication Rate Post-Operative Mortality Well nourished Malnourished

Health & Social Care Budget (England) Health & social care expenditure associated with malnutrition was 19.6 billion (15% of the total expenditure on health & social care)

2% 3 million malnourished 5% 93% The Costs of Malnutrition Community people with little or no contact with services Community people in contact with services Care Homes Total UK costs of approx 20 billion (2015) associated with malnutrition across health and social care NICE Guidance on Nutrition Support- 5th highest cost savings compared to savings calculated for all pieces of NICE guidance Hospital NIHR/BAPEN full cost/benefit analysis (2015) 300 to 400K savings per 100,000 population by implementing simple NICE nutritional measures in hospitals and care homes (largest savings in hospital)

The costs of providing nutrition support

The costs of providing nutrition support Nutrition support does not cost money, it saves money

BAPEN Video http://www.bapen.org.uk/how-good-is-yournutritional-care

Key Outcomes To achieved by March 2018 Leadership Understand the local burden of malnutrition Review existing service provision Commission services that: Identify at risk populations Implement appropriate interventions Connect hospital & community services to deliver a nutrition & hydration pathway Public awareness of the importance of good nutrition Monitor and evaluate services & outcomes

Measuring the Quality of your Nutritional Care How good is your Trust or Care Home?

Why has BAPEN developed a new Background measurement tool? Around 30% of patients admitted to UK hospitals are malnourished or at risk of malnutrition. Patients who are malnourished have poorer clinical outcomes which improve markedly if proper nutritional care is given, yet our learning from Trusts is that nutritional care continues to be fragmented In part, this may reflect the lack to date of any means of measuring the quality of the nutritional care they provide, despite NICE issuing both Guidance and Quality Standards for Nutritional Support in Adults I understand first-hand the impact nutritional care has on many other areas of an individual s health care. By implementing an effective monitoring process it will potentially have a positive impact on the patient s journey throughout the whole healthcare system which is surely a good thing! Steve Brown, Secretary of PINNT

Tick box exercise Problems identified in current approaches Measurement of nutritional care is lagging behind other areas e.g. Cancer, VTE Heavy reliance of measuring nutritional screening using retrospective audits Little if any focus on Accuracy of screening Quality of the nutritional care plan developed Monitoring of the implementation of the care plan (beyond poorly completed food record charts and fluid balance charts) Lack of focus on re-screening Poor measurement of patient experience of nutritional care Even poorer measurement of nutritional outcomes Poor understanding of the barriers (e.g. lack of equipment/nursing time)

Why has BAPEN developed a new measurement tool? The focus in healthcare is shifting from standalone audits to quality improvement informed by audits Data collection was paper based One week per year selected for national nutrition screening audit Transfer of data to electronic database by hand Analysis and written report time consuming Pre-2012 Post 2015 Data collection via a web platform Opportunity for frequent data collection Scope for extensive analytics with a nutrition dashboard Instant charting and tracking of data over time using funnel plots, pareto charts and run charts 80 70 % 60 C e n t r e s 50 40 30 20 10 0-25% patients 26-50% patients 51-75% patients 76-100% patients 0 2007 (N=175) 2008 (N=90) 2010 (N=141) 2011 (N= 147 ) Nutritional Care Dashboard

Aim To design a web-based, simple national nutritional care tool to enable clinicians and organisations to measure the different elements that are required for the delivery of good nutritional care (screening, care plans, outcomes and patient experience) in order to identify where local improvements are required

What does the new tool measure? Organisational details Demographics Nutritional care Organisation name Ward/unit Speciality Date of collection Professional group undertaking the survey Age group Feeding route Setting Diagnosis Screening (including score on admission) Re-screening Nutritional care plan documented and implemented Current weight Unplanned weight loss Height Acute illness AND has there been, or likely to be, no nutritional intake for more than 5 days Subjective criteria Barriers to nutritional screening Patient Experience questions Have you received all the food and drink or nutritional care you have needed? Have you received assistance to eat and drink when you have needed help?

What are the benefits of using the new tool in your practice? The first tool nationally available that will enable you to measure the quality of nutritional care delivered to your patients and to track improvements over time Provision of robust assurance to your trust board, through the nutritional care dashboard Point of care measures facilitate delivering improvements whilst the patient is still in your care Completely voluntary you decide the frequency and scale of use If used across an organisation will highlight areas of excellent practice and areas where improvements are needed It is free to all NHS and Social Care Organisations in the UK Contains patient experience questions, as well as screening, care planning and outcomes Online e- learning modules to help interpret the data collected

Steps to using the tool? Step 1 Speak to your Chief Nurse or MD or Nutrition Steering Committee Chair Step 4 Create an account: set a username and password Step 7 Decide which wards or areas will participate in data collection and who will collect the data Step 2 Agree that your organisation wishes to participate Step 5 Complete the Registration Form www.bapen.org.uk Step 8 Select a date to begin Step 3 Agree who will act as administrator Step 6 Read the User Guide on the website Step 9 Collect the data Step 10 Review the data collected using online analytics

Focus areas- the core dashboard 1. % received all the food and drink and/or nutritional care they have needed (Patient experience question 1) 2. % received all assistance to eat and drink they have needed (Patient experience question 2) 3. MUST on admission 4. MUST rescreening 5. Patients at risk of malnutrition 6. Patients with >5% weight loss in hospital

BAPEN malnutrition self screening www.malnutritionselfscreening.org

BAPEN e-learning www.bapen.org.uk

Aims of in-hospital nutrition support To meet EVERY patient s needs NORMALLY NOURISHED Undernourished BMI<20 Wt Loss >10% Partial IF IF

BANS HPN Data

BANS HPN Data 1600 1400 1200 1000 800 600 400 200 0 2008 2009 2010 2011 2012 2013 2014 2015 New Registra ons 157 148 228 262 351 472 400 420 Point Prevalence 413 345 523 611 888 1082 933 1144 Period Prevalence 521 435 624 743 1082 1310 1135 1360

BANS HPN + IV Fluids Data 1800 1600 1400 1200 1000 800 600 400 200 0 2011 2012 2013 2014 2015 New Registra ons 293 402 546 469 495 Point Prevalence 657 1000 1227 1084 1351 Period Prevalence 792 1210 1475 1308 1603

BANS HPN: Age Categories 25 20 15 10 2011 2015 5 0 16-20 Yrs 21-30 Yrs 31-40 Yrs 41-50 Yrs 51-60 Yrs 61-70 Yrs 71-80 Yrs 81-90 Yrs 91-100 Yrs % pts >70 yrs: 2008 10%; 2011 14%; 2015 18.5%

BANS IV Fluids: Age Categories 35 30 25 20 15 10 2011 2015 5 0 16-20 Yrs 21-30 Yrs 31-40 Yrs 41-50 Yrs 51-60 Yrs 61-70 Yrs 71-80 Yrs 81-90 Yrs 91-100 Yrs % pts >70 yrs: 2011 16%; 2015 24%

BANS HPN: Diagnosis 90 80 70 60 50 40 30 20 10 0 2008 2009 2010 2011 2012 2013 2014 2015 Cancer 15.3 9.5 14 16.4 18.8 24.6 25.5 27.4 Non-malignant GI 75.8 83.1 79.8 74.8 74.9 70.1 67.8 64.8 Other Condi ons 8.9 7.4 6.1 8.8 6.3 5.3 6.7 7.8 Cancer: 24 pts (2008); 43 pts (2011); 115 pts (2015)

BANS HPN + IV Fluids: Age & Diagnosis 300 250 200 150 100 50 0 16-70 71-100 16-70 71-100 16-70 71-100 Cancer GI Other 2011 47 9 242 43 18 4 2015 104 30 256 62 39 4

BANS HPN + IV Fluids: Age & GI Diagnosis

BAPEN s vision for success The 5 tenets of good nutritional care 1 2 3 4 5 Prevention of malnutrition and dehydration wherever possible Screening Identify malnutrition/ risk of malnutrition early through screening and assessment e.g. the MUST Tool Treatment high quality food and drink, assistance with feeding, nutritional support where required & individualised care pathways Education and training for all care staff appropriate to setting, profession and responsibilities Commissioning and Provider systems that facilitate multidisciplinary nutritional care in all health and social care settings Page 43