North West Wales NHS Trust Audit and Assurance Department

North West Wales NHS Trust Audit and Assurance Department Nutrition and Weighing of Patients on admission to Hospital April 009 Lisa Burne Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, LL7 PW

Contents Page Number. Quality Check List. Introduction. Key Findings MUST SCREENING TOOL. Standard MUST Screening Tool must be completed on admission. Standard MUST Screening Tool must be reviewed weekly. Appropriate action must be taken following MUST Screening Tool. Breakdown per ward 6. Key Findings WEIGHING OF PATIENTS. Standard All patients must be weighed on admission/or weekend. Breakdown per ward. Type of weighing scales 6 6. Barriers to weighing patients 6 7. Standards achieved 7 8. Action taken Medical Directorate 8 Action taken Women & Families Directorate 9 Action taken Mental Health & Learning Disabilities 9. Lessons learnt Nutrition and Weighing of patients Page of March 009

. Quality Check List Draft document discussions between: Lisa Burne, Senior Clinical Auditor Shan Kennedy, Health Care Standards Manager Dave Harries, Head of Audit and Assurance Anne-Marie Rowlands, Associate Nurse Director Final Report disseminated to: Heads of Nursing for action Liz Foden Shroff, Head of Dietetics Harriet Naylor, Dietician Directorate General Managers Anne-Marie Rowlands, Associate Nurse Director Shan Kennedy, Health Care Standards Manager Nursing and Midwifery Audit Group Ward Managers via Heads of Nursing Nutrition and Weighing of patients Page of March 009

. Introduction This audit combines the requirement of weighing patients on admission to hospital with completion of the MUST screening tool. Both these aspects are vital in identifying and early intervention in the care of patients at risk of malnutrition. Previous audits have been carried out separately: MUST Screening Tool audit (007) carried out by a dietician found that only % of patients had a MUST screening tool completed on admission which was reviewed weekly in only 9% of cases. The audit identified a lack of understanding of how to complete the tool and of the subsequent referral requirements. WEIGHING of patients on admission audit (May 008) carried out as part of the nursing & midwifery audit programme found that 96% of patients were weighed on admission. 8 patients were not weighed due to justifiable reasons however the MUST screening tool states that alternative measurements and considerations must be taken under these circumstances. In order to ascertain the reasons patients were not being weighed an audit was carried out to ascertain the availability of weighing scales on the wards: Standing Scales were available on 78% of the wards; sitting scales on 70% of the wards and hoist weighing scales on 9%. As a minimum requirement seated scales must be available on all wards to ensure effective nutritional screening and monitoring.. REASON FOR AUDIT All patients are to be weighed on admission and as required throughout their hospital stay; this should lead to more patients having the MUST nutritional assessment carried out on admission and hopefully leading to a reduction in length of hospital stay, infections, delayed wound healing and an increase in strength and mobility.. OBJECTIVE This is an extremely important audit to measure whether practice has improved following the action taken from the previous audit. ASSURANCE Strategic aim : Provide high quality of care Strategic aim : To attain, or surpass, government and local targets. Strategic aim 7: Be a learning organisation Strategic aim 8: Create an environment that is fit for user needs Domain: The Patient experience Healthcare Standards and 9 Domain: Clinical Outcomes Healthcare Standards and Domain: Healthcare Governance Healthcare Standard 8. SOURCE OF EVIDENCE ON WHICH AUDIT IS BASED Council of Europe Recommendations on Food and Nutritional Care in Hospitals Standards BAPEN Malnutrition Universal Screening Tool (MUST) Screening Tool National Institute of Clinical Excellence (NICE) (006) Nutrition Support in Adults Royal College of Nursing (RCN) (007) Nutrition Now. Principles for Nutrition and Hydration NSF for Older People Nutrition and Weighing of patients Page of March 009

. CLINICAL IMPLICATIONS TO THE PATIENT / RISK IMPLICATIONS TO THE TRUST Unrecognised malnutrition; increased length of hospital stay, increased risk of infection, reduced quality of life, reduced strength and mobility, delayed wound healing.6 PATIENTS TO BE INCLUDED A random selection of five patients per ward were to be audited..7 TIME PERIOD March 009.8 PATIENT AGES All ages.9 DATA SOURCE Case notes.0 SAMPLE SIZE responses Not applicable responses were received from: Theatres, Labour Ward, Minffordd and Dewi Ward. Data was received from Alaw and Marl ward after the report had been drafted so are not included.. DATA RETRIEVAL METHOD Retrospective Nutrition and Weighing of patients Page of March 009

. KEY FINDINGS MUST SCREENING TOOL. Standard MUST Screening Tool must be completed on admission Overall compliance is % Directorate Community Hospitals and Rehabilitation % compliance 7% Medical Directorate 6% Mental Health and Learning Disabilities % Surgical 8% Women and Families % Comments In 0 cases Aneurin and Dryll Y Car do not use or have access to the tool so this brought compliance down MUST was not carried out for any patients on Cybi ward as the patients were critically ill Please see page 6-0 for additional information and break down per ward. Standard MUST Screening Tool must be reviewed weekly Overall compliance is % (This is applicable whether or not the MUST was completed on admission or at any point during admission and only to patients with length of stay of over one week) Directorate Community Hospitals and Rehabilitation % compliance 79% Medical Directorate 7% Mental Health and Learning Disabilities % Surgical % Women and Families 0% Comments In 0 cases Aneurin and Dryll Y Car do not use or have access to the tool so this brought compliance down MUST was not carried out for any patients on Cybi ward as the patients were critically ill Please see page 6-0 for additional information and breakdown per directorate. Appropriate action must be taken following MUST screening assessment 99% compliance (This includes cases where no action was required) Nutrition and Weighing of patients Page of March 009

. Breakdown per Ward Community Hospitals and Rehabilitation Directorate Standard MUST Screening Tool must be completed on admission 6 MUST complete MUST not complete 0 Padarn, Eryri Peblig, Eryri Madog, BYG Bryn Beryl Fali, YPS Cybi, YPS Dysynni, Tywyn Blaenau Ff Mawddach, Dolgellau Cader, Dolgellau Overall there were responses from the Community Hospitals; compliance was 7%. Ward Padarn Ward () Peblig Ward () Madog Ward () Bryn Beryl () Fali () Reason for non-compliance (where provided) Eats and drinks well so not applicable Late transfer Not applicable No reason stated Screening commenced in Eryri so no assessment needed Reason not known Assessed in Ysbyty Gwynedd score 0 so no need for assessment Not applicable as patient not malnutritioned Transferred yesterday from Ysbyty Gwynedd No reason stated Patient nutritional state not compromised Patient nutritional state not compromised short stay document used in District Nursing Hospital Standard MUST Screening Tool must be reviewed weekly This was applicable to 8 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 0 (79%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: two patients were reviewed monthly or every two weeks. Other reasons provided were that the patients nutritional status was not compromised and that their oral intake was good. Nutrition and Weighing of patients Page 6 of March 009

Medical Directorate Standard MUST Screening Tool must be completed on admission 6 MUST complete MUST not complete 0 Moelwyn Aberconwy Morfa Gogarth Prysor Tryfan Overall there were responses from the Medical Directorate (six from Gogarth); compliance was 6%. Ward Reason for non-compliance (where provided) Moelwyn Good oral intake MUST completed day after admission Prysor Done on transfer to Prysor but not on admission NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON MORFA AND GOGARTH Standard MUST Screening Tool must be reviewed weekly This was applicable to 9 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); (7%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: no problems with eating and drinking, patient has good oral intake. Nutrition and Weighing of patients Page 7 of March 009

Mental Health and Learning Disabilities Directorate Standard MUST Screening Tool must be completed on admission 6 MUST complete MUST not complete 0 Coedlys Aneurin Cynan Glasmor Dryll Y Car Heulwen Taliesin Overall there were responses from the Mental Health & Learning Disabilites (one from Taliesin), data was incomplete in one case. Of the remaining compliance was %. Ward Reason for non-compliance (where provided) Aneurin () MUST screening tool not used in this setting * Dryll Y Car () Do not have MUST screening tool Heulwen () One patient refused and one patient had dementia NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON COEDLYS, CYNAN, OR GLASMOR * Dryll-y-Car is an unusual hospital environment. The ethos is to support people through change and we do this by working in partnership not dictatorship. There are no domestics or catering staff, the meals are planned and catered for by the nursing staff with the clients. Evening meals are planned with the clients, meeting all different nutritional needs. The evening meal is part of the therapeutic environment shared by the staff and clients to accommodate individual needs and abilities. Over the years this approach has influenced a change in the majority of the clients nutrition and physical activity through a gradual process. Fruit is always available and the fridges are well stocked with healthy options. Clients are weighed on each admission, and as clients use the service of Dryll-y-Car on a regular basis they are monitored for weight increase and loss and adjust/plan diets accordingly. Standard MUST Screening Tool must be reviewed weekly This was applicable to 9 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 6 (%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: two patients on Glasmor were reviewed frequently but not weekly and in one case it had not been recorded as being done weekly Nutrition and Weighing of patients Page 8 of March 009

Surgical Directorate Standard MUST Screening Tool must be completed on admission 8 MUST complete MUST not complete 6 6 0 Tegid Ogwen Aran Dulas Cybi Overall there were 6 responses from the Surgical Directorate (six from Cybi ward) - 8% compliance. Ward Reason for non-compliance Tegid () Transferred from Beuno Three patients were short stay patients Ogwen () No evidence of MUST tool patient was admitted to Hebog Cybi (6) Critically ill patients on admission unstable NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON ADMISSION TO ARAN, Standard MUST Screening Tool must be reviewed weekly This was applicable to 6 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); two (%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: patients on Dulas ward were reviewed every two weeks or monthly as their dietary intake was very good and there was nothing affecting their diet. One patient was not reviewed weekly on Ogwen and the reason was not known. In one case the patients MUST score was 0 and there was no evidence of weight loss. Nutrition and Weighing of patients Page 9 of March 009

Women and Families Directorate Standard MUST Screening Tool must be completed on admission 6 MUST complete MUST not complete 0 Llifon Ffrancon Overall there were 7 applicable responses from the Women and Families directorate; compliance was %. Not applicable: Patient in labour and went home the next day ( patients) Ward Reason for non-compliance NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON FFRANCON WARD OR LLIFON WARD Standard MUST Screening Tool must be reviewed weekly This was applicable to 6 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 0 (0%) patients had their MUST tool reviewed weekly. Reasons for non-compliance: no reasons specified Nutrition and Weighing of patients Page 0 of March 009

. KEY FINDINGS WEIGHING OF PATIENTS. Standard Patient must be weighed on admission and/or weekend Overall compliance is 7% Directorate Community Hospitals and Rehabilitation On admission COMPLIANT At weekend NON COMPLIANT Not weighed No evidence * 6 (8%) (%) (7%) (%) Medical Directorate (%) 6 (9%) 6 (9%) (6%) Mental Health and Learning Disabilities (8%) (6%) (%) Surgical 9 (%) (%) 9 (%) Women and Families 7 (70%) (0%) (9%) (Cybi ward) TOTAL 8 (7%) 6 (8%) (7%) (8%) * Where there is no evidence documented in the case notes that the patient has been weighed this has been included as non-compliant Refer to pages 6 for breakdown of wards Nutrition and Weighing of patients Page of March 009

. Breakdown per ward Community Hospitals and Rehabilitation Standard Patients must be weighed on admission/at weekend 6 Weighed Not weighed 0 Padarn, Eryri Peblig, Eryri Madog, BYG Bryn Beryl Fali, YPS Cybi, YPS Dysynni, Tywyn Blaenau Ff Mawddach, Dolgellau Cader, Dolgellau Overall there were responses from the Community Hospitals and Rehabilitation Directorate - 9% compliance. 6% of these patients were weighed at the weekend rather than on admission. Madog Ward: One patient was not weighed on admission but was weighed weekly thereafter Bryn Beryl: Three patients were not weighed on admission; one patient was aggressive and one would be weighed at weekend if feeling stronger, reason not documented for the third. However there was no documented evidence that the patients were weighed at all during their admission Nutrition and Weighing of patients Page of March 009

Medical Directorate Standard All patient must be weighed on admission/at weekend 6 Weighed Not weighed 0 Moelwyn Aberconwy Morfa Gogarth Prysor Tryfan Overall there were responses from the Medical Directorate - 6% compliance. 0% of these patients were weighed at the weekend rather than on admission. Morfa Ward: Five patients were not weighed on admission, two patients were weighed on transfer to rehab and one patient arrived at tea time. There was no documentation that two patients had been weighed at all during their admission. Gogarth Ward: Three patients were not weighed on admission; one patient had poor mobility, one patient remained in pain and the third patient was being barrier nursed and was bed bound chair hoist not appropriate there was no documentation that any of the three patients had been weighed during their admission. Moelwyn Ward: One patient was not weighed on admission as they had a fracture neck of femur and were in pain there was no documented evidence that the patient was weighed during their admission. Tryfan Ward: Two patients were not weighed on admission; the reason was not known in one case and in the other the patient was unable to weight bear. It was unknown in one case whether the patient was weighed at any point during admission and in one case it was not applicable as it was the patients first day. Nutrition and Weighing of patients Page of March 009

Mental Health and Learning Disabilities Directorate Standard patients must be weighed on admission/at weekend 6 Weighed Not weighed 0 Coedlys Aneurin Cynan Glasmor Dryll Y Car Heulwen Taliesin Overall there were responses from the Mental Health and Learning Disabilities Directorate - 90% compliance. 8% of these patients were weighed at the weekend rather than on admission. Coedlys: One patient was weighed the day after admission rather than on admission. Aneurin Ward: One patient refused to be weighed on admission but was weighed weekly thereafter. Glasmor Ward: One patient refused to be weighed on admission but was weighed frequently thereafter. Heulwen Ward: One patient was unable to be weighed on admission as they had dementia/restless agitation, but this patient was weighed weekly thereafter. Nutrition and Weighing of patients Page of March 009

Surgical Directorate Standard patients must be weighed on admission/at weekends 6 Weighed Not weighed 0 Tegid Ogwen Aran Dulas Cybi Overall there were 6 responses from the Mental Health and Learning Disabilities Directorate - 6% compliance. % of those patients weighed were weighed at the weekend rather than on admission. Tegid Ward: Five patients were not weighed on admission; the reason was not known in two cases; one patient was weighed in pre-op and one patient was weighed on transfer to rehab. Three of the five patients were overnight stay only. Ogwen Ward: One patient was not weighed on admission as they were too poorly but they were weighed when condition improved and weekly thereafter. Aran Ward: There was no documented evidence that two patients were weighed on admission or during their stay. One patient had a fracture neck of femur and was unable to be weighed; reason for second patient unknown. Dulas Ward: There was no documented evidence that one patient was weighed on admission or during their stay. Reason not known. Cybi Ward: Five patients were not weighed on admission as they were critically ill; however four patients were weighed during their admission and one could not be weighed in their current bed position (chair position) Nutrition and Weighing of patients Page of March 009

Women and Families Directorate Standard patients must be weighed on admission/at weekends Overall there were 0 responses from the Women and Families Directorate (three were not applicable as they were in labour and left the next day) - 00% compliance. Ffrancon Ward: Five patients were weighed on admission but were not weighed weekly thereafter as they had mobility and communication barriers. Labour Ward: Two patients were weighed on admission and one was weighed frequently thereafter however the second patient had not as yet been in for one week. Type of weighing scales Below is a summary of the types of weighing scales used in the Trust Directorates Community & Rehabilitation Medical Mental Health Surgical Women & Families Type of weighing machine used Seca sitting scales Arjo weighing hoist Marsden weighcare Arjo bath hoist Seca Weylex Leyland Seca sitting scales EKS 80 Seca sitting scales Seca standing scales Hill Rom Bed Seca upright 6 Barriers to weighing patients - Severe pain - Other caring needs are a higher priority - Heavy workload on rest of ward - If patient is non weight bearing there is no equipment on the ward, i.e. a hoist that also has a weighing scales mechanism; this is a shared hoist with adjacent ward - Resistance, refusal or uncooperative patient, for example patients with dementia - Poor mobility - Difficult to weigh at night left for day shift to weigh - Bed bound patients have to be hoisted and weighed with borrowed hoist from ITU (not always available) - Standing scales only available on ward therefore difficult to weigh patients who are unable to stand - If patient is not on a Hill Rom Bed and unable to be hoisted out of bed - unable to weigh Nutrition and Weighing of patients Page 6 of March 009

7 Standard Achieved Ref. CRITERION STATEMENT (Relating to the aspect of care being measured) % ACHIEVED March 009. MUST Screening Tool must be completed on admission %. MUST Screening Tool must be completed weekly % % ACHIEVED 007/008 % (November 007) 9% (November 007) The previous audit carried out in November 007 was undertaken by a dietician; therefore there may be some discrepancies in data collection and audit methodology.. Patients must be weighed on admission/at weekend 7% 96% (May 008) Nutrition and Weighing of patients Page 7 of March 009

8 Problems Identified/Action Taken Please discuss these results and complete the action plan to complete this audit and ensure practice is changed to improve patient care. If problems cannot be solved, please give the reason, i.e, resource implications. Ref. Finding/Problem Cause of problem Priority = High = Medium = Low Action Required Individual Responsible for action Implementation date MEDICAL DIRECTORATE ACTION PLAN... MUST Screening Tool is not consistently being completed on admission for all patients (% achieved) MUST Screening Tool is not being reviewed weekly Patients are not being weighed on admission Overall lack of understanding a common understanding is that if the nutritional state of the patient is not compromised a MUST screening tool is deemed not applicable Common conception is that if nutritional state not compromised (i.e. score = 0) then it does not need to be reviewed weekly. This is not the case the tool states to be reviewed weekly Poor documentation Unable to weigh patients (see barriers to weighing patients on page 6) Awareness and Education. Presentation given by Dietetics March 009 and ongoing awareness Session Awareness and Education Ongoing training with dietetics dept Awareness and Education Ongoing training with dietetics dept. Review of weighing HON, Ward Managers Ward Mangers Ward Mangers March 009 Ongoing Ongoing Nutrition and Weighing of patients Page 8 of March 009

. Data collection is variable for example one ward might state not applicable if a patient is unable to be weighed where as another ward might state No. The MUST screening tool states that if unable to weigh patients then alternative methods should be used. Must be agreed what constitutes a legitimate reason not to weigh a patient or complete a MUST screening tool. These can then be indicated as not applicable across the Trust equipment available Awareness and Education Ongoing training with dietetics dept within medicine Ward Mangers Ongoing Ref. Finding/Problem Cause of problem Priority = High = Medium = Low Action Required Individual Responsible for action Implementation date WOMEN AND FAMILIES DIRECTORATE ACTION PLAN. MUST Screening Tool is not consistently being completed on admission for all patients (% achieved) Overall lack of understanding a common understanding is that if the nutritional state of the patient is not compromised a MUST screening tool is deemed not applicable Awareness to be raised within ward areas about the use of MUST tool. Ward managers May 009. Nutrition and Weighing of patients Page 9 of March 009

... Clinical Audit on: Nutrition and Weighing of patients on admission to hospital MUST Screening Tool is not being reviewed weekly Patients are not being weighed on admission Data collection is variable for example one ward might state not applicable if a patient is unable to be weighed where as another ward might state No. Common conception is that if nutritional state not compromised (i.e. score = 0) then it does not need to be reviewed weekly. This is not the case the tool states to be reviewed weekly Poor documentation Unable to weigh patients (see barriers to weighing patients on page 6) The MUST screening tool states that if unable to weigh patients then alternative methods should be used. Must be agreed what constitutes a legitimate reason not to weigh a patient or complete a MUST screening tool. These can then be indicated as not applicable across the Trust Only applicable to Ffrancon ward. Maternity patients rarely are inpatients for a period of 7 plus days. Scales available in all clinical areas. Reminder to all staff to weigh patients on admission. All staff to be reminded to use MUST tool and document the reasons for not weighing patients on admission to wards. Ward Manager. May 009. Ward Manager May 009 Ward Manager May 009. Nutrition and Weighing of patients Page 0 of March 009

Ref. Finding/Problem Cause of problem Priority = High = Medium = Low MENTAL HEALTH AND LEARNING DISABILITIES DIRECTORATE ACTION PLAN.. MUST Screening Tool is not consistently being completed on admission for all patients (% achieved) Mental Health & LDS Aneurin and Dryll Y Car do not have access to the MUST tool, this significantly reduced compliance if not using MUST what tool is being used to assure patient s nutritional needs are met Overall lack of understanding a common understanding is that if the nutritional state of the patient is not compromised a MUST screening tool is deemed not applicable Action Required Dryll Y Car do not have copy of MUST screening tool. Associate Nursing Director and Head of Nursing made aware to reach decision and make available. Service Improvement sister has sent MUST screening tool and guidance sent to Dryll Y Car and will liaise with Aneurin ward also. Awareness and Education. Presentation given by Dietetics March 009 and ongoing awareness Session Individual Responsible for action Service Improvement Sister and Head of Nursing, MH&LDS HON, Ward Managers Implementation date July 009 March 009 Nutrition and Weighing of patients Page of March 009

ACTION PLAN. MUST Screening Tool is not consistently being completed on admission for all patients (% achieved) Cybi Ward (ITU) patients are critically ill on admission if not using MUST what tool is being used to assure patient s nutritional needs are met No response from Cybi ward Service Improvement Sister is to liaise with Cybi to arrange screening tool with them Service Improvement Sister July 009 9 Lessons Learnt The previous MUST screening tool audit was carried out by dieticians and therefore the audit methodology might vary and this could be reflected in the results. Legitimate reasons for not completing a MUST screening tool or weighing the patient must be agreed on; so that data collection does not vary across wards and departments. The MUST tool states if unable to obtain height and weight, use the alternative procedures shown in this guide Training Dietetics are providing training sessions in the form of 0 minute drop in sessions throughout selected days. Nutrition and Weighing of patients Page of March 009