MALNUTRITION UNIVERSAL SCREEING TOOL (MUST) MUST IS A MUST FOR ALL PATIENTS

MALNUTRITION UNIVERSAL SCREEING TOOL (MUST) MUST IS A MUST FOR ALL PATIENTS Eimear Digan Senior Dietitian, Tallaght Hospital

Groups at Risk of Pressure Ulcers Critically ill. Neurologically compromised e.g. Spinal cord injuries. Impaired mobility / immobile. Impaired nutrition. Obese. Poor posture or those who use equipment such as seating/beds that do not provide appropriate pressure relief. Population sub-groups e.g. elderly / pregnant women (NICE, 2005). It seems reasonable to recommend consultation with a dietitian for patients at risk of developing pressure ulcers. (Reddy et al, 2006)

Obesity may mask nutritional deficiencies i.e. morbidly obese individuals may still be undernourished (EPUAP, 2003) Increased frequency of wound infections and impaired wound healing. Adipose tissue is poorly vascularised, resulting in decreased blood flow to the wound and impaired delivery of nutrients. Increased frequency of wound dehiscence. (Thompson & Fuhrman, 2005).

Groups at Risk of Pressure Ulcers Critically ill. Neurologically compromised e.g. Spinal cord injuries. Impaired mobility / immobile. Impaired nutrition. Obese. Poor posture or those who use equipment such as seating/beds that do not provide appropriate pressure relief. Population sub-groups e.g. elderly / pregnant women (NICE, 2005). It seems reasonable to recommend consultation with a dietitian for patients at risk of developing pressure ulcers. (Reddy et al, 2006)

An undernourished patient may be by underweight, normal weight or overweight according to their BMI

Identify and Treat

More than 140,000 adults in Ireland are malnourished, or at risk of malnutrition, half are over 65yrs (Rice & Normond, 2012) Vast majority are living in the community 1in3patients admitted to hospital are at risk of malnutrition, > 75% are at high risk (BAPEN 2010, 2011) Nutritional status for many patients declinesduring hospital stay

Threefold greater risk of infection Between two & threefold greater mortality risk, according to age 30% longer length of stay, on average 85% higher risk of admission and re-admission (over 65yrs) Estimated cost of malnutrition in Ireland 1.4 billion per annum (Dublin South West population this equates to 47m 47m)

Decreased Recovery from illness or injury Mental state Tolerance of treatment Quality of life GI, pulmonary and renal function Ability to take part in rehab Strength and ability to perform ADLs Increased Risk and severity of infections Overall complication rate Difficult to heal wounds, pressure ulcers Immobility & risk of falls Need for help and care Morbidity Mortality

MALNUTRITION Impaired organ function Impaired Collagen synthesis I Impaired Immune Function Reduced antioxidant activity respiratory cardiovascular Red blood Cell synthesis Reduced Wound strength Increased Risk Infection Increased Free Radical Damage Reduced Vital Capacity Reduced Cardiac Output Anaemia Reduced Oxygen Supply IMPAIRED WOUND HEALING

Who is At Risk of Malnutrition?

Recommended that allpatients should be screened within 24 hours of hospital admission using a validated screening tool, such as the Malnutrition Universal Screening Tool (MUST MUST)

hospitals must now proceed without delay to implement a system to ensure that all patients are screened for risk of malnutrition on admission to hospital inline with evidence- based practice

A 5-step screening tool for adults Assess Risk Follow Care Plan Interventions On-going monitoring Re-assessment

Weight: Digital weighing scales are available on wards Height: Height is recorded using a stadiometer where possible. Self reported height if realistic and reliable is acceptable. If a patients height cannot be measured; an ulna length is recommended. Previous weight: Self reported previous weight or refer to previous documented weights within the patients healthcare record. If unknown or not available document this.

Blank nutrition nursing care plan BMI Wheel Ulna Ruler Percentage weight loss wheel

BMI = weight (kg) / height² (m) ² Calculate the patient s BMI score BMI Calculator According to NICE Guidelines, scales on all wards and in all care settings should be calibrated annually 2

Measure from the bony point of the elbow to the midpoint of the prominent bone of the wrist. Use left arm if possible. Use pink side for women and blue side for men. Rulers are cleaned after each patient Ulna Length Measure Ulna Length indicator

Note percentage unplanned weight loss and assign score

Acute Disease Effect (ADE) - score 2 if acutely ill and if there has been or is likely to be no nutritional intake for more than 5 days. Acutely ill are patients who may be critically ill, have swallowing difficulties (e.g. after stroke), or head injuries or are undergoing gastrointestinal surgery

SE1

Slide 28 SE1 Please include reference to referral to N&D on Key system and this must include MUST score and the rationale for this. Shauna Ennis, 17/11/2015

Causes of malnutrition in hospitals Difficulty mobilising, self feeding, chewing or swallowing Poor appetite due to pain, constipation, diarrhoea, nausea or worry Fasting, interruptions and distractions during mealtimes Restricted diets (appropriately or inappropriately) Increased requirements in sepsis, inflammation, wounds Malabsorption due to underlying illness

Interventions Early identification of patients at risk of malnutrition (MUST) OT if feeding aids required Hand hygiene & toileting assistance Protected Mealtimes Documentation of intake SLT for swallow assessment Meal set up Oral hygiene, dentures Feeding assistance Nourishing snacks available little and often Food fortification Menu selection Fasting policies Administration of appropriate medications pre meals Patient education Dietitian referral if MUST > 2 Nutrition Support

Protected Mealtimes

Prepare the patient & their environment Lead in assist with toileting, clear tray tables, position the table and the patient Set up / Supervision Minimal moderate assistance Maximal assistance

Why? When? Who? How?

Malnutrition in Irish hospitals is common but under identified and has multiple adverse effects on a patients physical and mental health Early identification of those at risk, using a validated screening tool such as MUST, followed by appropriate, simple nutrition interventions at ward level, can prevent deterioration and development of malnutrition and result in Improved patient outcomes Improved quality of life Cost savings

Food and Nutritional Care in Hospitals Guidelines for Preventing Under-Nutrition in Acute Hospitals Dept of Health and Children 2009. BAPEN (2003) The MUST Explanatory Booklet: A Guide to the Malnutrition Universal Screening Tool (MUST) for Adults http://www.bapen.org.uk/screening-for-malnutrition/must-calculator MUST app for iphone 10 Key characteristics of good nutritional care in hospitals. Council of Europe Resolution on food and nutritional care in hospitals 2003 NPSA Nutrition factsheets http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865 Get your 10 a day! The Nursing Care standars for Patient Food in Hospital. Dept of Health, Social Services and Public Safety, Northern Ireland Hungry to be Heard The scandal of malnourished older people in hospital. AGE Concern England Guidelines for the Management of the Patient who requires Enteral Tube Feeding in the Adult Setting. Tallaght Hospital 2011 Nutritional Nursing Care Plan (incorporating MUST) Tallaght Hospital

Thank you!

60yr old female (Mrs. P) admitted with IECOPD. Was quite unwell for 2 weeks prior to admission, unable to cook or go to shops due to SOB, was eating soup and toast. Reports normal weight of 75kg is unsure if she has lost weight. on admission Weight 69kg Height 1.55m Step 1:BMI 28.7kg Step 2: 8% Wt loss Step 3: PO intake Score= 0 Score= 1 Score= 0 MUST Score 1