Nutricia Screening for malnutrition using the Malnutrition - - PowerPoint PPT Presentation

Screening for malnutrition using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) Training Slides

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Aims and Objectives

By the end of this training session you will be able to :

• Define malnutrition (undernutrition), and understand its causes and

consequences in the clinical setting

• Understand the problem of malnutrition, its economic impact and the

prevalence across care settings

• Understand the need for nutritional screening, and what makes a good

screening tool

• Understand the stages involved in nutritional screening using the

‘Malnutrition Universal Screening Tool’ (‘MUST’)

• Use ‘MUST’ to screen individuals for malnutrition
• Implement appropriate management guidelines linked to malnutrition

risk category using nutrition care plans

• Understand the different options available to treat malnutrition

appropriately

1

Overview of Malnutrition

Definition of Malnutrition

Source: Elia. http://www.bapen.org.uk/information-and-resources/publications-and-resources/bapen-reports [01.07.2016]

“A state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients (e.g. vitamins) causes measureable adverse effects on tissue/body form and function and clinical outcome.”

Prevalence of Malnutrition

3 million people in the UK are malnourished1 93% of these are in the community 5% of these are in care homes 2% of these are in hospitals

• The prevalence of Malnutrition is higher

within2:  Older people 65 years and over (28% vs 21%)  Those in care homes (41%) and hospitals (25%)

1. Elia M. http://www.bapen.org.uk/pdfs/reports/advisory_group_report.pdf [19.05.16]. 2. Russell CA. http://www.bapen.org.uk/pdfs/nsw/nsw-2011-report.pdf [19.05.16].

Decreased intake Increased nutritional needs Increased nutrient losses

Causes of Malnutrition

• Availability of food
• Finances
• Reduced ability to cook
• Changes to sensory perception e.g.

taste and smell

• Health issues
• Social isolation

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Decreased intake

• Poor food provision
• Lack of interest in food
• Oral problems e.g. ill fitting dentures,

dry mouth

• Needing assistance with food
• Bad mealtime experience
• Depression/anxiety

Causes of Malnutrition

Causes of Malnutrition

Increased nutritional needs

• Involuntary movements e.g. Parkinson’s Disease or wandering in dementia
• Drug-nutrient interactions
• Illness/disease e.g. COPD, cancer, pneumonia

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Causes of Malnutrition

Increased nutrient losses

• Drug-nutrient interactions
• Polypharmacy
• Bacterial overgrowth
• GI losses e.g. vomiting, diarrhoea, fistulae, exudate from wounds or pressure sores

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

Groups at Risk of Malnutrition

Group Example Older people Frail elderly, prone to falls, less mobile, wounds/pressure ulcers Acute and chronic conditions Cancer, COPD, gastrointestinal illness, renal disease, liver disease, neurological disease Chronic, progressive conditions Dementia, neurological conditions (Parkinson’s Disease, MND) Inpatients Those in hospital but also those recently discharged, those at high risk of being admitted, and those at high risk of being readmitted

Consequences of Malnutrition

↑ Morbidity ↓ Wound healing ↑ Infections ↑ Complications ↓ Convalescence ↑ Mortality ↑ Treatment

↑ Length of stay in hospital

↑ GP visits ↑ Hospital admissions and readmissions Malnutrition ↓ QOL and ↑ COST

Source: Gandy J. Manual of Dietetic Practice. Wiley Blackwell Publishing, 2014

The Cost of Malnutrition Malnutrition £19.6 billion per annum1

Obesity £3.5 billion per annum

Source: Elia M. http://www.bapen.org.uk/pdfs/economic-report-full.pdf [01.06.16]

2.

Identifying Malnutrition

Identifying Malnutrition

• NICE Clinical Guideline 32 - Nutrition support for adults: oral nutrition

support, enteral tube feeding and parenteral nutrition (NICE CG32) is the NICE guideline providing recommendations for identifying and managing malnutrition

• This guideline is the basis of NICE Quality Standard 24 (QS24)
• It recommends:

‒ Screening for malnutrition and the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training. ‒ Screening of hospital inpatients on admission, and outpatients at their first appointment ‒ Screening should be repeated weekly for inpatients and when there is clinical concern for outpatients. ‒ People in care homes should be screened on admission and when there is clinical concern.

Source: NICE CG32 2006.

What is Nutritional Screening and Assessment?

Nutritional screening: Rapid, general, often initial evaluation undertaken by nurses, medical staff or any healthcare workers, to detect significant risk of malnutrition and to implement a clear plan of action (Elia 2003). Nutritional assessment: More detailed, more specific and more in depth evaluation of nutritional status by an expert, so that specific plans can be implemented, often for more complicated nutritional problems. Not everybody requires a nutritional assessment (Elia 2003).

Use of same screening tool avoids confusion and establishes continuity of nutritional care for patients moving across care settings.

What Makes a Good Screening Tool ?

Good screening tool

Quick & simple to use Practical Can be used for everyone Has a range of alternative measures if weight & height can’t be

• btained

Linked to a care plan Suitable for use across disciplines Evidence based Concurrent validity with

• ther tools

Good reproducibility between users Reliable

Source: NICE CG32 2006.

What Makes a Good Screening Tool ?

NICE Clinical Guideline 32, 2006 Screening should:

• assess BMI
• assess percentage unintentional weight loss
• consider the time over which nutrient intake has been

unintentionally reduced and/or the likelihood of future impaired nutrient intake. ‘MUST’ may be used to do this.

MUST is a reliable and validated screening tool (Elia 2003)

Source: NICE CG32 2006.

3.

Interactive explanation of the ‘MUST’

Malnutrition Universal Screening Tool (‘MUST’)

• The ‘MUST’ is a five step tool used to identify individuals who are

malnourished or at risk of malnutrition

• It gives a score that indicates malnutrition risk using:
• BMI
• Weight loss over the last 3-6 months
• Acute disease effect
• It also has suggested management guidelines based on the ‘MUST’

score

• For more information visit the ‘MUST’ website -

http://www.bapen.org.uk/screening-and-must/must/introducing-must

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

Malnutrition Universal Screening Tool (‘MUST’)

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

‘MUST’ Step 1: Body Mass Index (BMI) Score

• Height and weight are required to obtain BMI score
• You can use the ‘Step 1: BMI score chart’ to obtain the BMI score (see next page for

an explanation of how it can be used) Practical Tips

• The BMI score chart is set up as a traffic light system green score = 0, amber score = 1

and red score = 2

• If the individuals weight is a decimal round up or down to the nearest kilogram
• Actual BMI can be calculated using the following equation however this is not

necessary to complete nutrition screening

BMI (kg/m2) = Weight (kg) Height (m2)

For your information BMI greater than 20kg/m2 = Score 0 BMI 18.5-20kg/m2 = Score 1 BMI less than 18.5kg/m2 = Score 2

‘MUST’ Step 1: Body Mass Index (BMI) Score

• Locate the individual’s weight on the left
• r right of then chart and read along the

row to line up with their height at the top or bottom of the chart

• Use the colour in the chart to identify

the BMI score: Green score = 0 Amber score = 1 Red score = 2

How Can I Obtain a Persons Weight ?

Clinical impression (obvious wasting, loose clothing/jewellery/dentures Ask person/family (recalled) Use recently documented weight Use hoist scales Can’t weigh because unable to stand or transfer to sitting scales Weigh the individual on standing/sitting scales

What Type of Scales Should I Use ?

• Digital grade III medical scales
• Calibrated regularly

Tips

Standing scales: ensure person has nothing heavy in their pockets and weigh without shoes Chair scales: ensure the person’s feet are not touching the floor Ensure scales are balanced on flat ground (avoid uneven surfaces e.g. carpet), with zero displayed before weighing

How Can I Obtain a Persons Height ?

• Height only needs to be obtained once
• Height can be measured using a stadiometer
• Height can be recalled
• Height can be estimated using alternative measures

e.g. ulna length

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

Activity: Using Alternative Measures

Using the conversion table estimate Mrs M’s height from her ulna. Mrs M is a 70 year old care home resident who had recently been admitted and who needs to be

• screened. Before you can begin

screening using ‘MUST’ you must be able to obtain her weight and height. Mrs M is bed bound and is unable to recall her height; you measure her ulna, which is 26.5cm. The scales are not working in the care home and therefore you are unable to weigh her; a family member estimates Mrs M weight to be about 60kg.

Answer: Mrs M’s height is 1.66m

Activity: Calculating BMI and BMI Score

Calculate Mrs M’s BMI using the chart provided (click the link if you need to see it in a larger size http://www.bapen.org.uk/pdfs/must/must_full.pdf)

Answer: Mrs M’s BMI is 19kg/m2 You have obtained Mrs M’s height, which is 1.66cm, and you have now been able to weigh Mrs M; her weight is 53kg.

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

Activity: Calculating BMI and BMI Score

Calculate Mrs M’s BMI using your calculator: Answer: BMI = weight (kg)/height (m2)

Mrs M’s BMI = 53/(1.66x1.66) Mrs M’s BMI = 53/2.7556 Mrs M’s BMI = 19.2kg/m2 You have obtained Mrs M’s height, which is 1.66cm, and you have now been able to weigh Mrs M; her weight is 53kg.

Activity: Calculating BMI and BMI Score

What is Mrs M’s BMI score? Answer:

Mrs M’s BMI is 19kg/m2 therefore her BMI score is 1 You have obtained Mrs M’s height, which is 1.66cm, and you have now been able to weigh Mrs M; her weight is 53kg.

For your information BMI greater than 20kg/m2 = Score 0 BMI 18.5-20kg/m2 = Score 1 BMI less than 18.5kg/m2 = Score 2

‘MUST’ Step 2: Weight Loss Score

• Unintentional weight loss over 3-6

months

• A previous weight is required to obtain

weight loss score

• If no previous weight recorded, use a

recalled weight (if reliable and realistic)

• To calculate amount of weight lost =

previous weight – current weight

• Use the tool to the right to calculate

weight loss score (% weight loss)

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

‘MUST’ Step 2: Weight Loss Score

Practical Tips

• The chart is set up as a traffic light

system:

• Green = score 0 (<5% weight loss) Amber

= score 1 (5-10% weight loss) Red = score 2 (>10% weight loss)

• If the individual’s current weight is

between the numbers on the chart, e.g. 69.7kg, roundup or down to nearest number, e.g. 70kg

• If current weight is greater than or the

same as previous weight (not lost or gained weight) automatically score 0

• If weight loss is intentional score 0

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

Activity: Calculating Weight Loss and Weight Loss Score

• 1. How much weight has Mrs M lost?

Answer: Previous weight (56kg) – current weight (53kg) = 3kg

• 2. Using the ‘MUST’ determine Mrs M’s weight

loss category Answer: Mrs M has lost 3kg which places her in the 5- 10% weight loss category

• 3. What is Mrs M’s weight loss score?

Answer: Mrs M has lost 5-10% of her weight in the past three months therefore her weight loss score is 1. Mrs M has recently lost weight without trying; her weight three months ago was

• 56kg. From the previous activity her current weight is 53kg.

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

‘MUST’ Step 3: Acute Disease Effect Score

• Only a score of 0 or 2 can be given for this step
• If the individual has had no nutritional intake and is acutely ill for more than 5

days score 2

• If the individual is likely to have no nutritional intake for more than 5 days, and

is acutely ill score 2

• If neither of these statements are true score 0

Practical Tips

• This is only likely to apply in those who are acutely ill in hospital, e.g. critically ill,

swallowing difficulties after stroke, undergoing GI surgery or those likely to be unable to eat for more than 5 days

• This is very rare in the community setting

‘MUST’ Step 4: Overall Risk of Malnutrition

• Add up all the scores from Steps 1, 2 and 3 to determine the total score and risk

category

• Record score and malnutrition risk category in notes

Step 1

BMI score (0, 1 or 2)

Step 2

Weight loss score (0, 1 or 2)

Step 3

Acute disease affect score (0 or 2)

Risk

Score 0 = LOW risk Score 1 = MEDIUM risk Score 2-6 = HIGH risk

Example Record Chart

Activity: Acute Disease Effect and Overall ‘MUST’ Score

• 1. What score would you assign to Mrs M for acute disease effect?

Answer: 0

• 2. Using the information from the previous activities, calculate Mrs M’s overall

‘MUST’ score. What are he ‘MUST’ score and risk category? Answer:

Mrs M has diabetes and takes insulin everyday. She enjoys her meals and always eats at least half of what is provided. She always has biscuits in the afternoon with her cup of tea.

Step 1 Step 2 Step 3 Step 4 Weight (kg) Height (m) BMI (kg/m2) BMI score Prev. weight (kg) Weight loss (kg) Weight loss score Acute diseas e score Overall MUST score 53 1.66 19 1 56 3 1 2 High Risk

What if I am Unable to Calculate BMI?

Mid upper arm circumference (MUAC) can be used to give an indication of malnutrition risk:

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.06.2016].

MUAC and Subjective Measures

MUAC can be used to aid the use of subjective criteria and estimate overall malnutrition risk category (low/medium/high). Subjective measures include:

• Clinical impression — thin, acceptable weight, overweight; obvious

wasting (very thin) and obesity (very overweight) can also be noted

• Clothes and/or jewellery have become loose fitting (weight loss)
• History of decreased food intake, reduced appetite or swallowing

problems over 3-6 months and underlying disease or psychosocial/physical disabilities likely to cause weight loss

Activity: Using Alternative Measures to Give and Indication of BMI

What is Mrs M’s BMI likely to be considering her MUAC is 23cm? Mrs M is a 70 year old care home resident who had recently been admitted and who needs to be

• screened. Before you can begin

screening using ‘MUST’ you must be able to obtain her weight and height. Mrs M is bed bound and is unable to recall her height; you measure her ulna, which is 26.5cm. The scales are not working in the care home and you can, therefore, not weigh her; you measure her MUAC, which is 23cm.

Answer: Mrs M’s BMI is likely to be <20kg/m2

If MUAC is <23.5cm, BMI is likely to be <20kg/m2 If MUAC is >32.0cm, BMI is likely to be >30kg/m2

‘MUST’ Step 5: Management Guidelines (Care Plans)

• Care plans are usually agreed locally and tailored to specific clinical conditions
• Care plans should be developed in line with the associated risk category and actions

to be taken should be documented, including when to rescreen using ‘MUST’

Low Risk (Score 0) Routine Clinical Care Medium Risk (Score 1) Observe High Risk (Score 2+) Treat*

Repeat screening:

• Hospital: weekly
• Care home: monthly
• Community: annually for special

groups e.g. those more than 75 years Document dietary intake for 3 days if individual in hospital or care home

• If adequate intake: little concern,

repeat screening according to setting

• If no improvement: clinical

concern, follow local policy, set goals, improve and increase overall nutritional intake, e.g. advice regarding food and fluid intake, monitor and review care plan regularly Repeat screening:

• Hospital: weekly
• Care home: at least monthly
• Community: at least every 2-3

months

• Refer to dietitian, nutrition support

team or implement local policy

• Set goals, improve and increase
• verall nutritional intake, e.g. advice

regarding food and fluid intake, oral nutritional supplements and/or artificial nutritional support

• Monitor and review care plan:
• Hospital: weekly
• Care home: at least monthly
• Community: monthly

* Unless detrimental or no benefit is expected from nutritional support e.g. imminent death

Source: BAPEN. http://www.bapen.org.uk/musttoolkit.html [01.07.2016].

‘MUST’ Step 5: Management Guidelines (Care Plans)

A care plan based on ‘MUST’ score:

• 1. Sets aims and objectives of management
• 2. Manages underlying conditions
• 3. Manages malnutrition according to risk using nutritional interventions, including

food, oral nutritional supplements and/or artificial nutritional support

• 4. Is monitored and reviewed according to care setting and malnutrition risk. This is at

least weekly in hospitals and monthly in care homes

• 5. Reassesses an individual’s malnutrition risk regularly to ensure their care plan

continues to meet their needs, especially as they move through care settings

‘MUST’ Step 5: Management Guidelines (Care Plans)

For all risk categories:

• Record malnutrition risk category
• Manage underlying condition
• Provide help and advice on food choices, eating and drinking when necessary
• Record need for special diets
• Follow local policy
• Monitor
• Record presence of obesity. For those with underlying conditions, these are generally

controlled before the treatment of obesity

Example Care Plan

Activity: Care plans

Name: Mrs M DOB: 04.02.1946 Room: 2 Aim: 'MUST' score: 2 Action Sign and date Date Notes Sign

Consider Mrs M’s overall risk of malnutrition and, based on the recommendations

• f BAPEN, develop a nutrition care plan.

Think about how you can treat malnutrition and what you could do to increase nutritional intake.

Activity: Care plans

Name: Mrs M DOB: 04.02.1946 Room: 2 Aim: Improve oral intake, prevent further weight loss 'MUST' score: 2 Action Sign and date Record ‘MUST’ screening in care home notes A.Staff 01.07.16 Assist with menu ordering and feeding when necessary A.Staff 01.07.16 Encourage high energy high protein diet A.Staff 01.07.16 Commence 2 oral nutritional supplements per day A.Staff 01.07.16 Repeat ‘MUST’ weekly A.Staff 01.07.16 Date Notes Sign 11.04.08 Drinking 2 Fortisip per day. Oral intake slightly improved. ‘MUST’ score remains 2, high risk. Continue care plan, repeat ‘MUST 1/52. A.Staff 01.07.16

Consider Mrs M’s overall risk of malnutrition and, based on the recommendations

• f BAPEN, develop a nutrition care plan.

Think about how you can treat malnutrition and what you could do to increase nutritional intake.

Thank you