Nutrition screening: why bother

1. Nutrition screening: why bother Adapted presentation originally prepared by: Christine Russell RD Hon Treasurer BAPEN British Association for Parenteral and Enteral Nutrition www.bapen.org.uk Registered Charity No: 1023927

2. BAPEN • Multi-disciplinary charity dedicated to raising awareness and standards of nutritional care • Founded in 1992 – “A Positive Approach to Nutrition as Treatment” Kings Fund Centre Report • Increasing focus on nutritional care and status of all consumers of health & social care • ‘Malnutrition Universal Screening Tool’ (‘MUST’) 2003 • Health Economic Report 2005

3. King’s Fund Centre Report (1992) “ only when the assessment of every patient’s nutritional status has become routine will the full benefits of nutrition treatment be realised”

4. Defining malnutrition No universally accepted definition but the following has been suggested: “ A state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body structure and function and on clinical outcome”

5. Causes of malnutrition Multifactorial! Clinical – associated with disease leading to problems such as nausea and vomiting, pain, malabsoprtion, infections, difficulty eating and swallowing, confusion, medication… Important changes to the body with ageing Lifestyle – accessibility shops, finances, cultural, living conditions, bereavement, depression, cooking ability and knowledge

6. Prevalence of malnutrition % underweight adults (BMI<20kg/m2 ) living freely in the community, hospital & residential accommodation Elia/MAG 2003 General population: England 5.2% Scotland 5.5% Wales 5.0% Patients in the community: Major surgery previous 6 wks >10.6% Chronic diseases 12.2% Residential accommodation: In UK >65 yrs 16.0% In Scotland >65yrs 29.0% Hospital: 13-40%

7. Prevalence of malnutrition on admission (BAPEN NSW07) Hospitals • Overall 28% ( 22% high risk, 6% medium risk) • Acute hospitals 27% • Community hospitals 29% Care Homes • Overall 30% (20% high risk, 10% medium risk) • Nursing homes 35% • Residential homes 22% Mental Health Units • Overall 19% (12% high risk, 7% medium risk) • Acute units 31% • Long stay/rehab. 21%

8. Consequences of malnutrition • Increased morbidity • Increased length of stay • Increased dependency • Increased mortality • Increased costs of care

9. The Malnutrition Carousel 28% of patients admitted to hospital are malnourished Hospital Home More GP visits Longer stay More support post- discharge More likely to be discharged to Care Homes More hospital admissions Up to 70% of patients discharged from hospital weigh less than on admission

10. Why screen for malnutrition? • Malnutrition is frequently unrecognised and untreated • Malnutrition costs health and social care ≥£7.3b/year • Effective management of malnutrition improves clinical outcome and reduces costs • Regular screening is the only way that malnourished individuals can be identified and appropriate action taken • Recommended / required by variousbodies e.gNICE, NHSQIS, Council of Europe, Care Commissions

11. Who to screen & when? • In Hospital – on admission • In Care – on admission & monitor as appropriate • In the Community – on registering with a GP & at Annual Check for 75 years +

12. Definitions Nutritional screening Rapid, simple general procedure done at first contact with subject to detect risk of malnutrition, done by nurses, doctors or other HCWs Nutritional assessment Detailed, more specific in depth evaluation of subject’s nutritional status, done by those with nutritional expertise

13. How to screen? • Establish screening policy • Use a validated tool • One that is quick and easy to use • Establish care plans • Identify resources • Educate and train staff • Audit practice • ’ NICE Guidance and Scottish Standards based on ‘MUST’ www.bapen.org.uk Registered Charity No: 1023927

14. The ‘Malnutrition Universal Screening Tool’ (‘MUST’) • ’ www.bapen.org.uk Registered Charity No: 1023927

15. Malnutrition Universal Screening Tool

19. Screening as part of the patients journey Where is he/she now? • BMI an indication of current nutritional status Where has he/she come from? i.e past history • Recent weight loss Where is he /she going? i.e likely clinical course • Acute disease effect • ’ www.bapen.org.uk Registered Charity No: 1023927

20. Step 1: BMI • Obtain weight and height • Calculate BMI or use BMI chart provided to get score • Use recalled height and weight or recommended alternative methods of measurement if actual values cannot be obtained

21. BMI Score BMIScore >20 kg/m2 0 18.5-20 kg/m2 1 <18.5 kg/m2 2 >30 kg/m2 ( obese ) 0

22. Unintentional weight loss over 3-6 months • <5% body weight: normal intra-individual variation • 5-10% body weight: of concern • decrease in voluntary physical activity • increase in fatigue • less energetic • >10% body weight: of significance • changes in muscle function • disturbances in thermoregulation • poor response or outcome to surgery and chemotherapy

23. Step 2: Weight loss score • Indicates acute or recent-onset malnutrition Score <5% body weight: 0 5-10% body weight: 1 >10% body weight: 2

24. Step 3: Acute disease effect • Patients who are acutely ill AND have had or are likely to have no nutritional intake for more than 5 days • Most likely to apply to patients in hospital • Add 2 to score

25. Step 4: Overall risk of malnutrition • Total of scores from Steps 1, 2 and 3 • Document score 0 = Low risk 1 = Medium risk 2 or more = High risk

26. The old ones are the best “It is not for the sake of piling up miscellaneous information or curious facts but for the sake of saving life and increasing health and comfort” F Nightingale 1859 • ’ www.bapen.org.uk Registered Charity No: 1023927

27. Care plan • Set aims and objectives • Agree management of those at risk • Treat underlying conditions • Improve nutritional intake • Monitor and review • Reassess subjects at nutritional risk as they move through care settings

28. It’s not…

29. In summary We should bother to screen because: • Malnutrition in UK is common and costs ≥£7.3billion • Screening identifies those at risk, enabling early intervention. • Screening is simple and quick to do and recommended / required by various bodies • Working together helps overcome barriers