Malnutrition Screening and Care Pathway in
the Integrated Community Team.
[Draft Version:1]
Summary:
This is a procedure to guide staff in
integrated care teams to work within best practice guidelines for identifying and treating malnutrition (undernutrition).
Keywords (minimum of 5):
(To assist policy search engine)
MUST; Malnutrition; ICT, Integrated Weight, Undernutrition,
Target Audience: All staff in Integrated community teams
Next Review Date:
Approved & Ratified by: Date of meeting:
Date issued:
Author: Kathy Steward
Version Control
Change Record
Date Author Versi
on
Page Reason for Change
13/7/ 16 Kathy Steward 1 Created 14/3/ 17 Kathy Steward 2 Reviewed Reviewers/contributors
Name Position Version
Reviewed & Date
Kathy Wallis Programme Manager -WAHSN
Sarah Woodman Integrated Service Matron/Dietician Lisa Rice Tissue Viability Nurse
Specialist
Barry Edwards Integrated Service Matron/RMN
Aude Cholet Dietician - HHFT
CONTENTS
Page 1. Assessment of risk of malnutrition (Screening)
2. Care pathway
3. Oral Nutritional Supplements
4. Specialist support and advice
5. Hydration
6. Training available/recommended
A1 Care pathway
A2 Leaflet
A3 Leaflets condition specific– wound
/COPD/dementia/depression
A4 Oral nutritional support advice sheet A5 Oral nutritional support formulary and
1 Assessment of risk of malnutrition in a community setting 1.1 Incidence of malnutrition
A person can become malnourished through under nutrition or excess (obesity). This procedure sets out the approach and best practice for assessing and treating under nutrition in a community setting.
Malnutrition is defined as ‘a state of nutrition in which there is a deficiency (or
excess) of energy, protein and other nutrients which causes adverse effects on body form, function and clinical outcome’. As such it is essential that professionals
working in integrated community team are equipped and able to identify and appropriately treat or direct patients to appropriate care.
Whilst the emphasis over recent years has been on addressing issues of under nutrition in hospitals the fact remains that studies show that 1 in 10 people over 65 living in the community are malnourished or at risk of malnutrition (Bapen 2006). Children, the elderly, socially isolated and those with chronic disease are most at risk.
The costs of treating the consequences of malnutrition are in excess of £13 billion (Elia 2009) and half of this was spent on older adults. From a report released in 2003 (Elia 2003), it is evident that malnutrition is recognised and under-treated across care settings. It is documented that someone who suffers from malnutrition has more visits to their GP, more visits to hospital and longer hospital stays (where death more likely). They also have trouble with wound healing,
infections (due to poorer immune system), reduced mobility and falls. 1.2 Best practice guidelines
Providing best practice nutrition and hydration care involves five key principles, which incorporate NICE’s Nutrition support in adults quality standard (QS24) and clinical guidance (CG32). These are 1) raising awareness to prevent and treat malnutrition, 2) working together within and across organisations, 3) identifying
malnutrition risk early using screening tools, 4) developing individualized care plans, and 5) monitoring and evaluating the impact of care on an individual’s
outcome.(Malnutrition Taskforce 2013).
Despite NICE guidelines there is currently there is a lack of:
• Screening for malnutrition
• Documentation of nutritional status
• Monitoring and review
• Implementation of nutrition support
A good Nutritional Care Pathway looks like this
The first step is to identify the risk with a screening tool. Screening score effects treatment, and the effect of treatment is monitored and reviewed. This step is often missed. Nutritional support can be maximised in two ways – food first and oral nutritional supplements but without the initial steps and a review, clinical benefits are not seen.
1.3 Screening for risk using MUST (Malnutrition Universal Screening Tool) Assessment of nutritional status should take place within the initial assessment performed by the Integrated Community Team.
NICE recommends using ‘MUST’ across care settings as it is valid, reliable and easy to use, however, clinicians may use their clinical skills to employ other non-standardised nutritional screening tools to assess patient risk and progress. (see key questions 1.4). The MUST tool can be accessed via this link
http://www.bapen.org.uk/screening-and-must/must-calculator
Weighing Scales
To measure weight within the community setting it is acceptable to use the patient’s own scales but class 3 scales should be available in all teams. Scales for weighing
patients using hoists can be accessed via the Hampshire Integrated Equipment Store.
Nutrition screening frequency guidelines
Nutrition assessment takes place on initial assessment using MUST wherever possible.
Low risk – repeat MUST in one year or where new clinical concerns Medium and High Risk – repeat MUST in monthly intervals.
1.4 Key questions for assessing undernutrition.
Whilst the recommended tool for nutritional risk assessment is MUST it is
recognised that qualified clinicians may use their clinical skills to employ other non-standardised nutritional screening tools to assess patient risk and progress.
The following questions could be used where a clinician cannot complete a MUST score due to patient condition and to ascertain clinical concerns and need to repeat MUST. It is best practice to employ both the MUST and the clinical questions.
• Does the patient appear thin or very thin with loose fitting clothes/jewellery or dentures? Is this new for the patient?
• Has the patient lost weight (unplanned) in the last 3-6 months?
• Has the patient had new changes in appetite or swallowing difficulties?
• Does the patient now need assistance with feeding?
• Is the patient or carer reporting a reduction in dietary intake compared to normal?
• Does the patient require help with shopping or food preparation? For intentional rounding these questions can be simplified to
• Any unplanned weight loss in the last 3-6 months. ?
• Why have you lost weight?
The warning signs of undernutrition/malnutrition that clinicians should be aware of include, fragile skin, poor wound healing, apathy, wasted muscles, poor appetite, altered taste sensation, impaired swallowing, altered bowel habit, loose fitting clothing, being unable to keep warm and poor concentration.
2.1 Description of care pathway – the following care pathway was developed as
part of the Older Persons Essential Nutrition (OPEN) project in Eastleigh. It sets out nutritional care according to risk as assessed using the MUST tool. It can also be used where risk is established using nutritional assessment questions.
2.2 Low risk (MUST score of 0)
For low risk patients review of MUST is done yearly if the patient remains on the Integrated Care Team caseload. On each visit intentional rounding should be completed and include the intentional rounding questions from 1.4
Where new concerns emerge the MUST would be repeated before the next review date.
Clinician should also consider giving the patient healthy eating advice especially if concerns are identified regarding obesity or if the patient has a wound – specific nutrition for wound healing advice.. Further help for patients identified as obese can be obtained from their GP.
2.3 Medium and High risk (MUST score of 1,2,3)
Discuss and agree nutrition goals with patient using a food first approach. Record this in a care plan shared with the patient. This care plan should include
• Food fortification goals
• And consider referral to community services e.g. lunch clubs or social services where access to food or assistance with meals required.
The patient should be provided with the malnutrition leaflet (appendix 1) and other relevant advice sheets (determined by clinician). All patients with a wound should be given the ‘Healthy eating for healthy healing advice sheet’.
The following advice sheets are available in appendix 2
• Poor appetite
• Food fortification tips
• Eating well and dementia
If other medical concerns are identified for example nausea, vomiting constipation or diarrhoea a referral to GP should be made.
If difficulty swallowing identified (dysphagia) is identified a referral to Speech and Language Therapy should be discussed with the patient’s GP.
A review of the patient’s weight should take place in one month. If there is
improvement in the weight and/or MUST then follow the guidelines for that score. If there is deterioration in the MUST score to 2 or above or no improvement in a score of 2 or above oral nutritional supplements should be considered in
Sample packs of supplements can be obtained directly from the company for
patients to try. See http://www.westhampshireccg.nhs.uk/downloads/1138-guide-to-prescribing-ons-formularies-full-june-2016/file
• The patient should be provided with the ‘Tips for taking you supplements’ sheet.
• Appointments should be made to monitor weight monthly and the care plan updated with any actions recorded in the progress notes.
• If no improvement or further deterioration in weight or MUST the patient
should be referred to their GP for a review. Staff should also consider referral to rapid access geriatrician led clinics where they exist.
2.5 Palliative care/end of life care considerations
All patients being admitted onto the Integrated Community Team caseload require an assessment of nutritional status using MUST whenever possible. Where the patient is receiving palliative care it is necessary to modify the approach as a loss of appetite and desire for food plus weight loss is part of the disease and deterioration progress. Emphasis should be on alleviation of suffering such as treatment of dry mouth, nausea and vomiting and a holistic, supportive approach. Repeating the MUST and nutritional assessment would be based on clinical judgement and patient need.
2.6 Wound care and nutrition
Good nutrition is linked with good outcomes for wound healing. Specific advice regarding eating for wound healing should be given to all patients with wounds. If wound healing is static or deteriorating then nutrition should be considered and MUST repeated, and a care plan addressing nutrition established as this will have significant benefits in healing and the patient’s quality of life
3 Oral Nutritional Supplements 3.1 Formulary
A formulary exists to direct the appropriate prescribing of ONS. The most up-to-date formulary can be found on the West Hampshire CCG website –
http://www.westhampshireccg.nhs.uk/downloads/1138-guide-to-prescribing-ons-formularies-full-june-2016/file
A form to request prescriptions for ONS is contained in the formulary and should be used for all requests.
Direct to patient free samples can be obtained for each of the products on the formulary. It is recommended that a patient samples products to improve compliance.
4 Specialist Support 4.1 Dietician referral
Dietician support can be obtained via referral to the acute hospitals dietetic team via the patient’s GP. A list of contact details for the hospital dietetic team is available on the Southern Health Intranet.
4.3 Dementia
People living with dementia may find eating and drinking difficult or refuse food or drink for a number of reasons:
• Problems expressing hunger/thirst, or dislike of a particular food or drink • Low mood or lack of interest in food
• Confusion in recognising food and remembering how to eat
• Poor concentration making it difficult to sit down and finish a meal • Other challenges associated with dementia include:
• Reduced thirst sensation • Limited recognition of hunger • Paranoia surrounding food
• Difficulties chewing and swallowing
Advice for those caring for someone with dementia can be found in the leaflet ‘Eating and Drinking Well – Supporting People Living with Dementia.’
5. Hydration
5.1 Many older people prefer drinking tea or coffee to water and it can be difficult to persuade people to drink enough water. Furthermore, older people should not be expected to change their drinking habits just because they are receiving care services.
5.2 Hot drinks are good for hydration and only likely to act as a diuretic (making the body produce more urine) if they are high in caffeine and consumed in excessive amounts. Decaffeinated teas and coffees and herbal teas should be encouraged if this is a concern.
5.3 Based on the available information and the importance of good hydration in older people it would seem appropriate to encourage fluid intake generally, and to offer a selection of hot and cold drinks throughout the day and whenever people request them.
5.4There should only be cause for concern if an individual’s overall liquid intake is inadequate, or their intake of caffeinated and or sugary drinks is excessive. Medical advice should be sought if an individual has particular health problems that affect the maintenance of good hydration, which may require fluid restriction and close monitoring.
6. Training
6.1 Nutrition training pathway
All staff will receive training on nutritional care and management and
assessment of their competences to ensure they have the appropriate skills needed to ensure that patients’ nutritional needs are met.
It is recommended that all staff should undertake both NHLP 5 Planning and delivering Nutritional Care and NHLP Course 6 E-learning Malnutrition Universal Screening Tool (MUST)
References
1. ENHA, BAPEN, ILC-UK –‘Malnutrition among older people in the community: policy Recommendations for Change’ (2006)
2. Elia M, Russell CA. Combating malnutrition: Recommendations for action. : The British Association for Parenteral and Enteral Nutrition; 2009.
3. Malnutrition Task Force: “Malnutrition in later life: Prevention and Early Intervention” (2013)
4. Elia M. The 'MUST' report.Nutritional screening for adults: a multidisciplinary responsibility.Development and use of the 'Malnutrition Universal Screening Tool' ('MUST') for adults. : A report by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition; 2003.
Appendix A Care pathway
MUST>1 Score 1 or more Medium and High Risk Investigate & take action
Discuss and agree nutrition goals with patient. This should be a food first approach. Record this in a care plan shared with the patient/carers/GP.
This should include a plan on how to increase calorie/protein intake as well as fluid intake
Provide malnutrition leaflet and other relevant advice sheets
Arrange review in one month. Repeat MUST and/or assessment MUST
Score 0 Low Risk Provide healthy eating
advice sheet
Review MUST score if signs of deterioration noted through intentional rounding otherwise
repeat yearly.
If risk remains stable or improvement noted (e.g. weight stabilised, weight gain, pressure sores healing, goals fully or partially met, or MUST Score
decreased)
Continue and/or update plan. Document progress, and document further actions as appropriate
If risk deemed to worsen (e.g. weight decreasing further, goals not met…)
Discuss oral nutritional supplements with the patient and request prescription from GP using prescription request form
Provide ONS information sheet. Arrange follow up appointment in one month
Record actions on the nutritional care plan.
If further weight loss or no improvement, refer to GP or dietitian if available. Update care plan and record actions in progress notes
End of life care guidelines override this pathway
Establish the cause of malnutrition
When cause identified, take action, e.g. referral to community services e.g. lunch clubs or social services where access to food or assistance with meals required
If other medical concerns e.g. nausea, vomiting constipation or diarrhoea, refer to GP. If difficulty swallowing identified (dysphagia) refer to speech and language therapy
