Incidence and frequency of screening for nutritional risk in hospital inpatients in East Cheshire NHS Trust
Authors: Voyce C.J. , Seager H.E. 
Published: May 2009

Background:  The NICE guideline for adult nutrition support recommends that all hospital inpatients are screened for risk of malnutrition ‘on admission’ and that screening is repeated weekly (NICE, 2006). Malnutrition screening using the Malnutrition Universal Screening Tool (MUST) tool (BAPEN, 2003) was introduced to East Cheshire NHS Trust on 1 March 2008 following training of ward nursing staff in using the tool. The aim of this audit was to evaluate whether East Cheshire NHS Trust is meeting the NICE guideline for screening of malnutrition risk.

Methods:  An audit was conducted including 301 inpatients over a 1‐week period in June 2008. The main outcomes included the presence of a MUST score, date of MUST score relative to date of admission, weekly screening of inpatients where relevant, correct completion of MUST tool and referral to the dietetic service if the patient was at high risk of malnutrition. Correct completion of the MUST form was assessed by checking that each section of the form had been completed. The audit team chose 48 h as the cut‐off for screening ‘on admission’. Data were collected by the allocated ward dietitian or dietetic assistant and recorded on a data collection sheet. All outcome data were recorded from the MUST screening paperwork completed by nursing staff, except date of admission, which was recorded in nursing or medical admission documentation. Data analysis calculating frequencies, mean values and percentages were carried out using Microsoft Excel 2003 (Microsoft Corp., Redmond, WA, USA).

Results:  Ninety‐three inpatients (31%) had a MUST score recorded. Only 24 (8%) were screened within 48 h of admission. There was variation across specialities as to the rate of screening achieved. No patients on general surgical wards were screened, but at least 50% patients were screened on respiratory, diabetes/stroke and cardiology wards, the intensive care unit and stroke rehabilitation ward. Of those patients screened for malnutrition, 39 out of 93 (42%) had a score of two or more, indicating that they were at high risk of malnutrition. The care plan for people identified as being at high risk is to refer to the dietetic department; however, only 26 out of 39 (67%) were referred, meaning that one‐third of patients with a score of two or more were not referred. One hundred and fifty‐three patients were admitted to hospital for more than 1 week. Only 5% (eight of 153) of these patients were MUST screened weekly. Individual patients were not re‐screened to check accuracy of the data on the form. Of the 93 MUST forms completed, 25 (27%) were completed incorrectly. The most common error on 18 out of 93 forms was information missing from completion of stage 1, which is the calculation of body mass index. This is likely to be related to lack of correct weighing equipment on some wards (e.g. hoist scales). Lack of nursing time and screening forms not being included in admission documentation may also have contributed to the low screening rate.

Discussion:  The audit shows that, although malnutrition screening for inpatients has commenced in East Cheshire, the NHS trust is not yet compliant with recommendations in the NICE Guideline for Adult Nutrition Support (NICE, 2006). From 1 March 2008, all referrals made to the dietetic department are required to include a MUST score to encourage nursing staff to complete the screen. It is recommended that the MUST form is also incorporated into nursing assessment documents and that MUST training be included in mandatory training for nursing staff; this has been shown to contribute to increased screening rates in other hospital trusts (Wong and Gandy, 2008).

Conclusions:  Screening inpatients for malnutrition has been introduced using MUST in East Cheshire. However, screening does not currently meet NICE guideline recommendations.

References  BAPEN (2003) Malnutrition Universal Screening Tool. Available at http://www.bapen.org.uk/must_tool.html (accessed on 19th May 2008).

NICE (2006) Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Available at http://www.nice.org.uk/nicemedia/pdf/cg032fullguideline.pdf (accessed on 19th May 2008).

Wong, S. & Gandy, J. (2008). An audit to evaluate the effect of staff training on the use of Malnutrition Universal Screening Tool. J. Hum. Nutr. Diet.21, 405–406.