CASE STUDY
Potential barriers to effective MUST implementation Alison Smith
Prescribing Support Dietitian, Medicines Management Team, Aylesbury Vale CCG and Chiltern CCG; Nutrition Advisory Group for Older People (NAGE), British Dietetic Association
he National Collaborating Centre for Acute Care (2006) has stated that:
‘MUST [the Malnutrition Universal Screening Tool] has been shown to be simple and easy to implement, with initial training requirements of less than 1 hour’.
While MUST can be a simple tool to use, it is arguable that this is only the case once it has been fully understood. Furthermore, it seems from the author’s own clinical experience and anecdotal evidence from dietetic colleagues that the length of time required for training is often significantly greater than the ‘less than 1 hour’ quoted above.
Background Since 2007, the author’s clinical practice has included frequent training of community nursing and care home staff on the use of the Malnutrition Universal
ABSTRACT
The Malnutrition Universal Screening Tool (MUST) is frequently cited as a simple screening tool for malnutrition. However, anecdotally, it seems that not all staff find it simple to use. If staff do not find MUST simple to complete, then screening is less likely to be completed accurately. Accurate completion of MUST is essential for malnutrition to be identified and treated, otherwise the nutritional needs of patients with unrecognised malnutrition may be neglected. The use of simplified versions of body mass index score, weight loss score and ulna-length charts together with ongoing training and support may help to improve accurate MUST completion. Audit of MUST completion must consider the accuracy of completion rather than completion alone. Therefore, those auditing MUST completion require a good understanding of the tool. This article draws on the author’s own significant experience with applying the MUST tool and synthesises this with evidence from the literature to demonstrate the potential barriers to effective MUST implementation.
KEY WORDS
w Nutrition screening w MUST w Training w Malnutrition w Accuracy
S28
Screening Tool (MUST), and reviewing and auditing MUST completion in these settings. This direct clinical experience and discussion with a number of dietetic colleagues around the UK regarding MUST implementation informs this article. This anecdotal evidence is further supported by having provided training sessions at Royal College of Nursing study day on how to achieve accurate MUST completion, due to concerns that nurses nationally were struggling with MUST completion. This article will draw on the author’s own significant experience with applying the MUST tool and synthesise this with evidence from the literature to demonstrate the potential barriers to effective MUST implementation.
MUST MUST was introduced in 2003 (BAPEN, 2014a) and, since then, has become widely supported as the preferred screening tool for malnutrition in the UK (BAPEN, 2014a). MUST was specifically designed to be used in all health-care settings, including acute care, community care and care homes, with the plan that information regarding a patient’s nutritional status could ‘follow’ the patient between care settings (BAPEN, 2014a). It should be noted that this plan will only be useful if the MUST score that follows the patient is correct.
Literature Stratton et al (2004) conducted a study of the tool’s application in hospitals. They concluded that the study subjects found MUST easy to complete. It should be noted, however, that it was not reported whether these test subjects always completed MUST correctly. Furthermore, although most test subjects quoted in Elia (2003) state that they found the tool easy to use, some reported finding the tool difficult or very difficult to use. Raja et al (2008) reported that staff found MUST difficult to use until they had gained competence through training and experience. Interestingly, when comparing ‘inter-rate’ agreement, Elia (2003) mentions correcting ‘very obvious calculation errors’, although no
© 2014 MA Healthcare Ltd
T
Email: [email protected]
Nutrition, October 2014
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CASE STUDY
further mention seems to be made of these completion inaccuracies (Elia, 2003).
MUST completion versus correct MUST completion In the author’s own experience, MUST is often fully completed, but completion is frequently inaccurate. Furthermore, the errors in completion are often compounded by audits that only consider whether MUST has been completed (i.e., whether there is a completed entry for each MUST step), rather than whether MUST is completed correctly (i.e. whether the entry for each step is correct). Farrer et al (2013) drew similar conclusions and concluded that ‘it is vital that any form of screening must…be accurate’.
Training Provision of ongoing training for use of screening tools is demonstrated as important by a number of studies (Raja et al, 2008; Porter et al, 2009; Farrer et al, 2013; Green and James, 2013; Green et al, 2014). However, it is arguably the case that training needs to be supported by appropriate audit of screening tool completion. Individuals may have attended training on MUST and may therefore assume that they understand the tool, but without audit to alert them to errors, it remains impossible for them to know if they have completed it incorrectly. Farrer et al (2013) reported, during their 7-month project to effectively implement MUST within three acute wards, that 19 separate training sessions were required to achieve improvement in accuracy of MUST score. Raja et al (2008) recorded that one nurse asked to do the training twice in order to fully understand it.
Reasons for misunderstanding the tool
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In the author’s experience, neither academic ability nor work grade seem to influence ability to understand MUST. A catering assistant with English as an additional language grasped the tool very easily, while a community matron struggled to fully understand MUST. It is not at all uncommon for staff who have received previous training to recognise that they do not fully understand MUST. Baker et al (2010) identified having a sense of competence as a potential barrier to changing practice. This is also supported by a recent systematic review regarding nutritional screening (Green and James, 2013).
Case study: MUST completion in a nursing home An audit of MUST completion on care notes for 17 residents was carried out in a nursing home run by a national chain whose staff had already received in-house MUST training and where frequent audits took place. MUST recording was incomplete for 6/17 patients.
Nutrition, October 2014
However, for 10/17 patients the MUST score recorded was incorrect. More worryingly, 8/10 patients for whom MUST score was incorrect were recorded by staff as being at low risk of malnutrition (i.e. not malnourished) when they were in fact at medium or high risk of malnutrition. A 2013 Cochrane review makes it clear that patients who are wrongly ‘screened out’ could suffer neglect as a result of inaccurate screening (Omidvari et al, 2013).
Improving accuracy In 2007 the author provided staff training based on the standard MUST tool. On subsequent audit it was found that staff had not understood all aspects of the tool. The options available were either to provide more training to assist staff to understand the standard version of MUST, or to simplify MUST to make it easier to understand. Baker et al (2010) suggest that interventions tailored to overcome identified barriers are more likely to succeed than those that simply provide further guidelines or educational materials. Green et al (2014) consider that it is important to identify barriers to implementing nutritional screening with the staff responsible for carrying it out. This is the approach taken by Focus on Undernutrition (Focus on Undernutrition, 2012), whose version of MUST relies on simplified body mass index (BMI) and weight loss charts following the project’s early recognition that many staff do not find MUST easy to complete. With the permission of Focus on Undernutrition, the MUST BMI and weight loss charts were further simplified, and MUST training based on these simplified resources was found to significantly improve accurate MUST completion. The tool structure developed in this way was sent to BAPEN for approval, but the author was unable to see this process through to its conclusion due to changing employment.
Step 1: BMI score Most staff correctly identify BMI score for patients, although the chart that is used has the potential for confusion as staff may accidentally select an incorrect BMI or may be unsure whether to record the BMI figure shown on the chart or the score superimposed over it. The alternative version of the BMI chart (http:// tinyurl.com/ntcqofp) removes this confusion by simply indicating the BMI range for the patient’s current weight, since, for the purposes of MUST completion, BMI range rather than exact BMI is of significance.
Ulna length If height cannot be measured or obtained by recall (a not infrequent occurrence in the community), measurement of ulna length to provide an approximation of height can be used. However, it is important to remember that ulna length is only an approximation of height, rather than an exact measure and can be less reliable in black or Asian
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CASE STUDY
Step 2: weight loss score In the author’s experience, steps 2 and 3 of MUST (weight loss score and acute disease effect score) are the points at which the greatest number of errors tend to occur. As outlined by BAPEN (2014c), calculating weight loss score requires interpretation of information and mental arithmetic, both of which can introduce human error. For example, there is arguably a lack of clarity over how ‘unplanned weight loss in past 3–6 months’ should be interpreted—should weight lost unintentionally within the last 3, 4, 5 or 6 months be used? A frequent mistake witnessed by the author is to consider only weight lost within the last month—a situation that can lead to progressive unintentional weight loss (and therefore malnutrition) being missed for a considerable period of time. Even if weight lost in the last 3 months is used, it can overlook patients who have been gradually losing weight over a longer period of time.This is something that would be picked up if weight lost unintentionally over the last 6 months was instead considered. For this reason, the author has further developed the Focus on Undernutrition weight loss charts (Focus on Undernutrition, 2012) to consider weight lost unintentionally within the last 6 months only (http://tinyurl.com/ntcqofp). Standard weight loss charts (BAPEN, 2014c) require calculation of the amount of weight lost. However, Focus on Undernutrition took the practical step of eliminating this potential for error by producing weight loss charts comparing current and previous weight, rather than previous weight and amount of weight lost (Focus on Undernutrition, 2012). Weight loss charts of this type are now available as an alternative on the BAPEN MUST website (BAPEN, 2014d).
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When considering weight loss, it is also important to bear in mind situations that may result in apparently significant weight loss which would not have relevance to weight loss score, such as resolution of oedema (BAPEN, 2014e) or intentional weight loss in the case of an overweight patient. Apparently significant weight loss over a short period of time could even be due to incorrect weight recording or using different scales to obtain consecutive weights, so ruling out these factors can be helpful in ensuring that weight loss score is accurate.
Step 3: acute disease effect score Acute disease effect score is the third and final score that, when added together with BMI score and weight loss score, give overall MUST score. The score relies on the question ‘is the patient acutely ill and has there been or is there likely to be no nutritional intake for >5 days?’. Possible answers are ‘yes’ (score 2) or ‘no’ (score 0). In the author’s experience, this question, though perfectly clear, can be misinterpreted to mean ‘eating less than normal’, ‘has a long term condition, such as diabetes’ or other, similar variations. The author has also witnessed a score of 1 being applied as an acute disease effect score due to misinterpretation of the question. BAPEN (2014f) state that, outside of hospital, acute disease effect is unlikely to apply, and for this reason (and to avoid errors and confusion) some community trusts have chosen to remove this question from MUST entirely (NHS Tayside, 2012; Bedford NHS Hospital Trust, 2012). In the author’s experience, in practice the easiest way to think of acute disease effect score in the community is that the score will be zero for almost every patient.
Steps 4 and 5: overall risk of malnutrition and management plan Overall risk of malnutrition, which determines how existing malnutrition should be treated, requires the addition of BMI score, weight loss score and acute disease effect score (if used) and is therefore dependent on each of these individual scores being correct. If each step of MUST has been completed accurately, this can significantly increase identification of patients at risk of malnutrition. Once malnutrition is identified, following local management plans can ensure that patients receive the treatment their condition requires. Elia (2003) observed that effective recognition of malnutrition is linked to effective treatment and that nutritional interventions can be effective in improving clinical outcome and reducing cost of care. More recently, two Cochrane reviews have concluded that further research is needed into the impact of nutritional interventions on malnutrition in the community (Milne et al 2009; Baldwin and Weekes, 2011). However, in the author’s experience, many community-dwelling patients who are
© 2014 MA Healthcare Ltd
people (Madden et al, 2012). The author has witnessed a correctly measured ulna length overestimate an Asian carer’s height by 15cm—an error that could be sufficient to give a falsely high BMI score in a lean individual. Given the above, it is important to consider whether the recorded height seems correct for the patient that it has been recorded for. For example, if a health professional ‘works’ in metres but ‘thinks’ in feet and inches, a height conversion chart (from imperial to metric) can be a helpful resource to enable patient height to be considered objectively. Cook et al (2005) note that height is a measure that is ‘fraught with inaccuracy’ due in part to observer error. Ulna length charts are another area where errors can be made. The chart provided by BAPEN (2014b) has the appearance of one chart but is actually two (one placed on top of the other). In the author’s experience, staff frequently find this confusing. Redeveloped ulna length charts separated into charts for men and women and colour coded (http://tinyurl.com/m7prklx) can help to make make this difference more obvious.
Nutrition, October 2014
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CASE STUDY
identified (using MUST) as being at risk of malnutrition do appear to benefit from simple food-based nutritional interventions, with or without the addition of prescribed nutritional products.
KEY POINTS
Conclusion
the person auditing completion needs to have a full understanding of MUST w Inaccurate completion of MUST allows malnutrition to go undetected and therefore untreated
Improved completion of any screening tool can only be achieved through appropriate and ongoing training, use of interventions to overcome identified barriers (such as use of simplified but still valid versions of screening tools), developing proficiency through use in practice, and effective audit of screening tool use (Raja et al, 2008; Porter et al, 2009; Baker et al, 2010; Green et al, 2014). The above detailed experiences support these findings and may be helpful for health professionals who concur that MUST is a simple tool to use, but are nonetheless finding accurate completion difficult. BJCN
© 2014 MA Healthcare Ltd
Baker R, Camosso-Stefinovic J, Gillies C et al (2010) Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes (review). Cochrane Database Syst Rev 2010(3): CD005470. doi: 10.1002/14651858.CD005470.pub2 Baldwin C, Weekes CE (2011) Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults (review). Cochrane Database Syst Rev 2011(9): CD002008. doi: 10.1002/14651858. CD002008.pub4 BAPEN (2014a) Introducing MUST. http://tinyurl.com/q52vrx5 (accessed 25 June 2014) BAPEN (2014b) MUST—Alternative measurements: instructions and tables. http://tinyurl.com/mf6c9dd (accessed on 15 July 2014) BAPEN (2014c) MUST weight loss charts: weight loss. http://tinyurl.com/ lefkz9p (accessed 15 July 2014) BAPEN (2014d) MUST weight loss charts: previous weight. http://tinyurl. com/mmqy9qg (accessed 15 July 2014) BAPEN (2014e) The MUST explanatory booklet. http://tinyurl. com/7vrjsyb (accessed 20 July 2014) BAPEN (2014f) MUST: Re-assess subjects identified at risk as they move through care settings. http://tinyurl.com/mjoxmq9 (accessed 20 July 2014) Bedford Hospital NHS Trust Nutrition and Dietetic Department (2012) A guide to detecting, preventing and managing malnutrition for Care Homes for the Elderly in North Bedfordshire. http://tinyurl.com/ mo28za6 (accessed 20 July 2014) Cook Z, Kirk S, Lawrenson S, Sandford S (2005) Use of BMI in the assessment of undernutrition in older subjects: reflecting on practice. Proc Nutr Soc 64(3): 313–7 Elia M (2003) The ‘MUST’ Report: Nutritional Screening of Adults: A Multidisciplinary Responsibility. BAPEN, Redditch Farrer K, Donaldson E, Blackett B et al (2013) Nutritional screening of elderly patients: a health improvement approach to practice. J Hum Nutr Diet 27(2): 184–91 Focus on Undernutrition (2012) Focus resources/nutritional screening tool.
w Not all staff find the Malnutrition Universal Screening Tool (MUST) easy to understand or use
w A simplified version of MUST may be easier to understand w MUST audit should focus on accurate completion of MUST, therefore
County Durham and Darlington NHS Foundation Trust. http://tinyurl. com/njev5wu (accessed 25 June 2014) Green SM, James EP (2013) Barriers and facilitators to undertaking nutritional screening of patients: a systematic review. J Hum Nutr Diet 26(3): 211–21 Green SM, James EP, Latter S, Sutcliffe M, Fader MJ (2014) Barriers and facilitators to screening for malnutrition by community nurses: a qualitative study. J Hum Nutr Diet 27(1): 88–95. doi: 10.1111/jhn.12104 Madden AM, Tsikoura T, Stott DJ (2012) The estimation of body height from ulna length in healthy adults from different ethnic groups. J Hum Nutr Diet 25(2): 121–8. doi: 10.1111/j.1365-277X.2011.01217.x Milne AC, Potter J, Vivanti A, Avenell A (2009) Protein and energy supplementation in elderly people at risk from malnutrition (review). Cochrane Database Syst Rev 15(2): CD003288. doi: 10.1002/14651858.CD003288. pub3 National Collaborating Centre for Acute Care (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Collaborating Centre for Acute Care, London. http://tinyurl. com/kxo979l (accessed 26 September 2014) NHS Tayside (2012) Malnutrition Universal Screening Tool. http://tinyurl. com/ljab6nw (accessed 20 July 2014) Omidvari AH, Vali Y, Murray SM, Wonderling D, Rashidian A (2013) Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings (review). Cochrane Database Syst Rev 2013(6): CD005539. doi: 10.1002/14651858.CD005539.pub2 Porter J, Raja R, Cant R, Aroni R (2009) Exploring issues influencing the use of the Malnutrition Universal Screening Tool by nurses in two Australian hospitals. J Hum Nutr Diet 22(3): 203–9. doi: 10.1111/j.1365277X.2008.00932.x Raja R, Gibson S, Turner A et al (2008) Nurses’ views and practices regarding use of validated nutrition screening tools. Aus J Adv Nurs 26(1): 26–33 Stratton RJ, Hackston A, Longmore D et al (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92: 799–808
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Potential barriers to effective MUST implementation Alison Smith
Prescribing Support Dietitian, Medicines Management Team, Aylesbury Vale CCG and Chiltern CCG; Nutrition Advisory Group for Older People (NAGE), British Dietetic Association
he National Collaborating Centre for Acute Care (2006) has stated that:
‘MUST [the Malnutrition Universal Screening Tool] has been shown to be simple and easy to implement, with initial training requirements of less than 1 hour’.
While MUST can be a simple tool to use, it is arguable that this is only the case once it has been fully understood. Furthermore, it seems from the author’s own clinical experience and anecdotal evidence from dietetic colleagues that the length of time required for training is often significantly greater than the ‘less than 1 hour’ quoted above.
Background Since 2007, the author’s clinical practice has included frequent training of community nursing and care home staff on the use of the Malnutrition Universal
ABSTRACT
The Malnutrition Universal Screening Tool (MUST) is frequently cited as a simple screening tool for malnutrition. However, anecdotally, it seems that not all staff find it simple to use. If staff do not find MUST simple to complete, then screening is less likely to be completed accurately. Accurate completion of MUST is essential for malnutrition to be identified and treated, otherwise the nutritional needs of patients with unrecognised malnutrition may be neglected. The use of simplified versions of body mass index score, weight loss score and ulna-length charts together with ongoing training and support may help to improve accurate MUST completion. Audit of MUST completion must consider the accuracy of completion rather than completion alone. Therefore, those auditing MUST completion require a good understanding of the tool. This article draws on the author’s own significant experience with applying the MUST tool and synthesises this with evidence from the literature to demonstrate the potential barriers to effective MUST implementation.
KEY WORDS
w Nutrition screening w MUST w Training w Malnutrition w Accuracy
S28
Screening Tool (MUST), and reviewing and auditing MUST completion in these settings. This direct clinical experience and discussion with a number of dietetic colleagues around the UK regarding MUST implementation informs this article. This anecdotal evidence is further supported by having provided training sessions at Royal College of Nursing study day on how to achieve accurate MUST completion, due to concerns that nurses nationally were struggling with MUST completion. This article will draw on the author’s own significant experience with applying the MUST tool and synthesise this with evidence from the literature to demonstrate the potential barriers to effective MUST implementation.
MUST MUST was introduced in 2003 (BAPEN, 2014a) and, since then, has become widely supported as the preferred screening tool for malnutrition in the UK (BAPEN, 2014a). MUST was specifically designed to be used in all health-care settings, including acute care, community care and care homes, with the plan that information regarding a patient’s nutritional status could ‘follow’ the patient between care settings (BAPEN, 2014a). It should be noted that this plan will only be useful if the MUST score that follows the patient is correct.
Literature Stratton et al (2004) conducted a study of the tool’s application in hospitals. They concluded that the study subjects found MUST easy to complete. It should be noted, however, that it was not reported whether these test subjects always completed MUST correctly. Furthermore, although most test subjects quoted in Elia (2003) state that they found the tool easy to use, some reported finding the tool difficult or very difficult to use. Raja et al (2008) reported that staff found MUST difficult to use until they had gained competence through training and experience. Interestingly, when comparing ‘inter-rate’ agreement, Elia (2003) mentions correcting ‘very obvious calculation errors’, although no
© 2014 MA Healthcare Ltd
T
Email: [email protected]
Nutrition, October 2014
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CASE STUDY
further mention seems to be made of these completion inaccuracies (Elia, 2003).
MUST completion versus correct MUST completion In the author’s own experience, MUST is often fully completed, but completion is frequently inaccurate. Furthermore, the errors in completion are often compounded by audits that only consider whether MUST has been completed (i.e., whether there is a completed entry for each MUST step), rather than whether MUST is completed correctly (i.e. whether the entry for each step is correct). Farrer et al (2013) drew similar conclusions and concluded that ‘it is vital that any form of screening must…be accurate’.
Training Provision of ongoing training for use of screening tools is demonstrated as important by a number of studies (Raja et al, 2008; Porter et al, 2009; Farrer et al, 2013; Green and James, 2013; Green et al, 2014). However, it is arguably the case that training needs to be supported by appropriate audit of screening tool completion. Individuals may have attended training on MUST and may therefore assume that they understand the tool, but without audit to alert them to errors, it remains impossible for them to know if they have completed it incorrectly. Farrer et al (2013) reported, during their 7-month project to effectively implement MUST within three acute wards, that 19 separate training sessions were required to achieve improvement in accuracy of MUST score. Raja et al (2008) recorded that one nurse asked to do the training twice in order to fully understand it.
Reasons for misunderstanding the tool
© 2014 MA Healthcare Ltd
In the author’s experience, neither academic ability nor work grade seem to influence ability to understand MUST. A catering assistant with English as an additional language grasped the tool very easily, while a community matron struggled to fully understand MUST. It is not at all uncommon for staff who have received previous training to recognise that they do not fully understand MUST. Baker et al (2010) identified having a sense of competence as a potential barrier to changing practice. This is also supported by a recent systematic review regarding nutritional screening (Green and James, 2013).
Case study: MUST completion in a nursing home An audit of MUST completion on care notes for 17 residents was carried out in a nursing home run by a national chain whose staff had already received in-house MUST training and where frequent audits took place. MUST recording was incomplete for 6/17 patients.
Nutrition, October 2014
However, for 10/17 patients the MUST score recorded was incorrect. More worryingly, 8/10 patients for whom MUST score was incorrect were recorded by staff as being at low risk of malnutrition (i.e. not malnourished) when they were in fact at medium or high risk of malnutrition. A 2013 Cochrane review makes it clear that patients who are wrongly ‘screened out’ could suffer neglect as a result of inaccurate screening (Omidvari et al, 2013).
Improving accuracy In 2007 the author provided staff training based on the standard MUST tool. On subsequent audit it was found that staff had not understood all aspects of the tool. The options available were either to provide more training to assist staff to understand the standard version of MUST, or to simplify MUST to make it easier to understand. Baker et al (2010) suggest that interventions tailored to overcome identified barriers are more likely to succeed than those that simply provide further guidelines or educational materials. Green et al (2014) consider that it is important to identify barriers to implementing nutritional screening with the staff responsible for carrying it out. This is the approach taken by Focus on Undernutrition (Focus on Undernutrition, 2012), whose version of MUST relies on simplified body mass index (BMI) and weight loss charts following the project’s early recognition that many staff do not find MUST easy to complete. With the permission of Focus on Undernutrition, the MUST BMI and weight loss charts were further simplified, and MUST training based on these simplified resources was found to significantly improve accurate MUST completion. The tool structure developed in this way was sent to BAPEN for approval, but the author was unable to see this process through to its conclusion due to changing employment.
Step 1: BMI score Most staff correctly identify BMI score for patients, although the chart that is used has the potential for confusion as staff may accidentally select an incorrect BMI or may be unsure whether to record the BMI figure shown on the chart or the score superimposed over it. The alternative version of the BMI chart (http:// tinyurl.com/ntcqofp) removes this confusion by simply indicating the BMI range for the patient’s current weight, since, for the purposes of MUST completion, BMI range rather than exact BMI is of significance.
Ulna length If height cannot be measured or obtained by recall (a not infrequent occurrence in the community), measurement of ulna length to provide an approximation of height can be used. However, it is important to remember that ulna length is only an approximation of height, rather than an exact measure and can be less reliable in black or Asian
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CASE STUDY
Step 2: weight loss score In the author’s experience, steps 2 and 3 of MUST (weight loss score and acute disease effect score) are the points at which the greatest number of errors tend to occur. As outlined by BAPEN (2014c), calculating weight loss score requires interpretation of information and mental arithmetic, both of which can introduce human error. For example, there is arguably a lack of clarity over how ‘unplanned weight loss in past 3–6 months’ should be interpreted—should weight lost unintentionally within the last 3, 4, 5 or 6 months be used? A frequent mistake witnessed by the author is to consider only weight lost within the last month—a situation that can lead to progressive unintentional weight loss (and therefore malnutrition) being missed for a considerable period of time. Even if weight lost in the last 3 months is used, it can overlook patients who have been gradually losing weight over a longer period of time.This is something that would be picked up if weight lost unintentionally over the last 6 months was instead considered. For this reason, the author has further developed the Focus on Undernutrition weight loss charts (Focus on Undernutrition, 2012) to consider weight lost unintentionally within the last 6 months only (http://tinyurl.com/ntcqofp). Standard weight loss charts (BAPEN, 2014c) require calculation of the amount of weight lost. However, Focus on Undernutrition took the practical step of eliminating this potential for error by producing weight loss charts comparing current and previous weight, rather than previous weight and amount of weight lost (Focus on Undernutrition, 2012). Weight loss charts of this type are now available as an alternative on the BAPEN MUST website (BAPEN, 2014d).
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When considering weight loss, it is also important to bear in mind situations that may result in apparently significant weight loss which would not have relevance to weight loss score, such as resolution of oedema (BAPEN, 2014e) or intentional weight loss in the case of an overweight patient. Apparently significant weight loss over a short period of time could even be due to incorrect weight recording or using different scales to obtain consecutive weights, so ruling out these factors can be helpful in ensuring that weight loss score is accurate.
Step 3: acute disease effect score Acute disease effect score is the third and final score that, when added together with BMI score and weight loss score, give overall MUST score. The score relies on the question ‘is the patient acutely ill and has there been or is there likely to be no nutritional intake for >5 days?’. Possible answers are ‘yes’ (score 2) or ‘no’ (score 0). In the author’s experience, this question, though perfectly clear, can be misinterpreted to mean ‘eating less than normal’, ‘has a long term condition, such as diabetes’ or other, similar variations. The author has also witnessed a score of 1 being applied as an acute disease effect score due to misinterpretation of the question. BAPEN (2014f) state that, outside of hospital, acute disease effect is unlikely to apply, and for this reason (and to avoid errors and confusion) some community trusts have chosen to remove this question from MUST entirely (NHS Tayside, 2012; Bedford NHS Hospital Trust, 2012). In the author’s experience, in practice the easiest way to think of acute disease effect score in the community is that the score will be zero for almost every patient.
Steps 4 and 5: overall risk of malnutrition and management plan Overall risk of malnutrition, which determines how existing malnutrition should be treated, requires the addition of BMI score, weight loss score and acute disease effect score (if used) and is therefore dependent on each of these individual scores being correct. If each step of MUST has been completed accurately, this can significantly increase identification of patients at risk of malnutrition. Once malnutrition is identified, following local management plans can ensure that patients receive the treatment their condition requires. Elia (2003) observed that effective recognition of malnutrition is linked to effective treatment and that nutritional interventions can be effective in improving clinical outcome and reducing cost of care. More recently, two Cochrane reviews have concluded that further research is needed into the impact of nutritional interventions on malnutrition in the community (Milne et al 2009; Baldwin and Weekes, 2011). However, in the author’s experience, many community-dwelling patients who are
© 2014 MA Healthcare Ltd
people (Madden et al, 2012). The author has witnessed a correctly measured ulna length overestimate an Asian carer’s height by 15cm—an error that could be sufficient to give a falsely high BMI score in a lean individual. Given the above, it is important to consider whether the recorded height seems correct for the patient that it has been recorded for. For example, if a health professional ‘works’ in metres but ‘thinks’ in feet and inches, a height conversion chart (from imperial to metric) can be a helpful resource to enable patient height to be considered objectively. Cook et al (2005) note that height is a measure that is ‘fraught with inaccuracy’ due in part to observer error. Ulna length charts are another area where errors can be made. The chart provided by BAPEN (2014b) has the appearance of one chart but is actually two (one placed on top of the other). In the author’s experience, staff frequently find this confusing. Redeveloped ulna length charts separated into charts for men and women and colour coded (http://tinyurl.com/m7prklx) can help to make make this difference more obvious.
Nutrition, October 2014
h Journal of Community Nursing. Downloaded from magonlinelibrary.com by 138.253.100.121 on December 3, 2015. For personal use only. No other uses without permission. . All rights res
CASE STUDY
identified (using MUST) as being at risk of malnutrition do appear to benefit from simple food-based nutritional interventions, with or without the addition of prescribed nutritional products.
KEY POINTS
Conclusion
the person auditing completion needs to have a full understanding of MUST w Inaccurate completion of MUST allows malnutrition to go undetected and therefore untreated
Improved completion of any screening tool can only be achieved through appropriate and ongoing training, use of interventions to overcome identified barriers (such as use of simplified but still valid versions of screening tools), developing proficiency through use in practice, and effective audit of screening tool use (Raja et al, 2008; Porter et al, 2009; Baker et al, 2010; Green et al, 2014). The above detailed experiences support these findings and may be helpful for health professionals who concur that MUST is a simple tool to use, but are nonetheless finding accurate completion difficult. BJCN
© 2014 MA Healthcare Ltd
Baker R, Camosso-Stefinovic J, Gillies C et al (2010) Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes (review). Cochrane Database Syst Rev 2010(3): CD005470. doi: 10.1002/14651858.CD005470.pub2 Baldwin C, Weekes CE (2011) Dietary advice with or without oral nutritional supplements for disease-related malnutrition in adults (review). Cochrane Database Syst Rev 2011(9): CD002008. doi: 10.1002/14651858. CD002008.pub4 BAPEN (2014a) Introducing MUST. http://tinyurl.com/q52vrx5 (accessed 25 June 2014) BAPEN (2014b) MUST—Alternative measurements: instructions and tables. http://tinyurl.com/mf6c9dd (accessed on 15 July 2014) BAPEN (2014c) MUST weight loss charts: weight loss. http://tinyurl.com/ lefkz9p (accessed 15 July 2014) BAPEN (2014d) MUST weight loss charts: previous weight. http://tinyurl. com/mmqy9qg (accessed 15 July 2014) BAPEN (2014e) The MUST explanatory booklet. http://tinyurl. com/7vrjsyb (accessed 20 July 2014) BAPEN (2014f) MUST: Re-assess subjects identified at risk as they move through care settings. http://tinyurl.com/mjoxmq9 (accessed 20 July 2014) Bedford Hospital NHS Trust Nutrition and Dietetic Department (2012) A guide to detecting, preventing and managing malnutrition for Care Homes for the Elderly in North Bedfordshire. http://tinyurl.com/ mo28za6 (accessed 20 July 2014) Cook Z, Kirk S, Lawrenson S, Sandford S (2005) Use of BMI in the assessment of undernutrition in older subjects: reflecting on practice. Proc Nutr Soc 64(3): 313–7 Elia M (2003) The ‘MUST’ Report: Nutritional Screening of Adults: A Multidisciplinary Responsibility. BAPEN, Redditch Farrer K, Donaldson E, Blackett B et al (2013) Nutritional screening of elderly patients: a health improvement approach to practice. J Hum Nutr Diet 27(2): 184–91 Focus on Undernutrition (2012) Focus resources/nutritional screening tool.
w Not all staff find the Malnutrition Universal Screening Tool (MUST) easy to understand or use
w A simplified version of MUST may be easier to understand w MUST audit should focus on accurate completion of MUST, therefore
County Durham and Darlington NHS Foundation Trust. http://tinyurl. com/njev5wu (accessed 25 June 2014) Green SM, James EP (2013) Barriers and facilitators to undertaking nutritional screening of patients: a systematic review. J Hum Nutr Diet 26(3): 211–21 Green SM, James EP, Latter S, Sutcliffe M, Fader MJ (2014) Barriers and facilitators to screening for malnutrition by community nurses: a qualitative study. J Hum Nutr Diet 27(1): 88–95. doi: 10.1111/jhn.12104 Madden AM, Tsikoura T, Stott DJ (2012) The estimation of body height from ulna length in healthy adults from different ethnic groups. J Hum Nutr Diet 25(2): 121–8. doi: 10.1111/j.1365-277X.2011.01217.x Milne AC, Potter J, Vivanti A, Avenell A (2009) Protein and energy supplementation in elderly people at risk from malnutrition (review). Cochrane Database Syst Rev 15(2): CD003288. doi: 10.1002/14651858.CD003288. pub3 National Collaborating Centre for Acute Care (2006) Nutrition Support in Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. National Collaborating Centre for Acute Care, London. http://tinyurl. com/kxo979l (accessed 26 September 2014) NHS Tayside (2012) Malnutrition Universal Screening Tool. http://tinyurl. com/ljab6nw (accessed 20 July 2014) Omidvari AH, Vali Y, Murray SM, Wonderling D, Rashidian A (2013) Nutritional screening for improving professional practice for patient outcomes in hospital and primary care settings (review). Cochrane Database Syst Rev 2013(6): CD005539. doi: 10.1002/14651858.CD005539.pub2 Porter J, Raja R, Cant R, Aroni R (2009) Exploring issues influencing the use of the Malnutrition Universal Screening Tool by nurses in two Australian hospitals. J Hum Nutr Diet 22(3): 203–9. doi: 10.1111/j.1365277X.2008.00932.x Raja R, Gibson S, Turner A et al (2008) Nurses’ views and practices regarding use of validated nutrition screening tools. Aus J Adv Nurs 26(1): 26–33 Stratton RJ, Hackston A, Longmore D et al (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (‘MUST’) for adults. Br J Nutr 92: 799–808
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