Malnutri)on Universal Screening Tool (MUST)
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1 Malnutri)on Universal Screening Tool () Nutri&on screening mandated in acute care se1ngs in the US, UK and Canada - Iden&fy malnourished pa&ents and those at risk à warrant more detailed assessment/treatment = simple screen developed by BAPEN (UK) - 3 steps: BMI, %-Weight loss, Acute disease effect - High-risk score on associated with increased length of hospitaliza&on (25-40%), postopera&ve complica&ons, and nosocomial infec&ons - validated in several outpa&ent popula&ons: GI cancers, ESRD, Cys&c fibrosis, IBD Modifica&ons of screen - Pa&ent self-screen vs HCP-administered Mean &me of self-screen min Agreement with HCP-administered was 80-95% - Acute disease effect subscore No intake x 5 days à poor or very poor intake Mueller C et al: JPEN 2011 Scheisser M et al: Clin Nutr 2008
2 Nutri)on Care Pathway Step 1: Malnutri)on Screen LOW-RISK Normal BMI/weight loss Lower risk of secondary nutri&onal complica&ons Rescreen annually or with flares MODERATE-RISK Low BMI OR <10% weight loss Close observa&on warranted (MD, NP, RN) HIGH-RISK Likely more weight loss or also acute disease effect (ac&ve IBD) Increased risk of nutri&onal complica&ons Treatment needed, Die&cian referral Malnutri&on Universal Screening Test (): - Screening tool developed by the Bri&sh Associa&on of Parenteral & Enteral Nutri&on (BAPEN), validated in mul&ple inpa&ent/ outpa&ent popula&ons and as a pa&ent self-generated instrument. - Three critria: BMI, uninten&nal weight loss, acute disease effect
3 Nutri)on Care Pathway Screen LOW-RISK No further nutri&on workup necessary at this &me Provider: Consider checking Basic labs 1 & replete/followup prn Pa)ent: Repeat screen annually OR with any flares (Qorus previsit survey abnormal) Observe Primary Assessment Secondary/Urgent Assessment & Treatment
4 Nutri)on Care Pathway Screen LOW-RISK No further nutri&on workup necessary at this &me Provider: Consider checking Basic labs 1 & replete/followup prn Pa)ent: Repeat screen annually OR with any flares (Qorus previsit survey abnormal) Observe Primary Assessment 1 BASIC Nutri&on labs: BMP, CRP, Albumin, Ferri&n/iron studies, Vitamin D25-OH level, B12 Secondary/Urgent Assessment & Treatment If abnormal, providers/pa&ents will be directed to educa&onal materials regarding reple&on/recommended followup tes&ng
5 Nutri)on Care Pathway Screen LOW-RISK No further nutri&on workup necessary at this &me Provider: Consider checking Basic labs 1 & replete/followup prn Pa)ent: Repeat screen annually OR with any flares (Qorus previsit survey abnormal) Observe Primary Assessment Rou&ne Referral to Die&cian Provider: Encourage Malnutri&on Labs 2, Followup at least q1-2 mo HIGH-RISK Individualized Nutri&onal Treatment needed Die&cian referral (rou&ne vs urgent) GI Symptom Management ( Q#3) 9 Pre-visit >9 Secondary/Urgent Assessment & Treatment Urgent Referral to Die&cian (GI-Specialty, Ter&ary if possible) Provider: Encourage Malnutri&on Labs 2, Close f/u q2-4 weeks for likely Enteral/ Parenteral Support monitoring
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9 Ac)ve IBD 1 X X
10 Nutri)on Care Pathway HIGH-RISK Individualized Nutri&onal Treatment needed Die&cian referral (rou&ne vs urgent) GI Symptom Management ( Q#3) 2 Malnutri&on Labs Basic Labs + Mag, Phos, Vit B6, folate, zinc, methylmalonic acid, thiamine (Consider checking vitamin A, E If suspect malabsorp&on) Rou&ne Referral to Die&cian Provider: Encourage checking Malnutri&on Labs 2 Followup at least q1-2 mo 9 Pre-visit >9 Symptom management ( Ques&on #3) Provider/pa&ent will be directed to educa&onal materials (ie small frequent meals, lactose-free diet for anorexia/ diarrhea) Urgent Referral to Die&cian (GI-Specialty, Ter&ary if possible) Provider: Encourage Malnutri&on Labs 2, Close f/u q2-4 weeks for likely Enteral/ Parenteral Support monitoring
11 Screen Nutri)on Care Pathway Observe Primary Assessment Rescreen 3-4 mo, x 1 Then w/ flares Rou&ne Die&cian Referral Urgent Die&cian Referral MODERATE-RISK Close observa&on warranted return in 2-4 weeks to reassess Pa)ent: Encourage increased dietary intake (provided educa&onal materials on general dietary interven&ons for IBD) Provider: Encourage to check Malnutri&on Labs 2 Monitoring FU Visit Rou&ne Referral to Die&cian Provider: Encourage Malnutri&on Labs 2, Followup at least q1-2 mo HIGH-RISK Individualized Nutri&onal Treatment needed Die&cian referral (rou&ne vs urgent) GI Symptom Management ( Q#3) Pre-visit Secondary/Urgent Assessment & Treatment Urgent Referral to Die&cian (GI-Specialty, Ter&ary if possible) Provider: Order Malnutri&on Labs 2, Close f/u q2-4 weeks for likely Enteral/ Parenteral Support monitoring
12 Moderate-Risk Pa/ents: Close Observa/on Moderate-risk pa&ents warrant close observa&on for further weight loss à Pa&ents will return in 2-4 weeks for a visit en&rely for nutri&onal status check In interval, pa&ent should be encouraged to increase dietary intake Malnutri&on labs to be checked: Basic Labs + Mag, Phos, Vit B6, zinc, methylmalonic acid, thiamine, folate (Consider checking vitamin A and E if suspect fat malabsorp&on) Pa&ent/provider will be directed to educa&onal materials on general dietary interven&ons - Provide guidelines on calcula&ng es&mated energy needs based on BMI, protein needs for those with ac&ve IBD - Suggest use of oral nutri&onal supplements will be administered and reviewed at Followup Nutri&on Visit (can be with MD, NP, RN) - Triage will be based on
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14 Screen Nutri)on Care Pathway LOW-RISK No further nutri&on workup necessary at this &me Provider: Consider checking Basic labs 1 & replete/followup prn Pa)ent: Repeat screen annually OR with any flares (Qorus previsit survey abnormal) Observe Primary Assessment Rescreen 3-4 mo, x 1 Then w/ flares Rou&ne Die&cian Referral Urgent Die&cian Referral MODERATE-RISK Close observa&on warranted return in 2-4 weeks to reassess Pa)ent: Encourage increased dietary intake (provided educa&onal materials on general dietary interven&ons for IBD) Provider: Order Malnutri&on Labs 2 Monitoring FU Visit Rou&ne Referral to Die&cian Provider: Encourage checking Malnutri&on Labs 2 Followup at least q1-2 mo HIGH-RISK Individualized Nutri&onal Treatment needed Die&cian referral (rou&ne vs urgent) GI Symptom Management ( Q#3) Pre-visit Secondary/Urgent Assessment & Treatment Urgent Referral to Die&cian (GI-Specialty, Ter&ary if possible) Provider: Order Malnutri&on Labs 2, Close f/u q2-4 weeks for likely Enteral/ Parenteral Support monitoring 1 Basic Labs: BMP, CRP, Albumin, Ferri&n/iron studies, Vitamin D25-OH level, B12 2 Basic Labs + Mag, Phos, Vit B6, folate, zinc, methylmalonic acid, thiamine (Consider checking vitamin A, E If suspect malabsorp&on)
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