Aims. Topics. Background. Topics 12/3/2012. Nutritional screening workshop. Nutritional screening workshop. Dr Angela Madden

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1 Nutritional workshop Dr Angela Madden Nutritional workshop Dr Angela Madden Aims To provide an overview of nutrition and opportunity for discussion about: How to implement into practice The practical challenges that need to come Opportunities to optimise benefit from Topics Background Definition and purpose Screening tools Malnutrition Universal Screening Tool (MUST) Practical issues Training staff to use Where is the benefit? What happens next Topics Background Definition and purpose Screening tools Malnutrition Universal Screening Tool (MUST) Practical issues Training staff to use Where is the benefit? What happens next Background Disease-related malnutrition is very common Hospital patients 10-60% Care homes >50% Free-living individuals with severe disease >10% summarised in Stratton et al

2 Background Disease-related malnutrition related to impaired function Skeletal muscle mass Cardiac and respiratory systems Gastrointestinal tract Immune system Growth & development Psychological well-being summarised in Stratton et al 2003 Background Disease-related malnutrition associated with worse outcome Skeletal muscle mass wound healing Cardiac and respiratory systems risk of infection Gastrointestinal tract length of stay Immune system risk of mortality Growth & development cost of healthcare Psychological well-being quality of life summarised in Stratton et al 2003 Background Disease-related malnutrition can be managed Mortality and complication rates can be reduced by appropriate nutrition support Nutrition support is associated with risks and costs Need to identify people most likely to benefit Nutritional Definition a process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated nutrition Mueller et al 2011 Nutritional Nutritional Definition a process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated Purpose to predict the probability of a better or worse outcome due to nutritional factors, and whether nutritional treatment is likely to influence this obesity? Mueller et al 2011 Kondrup et al 2003a 2

3 Process Nutritional Rapid and simple process = routine Undertaken by admission or community staff Clear outcome: patient identified as: Not at risk of malnutrition At risk - devise a care plan At risk - unable to devise a care plan Doubt over risk Non-specialist staff Refer to nutrition specialist Challenge 1 Working with other staff Kondrup et al 2003a Screening tools Many different tools available Screening tools Many different tools available Most appropriate tool Practical for population and staff Supported by evidence of validity Screening tools Screening tools Practical Variables required can be obtained routinely in population Supported by evidence Developed using well-designed procedures, statistically robust e.g. height, weight Specific challenges with some patient t groups Time taken to assess Documentation and physical tools are available Process is clear ( and what happens next) Staff are trained and motivated All components assessed contribute Different assessors reach same results Results agree with 'gold standard' assessment Tested in a second, appropriate population Prognostic value Jones

4 Examples of tools include BMI Weight ± TSF Eating Illness Lab Challenge 2 Birmingham Nutrition Risk Score X X X X Reilly et al 1995 Malnutrition Screening Tool X X Ferguson et al 1999 Malnutrition Universal Screening Tool X X X Elia 2003 Maastricht Index X X Kuzu et al 2006 Nutrition Risk Screening 2002 X X X X Kondrup et al 2003b Choosing the right tool Prognostic Inflamm & Nutrition Index X Igenbleek et al 1985 Prognostic Nutritional Index X X Buzby et al 1980 Examples of tools include Malnutrition Universal Screening Tool BMI Weight ± TSF Eating Illness Lab Birmingham Nutrition Risk Score X X X X Reilly et al 2005 MUST Devised by British Association for Parenteral and Enteral Nutrition (BAPEN) Malnutrition Screening Tool X X Ferguson et al 1999 Malnutrition Universal Screening Tool X X X Elia 2003 Maastricht Index X X Kuzu et al 2006 Nutrition Risk Screening 2002 X X X X Kondrup et al 2003b Prognostic Inflamm & Nutrition Index X Igenbleek et al 1985 Prognostic Nutritional Index X X Buzby et al 1980 Reliability and validity extensively tested Used in many settings - hospital, outpatients, community Different patient populations - surgical, elderly, cardiac, renal, cancer, HIV Brazil, China, Greece, Israel, Netherlands, Portugal, UK, USA For example. Elia 2003 Malnutrition Universal Screening Tool Elderly Athens Hospital inpatients aged >60 years (mean 75.2 ± 8.5) N = 248 Assessed using six tools Concluded MUST most valid of six tools in evaluating nutritional risk Malnutrition Universal Screening Tool Patients self-screen Southampton Hospital outpatients aged years (mean 55) N = 205 Patients self-screened and then compared with healthcare professional's findings Agreement for categorisation 90% (κ = 0.7) Concluded acceptable, user-friendly and reliable Poulia et al 2012 Cawood et al

5 Malnutrition Universal Screening Tool MUST Five-step tool to identify adults who are malnourished, at risk of malnutrition or obese Includes management guidelines care plan For use in hospitals, community and other care settings Guide comprises: Flow chart showing the 5 steps BMI chart Weight loss tables Alternative measurements when cannot measure weight and height BAPEN 2012 MUST - five steps 1. Measure height and weight to get a BMI score using chart provided. If unable to obtain height and weight, use the alternative procedures shown 2. Note percentage unplanned weight loss and score using tables provided 3. Establish acute disease effect and score 4. Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition 5. Use management guidelines and/or local policy to develop care plan BAPEN 2012 Step 1 BMI score (kg/m 2 ) >20 score = score = 1 <18.5 score = 2 Step 2 Unplanned weight loss in past 3-6 months <5% score = % score = 1 >10% score = 2 If >30 = obese The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). Further information on 'MUST' see The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). Further information on 'MUST' see Step 3 If patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days Score = 2 Step 4 Add scores together to calculate overall risk of malnutrition: Score 0 = low risk Score 1 = medium risk Score 2 = high risk The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). Further information on 'MUST' see The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). Further information on 'MUST' see 5

6 Step 5 Management guidelines: Challenge 3 Low risk routine clinical care Medium risk observe High risk treat Try it out with case study The 'Malnutrition Universal Screening Tool' ('MUST') is reproduced here with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). Further information on 'MUST' see MUST - caution For use only with adults Not designed to detect deficiencies or excessive intakes of vitamins and minerals Refer to MUST Explanatory Booklet for more information when weight and height cannot be measured When difficult to interpret results, e.g. fluid disturbances plaster casts amputations critical illness pregnant or lactating women MUST - equipment Need body mass index Weight - reliable weighing scales Height - stadiometer that can be correctly used MUST - alternatives to height Calculation of height from measurement of ulna length Challenge 4 Prediction equations derived in Southampton population Concern over values in different ethnic groups Practical issues Elia 2003, Madden et al

7 Training & supporting staff Screening is undertaken by non-specialised staff Need training in whole process Collection of data Training tools available Example, MUST Learn Developed by dietitians working at the Norfolk & Norwich University Hospital Calculation of score Implementation of management guidelines Appropriate referrals Training delivered University of Hertfordshire Commissioned by NHS in Hertfordshire Delivering ~ 14 sessions per year x 20 staff Healthcare professionals from range of backgrounds Training delivered University of Hertfordshire Commissioned by NHS in Hertfordshire Delivering ~ 14 sessions per year x 20 staff Healthcare professionals from range of backgrounds Audited use after training 96% using MUST >75% confident in referring patients, implementing supplements Stammers & Kostrzewska 2012 Challenge 5 Implications Training and support staff is expensive and time consuming What is the evidence of beneficial outcome? Training & supporting staff 7

8 Impact of on outcome Potential benefit? Systematic review in progress Protocol registered with Cochrane Library: Rashidian et al: Nutritional for improving professional practice for patient outcomes in hospital and primary care settings Nutrition Watch this space! Elia & Stratton 2011 Potential benefit? Potential benefit? Nutrition Nutrition What happens next? Elia & Stratton 2011 Elia & Stratton 2011 Potential benefit? Potential benefit? Nutrition Programme of nutritional management Nutrition Optimise opportunity for positive outcomes Elia & Stratton 2011 Elia & Stratton

9 Challenge 6 Time to try the challenges 1. Working with other staff 2. Choosing the right tool Integrating & care 3. Try out MUST with case study 4. Practical issues 5. Training and supporting staff 6. Integrating with care Feedback on the challenges 1. Working with other staff 2. Choosing the right tool 3. Try out MUST with case study 4. Practical issues 5. Training and supporting staff 6. Integrating with care Summary Disease related malnutrition is common and can adversely influence clinical outcomes Providing appropriate nutrition support to malnourished patients may help reduce mortality and complications Nutrition helps identify people who might benefit from nutrition support Many challenges associated with Addressing these challenges and developing optimum care pathways might optimise outcomes Summary Disease related malnutrition is common and can adversely influence clinical outcomes Providing appropriate nutrition support to malnourished patients may help reduce mortality and complications Nutrition helps identify people who might benefit from nutrition support Many challenges associated with Addressing these challenges and developing optimum care pathways might optimise outcomes practice research 9

10 References 1 References 2 BAPEN (2012). Introducing MUST. accessed 20 November Buzby GP, Mullen JL, Matthews DC, Hobbs CL, Rosato EF (1980). Prognostic nutritional index in gastrointestinal surgery. American Journal of Surgery Cawood AL, Elia M, Sharp SK, Stratton RJ (2012). Malnutrition self- by using MUST in hospital outpatients: validity, reliability, and ease of use. American Journal of Clinical Nutrition Elia, M. (2003) The MUST Report. Nutritional Screening of Adults: A Multidisciplinary Responsibility. Development and Use of the Malnutrition Universal Screening Tool ( MUST ) for adults. Malnutrition Advisory Group (MAG), a Standing Committee of the British Association of Parenteral and Enteral Nutrition (BAPEN). Redditch: BAPEN. Elia M, Stratton RJ (2011). Considerations for tool selection and role of predictive and concurrent validity. Current Opinion in Nutrition and Metabolic Care Ferguson M, Capra S, Bauer J, Banks M (1999). Development of a valid and reliable malnutrition tool for adult acute hospital patients. Nutrition Ingenbleek Y, Carpentier YA (1985) A prognostic inflammatory and nutritional index scoring critically ill patients. International Journal for Vitamin and Nutrition Research Jones JM (2002). The methodology of nutritional and assessment tools. Journal of Human Nutrition and Dietetics Kondrup J, Allison SP, Elia M, Vella B, Plauth M (2003a). ESPEN guidelines for nutrition Clinical Nutrition Kondrup J, Rasmussen HH, Hamberg O, Stanga Z; Ad Hoc ESPEN Working Group (2003b). Nutritional risk (NRS 2002): a new method based on an analysis of controlled clinical trials. Clinical Nutrition Kuzu MA, Terzioğlu H, Genç V, Erkek AB, Ozban M, Sonyürek P, Elhan AH, Torun N (2006). Preoperative nutritional risk assessment in predicting postoperative outcome in patients undergoing major surgery. World Journal of Surgery Madden AM, Tsikoura T, Stott DJ (2012). The estimation of body height from ulna length in adults from different ethnic groups. Journal of Human Nutrition and Dietetics Mueller C, Compher C., Druyan ME, American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors (2011). ASPEN clinical guidelines: Nutrition, assessment and intervention. Journal of Parenteral and Enteral Nutrition Poulia KA, Yannakoulia M, Karageorgou D, Gamaletsou M, Panagiotakos DB, Sipsas NV, Zampelas A (2012) Evaluation of the efficacy of six nutritional tools to predict malnutrition in the elderly. Clinical Nutrition Reilly HM, Martineau JK, Moran A, Kennedy H (1995) Nutritional : Evaluation and implementation of a simple Nutrition Risk Score. Clinical Nutrition Stammers S, Kostrzewska S (2012). Community health professionals views and confidence in the use of nutrition for patients in a community health trust. Journal of Human Nutrition and Dietetics in press (abstract). Stratton RJ, Green CJ, Elia M (2003) Disease-related malnutrition: an evidence-based approach to treatment. Wallingford: CABI Publishing. 10