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Malnutrition screening using “MUST”:

A brief guide for improving

April 2016

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Table of contents

1 Introduction .......................................................................................................... 2

2 Screening for malnutrition .................................................................................... 2

3 How to use this guide .......................................................................................... 2

4 Forming the Team ............................................................................................... 3

5 Setting Aims – What are we trying to accomplish? .............................................. 4

6 Establishing Measures – How will we know that a change is an improvement? .. 4

6.1 Suggested measures .................................................................................... 4

6.2 Baseline measurement ................................................................................. 4

6.3 Displaying data .............................................................................................. 5

7 Selecting and testing Changes – What changes can we make that will result in

improvement? ............................................................................................................ 5

8 Implementing and spreading changes. ................................................................ 5

9 References .......................................................................................................... 6

10 Appendices ....................................................................................................... 7

10.1 Driver diagram and change ideas ................................................................. 7

10.2 Data collection tool & measurement plan .................................................... 10

10.3 Run chart examples .................................................................................... 12

10.4 PDSA sheet................................................................................................. 13

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1 Introduction

Malnutrition is both a cause and effect of illness and, if untreated, can lead to poorer

health outcomes, increase morbidity and significantly reduce quality of life. A number

of studies have shown that malnourished patients access health services more often

(acute hospital and GP) and, when admitted, have more complications, longer

inpatient stays and higher mortality rates (NICE 2006). As well as the consequences

for the individual patient, the costs associated with malnutrition are substantial,

estimated to be over €1.4 billion per annum (Rice & Normand, 2012).

It is reported that malnutrition affects over 1 in 4 patients admitted to Irish hospitals.

Of those patients that are affected over 25% are in the high risk category (Russell &

Elia, 2012).

When indicated and as appropriate for the individual, methods to improve or

maintain nutritional intake may improve clinical outcomes and quality of life. These

interventions are known as nutrition support and include oral nutritional supplements,

enteral feeding and parenteral feeding.

2 Screening for malnutrition

To ensure patients receive the right intervention at the right time requires in the first

instance that systems are in place to:

a) identify malnourished patients;

b) prevent patients from becoming malnourished.

A key recommendation of current national guidelines for preventing under-nutrition in

acute hospitals is use of the Malnutrition Universal Screening Tool (‘MUST’) 5 steps

screening tool (Department of Health, 2009). The ‘MUST’ is a method of identifying

the patient at nutritional risk and assignment of a risk score which leads to a

subsequent plan of care. While a 2011 survey (26 Irish hospitals and 1299 patients)

showed that some hospitals have made progress in implementing the ‘MUST’,

results also show there is variation in practice within and between hospitals (Russell

& Elia, 2012).

3 How to use this guide

This guide demonstrates the use of the Model for Improvement (Langley et al, 2009)

as an approach to improving malnutrition screening using the ‘MUST tool. The guide

is informed by expert opinion, review of other improvement initiatives and learning

from a demonstration project with a multidisciplinary team. It is expected that the

guide may be applicable where the ‘MUST’ is being used or is intended to be used

as an element of nutritional care policy. It does not seek to replace approaches to

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improvement being used by teams already, but can be used alone or to build on the

work already taking place.

Users of this guide and change package are encouraged to review the change

package to determine:

� What practices might already be in place in their care area(s) and decide if further

work is needed;

� Identify and prioritise the first few changes that a team will undertake, and

determine if these changes lead to an improvement (remember that improvement

takes time);

� What other changes will be undertaken at a later date by the team;

� Adapt any of the content to their own area.

4 Forming the team

It is likely that individual hospitals will have procedures in place for initiation,

execution and oversight of quality improvement projects and these should be

followed by the improvement teams. For maximum opportunity of success the

following structures are recommended for this project:

� A steering committee

This is needed to provide project oversight and to ensure the project team stay

focussed on the aim. This role is ideally suited to the hospital’s Nutrition Steering

Committee or equivalent.

� Executive sponsor

This should be someone from the Senior Management Team (SMT). The sponsor’s

role is to ensure that the team have access to someone with executive authority to

assist with overcoming organisational barriers, to provide accountability for the

project team and to serve as a link to the SMT. As the project is multidisciplinary and

spans a number of departments, joint executive sponsorship could also work well, for

example between the Allied Health Services Manager and the Director of Nursing.

� Project team

It is important to identify those who want to work on the project and work with them-

work with the willing- and perhaps expand the team as the project gains momentum

and credibility. However, the project team must be multidisciplinary and must include

the Clinical Nurse Manager and the Dietitian allocated to the ward. Support where

possible should be provided by a member of the hospital’s Quality and Safety

Department or Practice Development team with QI skills.

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It is useful to have a named coordinator of the team – a ‘go to’ person - for questions

and coordinating meetings etc. so identify this person at the outset. Thereafter,

everybody’s opinion and ideas count and should be heard.

5 Setting Aims

This project focuses specifically on improving the rate of screening. As seen in the

driver diagram (Appendix 1) the SMART aim is:

By y (insert date), x % of patients admitted to on (insert unit) will be screened for risk

of malnutrition.

The aim statement can be tailored to your own situation, but you must set a “stretch”

goal. A "stretch" goal is one to reach for within a certain timeframe. Setting stretch

goals communicates clearly that maintaining the status quo is not an option.

Likewise, an ambitious stretch goal will help focus the team’ attention on initiatives

that are highly effective.

6 Establishing Measures

Measurement is an essential part of testing and implementing changes. The

measures chosen should indicate whether the changes you are making are actually

leading to improvement. However, measurement is not the goal; improvement is the

goal. Measurement for improvement is not the same as measuring for research; the

improvement team needs ‘just enough’ data to know whether changes are leading to

improvement. The measurement plan in Appendix 2 demonstrates how to use

sampling as a method of gathering data that saves time and resources while

accurately showing performance.

6.1 Suggested measures

Measures based on the ‘MUST’ are provided in this guide as follows:

1. Elements of the ‘MUST’:

a. %Weight

b. % Height

c. % BMI

d. % weight loss score

e. % acute illness effect score

2. % completed ‘MUST’.

6.2 Baseline measurement

Before starting the project, using the measures gather some baseline data on

screening rates. This will allow you to get a picture of what is happening presently.

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You should find the data collection tool and a measurement plan provided in

Appendix 3 useful.

6.3 Displaying data

Use a run chart to plot your data over time. The run chart is a simple and effective

way to determine whether the changes you are making are leading to improvement.

Once you have started making changes, annotate the run chart to show what

changes you have made and when you made them. See examples in Appendix 4.

7 Selecting and testing changes

Included in this guide is a selection of change ideas that have been shown to result

in improvements in malnutrition screening rates. You can use some or all of these,

depending on your own setting and adapt or add to them as you wish. Use Plan-Do-

Study-Act (PDSA) cycles to test a change or group of changes on a small scale to

see if they result in improvement. If they do, expand the tests and gradually

incorporate larger and larger samples until you are confident that the changes should

be adopted more widely. A PDSA worksheet is included as Appendix 5.

8 Implementing and spreading changes.

Conducting the project on one unit and testing and learning from changes should

facilitate gathering of knowledge of the local context. Using this knowledge and the

change ideas from the project unit, develop an implementation plan to spread to

other units as appropriate. Using PDSA’s may also be helpful with spread efforts.

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9 References

BAPEN (2003) The ‘MUST’ Explanatory Booklet: A Guide to the ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults. Accessed on line at http://www.bapen.org.uk/pdfs/must/must_explan.pdf

Department of Health and Children (2009) Food and Nutritional Care in Hospitals; Guidelines for Preventing Under-Nutrition in Acute Hospitals.

IHI (2015) How to Improve. Accessed on line at http://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

Langley et al (2009) The Improvement Guide, A Practical Approach to Enhancing Organisational Performance. 2nd ed: Jossey-Bass, San Francisco.

NICE (2006) Nutrition Support for Adults Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. Guideline 32. Accessed on line at http://www.nice.org.uk/guidance/cg32/evidence/cg32-nutrition-support-in-adults-full-guideline2

Russell C. A. & Elia M. (2012) Nutrition Screening Survey in the UK and Republic of Ireland in 2011. Accessed on line at http://www.bapen.org.uk/pdfs/nsw/nsw-2011-report.pdf

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10 Appendices

10.1 Driver diagram and change ideas

Aim Primary Drivers Secondary Drivers

Aim statement:

By XX/XX, X% of patients admitted to xx unit will be screened for risk of malnutrition.

Measures:

1. % measurements completed: o Weight o Height o BMI

2. % weight loss score 3. % acute illness effect

score 4. % complete ‘MUST’.

Equipment

Admission procedures

Awareness &

knowledge

� Appropriate and user friendly equipment

� Tools for alternative measurements

� Include screening in local admission policy

� Provide ‘MUST’ documentation

� Routinely screen patients on admission

� Raise awareness of the issue amongst staff- make

the case

� Multidisciplinary team involvement

� Malnutrition education

� Training on using ‘MUST’

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Secondary driver Change ideas

� Raise awareness of the issue

- make the case;

� Multidisciplinary team

involvement.

� Malnutrition education;

� Training on using ‘MUST’;

� Engage the multidisciplinary team and develop a shared vision for and

sense of urgency for the quality improvement project:

o Tissue Viability Nurse to share information on pressure ulcer/wound

break down where malnutrition is a factor;

o Physiotherapist to share information on falls where malnutrition is a

factor;

� Develop visual displays; use key facts relating to malnutrition and the

‘MUST’ e.g. locally developed flyers or adapting existing flyers and

posters;

� Put malnutrition on the agenda at MDT journal club and team meetings;

� Ensure e-learning programme is accessible to staff and explore making it

part of mandatory training programme;

� Follow up on e-learning with short targeted practical sessions at ward

level;

� Make the project ‘visible’- for example on ‘Know How We Are Doing’

notice boards.

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Secondary driver Change ideas

� Include screening guidance in

hospital Nutrition Policy;

� Provide ‘MUST’

documentation;

� Routinely screen patients on

admission.

� Set a timeframe within which screening will be completed e.g. 24 hours of

admission;

� Consult with local documentation group to explore ways to embed ‘MUST’

in nursing admission documentation;

� Design ‘MUST’ form to be user friendly and intuitive, look for examples

from other hospitals/units and adapt to local setting;

� Provide ‘MUST’ packs with conversion tables, BMI charts;

� Develop an admission checklist and include ‘MUST’ as an admission risk

assessment tool along with falls risk, pressure ulcers etc.

� Suitable equipment;

� Tools for alternative

measurements.

� Provide weighing scales suitable for the patient group –

o Sit down scales;

o Hoist scales;

� Ensure equipment is operational;

� Optimise position of equipment on ward-make it easy to access;

� Focus on the use of alternative anthropometric measurements when

needed – i.e. match methods of measurement to patient group;

� Provide ulna length rulers and MUAC tapes.

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10.2 Data collection tool & measurement plan

Yes = √ No = X Ward: ............ Date: .........Time: ..........

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Total √ Total %

Weight recorded?

5 %

Height recorded?

5 %

BMI recorded?

5 %

% weight loss & timeframe recorded?

5 %

Hx. Of/Risk of impaired nutritional intake for > 5 days recorded? (Acute disease effect)

5 %

Total √ 5 5 5 5 5

Total % % % % % %

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Measurement plan PROCESS MEASURE: Percentage Composite Compliance with ‘MUST’

Measure Type Composite process measure

Measure name ‘MUST’ screening tool

Measure Description This is a composite measure (ALL or NOTHING) requiring 5 Yes answers per patient in data collection sheet for all 5 individual measures: o Weight o Height o BMI o % weight loss o Acute illness effect

Sampling Plan To collect this weekly measure, generate a list of at least the last 10 patients admitted

directly to ward. Select the healthcare record of every second patient on the list to a

maximum of 5 patients. If there are less than 10 admissions in a week, randomly select

any 5 charts.

Numeric goal Insert goal from aim statement here

10.3 Run chart examples

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Run chart examples

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10.4 PDSA sheet

PDSA worksheet

Aim:

Describe your first test(s) of change: Person responsible

When to be done

Where to be done

Plan

List the tasks needed to set up this test of change Person

responsible

When

to be

done

Where

to be

done

Predict what will happen when the test is

carried out

Measures to determine if prediction

succeeds

Study Describe the measured results and how they compared to the predictions

Act Are we ready to make a change? Plan for the next cycle.