Transcript MUST SCREENING TOOL TRAINING

Malnutrition Universal Screening Tool
(MUST)
Gill Cuffaro
Senior Lecturer - Dietetics
University of Hertfordshire
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What is nutritional screening
Why screen patients
The MUST tool - what is it?
The MUST tool – how can it be used?
March 2004 - Sip Feed Audit
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Appropriate Prescribing
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Compliance
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Monitoring
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Food First
GUIDELINES FOR THE IDENTIFICATION OF ADULT
COMMUNITY PATIENTS AT RISK OF MALNUTRITION
IN
WATFORD AND THREE RIVERS PCT
Produced by:
Community Nutrition and Dietetic Department &
Medicines Management
September 2005
Guidelines
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Screening Tool - MUST
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Nutritional Support Pathway
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First line dietary advice sheets
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Training to Primary Care Staff
National Institute for Health and Clinical
Excellence (NICE)
Clinical Guidence 32
February 2006
Nutrition support in adults
Oral nutrition support, enteral tube feeding and parenteral
nutrition
AIM:
To improve the practice of nutrition support by providing
evidence and information for all healthcare professionals,
patients and carers so that malnutrition whether in hospital
or the community is recognised and treated by the best
form of nutrition support at the appropriate time.
WHAT IS NUTRITIONAL
SCREENING?
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It is a rapid, simple, general procedure done at
first contact with patient to detect risk of
malnutrition or to identify malnutrition.
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It can be carried out by all health care
professionals
GROUPS AT RISK OF
MALNUTRITION
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Sick, frail elderly
Cancer
Chronic neurological conditions i.e MND, MS
Stroke
Acute/chronic pain
Chronic respiratory disorders i.e COPD
Chronic inflammatory bowel disease
HIV / AIDS
WHAT IS MALNUTRITON?
No universally accepted definition but it
Can be defined as:
‘ A state in which a deficiency of nutrients such as
energy, protein, vitamins and minerals causes
measurable adverse effects on body composition,
function or clinical outcome’
(NICE guideline – Nutritional support in adults, February 2006)
CONSEQUENCES OF
MALNUTRITION
Evidence that malnourished patients:
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Visit their GP more often
Need more prescriptions
Have more hospital admissions and longer stays
Have an increased morbidity and mortality
Have a reduced quality of life
WHY SCREEN FOR MALNUTRITION?
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Malnutrition is frequently unrecognised and
untreated
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Effective management of malnutrition reduces
the burden on healthcare and care resources
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Regular screening is the only way that
malnourished individuals can be identified and
appropriate action taken
Screen:
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All hospital inpatients on admission
All outpatients at their first appointment
All people in care homes on admission
All people on registration at GP surgeries
And upon clinical concern
Clinical concern includes, unintentional weight loss, fragile skin,
poor wound healing, apathy, wasted muscles, poor appetite, altered
taste sensation, impaired swallowing, altered bowel habit, loose
fitting clothes, or prolonged intercurrent illness
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Consider screening at other opportunities ie. health checks, flu
injections
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Repeat screening weekly for inpatients and when there is clinical
concern for all
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Screening should be carried out by healthcare professionals with
appropriate skills and training
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Screening should assess BMI (Body Mass Index) and percentage
unintentional weight loss and should also consider the time over
which nutrient intake has been unintentionally reduced and/or the
likelihood of future impaired nutrient intake. The Malnutrition
Universal Screening Tool (MUST), for example, may be used to do
this
WHAT IS MUST ?
Malnutrition Universal Screening Tool
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5 step tool used to identify adults who are malnourished or a risk of
malnutrition
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A validated tool across various settings including Care Homes,
Hospital wards, Outpatient Clinics and General Practice
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Quick and easy to use and give reproducible results
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Useful for patients in whom height and weight are difficult to obtain
as it includes alternative measures and subjective criteria which are
given to obtain BMI ( Body Mass Index )
COMPONENTS OF MUST
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A flow chart showing 5 steps to use for screening and
management
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BMI chart
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Weight loss tables
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Alternative measurements
Step 1: BMI
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Obtain weight and height
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Calculate BMI or use BMI chart provided
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Use recalled height and weight or recommended
alternative methods of measurement if actual values
cannot be obtained
SCORE
Step 2: Weight Loss Score
(Unplanned weight loss over 3-6 months)
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Note unplanned weight loss and refer to tables
SCORE
Step 3: Acute Disease Effect
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Patients who have had or are likely to have no
nutritional intake for more than 5 days
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Most likely to apply to patients in hospital
SCORE
Step 4: Overall Risk of Malnutrition
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Add up scores from Steps 1, 2 and 3
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Document score
0 = Low risk
1 = Medium risk
2 or more = High risk
Alternative measurements
Estimating Height from ulna length
BMI Category
Estimating BMI from mid upper arm circumference (MUAC)
If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2
If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2
MUST SCREENING TOOL –
How do we use it?
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MUST measurements
Case Studies
Feedback
MUST Measurements
Estimation
Estimate how tall your partner is……………………………………......
Estimate how much your partner weighs……………………………….
What is your partners estimated BMI?………………………………….
(do not tell them your estimation until you have recorded their reported measurements below)
Reported
Ask your partner how tall they think they are………………………….
Ask your partner how much they think they weigh……………………
What is your partners reported BMI?…………………………………..
Actual
Measure your partners height……………………………………………
Weigh your partner………………………………………………………..
What is your partners actual BMI?………………………………………
Mid Upper Arm Circumferance (MUAC)
Measure your partners MUAC…………………………………………..
What is their BMI range using MUAC?...............................................
Ulna Length
Measure your partners Ulna length………………………………………
How tall are they using ulna length measurements?...........................
Compare this to their actual height………………………………………
CASE STUDY D – Primary Care
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69 year old man living at home with his wife, has rheumatoid arthritis,
takes multiple painkillers and suffers with constipation and nausea
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Height: 1.73m
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Previous weight: 71kg (2 months ago when weighed at GP Surgery)
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Current weight: 69kg
Is patient at low, medium or high risk of malnutrition?
What would be your action plan?
CASE STUDY E – Primary Care
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38 year old lady living at home with regular visits during the day from
Carers. She has MS and is wheelchair bound. She reports that for the
last 6 months she has been experiencing difficulties swallowing and
has been eating less
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Height: ulna length 24.0cm
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Previous weight: 62kg (6 months ago at OP clinic)
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Current weight: 57kg
Is patient at low, medium or high risk of malnutrition?
What would be your Action Plan?
CASE STUDY F – Primary Care
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89 year old man admitted to hospital after a fall at home and whilst an
inpatient he contracted c.diff infection. Two months later he has been
discharged, he still has diarrhoea but it is improving with treatment.
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Height: 6’ 0” (estimated)
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Weight: 56kg (estimated)
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Previous weight: 65kg (before admission)
Is patient at low, medium or high risk of malnutrition?
What would be your Action Plan?
ANSWERS
CASE STUDY D - ANSWERS
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69 year old man living at home with his wife, has rheumatoid arthritis, takes multiple
painkillers and suffers with constipation and nausea
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Height: 1.73m
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Previous weight: 71kg (2 months ago when weighed at GP Surgery)
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Current weight: 69kg
Is patient at low, medium or high risk of malnutrition?
Low Risk
What would be your action plan?
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Repeat MUST monthly due to constipation, nausea and some weight loss
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Balanced diet advice sheet, for a regular meal pattern and adequate fobre
intake
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Give and discuss fluid advice sheet
CASE STUDY E - ANSWERS
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38 year old lady living at home with regular visits during the day from Carers. She
has MS and is wheelchair bound. She reports that for the last 6 months she has
been experiencing difficulties swallowing and has been eating less
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Height: ulna length 24.0cm
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Previous weight: 62kg (6 months ago at OP clinic)
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Current weight: 57kg
Is patient at low, medium or high risk of malnutrition?
Medium risk
What would be your Action Plan?
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Repeat MUST monthly due to weight loss
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Refer to Speech and Language therapist
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Food and fluid chart
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Give and discuss Making More of your food advice sheet
CASE STUDY F - ANSWERS
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89 year old man admitted to hospital after a fall at home and whilst an inpatient he
contracted c.diff infection. Two months later he has been discharged, he still has
diarrhoea but it is improving with treatment.
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Height: 6’ 0” (estimated)
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Weight: 56kg (estimated)
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Previous weight: 65kg (before admission)
Is patient at low, medium or high risk of malnutrition?
High Risk
What would be your Action Plan?
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Start food and fluid chart
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Give and discuss Making More of Your Food advice sheet
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Start sip feeds 2 per day for initial period of 2 weeks using Guide to Nutritional
Sip feed advice sheet
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Refer to Dietitian for urgent review