All Wales nutrition screening audit: nephrology inpatients.

StarterMalnutrition - a deficiency of energy, protein &

other nutrients that causes adverse effects on the body (shape, size & composition), the way it functions & clinical outcomes(MUST 2003).

• Major clinical problem in CKD, and in particular ESRD• Major clinical problem in CKD, and in particular ESRD- Reported prevalence in dialysis:

30-50%(Fouque at al, 2011).

- Independent predictor of poor clinical outcome-

morbidity, mortality, quality of lifelength of stay

Cost implications of Malnutrition

• The healthcare cost of managing individuals with malnutrition is more than twice that of managing non -malnourished individuals (Guest et al 2011).malnourished individuals (Guest et al 2011).

• Tackling malnutrition improves:- nutritional status, - clinical outcomes, and - reduces health care use. (Elia & Russell 2009).

Value for money

• Disease-related malnutrition costs in excess on £13 billion per annum , based on malnutrition prevalence figures & the associated costs of both health & socialcarecare (Elia et al 2009).

B.O.G.O.F

• NICE CG32 : ‘substantial cost savings can result from identifying & treating malnutrition’

• CG32 is ranked 3rd in the top clinical • CG32 is ranked 3 in the top clinical guidelines shown to produce savings(NICE 2006).

• The cost of managing malnutrition using prescribed nutrition support is low:- just 2.5% of the total expenditure on malnutrition (Stratton 2010).

Welsh Recipe -‘Blas o Gymru’

• The Welsh Government has recognised the importance of nutrition & catering as an essential part of the care patients receive in hospitals.

• 2009 All Wales Nutrition care pathway for • 2009 All Wales Nutrition care pathway for Hospitals……pathway for nutrition screening highlighted.

• 2011 All Wales Nutrition & catering standards for food & fluid provision for hospital inpatients.

• Nutritional screening is also recommended by DoH, RCN, RCP, NICE & NPSA.

Who’s role is it?

• Chief Executive & Executive Board

• Catering manager

• Dietitians

• Nursing staff (incl HCSW)

• Doctors • Pharmacists, SALT…….

• Everybody’s responsible!!!!

Underpinned by recommendations -

• Francis report (2013) and Andrews report (2014)

• “a small number of fundamental standards focusing on key areas of patient care”.

• “Whether patients are getting food and water, and help to eat and drink if they need”

All Wales Hospital Nutrition care Pathway protocol states:

• Standards(1) - “ Within 24 hours of admission to hospital all patients should be weighed & screened for malnutrition be weighed & screened for malnutrition or risk of malnutrition using a validated nutritional screening tool”

(WAASP / MUST ).

• Standards(2) - “When a Nutrition Risk Score (NRS) and weight has been established a multi-professional nutrition established a multi-professional nutrition care plan should be implemented. The care plan developed will depend on the NRS”.

Nutrition Risk Screening tool - WAASP

MUST

All Wales Renal Nutrition Screening Audit

• Audit the nutrition screening process of inpatients in acute nephrology beds across Wales.

• Collaborative pro-forma designed to look at patients on admission , duringadmission ,their nutritional assessment & on discharge .

Methodology

1. Assessment of nutritional screening process, nutritional care and effect on outcome in all patients admitted to nephrology/transplant wards in Wales over nephrology/transplant wards in Wales over same 2 weeks, June 2014.

2. All patients admitted during this period were assessed and followed up until discharge, or following 2 weeks after audit end.

Demographics 1 – CKD vs Acute

20

1830

40

50

60

CKD Acute

No.

pat

ient

s

2821

9 13 13

18

15 819

0

10

20

30

Cardiff-neph

Swansea Wrexham maelor

Glan Clwyd

Ysbyty Gwynedd

No.

pat

ient

s

Demographics 2 - DM vs non -DM

31

40

50

60

non DM DM

No.

pat

ient

s

179 12 10

513

31

30 27

1416

19

0

10

20

30

Cardiff -neph

Cardiff -Transplant

Swansea Wrexham maelor

Glan Clwyd

Ysbyty Gwynedd

No.

pat

ient

s

Demographics 3 - malignancy vs non

malign non-malig

No.

pat

ient

s.

8 5 7 4 2

40

39 3417

1730

Cardiff-neph Cardiff-trans Swansea Wrexham maelor Glan Clwyd Ysbyty Gwynedd

83 82 7588

40

50

60

70

80

90

100

Nutritional screening completed within 24 hours

%83 82

49

75

43

88

0

10

20

30

40

WAASP & MUST Mean & Median

2

3

6

8

10WAASP score MUST score

Monitor

Interventional

0

1

0

2

4

6

Cardiff-neph Cardiff-trans Swansea Wrexham maelor

Glan Clwyd Ysbyty Gwynedd

Low risk

Monitor

Weight before & after admission: Data completeness

Number % completion

Cardiff Nephrology 36/48 75%

Cardiff Transplant 36/39 92%

Swansea 21/38 97%

WXham 8/18 75%

GC 6/21 42%

YG 2/32 6%

Weight loss during admission

Number % patients losing weight

Cardiff Nephrology 22/36 61%

Cardiff Transplant 21/36 58%

Swansea 21/38 55%Swansea 21/38 55%

WXham 18/24 75%

GC 9/21 43%

Weight loss during admission: mean weight before & after

90

100

110

120

Before

Wei

ght K

g

50

60

70

80

Cardiff Nephrology Cardiff Transplant Swansea Wrexham G CLBefore 88.07 79.42 80.37 91.83 79.41After 80.45 74.94 74 85.3 62.34

Before

After

8.6

10.1

6

8

10

12

Kg

Weight loss for those admitted with no oedema

2.2

0.8 0.93 0.8 1 1.2

3.22.6

0

2

4

6

Referred to dietitian or not

19

18

40

50

60Not referred

Referred

2921 20 16

311

18 19

8

18

21

0

10

20

30

Cardiff-neph

Cardiff trans

Swansea Wxham GC YG

No.

pat

ient

s

Reason for referral to dietitian

NutritionSupport

K/P/ DM Fluid Other

Cardiff Nephrology

23/29 1/29 1/29 1/29 3/29

Cardiff Transplant 11/21 2/21 1/21 7/21

NutritionSupport

Electrolyte info (K/Po)

DM Fluid Other

Cardiff -Nephrology

79% 3.5% 3.5% 3.5% 10.5%

Cardiff -Transplant

52% 9.5% 4.5% 0 34%Cardiff Transplant 11/21 2/21 1/21 7/21

Swansea 16/20 3/20 1/20

WXm 11/16 2/16 1/16 2/16

GC 2/3 1/3

Transplant

Swansea 80% 15% 0 5% 0

WXham 69% 12.5% 6% 0 12.5%

GC 67% 0 0 0 33%

YG 82% 9% 0 0 9%

• Length of stay as an outcome .• Influence of the presence of sepsis.

Biochemical markers.• Any surgery received.• Bowels .• Type of nutrition support used by

dietitians.

Problems with NRS & audit incl:

• Not ‘renal focussed’- MUST not sensitive enough in renal inpatients(Lawson et al 2010)

• Relies on accurate weight/weight history ……oedema/nephrotic patients not history ……oedema/nephrotic patients not considered.

• Renal patients referred for other things (Na/K/Po/fluid ).

• Re-screen logistics.

• Over 2 weeks audit period was data collection true reflection?

• Acutely unwell patient group, complex treatments, multi-professional input.treatments, multi-professional input.

Conclusions

• We are currently not meeting standards, for many reasons…….

• Education central to moving forwards.

• Continue audit -cycle , & look at • Continue audit -cycle , & look at auditing other CKD groups.

• Renal nutrition group (RNG) work into producing a robust , universal renal-specific NST.

• Renal Registry area to look at.

Recommendations

All Wales Renal dietitian group to look into most appropriate screening tool, referral criteria at ALL stages of CKD to ensure:

• Equity of access to service• Equity of access to service• Timely referral & review• Risk reduction• Continuous monitoring & re-auditing

Time for dessert……• We are all responsible , & have unique

roles to play to ensure adequate nutritional care is attained & maintained in our complex patient group.

• UHW Sally Finlay , Claire Farley, Rachel Long, Fiona Hillen, Helen Long, Andrea Miller, Anne Williams.

• North Wales Harriet Williams , Elizabeth Wynne, Caroline Fazakerley, Ffion Huges, Sarah Gooda.

• ABMU Sara Watkins, Jill Skinner, Eleri Wright, Emma Catling .

• Thanks/Diolch - Dr A Mikhail, Tom Hurley, Chris Brown, Fiona Willingham (RNG)

Diolch –ThanksCwestiynau?- Questions?