Nutrition Audit in Community Hospitals

in Provide

Nisha Desai, Head of Medicines Management, Provide

Prevalence of malnutrition - UK

UK population in 2007

61 million people

3 million people (5%) in

the UK

‘at risk’ of malnutrition

• 5% in residential care

• 2% in hospital

• 93% in community

Elia & Russell 2009

Objectives

The objectives for this audit were to:

Assess current practice around the

provision of oral nutrition support

within community hospitals

The prevalence of malnutrition

Appropriate use of ONS in the

community hospitals

The audit was completed for all three

community hospitals:

• St Peters

• Braintree

• Halstead

Mainly rehabilitation and patients requiring

specialist support prior to being discharged

Identifying Current Practice

The audit designed to assess:-

• Patient characteristics (gender, DOB and current diagnosis)

• Present and previous care setting, including length of stay at current community hospital

• Weight and height information, including details of BMI and MUST scores

• Details of any nutrition care plan, including oral nutritional support (ONS) use, compliance, recommended dose and reason for prescription

• Healthcare professional contact (GP or dietician) during the last 3 months

• Any previous hospital admissions during the last 3 months

The number of patients in each community hospital

Table 1: Number of patients at each Community Hospital

Community

Hospital

Number of patients (%) Average LOS days

Braintree 20 (37) 30.7 ± 30.3

Halstead 13 (24) 8.0 ± 8.3

St Peters 21 (39) 19.1 ± 16.7

Total 54 (100) 20.4 ± 22.7

During the audit at Halstead three patients had been discharged that morning so

were not included

In total 54 patients were screened and average Length of Stay (LOS) was 20.4

±22.7 days

Patient Characteristics

Table 2: Description of subjects included in the audit

Gender (n=53)

Male Female Total

Number 17 36 53

Mean Age (years) 81.4±14.1 80.7±11.0 81.0±11.8

Age Range (years) 38-95 50-100 38-100

*Please note missing gender for one patient

• There were 17 male and 36 female patients

• One patient had no gender available in their notes

• The average age for all of the patients was 81.0

11.8 years, with an

age range of 38-100

Frequency of patients with documented Height, Weight and

BMI data

• 12 (23%) patients did not have a documented height

• 9 (17%) patients did not have a documented weight

• Four patients without a documented height had a BMI

• One patient without a documented weight had a BMI

• One patient had both weight and height documented, but no BMI

• Three patients had a total ‘MUST’ score but no documented height

Table 3: Number of patients with documented height, weight and BMI

Male (n17) Female (n36) Total (n54)

Height 14 (83%) 28 (78%) 42 (77%)

Weight 13 (76%) 32 (89%) 45 (83%)

BMI 14 (83%) 29 (81%) 43 (79%)

Reasons for Admission to Hospital Table 4: Reason for admission to current hospital

No. of patients (n=54) Percentage (%)

Infection 4 7

Orthopaedic 12 22

Cancer 5 9

Cardiac 15 27

Malnutrition 2 4

Neurological 6 11

Gastro-intestinal 4 7

Respiratory 5 9

Unknown 1 2 *stroke patients are included within a cardiac diagnosis

When a patient was diagnosed with a number of clinical conditions the most prevalent

condition, which would have the biggest impact on their nutritional status was used.

Documented ‘MUST’ scores

Breakdown of ‘MUST’ scores

‘MUST’- 3 steps

• BMI Score

• Weight Loss Score

• Acute Disease Effect Score

STEP 1: BMI

63% of patients had a documented BMI score

STEP 2: Weight Loss Score

0

10

20

30

40

50

60

70

80

90

100

<5% 5-10% >10% Missing

Pe

rce

nta

ge %

Weight Loss Score

Documented Step 2 Score (Weight loss)

No patients had a documented weight loss score

STEP 3: Acute Disease Effect Score

Only 1 patient had an Acute Disease Effect

Score

0

20

40

60

80

100

120

Yes No/Missing

Pe

rce

nta

ge %

Acute Disease Effect Score

Documented Step 3 Score (Acute disease effect)

Total ‘MUST’ Score documented in notes

0

10

20

30

40

50

60

0 1 2 - 6 Missing

Pe

rce

nta

ge %

Overall Score

Total Documented ‘MUST’ Score

46% patients had a documented ‘MUST’ Score

Recalculating the MUST Score

• Using the documented data for height and weight, BMI

and a BMI (‘MUST’) scores were recalculated

• If weight 3-6 months ago was available a weight loss

score was recalculated

0

10

20

30

40

50

60

70

80

Low Risk Medium Risk High Risk

Pe

rce

nta

ge %

'MUST' Risk Score

Recalculated 'MUST' Scores

Recalculated ‘MUST’ Scores using

documented data

n39 (missing data for 15 patients)

In total, using the documented data;

• 39 patients have had a recalculation using ‘MUST’.

• 12 of these patients are at risk (medium/high) of malnutrition which equates to

30% of patients.

Comparison of documented and recalculated

BMI Scores

Documented Recalculated

Nutritional Care Plan

Documented data for the nine

patients on ONS

0

1

2

3

4

5

6

7

8

Documented Height Documented Weight Documented BMI Total MUST

Nu

mb

er

of

Pat

ien

ts

Documented data for patients receiving ONS

Yes

No

Summary Documented use and compliance of prescribed ONS

ONS

name Dose/day

Reason for

Prescription

Compliance

information

Documented

BMI

Documented

Height

Documented

weight

Total

MUST

Recalculated

BMI

Reason for

Admission

Fresubin

stage 1

thickener

Unknown Unknown Unknown 23.0 Unknown Unknown Cardiac

Fresubin

Jucy OD

Increase calorie

intake

Doesn't like black

currant flavour,

but is managing

one per day

18.0 Unknown 17.5 Orthopaedi

c

Fresubin

Energy

Fibre

OD

Written notes by

Dietitian which

stated the patient

was transferred

from Broomfield

having 2 ONS per

day

Recommended

twice per day by

the Dietitian but

only written up for

1 per day. Reports

managed 3/4

bottle

21.0 0 21.0 Infection

Fresubin

5kcal

shot and

Fresubin

stage 1

thickener

Unknown Unknown Unknown

23.0 0 22.5 Cardiac

Unknown

Unknown

Unknown

Fresubin

5kcal

shot

BD Losing weight Prescribed on the

8/10/2013 19.0 1 19.0 Cancer

Fresubin

2Kcal OD

Loose stools and

moderate food

intake

Good, but has lost

9kg in a week.

Patient suffers

from oedema

21.5 Unknown 21.5 Cardiac

Fresubin

2Kcal OD Unknown Unknown 18.0 2 Unknown

Malnutritio

n

Fresubin

2Kcal Unknown Unknown Unknown Unknown Unknown Unknown Cancer

Fresubin

2Kcal Unknown Unknown Unknown unknown Unknown Unknown

Malnutritio

n

Summary

• Appropriate use of the MUST tool to identify high risk patients

• Identify inappropriate use of ONS e.g. volume and advise appropriately in reference to Policy

• Identify training needs and incorporate into mandatory training for clinical staff