Malnutrition Universal Screening Tool

(MUST) Gill Cuffaro

Senior Lecturer - DieteticsUniversity of Hertfordshire

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

Appropriate Prescribing

Compliance

Monitoring

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

Screening Tool - MUST

Nutritional Support Pathway

First line dietary advice sheets

Training to Primary Care Staff

National Institute for Health and Clinical Excellence (NICE)Clinical Guidence 32February 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?

It is a rapid, simple, general procedure done at first contact with patient to detect risk of malnutrition or to identify malnutrition.

It can be carried out by all health care professionals

GROUPS AT RISK OF MALNUTRITION

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:

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?

Malnutrition is frequently unrecognised and untreated

Effective management of malnutrition reduces the burden on healthcare and care resources

Regular screening is the only way that malnourished individuals can be identified and appropriate action taken

Screen:

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

Consider screening at other opportunities ie. health checks, flu injections

Repeat screening weekly for inpatients and when there is clinical concern for all

Screening should be carried out by healthcare professionals with appropriate skills and training

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

5 step tool used to identify adults who are malnourished or a risk of malnutrition

A validated tool across various settings including Care Homes, Hospital wards, Outpatient Clinics and General Practice

Quick and easy to use and give reproducible results

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

A flow chart showing 5 steps to use for screening and management

BMI chart

Weight loss tables

Alternative measurements

Step 1: BMI

Obtain weight and height

Calculate BMI or use BMI chart provided

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)

Note unplanned weight loss and refer to tables

SCORE

Step 3: Acute Disease Effect

Patients who have had or are likely to have no nutritional intake for more than 5 days

Most likely to apply to patients in hospital

SCORE

Step 4: Overall Risk of Malnutrition

Add up scores from Steps 1, 2 and 3

Document score

0 = Low risk

1 = Medium risk

2 or more = High risk

Alternative measurementsEstimating Height from ulna length

If MUAC is <23.5 cm, BMI is likely to be <20 kg/m2If MUAC is >32.0 cm, BMI is likely to be >30 kg/m2

BMI Category

Estimating BMI from mid upper arm circumference (MUAC)

MUST SCREENING TOOL –How do we use it?

MUST measurements Case Studies Feedback

MUST Measurements

EstimationEstimate 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) ReportedAsk your partner how tall they think they are………………………….Ask your partner how much they think they weigh……………………What is your partners reported BMI?…………………………………..

ActualMeasure 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 LengthMeasure your partners Ulna length………………………………………How tall are they using ulna length measurements?...........................Compare this to their actual height………………………………………

CASE STUDY D – Primary Care

69 year old man living at home with his wife, has rheumatoid arthritis, takes multiple painkillers and suffers with constipation and nausea

Height: 1.73m

Previous weight: 71kg (2 months ago when weighed at GP Surgery)

Current weight: 69kg

Is patient at low, medium or high risk of malnutrition?

What would be your action plan?

CASE STUDY E – Primary Care

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

Height: ulna length 24.0cm

Previous weight: 62kg (6 months ago at OP clinic)

Current weight: 57kg

Is patient at low, medium or high risk of malnutrition?

What would be your Action Plan?

CASE STUDY F – Primary Care 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.

Height: 6’ 0” (estimated)

Weight: 56kg (estimated)

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 69 year old man living at home with his wife, has rheumatoid arthritis, takes multiple

painkillers and suffers with constipation and nausea

Height: 1.73m

Previous weight: 71kg (2 months ago when weighed at GP Surgery)

Current weight: 69kg

Is patient at low, medium or high risk of malnutrition?Low Risk

What would be your action plan? Repeat MUST monthly due to constipation, nausea and some weight loss Balanced diet advice sheet, for a regular meal pattern and adequate fobre

intake Give and discuss fluid advice sheet

CASE STUDY E - ANSWERS

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

Height: ulna length 24.0cm

Previous weight: 62kg (6 months ago at OP clinic)

Current weight: 57kg

Is patient at low, medium or high risk of malnutrition?Medium risk

What would be your Action Plan? Repeat MUST monthly due to weight loss Refer to Speech and Language therapist Food and fluid chart Give and discuss Making More of your food advice sheet

CASE STUDY F - ANSWERS 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.

Height: 6’ 0” (estimated)

Weight: 56kg (estimated)

Previous weight: 65kg (before admission)

Is patient at low, medium or high risk of malnutrition?High Risk

What would be your Action Plan? Start food and fluid chart Give and discuss Making More of Your Food advice sheet Start sip feeds 2 per day for initial period of 2 weeks using Guide to Nutritional

Sip feed advice sheet Refer to Dietitian for urgent review