M alnutrition U niversal S creening T ool ( MUST ) Gill Cuffaro Senior Lecturer - Dietetics University of Hertfordsh

1. Malnutrition Universal Screening Tool (MUST)Gill CuffaroSenior 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?

2. March 2004 - Sip Feed Audit • Appropriate Prescribing • Compliance • Monitoring • Food First

3. 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

4. Guidelines • Screening Tool - MUST • Nutritional Support Pathway • First line dietary advice sheets • Training to Primary Care Staff

5. 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

6. 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.

7. WHAT IS NUTRITIONAL SCREENING? • It is a rapid, simple, general procedure done at first contact with patient to detect risk of malnutritionor to identify malnutrition. • It can be carried out by all health care professionals

8. 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

9. 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)

10. 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

11. 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

12. 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

13. 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 percentageunintentional 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 MalnutritionUniversal Screening Tool (MUST), for example, may be used to do this

14. 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 )

15. COMPONENTS OF MUST • A flow chart showing 5 steps to use for screening and management • BMI chart • Weight loss tables • Alternative measurements

16. 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

17. Step 2: Weight Loss Score(Unplanned weight loss over 3-6 months) • Note unplanned weight loss and refer to tables SCORE

18. 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

19. 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

20. Alternative measurementsEstimating Height from ulna length

21. 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

22. MUST SCREENING TOOL –How do we use it? • MUST measurements • Case Studies • Feedback

23. 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………………………………………

24. 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?

25. 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?

26. 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?

27. ANSWERS

28. 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

29. 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

30. 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