Malnutrition in Summer

Key points from BAPEN’s NSW 2008 Report:

  • Many hospitals, care homes and mental health units not calibrating scales for weighing regularly in contravention of a DH alert
  • Prevalence of malnutrition on admission to hospital, care homes and mental health units reconfirmed as affecting up to1 in 3 of all adults of all ages
  • Not all hospitals or mental health units ‘handing on’ nutrition information on patients at malnutrition risk on discharge

BAPEN thanks the 222 reporting centres which contributed to this Report covering the summer period. Reporters have received their data back so local information can be benchmarked against the national picture on ‘malnutrition’ and nutritional care policy and practice.

BAPEN also thanks the RCN and BDA together with the NPSA and government departments across England, Wales, Scotland and Northern Ireland for their continuing support of this initiative.

All four seasons will eventually be covered by BAPEN’s Screening Weeks (final NSW to be organised in spring 2011) after which the data collected across all seasons will be amalgamated and compared thus providing a fuller picture on ‘malnutrition’ in the UK.


Summary

1. The Nutrition Screening Survey
1.1
This report provides a summary of the second nutrition screening survey undertaken in the UK. The survey was carried out from 1-3 July 2008 reflecting the prevalence of ‘malnutrition’ during the summer. Reporters from 130 hospitals, 75 care homes and 17 mental health units in the UK completed a general questionnaire and an anonymous patient questionnaire as part of a national audit on nutritional screening using criteria based on the ‘Malnutrition Universal Screening Tool’ (‘MUST’) in all care settings. Data were collected on patients during the first three days of admission to hospitals and acute mental health units, and on residents admitted to care homes and long stay/rehabilitation mental health units in the previous six months. The combination of medium and high risk categories is henceforth referred to as ‘malnutrition’ for simplicity.

The results of the 2008 survey have been compared with those of the 2007 nutrition screening survey which was undertaken in the autumn between 25-27th September 2007.

2. Hospitals
2.1
Of 5089 patients who were screened on admission to hospital, 28% were found to be at risk of malnutrition, high risk (22%), and medium risk (6%), the same proportions found to be at risk in the 2007 survey.

2.2 Overall the results for the hospital survey in 2008 including those on policies and practice were similar to those for 2007.

2.3 78% of patients included in the survey were admitted from their own homes, suggesting that the risk of malnutrition largely originated in the community. Strategies to prevent and treat malnutrition in the community setting should therefore be considered.

2.4 ‘Malnutrition’ varied significantly according to source of admission (26% from home, 34% from another hospital, 32% from another ward, and 52% from a care home), type of admission (34% for emergency admission, 19% for elective admission), and type of ward (e.g. 42% in oncology wards and 19% in orthopaedic/trauma wards). However, unlike in the 2007 survey, it was not greater in hospitals that had a screening policy than in those that did not (29% v 30%), and there was no significant difference between larger hospitals with ≥1000 beds and those with <1000 beds.

2.5 ‘Malnutrition’ was common in all age groups and diagnostic categories, but it was significantly more common in women (30% v 26%), who were older than men, in subjects aged over 65 years than under 65 years (32 v 23%), and in certain diagnostic categories compared with others (e.g. gastrointestinal disease (41%) and neurological disease (31%) versus cardiovascular disease (20%) and musculoskeletal conditions (20%)).

2.6 12 % of patients included in the survey were reported to have cancer.‘Malnutrition’ was significantly higher in those patients with cancer than those without (40% v 26%).

2.7 A low body mass index (BMI <20 kg/m2) contributed to a ‘MUST’ category (medium + high) in 44% of ‘malnourished’ patients.

2.8 Most hospitals reported that they had a screening policy (82%), but weighing on all wards was carried out in just over half the hospitals in the survey, and only a little over a quarter of the patients (27%) involved in the survey were in hospitals where weighing was carried out on all wards. Furthermore, only 6 out of 10 hospitals stated that the scales on all wards had been calibrated within the last 12 months.

2.9 Nutrition information on those patients identified as ‘malnourished’ was not always included in discharge communications. About half the hospitals reported that they always or usually included this information, 39% said they sometimes included it and 8% either did not or did not know. This suggests that ‘malnutrition’ may be under- recognised and under-treated following discharge from hospital.

2.10 Compared to hospitals without a nutrition screening policy, those with a nutrition screening policy were more likely to undertake weighing on all wards (53% v 21%), use scales that had been calibrated on all wards (60% v 50%) and communicate nutrition information on discharge from hospital (always + usually = 52% v 36%).

3. Care homes
3.1
Of 614 residents recently admitted and screened 42% were ‘malnourished’ (30% high risk, 11% medium risk) which was much higher than in the 2007 survey when 30% residents were ‘malnourished (20% high risk, 10% medium risk). This may be due to the difference in mix of care homes that took part in the 2 surveys with more exclusively nursing homes, fewer exclusively residential homes and more care homes with nursing facilities participating in 2008 than in 2007.

3.2 The prevalence of ‘malnutrition’ was greater in residents admitted from hospitals (45%) and other care homes (45%) than in those admitted from their own homes (36%). The prevalence was also greater in nursing homes (46%) than residential homes (36%).

3.3 Most care homes (89%) reported that they had a screening policy and almost all (96%) reported that they had a policy to weigh residents on admission and 65% recorded the height of residents on admission. 99% of care homes said they regularly weighed residents during their stay. 84% of care homes used scales that had been calibrated within the last 12 months.

3.4 A low BMI (<20 kg/m2) contributed to the ‘MUST’ category (medium + high) in about 8 out of 10 ‘malnourished’ residents. Underweight was 4 to 5 fold more common than obesity. The subjects in care homes were older than those in hospitals and mental health units, more than half of them being 85 years and over. The prevalence of ‘malnutrition’ increased with age and was higher than that reported in 2007 (36% v 26% in those <70 years, 37% v 29% in those 70-84 years and 46% v 32% in those ≥85 years; p = 0.076 and p (trend) = 0.031) and duration of stay (up to 6 months; p <0.01).

3.5 Women were older and had a greater prevalence of ‘malnutrition’ than men (45% v 34%).

3.6 Over half the residents had neurological conditions, 17% residents were classified as frail elderly both with an associated ‘malnutrition’ prevalence of 43%. The highest prevalence (83%) was found in residents with gastrointestinal disease though these accounted for only 1% of residents (n = 6) in the survey. 6% residents were reported to have cancer.‘Malnutrition’ was higher in those residents with cancer than those without (55% v 41%).

4. Mental health Units
4.1
Of 185 adults screened on admission, 20% were ‘malnourished’ (15% high risk, 5% medium risk), with no significant difference between acute units (19%) and Long-stay units (21%). The overall prevalence (20%) was very similar to that reported in the 2007 survey (19%).

4.2 About 8 out of 10 units that participated in the 2008 survey reported that they had a screening policy as opposed to less than half the units who took part in the 2007 survey and more than three quarters of patients were reported from units with a screening policy. Likewise more units in 2008 had access to a nutrition support team than those who took part in 2007 (65% and 41% respectively).

4.3 All units said their policy was to weigh patients on admission but only about a third of units used scales on all wards that had been calibrated in the last 12 months. 1 in 8 units said that the scales had not been calibrated during the past 12 months.

4.4 A low BMI (<20kg/m2) was present in 17% of patients (8% with a BMI < 18.5 kg/m2). The mean age of subjects was higher than in the 2007 survey (66yr v 59 yr respectively) and those subjects aged 65 years and over (66%) had a greater prevalence of ‘malnutrition’ (27%) than those less than 65 years (6%).

4.5 Only about 1 in 5 units said they always included nutrition information on all patients identified as being ‘malnourished’ in discharge communications.

5. A comparison across care settings
5.1 The prevalence of ‘malnutrition’ on admission to hospitals in this second survey was the same as that found in 2007 (28%) but the prevalence on admission to care homes in 2008 was significantly higher than in 2007(42% v 30%). The prevalence of ‘malnutrition’ on admission to mental health units was lower than to other care settings and similar to that found in mental health units in 2007 (20% v 19%), although a much smaller number of subjects were reported from mental health units.

5.2 In all care settings most of the ‘malnutrition’ was high risk ‘malnutrition’.

5.3 The prevalence of ‘malnutrition’ amongst patients admitted to hospitals or care homes varied significantly according to source of admission, being lower in those that came from their own homes than from institutions (other wards, hospitals and care homes). The differences in hospitals were significant.

5.4 In hospitals and care homes women outnumbered men (ratio 1.07:1 in hospitals and 2.3:1 in care homes).In mental health units men outnumbered women (1.0:0.9) in all care settings women were older and had a greater prevalence of ‘malnutrition’ than men.

5.5 BMI contributed to over 4 out of 10 subjects categorised as ‘malnourished’ (medium + high risk) in acute hospitals, 6 out of 10 in community hospitals and mental health units, and 8 out of 10 in care homes. Underweight (BMI <20kg/m2) was most common in care homes, affecting 33% of residents. The mean BMI in care homes (23.0 kg/m2) was significantly lower (p <0.001) than in hospitals (26.4 kg/m2) and mental health units (25.6 kg/m2). In care homes underweight was more common than obesity (BMI >30kg/m2), in mental health units it was equally common whilst in hospitals obesity was more common than underweight.

5.6 The practice of regular calibration of scales varied in all care settings. It was more likely to occur in care homes than in hospitals and least likely to happen in mental health units.

5.7 9 out of 10 hospitals said they had care plans for the management of malnourished patients (yes 92%; no, 8%; no response, <1%). Half the hospitals reported that they always or usually included nutritional information in discharge communications but only just over a third of mental health units always or usually did so. The majority of care homes also reported that they had care plans for the management of malnutrition (yes, 96%; no, 3%; and no response 1%). The presence of care plans was also reported in mental health units (yes, 82%; no, 6%; and no response,12%)

6. Recommendations
6.1 Patients or residents admitted to all institutional care settings should be screened, and repeat measurements made at intervals according to care setting, using accurate and reliable instruments (see ‘MUST’ report).

6.2 Scales on all wards and in all care settings should be calibrated annually.

6.3 Staff involved in nutritional screening should be trained and be competent to undertake screening and implement care plans.

6.4 The results of nutritional screening should be linked to care plans, which may vary according to local resources and policies.

6.5 Nutritional information should be included in communications regarding subjects identified as ‘malnourished’
on discharge from hospital and mental health units.

6.6 Access to nutrition advice and nutrition support teams should be available in all care settings.

6.7 The practice of nutritional screening should be audited regularly.

6.8 Consistent strategies to detect, prevent, and treat malnutrition should be in place in all care settings, including the community, where most malnutrition originates.

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