Summary

1. The Nutrition Screening Survey
1.1
This Report provides a summary of the fourth nutrition screening survey undertaken in the UK. It also includes, for the second time, data from hospitals and care homes in the Republic of Ireland (ROI). The survey was carried out from 5th -7th April 2011 reflecting the prevalence of ‘malnutrition’ during the spring. Reporters from 171 hospitals, 78 care homes and 67 mental health units in the UK and 26 hospitals and 6 care homes in ROI completed a general questionnaire and an anonymous patient / client 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.

For the UK, the results of the 2011 survey have been compared with those of the 2010, 2008 and 2007 nutrition screening surveys which were undertaken in the winter from 12th -14th January 2010, in the summer from 1st -3rd July 2008 and in the autumn from 25th-27th September 2007. The results for Ireland have been compared with those from the 2010 survey although it is difficult to be confident about the comparisons involving care homes due to small sample size in the 2011 survey.

2. UK Survey
2.1. Hospitals
2.1.1. Of 7541 patients who were screened on admission to hospital, 25% were found to be at risk of malnutrition, high risk (18%), and medium risk (7%), lower than the overall prevalence found in the 2010, 2008 and 2007 surveys. There was a significant difference in the prevalence of ‘malnutrition’ between 3 nations (England, Scotland and Wales) of the UK. Most patients (68%) were admitted to hospitals in England, 19% to hospitals in Scotland, 11% to hospitals in Wales but none to hospitals in Northern Ireland.

2.1.2. 73% of patients included in the survey were admitted directly from their own homes, 23% of whom were at risk of ‘malnutrition’ suggesting that this largely originated in the community. Strategies to prevent, identify and treat malnutrition in the community setting should therefore be considered.

2.1.3. ‘Malnutrition’ varied significantly according to source of admission (23% of patients admitted from home, 33% of those from another hospital, 26% from another ward, and 41% from a care home), type of admission (27% for emergency admission, 20% for elective admission), and type of ward (e.g. 34% in care of the elderly wards and 16% in orthopaedic/trauma wards). There was a significant difference between the prevalence of ‘malnutrition’ in hospitals with less than 1000 beds and larger hospitals with 1000 or more beds (25% v 31%). Three quarters of patients in the survey were admitted to hospitals with less than 1000 beds.

2.1.4. A low body mass index (BMI <20kg/m2) contributed to a ‘MUST’ category (medium + high) in 49% of‘malnourished’ patients

2.1.5. ‘Malnutrition’ was common in all age groups and diagnostic categories, but it was significantly more common in women (28% v 22%), who were older than men, in subjects aged 65 years and over than under 65 years (28 v 21%), and in certain diagnostic categories compared with others (e.g. gastrointestinal disease (38%) and respiratory disease (31%) versus musculoskeletal conditions (18%) and cardiovascular disease (16%). Fewer patients were admitted with respiratory disease than in the 2010 and 2008 surveys.

2.1.6. 15% of ‘malnourished’ patients included in the survey were reported to have cancer which was a higher proportion than in the 2010 and 2008 surveys (13% and 12% respectively). ‘Malnutrition’ was significantly higher in those patients with cancer than in those without (34% v 23%).

2.1.7. Overall the results for the hospital survey in 2011 regarding those on policies and practice showed an increased proportion of centres had Nutrition Steering Committees, policies for nutritional screening and access to Nutrition Support Teams compared to those for 2010, 2008 and 2007.

2.1.8. Almost all hospitals audited the practice of nutritional screening, an improvement from the previous three surveys, with most undertaking an audit at least every year.

2.1.9. The majority (86%) of hospitals stated that they knew what proportion of their patients were screened on admission and of those, 78% screened 76-100% patients. This is higher than in 2010, 2008 and 2007 where 61%, 56% and 6% hospitals respectively screened ≥76% patients on admission.

2.1.10. Almost all hospitals (99%) in this survey reported that they had a screening policy, but weighing on all wards was carried out in only 67% of the hospitals, and height was recorded on all wards in only 60% of hospitals. However, these results represent an improvement from the three previous surveys. There was also an improvement in the proportion of patients admitted to wards where it was stated that scales had been calibrated within the last 12 months, from 59% in 2010 to 70% in 2011, but at the same time, 25% of patients were admitted to wards where the reporter did not answer or did not know if the scales had been recently calibrated, and 5% to wards where the scales had not been calibrated.

2.1.11. Just over two thirds of hospitals were aware of standards regarding weighing scales and almost half of them were able to specify those issued by the Department of Health (1) or the European Commission (2). Most respondents however were aware that scales should be regularly calibrated.

2.1.12. Almost all hospitals (97%) reported using a nutrition screening tool and of those that did, ‘MUST’ was used in 85% of centres. Lectures / workshops were the most commonly used format for training staff on nutritional screening.

2.1.13. Nutrition information on those patients identified as ‘malnourished’ was not always included in discharge communications. 7 out of 10 hospitals reported that they always or usually included this information, just over a quarter said they sometimes included it and the remainder either did not know or did not answer. This suggests that ‘malnutrition’ may be under-recognised and under-treated following discharge from hospital.

2.2. Care Homes

2.2.1. Of 523 residents recently admitted and screened 41% were ‘malnourished’ (25% high risk, 16% medium risk) which was higher than in the 2010 and 2007 surveys but similar to the 2008 survey. In 2008, 42% residents were at risk (30% high risk, 11% medium risk), in 2010, 37% residents were at risk (23% high risk, 15% medium risk) and in 2007 30% residents were ‘malnourished’ (20% high risk, 10% medium risk). This may be due to the difference in the mix of care homes that took part in the 4 surveys.

2.2.2. The prevalence of ‘malnutrition’ was greater in residents admitted from other care homes (44%) than those admitted from hospitals (40%) or from their own homes (40%). The prevalence was also greater in homes that provided nursing care only (46%) than in those providing residential care only (41%). The prevalence of ‘malnutrition’ in residents recently admitted to residential homes was higher in this survey than in all 3 previous surveys (41% v 30% v 36% v 22%).

2.2.3. The subjects in care homes were older than those in hospitals and mental health units, more than 4 out of 10 of them being 85 years and over and among those identified as ‘malnourished’ just under half were 85 years and over. The prevalence of ‘malnutrition’ increased with age but it was not significantly related to duration of stay (up to 6 months).

2.2.4. Women were older and had a greater prevalence of ‘malnutrition’ than men (46% v 31%).

2.2.5. The mean BMI of care home residents was 23kg/m2 which was similar to that in previous surveys. A low BMI (<20kg/m2) contributed to the ‘MUST’ category (medium + high) in just under 8 out of 10 ‘malnourished’ residents. Underweight was 3 times more common than obesity.

2.2.6. Most residents (41%) had neurological conditions, with an associated ‘malnutrition’ prevalence of 41%, and 9% of residents were classified as frail elderly with an associated ‘malnutrition’ prevalence of 44%. The highest prevalence (67%) was found in residents with gastrointestinal disease although these accounted for only 3% of residents (n = 15) in the survey. Six percent of residents were reported to have cancer, which was associated with a higher prevalence of ‘malnutrition’ than in those without cancer (55% v 40%).

2.2.7. Almost all care homes (99%) reported that they had a policy to screen and weigh residents on admission. In this survey, a higher proportion of care homes (90%) recorded the height of residents on admission than in the 2010 (82%), 2008 (65%) and 2007 (71%) surveys. Ninety-nine percent of care homes said they regularly weighed residents during their stay. Nevertheless, whilst 69% residents were admitted to care homes where it was stated that the scales had been calibrated within the last 12 months, 14% were in care homes where the reporter did not know if the scales had been recently calibrated and 18% in care homes where the scales had either not been calibrated or the reporter did not answer the question.

2.2.8. There was a small increase in the proportion (73%) of care homes that audited the practice of nutritional screening compared to the 3 previous surveys when around two thirds of care homes audited screening practice. Most care homes undertook audit at least every year.

2.2.9. Only just over half of reporters were aware of standards relating to weighing scales and some of them were able to specify those issued by the Department of Health (1) or the European Commission (2). Most respondents, however, were aware that scales should be regularly calibrated.

2.2.10. Almost all care homes reported using a nutrition screening tool and in those that did, ‘MUST’ was used in 92% of centres. Lectures / workshops were the most commonly used format for training staff on nutritional screening. 7% of care homes reported receiving no training for staff on nutritional screening.

2.3. Mental Health Units
2.3.1. Of 543 adults screened on admission, 19% were ‘malnourished’ (10% high risk, 9% medium risk). There was no significant difference in prevalence between acute units (16%), long-stay units (19%) and combined acute and long stay units (21%). This survey adds confidence in the results obtained in previous surveys because more than 3 times as many units took part in 2011 compared to previous surveys but the overall prevalence of malnutrition (19%) was very similar to that reported in the 2010 survey (18%), 2008 survey (20%) and the 2007 survey (19%).

2.3.2. Unlike the hospital and care home settings, there were more men than women included in the survey but the women were older (mean age women 60 years, mean age men 53 years) and more at risk of ‘malnutrition’ than the men (24% v 14%).

2.3.3. The mean age of subjects was higher than in the 2010 survey but lower than in the 2008 and 2007 surveys (56 years v 50 years v 66 years v 59 years respectively). Subjects aged 65 years and over (40%) had a greater prevalence of ‘malnutrition’ (24%) than those less than 65 years (15%).

2.3.4. The mean BMI was 26.4kg/m2 which was similar to that in 2010, 2008 and 2007. A low BMI (<20kg/m2) was present in 12% of patients (6% with a BMI < 18.5kg/m2). 21% had a BMI >30kg/m2. A low BMI (<20kg/m2) contributed to the ‘MUST’ category (medium + high) in about 67% ‘malnourished’ subjects.

2.3.5. About 8 out of 10 units that participated in the 2011 survey reported that they had a screening policy and just under two thirds of patients were reported from units with a screening policy. Over 90% of units audited their screening practice, mainly every year. Almost 40% of units had access to a nutrition support team which is higher than the 2010 survey but almost all units had access to nutrition and dietetic services.

2.3.6. Almost all units said their policy was to weigh patients on admission and regularly throughout their stay. Eighty-four percent of units reported having a policy to record patients’ heights on admission. Nevertheless, whilst 67% patients were admitted to wards where it was stated that the scales had been calibrated within the last 12 months, 23% were on wards where the reporter did not know if the scales had been recently calibrated and 10% on wards where the scales had not been calibrated or the reporter did not answer the question.

2.3.7. About half of units said they were aware of standards relating to weighing scales and 42% of these specified those issued by the Department of Health (1) or by the European Commission (2). Most respondents were aware that scales should be regularly calibrated.

2.3.8. 65 out of the 67 units reported using a nutrition screening tool and of these ‘MUST’ was used in 75%. Local tools were used in 23% of centres that used a screening tool. Lectures / workshops either alone or in combination with other forms of training were the most commonly used format for training staff on nutritional screening. 10% units reported receiving no training on nutritional screening.

2.3.9. Almost all units linked the results of screening to a care plan and more than three quarters of them said they ‘always’ or ‘usually’ included nutrition information on all patients identified as being ‘malnourished’ in discharge communications which was higher than in the 2010 and 2008 surveys.

2.4. A comparison across care settings
2.4.1. The prevalence of ‘malnutrition’ on admission to hospitals in this fourth survey was lower than that found in 2010, 2008 and 2007 (25% v 34% v 28% v 28%) but the prevalence on admission to care homes was higher than in 2010 and 2007 but similar to 2008 (41% v 37% v 30% v 42% respectively). The prevalence of ‘malnutrition’ on admission to mental health units was lower than in those admitted to other care settings but very similar to those found in the mental health units of 2010, 2008 and 2007 (19% v 18% v 20% v 19% respectively).

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

2.4.3. The prevalence of ‘malnutrition’ amongst subjects admitted to hospitals, care homes or mental health units varied according to source of admission. In hospitals ‘malnutrition’ was lower in those that came from their own homes than from institutions (other wards, hospitals and care homes). This was not the case in care homes where ‘malnutrition’ was the same in those subjects admitted from home or hospitals but lower than those admitted from other care homes.

2.4.4. In hospitals and care homes women outnumbered men (ratio 1.15:1 in hospitals and 1.8:1 in care homes). In mental health units, men outnumbered women (1.18:1). In all care settings women were older and had a greater prevalence of ‘malnutrition’ than men.

2.4.5. BMI contributed to over 45% subjects categorised as ‘malnourished’ (medium + high risk) in acute hospitals, 65% subjects in community hospitals, 71% subjects in combined acute /community centres, 67% in mental health units, and 77% in care homes. Underweight (BMI <20kg/m2) was most common in care homes, affecting 32% of residents. The mean BMI in care homes (23.2kg/m2) was significantly lower (p <0.001) than in hospitals (26.7kg/m2) and mental health units (26.4kg/m2). In care homes underweight was more common than obesity (BMI >30kg/m2), in mental health units and in hospitals obesity was more common than underweight.

2.4.6. Almost all hospitals and care homes said they had a nutrition screening policy although this was the case in only about 8 out of 10 mental health units. Awareness of standards for weighing scales used in healthcare settings varied and only some of the centres that took part in the survey specified those issued by the Department of Health (1) or the European Commission (2). However, most respondents who said they were aware of standards knew that scales should be regularly calibrated.

2.4.7. Screening tools were used in almost all hospitals, care homes and mental health units. ‘MUST’ was the most commonly used tool in all care settings and lectures / workshops was the most usual form of training on nutritional screening. In all settings some centres reported that no training on nutritional screening had been provided. The practice of auditing nutritional screening varied across care settings. It was most likely to happen in hospitals and mental health units and least likely to happen in care homes.

2.4.8. Almost all centres in all care settings said they had care plans for the management of malnourished patients. However, about three quarters of the hospitals and mental health units reported that they always or usually included nutritional information in discharge communications.

3. Republic of Ireland Survey

3.1. Hospitals
3.1.1. Of 1102 patients who were screened on admission to hospital, 27% were found to be at risk of malnutrition (20% high risk, 7% medium risk), a lower overall prevalence to that found in the 2010 survey.

3.1.2. ‘Malnutrition’ varied significantly according to source of admission (27% of patients admitted from home, 23% of those from another hospital, 13% from another ward, and 42% from a care home), type of admission (31% for emergency admissions, 18% for elective admissions), and type of ward (e.g. 41% in care of the elderly wards and
8% in orthopaedic/trauma wards). 90% of patients were admitted from their own homes, suggesting that the risk of malnutrition largely originated in the community. Strategies to prevent, identify and treat malnutrition in the community setting should therefore be considered.

3.1.3. ‘Malnutrition’ was common in all age groups and diagnostic categories. Risk increased with age and was higher in women who were significantly older than men (30% v 24%). The prevalence varied according to diagnostic category (e.g. gastrointestinal disease (45%), respiratory disease (30%) and neurological disease (22%) versus cardiovascular disease (16%) and musculoskeletal conditions (16%)).

3.1.4. 13% of patients included in the survey were reported to have cancer. ‘Malnutrition’ was significantly higher in those patients with cancer than in those without (34% v 26%).

3.1.5. A low body mass index (BMI <kg/m2) contributed to a ‘MUST’ category (medium + high) in 28% of ‘malnourished’ patients.

3.1.6. Policies and practice regarding nutritional care varied. Just under a third of hospitals reported having a nutrition steering committee and just over a quarter had a nutritional screening policy. All hospitals in the survey had access to nutrition and dietetic services and also access to a nutrition support team.

3.1.7. Only 3 hospitals stated that patients were routinely weighed on admission to all wards and on some wards in a further 20 hospitals. However, 6 out of 10 hospitals were aware of standards in relation to weighing scales and some of them were able to specify European standards (2). Most respondents were aware that scales should be regularly calibrated. Nevertheless, whilst most patients (78%) were admitted to wards where the scales had been calibrated in the past 12 months, 13% were admitted to wards where the reporter did not know if scales had been recently calibrated and 9% to wards where the scales had not been calibrated or the reporter did not answer the question.

3.1.8. Just over 6 out of 10 hospitals reported using a nutrition screening tool and in centres where this was the case, ‘MUST’ was used in 88%. Lectures / workshops were the most commonly used format for training staff on nutritional screening. However, only around a third of hospitals audited their practice of nutritional screening although the majority did not report the frequency of audit.

3.1.9. The results of nutritional screening were linked to a care plan in about two thirds of hospitals in the survey. Nutrition information on those patients identified as ‘malnourished’ was not always included in discharge communications. Only 12% of the hospitals reported that they always or usually included this information, 85% said they sometimes included it and 4% never included it. This suggests that ‘malnutrition’ may be under-recognised and under-treated following discharge from hospital.

3.2. Care Homes
3.2.1. Only 6 care homes took part in the 2011 survey providing data on 29 residents (20 women and 9 men) with a ‘MUST’ score . All 6 care homes participated in the 2010 survey,. Of the 29 residents recently admitted and screened 21% were ‘malnourished’ (14% high risk, 7% medium risk) which was lower than in 2010 when 32% residents were at risk of ‘malnutrition’. Whilst the information is useful it is limited by sample size and it is difficult to draw firm or general conclusions from this survey.

3.2.2. Four of the 29 residents were in exclusively nursing homes, none were in residential homes and the remainder were in homes providing a range of care facilities. Residents in exclusively nursing homes were at higher risk than in those in other types of homes (25% v 20%).

3.2.3. Almost half the residents were admitted from their own homes but the prevalence of ‘malnutrition’ was greater in residents admitted from other care homes (33%) than those admitted from home (21%) or from hospitals (17%).

3.2.4. The mean BMI was 25.5kg/m2. Four residents had a BMI of <20kg/m2, all with a BMI of <18.5kg/m2. Seven residents were obese. A low BMI (<20kg/m2) contributed to the ‘MUST’ category (medium + high) in about two thirds of ‘malnourished’ residents.

3.2.5. The mean age of the residents was 83.5 years and the women were older than the men. The prevalence of ‘malnutrition’ tended to increase with age. Over half the 29 residents were aged 85 years and over. There was no significant difference in risk of ‘malnutrition’ between men and women.

3.2.6. Over half the residents had neurological conditions, with an associated ‘malnutrition’ prevalence of 25%. The highest prevalence (50%) was found in residents with cardiovascular disease or musculoskeletal conditions although these accounted for only 7% of residents, respectively. 2 residents were reported to have cancer but were not identified as at risk of ‘malnutrition’.

3.2.7. Most care homes (94%) reported that they had a screening policy and all reported that they had a policy to weigh residents on admission and regularly throughout their stay. Five of the 6 care homes had a policy to record the height of residents on admission.

3.2.8. Only 1 care home was aware of standards in relation to weighing scales but it did not specify which standards applied or that scales should be regularly calibrated. Only 8% residents were admitted to care homes where the scales had been calibrated in the past 12 months, 60% to care homes where they had not and 32% to homes where the reporter did not know if the scales had been recently calibrated.

3.2.9. All 6 care homes reported using a nutrition screening tool; ‘MUST’ was used in 5 of them and the Malnutrition Screening Tool (MST) was used in the other. Lectures / workshops were the most commonly used format for training staff on nutritional screening. Two care homes audited their practice of nutritional screening, undertaking an audit every year.

4. Recommendations
4.1. Patients or residents admitted to all institutional care settings should be screened using a validated screening tool such as ‘MUST’, and repeat measurements made at intervals according to care setting, using accurate and reliable instruments (see ‘MUST’ report).

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

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

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

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

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

4.7. The practice of nutritional screening should be audited regularly.

4.8. 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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