Implementing the Paediatric Yorkhill Malnutrition Score Tool as a CQUIN Target

Hazel Rollins CBE

Team Leaders

  • Hazel Rollins CBE, Clinical Nurse Specialist, Gastroenterology and Nutrition, Luton and Dunstable Hospital
  • Naomi Riley, Advanced Specialist Paediatric Dietitian, SEPT community Health Services

Team Members

  • Hazel Rollins, Clinical Nurse Specialist, Gastroenterology and Nutrition
  • Naomi Riley, Advanced Specialist Paediatric Dietitian
  • Marva Desir, Matron, Paediatrics
  • Luci Kilby, Ward Sister
  • Louise Kaptanoglu, Ward Sister
  • Eileen Forbes, Nurse Practitioner, Paediatric Assessment Unit
  • Sandra Donaldson, Sister, Paediatric Assessment Unit
  • Melanie Collins, Paediatric Practice Development Nurse

The team could not have done this without great support from the Consultant Paediatricians, especially Dr Nisha Nathwani, Dr Meena Ashworth and Dr Anita Modi. We were also supported by Elaine Hide, Director of Quality and Tanith Ellis, General Manager, Paediatrics.

What was the problem you were trying to address?

While the concept of adult nutrition screening is widely accepted using the MUST tool for example, routine use of a validated paediatric nutrition screening tool has lagged behind. Nevertheless it is clear that malnutrition exists in the paediatric population, and may be missed during a hospital stay. Our commissioners required us to select and implement a paediatric nutrition screening tool as a CQUIN target for 2011. We therefore set out to select, implement and evaluate a validated paediatric nutrition screening tool within one year from April 2011 to March 2012. We were required to achieve 95% compliance with nutrition screening in order to meet the CQUIN target.

How did you create your project plan?

We had been inspired to use the PYMS tool after hearing presentations on the paediatric BAPEN day in 2010.  Meetings were held to ensure all the following staff groups were included in the implementation and evaluation:

  • Matron, senior nurses, ward sisters and nutrition link nurses
  • Paediatric dietitians
  • Paediatric medical staff
  • General Manager
  • Director of Quality

The team leads met fortnightly to keep the project moving. Members of the project team met on an ad hoc basis to discuss progress and drive further actions. Action plans were developed, jobs were assigned to individuals and deadlines were set and checked regularly.

The project would not have been a success without support from Diana Flynn and the PYMS team at The Royal Hospital for Sick Children, Glasgow.

Key Actions

  • Monitor in-patients prior to implementation to determine quality of nutrition related information taken at admission – quarter 1.
  • Evaluate paediatric nutrition screening tools available and select tool to use – quarter 1
  • Provide additional equipment (Paediatric BMI wheels, scales, stadiometers, disposable tape measures in a range of sizes) – quarter 2 and 3
  • Set up weighing stations at appropriate points on the unit
  • Work with our Health Records Team to introduce the PYMS tool locally – quarter 2 and 3
  • Work with IT department to include PYMS score on electronic dietetic referral for eligible children over 1 year
  • Set up a teaching board on the Woodlands Children’s Unit to support implementation – quarter 2 and 3
  • Run ward-based group and one to one training using PYMS and local case histories to support learning – quarter 2 to 4
  • Amend staff handover sheet to prompt discussion of PYMS score – quarter 3
  • Amend Paediatric Electronic Discharge Letters to include screening information – quarter 3
  • Go live – quarter 4
  • Add PYMS training to Paediatric Clinical Nutrition Study, staff induction and  annual Trust statutory training days held throughout the year – ongoing
  • Monitor outcomes – monthly as part of ward clinical indicators and by spot checks – ongoing

Main Outcomes

  • Improved patient screening (achieved 80% compliance by 31st March 2012. Mostly 100% compliance at spot checks and monthly audit thereafter)
  • Appropriate dietetic referrals containing PYMS score
  • Widespread use of BMI in paediatrics for the first time

How are you going to maintain the improvement?

In the days of competing priorities for finance, we are thrilled that nutrition screening in paediatrics was mandated as part of commissioning, with financial penalties for failure to achieve targets. Our Senior Sisters will continue to audit PYMS scores as part of their clinical indicators and will report compliance at a senior level. Training will continue on an ongoing basis.

Tips for others planning similar projects

  • Identify all your stakeholders
  • Engage senior management
  • Be realistic about the amount of time it will take
  • Lobby hard for sufficient resources
  • Develop a robust action plan
  • Keep checking to ensure you don’t slip

Top Quotes

“oh it’s easy” –  staff nurse – Rabbit Ward

“about time too – I’m fed up of hearing about the adult tool and not having one to use” – Sister – Squirrel Ward

“these new scales are brilliant – I can do the BMI now” – Sister – Rabbit Ward

“Hazel this PYMS tool is amazing – I would have completely missed malnutrition in this patient but his score is 5 – we’ve already referred him to the dietitian” – HCA – Paediatric Assessment Unit