Use of the 'MUST' to Improve Nutrition and Dehydration among the Elderly in the NHS
The World Health Organisation (WHO) defines malnutrition as a "cellular imbalance between supplies of nutrients and energy and the body’s demand for them to ensure growth, maintenance and specific functions." (WHO, 2000). According to NICE, malnutrition is “a state in which a deficiency of nutrients such as energy, protein, vitamins, and minerals causes measurable adverse effects on body composition, function (including social and psychological) and clinical outcome.” (NICE, 2012). On the other hand, dehydration is defined as: “a state in which a relative deficiency of fluid causes adverse effects on function and clinical outcome” (NHS England 2015, p. 11). Dehydration among the elderly is associated with limited intake of fluid and is usually manifested in elevated osmolality.
The adverse outcomes related to malnutrition and dehydration add to the overall health-care cost of the NHS (National Health Service). For example, a 2005 estimate by the BAPEN (British Association for Parenteral and Enteral Nutrition) indicates that the NHS Incurred an annual cost of £7.3 billion due to malnutrition, which is twice the cost it incurs owing to obesity-related complications (Russell & Elia, 2009).
Guidelines by NICE recommend that all patients admitted to hospitals ought to be subjected to nutritional screening up admission, with the procedure being repeated weekly (NICE, 2008). NICE guidelines further recommend that patient determined to be malnourished, as evidenced by a BMI of ≤18.5 to receive nutritional support, or if the health care team establishes that the patient has lost over 10% of their body weight over the past 3-6 months (Tewari et al., 2013). Going by the NICE guidance, nutrition support ought to be given through the coordinated effort of multidisciplinary teams made up of dieticians, nurses, doctors, nutritional nurses, pharmacists, and other health professionals (NICE, 2008). However, recent surveys indicated that only 80% of the hospitals in the UK had implemented nutrition policies and screening tools (Tewari et al., 2013).
There are various techniques in place to assist the healthcare professional with screening for malnutrition. Some of these techniques include measurements like the mid-arm circumference and dietetic assessments like BMI. We also have various screening tools like NRS (Nutrition Risk Screening), MNA-SF (Main Nutritional Assessment Short Form), and MUST (Malnutrition Universal Screening Tool) (Raslan et al., 2010). MUST entails five crucial steps of screening, developed to aid health care professionals to identify adults who are obese or malnourished, and hence at risk of malnutrition, or those who are already malnourished. MUST also encompass various useful management guidelines the health care team can utilise to develop a patient's care plan. The objective of this study was to implement the use of the 'MUST' in a nursing home. Tewari et al. (2013) estimate the prevalence of malnutrition among patients admitted to hospitals at 40%. Accordingly, the goal was to enable the staff at nursing homes for the elderly to detect the problem through screening and in this way, improve the overall health and well-being of the patients. Review of relevant literature was accompanied by using the google scholar search engine. The BOOLAN operators 'AND' and 'OR' were used with such terms as 'malnutrition', 'nutrition', 'dehydration', 'hydration', 'prevalence of malnutrition', 'dehydration AND malnutrition', and 'dehydration AND malnutrition among the elderly'. The purpose of adopting such a search strategy was with aimed at examining the extent to which the problem of malnutrition and dehydration affects adults, especially the elderly. This is important because the elderly especially those in nursing home residents are most vulnerable to malnutrition and dehydration. For example, Lecko (2013) reports that between 50 and 92 percent of patients receiving care under nursing homes do not have access to sufficient fluid intakes. In addition, the same report shows that 31 percent of the patients who had been admitted at nursing homes were malnourished, while those admitted for between two and six months had a 42 percent prevalence of malnutrition (Lecko 2013).
Scale of the problem
According to Lecko (2013) the scale of the problem caused by hydration and malnutrition across the healthcare sector in the UK remains unknown. This, even as the National Patient Safety Agency, along with several other lobbying groups and professional associations have done a lot of work in their quest to raise awareness among policy makers, healthcare staff and service providers of the impact and costs linked to dehydration and malnutrition. Hydration and nutrition issues affecting patients across the healthcare sector remain largely under-reported, while the various toolkits, campaigns, and guidance have done little to ensure that the most vulnerable individual, especially the elderly, realise reliable and sustainable improvements in hydration and nutrition delivery and provision.
NHS England (2015) has identified malnutrition as a leading cause of ill-health across the UK, with over three million individuals being affected by it at any given time (Allied Health Professionals, 2012). Estimates by NHS England reveal that about a third (1 out of 3) of patients receiving care and treatment in acute health settings are either at risk of being malnourished or are already malnourished (NICE, 2012). The report further reveals that about 35 percents of individuals admitted to care homes are also at risk of being affected.
The greatest burden of the problem is in the community setting where 93 recent individuals suffering from malnutrition or at risk of being malnourished are to be found (Wise 2015). While we are yet to fully get acquainted with the scale of dehydration across the UK, what is not in doubt are the various causes of harm linked to malnutrition (NHS England 2015). Malnutrition among young people and children is often linked to poor food choices and poverty (NHS England, 2015). Dehydration is also not unusual among these people but the total number of the individual at risk or those affected is far from clear. Elia and Stratton (2009) have estimated the cost for diseases linked to malnutrition in terms of social and health care expenditure or amount to over £13 billion. This is a clear indication of the importance of recognising and treating dehydration and malnutrition problems. In addition, identifying and treating malnutrition and dehydration ids in the minimisation of pharmaceutical waste, thereby leading to better utilisation of scarce health resources.
Age UK (2010) recognises dehydration and malnutrition as commons health problems that all too often are not recognised and hence the patients usually go untreated. A report by the European Nutrition for Health Alliance et al (2006) showed that over 10 percent of the individuals 65 years of age and above are usually malnourished while in the UK, nearly 70 percent of undernutrition is rarely recognised. According to Malnutrition Pathway (2012) between 2005 and 2009, dehydration and malnutrition were recognised as the contributing factors and underlying causes of deaths in over 650 care home residents across the UK.
Impact of malnutrition and dehydration on health
Dehydration and malnutrition are associated with significant adverse effects on a person’s health and well-being, thereby resulting in an escalation of diseases in the residential care, community, as well as hospital setting (NHS England 2014). Nevertheless, in spite of good evidence to the effect that specific efforts directed at remedying the problems lead to improved health outcomes, both dehydration and malnutrition usually go undetected. This, therefore, implies that the conditions are likely to also go untreated.
According to Elia et al. (2009), mortality rates among malnutrition and dehydration patients admitted to hospitals tend to be quite high, while failed discharges are also not uncommon. Statistics released by the Office for National Statistics (ONS) show that in 2011 alone, some 150 patients in hospital wards across wards England and Wales died as a result of either dehydration or malnutrition. Of these deaths, 43 were attributed to malnutrition, while 111 were a result of dehydration. The ONS figures further revealed that some 291 people had malnutrition identified as the cause of death on their death certificate while another 669 people had dehydration recorded on their death certificate. This could be a clear indication that deaths due to dehydration and malnutrition are not just restricted to the primary care setting. Moreover, the ONS figures revealed that some eight people were starved to death while receiving care in different care homes, with a further twenty-one succumbing as a result of dehydration. Again, this acts as a sign that even in care homes, patients are at risk of developing complications induced by dehydration and malnutrition.
Both dehydration and malnutrition have also been associated with a significant effect on the overall health economy (NHS England, 2015), resulting in increased demands on out of hours services, General Practice services, not to mention that they also lead to a rise in rates of patient transition across various pathways of care (NHS England, 2015). Patients admitted to the hospital with dehydration or malnutrition are likely to remain there for three days longer than is necessary, on average. NICE has revealed that complications associated with malnutrition and dehydration, along with the length of stay in hospital could be drastically reduced through better nutritional care for the patients (NICE, 2012). NICE cost-saving calculations further reveal that subjecting malnourished and dehydrated patients to better nutritional care would go a long way in helping the NHS make significant savings in its net costs (NICE, 2011).
Furthermore, evidence from Carers UK (2012) shows that there are other extra benefits to be had by providing care to malnourished and dehydrated patients namely, reduced caring activities. This in turn leads to an economic impact but more importantly, it aids in the realisation of improved quality of life. Accordingly, commissioners should see to it that the social and health care organisations that they oversee prevent the occurrence of dehydration and malnutrition; recognises malnutrition incidents as and when they occur by means of screening patients using active nutritional screening methods (for example, the 'MUST' (Malnutrition Universal Screening Tool) in case of adults); rely on care pathways that comply with NICE guidelines while treating individuals at risk of dehydration or malnutrition (for example, guidelines on oral nutritional supplements, utilisation of drinks and food, et cetera); educate staffs, carers, patients, voluntary workers and patients on the value of hydration and good nutrition as a crucial step towards restoring wellbeing and better health, improving patient recovery from injury or illness, as well as in aiding in the proper management of long-term health conditions. Commissioners must also consider the duties bestowed upon them under the 2010 Equality Act that relates to ensuring health inequalities have been reduced, as well as the duties identified by the 2012 Health and Social Care Act. Moreover, commissioners must always ensure that the communication and service design is accessible and suitable for fulfilling the needs of diverse individuals within the community (NHS England, 2014).
Human costs of malnutrition and dehydration
In terms of human costs, dehydration and malnutrition have been reported to greatly escalate a person’s vulnerability to illness. In addition, there is also a higher risk of developing clinical complications and ultimately, death (BAPEN 2012). The Royal College of Nursing (2017) reports that dehydration is a key risk factor for the increased cases of falls amongst elderly people, and is often linked to faecal impaction, pressure ulcers, as well as cognitive impairment. Malnutrition is further associated with clinical consequences and effects. For example, a malnourished individual is at a greater risk of developing impaired immune responses and this could further weaken the ability of such an individual to fight illness and infections. Moreover, malnutrition leads to fatigue and reduced muscle strength. This is likely to hinder an individual's ability for self-care and could lead to falls. Malnourished in-bed patients are especially at a greater risk because malnourishment could lead to blood clots and pressure ulcers.
Malnutrition Taskforce (2013) recognises malnutrition as a leading cause and source of poor health, with older people being the most vulnerable. Estimates show that nearly 1 million people in the UK aged 65 years and over are either at risk of malnutrition or are already malnourished (Malnutrition Taskforce, 2013). Not only does malnutrition leads to harrowing human cost for the individuals affected themselves, but it has also been shown to affect their carers as well. Malnutrition and dehydration among older people in care homes occur because carers leave water and food out of reach of the patients and because of their limited mobility, it means that they cannot reach it. The elderly also lacks the support needed to drink and eat. Not getting supplements also contributes to malnutrition and dehydration.
Malnutrition Pathway (2014) reports that disease-related malnutrition accounts for over £13 billion in the annual costs incurred by the NHS. This cost is computed going by the malnutrition figures as well as the associated social and health care. If only the NHS can realise a one percent annual savings on health and social care costs associated with malnutrition, this would translate into an annual saving of £130 million (Malnutrition Pathway 2012).
In its 2012 report, Carers UK provides findings of a study that sought to examine the experiences of over 2,000 carers in attending to patients with malnutrition. The report identifies malnutrition as a hidden issue. The report further notes that because malnutrition is not always so obvious and most carers are not well acquainted with malnutrition, there is the likelihood that carers may not know where to go for help. Moreover, carers are likely to feel guilty and isolated that the patients under their care are at risk of becoming malnourished. According to NHS England (2014), it is important to raise knowledge and awareness among carers and staff in order to ensure that they have the necessary competencies and skills that were required to meet the healthcare needs of the population. Moreover, there is a need to highlight specific risks from malnutrition or dehydration at transition or discharge (NHS England 2015). It is also important to raise awareness amongst patients, the public, carers, and service users, of the likely task of dehydration and malnutrition, along with the strategies available to re-address or prevent these (NHS England, 2014).
State of services
According to Malnutrition Pathway (2014), screening patients to detect dehydration and malnutrition, coupled with planning for effective hydration and nutrition are mandatory in all care settings. In addition, there is a need to ensure that patients have access to quality beverage and food services and that they also have easy access to suitable nutritional support, on a need basis (European Nutrition for Health Alliance et al., 2006). According to Malnutrition Pathway (2014), this also encompasses considerations around oral nutrition and enteral and parenteral feeding. However, evidence collected by Age UK (2010) reveals that these considerations are rarely taken into account. There are also growing concerns regarding screening, monitoring, and assessment processes to which patients are subjected when parenteral nutrition is being administered, in order to ensure safety and effectiveness (Malnutrition Pathway, 2014).
The MUST (Malnutrition Universal Screening Tool) was developed by BAPEN in order to assist health care providers in identifying underweight adults who face a higher risk of malnutrition. In addition, the MUST aids in the identification of obese adults. Since the MUST was launched in 2003, it has been reviewed on several occasions to assess its effectiveness. Various non-governmental and governmental organisations such as the RCN (Royal College of Nursing), the BDA (British Dietetic Association), as well as the RNHA (Registered Nursing Home Association) support the MUST. Consequently, the MUST has emerged as the most widely used screening tool for obese and underweight adults in the UK. The MUST has also been shown to aid healthcare professionals in their execution of new Quality standards developed by NICE.
A 2009 BAPEN report delineates the use of the MUST to identify adults living in sheltered housing who were at risk of malnutrition. Using this tool, the study identified 24% of the adults who were screened as being obese, while another 14% were identified as 'malnourished' (Elia & Russell, 2009). The findings of this research reveal that healthcare providers can rely on nutritional screening to identify adults at risk of malnutrition. This goes a long way in enabling healthcare providers to take appropriate action. Elsewhere, findings of a study conducted by Walsall Healthcare NHS Trust (2011) show that in the absence of ongoing resident screening using MUST be coupled with staff training on the use of the same, levels of malnutrition among patients would have remained unrecognised, and hence patients would not have received the treatment and care that they deserve. In this case, the MUST aids in the identification of malnourished patients, thereby enabling health care staff to implement appropriate treatment. Consentingly, this facilitates the reduction of the overall health care costs.
According to the 2009 BAPEN report, the MUST has undergone extensive evaluation in outpatient clinics, hospital wards, care homes, general practice, as well as in the community. The MUST enables healthcare professionals to group patients at risk of malnutrition in a reproducible, easy, rapid, and internally consistent manner. The MUST can also be applied to the patient in whom health care professionals find it hard to obtain weight and height measurements, which are key requirements for computing BMI (Body Mass Index). The BMI parameter helps to determine under-nutrition or over-nutrition.
The MUST encompasses 5 simple screening steps that an individual goes through in an attempt to identify if they are underweight, and hence at increased risk of malnutrition. The MUST is widely recognised as a suitable tool for early nutritional intervention, thereby improving health care outcomes. This helps to minimise GP visits owing to malnutrition-linked complications and possible hospital admissions (BAPEN, 2009). Moreover, this tool helps to inform clinicians' individual professional judgement.
Change Management model
Service improvement constitutes a key aspect of the NHS. Through service improvement, patients within the NHS can experience improved quality of care and service delivery (Maher & Penny 2005) Change must be implemented in a calculated, purposeful, and collaborative manner. This is necessary if all the desired improvements are to be realised (Roussel, 2006). Nurses are required to ensure that they deliver care on the basis of best practice or best available evidence (Nursing and Midwifery Council, 2008). This is indicative of an ongoing need to keep abreast of or institute necessary changes, to the nursing practice.
Nonetheless, executing change is not as simple as one is bound to imagine. This is because there are numerous challenges that face change agents in their quest to implement the desired change. According to Szaba (2007), two out of three organisational change projects do not see the light of day. The need to institute change in the health care sector is informed by a number of factors, such as workforce shortages, increasing health care costs, advances in science and technology, professional obligations, including codes of conduct and clinical governance, the possibility to enhance patient satisfaction, an aging population, and the need to advance staff and patient safety (Nursing and Midwifery Council, 2008). In this case, implementing the MUST at the care home is informed by the need to make early diagnoses of elderly patients at risk of malnutrition. This will not only ensure that they receive timely treatment and care, but it will also reduce escalating healthcare costs incurred by the NHS and more importantly, save potential lives that could be lost if malnutrition goes undetected.
However, implementation of desired change is likely to be faced with certain restraining forces like under-motivated staff, inappropriate leadership; poor development action plans, and ineffective communication (O'Neal & Manley, 2007). According to Price (2008) nurses feel obliged to implement change in their practice as a means of complying with the existing nursing policies and professional guidelines. Whereas change is necessary in order to make progress, nursing literature is awash with various complexities linked to actualising proposed plans, while endeavours to institute change often fail since change agents assume an unstructured approach in their quest to execute change. There is a need therefore for change agents or managers to identify a suitable change model or theory that will afford them an ideal framework to execute, manage and assess chance (Pearson et al., 2005). One of the change models that have found wide application in the health care sector is Lewin's change model. This model consists of three crucial stages that are necessary in order for change to become successful: unfreezing; moving, and refreezing.
New behaviours and procedures seek to de-stabilise the status quo, creating a disequilibrium that forms the basis for resistance to the proposed change. In implementing the MUST tool at the nursing, the staffs are likely to resist this new tool despite its numerous benefits. This is because it represents a break from their normal practices. To overcome or reduce such resistance, it is important that the change agent reinforce the practice by identifying staff that will help to champion the change (Roussel, 2006). This could be the nurse in-charge of the nursing home or key stakeholders such as the directors of the care home.
During this stage, the organisation permits a trial-and-error period during which the new social norms and practices that identify the proposed change act as a guide to the people. As the individuals develop favourable attitudes towards the practices, resistance declines (Pearson et al., 2005). During this period, the process will be assessed at various levels to assess areas of improvement and to enable the staff to become acquainted with the tool.
The new practice will by now have changed the organisational setting, compelling it to embrace the new practice socially and procedurally. By now, the new practice can be sustained by adding reinforcements to the new procedures. Otherwise, there is the risk of reverting to the status quo (Roussel, 2006). Once again, the clinical champions who were instrumental in the unfreezing stage will once again prove essential. At this point, it may be necessary to train the staff on how to utilise the new tool. This will necessitate the allocation of resources such as staff and funds to facilitate the booster sessions.
Barriers to implementation
The success of a service improvement begins with a clear understanding of the forms of barriers that one is likely to encounter. Evidence reveals that health care professionals are often unfamiliar with or even unaware of the need for change in their current practices, while others view change as an undermining component of their autonomy (NICE, 2007). These barriers could be faced while implementing the proposed change. The service improvement demands that the staff at the nursing home acquire new skills on how to use the tool, and this is yet another source of the barrier. To alleviate these barriers, it is important to create awareness through holding informative meetings on the benefits of using the MUST to screen patients and the ensuing benefits. Training staff on how to use the tool will also help to reduce resistance to change. Including staff in the planning process will also help to reduce the initial resistance. Since this proposed intervention calls for financial and human resources, there could be resistance from the senior management at the nursing home. However, this resistance can be reduced by enumerating the benefits of the service improvement, such as improved health outcomes, savings on the NHS and satisfied staff.
Almost 70% of the NHS improvement projects fail due to poor sustainability (NHSIII (2012). to ensure project continuity, patient safety, staff satisfaction, and positive outcomes, it will be necessary to institute control measuring a sustainability tool (Langley et al., 2009). In this case, a MEWS audit will be conducted once a month not just as a means of ensuring the sustainability of the improvement project, but also in keeping with NICE guidelines.
Malnutrition and dehydration are well documented in the NHS. The elderly, especially those admitted to hospitals or nursing homes are especially vulnerable to malnutrition due to their reduced mobility and hence the inability to reach food. The NICE guidelines demand that hospitals screen patients under their care for malnutrition and provide nutritional resistance to correct this problem. While there are various tools that have been developing to assist with the screening of malnutrition, only 80% of hospitals in the UK have been shown to use these. This project endeavoured to implement the use of the MUST at a nursing home setting caring for elderly patients to assist with the screening of patients who are obese and hence at risk or those who are already malnourished. The project relies on Lewin's model of change to aid in implementing this tool. Awareness creation will help to minimises resistance to change, while the use of the MEWS audit will help to ensure its sustainability.
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