Interprofessional Learning Unit 3

Group Number: 69

Confidentiality has been respected throughout this work and no names of people or places have

been included

This report is entirely our own work

Group 69. confirm that we fully understand that this report remains the property of the host

organisation and we may not personally/professionally share or use any part of it, without the

express permission of the host organisation. We appreciate that no member should retain

copies subsequent to successful completion of IPLU2/IPLU3 and if we wish to evidence our

success we know we may use/refer to the Group Project Assessment Report.

Word Count: 2918

Page 1

Contents 1 Business Case Summary Page 2 2 Introduction Page 4 2.1 Why was the project commissioned? Page 4 2.2 National and local nutrition policy Page 4 2.3 Project objectives Page 6 2.4 The current situation: audit results and questionnaire Page 8 3 Options for service improvement Page 9 3.1 MUST policy Page 9 3.2 Training Page 9 3.3 Nutrition Link Nurse Page 10 3.4 IT Page 11 4 Recommendations Page 12 5 Conclusions Page 14 6 References Page 15 7 Appendices Appendix A Page 18 Appendix B Page 19 Appendix C Page 20 Appendix D Page 21 Appendix E Page 22 Appendix F Page 23

Page 2

1 Business Case Summary

See relevant section of report indicated in left margin for further details.

2 Introduction

This business case was commissioned to provide recommendations aimed at

improving compliance in using the Malnutrition Universal Screening Tool (MUST)

within a Critical Care Unit (CCU) in a hospital in the South of England.

2.1 Malnutrition is associated with adverse clinical outcomes and is estimated to cost the

UK £13 billion annually.1

Providing good quality nutritional care is a multi-disciplinary responsibility.2, 3

2.2 National Institute for Health and Clinical Excellence (NICE) guidelines recommend

nutrition screening on admission to hospital and at regular intervals for inpatients as a

key clinical priority.2 The guidelines identify MUST as an appropriate screening tool.2

Failure to comply with MUST screening is associated with negative financial

implications for the Trust.4

2.3 Within the project setting, an audit on MUST compliance was carried out and a staff

questionnaire was distributed. Further information was gained through engagement

with key stakeholders and a review of relevant literature.

2.4 Audit data revealed that although compliance with the MUST tool met the national

standard, compliance within the project setting for completing MUST scores on a daily

basis averaged 64% over a 7 day period.

3 Options for service improvement

Potential options for service improvement were considered and analysed under 4 sub-

sections: MUST policy, Training, Nutrition Link Nurse and Information Technology (IT).

3.1 MUST policy

The group considered the potential impact of redrafting local guidelines to more

accurately reflect expectations regarding frequency of MUST usage. The group

considered how the multi-disciplinary team (MDT) could collectively manage the

responsibility for nutrition screening within the project setting.

3.2 Training

The group considered two evidence based training strategies that both have potential

application to the project setting.

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3.3 Nutrition Link Nurse

This option considers expanding the existing link nurse role to include responsibility for

• an ongoing teaching programme for new and existing staff

• future audits of daily MUST compliance.

3.4 IT

MUST scores are recorded in electronic patient records. The group’s research

confirms the feasibility of incorporating the following potential improvements into the IT

system:

• checklist showing outstanding daily tasks including MUST

• patient height and weight must be completed before MUST score can be

documented.

4 Recommendations

The group’s recommendations contain elements from all four sub-sections, they are:

• A statement to the effect of “MUST should be carried out daily for every patient.

Documentation of the MUST score is the responsibility of the patient’s named

nurse during the day shift” should be included within the unit’s nutrition policy.

• Education on the importance of MUST and how to use the tool should be

delivered through the existing staff education seminars.

• The unit’s link nurses should be formally involved in the delivery of MUST

training to new and existing staff.

• IT system to include checklist screen.

5 Conclusion

This report contains recommendations to improve MUST compliance within the project

setting which are achievable given the resources available.

Page 4

2 Introduction

As part of an Inter-Professional Learning (IPL) project, a group of thirteen health and

social care students were commissioned to improve compliance in using the Malnutrition

Universal Screening Tool (MUST) within a Critical Care Unit (CCU) in a hospital in the

South of England. The following document will outline the rationale for undertaking the

project, the methodology employed to meet the project objectives, an appraisal of options

for service improvement and finally, recommendations for improving MUST compliance

within the placement setting.

2.1 Why was the project commissioned?

A 2008 survey carried out across the UK found that malnutrition affected almost a third of

adults on admission to hospital.5 Malnutrition can be defined as a state of nutrition in

which a deficiency of energy, protein, and other nutrients causes measurable adverse

effects on tissue, function and clinical outcome.2

The clinical implications of malnutrition include:

• impaired immune responses (increasing infection risk)

• delayed recovery from illness

• impaired wound healing and

• increased length of hospital stay;

all of which are pertinent to the project setting and it’s service users.7

Despite its high prevalence within the hospital population and the adverse clinical

consequences associated with malnutrition, it is an under-recognised and under-treated

problem.2, 8 In addition to its negative impact on patient’s physical and psychological

wellbeing, malnutrition is estimated to cost the UK £13 billion annually.1, 9

Providing good quality nutritional care requires co-ordinated and complementary efforts

from a range of health care workers to ensure those at risk of malnutrition are identified,

offered appropriate interventions and followed up throughout their care - nutritional care is

therefore a multi-disciplinary responsibility.2, 3

2.2 National and local nutrition policy

In 2006, the National Institute for Health and Clinical Excellence (NICE) produced a

guideline outlining best practice care for adults at risk of malnutrition.2 The report

Page 5

identified nutrition screening on admission to hospital and at regular intervals as a key

clinical priority.2 NICE guidelines identify MUST as an appropriate nutritional screening

tool to be used across a range of healthcare settings.2 The tool utilises a five step process

to identify a patient's overall risk of malnutrition which is graded as low, medium or high

(appendix A). Management guidelines are provided as part of the tool pro forma, which

can be adapted to reflect local policy.

MUST is rapid and easy to use, with good validity and reliability and can be used by a

variety of healthcare professionals.8, 9 MUST is used on all adult service users in the

hospital to ensure malnutrition risk is screened in a consistent way throughout.

Within the project setting, it is expected that nutritional screening using MUST should be

carried out and documented daily.4 Local policy states that responsibility for recording

MUST is a multi-disciplinary task.10 Compliance figures are regularly reviewed by the

Trust’s clinical governance department and are also sent to the Department of Health.4

Failure to comply with MUST screening has negative financial implications for the trust.4

In addition to local and national guidelines, public perception was identified as a driver

influencing practice within the project setting. The current public inquiry into failings at the

Mid-Staffordshire NHS trust,11 newspaper headlines such as “Malnutrition in hospitals

more rife than believed”12 and campaigns such as Age UK’s “Hungry to be Heard”13 have

all captured the public’s attention resulting in increased political pressure to take the issue

of nutrition in hospitals seriously.

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2.3 Project objectives

The overall aim of the project was to formulate recommendations which could improve

MUST compliance within the project setting. The importance of demonstrating a specific

level of MUST compliance is linked to the setting securing future funding. The potential

impact on service arising from these recommendations is most likely to be associated

with the indirect impact this funding would have for the project setting.

The group used the Department of Health’s “Framework for Improvement” pro forma14 to:

1. clearly define the remit for the project

2. identify secondary objectives which would contribute to achieving the overall

project aim

3. plan appropriate tasks to achieve our objectives.

Sections of the framework relevant to this business case are shown in table 1. The full

framework can be found in appendix B.

Page 7

Table 1: Sections of the “Framework for Improvement” 14 relevant to assembling this

business case.

IPL group enters cycle here

Secondary objectives

required to achieve this

step

Action plan to achieve

secondary objectives

Step 3:

Understand the

problem

1. Determine current MUST

compliance within the

setting.

2. Obtain views of frontline

staff on using MUST.

3. Engage with other

stakeholders and

determine their views.

1. Audit MUST compliance and

compare to policy.

2. Gather staff opinion through

an anonymous

questionnaire.

3. Dietetics, Information

Technology department, and

the department’s nutrition

link nurses identified as key

stakeholders. Initiate contact

with all.

Step 4:

Investigate

potential

options for

service

improvement

1. Formulate options to

improve MUST compliance

in the setting.

2. Compare the potential

options.

1. Consider data collected in

step 3 and perform a

literature search to identify

potential options and their

evidence base.

2. Perform a SMART analysis15

on the options.

Action plan to achieve primary objective:

Based on our analyses, make recommendations to the project setting via written

report and presentation.

IPL group leaves cycle here

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2.4 The current situation: audit result and questionnaire

MUST screening is currently recorded in electronic notes within the placement setting. In

order to audit MUST usage, it was necessary for members of the group to access patient

records. All members of the group agreed to abide by the hospital's policy on

confidentiality and all information remained anonymous.

The audit revealed over a seven day period, the level of compliance with recording daily

MUST score averaged 64% (appendix C shows full audit data). It should be noted that

although the level of MUST compliance did not meet the unit’s own target, the national

standard for nutrition screening target was met.

In addition to the audit performed, a questionnaire was distributed among staff members

in the unit to enhance the group’s understanding of their views (appendix D). Responses

from the questionnaire remained confidential.

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3 Options for service improvement

Potential options and their evidence base are discussed within four areas. The feasibility

of implementing particular strategies within the project setting will be further considered

using a SMART analysis (appendix E).15

3.1 MUST Policy

The project setting’s official policy on nutrition states that screening should be carried out

on admission and thereafter at regular intervals throughout an inpatient stay.10 This is an

ambiguous statement which is open to individual interpretation. The group’s research

suggests that easily comprehensible, clearly written guidelines are more likely to be

followed correctly.16 To improve MUST compliance on a daily basis, the nutrition policy

could be altered to explicitly state that MUST should be carried out daily.

Some sources believe nurses should be made more accountable for nutritional care in

hospitals.17,18 In contrast, local and national guidelines assert that providing good

nutritional care is a multi-disciplinary responsibility.19-21 The questionnaires revealed that

only 39% of staff thought completing MUST was a nursing responsibility. The group

acknowledges that providing good nutritional care is the responsibility of every MDT

member, however, within the project setting, the group believes that MUST

documentation could be managed most effectively if it was the designated responsibility

of the nursing staff.

In summary, the unit’s nutrition policy could be made clearer by stating the requirement

that MUST should be performed daily by nursing staff.

3.2 Training

The questionnaires revealed that 73% of staff in the project setting felt they would benefit

from further MUST training (appendix D). Additionally, the questionnaires identified

inconsistencies in how staff scored patients in ‘Step 3’ of MUST. These findings are

significant since lack of appropriate training and clarity of scoring have both been

identified as barriers to compliance with nutritional screening in the NHS.22

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Training has been shown to have a positive effect on MUST compliance23-25 and from the

literature, we were able to identify two main training strategies:

1. all frontline staff receive training directly from an expert (e.g. dietician)23, 25

2. a cascade system where a nominated representative (e.g. nutrition link nurse) receives

training from an expert and is then responsible for disseminating this knowledge within

their unit.24

Both strategies have potential for application in the project setting. The dietetics

department are willing to deliver a seminar on MUST which could form part of the existing

lunchtime education programme.26 Alternatively, use of a MUST e-learning package could

be considered (appendix F).

In summary, good evidence exists to support training as way of improving MUST

compliance. Within this setting, staff and teaching structures exist which could realistically

facilitate further MUST training.

3.3 Nutrition Link Nurse

Two nutritional link nurses are currently based in the project setting. Part of their role is to

maintain strong links to the dietetics department through which they are able to access

additional MUST training.27 The link nurses are then expected to share their knowledge

with other staff in the unit.4, 27

The training role of the link nurse could include regular nutrition teaching sessions with

emphasis on daily documentation of MUST scores. Other approaches could include

dietician-led sessions, and also bedside training specific to recording the MUST scores

regularly and appropriately.

In order to oversee that MUST score documentation is being carried out correctly, it would

be appropriate for the link nurses to extend their current twice annually audit to include

assessment of daily use of the MUST tool and documentation of scores.27

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3.4 IT

Electronic patient records have the potential to bring huge benefits to both patients and

staff and are becoming increasingly integrated into patient care.28 Within the project

setting, MUST scores are recorded electronically in patient notes. Compliance with MUST

will therefore be affected by the IT systems in use.

Research showed that the current IT system will be replaced in five months time.

Following a discussion with the IT department about the limitations of the current system

and the capabilities of the new system,29 the following improvements could be configured

into the new system:

• A checklist screen showing all daily tasks requiring completion, including MUST.

Once a task has been completed, it is removed from the checklist screen.

• Ability to complete MUST score is conditional upon the patient’s height and weight

having been entered to ensure the tool is accurately completed.

In summary, the introduction of a new IT system within the project setting presents an

opportunity to introduce new features which may help to improve MUST compliance.

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4 Recommendations

The four options identified within the report have been analysed with consideration given

to the positives and negatives of each and how achievable their implementation would be

in the project setting.

The group’s overall recommendations encompass aspects from all of the options that

were appraised.

The group believes that a revision to the wording of the current unit policy is necessary to

clarify expectations to all staff within the project setting. A statement to the effect of

“MUST should be carried out daily for every patient. Documentation of the MUST score is

the responsibility of the patient’s named nurse during the day shift” within the unit policy.

This would define with whom the responsibility of compliance lies and would identify

areas of accountability.

An initial re-education on the importance of the MUST tool and a continuing training plan

will improve staff awareness and confidence when applying the screening tool within the

clinical setting. This could take place as part of the unit’s lunchtime education series. The

initial session should be run by the dietetic team with plans in place for the link nurses to

take on training in the medium to long term.

The responsibilities of the nutrition link nurses within the clinical setting should be

expanded and made more visible to other members of staff. Implementation of an

ongoing training programme for new and existing staff will ensure that information and

education is cascaded throughout the unit leading to a standardisation of MUST tool use.

Following the planned update of the IT system in 5 months time, it is recommended that

an electronic prompt is introduced. This would remind staff to complete daily MUST

documentation as part of an outstanding tasks checklist.

Our recommendations are realistically achievable within a relatively short timescale at

minimal cost to the trust.

Page 13

The potential advantages for the stakeholders associated with the project include financial

benefits, as well as benefits to the trust, staff, patients and members of the public. An

improvement in compliance with the MUST tool will improve clinical outcomes for patients

and would also benefit the trust as length of hospital stays would be reduced.

Implementation of these recommendations will enable staff to develop and expand their

roles as professionals, increasing and improving their skills which would then be

transferable across all healthcare settings. An improvement in the current level of

compliance within the project setting will result in a rise in standards in nutritional care.

The project setting would continue to achieve the benchmark standards set by the Quality

Care Commission and the Essence of Care framework.30 31 In addition, the target of daily

MUST documentation set by the project setting would hopefully be achieved.

Current public opinion following serious case reviews, such as the Staffordshire hospital

inquiry11 and subsequent litigation against NHS trusts, have fuelled a misconception

among the general public with regard to the standard of care and the provision of

treatment to patients. The project setting would be able to provide accountability through

evidence based practice concerning the quality of nutritional care which patients receive

by implementation of our recommendations.

Page 14

5 Conclusions

The group undertook research of current literature regarding the adverse impact of

malnutrition on patient’s health and recovery. This information was used in conjunction

with data collected by the group in the project setting. An audit of the current clinical

situation along with the responses from a questionnaire highlighted some discrepancies in

standards aspired to by the unit regarding MUST tool compliance.

As a result of the research, a range of options were considered and developed to make

improvements in the project setting. The group formulated a set of realistic, achievable

recommendations that could be implemented by the unit to improve MUST compliance

and bring about an improvement in overall service delivery. Regular, ongoing audit of

MUST compliance will be necessary to ensure these recommendations have a lasting

positive impact. The outcome and lessons learned from this process should be made

available within the project setting to ensure that best practice can be shared across

departments.

Page 15

References

1. Elia M, Russell CA, Stratton RJ. Malnutrition in the UK: policies to address the problem. Proc Nutr Soc 2010;69(4):470-6. http://www.ncbi.nlm.nih.gov/pubmed/20550750 (accessed 11 Nov 2010). 2. National Institute for Health and Clinical Excellence. Nutrition Support in Adults. 2006. http://www.nice.org.uk/nicemedia/live/10978/29979/29979.pdf (accessed 11 Nov 2010). 3. Powell-Tuck P (ed). Organisation of Food and Nutritional Support in Hospitals. British Association for Parenteral and Enteral Nutrition. 2007. http://www.bapen.org.uk/ofnsh/OrganizationOfNutritionalSupportWithinHospitals.pdf (accessed 12 Nov 2010). 4. Project Facilitator. Personal Communication. November 2010. 5. Russell CA, Elia M (eds). Nutrition Screening Survey in the UK 2008: Hospitals, Care homes and mental health units: Nutrition Screening Week Survey and Audit. British Association for Parenteral and Enteral Nutrition. 2009. http://www.bapen.org.uk/pdfs/nsw/nsw_report2008-09.pdf (accessed 11 Nov 2010). 6. British Association for Parenteral and Enteral Nutrition. Backgrounder 2: Malnutrition and the wider context. http://www.bapen.org.uk/res_press_rel9.html (accessed 11 Nov 2010). 7. Todorovic V, Russell C, Stratton R, Ward J and Elia M (eds). The ‘MUST’ Explanatory Booklet: A guide to the ‘Malnutrition Universal Screening Tool’ (MUST) for Adults. British Association for Parenteral and Enteral Nutrition. 2003. http://www.bapen.org.uk/pdfs/must/must_explan.pdf (accessed 11 Nov 2010). 8. Elia M (ed). The ‘MUST’ report: Nutritional screening of adults: a multidisciplinary responsibility: Executive summary. British Association for Parenteral and Enteral Nutrition. 2003. http://www.bapen.org.uk/pdfs/must/must_exec_sum.pdf (accessed 11 Nov 2010). 9. Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C, Elia M. Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ‘malnutrition universal screening tool’ (MUST) for adults. British Journal of Nutrition 2004;92:799-808 (accessed 12 Nov 2010). 10. Portsmouth Hospitals. Nutrition Policy (adult). Portsmouth NHS Trust. Issue 4. 2010. 11. The Guardian. Stafford hospital inquiry hailed by campaigner. http://www.guardian.co.uk/society/video/2010/nov/08/stafford-hospital-inquiry-campaigner-video (accessed 15 Nov 2010).

12. The Independent. Malnutrition in hospitals more rife than believed. http://www.independent.co.uk/life-style/health-and-families/health-news/malnutrition-in-hospitals-more-rife-than-believed-1911318.html (accessed 15 Nov 2010).

13. Age UK. Malnutrition in hospital: Still hungry to be heard. http://www.ageuk.org.uk/get-involved/campaign/malnutrition-in-hospital-hungry-to-be-heard/ (accessed 14 Nov 2010).

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14. Department of Health. Improvement Leaders’ Guide: Process mapping, analysis and redesign. 2005. In: Interprofessional Learning Unit 3 Student Handbook 2010-11. Common Learning: University of Southampton: University of Portsmouth. https://www.commonlearning.net/uploadedfiles/IPLU3%20Student%20Handbook%202010-11.pdf (accessed 15 Nov 2010). 15. Project Smart. SMART goals. http://www.projectsmart.co.uk/smart-goals.html (accessed 15 Nov 2010). 16. Department for Buisness, Innovation and Skills. Code of Practice on Guidance and Regulation. London: Crown Copy Right; 2009. 17. Macdonald, B. Nurses need to take more control of patients' nutritional needs. Nursing Times 2009. http://www.nursingtimes.net/nursing-practice-clinical-research/practice-comment-archive/nurses-need-to-take-more-control-of-patients-nutritional-needs/5000703.article (accessed 16 Nov 2010). 18. Mould.J. Nurses 'MUST' control of the nutritional needs of stroke patients. British Journal of Nursing 2009;18(22): 1410-14.

19. Royal College of Nursing. Principles for Nutrition and Hydration. 2007. http://www.rcn.org.uk/newsevents/campaigns/nutritionnow/principles (accessed 10 Nov 2010). 20. National Nursing, Midwifery and Health Visiting Advisory Comittee. Promoting Nutrition for older Adult In-Patients in NHS Hospitals in Scotland. Glasgow: The Scottish Government: 2002. 21. Perry L. Using nutritional screening tools to identify malnourished patients. http://www.nursingtimes.net/using-nutritional-screening-tools-to-identify-malnourished-patients/1958881.article (accessed 10 Nov 2010). 22. National Patient Safety Agency. Nutrition Factsheets: Nutrional Screening Structured Investigation Project. 2009. www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60228&type=full%servicetype=Attachment (accessed 15 Nov 2010). 23. An audit to evaluate the effect of staff training on the use of Malnutrition Screening Tool. Journal of Human Nutrition and Dietetics (2008) Volume: 21, Issue: 4, Pages: 405-406. 24. Lee R, Scott F. Competent to care: a train-the-trainer method of teaching as a way of implementing the correct use of the ‘Malnutrition Universal Screening Tool’ in Norfolk: is it effective? Proceedings of the Nutrtion Society 2009;68: 300-5. 25. Bailey, R. Applied leadership, Implementing Nutritional Screening. Nursing Management, 2006;13(3): 20-24. 26. Dietician. Personal Communication. November 2010. 27. Nutrition Link Nurse. Personal Communication. November 2010.

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28. House of Commons Health Committee. The Electronic Patient Record, Sixth report of session 2006-7 Volume 1. http://www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/422/422.pdf (accessed 10 Nov 2010). 29. IT Technician. Personal Communication. November 2010. 30. Care Quality Commission. Guidance for Professionals. http://www.cqc.org.uk/guidanceforprofessionals/nhstrusts.cfm (accessed 15 Nov 2010). 31. Department of Health. Essence of Care (Benchmark Standards). http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119974.pdf (accessed 13 Nov 2010). 32. BAPEN. ‘Malnutrition Universal Screening Tool.’ http://www.bapen.org.uk/pdfs/must/must_full.pdf (accessed 13 Nov 2010). 33. BAPEN. MUST e learning resource: information and cost. http://www.bapen.org.uk/pdfs/must/e-learning-flyer.pdf (accessed 13 Nov 2010). 34. BAPEN (bapen@bapen.org.uk). MUST elearning. Wood T. (tbw106@soton.ac.uk) 12 November 2010.

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Appendices

Appendix A – MUST tool32

Page 19

Appendix B – Adapted from ‘A Framework for Improvement’14

Step 1: project aim Defined by the project facilitators

To make recommendations which will improve MUST compliance within the project setting.

Step 2: how will we know if a change is an improvement?

The change we are seeking to bring about is an increase in MUST compliance which is associated with a financial incentive for the project setting. Therefore, the change we are proposing is likely to result in an improvement to service delivery.

IPL group enters cycle here

Secondary objectives required to achieve this

step

Action plan to achieve secondary objectives

Step 3: Understand the problem

1. Determine current MUST compliance within the setting. 2. Obtain views of frontline staff on using MUST. 3. Engage with other stakeholders and determine their views.

1. Audit MUST compliance and compare to policy. 2. Gather staff opinion through an anonymous questionnaire. 3. Dietetics, Information Technology department, and the department’s nutrition link nurses identified as key stakeholders. Initiate contact with all.

Step 4: Investigate potential options for service improvement

4. Formulate options to improve MUST compliance in the setting. 5. Compare the potential options.

4. Consider data collected in step 3 and perform a literature search to identify potential options and their evidence base. 5. Perform a SMART analysis15 on the options.

Action plan to achieve primary objective: Based on our analyses, make recommendations to the project setting via written

report and presentation.

IPL group leaves cycle here

Step 5: test recommendations

Pilot the recommendation and re-audit to determine whether there was any service improvement

Step 6: incorporate successful recommendations into policy

Implement recommendations which successfully improved the service

Step 7: Continue to re-evaluate and look for further ways to improve

Re-audit and reassess. Disseminate best practice to support improvement in other settings.

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Appendix C - Audit Data Data for 9 patients present on the unit during the audit period was unavailable. We have removed these 9 patients from our analyses. Table 2: Raw audit data.

Table 3: Raw data shown as percentages

Day No. of patients

Height Weight BMI MUST recorded

No. Of patients fed

1 14 7 14 11 11 14

2 15 6 9 11 11 15

3 15 10 15 11 11 15

4 13 8 12 8 8 13

5 14 7 13 8 8 14

6 11 6 11 6 6 11

7 13 8 12 6 6 13

TOTAL 95 52 86 61 61 95

Day % height recorded

% weight recorded

% BMI recorded

% MUST recorded

1 50 100 79 79

2 40 60 73 73

3 67 100 73 73

4 62 92 62 62

5 50 93 57 57

6 55 100 55 55

7 62 92 46 46

MEAN 55 91 64 64

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Appendix D – Questionnaire Data Table 4: Questionnaire pro forma with the totalled responses in bold. Job titles of participants: Nurse 21 Dr 4

Physiotherapist 1

Whose responsibility is it to complete the MUST assessment? Nurse 10

Dr 0 Dietician 0 Any MDT member 16

Do you understand the purpose of the MUST tool? Yes 23 No 3 Note: 2 nurses & 1 physiotherapist

answered ‘No’ How often should the MUST tool be completed according to unit policy? Daily 20 2-3 days 0 4-5 days 4 Weekly 2 Do you complete your patients MUST assessment every shift? Yes 16 No 9 Note: 5 nurses & 4 doctors answered

‘No’ If your patient is acutely unwell and is being nutritionally supplemented, what score would you give them on stage 3 of the MUST assessment? Score 0 1

Score 2 24

Do you feel you would benefit from further training regarding the MUST assessment? Yes 19 No 7 Note: All ‘No’ answers from nurses

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Policy - Clarification of current policy

Training – Make changes to current training on the use of MUST

Link nurse – Expand the role of the link nurse

IT – Introduction of new features on the IT system

Specific Amend the unit’s policy stating exactly how often MUST should be performed and by who.

All front line staff to receive training from an expert – during existing lunch time sessions and link nurses to be responsible for relaying information received to other unit staff members.

Link nurse to be responsible for running a cascade training system throughout the unit, training new members on use of MUST.

Implement a checklist screen showing daily tasks (including MUST). Make the completion of MUST score conditional upon entry of patient’s height and weight.

Measurable Re-wording of the units policy.

Ensure that there is a register at staff education sessions to act as a record of the training that individuals have received. Ensure that there is a sign of sheet available for all relevant members of staff to record that they have received appropriate training.

Link nurse to perform an audit on the compliance of MUST to assess the impact of the cascade training system.

Patients with missing height and weight will not have a MUST score; this will reduce compliance with the use of the tool. A checklist will encourage staff to complete MUST. The activities of each staff member could be logged and recorded.

Achievable Yes – the option clearly state what needs to be put in the policy. Time and costs will be minimal.

Yes – staff and teaching systems already exist which would only need to be revised.

Yes. Yes – as the computer system is being up dated in five months.

Realistic Yes – easy to implement

Yes – No further cost to the trust as health professionals providing training are already in employment and have a responsibility to partake in continual professional development.25

Yes – link nurses already on the unit.

Yes – the new IT system will be able to implement the suggested additions.

Time One month for revision of policy and circulation to staff.

1 Month – Allowing for a member of the dietetics team to prepare for and be available for seminar.

Link nurses to take responsibility from present. Audit to be performed every 6 months.

5 months.

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Appendix E: SMART15 table to compare recommendation options

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Appendix F – BAPEN MUST e-learning resource: information and cost

Customisation Costs for NHS Trusts and Health Boards for the e- Learning Resource ‘Nutritional Screening is a ‘MUST’.34 Package A = £400 +VAT Customising resource with Logo, welcome from a senior manager and set up of customised tracking and reporting system on module uptake and completion (stratified by area, ward). Cost includes data cleaning and housing account on secure server for first year (thereafter £250 + VAT/year). Package B = £900 +VAT approximately (dependant on individual requirements) Includes Package A and inclusion of local care plans, policies and procedures. Individual quotes will be provided and the cost will depend on the number and complexity (i.e. interactive elements) of inclusions. The costing above is based on inclusion of approximately five bespoke elements.

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