Nutritional support of patients with long
Risk of malnutrition / malnutrition among hospitalised patients with long-term conditions is a widespread problem leading to serious or adverse health outcomes (Ferreira et al 2009). Whereas some patients' nutritional status deteriorates during a hospital stay due to their medical condition or inadequate attention paid to their nutritional needs, other patients are admitted to hospital with malnutrition. It is estimated that 60% of older people are at risk of becoming malnourished, or their situation getting worse in hospital (DH 2007). There is evidence to suggest that under-nutrition delays recovery, and lowers resistance to medical complications, with a link observed between under-nutrition and lengthened hospital stay, morbidity and mortality (NICE 2006).
The nutritional status of many patients with malnutrition or at risk of malnutrition can be improved through more effective oral nutrition support (NICE 2006). However, the Association of Community Health Councils report 'Hungry in Hospital' (ACHCEW 1997) identified that a significant proportion of patients in hospitals are not receiving the nutritional support they need.
The Department of Health's nutrition action plan (DH 2007) included a number of measures to be introduced by acute trusts to improve nutrition support. However, a recent survey suggests that the plan has had little impact on care nationally, and there are huge inconsistencies across organisations in the extent to which malnutrition has been tackled (HSJ 2009). Despite efforts targeted at improving the nutritional status of patients and the quality of nutrition support in hospitals, under nutrition, whether caused in hospital or not, remains widespread among in-patients.
The Local Context
Nutrition was highlighted as a priority to address by the Chief Nurse/Director of Operating Services. In order to ensure the project focused on relevant aspects of nutritional care and management, the TK2A team worked in partnership with the Trust Nutrition Steering Group (TNSG), Nurse Directors and Professional and Practice Development Manager. The final project proposal was coproduced with them and in particular the Chair TNSG (a Consultant Gastroenterologist) and Head of Dietetics Department. All their input and involvement in shaping the work of the project continued throughout and now as they are taking forward the learning from the project.
EQONS became a 31 month (September 2009 – April 2012) knowledge translation project to implement a validated nutrition assessment the Malnutrition Universal Screening Tool (MUST) to replace STHFT current documentation which did not 'score' the level of malnutrition risk. Additional assessment questions were included to identify patient's potential additional needs due to swallowing difficulties, cognition and disease specific conditions that affect nutrition leading the project to describe the initial nutrition assessment as 'MUST+'. A local STHFT based nursing care guideline was developed using evidence of best practices to address patients who have a poor appetite.
To enhance the quality of oral nutrition support provided by the multi-disciplinary team to adult patients with long term conditions through the implementation of a nutrition screening tool (MUST+) and associated care guidelines.
- To develop, trial and evaluate two implementation strategies designed to promote the uptake and effective use of MUST+ and associated care guidelines in acute hospital wards.
- To evaluate the implementation of MUST+ and associated nursing care guidelines on oral nutritional support in terms the impact on patients and on the multi-disciplinary team.
- To develop the capacity and capability of the multi-disciplinary team to provide clinically effective nutrition support to patients with / at risk of developing malnutrition.
- To disseminate learning across the CLAHRC partnership organisations and to facilitate its uptake into undergraduate nursing, medical, allied health professional curricula and continuing professional development.
The project used the Knowledge to Action framework (Graham et al 2006) as a conceptual underpinning with an action research approach enabling collaboration, participation, engagement and ownership. The project evolved over time to include the main study, a small exploratory study of a volunteer administered survey and volunteer feeding programme and two master's dissertations. The following projects were undertaken:
- Development, trial and evaluation of two implementation strategies to promote the uptake and effective use of MUST+ and associated guideline. The two implementation strategies were:
- Ward based nutrition champions
- Facilitation of the multidisciplinary team by dietitians
- Evaluation of MUST+ and associated guidelines from the perspective of staff
- The use of volunteers for surveying patients experiences of nutrition in hospital
- The use of volunteers to assist patients with eating
- Ward based nutrition champions to support implementation of new guidelines: A pluralistic evaluation (MSc dissertation included in the nutrition champion section)
- Understanding patient's perceptions of nutritional intake and support: A qualitative study (MSc dissertation included in the patient perspective section)