Professor Marinos Elia highlights the requirement for good communication within and between care settings in implementation of the quality standard on nutrition support
  • Malnutrition:
    • affects approximately 3 million or more individuals in the UK, exists in every healthcare setting, and at a given point in time, around 93% of cases exist within the community
    • affects every medical discipline and disease category and is found in every type of care home, hospital ward, and GP surgery
    • delays recovery from illness and has detrimental effects on wellbeing and on the quality of life of all patient groups
  • Failure to prevent malnutrition or delay in its recognition and treatment increases GP visits, institutional (hospitals and care homes) admissions, and length of hospital stay
  • The total cost of malnutrition accounts for around 10% of the total public expenditure on healthcare and social care
  • Nutritional support is a multidisciplinary responsibility
  • The five quality statements on nutrition support in adults aim to address and improve nutritional care, and reduce inequalities, resource use, and cost, by influencing key points of the nutritional management pathway involving diagnosis, treatment, and follow up
  • Identification of malnutrition using a validated screening procedure is the first important step in the management pathway—the Malnutrition Universal Screening Tool (MUST) is the most widely used screening tool in hospitals, care homes, and in the community in the UK
  • The results of nutritional screening should be linked to a care plan—both should be documented in writing and communicated within and between care settings to appropriate healthcare and social care workers involved in multidisciplinary care
  • People managing their own artificial nutrition (and/or their carers) outside hospital should be trained to recognise and prevent problems; they should have details of appropriate healthcare professionals who can be contacted for help, including urgent advice when necessary.

Malnutrition is a common clinical and public health problem, which predisposes people to disease, delays recovery from illness, and adversely affects wellbeing and clinical outcomes. It is associated with an estimated cost of over £13 billion per year, approximately 10% of total expenditure on healthcare and social care.1 It has multiple causes, ranging from disease-related factors, poverty, and social isolation, to adverse effects from drugs, radiotherapy, and surgery.

Prevalence

Although malnutrition is under-detected and under-treated, it is estimated to affect at least 3 million people in the UK, with detrimental effects on individuals, healthcare and social care services, and society.1 At a given point in time, approximately:1

  • 93% of malnutrition cases are found in the community (of which around 3% are in sheltered housing)
  • 5% of malnutrition cases are found in care homes
  • 2% of malnutrition cases are found in hospitals.

Malnutrition affects every medical discipline; and its management should be the concern and responsibility of all types of healthcare and social care workers and not one specific group of professionals. As there is a large and rapid turnover of hospital inpatients and outpatients, identification of malnutrition in the hospital setting can allow treatment to either begin in hospital and continue in the community, or to begin in the community. A series of UK national surveys undertaken by the British Association for Parenteral and Enteral Nutrition (BAPEN) suggests that malnutrition affects approximately:2-5

  • 29% of people admitted to a wide range of hospital wards
  • 18% of people admitted to acute and rehabilitation mental health units
  • 35% of people admitted to residential and nursing homes in the previous 3–6 months.

Additionally, a degree of protein-energy malnutrition is also estimated to occur in about 10% of people visiting their GP.6 Malnutrition occurs in individuals of all ages, although it is more common in older people. Most cases of malnutrition develop in the community and are largely responsible for those occurring in hospital.7 Significant improvements to wellbeing, dignity, and clinical outcomes of malnourished patients can be achieved through appropriate nutritional (including fluid) interventions in various care settings.

NICE quality standard for nutrition support

Various surveys and audits in different care settings, including hospitals and the community, have identified substantial variation in the extent to which malnutrition is identified and treated.2-5,8,9 It is an important patient safety issue10,11 not only because of the potential problems that may arise from specific types of treatment, such as misplacement of enteral feeding tubes, which can lead to aspiration, pneumonia, and death, but also because of the multiple, clinically relevant adverse effects that result from the frequent failure to identify malnutrition at an early stage and to provide appropriate treatment. Concerns have been raised by a number of organisations about the lack of multidisciplinary care, and continuity of care both within and between settings.12 Furthermore, recent reports by the Care Quality Commission suggest that one-fifth of hospitals and nursing homes are not meeting at least one of the basic or essential standards on nutrition and hydration.13

The NICE quality standard for nutrition support in adults is intended to provide a clear description of what a high-quality service would look like (see Table 1, below).14 Quality standards enable organisations to move towards improving quality and delivering excellence, and aim to be aspirational, but achievable.14 The quality standard for nutrition support applies to a wide range of care settings, but only covers adults (18 years and over).14 It is supported by two other documents: a guide for commissioners and others on how to use the quality standard,15 and an information guide for people who use NHS Support Services (see below).16

The NICE quality standard does not cover every aspect of nutritional care, but instead the five statements aim to define high-quality, cost-effective care at key points of the management pathway for nutritional support.14 The quality statements are in order of identification, treatment, and follow up of malnutrition. They can be linked to key performance indicators and used to audit practice. Equality and diversity issues are also considered in the standard and are summarised below after a brief overview of each quality statement.

Table 1: NICE quality standard for nutrition support in adults14
No. Quality statements
1 People in care settings are screened for the risk of malnutrition using a validated screening tool.
2 People who are malnourished or at risk of malnutrition have a management care plan that aims to meet their nutritional requirements.
3 All people who are screened for the risk of malnutrition have their screening results and nutrition support goals (if applicable) documented and communicated in writing within and between settings.
4 People managing their own artificial nutrition support and/or their carers are trained to manage their nutrition delivery system and monitor their wellbeing.
5 People receiving nutrition support are offered a review of the indications, route, risks, benefits, and goals of nutrition support at planned intervals.
National Institute for Health and Care Excellence website. Quality standard for nutrition support in adults. Reproduced with kind permission.
Available at: www.nice.org.uk/guidance/QS24

Screening for the risk of malnutrition—statement 1

Nutritional screening is important in a variety of care settings, including hospital inpatient and outpatient settings, care homes and general practices, as identification of malnutrition is the first step of the nutritional management pathway. Screening in general practice should be undertaken at initial registration, and when there is clinical concern, for example, unplanned weight loss, loosely fitting clothes, wasting of muscles, poor appetite, impaired swallowing, fragile skin, poor wound healing, and prolonged intercurrent illness. Screening facilitates implementation of effective nutritional interventions for people who need them, and prevents unnecessary treatment for those who do not.

The screening process should use a validated tool to ensure that it is user friendly, and as accurate and reliable as possible.14 Nutritional care is a shared responsibility and the chosen screening tool should have been developed by a multidisciplinary group to ensure that the scoring system and its link to care plans are appropriately considered and balanced. The most commonly used screening tool in the UK, the Malnutrition Universal Screening Tool (MUST),17 is considered to fulfil the requirements of this quality statement.

Nutritional screening should be performed by healthcare and social care workers who have been trained in measuring procedures and interpreting results, and it should involve the use of calibrated equipment, including weighing scales.18

Treatment (linking results of malnutrition risk to a care plan)—statement 2

People identified as being at risk of malnutrition need to have appropriate support to ensure that the total nutritional intake is complete to facilitate recovery and reduce the impact on healthcare, including hospital admissions. Therefore, it is appropriate to expect malnourished people or those at risk of malnutrition to be offered a care plan that aims to meet their complete nutritional requirements, and an appropriate infrastructure to achieve this should be in place.14

Documentation and communication—statement 3

It is important to ensure that there is documented and written communication of the results of nutritional screening during the patient journey within and between care settings because malnourished people frequently move between primary and secondary care, and are managed by a wide range of healthcare and social care workers. The results of nutritional screening should be linked to an on-file care plan: those people who are deemed to be well-nourished are normally offered routine care, and those who are deemed to be malnourished are typically offered specific care plans with associated nutritional goals. Such procedures not only help improve efficiency, but also continuity of care during the person’s ‘care journey’.14

Self-management of artificial nutrition support—statement 4

The term ‘artificial nutrition’ in this quality statement refers to enteral tube feeding and parenteral (intravenous) nutrition.14 At a given point in time, the majority of enteral tube feeding and a much smaller proportion of parenteral nutrition take place outside the hospital setting, where nutritional support is managed by the patients and/or their carers. Such individuals need to be able to prevent problems, rapidly recognise deterioration in their wellbeing (or the wellbeing of people they are caring for), especially if related to nutritional support, and contact a specialist for urgent advice when necessary; to do this, patients and/or their carers should be trained to ensure that they are competent to undertake these tasks. For example, they should be confident in managing their own delivery system, the equipment used to deliver the feed, and identifying an appropriate environment to store the feed until it is used.

Quality statement 4 does not imply that self-management (or management by a carer) is a replacement for professional responsibility; instead, it should be regarded as a partnership between the patient (and/or carer) and the professional.14

Review—statement 5

The quality statement on review applies to any type of nutritional support (dietary advice, oral, enteral, or parenteral nutrition, either alone or in combination). As nutritional requirements and the need for support can change over time, sometimes rapidly, this quality statement aims to ensure that the people receiving nutritional support are offered a review of the indications, route, risks, benefits, and goals of nutritional support at planned intervals.14

Equality and diversity issues

The quality standard pays particular attention to equality and diversity considerations. For example, nutritional screening (quality statement 1) should be available to all individuals for whom it is appropriate, irrespective of whether they are unconscious, sedated, or unable to communicate because of their clinical condition or language difficulties.14 Screening should also be made available to people who cannot be weighed or have their height measured.

The recommendation that a validated screening tool is developed by a multidisciplinary group of professionals14 reduces the potential bias towards the viewpoints of a single profession.

Development of a care plan should be consistent with cultural and religious beliefs, with regards to an individual’s special dietary requirements (quality statement 2).14

An additional example of an equality and diversity consideration concerns education and training for self?management of artificial nutrition (quality statement 4). Such training should be available to people who have difficulties reading or speaking English and to individuals who need information in a non-written format.14

Supporting documents

NICE has produced two supporting documents to accompany the quality standard on nutrition support.

One aims to help commissioners and others to understand the implications and potential resource impact of the standard. This item was developed as part of the implementation programme, and provides an overview of nutritional support in adults in the context of the epidemiology of malnutrition, the importance of integrated care within and between care settings, and the estimated cost benefit associated with implementing appropriate nutritional support.15 The other document provides information for people who use NHS nutrition support services.16

Implementation of the quality standard

To facilitate use of the quality standard on nutrition support and to put healthcare and social care policies in context, a variety of resource materials are available from NICE and other organisations (see Box 1, next page). It is important to appreciate that malnutrition not only has detrimental effects in the care setting in which the person is being managed, but also in other settings; for example, compared with well-nourished individuals, malnourished people have both more GP visits and hospital admissions. Similarly, patients discharged from hospital not only have additional readmissions to hospitals but also more GP visits.

Box 1: Useful resource materials for implementing the quality standard for nutrition support

NICE resources (www.nice.org.uk/guidance)

  • NICE quality standard on nutrition support in adults14
  • NICE support for commissioners and others using the quality standard on nutrition support in adults:15
    • supporting material for commissioners and others using this quality standard
  • Patient information:16
    • this document is written for people and/or their carers who use the NHS nutrition support services, but it may also be useful for family members, friends, advocates of nutritional support, and those with an interest in malnutrition
  • Clinical Guideline 32 and associated slide set:
    • the 2006 NICE Clinical Guideline on Nutrition support in adults19 and the accompanying slide set help put the quality standard into context
  • NICE shared-learning database:
    • this database provides examples of good practice including those involving nutritional care 20 (e.g. Fighting malnutrition: a strategic, multidisciplinary approach; a partnership approach to improving the nutritional care of our patients, implementing nutritional screening in care homes; and weighing scales and stadiometers: the need for accurate instruments in adults nutrition support).

Related NICE quality standards (www.nice.org.uk/guidance/qualitystandards/qualitystandards.jsp)

  • Patient experience in adult NHS Services (2012)21
  • Service user experience in adult mental health (2011).22

National Prescribing Centre (www.npc.co.uk)

  • Prevention and treatment of adult malnutrition: appropriate prescribing of oral nutritional supplements.23

Care Quality Commission (www.cqc.org.uk)

  • Essential standards of quality and safety.24

Department of Health (www.dh.gov.uk)

  • Improving nutritional care25
  • Essence of care.26

Age Concern (www.ageuk.org.uk)

  • Hungry to be heard: the scandal of malnourished older people in hospital.8

British Association for Parenteral and Enteral Nutrition (www.bapen.org.uk)

  • ‘MUST’ toolkit (includes aids such as charts, apps, and calculators), ‘MUST’ app, ‘MUST’ calculator, and ‘MUST’ report27
  • A toolkit for commissioners and providers in England28
  • e-Learning resources on nutritional screening for hospitals and the community (separate modules for hospital, care home, and primary care modules)29
  • Combating malnutrition: recommendations for action1
  • Screening for malnutrition in sheltered housing30
  • Improving nutritional care and treatment: perspectives from population groups, patients and carers31
  • Nutrition screening surveys.2-5

National Confidential Enquiry into Patient Outcome and Death (www.ncepod.org.uk)

  • A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition.9

National Patient Safety Agency (www.npsa.nhs.uk)

  • Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants10
  • Nutrition factsheets.11

Centre for Sheltered Housing Studies (www.chs.ac.uk)

  • Good practice guide on addressing malnutrition.32

Guidelines (for primary care) (www.guidelines.co.uk)

  • The Malnutrition Universal Screening Tool (MUST) for adults.33

Summary

To combat the problem of malnutrition effectively it is necessary to apply the NICE quality standard on nutrition support in adults in all care settings, using consistent criteria and joined-up policies whenever possible. The framework suggested by the quality standard aims to facilitate such processes and the development of appropriate infrastructures to help deliver them.

  • The proportion of people:
    • in care settings (e.g. on admission to hospital or care home, or at first attendance at a GP surgery) who are screened for malnutrition using a validated screening tool
    • who have been identified as malnourished or at risk of malnutrition through screening who have a management plan
    • screened for malnutrition who have their results and nutrition support goals (if applicable) communicated in writing when transferred within and between care settings
    • receiving oral nutritional supplements who are offered a review of the indications, risks, benefits, and goals of nutritional support at 6-month intervals (ideally 3-month intervals).
  • Commissioners should ensure that the NICE quality statements for nutrition support are reflected and incorporated in contracts with providers of care, particularly those involved with inpatient care
  • CCGs should look to ensure sufficient dietetic services are provided to support general practices in community care, where such support is often deficient
  • CCGs should be wary of the potential costs to the prescribing budget from sip feeds, and agree with dietitians when and which of these products should be prescribed, and include these in local formularies
  • Screening for nutritional status happens rarely in general practice and is not included in the QOF; therefore educational support and a scheme for prioritisation of screening could be initiated by CCGs (possibly as a local enhanced service)
  • The issue of nutritional support in residential settings is likely to be thrown into sharp focus by the publication of the Francis Report and is likely to become an increasing priority for both commissioners and providers.
  1. Elia M, Russell C. Combating malnutrition: recommendations for action. Output of a meeting of the Advisory Group on Malnutrition, led by The British Association for Parenteral and Enteral Nutrition. Redditch: BAPEN, 2009. Available at: www.bapen.org.uk/professionals/publications-and-resources/bapen-reports/combating-malnutrition-recommendations-for-action.
  2. Russell C, Elia M. Nutrition screening survey in the UK in 2007. A report by The British Association for Parenteral and Enteral Nutrition. Redditch: BAPEN, 2008. Available at: www.bapen.org.uk/pdfs/nsw/nsw07_report.pdf
  3. Russell C, Elia M. Nutrition screening survey in the UK in 2008. A report by The British Association for Parenteral and Enteral Nutrition. Redditch: BAPEN, 2009. Available at: www.bapen.org.uk/pdfs/nsw/nsw_report2008-09.pdf
  4. Russell C, Elia M. Nutrition screening survey in the UK and Republic of Ireland in 2010. Redditch: BAPEN, 2011. Available at: www.bapen.org.uk/pdfs/nsw/nsw10/nsw10-report.pdf
  5. Russell C, Elia M. Nutrition screening survey in the UK and Republic of Ireland in 2011. Redditch: BAPEN, 2012. Available at: www.bapen.org.uk/pdfs/nsw/nsw-2011-report.pdf
  6. McGurk P, Cawood A, Walters E et al. The prevalence of malnutrition in general practice. Proc Nutrition Soc 2011; 70 (OCE5): E267.
  7. Russell C, Elia M. Malnutrition in the UK: where does it begin? Proc Nutr Soc 2010; 69 (4): 465–469.
  8. Age Concern. Hungry to be heard. The scandal of malnourished older people in hospital. London: Age Concern, 2006. Available at: www.scie.org.uk/publications/guides/guide15/files/hungrytobeheard.pdf
  9. National Confidential Enquiry into Patient Outcome and Death. A mixed bag: an enquiry into the care of hospital patients receiving parenteral nutrition. London: NCEPOD, 2010. Available at: www.ncepod.org.uk/2010pn.htm
  10. NHS Patient Safety Agency. Patient safety alert NPSA/2011/PSA002: reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. London: NHS NPSA, 2011.
  11. NHS Patient Safety Agency website. Nutrition factsheets. www.nrls.npsa.nhs.uk/resources/?entryid45=59865 (accessed 29 January 2013).
  12. Royal College of Physicians, Royal College of General Practitioners, Royal College of Paediatrics and Child Health. Teams without walls: the value of medical innovation and leadership. Suffolk: The Lavenham Group Ltd, 2008.
  13. Care Quality Commission. The state of health care and adult social care in England. London: The Stationery Office, 2012. Available at: www.cqc.org.uk/public/reports-surveys-and-reviews/reports/state-care-report-2011/12
  14. National Institute for Health and Care Excellence website. Quality standard for nutrition support in adults. NICE Quality Standard 24. London: NICE, 2012. Available at: www.nice.org.uk/guidance/qs24
  15. National Institute for Health and Care Excellence. NICE support for commissioners and others using the quality standard on nutrition support in adults. NICE Quality Standard 24. London: NICE, 2012. Available at: www.nice.org.uk/guidance/QS24
  16. National Institute for Health and Care Excellence. Information for people who use NHS nutrition support services. NICE Quality Standard 24. London: NICE, 2012. Available at: www.nice.org.uk/guidance/QS24/PublicInfo/pdf/English
  17. British Association for Parenteral and Enteral Nutrition. The ‘MUST’ explanatory booklet: a guide to the ‘malnutrition universal screening tool’ for adults. London: BAPEN, 2003.
  18. Department of Health. Estates and facilities alert. Ref: EFA/2010/001. DH, 2010. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_114048.pdf
  19. National Institute for Health and Care Excellence. Nutrition support in adults. NICE Clinical Guideline 32. London: National Collaborating Centre for Acute Care, 2006. Available at: www.nice.org.uk/guidance/CG32/NICEGuidance/pdf
  20. National Institute for Health and Clinical Excellence website. Shared learning: implementing NICE guidance.www.nice.org.uk/usingguidance/sharedlearningimplementingniceguidance/shared_learning_implementing_nice_guidance.jsp (accessed 29 January 2013).
  21. National Institute for Health and Care Excellence website. Quality standard for patient experience in adult NHS services. NICE Quality Standard 15. London: NICE, 2012. Available at: www.nice.org.uk/guidance/qs15
  22. National Institute for Health and Care Excellence website. Quality standard for service user experience in adult mental health. NICE Quality Standard 14. London: NICE, 2011. Available at: www.nice.org.uk/guidance/qs14
  23. National Prescribing Centre. Prescribing of adult oral nutritional supplements: guiding principles for improving the systems and processes for ONS use. NPC, 2012. Available at: www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf
  24. Care Quality Commission. Essential standards of quality and safety. London: CQC, 2010. Available at: www.cqc.org.uk/content/essential-standards-quality-and-safety
  25. Department of Health, Nutrition Summit Stakeholder Group. Improving nutritional care: a joint action plan from the Department of Health and Nutrition Summit Stakeholders. London: DH, 2007. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_079931
  26. Department of Health. Essence of care 2010. London: DH, 2010. Available at: www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_119978.pdf
  27. British Association for Parenteral and Enteral Nutrition website. The ‘MUST’ itself. www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/the-must-itself (accessed 29 January 2013).
  28. British Association for Parenteral and Enteral Nutrition. Malnutrition matters. Meeting quality standards in nutritional care. Redditch: BAPEN, 2012. Available at: www.bapen.org.uk/pdfs/bapen_pubs/bapen-toolkit-for-commissioners-and-providers.pdf
  29. British Association for Parenteral and Enteral Nutrition website. e-learning resources on nutritional screening for hospitals and the community. www.bapen.org.uk/screening-for-malnutrition/must/must-toolkit/e-learning-resources-on-nutritional-screening-for-hospitals-and-the-community (accessed 29 January 2013).
  30. Elia M, Russell C (on behalf of the Group on Nutrition and Sheltered Housing). Screening for malnutrition in sheltered housing. Redditch: The British Association for Parenteral and Enteral Nutrition, 2009. Available at: www.bapen.org.uk/professionals/publications-and-resources/bapen-reports/screening-for-malnutrition-in-sheltered-housing
  31. Elia M, Smith R (on behalf of The British Association for Parenteral and Enteral Nutrition and its collaborators). Improving nutritional care and treatment: perspectives and recommendations from population groups, patients and carers. Redditch: BAPEN, 2009. Available at: www.bapen.org.uk/pdfs/improv_nut_care_report.pdf
  32. Centre for Sheltered Housing Studies. Good practice guide: addressing malnutrition. CSHS, 2009. Available at: www.chs.ac.uk/index.php?page=_Good_Practice_Service&id=2033