Malnutrition remains a major healthcare problem affecting a significant number of patients admitted to UK hospitals and care homes. Dr Ailsa Brotherton, chair of the British Association for Parenteral and Enteral Nutrition (BAPEN) Quality and Safety Committee, provides an insight into best practice measures in nutritional care.
The largest nutrition screening survey undertaken in the UK by BAPEN found malnutrition is a major health problem affecting around a quarter of patients admitted to hospital and a third of residents admitted to care homes, yet there has been no widely available measurement tool to measure the quality of nutritional care patients receive. Failures in trusts and care homes to meet the required standards of nutritional care for patients and residents have been highlighted in recent years, resulting in a number of inspections and a plethora of nutritional standards and initiatives all aiming to improve the quality of nutritional care that is delivered.
Some progress has been made and there are undoubtedly pockets of excellent practice, but care across the UK remains fragmented and we have been unable to eliminate the unnecessary variation that exists within and between hospitals and other care settings. To date, most organisations have focused on measuring their compliance to nutritional screening on admission and on the implementation of catering standards with little, if any, focus on measuring the quality of nutritional care actually provided, even though there are standards outlining the quality of care that should be delivered. It would be totally unacceptable to offer screening programmes for diseases such as cancer, dementia and diabetes that didn’t then provide and measure the provision of appropriate treatment. The same principle applies to the early detection and treatment of malnutrition; so why does it remain so difficult to deliver good nutritional care and to measure the quality of care that patients receive.
This article highlights the importance of good nutritional care and outlines how organisations can implement a new tool to measure the quality of their nutritional care, highlight where variation exists and identify where they need to make improvements in a ward. The dashboard tool can also be used in care homes and provides assurance evidence for management teams and trust boards.
Why is nutritional care important?
Malnutrition is both a cause and consequence of disease and continues to affect over three million people in the UK with associated health costs exceeding £19.6 billion annually in England alone (Elia 2015). Yet it is still often unrecognised and untreated, especially in frail, elderly individuals, despite having a substantial impact on health and disease in all community care settings and hospitals (Stratton et al, 2003). The NHS is currently facing an unprecedented financial challenge, with many reporting an increase in acuity of their patients, especially in urgent and emergency care pathways, placing even higher demands on scarce resources.
There appears to have been a loss of focus on getting the fundamental elements of care right, especially as patients move between care settings, where it is easy for their nutritional needs to become ignored, amongst the handover of complex clinical information. In these challenging circumstances, organisations can no longer afford to ignore malnutrition and its impact on patient outcomes and length of stay. The benefits of improving nutritional care for patients are immense, especially for those with long term conditions such as stroke, pressure ulcers or falls (BAPEN, 2010).
The evidence clearly demonstrates that if nutritional needs are ignored, health outcomes are worse and meta-analyses of trials suggest that provision of nutritional supplements to malnourished patients reduces complications such as infections and wound breakdown by 70% and mortality by 40% (BAPEN, 2010). The delivery of better nutritional care for individuals at risk will therefore result in substantial cost savings to the NHS (Elia et al, 2005).
What is the scale of the problem?
Whilst there has been widespread recognition of the prevalence of malnutrition for a number of years, BAPEN’s national nutrition screening week data demonstrated that the prevalence of malnutrition remains high, with 24-30% of patients admitted to a UK hospital malnourished or at risk of malnutrition. Despite numerous nutrition initiatives (many of them national) such as ‘protected mealtimes’ and ‘Nutrition Now’ (Royal College of Nursing), and the publication of a plethora of standards, including the NICE Guideline 32 (Nutritional Support in Adults) and the NICE Quality Standards, helping to raise the profile of nutrition, these figures show much more has to be done, not just in hospitals but across a range of care settings. It is unacceptable that the NICE guideline for nutritional support, published over a decade ago, has still not been fully implemented. Around 40% of hospitals have still not invested in the creation of a multidisciplinary nutrition support team; one of the key recommendations in the NICE Guideline. Sadly the costs associated with malnutrition, within the UK have continued to rise; a cost likely to continue to increase without a different approach.
Why is there a need for a nutritional care measurement tool?
Concerns regarding the quality of nutritional care led the Care Quality Commission to undertake themed inspections (dignity and nutrition) in 2011-12 that highlighted shortfalls in care. Despite these efforts, there continues to be widespread failure to deliver system wide quality improvements in nutritional care across acute, community and care home settings, with the exception of small pockets of excellent practice. Nutrition experts have voiced their concerns regarding the ‘tick box’ approach to the process measurement of numbers of patients who have been screened for nutritional risk and numbers with care plans, which has been adopted by many organisations. NHS England has recognised the scale of the problem and has produced commissioning guidance for all commissioners in England, ‘Commissioning Excellent Nutritional Care for all.’
There is also clarity regarding the responsibilities of organisations and the nutritional care they deliver. Every Trust and provider organisation has a duty under the Health and Social Act 2008 (Regulated Activities) Regulations 2014 (Regulation 14) to ensure that patients in their care have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so. Individuals “must have their nutritional needs assessed and food must be provided to meet those needs. This includes where people are prescribed nutritional supplements and/or parenteral nutrition” (Health and Social Care Act, 2008; Care Quality Commission). We have however, until now, not had a widely available measurement tool that allows organisations to measure the quality of the nutritional care they deliver.
Delivering good nutritional care
BAPEN has long been promoting improvements in nutritional care and has promoted five tenets of good nutritional care; 1. Prevent malnutrition where possible. 2. Early screening and detection of malnutrition (For example the ‘MUST’ screening tool www.bapen.org/MUST). 3. Individual nutritional care plans when malnutrition risk is detected. 4. Training and education for all frontline staff involved in the delivery of nutritional care. 5. Improved management and monitoring systems, including an integrated nutritional pathway of care.
However, we know from the national nutrition screening week data that the prevalence of malnutrition in all care settings remains high. BAPEN has therefore developed a tool to support hospitals and care homes to measure the quality of the nutritional care they provide. Building on the work undertaken during the Nutrition Screening Weeks, which created a national picture of the prevalence of malnutrition in the UK, BAPEN has developed a web-based Nutritional Care Tool which enables care homes and hospitals to monitor nutritional screening, the effectiveness of the nutritional care they provide and patient experience.
We appreciate that the complexities of delivering good nutritional care make measurement fraught with difficulty. However, we believe that measurement is key to delivering further improvements in the quality of nutritional care patients receive. The tool was developed and tested with over 80 frontline healthcare professionals across the UK to ensure clinical utility and practicality. This tool utilises quality improvement methodology (i.e. these data are intended to identify improvement opportunities within an organisation, not performance management or research). The tool contains three different types of measures:
The BAPEN Nutritional Care Tool overview
Monitoring nutritional care
Ensuring that individuals who are malnourished have an individualised nutritional care plan which is properly implemented is a basic fundamental element of care that is too often overlooked. Monitoring an individual’s nutritional care, including tracking their weight and any weight changes over time is also important. A key element of this tool is the patient experience section which will support healthcare providers to ensure that patients are receiving sufficient support to meet their nutritional needs. This is of particular importance given the findings of the London School of Economics report that described the widespread failure of hospitals to deliver the support that patients need to eat and drink. The report highlights “Inconsistent and poor standards of help with eating during hospital stays were also a key concern. In 2012, about a quarter of all survey respondents indicated that they needed support with eating during their hospital stay. This is a substantial proportion and points towards the issue of support with eating being a major issue for significant numbers of inpatients - just under three and a half million each year - rather than being a marginal or specialist issue. Of those who needed help with eating, more than one in three (38%) reported that they only sometimes received enough help with eating from staff, or did not receive enough help from staff. We estimate that this is equivalent to around 1.3 million people on an annual basis, of whom about 640,000 are aged 65 or over”. (London School of Economics and Political Science, 2015).
BAPEN has designed the nutritional care tool to be suitable for care homes as well as hospitals, with appropriate setting specific questions. The tool has been extensively tested in both hospitals and care homes with over 50 organisations now registered to use the tool. We also provide a helpline for any queries relating to the implementation of the tool.
The analytics and dashboards
Three core dashboards are available on the tool which covers a range of measures that are likely to be of interest to organisations in assuring their quality of nutritional care. Security protocols ensure that individual organisations will be able to view their own ward and own organisational level data, but not any other organisations’.
The contents of each dashboard are as follows:
Benefits of using the tool
At the moment, to our knowledge, there is no measurement tool which has attempted to measure the quality of nutritional care provided by organisations and therefore, in the absence of such a tool, the Care Quality Commission (CQC) have had to rely heavily on the ‘expert inspection’ and ‘judgement’ elements of their previous inspection model. A major criticism from providers, and especially nurses, has been that this approach is insufficiently robust and is ‘anecdotal’, but neither the CQC nor providers have had a measurement tool which enables ongoing monitoring of nutritional care at a local level and a national level.
Some organisations appear to be continuing to fail to meet this basic standard in a way that meets patients’ expectations (Inpatient Survey, 2013 and 2014). The CQC have powers to prosecute providers who breach this regulation if failure results in avoidable harm. In addition, all Trusts in England are required to demonstrate compliance with the Hospitals Food Standards Panel report (Department of Health) from April 2015 and to have a food and drink strategy in place.
BAPEN has therefore designed the new ‘nutritional care tool’ to enable organisations to measure the nutritional patient care it provides and in doing so enable them to more robustly demonstrate compliance to the nutrition regulation and/or to identify where improvements are required.
This tool has been designed to complement the other work that BAPEN has previously undertaken to support organisations to deliver improvements in nutritional care and our ambition for 2017 is to maximise implementation of the tool.
BAPEN produces a wide range of tools, resources and guidelines designed to help healthcare professionals in hospitals, care homes and the community prevent malnutrition occurring when possible and treat it properly when it does occur. BAPEN’s publications and resources are available on the BAPEN website.
1 BAPEN. Malnutrition Matters - Meeting Quality Standards in Nutritional Care: A Toolkit for Commissioners and Providers in England, ISBN: 978-1-899467-36-5. 2010.
2 Department of health The Hospital Food Standards. Panel’s report on standards for food and drink in NHS hospitals. 2014.
3 Elia M, Stratton R, Russell C, Green C, Pang F. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. Health Economic Report on Malnutrition in the UK. Redditch: BAPEN, 2005.
4 Elia M, Russell CA (eds). Combating malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN. Redditch: BAPEN, 2009.
5 Stratton RJ, Green C and Elia M. Disease related malnutrition; an evidence-based approach to treatment. Oxford: CABI, 2003.
6 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, last accessed 30th June 2015 [http://www.cqc.org.uk/content/ regulations-service-providers-and-managers].
7 Institute of Healthcare Improvement Last accessed on 30th June 2015 [http://www.ihi.org/resources/ Pages/Measures/default.aspx].
8 London School of Economics and Political Science, Older people’s experiences of dignity and nutrition during hospital stays: Secondary data analysis using the Adult Inpatient Survey, Case Report 91, 2015.
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