National Update on Malnutrition

Dr Trevor Smith Consultant Gastroenterologist

University Hospital Southampton

BAPEN Executive Officer Chair, British Artificial Nutrition Survey

B A P E N

Malnutrition Matters

British Association for Parenteral and Enteral Nutrition

A multi-disciplinary charity committed to raising awareness of malnutrition and the options for nutritional treatment, along with the impact on health outcomes, resource utilization, and

health & social care budgets.

• Malnutrition = medium + high risk MUST score

• 4 annual screening weeks 2007-11

• 2/3 of hospitals had a nutrition team

• 661 hospitals

• 34,699 patients

• 28% malnourished on admission to hospital

BAPEN NSW Data

BAPEN NSW Data

BAPEN NSW Data

BAPEN NSW Data

• 474 care homes

• 3971 adults

• 35% malnourished

BAPEN Care Home report

BAPEN Care Home report

Prevalence and consequences of malnutrition in the UK

SECONDARY CARE

complications

length of stay

readmissions

mortality

CARE HOMES

30-42% of recently

admitted residents

HOSPITAL

28% of admissions

PRIMARY CARE

hospital dependency

GP visits

prescription costs

SHELTERED HOUSING

10-14% of tenants

HOME

General population (adults)

BMI <20kg/m2 : 5%

BMI <18.5kg/m2 : 1.8%

Elderly: 14%

Prevalence of

malnutrition

Complications of abdominal operations for malignant disease

Meguid et al. Am J Surg 1988

0 10 20 30 40 50 60 70 80 90

100

Complication Rate Post-Operative Mortality

Well nourished

Malnourished

Health & Social Care Budget (England)

Health & social care expenditure associated with malnutrition was £19.6 billion (15% of the total expenditure on health & social care)

Community – people with little or no contact with

services

Community – people in contact

with services

Care Homes

Hospital

93

%

5%

2

%

3 m

illio

n m

aln

ou

rish

ed

The Costs of Malnutrition

Total UK costs of approx

£20 billion (2015)

associated with

malnutrition across

health and social care

NIHR/BAPEN full cost/benefit analysis (2015) – £300 to 400K savings per 100,000 population by implementing simple NICE nutritional measures in hospitals and care homes (largest savings in hospital)

NICE Guidance on Nutrition Support- 5th highest cost savings compared to savings calculated for all pieces of NICE guidance

The costs of providing nutrition support

The costs of providing nutrition support

Nutrition support does not cost money, it saves money

BAPEN Video

• http://www.bapen.org.uk/how-good-is-your-nutritional-care

Key Outcomes

• To achieved by March 2018

– Leadership

– Understand the local burden of malnutrition

– Review existing service provision

– Commission services that:

• Identify at risk populations

• Implement appropriate interventions

• Connect hospital & community services to deliver a nutrition & hydration pathway

– Public awareness of the importance of good nutrition

– Monitor and evaluate services & outcomes

Measuring the Quality of your Nutritional Care

How good is your Trust or Care

Home?

Why has BAPEN developed a new measurement tool?

Background

•Around 30% of patients admitted to UK hospitals are malnourished or at risk of malnutrition.

•Patients who are malnourished have poorer clinical outcomes which improve markedly if proper nutritional care is given, yet our learning from Trusts is that nutritional care continues to be fragmented

•In part, this may reflect the lack to date of any means of measuring the quality of the nutritional care they provide, despite NICE issuing both Guidance and Quality Standards for Nutritional Support in Adults

“I understand first-hand the impact nutritional care has on

many other areas of an individual’s health care. By implementing

an effective monitoring process it will potentially have a positive

impact on the patient’s journey throughout the whole healthcare

system which is surely a good thing!”

Steve Brown, Secretary of PINNT

Problems identified in current approaches

‘Tick box’ exercise

Measurement of nutritional care is lagging behind other areas e.g. Cancer, VTE

Heavy reliance of measuring nutritional screening using retrospective audits

Little if any focus on

Accuracy of screening

Quality of the nutritional care plan developed

Monitoring of the implementation of the care plan (beyond poorly completed food record charts and fluid balance charts)

Lack of focus on re-screening

Poor measurement of patient experience of nutritional care

Even poorer measurement of nutritional outcomes

Poor understanding of the barriers (e.g. lack of equipment/nursing time)

Why has BAPEN developed a new measurement tool?

Pre-2012 Post 2015

0

10

20

30

40

50

60

70

80

2007 (N=175)

2008 (N=90)

2010 (N=141)

2011 (N= 147 )

%

C

e

n

t

r

e

s

0-25% patients

26-50% patients

51-75% patients

76-100% patients

•Data collection was paper based •One week per year selected for national nutrition screening audit •Transfer of data to electronic database by hand •Analysis and written report time consuming

The focus in healthcare is shifting from standalone audits to

quality improvement informed by audits

•Data collection via a web platform •Opportunity for frequent data collection •Scope for extensive analytics with a nutrition dashboard •Instant charting and tracking of data over time using funnel plots, pareto charts and run charts

Nutritional Care Dashboard

Aim • To design a web-based, simple national nutritional care tool to

enable clinicians and organisations to measure the different elements that are required for the delivery of good nutritional care (screening, care plans, outcomes and patient experience) in order to identify where local improvements are required

What does the new tool measure?

Organisational details

•Organisation name •Ward/unit •Speciality •Date of collection •Professional group undertaking the survey

Demographics •Age group •Feeding route •Setting •Diagnosis

Nutritional care •Screening (including score on admission) • Re-screening •Nutritional care plan – documented and implemented •Current weight •Unplanned weight loss •Height •Acute illness AND has there been, or likely to be, no nutritional intake for more than 5 days •Subjective criteria •Barriers to nutritional screening

Patient Experience questions

•Have you received all the food and drink or nutritional care you have needed? •Have you received assistance to eat and drink when you have needed help?

What are the benefits of using the new tool in your practice?

The first tool nationally available that will enable you to measure the quality of nutritional care delivered to your patients and to track improvements over time

Provision of robust assurance to your trust board, through the nutritional care dashboard

Point of care measures – facilitate delivering

improvements whilst the patient is still in your care

Completely voluntary – you

decide the frequency and scale

of use

If used across an organisation will highlight areas of

excellent practice and areas where

improvements are needed

It is free to all NHS and Social Care

Organisations in the UK

Contains patient experience questions, as well as screening,

care planning and outcomes

Online e-learning

modules to help interpret the

data collected

Steps to using the tool?

Step 1

Speak to your Chief Nurse or MD or Nutrition

Steering Committee Chair

Step 2

Agree that your organisation wishes to

participate

Step 3

Agree who will act as administrator

Step 6

Read the User Guide on the website

Step 5

Complete the Registration Form

www.bapen.org.uk

Step 4

Create an account: set a username and password

Step 7

Decide which wards or areas will participate in

data collection and who will collect the data

Step 8

Select a date to begin

Step 9

Collect the data

Step 10

Review the data collected using online analytics

Focus areas- the core dashboard

1. % received all the food and drink and/or nutritional care they have needed (Patient experience question 1)

2. % received all assistance to eat and drink they have needed (Patient experience question 2)

3. ‘MUST’ on admission

4. ‘MUST’ rescreening

5. Patients at risk of malnutrition

6. Patients with >5% weight loss in hospital

BAPEN malnutrition self screening www.malnutritionselfscreening.org

BAPEN e-Learning www.bapen.org.uk

Aims of in-hospital nutrition support

NORMALLY NOURISHED Undernourished

BMI<20 Wt Loss >10%

Partial IF IF

To meet EVERY patient’s needs

BANS HPN Data

BANS HPN Data

2008 2009 2010 2011 2012 2013 2014 2015

NewRegistra ons 157 148 228 262 351 472 400 420

PointPrevalence 413 345 523 611 888 1082 933 1144

PeriodPrevalence 521 435 624 743 1082 1310 1135 1360

0

200

400

600

800

1000

1200

1400

1600

BANS HPN + IV Fluids Data

2011 2012 2013 2014 2015

NewRegistra ons 293 402 546 469 495

PointPrevalence 657 1000 1227 1084 1351

PeriodPrevalence 792 1210 1475 1308 1603

0

200

400

600

800

1000

1200

1400

1600

1800

BANS HPN: Age Categories

0

5

10

15

20

25

16-20Yrs

21-30Yrs

31-40Yrs

41-50Yrs

51-60Yrs

61-70Yrs

71-80Yrs

81-90Yrs

91-100Yrs

2011

2015

% pts >70 yrs: 2008 – 10%; 2011 – 14%; 2015 – 18.5%

0

5

10

15

20

25

30

35

16-20Yrs

21-30Yrs

31-40Yrs

41-50Yrs

51-60Yrs

61-70Yrs

71-80Yrs

81-90Yrs

91-100Yrs

2011

2015

BANS IV Fluids: Age Categories

% pts >70 yrs: 2011 – 16%; 2015 – 24%

BANS HPN: Diagnosis

2008 2009 2010 2011 2012 2013 2014 2015

Cancer 15.3 9.5 14 16.4 18.8 24.6 25.5 27.4

Non-malignantGI 75.8 83.1 79.8 74.8 74.9 70.1 67.8 64.8

OtherCondi ons 8.9 7.4 6.1 8.8 6.3 5.3 6.7 7.8

0

10

20

30

40

50

60

70

80

90

Cancer: 24 pts (2008); 43 pts (2011); 115 pts (2015)

BANS HPN + IV Fluids: Age & Diagnosis

16-70 71-100 16-70 71-100 16-70 71-100

Cancer GI Other

2011 47 9 242 43 18 4

2015 104 30 256 62 39 4

0

50

100

150

200

250

300

BANS HPN + IV Fluids: Age & GI Diagnosis

BAPEN’s vision for success

Page 43

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2

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5

Prevention of malnutrition and dehydration wherever possible

Screening Identify malnutrition/ risk of malnutrition early through

screening and assessment e.g. the ‘MUST’ Tool

Treatment – high quality food and drink, assistance with feeding,

nutritional support where required & ‘individualised’ care pathways

Education and training for all care staff appropriate to setting, profession and

responsibilities

Commissioning and Provider systems that facilitate multidisciplinary

nutritional care in all health and social care settings

The 5 tenets of good nutritional care