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Anticipatory Management

As well as preventing malnutrition it is important to anticipate those people who may be at risk of malnutrition. This is achieved through nutritional screening. In 2006, NICE15 estimated that only 30% of patients were screened for malnutrition on admission to hospital.
To address this, the following four core questions are currently being used in hospitals in NI to inform the need for more detailed nutritional screening.
  1. A history of recent unintentional weight loss?
  2. Altered/decreased appetite for 7 days or more?
  3. A risk of under nutrition due to current illness e.g. difficulty eating/drinking?
  4. A need for assistance with feeding?
In other health and social care settings including people's own home, these questions may act as a trigger for the beginning or continuation of a comprehensive assessment of need.

Screening

Screening for malnutrition and the risk of malnutrition should be carried out on people in a range of settings (Figure 6)15.
Figure 6: Example of Settings

  • All inpatients on admission to hospital.
  • On admission to care homes.
  • All patients at their first clinic appointment.
  • On initial registration with a general practice surgery.
  • Repeat screening should be carried out weekly for inpatients and where there is clinical concern in other settings.
Screening should assess body mass index (BMI) and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of further impaired nutrient intake15.

MUST - Malnutrition Universal Screening Tool

Nutritional screening should be undertaken using a validated screening tool. MUSTLink to an external website has been validated for all health and care settings and for use by a range of professionals. Building on "Get your 10 a Day" regional implementation for hospitals, MUST17 is being adopted and is recommended as the first line tool for nutritional screening in all care settings including people's own home. MUSTLink to an external website recommends that people at high risk of malnutrition (i.e. > 2) should be referred to a Dietitian, Nutrition Support Team or implement local policy. This will allow for a full nutritional assessment and treatment plan to be delivered in conjunction with nursing staff and carers and those providing food.
Specialist screening tools may also be used for specific clinical conditions or client groups e.g. Malnutrition Screening Tool (MST) for patients undergoing cancer treatment.
There may be other reasons why people need input from a dietitian e.g. other medical conditions that require special dietary intervention (for example coeliac disease) but where malnutrition is not present. These people should be referred to a dietitian in the normal way.

Enhanced Recovery Programme

The Enhanced Recovery Programme18 is a new approach to the preoperative, intraoperative and postoperative care of people undergoing surgery. It improves quality of care by helping people get better sooner after major surgery and reduces length of hospital stay.
From a nutritional perspective it involves carbohydrate loading (high energy drinks) presurgery and early oral nutrition and hydration postsurgery.