Introduction
Malnutrition is a significant concern in care homes, often going unnoticed and leading to adverse health outcomes for residents. Implementing a robust nutritional screening process is crucial. The Malnutrition Universal Screening Tool (‘MUST’) is a widely recognised tool designed to identify adults who are malnourished, at risk of malnutrition, or obese. This article explores the implementation of MUST in care settings, drawing upon a quality improvement project that used Plan-Do-Study-Act (PDSA) cycles to enhance its effectiveness. While the original project was conducted in a hospital, the lessons learned are highly applicable to care homes looking to improve their nutritional screening processes using MUST as a key tool.
Initial Challenges in Implementing MUST in Care Settings
The first step in improving any process is to understand the current challenges. An initial assessment, similar to the first audit cycle in the hospital project, within a care home setting might reveal key issues such as:
- Lack of Staff Training: Care staff may not be adequately trained on how to correctly use the MUST tool. This includes accurately calculating MUST scores and understanding the appropriate actions to take based on different risk levels. Incorrect scoring and inaction on high-risk scores can undermine the entire screening process.
- Difficulty in Obtaining Weight History: A significant component of MUST is assessing weight loss. Care homes may face challenges in obtaining accurate pre-admission weight information for residents. This is vital for calculating percentage weight loss, a key indicator of malnutrition risk.
These initial findings highlight the need for targeted interventions to improve the implementation and effectiveness of MUST in care homes.
Enhancing MUST Accuracy and Action Through PDSA Cycles
The PDSA cycle provides a structured approach to quality improvement. Applying this methodology to MUST implementation in care homes can lead to significant enhancements.
PDSA Cycle 1: Education and Information Gathering
Drawing from the hospital project, the first PDSA cycle for a care home should focus on addressing the identified issues:
- Staff Education: Implement comprehensive training programs for all care staff on the correct use of MUST. This training should cover score calculation, interpretation of scores, and the protocols for referral and nutritional support based on risk levels.
- Improving Weight History Collection: Establish a clear process for gathering residents’ pre-admission weight. This could involve requesting information from family members, previous healthcare providers, or using GP records. Documenting this information clearly in resident records is essential.
PDSA Cycle 2: Monitoring and Refining the Process
After implementing the initial changes, the next cycle involves monitoring the impact and refining the process. In the hospital example, while the number of patients screened increased significantly, the accuracy of scoring needed further attention. For care homes, this might translate to:
- Auditing MUST Completion and Accuracy: Regularly audit resident records to check for MUST completion rates and the accuracy of the scores. This will help identify ongoing training needs or areas where the process is still not being followed correctly.
- Ensuring Appropriate Referrals: Monitor whether residents identified as high risk by MUST are being appropriately referred to dietitians or other healthcare professionals for further assessment and intervention.
PDSA Cycle 3: Sustaining Improvement and Proactive Measures
The final PDSA cycle focuses on embedding the improved processes and proactively addressing any remaining challenges. In the hospital project, they found referral rates dipped in the third cycle, highlighting the need for continuous monitoring. For care homes, this could involve:
- Regular Review of MUST Data: Establish a system for regularly reviewing MUST data to identify trends, ongoing training needs, and areas for further improvement.
- Proactive Dietitian Involvement: Consider proactive dietitian involvement, such as regular visits to the care home to review residents at high nutritional risk and provide ongoing support and education to staff. This mirrors the dietitian-led ward rounds implemented in the hospital project.
Conclusion
The MUST tool is a valuable asset for nutritional screening in care homes, but its effectiveness hinges on proper implementation and ongoing quality improvement. By adopting a structured approach like PDSA cycles, care homes can address common challenges such as staff training and data collection, ensuring that MUST becomes an integral and effective part of resident care. Continuous monitoring and refinement are key to maximizing the benefits of MUST and ultimately improving the nutritional health and well-being of care home residents.
