north west wales nhs trust audit and assurance … and weighing of... · clinical audit on:...

North West Wales NHS Trust Audit and Assurance Department

Nutrit ion and Weighing of Patients on admission to Hospital

April 2009

Lisa Burne

Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd, LL57 2PW

Clinical Audit on: Nutrition and Weighing of patients on admission to hospital

Nutrition and Weighing of patients Page 1 of 22 March 2009

Contents

Page Number 1. Quality Check List 2 2. Introduction 3 3. Key Findings – MUST SCREENING TOOL 5 3.1

Standard 1 – MUST Screening Tool must be completed on admission 5

3.2 Standard 2 – MUST Screening Tool must be reviewed weekly 5 3.3

Appropriate action must be taken following MUST Screening Tool 5

3.4 Breakdown per ward 6 4. Key Findings – WEIGHING OF PATIENTS 11 4.1

Standard 3 – All patients must be weighed on admission/or weekend 11

4.2 Breakdown per ward 12 5. Type of weighing scales 16 6. Barriers to weighing patients 16 7. Standards achieved 17 8. Action taken – Medical Directorate 18 Action taken – Women & Families Directorate 19 Action taken – Mental Health & Learning Disabilities 21 9. Lessons learnt 21



1. Quality Check List

Draft document discussions between: Lisa Burne, Senior Clinical Auditor Shan Kennedy, Health Care Standards Manager Dave Harries, Head of Audit and Assurance Anne-Marie Rowlands, Associate Nurse Director Final Report disseminated to: Heads of Nursing – for action Liz Foden Shroff, Head of Dietetics Harriet Naylor, Dietician Directorate General Managers Anne-Marie Rowlands, Associate Nurse Director Shan Kennedy, Health Care Standards Manager Nursing and Midwifery Audit Group Ward Managers via Heads of Nursing



2. Introduction This audit combines the requirement of weighing patients on admission to hospital with completion of the MUST screening tool. Both these aspects are vital in identifying and early intervention in the care of patients at risk of malnutrition. Previous audits have been carried out separately: MUST Screening Tool audit (2007) – carried out by a dietician found that only 51% of patients had a MUST screening tool completed on admission which was reviewed weekly in only 9% of cases. The audit identified a lack of understanding of how to complete the tool and of the subsequent referral requirements. WEIGHING of patients on admission audit (May 2008) – carried out as part of the nursing & midwifery audit programme found that 96% of patients were weighed on admission. 28 patients were not weighed due to justifiable reasons however the MUST screening tool states that alternative measurements and considerations must be taken under these circumstances. In order to ascertain the reasons patients were not being weighed an audit was carried out to ascertain the availability of weighing scales on the wards: Standing Scales were available on 78% of the wards; sitting scales on 70% of the wards and hoist weighing scales on 39%. As a minimum requirement seated scales must be available on all wards to ensure effective nutritional screening and monitoring.

2.1 REASON FOR AUDIT

All patients are to be weighed on admission and as required throughout their hospital stay; this should lead to more patients having the MUST nutritional assessment carried out on admission and hopefully leading to a reduction in length of hospital stay, infections, delayed wound healing and an increase in strength and mobility.

2.2 OBJECTIVE

This is an extremely important audit to measure whether practice has improved following the action taken from the previous audit

2.3 ASSURANCE

Strategic aim 1: Provide high quality of care Strategic aim 1: To attain, or surpass, government and local targets. Strategic aim 7: Be a learning organisation Strategic aim 8: Create an environment that is fit for user needs Domain: The Patient experience – Healthcare Standards 2 and 9 Domain: Clinical Outcomes – Healthcare Standards 11 and 12 Domain: Healthcare Governance – Healthcare Standard 28

2.4 SOURCE OF EVIDENCE ON WHICH AUDIT IS BASED

Council of Europe Recommendations on Food and Nutritional Care in Hospitals Standards BAPEN Malnutrition Universal Screening Tool (MUST) Screening Tool National Institute of Clinical Excellence (NICE) (2006) Nutrition Support in Adults Royal College of Nursing (RCN) (2007) Nutrition Now. Principles for Nutrition and Hydration NSF for Older People



2.5 CLINICAL IMPLICATIONS TO THE PATIENT / RISK IMPLICATIONS TO THE

TRUST Unrecognised malnutrition; increased length of hospital stay, increased risk of infection, reduced quality of life, reduced strength and mobility, delayed wound healing

2.6 PATIENTS TO BE INCLUDED A random selection of five patients per ward were to be audited. 2.7 TIME PERIOD March 2009 2.8 PATIENT AGES All ages 2.9 DATA SOURCE Case notes 2.10 SAMPLE SIZE 143 responses

Not applicable responses were received from: Theatres, Labour Ward, Minffordd and Dewi Ward. Data was received from Alaw and Marl ward after the report had been drafted so are not included.

2.11 DATA RETRIEVAL METHOD Retrospective



3. KEY FINDINGS – MUST SCREENING TOOL

3.1 Standard 1 – MUST Screening Tool must be comple ted on admission Overall compliance is 51%

Directorate % compliance Comments

Community Hospitals and Rehabilitation 73% Medical Directorate 65% Mental Health and Learning Disabilities 23%

In 10 cases Aneurin and Dryll Y Car do not use or have access to the tool so this brought

compliance down

Surgical 38% MUST was not carried out for any patients on Cybi ward as the patients were critically ill

Women and Families 14% Please see page 6-10 for additional information and break down per ward

3.2 Standard 2 – MUST Screening Tool must be review ed weekly Overall compliance is 53% (This is applicable whether or not the MUST was completed on admission or at any point during admission and only to patients with length of stay of over one week)

Directorate % compliance Comments

Community Hospitals and Rehabilitation 79% Medical Directorate 74% Mental Health and Learning Disabilities 32%

In 10 cases Aneurin and Dryll Y Car do not use or have access to the tool so this brought

compliance down

Surgical 13% MUST was not carried out for any patients on

Cybi ward as the patients were critically ill Women and Families 0%

Please see page 6-10 for additional information and breakdown per directorate

3.3 Appropriate action must be taken following MUST screening assessment

99% compliance (This includes cases where no action was required)



3.4 Breakdown per Ward Community Hospitals and Rehabilitation Directorate Standard 1 – MUST Screening Tool must be completed on admission

1

4 4

1

3

5 5 5

2

3

4

1 1

4

2

0

2

4

6

Padarn

, Eryr

i

Peblig

, Eryr

i

Madog,

BYG

Bryn B

eryl

Fali, Y

PS

Cybi, Y

PS

Dysyn

ni, T

ywyn

Blaena

u Ff

Mawdd

ach,

Dolgell

au

Cader

, Dolg

ellau

MUST complete MUST not complete

Overall there were 45 responses from the Community Hospitals; compliance was 73%.

Ward Reason for non-compliance (where provided) Padarn Ward (4) Eats and drinks well so not applicable Late transfer Not applicable No reason stated Peblig Ward (1) Screening commenced in Eryri so no assessment needed Madog Ward (1) Reason not known Bryn Beryl (4) Assessed in Ysbyty Gwynedd – score 0 – so no need for

assessment

Not applicable as patient not malnutritioned Transferred yesterday from Ysbyty Gwynedd No reason stated Fali (2) Patient nutritional state not compromised Patient nutritional state not compromised – short stay

document used in District Nursing Hospital

Standard 2 – MUST Screening Tool must be reviewed weekly

This was applicable to 38 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 30 (79%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: two patients were reviewed monthly or every two weeks. Other reasons provided were that the patients’ nutritional status was not compromised and that their oral intake was good.



Medical Directorate Standard 1 – MUST Screening Tool must be completed on admission

2

5

4

1

3

5

3

1

5

1

0

2

4

6

Moelwyn Aberconwy Morfa Gogarth Prysor Tryfan


Overall there were 31 responses from the Medical Directorate (six from Gogarth); compliance was 65%.

Ward Reason for non-compliance (where provided) Moelwyn Good oral intake MUST completed day after admission Prysor Done on transfer to Prysor but not on admission NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON MORFA AND GOGARTH


This was applicable to 19 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 14 (74%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: no problems with eating and drinking, patient has good oral intake.



Mental Health and Learning Disabilities Directorate Standard 1 – MUST Screening Tool must be completed on admission

3 3

1

4

5 5

2

5

2

0

2

4

6

Coedlys Aneurin Cynan Glasmor Dryll Y Car Heulwen Taliesin


Overall there were 31 responses from the Mental Health & Learning Disabilites (one from Taliesin), data was incomplete in one case. Of the remaining compliance was 23%.

Ward Reason for non-compliance (where provided) Aneurin (5) MUST screening tool not used in this setting * Dryll Y Car (5) Do not have MUST screening tool Heulwen (2) One patient refused and one patient had dementia NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON COEDLYS, CYNAN, OR GLASMOR

* Dryll-y-Car is an unusual hospital environment. The ethos is to support people through change and we do this by working in partnership not dictatorship. There are no domestics or catering staff, the meals are planned and catered for by the nursing staff with the clients. Evening meals are planned with the clients, meeting all different nutritional needs. The evening meal is part of the therapeutic environment shared by the staff and clients to accommodate individual needs and abilities. Over the years this approach has influenced a change in the majority of the clients’ nutrition and physical activity through a gradual process. Fruit is always available and the fridges are well stocked with healthy options. Clients are weighed on each admission, and as clients use the service of Dryll-y-Car on a regular basis they are monitored for weight increase and loss and adjust/plan diets accordingly. Standard 2 – MUST Screening Tool must be reviewed weekly

This was applicable to 19 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 6 (32%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: two patients on Glasmor were reviewed frequently but not weekly and in one case it had not been recorded as being done weekly



Surgical Directorate Standard 1 – MUST Screening Tool must be completed on admission

1

4

5

4

1

5

6

0

2

4

6

8

Tegid Ogwen Aran Dulas Cybi


Overall there were 26 responses from the Surgical Directorate (six from Cybi ward) - 38% compliance.

Ward Reason for non-compliance Tegid (4) Transferred from Beuno Three patients were short stay patients Ogwen (1) No evidence of MUST tool – patient was admitted to Hebog Cybi (6) Critically ill patients on admission – unstable NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON ADMISSION TO ARAN,


This was applicable to 16 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); two (13%) did have the MUST screening tool reviewed weekly. Reasons for non-compliance: patients on Dulas ward were reviewed every two weeks or monthly as their dietary intake was very good and there was nothing affecting their diet. One patient was not reviewed weekly on Ogwen and the reason was not known. In one case the patients MUST score was 0 and there was no evidence of weight loss.



Women and Families Directorate Standard 1 – MUST Screening Tool must be completed on admission

1 1

5

0

2

4

6

Llifon Ffrancon


Overall there were 7 applicable responses from the Women and Families directorate; compliance was 14%. Not applicable: Patient in labour and went home the next day (3 patients)

Ward Reason for non-compliance NO REASONS WERE PROVIDED FOR PATIENTS NOT SCREENED ON FFRANCON WARD OR LLIFON WARD


This was applicable to 6 patients overall (MUST screening tool had been completed either on admission or during admission and the patient has been in hospital for over one week); 0 (0%) patients had their MUST tool reviewed weekly. Reasons for non-compliance: no reasons specified



4. KEY FINDINGS – WEIGHING OF PATIENTS

4.1 Standard 4 – Patient must be weighed on admissi on and/or weekend Overall compliance is 75%

COMPLIANT NON COMPLIANT

Directorate On admission

At weekend

Not weighed

No evidence *

Community Hospitals and Rehabilitation

26 (58%) 15 (33%) 3 (7%) 1 (2%) Medical Directorate 14 (45%) 6 (19%) 6 (19%) 5 (16%) Mental Health and Learning Disabilities

25 (81%) 2 (6%) 4 (13%) Surgical 9 (35%) 3 (12%) 9 (35%)

5 (19%) (Cybi ward)

Women and Families 7 (70%) 3 (30%) TOTAL 81 (57%) 26 (18%) 25 (17%) 11 (8%)

* Where there is no evidence documented in the case notes that the patient has been weighed this has been included as non-compliant Refer to pages 12 – 16 for breakdown of wards



4.2 Breakdown per ward Community Hospitals and Rehabilitation Standard 4 – Patients must be weighed on admission/at weekend

5 5

4

2

5 5 5 5

2

3

1

3

0

2

4

6

Padar

n, Eryr

i

Peblig

, Eryr

i

Mad

og, BYG

Bryn B

eryl

Fali, YPS

Cybi, Y

PS

Dysyn

ni, T

ywyn

Blaenau

Ff

Maw

ddach

, Dolg

ellau

Cader,

Dolgell

au

Weighed Not weighed

Overall there were 45 responses from the Community Hospitals and Rehabilitation Directorate - 91% compliance. 36% of these patients were weighed at the weekend rather than on admission. Madog Ward: One patient was not weighed on admission but was weighed weekly thereafter Bryn Beryl: Three patients were not weighed on admission; one patient was aggressive and one would be weighed at weekend if feeling stronger, reason not documented for the third. However there was no documented evidence that the patients were weighed at all during their admission



Medical Directorate Standard 4 – All patient must be weighed on admission/at weekend

4

5

3

5

3

1

5

3

2

0

2

4

6

Moelwyn Aberconwy Morfa Gogarth Prysor Tryfan

Weighed Not weighed

Overall there were 31 responses from the Medical Directorate - 65% compliance. 30% of these patients were weighed at the weekend rather than on admission. Morfa Ward: Five patients were not weighed on admission, two patients were weighed on transfer to rehab and one patient arrived at tea time. There was no documentation that two patients had been weighed at all during their admission. Gogarth Ward: Three patients were not weighed on admission; one patient had poor mobility, one patient remained in pain and the third patient was being barrier nursed and was bed bound – chair hoist not appropriate – there was no documentation that any of the three patients had been weighed during their admission. Moelwyn Ward: One patient was not weighed on admission as they had a fracture neck of femur and were in pain – there was no documented evidence that the patient was weighed during their admission. Tryfan Ward: Two patients were not weighed on admission; the reason was not known in one case and in the other the patient was unable to weight bear. It was unknown in one case whether the patient was weighed at any point during admission and in one case it was not applicable as it was the patients’ first day.



Mental Health and Learning Disabilities Directorate Standard 4 – patients must be weighed on admission/at weekend

4

5 5

4

5

4

11 1 1

0

2

4

6

Coedlys Aneurin Cynan Glasmor Dryll Y Car Heulwen Taliesin

Weighed Not weighed

Overall there were 31 responses from the Mental Health and Learning Disabilities Directorate - 90% compliance. 8% of these patients were weighed at the weekend rather than on admission. Coedlys: One patient was weighed the day after admission rather than on admission. Aneurin Ward: One patient refused to be weighed on admission but was weighed weekly thereafter. Glasmor Ward: One patient refused to be weighed on admission but was weighed frequently thereafter. Heulwen Ward: One patient was unable to be weighed on admission as they had dementia/restless agitation, but this patient was weighed weekly thereafter.



Surgical Directorate Standard 4 – patients must be weighed on admission/at weekends

4

3

4

5

1

2

1

5

0

2

4

6

Tegid Ogwen Aran Dulas Cybi

Weighed Not weighed

Overall there were 26 responses from the Mental Health and Learning Disabilities Directorate - 46% compliance. 25% of those patients weighed were weighed at the weekend rather than on admission. Tegid Ward: Five patients were not weighed on admission; the reason was not known in two cases; one patient was weighed in pre-op and one patient was weighed on transfer to rehab. Three of the five patients were overnight stay only. Ogwen Ward: One patient was not weighed on admission as they were too poorly but they were weighed when condition improved and weekly thereafter. Aran Ward: There was no documented evidence that two patients were weighed on admission or during their stay. One patient had a fracture neck of femur and was unable to be weighed; reason for second patient unknown. Dulas Ward: There was no documented evidence that one patient was weighed on admission or during their stay. Reason not known. Cybi Ward: Five patients were not weighed on admission as they were critically ill; however four patients were weighed during their admission and one could not be weighed in their current bed position (chair position)



Women and Families Directorate Standard 4 – patients must be weighed on admission/at weekends Overall there were 10 responses from the Women and Families Directorate (three were not applicable as they were in labour and left the next day) - 100% compliance.

Ffrancon Ward: Five patients were weighed on admission but were not weighed weekly thereafter as they had mobility and communication barriers.

Labour Ward: Two patients were weighed on admission and one was weighed frequently thereafter however the second patient had not as yet been in for one week. 5 Type of weighing scales Below is a summary of the types of weighing scales used in the Trust

Directorates Type of weighing machine used

Seca sitting scales Arjo weighing hoist

Community & Rehabilitation

Marsden weighcare Arjo bath hoist Medical

Seca Weylex Leyland

Seca sitting scales Mental Health

EKS 830 Seca sitting scales

Seca standing scales Surgical Hill Rom Bed

Women & Families Seca upright

6 Barriers to weighing patients

- Severe pain - Other caring needs are a higher priority - Heavy workload on rest of ward - If patient is non weight bearing there is no equipment on the ward, i.e. a hoist that

also has a weighing scales mechanism; this is a shared hoist with adjacent ward - Resistance, refusal or uncooperative patient, for example patients with dementia - Poor mobility - Difficult to weigh at night – left for day shift to weigh - Bed bound patients have to be hoisted and weighed with borrowed hoist from ITU

(not always available) - Standing scales only available on ward therefore difficult to weigh patients who are

unable to stand - If patient is not on a Hill Rom Bed and unable to be hoisted out of bed - unable to

weigh



7 Standard Achieved

Ref. CRITERION STATEMENT (Relating to the aspect of care being measured )

% ACHIEVED

March 2009

% ACHIEVED 2007/2008

1. MUST Screening Tool must be completed on admission 51% 51%

(November 2007)

2. MUST Screening Tool must be completed weekly 53% 9%

(November 2007)

The previous audit carried out in November 2007 was undertaken by a dietician; therefore there may be some discrepancies in data collection and audit methodology.

3. Patients must be weighed on admission/at weekend 75% 96%

(May 2008)



8 Problems Identified/Action Taken

Please discuss these results and complete the action plan to complete this audit and ensure practice is changed to improve patient care. If problems cannot be solved, please give the reason, i.e, resource implications.

Ref. Finding/Problem Cause of problem

Priority 3 = High 2 = Medium 1 = Low

Action Required Individual

Responsible for action

Implementation date

MEDICAL DIRECTORATE – ACTION PLAN

1.

MUST Screening Tool is not consistently being completed on admission for all patients (51% achieved)

Overall lack of understanding – a common understanding is that if the nutritional state of the patient is not compromised a MUST screening tool is deemed not applicable

3

Awareness and Education. Presentation given by Dietetics March 2009 and ongoing awareness Session

HON , Ward Managers

March 2009

2. MUST Screening Tool is not being reviewed weekly

Common conception is that if nutritional state not compromised (i.e. score = 0) then it does not need to be reviewed weekly. This is not the case the tool states to be reviewed weekly

3 Awareness and Education Ongoing training with dietetics dept

Ward Mangers Ongoing

3. Patients are not being weighed on admission

Poor documentation Unable to weigh patients (see barriers to weighing patients on page 16)

3

Awareness and Education Ongoing training with dietetics dept. Review of weighing




The MUST screening tool states that if unable to weigh patients then alternative methods should be used.

equipment available

4.

Data collection is variable for example one ward might state not applicable if a patient is unable to be weighed where as another ward might state No.

Must be agreed what constitutes a legitimate reason not to weigh a patient or complete a MUST screening tool. These can then be indicated as not applicable across the Trust

3

Awareness and Education Ongoing training with dietetics dept within medicine






Implementation date

WOMEN AND FAMILIES DIRECTORATE – ACTION PLAN

1.



3 Awareness to be raised within ward areas about the use of MUST tool.

Ward managers May 2009.



2. MUST Screening Tool is not being reviewed weekly

Common conception is that if nutritional state not compromised (i.e. score = 0) then it does not need to be reviewed weekly. This is not the case the tool states to be reviewed weekly

2

Only applicable to Ffrancon ward. Maternity patients rarely are inpatients for a period of 7 plus days.

Ward Manager. May 2009.

3. Patients are not being weighed on admission

Poor documentation Unable to weigh patients (see barriers to weighing patients on page 16) The MUST screening tool states that if unable to weigh patients then alternative methods should be used.

2

Scales available in all clinical areas. Reminder to all staff to weigh patients on admission.

Ward Manager May 2009

4.

Data collection is variable for example one ward might state not applicable if a patient is unable to be weighed where as another ward might state No.

Must be agreed what constitutes a legitimate reason not to weigh a patient or complete a MUST screening tool. These can then be indicated as not applicable across the Trust

2

All staff to be reminded to use MUST tool and document the reasons for not weighing patients on admission to wards.

Ward Manager May 2009.







Implementation date

MENTAL HEALTH AND LEARNING DISABILITIES DIRECTORATE – ACTION PLAN

1.

Mental Health & LDS – Aneurin and Dryll Y Car do not have access to the MUST tool, this significantly reduced compliance – if not using MUST what tool is being used to assure patient’s nutritional needs are met

3

Dryll Y Car – do not have copy of MUST screening tool. Associate Nursing Director and Head of Nursing made aware to reach decision and make available. Service Improvement sister has sent MUST screening tool and guidance sent to Dryll Y Car and will liaise with Aneurin ward also.

Service Improvement Sister and Head of Nursing, MH&LDS

July 2009

2.



3

Awareness and Education. Presentation given by Dietetics March 2009 and ongoing awareness Session

HON , Ward Managers

March 2009



ACTION PLAN

1.


Cybi Ward (ITU) – patients are critically ill on admission – if not using MUST what tool is being used to assure patient’s nutritional needs are met

3

No response from Cybi ward – Service Improvement Sister is to liaise with Cybi to arrange screening tool with them

Service Improvement Sister

July 2009

9 Lessons Learnt

The previous MUST screening tool audit was carried out by dieticians and therefore the audit methodology might vary and this could be reflected in the results. Legitimate reasons for not completing a MUST screening tool or weighing the patient must be agreed on; so that data collection does not vary across wards and departments. The MUST tool states ‘if unable to obtain height and weight, use the alternative procedures shown in this guide’ Training – Dietetics are providing training sessions in the form of 30 minute drop in sessions throughout selected days.

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