Best practice for preventing malnutrition

Malnutrition is defined by the National Institute for Health and Care Excellence (NICE) as being a body mass index (BMI) of less than 18.5 kg/m2; unintentional weight loss greater than 10% within the last 3-6 months; or a BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last 3-6 months. Those who have eaten little or nothing for more than five days and/or are likely to eat little or nothing for five days or longer are also at risk and should also be considered for nutrition support. Malnutrition continues to be a major cause and consequence of poor health in older people. According to the British Association for Parenteral and Enteral Nutrition (BAPEN), 33% of people over 65 years old are currently malnourished or are at risk of malnutrition on admission to hospital.1 Those aged over 75 are at the highest risk of malnutrition and this sector of the population is projected to double in the next 30 years.2 The final recommendations in the Francis Report3 on the Mid Staffordshire NHS Foundation Trust and the Care Quality Commission Dignity and Nutrition inspections4 demonstrate that organisations are repeatedly failing to provide older people with the basic right to food, drink and support when they need it. Because older people account for a great deal of hospital activity, if mechanisms are not put into place now to address the issues surrounding malnutrition, the numbers of malnourished people and the associated human and financial costs could spiral upwards in the future. The cost of malnutrition already runs into billions of pounds,5 despite the fact that there are proven interventions that can help prevent, identify and manage the problem and risks promptly, thereby reducing the human suffering and the significant associated costs. Indeed, NICE has identified malnutrition as the sixth largest source for NHS savings6 and has identified that early identification and treatment of malnutrition in adults could save the NHS £45.5 million a year, even after taking into account the costs of training and screening.7 NICE demonstrated the costs and benefits associated with screening and early intervention, and estimated a saving of £71,800 per 100,000 people.8

Consequences of malnutrition

Research has found that individuals who are malnourished will experience increased ill health, increased hospital admissions, increased risk of infection and antibiotic use, longer recovery time from surgery and illness and increased risk of mortality.9-11 When compared with well-nourished people, malnourished individuals have three times the number of hospital admissions and stay in hospital more than three days longer.12 A new guide has recently been produced by the Malnutrition Task Force (MTF) – an independent group of experts from health, social care and local government, united to address preventable malnutrition and dehydration in hospitals, care homes and in the community – designed to help hospitals improve their standards of nutrition and hydration care, particularly among the elderly. The Hospital Guide Preventing Malnutrition in Later Life: Best Practice Principles & Implementation Guide aims to provide an easy to use framework for implementing real change. It also signposts useful resources and tools that are currently available to help hospital staff implement the necessary changes to make a real difference. Commenting on the guide, Dr Mike Stroud, chair of BAPEN’s Quality Group, co-chair of the MTF and leader of the NICE Guideline Development Group on Nutrition Support, said: “This guide is an important step forward as it outlines how hospitals can actually deliver improved nutritional care and comply with existing guidelines. We should not underestimate the complexity involved in delivering good nutritional care across hospital systems given the number of processes, health care professionals and departments involved. However, it has now been seven years since the publication of the NICE Guideline for nutritional support and it is unacceptable that some hospitals are still not compliant with these recommendations – a failure highlighted by both the final recommendations of the Francis Report (2013) on the Mid Staffordshire NHS Foundation Trust Public Inquiry and the Care Quality Commission’s (CQC) Dignity and Nutrition inspections (2013), which have both shown that that hospitals repeatedly fail to provide older people with the basic right to food, drink and nutrition support when they need it. There has never been a more urgent need to act.” The new guide identifies many examples of good practice and existing guidelines, tools and resources that are readily available. It draws on these principles of best practice and provides a clear framework to support senior hospital leaders and clinical teams delivering front line care to take action and make the changes needed. Dianne Jeffrey, chairman of the Malnutrition Task Force explained further why it was necessary to produce the guide. She said: “While there is good practice in many hospitals, CQC reports show that there is still room for improvement and some are failing to provide good nutrition and hydration care for their patients. There is still some way to go before older people can be confident of the good nutritional care they deserve. We have drawn together principles of best practice and examples of what already works well in countering malnutrition as well as identified barriers and have formed this guide. It is designed to help you take action and make the changes needed to improve nutrition and hydration care for your patients. We urge you to work together to implement change and provide safe and high quality care that ensures the dignity of each and every patient.” The guide highlights the five main principles behind the provision of best practice nutrition and hydration care. These incorporate NICE’s nutrition support in adults quality standard (QS24)13 and clinical guidance (CG32).14 These principles include: