BAPEN Nutritional Care Tool

introduCing the BAPen nutritionAl CAre tool

Anne holdoway consultant dietitian, chair of Parenteral & enteral nutrition group of the bdA and bAPen council Member

Mike Stroud President of bAPen

Ailsa brotherton chair of the quality and Safety committee, bAPen

dr Ailsa Brotherton, Anne holdoway, dr mike Stroud on behalf of the BAPen Quality group*.

a new measurement tool to support the delivery of improvements in nutritional screening, nutritional care processes, outcomes and the patient experience.

In recent years, in collaboration with key stakeholders, including the British Dietetic Association and the Royal College of Nursing, the BAPEN Malnutrition Action Group have undertaken several national nutrition screening weeks (NSWs). Conducted over four years (one per season) in a variety of care settings, the NSWs have generated one of the largest malnutrition data sets in the world. Despite best efforts of many organisations and individuals to tackle malnutrition, the data illustrates the continuing high prevalence of malnutrition in the UK, with an estimated three million individuals being malnourished or at risk of malnutrition.

Failure to treat malnutrition is a costly business. In 2007, the costs associated with malnutrition were estimated to be £13 billion; this has risen to approximately £20 billion in 2014. These costs arise from the increased cost of caring for someone with malnutrition and the greater utilisation of healthcare resources. The personal cost to individuals and their families is also significant, and are reflected in an increased mortality rate, increased admissions to hospital, increased pressure ulcers, falls and infections and an overall decrease in quality of life.

Combating malnutrition in the UK continues to present a significant challenge. A shift in mind-set is now needed to work together to find innovative solutions and monitor their impact. In this article we introduce the latest data-gathering tool that will enable us to work together towards monitoring the provision of nutritional care, evaluate practice and identify areas for improvement.

tAcklIng MAlnutrItIon - AchIeveMentS to dAte In 1992, the King’s Fund published the report: ‘A Positive Approach to Nutrition as Treatment’. This landmark document became available as a motivated group of nutrition champions established BAPEN. Founded by core groups representing nursing, dietetics, doctors, pharmacy and scientific professions, patients and members of industry, BAPEN set in motion a move to raise the profile of nutrition as an integral component of healthcare.

In conjunction with the work of BAPEN, the last two decades have seen numerous national, regional and local nutrition initiatives such as ‘protected mealtimes’ and ‘Nutrition Now’ (Royal College of Nursing) and the publication of numerous standards, including the NICE guidance CG32, ‘Nutritional support in adults’ (2006) and the NICE quality standards QS24 (2012), which have helped to raise awareness of the prevalence and treatment of malnutrition. In addition, both governmental and non-governmental organisations have championed the need for nutritional care across care settings, facilitated by those in practice and those commissioning services.

Whilst it is evident that ‘MUST’ has helped to detect malnutrition, malnutrition rates have changed little in 20 years. Combating malnutrition therefore remains a significant challenge. Part of the reason for the ongoing issue may be a lack of focus on measuring

Measurement for research Measurement for learning and process improvement

Purpose to discover new knowledge

to bring new knowledge into daily practice tests one large “blind” test Many sequential, observable tests biases control for as many biases as possible Stabilise the biases from test to test data gather as much data as possible, ‘just in case’ gather ‘just enough’ data to learn and complete another cycle duration can take long periods of time to obtain results ‘Small tests of significant changes’ accelerates the rate of improvement

Source: Institute for health care improvement: www.ihi.org/resources/Pages/howtoImprove/ScienceofImprovementestablishingMeasures.aspx

the impact of initiatives in delivering real improvements in nutritional care. Measurement to date has largely focused on catering, the quality of food served, rates of nutritional screening and targeted reductions in oral nutritional supplement usage. Measurements have however failed to capture in a meaningful way and at scale, the quality of nutritional care planned, delivered and the nutritional outcomes achieved.

the rAtIonAle for develoPIng A new MeASureMent tool Amongst senior professionals within BAPEN, it was noted that, whilst the NSWs have illustrated improvements in screening rates, smaller scale audits, submitted as abstracts to the Annual BAPEN conferences, suggest that there might be a problem with accuracy of completion of screening tools. In addition, little remained known, collectively, on the provision of nutritional care that followed on from screening.

These concerns prompted the multidisciplinary quality group within BAPEN to focus on a shared interest, which was to develop a new measurement tool to answer key questions that were emerging. Questions included: • How accurate is the screening that is being undertaken? • What proportions of patients at risk have a nutritional care plan and are those care plans implemented and acted upon? • What are the nutritional outcomes following screening and care planning? • How good is the patient’s experience of nutritional care? • How do we benchmark nutritional care and what variation exists across the system? • Which organisations or units are outliers, both positive and negative?

To gather such information in a systematic way on a national basis, the Quality group felt that a measurement tool was essential. This drive reflected recent shifts in the NHS where new measures to track improvement, as opposed to measurement for performance (judgement) or measurement for research, have evolved. We were fortunate to welcome Kate Cheema from the Quality Observatory to the working group. Kate brought knowledge of measurement within the wider healthcare arena to the group and her involvement helped facilitate the groups’ understanding of measurement, highlighting that measurement to determine improvements could be differentiated from measurements for research.

Put simply, appropriate measures are essential for a team to determine if the changes they are implementing are leading to improvements and for measuring the sustainability of improvements. Table 1 below outlines the difference between measurements for research purposes and measurement for process improvement (IHI).

the PurPoSe of the bAPen nutrItIonAl cAre tool Over many months, through a process of iteration and testing amongst users, including more than 80 representatives from nursing and dietetics, the new measurement tool, suitably named the BAPEN Nutritional Care Tool, was devel-

oped to enable teams to deliver and measure improvements in nutritional care at a local level.

Building on the national nutrition screening weeks’ data collection, the tool utilises quality improvement methodology (i.e. the data is intended for improvement purposes, not performance management or research). The final tool is of succinct design that incorporates: • process measures - prevalence of malnutrition and nutritional care processes; • outcome measures - weight loss (trackable over time for the duration of admission); • patient experience measures - of the nutritional care received.

Designed by the multi-professional BAPEN Quality and Safety Committee, the tool underwent multiple rounds of testing and development within BAPEN’s core groups’ membership. The final rounds of testing involved dietitians and nurses beyond the BAPEN membership. Participants were invited from specialist groups of the BDA such as NAGE; oncology and nursing staff in acute and community care settings and care homes for older people. The patient experience questions were designed and approved by PINNT. Feedback from more than 80 users was obtained from several WebEx online forums resulting in further refinement of the measurement tool following testing in practice. The tool underwent a final round of testing in April and is to be launched at the second Digestive Diseases Federation (DDF 2015) meeting at Excel, London on 22nd to 25th June, where 4,500 delegates are expected to attend from many healthcare disciplines. Following launch at the DDF 2015, there will be pro-active rollout of the BAPEN Nutritional Care Tool and promotion to encourage adoption and implementation.

benefItS of uSIng the bAPen nutrItIonAl cAre tool In your orgAnISAtIon Dr Mike Stroud President of BAPEN commented: “The evidence shows that good nutritional care is one of the most effective treatments available in the NHS, with meta-analyses demonstrating proven benefits from active nutritional support in malnourished patients. As around a third of patients in NHS care are in that group and their higher than average complication and mortality rates can be reduced by a third or more, the evidence is quite clear: the NHS can make enormous cost savings through improved nutritional care in the acute sector.”

Many professionals across the length and breadth of the country are currently involved in leading improvements in the delivery of good nutritional care in our organisations. Trust Boards and/or management teams are undoubtedly asking those leading on the implementation of screening and nutritional care programmes, to provide assurance that the nutritional care subsequently delivered meets existing standards and compares favourably to the care provided in similar organisations. Equally, it is likely that many of us will be required to demonstrate ongoing improvements over time. In the absence of a standardised measurement tool, it will be a challenge to demonstrate goals achieved. We, therefore, anticipate the benefits of using the BAPEN Nutritional Care Tool to include: • assessment of the accuracy of the completion of ‘MUST’ screening across your organisation; using the tool will identify where variation exists for example identify wards who are completing ‘MUST’ accurately and wards who require additional support, e.g. education and training, to deliver improvements; • better identification of the prevalence of malnutrition on admission to an organisation and the variation that exists, e.g. between care of the elderly wards and medical/surgical wards; • assurance of compliance to nutritional care processes and/or identification of where improvements are needed; • a measure of nutritional outcome; a key indicator being the median patients’ weight loss during their admission under your care, taking into account their diagnosis (the tool has been designed to screen out patients for whom tracking weight would not be advisable, e.g. patients with ascites or irreversible severe cachexia); • a measure of the patient experience - this is a unique question in the new tool as other patient experience measures have tended to focus on food availability and quality.

tional care makes a difference. Many dietitians work locally to prove that nutritional care does make a difference. As Dr Mike Stroud President of BAPEN concludes, “If this tool becomes widely adopted, it will also answer a lot of questions currently being asked about malnutrition. It will enable prevalence to be tracked on an ongoing basis, removing the need to undertake separate annual surveys, and the tool contains far more information about the nature of the patients. It can, therefore, generate data which will identify not only prevalence in specific patient groups but acceptable benchmarks for acceptable levels of weight loss for specific diseases, operations and the type of ward/unit providing care. We will then know what good looks like and, hence, where improvements are needed. The new tool is really the next logical step to using ‘MUST’ and it will help to deliver the changes that the NHS is looking for in care and the patient experience.”

We appreciate that the complexities of delivering good nutritional care make measurement fraught with difficulty, especially around the implementation of care plans. As an example, evidence suggests that food record charts are often poorly completed. Similar difficulties exist in selecting appropriate outcome measures given that nutritional status is often affected by many factors other than nutritional intervention, including the presence of underlying disease. However, we believe that beyond advancing the measurement of malnutrition, nutritional care is key to delivering further improvements. The new tool is available to all acute trusts, community hospitals and nursing/residential/care homes that wish to participate in future screening weeks. Summing up, Rachael Masters, Senior Special- ist Dietitian from the Focus on Undernutrition team County Durham commented, “The scale up of the Malnutrition Measurement Tool has the potential to radicalise nutritional care across the UK. This tool could make the vision ‘let’s be the generation that eliminates unnecessary malnutrition’ a reality!” The BAPEN Nutritional Care Tool is being launched at DDF2015. The first national screening week using the new tool is scheduled for September 2015. To register your organisation, please email bapen@bapen.org.uk

Acknowledgements: With thanks to members of the BAPEN Quality and Safety Group, the BAPEN core groups; NNNG and PINNT and members of the BDA who participated in the testing and refinement of the tool.

*Members of the BAPEN Quality and Safety Group – Dr Ailsa Brotherton, Dr Christine Baldwin, Kate Cheema, Liz Evans, Anne Holdoway, Rachael Masters, Lyn McIntyre, Dr Mike Stroud, Vera Todorovic, Dr Elizabeth Weekes, Carolyn Wheatley, Wendy Ling-Relph, Andrea Cartwright, Katherine Wallis and Dr Nicola Turing