CONDITIONS & DISORDERS
ONS IN CARE HOMES AND THE COMMUNITY: NUTRITION REVIEW AND STAFF EDUCATION Maria Cazzulani RD Community Dietitian, Derby Teaching Hospitals Maria has training in the specialist areas of body composition, assessment of nutritional status and in using ‘MUST’. She has clinical experience in older people’s nutrition, undernutrition and COPD.
REFERENCES For full article references please CLICK HERE . . .
In Association with the BDA's Older People Specialist Group
Care homes play an important role in the cycle of malnutrition and patient admission to hospital. They are well placed to detect risk and prevent undernutrition in the elderly. Derby Hospitals Community Dietetic Team completed a pilot project within five Derbyshire nursing and care homes around the education of care home staff. This article provides an overview of the work done by the hospital dietetic team to date. There is no universally accepted definition of malnutrition, but one of the most commonly used is, ‘a state of nutrition in which a deficiency, excess, or imbalance of energy, protein and other nutrients, causes measurable adverse effects on tissue/body form, function and clinical outcomes’.1 For many older people, malnutrition is characterised by low body weight or weight loss, meaning simply that some older people are not eating well enough to maintain their health and wellbeing.2 Of the 11.6 million older people in the UK, over a million are estimated to be malnourished or at risk of malnutrition.3 Older adult care home residents are especially vulnerable to the effects of disease-related undernutrition and malnutrition, with 30 to 40% of UK adults at medium to high risk within six months of admission.4 Critically, once a malnourished patient has been identified, then malnutrition can be managed by dietary advice to optimise oral intake as well as with the use of oral nutritional supplements (ONS).5 The efficacy of the use of ONS in malnourished patients is well understood; however, their use may not always be appropriate or acceptable and other methods, such as food fortification, may result in either equal or better outcomes for considerably lower costs.6 Based on this premise, in 2016, Derby Hospitals Community Dietetic Team ran a pilot project within five Derbyshire nursing and care homes based on the education of care home staff.
The outcomes of the pilot were: improved nutritional state of patients measured by an improved Body Mass Index (BMI) and Malnutrition Universal Screening Tool (‘MUST’) score; increased percentage weight gain; reduced length of stay in hospital if admitted; and reduced spend on ONS prescribing. Following the success of the initial pilot project, one dietitian and three dietetic assistants, part of the Derby Hospitals Community Dietetic Team, were funded by South Derbyshire Clinical Commissioners Groups (CCG). OVERVIEW OF PROJECT
Care home residents within the 38 care homes included in the project, were initially screened for nutritional status using the ‘MUST’ tool and current prescription of ONS. Data collected during the initial screening was repeated three and six months after commencement of the intervention. Clusters of residents at care homes were randomly assigned to either ‘intervention’ or ‘wait’ group. Such a design is often acceptable to communities which would not be comfortable with a ‘no-treatment’ group. The intervention consisted of two phases: • Training of care home staff in Food First approach including ‘MUST’ training. • Assessment of nutrition action plans and appropriateness of current ONS prescriptions. www.NHDmag.com July 2018 - Issue 136
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Date of preparation: May 2018 ANUKANI180120b
Like all juice-style ONS, Ensure Plus juce contains milk protein, and is not suitable for patients on a milk protein restricted diet.
Table 1: Care home staff (n=525) feedback on ‘MUST’ and Food First training n = 525
Yes
Yes with practice
No 0
Will change way of working
468 (92.5%)
-
38 (7.5%)
Confidence in ‘MUST’ scoring
381 (75.0%)
111 (21.9%)
2 (0.4%)
Confidence in food fortification
515 (99.8%)
-
1 (0.2%)
The wait group received the intervention after completion of the three-month review. The two phases consisted of the following: Phase 1: Following the baseline assessment, the dietitian and dietetic assistant completed a two-hour training programme on the identification, prevention and treatment of malnutrition, through a Food First approach, discussing the meaning of ‘food fortification’ which implies that everyday foods are added to the diet to increase energy and protein content without increasing volume of food consumed.7 ‘MUST’ training was included in the two-hour session. The training was a whole team approach, including a manager, trained staff, catering staff and healthcare assistance, and required a minimum of 10 staff to attend for each care home. To complete the training, the staff worked through case studies to allow the opportunity to practice completing the ‘MUST’ and were also asked to put together a nutritional action plan, which consisted of an individualised strategy, making the learning relevant to their workplace and allowing the carers to take ownership of changes that needed to take place. Phase 2: At the point of review, the dietitian also assessed the appropriateness of current ONS prescriptions and amended the prescription where required. Feedback from training of staff was extremely positive (see Table 1). Only two members of staff were not confident in using the ‘MUST’ tool, no comments were provided and it is not clear why 38 members of staff stated that they would not change practice; it may be that this was based on existing knowledge, or a reluctance to change. RESULTS AT FOLLOW-UP
No differences were recorded between the train and wait groups and there were no notable differences or changes over time in the ability
of the care home staff to accurately determine ‘MUST’ score. The accuracy of ‘MUST’ score was still low at three and six months’ review (29%). Analysis of the interventions made by the dietitians highlighted issues with the implementation of the ONS stops and switches. For the train group, the data suggests that after baseline, 32 interventions were not implemented correctly (47 correct), similarly, for the wait control group after baseline, 23 interventions were not implemented correctly (29 correct). The same was true following the three-month review for the train group, with 40 interventions incorrectly implemented (39 correct) and the wait group 19 incorrectly implemented (38 correct). CONCLUSION
The work of the Derby Hospitals Community Dietetic Team has been substantive, reviewing residents across 38 care homes. This has realised significant cost savings, without any notable changes in resident outcomes (positive or negative). However, the analysis of the dataset has identified a number of issues with the implementation of the dietitians’ recommendations. Principally, while recommendations were made to stop or switch residents’ prescribed ONS supplements following dietetic plans and advice, between 49% to 67% of the time, these recommendations were not acted upon. I think that the ‘MUST’ and Food First approach training should be delivered with a well-defined diary in conjunction with both community dietetic teams and care home staff. Repeating the training with a regular timescale will allow the staff of each care home to develop their confidence in using the ‘MUST’ tool, as well as putting in place a dietetic plan if ‘MUST’ score is 0 or 1. Furthermore, I think that the implementation of food fortification with everyday food, could be beneficial for residents in terms of palatability, acceptance and, consequently, improvement in malnutrition. www.NHDmag.com July 2018 - Issue 136
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