All Wales nutrition screening audit: nephrology inpatients.
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All Wales nutrition screening audit: nephrology inpatients.
Starter
Malnutrition- a deficiency of energy, protein &
other nutrients that causes adverse effects on
the body (shape, size & composition), the way it
functions & clinical outcomes(MUST 2003).
• Major clinical problem in CKD, and in particular ESRD
- Reported prevalence in dialysis:
30-50%(Fouque at al, 2011).
- Independent predictor of poor clinical outcome-
morbidity, mortality, quality of life
length of stay
Cost implications of Malnutrition • The healthcare cost of managing individuals with malnutrition is more than twice that of managing non- malnourished individuals (Guest et al 2011). • Tackling malnutrition improves: - nutritional status, - clinical outcomes, and - reduces health care use.(Elia & Russell 2009).
Value for money • Disease-related malnutrition costs in excess on £13 billion per annum, based on malnutrition prevalence figures & the associated costs of both health & social care(Elia et al 2009).
B.O.G.O.F • NICE CG32 : ‘substantial cost savings can result from identifying & treating malnutrition’ • CG32 is ranked 3rd in the top clinical guidelines shown to produce savings (NICE 2006). • The cost of managing malnutrition using prescribed nutrition support is low: - just 2.5% of the total expenditure on malnutrition(Stratton 2010).
Welsh Recipe -
‘Blas o Gymru’
• The Welsh Government has recognised the importance of
nutrition & catering as an essential part of the care
patients receive in hospitals.
• 2009 All Wales Nutrition care pathway for
Hospitals……pathway for nutrition screening highlighted.
• 2011 All Wales Nutrition & catering standards for food &
fluid provision for hospital inpatients.
• Nutritional screening is also recommended by DoH, RCN,
RCP, NICE & NPSA.Who’s role is it?
• Chief Executive & • Dietitians
Executive Board
• Nursing staff (incl
• Catering manager HCSW)
• Doctors • Pharmacists, SALT…….
• Everybody’s
responsible!!!!Underpinned by recommendations- • Francis report (2013) and Andrews report (2014) • “a small number of fundamental standards focusing on key areas of patient care”. • “Whether patients are getting food and water, and help to eat and drink if they need”
All Wales Hospital Nutrition care
Pathway protocol states:
• Standards(1)- “ Within 24 hours of
admission to hospital all patients should
be weighed & screened for malnutrition
or risk of malnutrition using a validated
nutritional screening tool”
(WAASP / MUST).• Standards(2)- “When a Nutrition Risk Score (NRS) and weight has been established a multi-professional nutrition care plan should be implemented. The care plan developed will depend on the NRS”.
Nutrition Risk Screening tool - WAASP
MUST
All Wales Renal Nutrition
Screening Audit
• Audit the nutrition screening process of
inpatients in acute nephrology beds
across Wales.
• Collaborative pro-forma designed to look
at patients on admission, during
admission,
their nutritional assessment
& on discharge.Methodology 1. Assessment of nutritional screening process, nutritional care and effect on outcome in all patients admitted to nephrology/transplant wards in Wales over same 2 weeks, June 2014. 2. All patients admitted during this period were assessed and followed up until discharge, or following 2 weeks after audit end.
Demographics 1 – CKD vs Acute
60
CKD Acute
50
No. patients
40
20
30 18
20
19
15 8
28
10 21
9 13 13
0
Cardiff- Swansea Wrexham Glan Ysbyty
neph maelor Clwyd GwyneddDemographics 2- DM vs non-DM
60
non DM DM
50
No. patients
40
31
30
27
30
19
20
14
16
10
17
12 13
9 10
5
0
Cardiff- Cardiff- Swansea Wrexham Glan Ysbyty
neph Transplant maelor Clwyd GwyneddDemographics 3- malignancy vs non
malign non-malig
No. patients.
40
34
39
17 30
17
8 5 7 4 2
Cardiff-neph Cardiff-trans Swansea Wrexham maelor Glan Clwyd Ysbyty GwyneddNutritional screening completed within 24 hours
100
90
80
70
60
% 50
83 88
40 82
75
30
49 43
20
10
0WAASP & MUST
Mean & Median
WAASP score MUST score
10 3
Interventional
8
2
6 Monitor
4
Low risk 1
2
0 Cardiff-neph Cardiff-trans Swansea Wrexham Glan Clwyd Ysbyty
0
maelor GwyneddWeight before & after admission:
Data completeness
Number % completion
Cardiff Nephrology 36/48 75%
Cardiff Transplant 36/39 92%
Swansea 21/38 97%
WXham 8/18 75%
GC 6/21 42%
YG 2/32 6%Weight loss during admission
Number % patients losing
weight
Cardiff Nephrology 22/36 61%
Cardiff Transplant 21/36 58%
Swansea 21/38 55%
WXham 18/24 75%
GC 9/21 43%Weight loss during admission:
mean weight before & after
120
110
Weight Kg
100
90
Before
80
After
70
60
50
Cardiff Nephrology Cardiff Transplant Swansea Wrexham GCL
Before 88.07 79.42 80.37 91.83 79.41
After 80.45 74.94 74 85.3 62.34Weight loss for those admitted with no oedema
12
Kg
10.1
10
8.6
8
6
4 3.2
2.6
2.2
2 1.2
0.8 0.93 0.8 1
0Referred to dietitian or not
60
Not referred
Referred
50
40
19
30 18 19
20 8 21
29
10 21 20 18
16
11
No. patients
0 3
Cardiff- Cardiff Swansea Wxham GC YG
neph transReason for referral to dietitian
Nutrition
Nutrition Electrolyte
K/P/ DM
DM Fluid
Fluid Other
Other
Support
Support info (K/Po)
Cardiff
Cardiff - 79%
23/29 3.5% 1/29 3.5%
1/29 3.5%
1/29 10.5%
3/29
Nephrology
Nephrology
Cardiff -
Cardiff Transplant 52%
11/21 9.5% 2/21 4.5%
1/21 0 34%
7/21
Transplant
Swansea
Swansea 16/20
80% 15% 3/20 0 1/20
5% 0
WXm
WXham 11/16
69% 12.5% 2/16 1/16
6% 0 2/16
12.5%
GC
GC 2/3
67% 0 0 0 1/3
33%
YG 82% 9% 0 0 9%• Length of stay as an outcome. • Influence of the presence of sepsis. Biochemical markers. • Any surgery received. • Bowels. • Type of nutrition support used by dietitians.
Problems with NRS & audit incl: • Not ‘renal focussed’- MUST not sensitive enough in renal inpatients(Lawson et al 2010) • Relies on accurate weight/weight history……oedema/nephrotic patients not considered. • Renal patients referred for other things (Na/K/Po/fluid). • Re-screen logistics.
• Over 2 weeks audit period was data collection true reflection? • Acutely unwell patient group, complex treatments, multi-professional input.
Conclusions • We are currently not meeting standards, for many reasons……. • Education central to moving forwards. • Continue audit-cycle, & look at auditing other CKD groups. • Renal nutrition group (RNG) work into producing a robust, universal renal- specific NST. • Renal Registry area to look at.
Recommendations
All Wales Renal dietitian group to look into
most appropriate screening tool, referral
criteria at ALL stages of CKD to ensure:
• Equity of access to service
• Timely referral & review
• Risk reduction
• Continuous monitoring & re-auditingTime for dessert…… • We are all responsible, & have unique roles to play to ensure adequate nutritional care is attained & maintained in our complex patient group.
• UHW Sally Finlay, Claire Farley, Rachel Long, Fiona Hillen, Helen Long, Andrea Miller, Anne Williams. • North Wales Harriet Williams, Elizabeth Wynne, Caroline Fazakerley, Ffion Huges, Sarah Gooda. • ABMU Sara Watkins, Jill Skinner, Eleri Wright, Emma Catling. • Thanks/Diolch - Dr A Mikhail, Tom Hurley, Chris Brown, Fiona Willingham (RNG)
Diolch –Thanks Cwestiynau?- Questions?
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