Managing Adult Malnutrition

Including a pathway for the appropriate use of
oral nutritional supplements (ONS)


Sharing Best practice: Previous Award Winners

    Great Western Hospitals NHS Foundation Trust has been given a best practice award for their work in implementing the 'MANAGING MALNUTRITION IN COPD' guide to assess the nutritional status, well-being and health care use of malnourished patients with COPD in the community. The study found that implementation of the pathway can significantly reduce malnutrition risk and health care usage.

    A project team consisting of the Community Dietetic Team Leader, Dietetic Assistant and Community Respiratory Nurse was formed to implement the Managing Malnutrition in COPD pathway, which was launched in 2016. The project aimed to evaluate the current nutritional management of malnourished COPD patients in the locality and assess whether this could be improved by implementing the pathway, while educating patients and healthcare professionals on the importance of nutrition in COPD and raising the profile of dietetics in this field.

    The project was led by the department's dietetic assistant. Nineteen COPD patients identified to be at high risk of malnutrition were managed as per the ‘Managing Malnutrition in COPD’ guide; receiving dietary advice in the form of the ‘Nutrition support in COPD’ patient leaflet, as well as a low volume, high energy, high protein oral nutritional supplement twice daily and were followed up at 6 and 12 weeks. ‘MUST’ score, health care use, health rating and COPD assessment test (CAT) score, over the 12 weeks before and after implementation, were recorded. Compliance with the oral nutritional supplement was assessed over the 12 weeks and patient satisfaction with the management of their malnutrition was measured at the end of the project.

    Implementation of the pathway led to a significant reduction in malnutrition risk (based on ‘MUST’ score) and significant improvement in CAT and mean health rating. The patients’ health care use reduced across the board; including a 50% reduction in hospital admissions and a 20% reduction in GP visits. Patient satisfaction with the management of their malnutrition was very high (96% ) as was their compliance with the low volume, high energy, high protein oral nutritional supplement (90% ).

    On the basis of these results and using average costs1 as well as the cost of ONS2 the team was able to estimate the cost savings of the project to the CCG. The results showed a total cost saving of £80.82 per patient which equated to a total saving of £1,535.58 over the 12 weeks.

    “These figures demonstrate the cost savings on a small pilot study,” says Natalie Kominek, Community Dietetic Team Leader at Great Western Hospitals NHS Foundation Trust. “Whilst we recognise the limitations of such a small study if we were to utilise CCG and prevalence data to estimate the number of adults with COPD and proportion of those likely to be malnourished within the CCG, we estimate that 676 adults with COPD in Swindon CCG may be malnourished or at risk of malnutrition and would benefit from appropriate management. Based on these prevalence figures, implementation of the pathway in all malnourished COPD patients could produce significant and sustainable cost savings for the CCG. With this in mind we are continuing to use the pathway with our COPD patients and have plans to expand its use across the whole community setting.”

    “This project is an excellent example of the work being carried out across the UK to tackle the issue of malnutrition in the community,” says Anne Holdoway, Consultant Dietitian and Chair of the Managing Adult Malnutrition in the Community panel. “We hope by sharing this best practice other professionals will be encouraged to implement such projects in order to ensure that vulnerable individuals, who are at risk of malnutrition, are screened early and receive appropriate and timely nutritional care in the community.“

    1. Curtis, L. & Burns, A. (2015) Unit Costs of Health and Social Care 2015, Personal Social Services Research Unit, University of Kent, Canterbury.


    The Nutrition Support Community Dietetics Team at the 5 Boroughs Partnership NHS Foundation Trust in North West England has utilised the malnutrition pathway materials as part of their ‘Nutrition Link Programme’.

    The aim of this programme was to improve the quality of nutritional care for patients by providing training to care homes and in-patient ward representatives, who are referred to as ‘Links’.

    ‘Links’ are enlisted as a nutritional care lead, acting as a point of contact for staff to disseminate information and lead practical application of nutritional care in their setting. It is hoped that improved standards of nutritional care will improve the quality of life of the patients and increased knowledge will contribute to promoting and encouraging appropriate prescribing and use of oral nutritional supplements.

    The programme was implemented in care homes and with in-patients in community hospitals and on mental health wards in St. Helens and Knowsley. Education sessions were run in various venues across the area.

    The programme began with a scoping meeting to correlate feedback from care homes and community wards on the type of education they would like to receive on malnutrition, in order to address any gaps in knowledge. Based on this feedback, a series of eight education sessions were planned and these are now run on a quarterly basis, consisting of a two-year cycle.

    Topics such as ‘Nutrition and Hydration in Dementia’, ‘Homemade Supplements and Menu Planning for Chefs’, ‘Enriching at Point of Care for Carers’, ‘Introduction to Dysphagia and Texture Modification’ and ‘Understanding Oral Nutritional Supplement Prescribing’ are examples of education sessions that have been run in the first year of the programme.

    All care homes and community wards in the St. Helens and Knowsley area were invited to the quarterly sessions, which are then repeated according to demand. The programme is also used to raise awareness of local nutritional guidelines and the training provided by the dietetics department.

    The ‘Managing Adult Malnutrition in the Community’ website and the videos were signposted as tools for training staff not present at the education sessions, resources of particular use to the project were the practical tool for calculating percentage weight loss (an area which was identified by ‘Links’ as often miscalculated or not understood), the ‘Managing Malnutrition using Risk Category according to MUST’ information sheet and the patient information leaflets - ‘Making the most of your Food’ and ‘Nutrition Drinks: advice for patients and carers’.

    Having these reference materials already produced and available to use free of charge allowed the programme to focus its resources on developing and providing the education sessions while still being able to provide the ‘Managing Adult Malnutrition in the Community’ guidance for written reference.

    An evaluation form of approximately 20 questions was been designed to gather information on current practices in ‘Links’ care settings. This evaluation aims to assess compliance to national guidance such as NICE guidance, NICE quality standards and CQC outcomes. This evaluation will be repeated six monthly throughout the course of the project to determine if involvement in the programme has increased compliance to these standards.

    At each education session participants are asked for feedback on ‘what they found useful / liked about the session’ and ‘what they thought could have been done better / other information they would like’. This information is collected to inform the structure and operation of future sessions.

    In the future we hope to collect more qualitative data on the ‘Links’ experience of being involved in the Nutrition Link Programme and how this has changed and improved practices within each care setting.

    These outcome measures will be used to inform and shape the education provided in order to improve nutritional care standards and strive to increase compliance with national standards.

    For further information on the project please contact The Nutrition Support Team Community Dietetics Service, 5 Boroughs Partnership NHS Foundation Trust, Community Health Services, Unit 4, Kings Business Park, Prescot, L34 1PJ.

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