Malnutrition is a significant problem prevalent in primary healthcare settings. Although widely reported in acute hospitals it is clear that there are greater numbers of patients at risk of malnutrition living at home or in care settings. One study showed that 40% of acute hospital patients were already malnourished on admission.(1)
A local dietetic led project had previously developed and disseminated a structured approach to treatment of malnutrition in Primary Care based on the NICE guidelines(2) using MUST but it was clear that most GP's would not have time during a routine appointment to screen patients. A BMI ⩽18.5 immediately puts a patient in the high risk category, with a MUST score of 2. The aim of this project was to explore whether a single marker could be used to highlight the risk of malnutrition with sufficient impact to draw attention to the problem. Ethical approval for the research was obtained from the Bioscience Research Ethics Committee of the University of Portsmouth. Advice that NHS REC approval was not required due to the nature of the project (audit and service development) was given.
Searches were carried out on the databases at four local surgeries, searching for all patients over 18 years with a BMI ⩽18.5, all patients prescribed Sip Feeds and for patients in both categories. Having identified the cohort of patients, their individual records were searched looking for evidence that their nutritional vulnerability had been recognized and action taken. This included noting age and social demographics, whether they were on a long term conditions register, if they had been referred to a dietitian and if follow up monitoring was in place.
A total of 204 patients were identified from the searches. 89 (44%) had a BMI ⩽18.5 and were not on ONS. 66 (32%) were prescribed ONS with a BMI >18.5. 27 (13%) had BMI ⩽18.5 and were on ONS. 134 (65%) of the total cohort were aged >65. 52 (25%) of patients suffered from one or more of the co-morbidities for which a register is required and that have been identified as being a risk factor for malnutrition; COPD, Heart Failure, Dementia and Cancer. 22 patients were referred to a dietitian. Data was not complete since 22 patients on ONS had no BMI recorded.
The results of the audit indicate that for the majority of patients with low BMI there is no evidence in their medical records to indicate that the risk has been recognized or any action taken. ONS prescribing to patients with normal or high BMI could be taken to indicate that nutritional compromise has been recognized other than through low body weight, but little monitoring is in evidence to evaluate the efficacy of the treatment. The high level of entry to registers for long term conditions and the guidelines associated with the registers outlining desirable frequency of review, offers an opportunity to screen and monitor nutrition status.