What is the Malnutrition Universal Screening Tool (MUST)?
Before delving into the details of step 5, it is helpful to understand the purpose of the overall MUST framework. Developed by the Malnutrition Advisory Group (a committee of BAPEN), the MUST is a straightforward, five-step screening tool designed for use by all healthcare professionals across various settings. It systematically identifies adults who are malnourished, at risk of malnutrition, or obese by combining data from three distinct areas: Body Mass Index (BMI), recent unplanned weight loss, and the effect of acute disease. This structured approach ensures a consistent and evidence-based assessment of a patient's nutritional status, forming the basis for subsequent actions.
The Purpose and Process of Step 5
What is step 5 of a MUST screening? Step 5 is the application of management guidelines and/or local policy to formulate a comprehensive care plan. This stage directly follows the calculation of the patient's overall malnutrition risk score (step 4), which categorizes them as low (score 0), medium (score 1), or high risk (score ≥2). The primary goal is to ensure that appropriate nutritional interventions are initiated and regularly monitored, aligning with the patient's specific level of risk.
The actions taken in step 5 are dictated by the patient’s risk category and may vary slightly depending on the specific care setting, such as a hospital, care home, or community. However, the core principles remain the same: provide immediate and appropriate nutritional support, set clear and achievable goals, and establish a consistent schedule for reassessment.
Implementation of the Action Plan by Risk Category
Each risk category triggers a distinct set of actions and management protocols within step 5. This tiered approach ensures that healthcare resources are allocated effectively, providing more intensive support for those with a higher risk of malnutrition.
Low Risk (MUST Score 0):
- Action: Routine clinical care is maintained.
- Interventions: No immediate nutritional intervention is needed, but health and eating advice can be provided if necessary.
- Monitoring: The screening should be repeated periodically based on the clinical setting: weekly in hospitals, monthly in care homes, and annually for at-risk groups in the community.
Medium Risk (MUST Score 1):
- Action: An observation period is initiated.
- Interventions: Dietary intake is monitored and documented, typically over a three-day period. Initial 'food first' advice is often given to encourage high-energy and high-protein foods.
- Monitoring: If intake is adequate, the patient reverts to routine screening, albeit on a more frequent schedule than low-risk individuals (e.g., every 2-3 months in the community). If intake is inadequate, a full care plan is developed, and monitoring continues regularly.
High Risk (MUST Score ≥2):
- Action: Immediate and comprehensive nutritional support is initiated.
- Interventions: This involves implementing the 'food first' approach, providing dietary fortification, and often requires referral to a specialist dietitian or a nutritional support team. The plan focuses on setting clear goals to increase overall nutritional intake.
- Monitoring: The care plan is monitored and reviewed regularly, with weekly reviews typically recommended in hospitals and monthly in care home or community settings.
Comparison of MUST Action Plans by Risk Score
| Feature | Low Risk (Score 0) | Medium Risk (Score 1) | High Risk (Score ≥2) |
|---|---|---|---|
| Primary Action | Routine Clinical Care | Observe and Document Intake | Treat and Refer |
| Interventions | General healthy eating advice as needed | 'Food first' approach, fortified foods if necessary | 'Food first' approach, food fortification, oral nutritional supplements |
| Referral | No referral required | Refer to dietitian if intake is inadequate | Prompt referral to dietitian or Nutrition Support Team |
| Re-screening Frequency | Weekly (hospital), Monthly (care home), Annually (community) | Weekly (hospital), Monthly (care home), Every 2-3 months (community) | Weekly (hospital), Monthly (care home), Monthly (community) |
| Monitoring | Regular weighing and rescreening | Dietary intake charts (3 days) | Close monitoring of care plan, weight, and intake |
Developing a Personalized Nutritional Care Plan
Crucial to step 5 is the development of a personalized care plan, especially for medium and high-risk patients. This involves moving beyond the standardized protocols to address the specific root causes of the individual's malnutrition risk. For instance, the plan might involve: assessing for swallowing difficulties with a speech and language therapist, considering dental issues, addressing mobility problems that affect access to food, and providing meals and fluids with a higher energy and protein content. Ultimately, the care plan serves as a living document, detailing the agreed aims, interventions, and review dates to ensure continuous, person-centered nutritional care.
Conclusion
What is Step 5 of a MUST screening? It is the critical, final stage where the raw data from the initial screening steps are translated into a practical, risk-stratified action plan. By implementing these management guidelines, healthcare professionals can effectively address identified malnutrition risks, ensuring patients receive the right level of nutritional support and monitoring. This final step is what transforms the assessment from a data-gathering exercise into a meaningful clinical intervention, directly improving patient outcomes and overall well-being.
Resources and Further Reading
For more detailed information, consult the official guide from the British Association for Parenteral and Enteral Nutrition (BAPEN).
Further Considerations in Step 5
- Addressing underlying clinical conditions should take priority over other issues, such as treating obesity, for high-risk patients.
- When nutritional intervention is deemed inappropriate, such as in end-of-life care, this is noted and the plan is discontinued in agreement with the medical team.
- The presence of edema or ascites can affect weight readings, so step 5 involves making appropriate adjustments to the weight interpretation to ensure an accurate care plan.
