The Malnutrition Universal Screening Tool (MUST) is a practical and systematic method developed to help healthcare workers identify adults who are malnourished, at risk of malnutrition, or obese. Created by the Malnutrition Advisory Group of BAPEN in 2003, it is widely adopted in hospitals, care homes, and community settings. The tool uses a scoring system based on three independent criteria to determine the overall risk of malnutrition.
The Five Steps of the MUST Screening Tool
Implementing the MUST tool is a straightforward, five-step process that can be performed by any trained healthcare professional with minimal equipment, such as scales and a tape measure.
- Step 1: Calculate the Body Mass Index (BMI). The individual's weight in kilograms is divided by the square of their height in meters ($kg/m^2$). A BMI score is assigned based on the result. Alternative measurements, like ulna length or Mid Upper Arm Circumference (MUAC), can be used if height and weight are not obtainable.
- Step 2: Note Unplanned Weight Loss. The percentage of unintentional weight loss over the past 3-6 months is assessed. A score is given based on the percentage of weight lost.
- Step 3: Establish Acute Disease Effect. This step determines if the patient is acutely ill and has had, or is likely to have, little or no nutritional intake for more than five consecutive days. A score is assigned if this condition applies.
- Step 4: Combine the Scores. The scores from steps 1, 2, and 3 are added together to calculate the overall MUST score. This total score indicates the patient's level of malnutrition risk: low (0), medium (1), or high (2 or more).
- Step 5: Use Management Guidelines. Based on the total score, healthcare professionals can develop a tailored care plan. This may involve monitoring, dietary advice, or referral to a specialist such as a dietitian.
Management Guidelines Based on MUST Score
Once the MUST score has been calculated and the risk level identified, specific management guidelines are followed to address the patient's nutritional needs.
Low Risk (Score = 0)
- Routine Clinical Care: No specific nutritional intervention is required beyond routine care. This can include general healthy eating advice.
- Rescreening: Regular re-screening is recommended. The frequency depends on the clinical setting: weekly in hospitals, monthly in care homes, and annually for high-risk community groups.
Medium Risk (Score = 1)
- Observe and Monitor: The patient's dietary intake should be monitored and documented over a 3-day period.
- Intervention: If intake is inadequate or a concern arises, a care plan is developed to improve nutritional intake.
- Rescreening: More frequent monitoring is necessary, with screening repeated weekly in hospitals or monthly in care homes.
High Risk (Score = 2 or more)
- Intensive Intervention: Immediate and comprehensive nutritional support is initiated.
- Specialist Referral: A referral to a dietitian or a nutritional support team is essential for a detailed assessment and an individualized care plan.
- Regular Review: The care plan should be reviewed frequently to monitor progress and adjust treatment.
Comparison of Risk Levels and Management
| Feature | Low Risk (Score 0) | Medium Risk (Score 1) | High Risk (Score ≥2) |
|---|---|---|---|
| Screening Frequency | Weekly (hospital), Monthly (care home), Annually (community) | Weekly (hospital), Monthly (care home), Every 2-3 months (community) | Weekly (hospital), Monthly (care home or community) |
| Initial Action | Routine clinical care | Observe dietary intake for 3 days | Treat immediately |
| Required Intervention | General healthy eating advice | Dietary advice, food fortification, nourishing drinks, snacks | Referral to dietitian/nutritional support team, intensive therapy |
| Specialist Referral | Not usually required | Consider if intake is inadequate or there are concerns | Immediate referral required |
| Purpose | Ongoing monitoring of nutritional health | Prevent deterioration and address emerging needs | Reverse malnutrition and prevent serious complications |
The Importance of MUST in Healthcare
Early identification of malnutrition through tools like MUST is crucial for preventing adverse health outcomes. Unrecognized or untreated malnutrition can lead to longer hospital stays, increased risk of infections, slower wound healing, and higher mortality rates. The MUST tool's strength lies in its simplicity and reliability, making it suitable for a wide range of clinical settings and for use by various healthcare professionals. By providing a standardized and proactive approach to nutritional care, it helps allocate resources effectively and ensures that patients receive the right level of nutritional support at the right time. A systematic nutritional screening program with MUST has been proven to improve patient outcomes. However, it's important for clinicians to use their professional judgment alongside the tool, as MUST is a screening tool, not a full diagnostic tool. For more information on the tool and its application, see the British Association for Parenteral and Enteral Nutrition (BAPEN) website.
Conclusion
The Malnutrition Universal Screening Tool (MUST) provides a structured and efficient framework for identifying and managing malnutrition in adult patients across all care settings. By assessing BMI, unintentional weight loss, and the impact of acute disease, the tool produces a clear risk score that guides healthcare professionals toward appropriate interventions. Implementing MUST correctly ensures that at-risk individuals receive timely and targeted nutritional support, improving their health outcomes and quality of life while optimizing healthcare resource allocation. Its widespread adoption highlights its effectiveness and importance in modern clinical nutrition practice.
