Understanding a High-Risk MUST Score
The Malnutrition Universal Screening Tool (MUST) is a five-step process designed to identify adults who are malnourished, at risk of malnutrition, or obese. A MUST score is based on a patient's Body Mass Index (BMI), recent unplanned weight loss, and the presence of any acute disease affecting nutritional intake. When a patient receives a score of 2 or more, they are officially classified as 'high risk' for malnutrition. This score is not a diagnosis but a trigger for immediate, proactive nutritional management to mitigate the severe health risks associated with undernutrition, such as increased hospital stays, complications, and higher mortality rates.
Immediate Action Steps
For any patient with a MUST score of 2 or more, immediate action is paramount. Healthcare practitioners should follow a structured care plan to stabilize and improve the patient's nutritional status.
- Implement a 'Food First' approach: This is the cornerstone of initial treatment. This involves modifying the patient's diet to be high in calories and protein without relying solely on supplements. Examples include fortifying meals with butter, cream, or cheese, and offering nourishing drinks like milk-based shakes or fruit juices throughout the day.
- Provide nourishing snacks: Offer at least two nutrient-dense snacks between meals. Snacks should be appetizing and easy to consume, such as cheese and crackers, yogurt, or fortified milk drinks.
- Record dietary intake: Begin a food and fluid chart immediately to monitor the patient's actual consumption. This provides a baseline and helps track progress. Documenting intake for at least three days is a common practice.
- Investigate underlying causes: A high MUST score is a symptom of a larger problem. Investigate factors that may be contributing to poor nutritional intake, such as:
- Nausea or vomiting
- Pain
- Dysphagia (difficulty swallowing)
- Constipation or diarrhea
- Infection
- Psychological issues, like depression
- Social factors, such as inability to shop for or prepare food
The Crucial Role of the Dietitian
For a patient with a MUST score of 2 or more, prompt referral to a dietitian is a non-negotiable step in the care pathway. While initial 'Food First' advice can be implemented by nurses or other staff, a dietitian provides the specialized, in-depth nutritional assessment and care planning required for high-risk patients. The dietitian will:
- Conduct a comprehensive nutritional assessment to gather more detailed information on dietary history, food preferences, and barriers to eating.
- Formulate a tailored dietetic care plan that may include a detailed meal plan, oral nutritional supplements (ONS), or more complex interventions if needed.
- Address and manage specific clinical needs, such as modifying the diet for swallowing difficulties or high-grade pressure ulcers.
- Work with the patient and family to provide education and support, ensuring the care plan is sustainable.
Ongoing Monitoring and Management
Monitoring is critical to ensure the high-risk care plan is effective. The frequency of monitoring depends on the care setting:
- Hospitals: Patients should be re-screened at least weekly, or more frequently if clinically indicated.
- Care Homes: Re-screening should occur at least monthly.
- Community: Patients should be reviewed at least monthly.
If the patient's nutritional status does not improve after implementing the initial 'Food First' and dietitian interventions, or if weight continues to decline, further escalation is necessary. This may involve re-evaluating the current plan, considering different types of oral nutritional supplements, or discussing alternative feeding methods with the medical team.
A Comparison of Malnutrition Risk Management
| Feature | MUST Score 0 (Low Risk) | MUST Score 2 or more (High Risk) |
|---|---|---|
| Action | Routine clinical care. | Immediate action and referral. |
| Nutritional Advice | No specific advice required beyond ensuring adequate intake if concerns exist. | Intensive 'Food First' strategies: fortified diet, regular nourishing drinks and snacks. |
| Dietitian Referral | Not routinely required. | Prompt referral to a dietitian or nutritional support team. |
| Monitoring | Rescreening based on setting: monthly (care home), annually (community), weekly (hospital). | More frequent monitoring: weekly in hospitals, monthly in care homes/community, with weight and intake checks. |
| Care Plan | No specific nutritional care plan. | A comprehensive, documented nutritional care plan with specific goals. |
| Focus | Maintenance of current nutritional status. | Aggressive intervention to reverse malnutrition. |
Conclusion
A patient with a MUST score of 2 or more is at a high risk of malnutrition and requires a systematic, multi-disciplinary approach to care. The foundation of this care involves immediate dietary modifications through a 'Food First' strategy, coupled with a prompt referral to a dietitian for specialized assessment and management. Regular monitoring and a proactive stance towards investigating and addressing underlying issues are essential for successful outcomes. By adhering to a clear care pathway, healthcare professionals can significantly improve the nutritional status and overall health of these vulnerable patients. For more authoritative information on the MUST tool, visit the BAPEN website.
References
- BMJ Open Quality. (2015). Nutritional assessment in elderly care: a MUST!
- ScienceDirect. (2021). Malnutrition Universal Screening Tool and Patient-Generated Subjective Global Assessment Short Form in relation to clinical outcomes in a university hospital cohort
- Harrogate and District NHS Foundation Trust. (2015). ‘Malnutrition Universal Screening Tool’ (‘MUST’) for Adults
- Devenish Practice. (2015). Promoting Good Nutrition 'MUST'
- Sirona care & health. (2021). Nutrition and 'MUST' Care Plan
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