Nutrition management of acutely unwell patients in acute medical units

The purpose of this investigation was to support improvements in the identification of malnutrition and management of nutritional needs for patients within acute medical units (AMUs). AMUs are the first point of entry for patients referred to hospital as an acute medical emergency by their GP and those requiring admission from the emergency department (ED).

The investigation uses, as an example, a real patient safety incident in which a man’s nutritional needs were not met for 19 days stay in hospital, of which 13 days were in AMU resulting in him losing up to 26% of his body weight within a six-week period. This is referred to as ‘the reference event’ and was used to examine wider national issues.

The reference event occurred during the COVID-19 pandemic, but the investigation identified that the findings are still relevant to the healthcare system.

Mike was a 61-year-old male who was taken to his local emergency department (ED) by ambulance having been found at home by his son having a suspected seizure. After a day in the ED he was transferred to the AMU.

When he first arrived on AMU, a nutrition screening was carried out using the Malnutrition Universal Screening Tool (MUST). However, the scoring did not reflect his actual risk of malnutrition.

During his stay on AMU, there were attempts to feed him via a feeding tube. These attempts were unsuccessful and Mike did not receive sufficient nutritional support.

Mike’s weight had been documented six weeks earlier, during a previous admission, to be 80.2kg. However, by day 33 in hospital, nursing staff recorded his weight to be 57.8kg. This was a loss of approximately 26% of his body weight.

• Increased length of stays have resulted in a change to the role of AMUs with additional tasks required to meet the ongoing needs of patients. This includes increased needs for nutritional screening but may also be relevant to other areas of clinical care.
• The change in the role of AMUs has also required a change in the type of care delivered by staff working in AMUs who may not have previously been familiar with, or required, to provide nutritional care or interact with dietetics or speech and language therapy.
• Where AMUs are short-staffed or rely heavily on agency workers who may be unfamiliar with the environment or process, there is a risk that screening for malnutrition may not always happen in a timely way.
• Recruitment challenges created conditions where the national staffing guidance could not be followed.
• There are digital systems available that have the functionality to support staff in managing initial and ongoing nutrition assessments. However, these may not be widely available or consistently used.

HSSIB suggests the following safety prompts for local organisations (local-level learning) to help improve the identification of malnutrition and management of nutritional needs in AMUs:

• NHS trusts can improve patient safety by supporting staff in acute medical units to complete and review MUST screening, identifying where a subjective assessment has been completed, and when further MUST screenings should take place.
• NHS trusts can improve patient safety in acute medical units by identifying and planning for the increased need for routine periodic and ongoing nutritional screening and monitoring to account for increased length of patient stays.
• NHS trusts can improve patient safety by ensuring that both permanent and temporary staff in acute medical units are supported in accessing training, achieving competence, and seeking support in completing MUST screening in line with trust processes.
• NHS trusts can improve patient safety in acute medical units by implementing, and if already implemented then appropriately using, digital systems to monitor and highlight nutritional screening requirements.
• NHS trusts can improve patient safety by reviewing policies, processes, and procedures in acute medical units to ensure they provide clear and easily accessible pathways to refer patients to dietetics or speech and language services.