A validated nutrition screening tool (NST) was implemented on the general medical and elderly care wards of an acute London Trust in March 2000 and became mandatory for all patients in 2006, to comply with NICE(1) and Trust guidelines. Regular audits over the last decade suggest that the NST is not routinely completed in clinical practice with an average completion rate of 35%(Reference Cundy and Weekes2, Reference Gibbs and Weekes3). The aim of this study was therefore to identify the factors that prompt ward staff to refer malnourished patients to the dietetic department.
A service evaluation was conducted on three wards; two general (wards 1 and 2) and one respiratory (ward 3) over a six-week period. All referrals received by the dietetic department (see table) were reviewed by the researcher to identify the staff member who had made the referral. The member of staff initiating the referral was then interviewed by the researcher using a semi-structured questionnaire and asked to describe the factors that had prompted the referral. Responses were grouped according to similar themes. End of bed charts for all the patients referred were reviewed and NST completion rates were recorded. A one-week audit of NST completion by ward staff was also undertaken on ward 2. The hospital NST was completed by the researcher for comparison with the results obtained by ward staff.
During interview, nursing staff reported that 26 of 49 (53%) referrals made to the dietetic department were not initiated using the NST. While 47% of referrals were initiated using the NST, several ward staff reported only completing an NST to ensure their patient would qualify for referral. Reasons for referral when the NST was not used (53%) include: (a) subjective assessments such as visual examination of the patient, (b) nothing else was working thus a referral was a last resort and (c) ward staff referred with an expectation that their patient would receive a particular treatment, such as nutritional supplements.
The prevalence of malnutrition identified by the researcher in the one-week audit was 29% (n 19). Only three (16%) of these malnourished patients were identified by ward staff using the NST (despite the fact that both researcher and ward staff had access to the same NST). Six of the 19 malnourished patients (32%) were referred to the dietetic service, while 13 malnourished patients (68%) failed to receive a referral.
This study suggests that in this Trust ward staff routinely use subjective criteria to initiate referrals to the dietetic department, failing to use the NST in accordance with hospital policy. As a result, many patients who were identified as nutritionally at risk were not referred to the dietetic department. Although the Trust provides mandatory training on the need for and completion of the NST, it appears that ward staff fail to recognise the role of NST in the appropriate referral of at-risk patients.
