Implementing and sustaining cultural and practice change to improve the nutritional status of patients in the acute care setting

Three linked interventions: (i) the introduction and use of a nutritional screening tool - MUST - Malnutrition Universal Screening Tool, (ii) the provision of food supplements at ward level, and (iii) the introduction of a red tray system to identify those patients requiring help with eating and drinking) will be introduced. The interventions will be introduced over a two month period using a stepped wedge trial that ensures that all wards in the hospital will ultimately be included in the intervention. Varying amounts of historical control data will be recorded at all wards in the hospital prior to the introduction of the intervention. The intervention itself will be implemented by pairs of facilitators across four steps (or groups) of six hospital wards each; there will be eight facilitators. One of the facilitatory pair will be a senior nurse from one of the six wards, the other will be a dietician from the hospital. The two facilitators will be educated on the intervention using a 'train-the-trainer' approach and supplied with educational materials for subsequent transmission to nurses (enrolled and registered) working across the six wards in their group. With respect to the intervention: (i) The MUST tool is a standard tool for assessing patients at risk of malnutrition. It comprises four steps including measurement of current weight, height, weight 3-6 months ago and nutritional intaks. Staff will be trained in the use of the tool, and compliance with tool use will be recorded by reviewing patient records. (ii) Patients identified by the MUST as being at medium or high risk of malnutrition will be offered nutritional supplements and nourishing fluids using supplies available at ward level, instituting a menu suitable for people with poor appetites to include nourishing mid-meals and ensuring access to mid meal snacks for “at risk” patients. (iii) a red tray, jug and glass will be provided to patients requiring assistance and encouragement with meals due to inability to feed themselves to a satisfactory level, as identified by the MUST.