CLN-SOP-003: Nutritional risk screening and therapeutic diets

Organisation name Site or unit		Standard operating procedure Nutritional Risk Screening and Therapeutic Diets
Document ID	CLN-SOP-003-EN	Version	1.2
Status	To be issued	Issue date
Review date		Replaces	1.0
Owner	Clinical lead for this procedure	Approved by
Classification	Internal	Applies to	All clinical areas
Signature

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

1. Purpose	2
2. Scope	2
3. Definitions	2
4. Background	3
5. Responsibilities	3
6. Materials and equipment	3
7. Safety and exceptions	3
8. Procedure	3
9. Worked example	4
10. Decision points	5
11. Escalation	6
12. Monitoring and compliance	6
13. Records	6
14. Training and competence	6
15. Related documents	6
16. References	6
17. Change history	7
Abbreviations	2
Annex A. Nutrition audit record	7
Annex B. Monitoring chart	7

Abbreviations

Abbreviation	Meaning
MUST	Malnutrition Universal Screening Tool
QS24	NICE quality standard 24, Nutrition support in adults
SOP	Standard operating procedure

Key points

Screen every admitted patient for malnutrition risk with MUST (Malnutrition Universal Screening Tool), using its three steps and total score [1].
A total score of 2 or more is high risk: refer to the dietitian, set goals, and monitor weekly in hospital [1].
Check every therapeutic diet against the order before it is served. A diet that differs from the order is not served.
Stop and get help straight away if an at-risk patient has no screen, or receives a diet different from the order.

Purpose

To treat nutrition as part of clinical care: to identify patients at risk of malnutrition using a validated tool, to put a nutrition plan in place, and to make sure therapeutic diets are delivered exactly as ordered. Malnutrition slows healing, weakens the immune response, and raises the risk of falls and pressure injury. This SOP supports criterion 1.5.

Scope

Element	Coverage
Who	Ward nurses who screen, dietitians, catering staff who prepare and deliver diets, and the clinicians who order diets.
Where	All wards, clinics and departments of the facility, and the catering service.
When	On admission; at the screening interval set in Step 1; when the clinical condition changes; and at every diet order.
Not covered	Enteral and parenteral feeding, which follow the specialist feeding protocol.

Definitions

Term	Meaning
MUST	Malnutrition Universal Screening Tool, a validated tool with three steps: BMI, unplanned weight loss, and acute disease effect [1].
Unplanned weight loss	Weight loss that the patient did not intend, measured over the past 3 to 6 months [1].
Therapeutic diet	A diet prescribed to meet a clinical need, such as texture-modified, diabetic, or low-salt.
Nutrition plan	The record of food, fluid, supplements and referral for a patient at risk.

Background

Malnutrition in hospital is common and is often not recognised. NICE quality statement 1 of the nutrition support in adults standard (QS24) states that people in all care settings are screened for malnutrition and the risk of malnutrition using a validated screening tool, and that hospital inpatients are screened on admission and weekly thereafter [2]. MUST is one such validated tool. This SOP applies MUST as the screening instrument, and sets out how the result is acted on.

Responsibilities

Role	Responsibility
Clinical director	Approves this SOP and receives the quarterly audit.
Ward nurse	Completes MUST on admission, records the score and risk category, starts the nutrition plan, and checks each diet tray against the order.
Dietitian	Assesses patients referred from screening, sets therapeutic diets, and reviews the plan.
Catering lead	Ensures each diet is prepared to the order and delivered under food safety rules.

Materials and equipment

Item	Requirement
MUST screening form	The facility’s current MUST form, on the electronic or paper record.
Scales and height measure	Calibrated, checked each month. Bed or chair scales where the patient cannot stand.
Diet order and tray label	The current order, with the patient’s identifiers on the tray label.

Safety and exceptions

A patient with a known food allergy or intolerance is checked against the diet order before any food is served.
Food is handled under basic food safety rules at every stage, from preparation to delivery.
Where a patient cannot be weighed, record the reason, estimate the weight by a validated method if the facility policy allows, and tell the dietitian.

Procedure

Before you start

Check that the scales are calibrated and that the MUST form is current.
Check the diet order and any allergy alert.

Step 1. Screen with MUST

Step 1 of MUST: BMI. Calculate BMI as weight in kilograms divided by height in metres squared. Score 0 for BMI above 20 (above 30 is recorded as obese, but is scored 0), 1 for 18.5 to 20, and 2 for below 18.5 [1].
Step 2 of MUST: unplanned weight loss. Score 0 for less than 5% loss, 1 for 5 to 10%, and 2 for more than 10%, over the past 3 to 6 months [1].
Step 3 of MUST: acute disease effect. Score 2 if the patient is acutely ill and has had no nutritional intake, or likely none, for more than 5 days [1].
Add the three scores to give the total, and record the risk category.

Step 2. Act on the risk category

Total score	Risk category	Action
0	Low	Routine clinical care. Repeat the screen weekly in hospital. Treat the underlying condition and advise on food and drink.
1	Medium	Observe: record dietary intake for 3 days. If intake is adequate, repeat the screen. If it is inadequate, treat as a clinical concern, set goals, and review the care plan regularly.
2 or more	High	Treat: refer to the dietitian or nutrition support team, set goals, increase overall nutritional intake, and review the care plan weekly in hospital. Treatment is withheld where it would be detrimental or no benefit is expected, and the decision is recorded [1].

Step 3. Plan and refer

For a medium or high score, start the nutrition plan on the same day, and refer to the dietitian for a high score.
The dietitian sets the therapeutic diet and records it on the order.
Record the presence of obesity separately. Obesity does not change the MUST score, but it is recorded so that the underlying conditions can be managed.

Step 4. Deliver and check the diet

Before each tray is served, check the diet on the tray against the current order, the patient’s identifiers on the label, and any allergy alert.
If the diet differs from the order, do not serve it. Inform the catering lead and the ward nurse at once.
Record any refusal or fall in intake, and report it to the ward nurse. Intake that falls below the level in the plan triggers a review the same day.

Worked example

Situation	Scoring and action
A 79-year-old man is admitted with pneumonia. Height 1.70 m, weight 52 kg. He has lost 6 kg over 4 months (about 10%). He has had little food for 4 days.	BMI is 52 ÷ (1.70 × 1.70) = 18.0, which is below 18.5, so Step 1 scores 2. Weight loss of 6 kg from 58 kg is 10.3%, which is above 10%, so Step 2 scores 2. Little intake for 4 days is below the 5-day threshold, so Step 3 scores 0. Total 4: high risk. Refer to the dietitian the same day, set goals, and review the plan weekly.
A patient’s tray arrives with a texture-modified diet, but the order is for a low-salt diet.	Do not serve. Inform the catering lead and the ward nurse at once, and check whether the order has been changed. Record the event as an incident.

Figure 1. MUST screening and action

Decision points

If	Then
Total score 0	Routine care; repeat screen weekly in hospital.
Total score 1 with adequate intake	Repeat the screen.
Total score 1 with inadequate intake, or total score 2 or more	Start the nutrition plan; refer to the dietitian for a high score.
Delivered diet differs from the order	Do not serve it; inform the catering lead and the ward nurse.

Escalation

Event	Inform	Timescale
At-risk patient with no screen	Ward or unit manager	Immediately
Diet served in error	Ward nurse, dietitian and catering lead	Immediately; incident report within 24 hours
Repeated diet errors on one unit	Clinical director and quality team	Within one week

Monitoring and compliance

Indicator	Target	Method	Frequency	Owner
Admissions screened with MUST within the shift	100% of admissions	Audit of 20 records per unit	Monthly	Ward manager
High-risk patients referred to the dietitian the same day	100% of high-risk patients	Audit of high-risk records	Monthly	Dietitian
Diets delivered as ordered	100% of sampled trays	Tray check of 20 diets per unit	Monthly	Catering lead

Records

Record	Kept in	Retention
MUST score, risk category and nutrition plan	Patient record	As set by the institutional retention policy
Diet orders and incident reports	Patient record and incident system	As set by the institutional retention policy

Training and competence

Induction: MUST scoring, the risk actions, weight and height measurement, and the tray check. Competence is assessed by scoring three practice cases correctly.
Annual update: MUST rescoring of audited records, with food safety refresher.

ID	Title	Relationship
CLN-SOP-001-EN	Structured clinical assessment on admission	Admission assessment
CLN-SOP-002-EN	Individualised care planning	Nutrition plan in the care plan

References

BAPEN and Malnutrition Advisory Group. MUST (Malnutrition Universal Screening Tool): the full tool, scoring steps and actions (first published 2003; reprinted 2011). Source read: NHS Scotland copy, https://rightdecisions.scot.nhs.uk/media/1624/must-full.pdf
NICE. Nutrition support in adults, quality statement 1, quality standard QS24. Source read: the 2012 draft quality standard text (consultation draft released 4 July 2012). The final text and its status must be confirmed before publication. https://www.nice.org.uk/guidance/qs24

Change history

Version	Date	Summary of change	Approved by
1.0		First approved version.	ASF Expert Committee
1.2		Substantive revision: MUST scoring steps and actions added from the source; worked example; diet check steps; flowchart and references checked.

Annex A. Nutrition audit record

Use this record for each audit session. Record one line per patient or task observed. Enter Y, N or NA as shown in the column heading.

Date	Unit	Patient reference	Screened on admission (Y / N)	Plan in place if at risk (Y / N / NA)	Diet delivered as ordered (Y / N)	Refusal or intake change recorded (Y / N / NA)	Comment

Annex B. Monitoring chart

The unit records its monthly result on this chart and reviews it at the monthly meeting. Plot each month as a point or a bar, and note the actions taken beside it.

Figure B.1 Admissions screened for nutritional risk by month. Target as set by the facility (see the monitoring table).

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