Nutrition screening practices amongst australian Residential Aged Care Facilities

Abstract

Objectives

To determine the proportion of Residential Aged Care Facilities (RACFs) in Australia who use a nutrition screening tool on residents to identify those at risk of malnutrition, and to review practice following identification of residents as being at high risk of malnutrition.

Design

Multi-center, cross sectional observational study. Setting: Residential Aged Care Facilities.

Participants

The Director of Nursing at each site was contacted by telephone and asked questions relating to current nutrition screening practices at their residential aged care facility.

Measurements

Data was collected from a stratified sample of 229 residential aged care facilities in each state and territory in Australia.

Results

82% of RACFs (n = 188) use a nutrition screening tool on residents to identify those at risk of malnutrition, however only 52% of RACFs (n = 119) used a screening tool which is validated in the residential aged care setting. There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening (p < 0.001). Facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005). The most frequently used nutrition screening tool was the ‘Mini Nutritional Assessment–Short Form (MNA-SF)', which was used by 32% (n = 60) of the RACFs, followed by the ‘Malnutrition Universal Screening Tool (MUST)' (15%, n = 29).

Conclusion

We found that the majority of RACFs in Australia use a nutrition screening tool, however many of these RACFs use a tool which has not been validated in the RACF setting. This study highlights the need for greater dietetic advocacy in using validated nutrition screening tools to ensure malnutrition is identified.

Introduction

Malnutrition is frequently unrecognised in older adults living in residential aged care facilities (RACFs) (1). Malnutrition in older adults has been strongly associated with adverse clinical outcomes such as poor physical function and delayed recovery from illness (2, 3, 4), increased risk of osteoporosis (5), an increased incidence of falls (3), hip fractures (6), pressure ulcers (7), and depressive symptoms (8). Recent Australian data has reported that up to 50% of aged-care residents are malnourished (9, 10).

Nutrition screening has been defined by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) as cited in Mueller et al (11) as, “a process to identify an individual who is malnourished or who is at risk for malnutrition to determine if a detailed nutrition assessment is indicated”. Nutrition screening in residential aged care facilities requires documentation of nutrition information and the use of nutrition care plans which triggers dietetic interventions which in turn leads to a reduction in hospital admissions by 31% and reducing the length of hospital stays by 58% (12).

There are five nutrition screening tools that have been validated in the residential aged care setting. These are the Mini Nutritional Assessment-Short Form (MNA-SF) (used in older adults only) (13), Malnutrition Universal Screening Tool (MUST) (14), Malnutrition Screening Tool (MST) (15), Simplified Nutritional Appetite Questionnaire (SNAQ) (16), and Simple Nutrition Screening Tool (17, 18).

Isenring et al (2012) (19) assessed the validity of several malnutrition screening tools for use in the long-term aged care residential setting and anthropometric parameters against the Subjective Global Assessment tool (SGA) which is a validated nutrition assessment tool in the residential aged care setting (20). They found that the Malnutrition Screening Tool (MST) (15), MUST (14) and MNA-SF (13) have acceptable concurrent validity. The MST (15) had the best sensitivity and specificity compared to SGA, followed by the MNA-SF (13), MUST (14) and Simplified Nutritional Assessment Questionnaire (SNAQ) (16).

As there are currently no data on nutrition screening practices in Australian aged care residences, the aim of this research was to determine how many RACFs in Australia routinely use a nutrition screening tool on residents to determine those at risk of malnutrition and to review practice following identification of residents as being at high risk of malnutrition.

Methods

In this cross-sectional study, data was collected from a stratified sample of residential aged care facilities in each state and territory in Australia in 2014. A sample of 25% of the RACFs in Australia was systematically selected in a 1 in 4 order from an alphabetically listed group. The Director of Nursing at every fourth residential aged care facility in each state and territory (as listed on the aged care connect website: www.agedcareconnect.com.au) was contacted by telephone and asked standardised questions relating to current nutrition screening practices at their residential aged care facility. RACFs were categorised as metropolitan or rural.

Data were entered into IBM SPSS Version 21.0 software (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). Sample characteristics were reported as frequencies, means and standard deviations. Associations between non-continuous variables were assessed using the Chi-squared test. Associations between non-continuous variables and continuous variables were assessed using an independent T-test. A p-value of less than 0.05 was considered to be statistically significant.

The research was approved by the University of Canberra Human Research Ethics Committee, protocol approval number HREC 14 53. Informed consent to participate in the study was obtained from all participants.

Results

Of 2756 RACFs in Australia, 869 were contacted by telephone. Of these, 88 declined, and 552 were not available to speak or could not be contacted, providing a response rate of 26.4%. Two-hundred and twenty-nine RACFs participated in the study across all states and territories in Australia. Thirty-one from Queensland, 26 from New South Wales, 64 from Victoria, 9 from the Australian Capital Territory, 21 from Tasmania, 43 from South Australia, 6 from the Northern Territory and 29 from Western Australia.

The median number of residents within all facilities was 65.0 (range 10-210). The baseline characteristics of our study population are summarised in Table 1.

Table 1.

Baseline characteristics of study population

Type of care	Median number of residents	Range
Low care	7	0-140
High care	45	0-185
Dementia	18	0-5

Eighty-two percent (n = 188) of RACFs reported using a nutrition screening tool to identify residents at risk of malnutrition, however only 52% of RACFs (n = 119) used a screening tool which has been validated in the residential aged care setting. Nutrition screening occurs when the resident arrives at the RACF in 75% (n = 172) of RACFs. There was no association between using a nutrition screening tool and location (metropolitan or rural/remote) (p = 0.512). All RACFs in both South Australia and the Australian Capital Territory used a nutrition screening tool. Figure 1 shows the frequency of nutrition screening after arrival in Australian RACFs.

Figure 1.

Frequency of nutrition screening after arrival in Australian RACFs

Figure 2 shows the distribution of nutrition screening tools used amongst RACFs in Australia. The most frequently used nutrition screening tool was the ‘Mini Nutritional Assessment – Short Form (MNA-SF)', which was used by 32% (n = 60) of RACFs. Followed by the ‘Malnutrition Universal Screening Tool (MUST)' (15%, n = 29), and the ‘Malnutrition Screening Tool (MST)' (14%, n = 27). The ‘Simplified Nutritional Appetite Questionnaire (SNAQ)' was used by 2% (n = 3) of RACFs. Twelve percent of RACFs (n = 22) were unsure as to which nutritional screening tool was used in their facility, and 8% (n = 16) used a nutritional screening tool which was “developed by the organisation”.

Figure 2.

Distribution of nutrition screening tools used amongst RACFs in Australia (n = 188)

‘Nutrition and hydration assessment' as the nutritional screening tool was used by three sites (2%), and one site (0.5%) used the ‘Aged Care Funding Instrument (ACFI)' as their screening tool. Twelve RACFs (6%) used a nutrition screening tool as part of a computer package. Four sites (2%) used ‘I-care', three sites (2%) used ‘Leading Nutrition: Weight Tracker', three sites (2%) used ‘Platinum 5', one site (0.5%) used ‘Management advantage' and one site (0.5%) used ‘Autumn Care'.

The staff members in 63% of RACFs (n = 144) had been trained to conduct nutrition screening. In 23% (n = 44) of RACFs, the same staff member screens residents, with the staff member who screens residents varying in 58% (n = 111) of RACFs, and the staff member who screens the residents sometimes varying, but often the same staff member in 18% (n = 35) of RACFs. The staff member most likely to conduct the nutrition screening was the Registered Nurse (RN) (45.3%, n = 86), or a combination of staff members (including a combination of Enrolled Nurses (EN), RNs, Clinical Nurse Specialists (CNS), Dietitians and Personal Care Workers) (44%, n = 84). A Dietitian was responsible for conducting nutrition screening in 10 RACFs (5%), and a CNS in 7 RACFs (4%), and an EN in 3 RACFs (2%). There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening (p < 0.001).

Residents that are identified to be ‘at risk' of malnutrition were both referred to a dietitian and placed on a high protein, high energy diet in 40% of RACFs (n = 76). Seventy-three RACFs (38%) referred ‘at risk' residents to a dietitian, and 31 RACFs (16.2%) placed ‘at risk' residents on a high protein, high energy diet. Eleven RACFs (6%) did not refer to a dietitian or place the resident on a high protein, high energy diet. The responses from these facilities were varied and included; placing the resident on a food intake chart, further monitoring, and referring resident to a General Practitioner (GP).

Seventy-eight percent of RACFs (n=178) employed a dietitian. In 39% (n = 69) of these facilities this was on an ‘ad-hoc' or ‘as-needed' basis. Thirty percent (n = 53) of these facilities employed a dietitian on a casual basis only, with 16% (n = 28) employed for less than ten hours per week, 2% (n = 4) employed for less than twenty hours per week, and 10% (n = 18) employed between 20 and 40 hours per week. Three percent of RACFs (n = 6) were unsure how many hours per week the dietitian is employed at their facility.

In the 178 RACFs that employed a dietitian, the dietitian in 103 facilities (58%) were involved in menu planning, 133 were involved in menu review (75%), 92 were involved in nutrition screening (52%), and 167 (94%) were employed to conduct resident consultations. Facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005).

Of the 41 RACFs who did not currently use a nutrition screening tool, fifteen (7%) stated that they were considering implementing a nutrition screening tool in the future. Four RACFs made a comment that overweight residents or weight gain in residents was a bigger issue for them rather than undernutrition.

Discussion

This is the first study to our knowledge that has contributed knowledge to the paucity of research exploring nutrition screening practices and employment of dietitians in RACFs in Australia. In this study we found that 82% of RACFs in Australia use a nutrition screening tool, however only 52% of RACFs use a tool which has been validated in the residential aged care setting. It is imperative that validated nutrition screening tools are used to ensure that malnutrition does not go undetected, and to enable staff to introduce relevant interventions such as a high protein, high energy diet.

Fourteen percent of facilities used a tool that was either “developed by the organisation” (8%, n = 16) or was part of a computer package (6%, n = 12). Although this study did not evaluate which screening tool was included in these computer packages, with the increase in the use of technology and mobile devices, it is important that Dietitians are involved in the development and implementation of relevant computer packages or mobile device applications in the aged care setting to ensure that appropriate, validated nutrition screening tools are used in this capacity. In this study, we found that facilities that employed a dietitian were more likely to use a validated nutrition screening tool (p < 0.005). Dietitians are nutrition experts who are able to assist RACFs to identify and implement relevant nutrition screening tools for the residential aged care setting.

Although the importance of screening and assessment of aged care residents to identify those at risk of malnutrition has been identified (1, 21), there are currently no evidencebased statements regarding frequency of nutrition screening for malnutrition in residential aged care settings. However, it has been recommended that nutrition screening occurs on admission in RACFs with periodic reassessment (21, 22, 23, 24). It has been suggested that this reassessment occurs on a monthly basis in this population (25), or more frequently where there is clinical concern (21). In this study, we found that 34% of RACFs screened residents for malnutrition on a monthly basis, and 28% of RACFs screened residents when there was a clinical concern. Merrell et al (24) found that RACFs did not conduct routine nutritional screening to identify those at risk of malnutrition, contrary to national guidelines, but relied on ad-hoc observations and monitoring. Increasing knowledge of the importance of nutrition screening and the suggested frequency amongst RACF staff may improve the frequency of nutrition screening. Nutrition screening should therefore be occurring on admission, and then on a monthly basis (or more frequently where there is a clinical concern).

There was a significant association between facilities using a nutrition screening tool and the staff members being trained to conduct nutrition screening. This is consistent with previous research by Porter et al (26) who found that factors enabling nutrition screening amongst nursing staff were proficient skills and knowledge. Porter et al (26) found that factors that enable nutrition screening included nurses' positive perceptions of the value of the process, and competence in completing the task. Merrell et al (24) also found that attitudes towards nutritional care appear to be linked to staff education improved residents' nutritional status. Beattie et al (27) found that nursing staff have limited knowledge regarding human fluid requirements and the nutrition needs of aged care residents. Bauer et al (28) also found that the majority of residential aged care nursing staff were unable to identify the ‘normal' Body Mass Index (BMI) of older residents. A failure to recognise nutrition as an important aspect of care has been identified as contributing to malnutrition and dehydration in RACFs (27, 29). Our finding highlights the importance of ensuring that residential aged care staff have access to training on nutrition screening, which provides an introduction to further education on the importance of nutrition in RACFs.

A large number (78%, n = 178) of the RACFs employed a dietitian, however the majority of these facilities (84%, n = 150) only employed a dietitian on either an ‘ad-hoc' basis, a casual basis, or less than ten hours per week. Findings from a previous study conducted in the Netherlands (30) found that only 54% of the undernourished aged care residents received nutritional intervention from a dietitian. A limitation of this study is that we did not follow-up on the impact of employing dietitians on the malnutrition prevalence in the RACFs. Future research should also compare patient outcomes in facilities with a full-time dietitian versus an ‘ad-hoc' dietetic service.

With the ageing population, and the increasing need for RACFs in Australia, this sector of the health service is an area of potential employment opportunities for Accredited Practising Dietitians. National Quality of Care Principles for Australian RACFs currently include the requirement that ‘meals of adequate variety, quality and quantity for each care recipient' be provided (31). Dietitians need to be engaged with RACFs to ensure that the nutritional needs of the residents are being met. In addition, Dietitians may improve the nutritional status of residents by being actively engaged in activities such as menu planning, menu review, nutrition screening, nutrition assessment, resident consultations, and staff and resident education sessions.

Early recognition is one of the most important and effective ways to prevent and reduce the prevalence of malnutrition in older people. Nutrition screening is a simple, cost-effective and efficient way to identify malnutrition in our residential aged care residents. This study highlights the need for greater dietetic advocacy in using validated nutrition screening tools and using them at an appropriate frequency. Introducing new Australian National Aged Care Standards (Quality of Care Principles) to include mandatory malnutrition screening of all aged care residents, with appropriate follow-up by Accredited Practising Dietitians, may reduce the risk of malnutrition not being recognised.

Acknowledgements: We would like to thank Sarah Cooper, Mai Duong, Eugenie Hendriksen, Tina Li, Rosalind Morland, Asheesh Saxena and Matthew Walter for their assistance with data collection.

Ethical Standards: This research was approved by the University of Canberra Human Research Ethics Committee, protocol approval number HREC 14 53. Informed consent to participate in the study was obtained from all participants.

Conflict of interest: The authors have no conflicts of interest.