Enhancing the nutritional care of older people by recording actual body weight: a quality improvement project
Intended for healthcare professionals
Evidence and practice    

Enhancing the nutritional care of older people by recording actual body weight: a quality improvement project

Cathy Shannon Registered nurse, high dependency unit, Daisy Hill Hospital, Southern Health and Social Care Trust, Newry, County Armagh, Northern Ireland

Why you should read this article:
  • To recognise that accurate, reliable and regular weight measurement is an important intervention to prevent and manage malnutrition in people aged over 65 years

  • To read about a project in an emergency assessment unit that improved the recording of older patients’ actual weight and the completion of Malnutrition Universal Screening Tool scores

  • To identify the need to involve nursing staff at the outset of quality improvement projects if they are to be meaningful and sustainable

Malnutrition can have significant negative effects on older people’s health, as well as a cost burden for health and social care services. Accurate, reliable and regular measurement of a patient’s weight is important for prompt identification and management of malnutrition. This article discusses a quality improvement project that was undertaken in an emergency assessment unit for patients aged over 74 years in Northern Ireland. The aim of the project was to improve completion of Malnutrition Universal Screening Tool (MUST) scores for patients attending the unit by nursing staff recording actual weight rather than recalled weight. A simple intervention of relocating weighing scales in the unit’s triage bay resulted in an increase in completed MUST scores from 60% (n=18) to 97% (n=29) in the six months following the intervention. Feedback from members of the multidisciplinary team indicated that the intervention had a positive effect on the care they provided to patients and on their working relationships with colleagues.

Emergency Nurse. doi: 10.7748/en.2023.e2180

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@cshannon3105

Correspondence

cathy.shannon@southerntrust.hscni.net

Conflict of interest

None declared

Shannon C (2023) Enhancing the nutritional care of older people by recording actual body weight: a quality improvement project. Emergency Nurse. doi: 10.7748/en.2023.e2180

Acknowledgements

The author would like to thank the staff who worked at Belfast City Hospital Direct, Northern Ireland, for their cooperation throughout the project

Published online: 24 October 2023

Background

Malnutrition is ‘a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function, and clinical outcome’ (Elia 2003). While malnutrition can refer to overnutrition and/or undernutrition, in this article it refers to undernutrition.

Malnutrition costs the health and social care system in Northern Ireland an estimated £700 million per year (Managing Malnutrition in the Community 2022). Despite popular assumptions, weight loss is not a normal part of ageing (British Association for Parenteral and Enteral Nutrition (BAPEN) 2017). Accurate and reliable measurement of a patient’s weight is important for the effective and prompt identification and management of malnutrition (Elia 2003, Stratton et al 2006). Weight measurement is integral information required by the multidisciplinary team. It is recorded by nurses as part of a patient’s hospital admission and is a component of the Malnutrition Universal Screening Tool (MUST), which was developed by BAPEN in 2003 and can be used to identify undernutrition (Elia 2003).

Evidence shows that patients with an accurate measurement of weight and completed MUST score have better clinical outcomes (Stratton et al 2006, Managing Malnutrition in the Community 2022). There is also evidence suggesting that visual estimation of patients’ weight is inaccurate and that using this incorrect information as part of clinical decision-making increases the likelihood of negative clinical outcomes (Lorenz et al 2007).

Key points

  • Accurate and reliable measurement of a patient’s weight is important for the effective and prompt identification and management of malnutrition

  • A quality improvement project was undertaken in an emergency assessment unit for older people, involving a simple intervention in which weighing scales were placed in the unit’s triage bay

  • The project led to an improvement in the recording of patients’ actual weight and an increase in completed Malnutrition Universal Screening Tool scores

  • Recording patients’ actual weight early in their time in hospital appeared to be beneficial, leading to improvements in care across the multidisciplinary team

Literature review

Clear and accurate recordkeeping, including patient records, is one of the professional standards that nurses must uphold (Nursing and Midwifery Council 2018). It informs decision-making, as well as providing continuity of care among professionals.

Completion of MUST scores is a nursing key performance indicator (KPI) in all health and social care trusts in Northern Ireland. KPIs are a set of standards to measure, evidence and monitor the quality of patient and client care delivered by nurses and midwives (Northern Ireland Practice and Education Council for Nursing and Midwifery 2018). All health and social care trusts in Northern Ireland stipulate that MUST scores should be completed within six hours of admission, and this time frame is stated at the top of the page in the nursing admission booklet used in secondary care. The time frame for MUST completion is drawn from the National Institute for Health and Care Excellence (2015) quality standard on pressure ulcers, which states that a pressure ulcer risk assessment should be completed within six hours of admission to hospital or a care home. Malnutrition is a risk factor for pressure ulcer development.

A variety of tools are available to estimate an older person’s weight, such as prediction equations using height, mid-upper arm circumference, waist circumference, calf circumference and triceps skinfold thickness (Guerra et al 2021). Many healthcare professionals often use a visual estimation of an older person’s weight, but this can be inaccurate because of the weight redistribution associated with ageing (Guerra et al 2021), and may subsequently lead to an erroneous MUST score being recorded (Seidell and Visscher 2000). As a result, opportunities for early intervention in older people’s nutritional care may be missed (Cattermole and Wells 2021), leading to suboptimal quality of care (Gibson et al 2012, Geriatric Medicine Research Dalhousie University 2020). Furthermore, the inaccurate weight from the nursing admission booklet may subsequently be transcribed by allied health professionals, such as physiotherapists and occupational therapists, thus adversely affecting their risk assessments.

Weight and nutrition is considered in the physical assessment domain of the comprehensive geriatric assessment, a multidimensional holistic process (British Geriatrics Society 2019). Unintentional weight loss is an important factor in the diagnosis of frailty, a multidimensional syndrome of loss of physiological reserves that gives rise to vulnerability (Rockwood et al 2005). Therefore, it is crucial that an accurate weight is obtained for older people in the emergency care setting at the earliest opportunity to ensure they receive effective care (British Geriatrics Society 2019).

The author of this article undertook a quality improvement project in 2016 to improve the accuracy of patients’ recorded weight and to improve the completion of MUST scores. While it is acknowledged that the data are from several years ago, the implementation and findings of the project remain relevant to current clinical practice and are transferrable to other settings.

Project rationale

The project originated from a serious adverse incident in Belfast City Hospital (BCH) Direct, an emergency assessment unit for patients aged over 74 years in Belfast Health and Social Care Trust, Northern Ireland. The incident involved a patient who received an incorrect medicine dose based on an inaccurately guessed weight. The root cause analysis of the incident identified a need to implement a more effective way of ensuring patients were weighed accurately and promptly.

The project leader (CS) was a registered nurse and MUST champion. In healthcare a ‘champion’ is a local opinion leader (White 2011) who is able to lead change from within an organisation at ground level to promote evidence-based practice and act as a resource. They are frequently experts in the topic they are championing and may attend specialist training which they can subsequently pass on to colleagues via cascade training.

In BCH Direct, the recording of a patient’s weight was the responsibility of nursing staff (nurses and healthcare assistants). MUST score completion was the responsibility of nurses. Staff had the option to record actual weight (measured on weighing scales at point of admission) or recalled weight (patient verbally informing staff of their weight or staff visually estimating their weight) when completing the MUST score.

Before the project, staff often visually estimated a patient’s weight based on their own best guess or the weight verbally provided by the patient when questioned, which on further exploration often proved to be the patient’s guess rather than an actual recollection of a recorded weight. Staff documented this as recalled weight. None of the tools available to estimate an older person’s weight were used by staff at BCH Direct.

Patients were also weighed on an ad hoc basis before the project. Frequently no weight was recorded in the unit because patients often spent less than six hours there before being admitted to a ward or directed to a different care pathway, for example the acute care at home service, discharged for follow-up care from their GP or an outpatient clinic.

Aim

To improve completion of MUST scores for older patients attending BCH Direct from 60% to more than 85% within three months, by recording actual weight rather than guessing, recording a recalled weight or not recording weight. More than 85% MUST score completion was a trust-set target.

Method

Setting and population

The project took place in BCH Direct, where the primary aim was to reduce the number of people aged over 74 years attending an emergency department (ED) by using the unit as an alternative to an ED with some exclusions, for example patients with major trauma, suspected fractures, stroke, head injury, heart attack or chest pain. BCH Direct received referrals from paramedics, GPs, the acute care at home service and specialist community nurses. BCH Direct was led by a consultant geriatrician, with a multidisciplinary team comprising a staff grade doctor, registered nurses, healthcare assistants, a pharmacist, a physiotherapist and an occupational therapist.

BCH Direct had been open since October 2014, but it closed during the coronavirus disease 2019 (COVID-19) pandemic in 2020 as the BCH site became a Nightingale hospital. The unit has since been dissolved, with its staff redeployed to the acute care at home service.

Triage process

BCH Direct aimed to have patients in the triage bay for a maximum of 30 minutes. In this time, the following tasks were completed:

  • Greeting the patient.

  • Ambulance handover.

  • Patient’s demographic information confirmed.

  • Electrocardiogram (ECG) recorded.

  • Blood samples taken, with or without cannula insertion.

  • Clinical observations, including sitting and standing blood pressure.

  • Pressure area check.

  • Chest X-ray ordered if required.

Once these tasks were completed, the patient would stand up from the triage chair and turn to sit in the porter’s chair to be taken to radiology for a chest X-ray. No other staff were involved in the triage bay unless there was an emergency.

The project leader thought that triage would be the optimal time to record patients’ weight. However, the seated weighing scales and hoist scale used to weigh patients were routinely stored in a locked cupboard furthest from the triage bay.

Most patients were mobile and would have to transfer from the triage chair to the porter’s chair to attend radiology. Once the existing tasks were completed, the patient would stand up from the triage chair and turn to sit in the seated weighing scales. A nursing staff member would record their weight. The patient would stand up again, the seated weighing scales would be removed and the porter’s chair placed behind the patient for them to sit down and be taken to radiology. This additional manoeuvre took less than a minute.

All patients were considered eligible to have their actual weight recorded, rather than using a recalled weight.

PDSA cycles

To decide what the intervention would be, the reason why staff were not weighing patients or were only using a recalled weight needed to be understood. To achieve this, three Plan-Do-Study-Act (PDSA) cycles were undertaken. PDSA is a widely used quality improvement tool for identifying and testing a change in practice (Institute for Health Improvement 2017).

PDSA cycle 1

Informally, the project leader sought nursing staff members’ reasons for not weighing patients, which included: a lack of motivation to get the scales; staff not considering measuring weight to be an integral early part of the nursing or multidisciplinary team process, but instead as something that could be done later, believing an estimate would be accurate or sufficient; and staff being unwilling to leave patients who were at risk of falls unattended to get the scales.

The initial intervention was to place the seated weighing scales and hoist scale in the triage bay every morning alongside the other triage equipment, rather than the scales remaining in a locked cupboard until a staff member decided to use them. Placing the scales next to the other triage equipment provided a visual reminder to staff to record weight as an essential part of the triage process. In addition, the project leader mentioned the new location of the scales at the daily safety brief and allocated one nursing staff member to ensure that all patients arriving in triage had their weight recorded. This staff allocation was also done in advance of the project leader’s time off to ensure continuity. Any meaningful and sustainable change should take place regardless of who was on duty.

Most nursing staff in the unit were amenable to the intervention. They were already familiar with completion of MUST score as a KPI and no additional training was required. The culture in BCH Direct could be described as forward thinking and most staff appeared to be receptive to new ideas.

The intervention achieved an increase to 100% (n=30) of patients with actual weight recorded and 100% (n=30) completion of MUST scores within the first month of the project. However, feedback received indicated that this was not sustainable for every patient, for example those who were in pain, distressed or immobile and required a hoist scale. To measure weight using a hoist scale may involve significant discomfort to the patient as well as additional triage time in an already limited time frame of 30 minutes. There was also limited space in the triage bay and keeping the hoist scale in the bay was a potential falls hazard.

PDSA cycle 2

To strengthen the focus of the intervention, it was agreed that those patients who were not suitable to be weighed in triage, for example those requiring a hoist scale, or who were in pain, agitated or distressed would be weighed at a later point during their time in hospital. Decisions about patients’ suitability for weighing in triage or at a later point were left to staff discretion rather than being based on set criteria. This adjustment eased the pressure on staff in triage and shifted the focus to the BCH Direct assessment bay, where weight could be recorded as a task outstanding from triage. While weight recording decreased from 100% (n=30) compliance in triage to 70% (n=21), it was seen as an acceptable compromise to prioritise patient safety and comfort and to improve staff compliance with the intervention. It also ensured that the patient was at the centre of care, rather than the focus being on meeting targets.

PDSA cycle 3

It became apparent that nursing staff were surprised at the disparity between their estimation of a patient’s weight and the actual weight recorded, despite providing nutritional care to patients daily. As a result, with the patient’s permission, it was decided to include the patient’s weight as part of the information relayed to the patient and their families and/or carers as standard practice.

Families and carers were often shocked to learn the patient’s actual weight. They felt reassured from the beginning of the patient’s time in hospital that their weight would be considered in the care plan and immediate steps were taken to reduce the risk of malnutrition, for example by suggesting that patients drink full-fat milk or eat high-calorie snacks, completing food and fluid charts, and making referrals to the dietitian where appropriate. This reinforced to all staff the importance of obtaining the actual weight from the beginning of the patient’s time in hospital and reinforced the new process of weighing patients in the triage bay. There was improved communication with families, as they were often unaware how underweight their relative was. However, because this information was relayed to them within hours of the patient arriving at hospital, it provided families with an understanding of the patient’s nutritional status and what might be involved in their care.

Costs and time frame

The procurement of a trolley or gurney with inbuilt weighing scales was explored, but this was ruled out due to financial pressures. A hoist with clip-on scales was already in place, which was a cheaper, accessible alternative. There were no additional costs incurred because of the project. The project took place in 2016. The delay in publishing this article is due to the author’s personal circumstances and redeployment during the COVID-19 pandemic.

Data collection

The project began in October 2016. Data collection focused on completed MUST scores, which were already collated monthly by the project leader. Data were collated in the same way from the first day of project implementation. Any change in completed MUST scores was a direct result of the project intervention (changing the location of the weighing scales to improve compliance). No other factor in the weighing process was changed. A total of 30 nursing booklets were sampled and audited every month, as this was thought to provide a reasonably accurate reflection of all patients attending BCH Direct.

Ethical considerations

No permissions were necessary to complete this quality improvement project, and there was no requirement for ethical approval. Each patient was asked if they could be weighed and for their weight to be recorded. Those patients who declined to be weighed had a recalled weight recorded with a view to follow-up within one week, as stipulated in the MUST report (Elia 2003).

Findings

An unpublished audit showed consistent results of 60% (n=18) of MUST scores completed for patients attending BCH Direct since it opened in October 2014 to the beginning of the project in October 2016. For example, data from July 2016 showed that of the 60% of MUST scores completed, 89% (n=16/18) had a recalled weight recorded. Around 11% (n=2/18) of MUST scores completed had an actual weight recorded on the patient’s day of arrival at BCH Direct. Of the 40% (n=12) of patients with no MUST score completed, there was no actual or recalled weight recorded on the day of their arrival at BCH Direct.

Within the first month of the project, completed MUST scores were 100% (n=30). However, following feedback from staff regarding the time taken to weigh some patients and the adjustment mentioned in PDSA cycle 2, compliance reduced to 97% (n=29) completed MUST scores in the six months following the intervention.

Discussion

Allied health professionals – that is, the pharmacist, physiotherapist and occupational therapist – working at BCH Direct appreciated an actual baseline weight being recorded as it enabled their assessments to be more accurate and completed at an earlier stage in the patient journey. This demonstrated the importance of weight measurement in the holistic assessment of patients by members of the multidisciplinary team. The physiotherapist and occupational therapist were able to select and recommend aids and exercises based on the person’s weight loss or gain. In line with the MUST score recommendations (Elia 2003), nursing staff were able to identify patients’ additional dietary needs within the first hours of admission. Anecdotally, it was identified that the pharmacist was also able to complete their medicines reconciliation more accurately, while doctors could dose fluids and medicines with greater accuracy. There is evidence that doctors can improve the accuracy of frailty scores with complete information, such as weight loss (British Geriatrics Society 2019). Many doctors decided to include the patient’s actual weight on their subsequent discharge letter to inform the primary care team about this as soon as possible.

Falls were one of the main reasons for patients presenting to BCH Direct. During patients’ medicines reconciliations, the pharmacist was able to liaise with the doctor immediately regarding dose adjustments based on weight loss or gain to reduce the risk of repeat falls. This may have subsequently reduced hospital admissions, length of stay, bed days and repeat admissions to hospital; however, it was not possible to quantify this.

Improvement in completed MUST scores on the care of older people wards in the hospital was another unintended consequence of the project. Dietitians commented that having patients’ actual weight recorded had a positive effect on their relationship with nursing staff as it meant they did not have to ‘bother’ them by asking for an updated actual weight and/or completed MUST score. In addition, the three ward sisters on the care of older people wards mentioned to the lead nurse that they had seen a marked improvement in completed MUST scores. They believed this was a direct result of the initial MUST score being recorded in BCH Direct and the onus now being on the ward nurses to record the score on a weekly basis, as stipulated in the MUST report (Elia 2003). The ward sisters noted that there was a reduction in patient complaints to the wards mentioning weight loss; however, this evidence is anecdotal and there were no baseline data available to support it. For those complaints which referenced weight, the ward sisters and lead nurse had evidence of an actual weight recorded within hours of admission and subsequent weekly weight recorded.

The project intervention needed to be straightforward to ensure it was suitable for BCH Direct and easily transferrable to other wards. It also needed to decrease staff workload rather than add to it, particularly in terms of documentation. An important lesson learned during the implementation process was the importance of PDSA cycles, which helped to optimise the intervention, thereby promoting learning and trust among the team.

Nursing staff members’ cooperation was essential to the success of the project, so they were involved throughout the implementation process. In addition, other members of the multidisciplinary team were kept up to date with progress through daily safety briefings, monthly staff meetings and individual discussions. Their input during the planning stages and in discussions about the importance of recording patients’ actual weight garnered support for the project to ensure a sustainable change in practice.

The project identified as a barrier that some staff needed to be convinced to embrace a simple change, but demonstrated that a seemingly small adjustment can have a significant effect on patient care. It was essential that staff were able to take ownership of the change and feel empowered by it, rather than ‘being told what to do’. To achieve this in practice, a rotating ‘weight champion’ was appointed on the roster. The person chosen was not the nurse in charge for the day and regularly included healthcare assistants.

It was clear from the disparity between patients’ visually estimated weight and their actual weight that there was a knowledge gap among nursing staff, so they may require further education on this area of practice, particularly in older people with frailty. In light of the emergence of e-learning and online education and training as a result of the COVID-19 pandemic, an e-learning module specific to nursing older people is feasible and should be explored further, particularly because nearly two thirds of all hospital admissions are for people aged over 65 years (Nuffield Department of Population Health 2021). Since this quality improvement project was undertaken, a national digital learning platform called LearnHSCNI has been developed, which enables health and social care staff in Northern Ireland to undertake e-learning and includes a programme on frailty awareness.

Limitations

This was a small quality improvement project in an emergency assessment unit in one health and social care trust in Northern Ireland, so its findings might not be generalisable to other areas. For example, although this project had the resources to implement improvements, many wards are experiencing critical shortages of staff and therefore implementing change can present a significant challenge. However, this project is easily transferable and could be implemented in other settings given that no additional cost or equipment was required.

Additional limitations were that this project did not collect any baseline data on the KPIs of other members of the multidisciplinary team aside from nurses, complaints to BCH Direct or other wards that mentioned patients’ weight loss, or patients’ and family members’ satisfaction with the nutritional care provided on the unit. Furthermore, no baseline qualitative data were collected on the opinions of the multidisciplinary team in terms of how recording patients’ actual weight might affect their role.

Another limitation was that the project was undertaken in 2016 and there may have been significant changes in practice since then, and the unit has since closed so it is not possible to obtain more recent data. Additionally, many of the findings are anecdotal as they are based on informal feedback, so further research is warranted.

Implications for practice

The informal feedback received post-intervention was positive, indicating that recording patients’ actual weight influenced the team members’ decision-making and improved the quality of care they delivered. This was particularly the case for the pharmacist and doctors in relation to dose adjustment and fluid management. Allied health professionals also identified that actual weight had some influence on their choice of aids for patients.

Some qualitative feedback suggested that further cascade training on MUST and recording weight for nurses caring for older people is required to maintain standards of care. Although recording patients’ actual weight early in their time in hospital appeared to be beneficial, there is a risk that staff may continue to document recalled or visually estimated weights. This presents a further risk that other multidisciplinary team members might assume that the patient’s actual weight has been recorded. To address this, a future project should explore training the different members of the multidisciplinary team together in aspects of patient care, particularly for the care of older people. Interdisciplinary education among undergraduate healthcare students already takes place in various higher education institutions, but these tend to focus on emergency care, for example intermediate or advanced life support, rather than medical specialties such as geriatrics (Langins and Borgermans 2015).

Conclusion

The quality improvement project discussed in this article identified that the change in location of weighing scales improved the completion of MUST scores. Furthermore, recording patients’ actual weight rather than recalled weight led to improvements in the quality of care provided to older people who attended BCH Direct. This illustrates the importance of considering the various elements involved in meeting a KPI, instead of solely focusing on the target itself.

The simplicity of the intervention empowered staff to believe that it was possible to achieve meaningful change in practice and that doing so was not always dependent on additional equipment, training or costs. The intervention also enabled relevant and accurate information to be exchanged between all members of the multidisciplinary team, thereby improving the quality of patient care they provided and their working relationships with colleagues.

References

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