The cost of malnutrition and associated disease has been estimated to be more than £7.3 billion in 2003; the majority of this expenditure was due to treatment of malnourished patients in hospital and long-term care (£3.8 billion)(Reference Elia, Stratton and Russell1). Given this profound economic impact and the emergence of evidence that improving patient nutrition can reduce hospital stay and complications, national campaigns have raised awareness of malnutrition in an attempt to reduce its prevalence in UK hospitals(2, 3).
National guidance includes risk assessment for malnutrition for all new hospital admissions. Patients at risk of malnutrition include those who have eaten little or nothing for five or more days or are likely to eat little or nothing in the following 5 d(4). We considered that inpatients who are ‘Nil by Mouth’ (NBM) represent a particularly high risk cohort for malnutrition. The aims of our study included assessment of (i) the prevalence and duration of NBM, (ii) whether the indication was appropriate, (iii) whether these patients had been screened for malnutrition risk on admission, (iv) whether alternative nutritional supplementation had been arranged and (v) whether the Nutrition Multidisciplinary Team were adequately involved in patient care. We audited four wards (two general medical, one acute stroke unit and one surgical) within Barnet Hospital on two separate occasions, encompassing 192 patients in total.
We recorded the time from when a patient was made NBM until the advent of alternative nutritional replacement, with 42% of patients failing to receive optimal alternative supplementation as per best practice guidelines. We also identified delays in the involvement of speech and language therapists and dietitians in the care of some patients who were NBM, finding this to be associated with a delay in the provision of alternative nutritional replacement in 32% of patients.
Following our analysis, a number of clinical practice recommendations were considered; for example methods for improvement of (i) risk screening, (ii) more prompt involvement of the Nutrition Multidisciplinary Team and (iii) documentation of nutritional parameters in the medical notes. Together with our key findings, these were disseminated in the following ways; (i) presentation and discussion at the quarterly Nutrition Steering Committee Meeting, (ii) presentation at the Medical Grand Round and (iii) design of a promotional leaflet for nursing staff, distributed by hospital matrons.
In conclusion, in a district general hospital, a significant proportion of inpatients are made NBM, particularly the elderly. Often they are NBM for more than 5 d, with variable delays in both obtaining assessment from dietitians and speech and language therapists and providing alternative nutritional replacement to meet their needs. We have therefore recommended that an IR1 form is completed if a patient is NBM for five or more days without provisional of alternative means of nutritional support.
