MUST Step 5 guidance notes - NHSGGC

The MUST Step 5 document should be completed by a qualified member of staff for any
resident scoring a MUST 1 or above. It will provide evidence that you have highlighted that
this resident is at nutritional risk and what your nutritional action plan will be.
Actions to be carried out as part of MUST step 5:

• Weekly weights and MUST screening
• Daily food and fluid record charts (FRC)
• Food fortification and food first methods, including fortified milkshakes
• Set agreed aims/goals and document in MUST Step 5 paperwork
• Review at 4 weeks – at this point also review if person has met the nutritional aims of
  the MUST Step 5 (refer to section 2)

Complete resident demographics then sign your name and designation in the “Assessed by”
box.
Note “Activity Levels” will range from “bedbound/immobile” to “highly active” for those who
continuously pace. This will help to highlight any changes in energy expenditure and
possible reasons for weight loss.
Please ensure you take into account whether the resident has any visible oedema or ascites
as this will affect weight recordings. Correcting a resident’s weight by using the table below
will allow a more accurate guide to current BMI as well as percentage weight loss:

Ref: - The Parenteral and Enteral Nutrition Group – Pocket Guide to Clinical Nutrition

Initially, detailed food and fluid charts should be recorded for 3 days and assessed prior to
completing Section 1 of the document if this is a new resident to the home. This will enable
staff to gain an idea of any changes to nutritional intake and identify any common themes,
e.g. frequent food refusal, texture difficulties, time of day for optimal intake.
Ensure all dietary needs, including physical and environmental, are being met and that
alternative options are available if required e.g. texture modified snacks, finger foods, etc.
Also ensure all food and fluid offered reflects resident’s recorded likes and dislikes.

From a combination of your clinical assessment of the resident and the results of the food
and fluid records you should now be able to circle whether any of the factors listed in the
table have been affecting their ability to eat and drink and/or nutritional status. If you have
circled “yes” please indicate what action you have or will put in place for each.

For example:
a) Swallowing difficulties – consider referral to Speech and Language Therapy
b) Dental problems – encourage improved oral hygiene, consider referral to Community
Dentist
c) Postural problems/requires support – ensure food/fluid easily ,consider finger foods
use small eating and drinking aids, consider referral to Community Physiotherapist
and/or Occupational Therapist
d) Recent acute medical issues – this could include infection (urine/chest), vomiting
and/or diarrhoea, constipation, fracture/falls, pressure sores, oedema or nausea, all
of which could have resulted in a recent hospital admission, liaise with GP and
review medications.
e) Mental health issues/challenging behaviour – liaise with GP and review, consider
referral to Community Psychiatric Nurse (CPN).

MUST Step 5 can be discontinued if end of life palliative:
If disease progression is recognised as the likely cause of increased nutritional risk,
discuss with the resident’s GP whether nutritional intervention remains appropriate.
It may be that no benefit is expected from nutritional support and/or could be
detrimental to the resident’s quality of life. If agreed with the GP that nutritional
intervention is not appropriate, tick the box and sign. There is no need to fill out the
rest of the form and the MUST step 5 can be discontinued.

You now need to think about what you would like to achieve with nutritional intervention.
Read the 4 options and choose the most suitable for your resident (this could be more than 1
option). Please note that option 1 and option 2 contradict each other so should not be
selected at the same time. If a resident has recent weight loss with a low BMI you could
select option 1 and then once weight has increased to recent weight this could be changed
to option 2 weight maintenance as the BMI will not return to a healthy range. Options can be
changed at each 4 week review as necessary.

1) Promote weight gain back to healthy BMI range
This would be if your resident had previously sat within the healthy BMI category and recenty
lost weight, you would want to aim to regain weight back to within healthy parameters. If
your resident was in the overweight category previously then had lost weight, you would
want to promote weight gain within the healthy BMI range and not necessarily back to their
previous weight.

2) Maintain current weight/nutritional status
This would be if your resident was of a low BMI but had maintained their weight and
nutritional status for 6 months or more.

3) Optimise nutrient intake during period of illness
This would be if your resident is unwell and oral dietary intake is reduced, resulting in
nutritional requirements not being met. This can be achieved through food fortification (see
section 3)

4) Increase and promote adequate fluid intake
This would be if your resident’s fluid intake had reduced and failing to meet daily targets. It
could also be if fluid losses are apparent, for example through diarrhoea and vomiting, large
volumes of wound exudate, or increased perspiration due to fever/environment.
All residents should be offered at least 10 cups (150mls) of fluid per day. If resident’s are
struggling with this volume or additional fluid is required, try encouraging jelly/ice-lollies/etc
which can also contribute to fluid intake.
Once you have established your aim(s), sign and date beside your chosen option(s) and
move on to section 3.

First line dietary interventions should be implemented at this point. These include offering 3
energy dense meals per day (small portions may be indicated if the resident has a poor
appetite) and up to 3 nourishing snacks per day. Remember to have texture modified
options available for those that require them. Also, take into account your resident’s likes
and dislikes.

The table provides examples of food fortification methods that can be used to increase the
energy content of meals/snacks. Please try to incorporate options with a maximum of 3
options at a time which would work giving an extra 600 calories oer day as indicated on the
MUST Step 5 form.

If you have a resident with diabetes requiring food first, try to avoid the options of adding
extra sugar/jam/honey to drinks and puddings as this would not be suitable.

Any changes to your resident’s dietary requirements should be shared with the kitchen and
all resident documentation should be updated.

For further guidance on food fortification please refer to your MUST reference folder

Daily food and fluid charts should be kept during this 4 week period for further
assessment and to provide evidence that first line interventions have been
implemented.

Once commencing the MUST step 5, the actions that should be carried out alongside the
form should be:

• Weekly weights and MUST screening – this includes completing a full MUST
  screening once a week with a total MUST score (completing an updated score for
  BMI, weight loss and acute disease)
• Food Record Charts (FRC) – daily food and fluid record charts detailing all oral intake
  with evidence of food fortification
• Food fortification and food first methods including fortified milkshakes

After the initial 4 week period you now want to assess whether first line intervention has
been successful. Document the date of your review then refer back to your original aim(s)
and tick whether this has been met, partially met or not met.

For example, if your aim was to promote weight gain back to healthy BMI range and this had
been achieved, you would tick the “Aim(s) fully met” box and document your explanation and
action taken. Your explanation could be “Food fortification successful, BMI now stable at 21”.
Action taken could be “Continue first line dietary interventions. If weight increases further
discontinue and offer normal diet” There would now be no need to carry on filling out the
rest of the form.

If the resident’s weight had started to increase but had not quite reached the healthy BMI
range yet, you would tick the “Aim(s) partially met” box. Your explanation could be “Slight
weight gain however BMI remains low at 17.5, oral dietary intake marginally improved,
dislikes cream but taking fortified milk well.” Your action taken could be “Continue first line
interventions including food and fluid charts and review in 4 weeks.”

If no progress had been made e.g. the resident’s weight continued to drop, you would tick the
“Aim(s) not met” box. Your explanation could be “Further weight loss, no improvement in
oral intake which remains poor, dislikes fortified milk” At this point you know first line
intervention has been unsuccessful and your action taken would then be to contact your
relevant health care professional for further advice.

In the next box please record who you have contacted, the date contact was made, then
sign and document your profession.

For Care Homes Within Greater Glasgow NHS area please refer also to your existing Care
Pathway poster. It helps to work with these guidance notes to give better clarity to decision
making. Your initial HealthCare Professional after 4 weeks will be your Care Home Liaison
Nurse. She/He will provide you initial support to maximise oral dietary intake and review the
MUST Step 5 to review if anything else could be tried in section 1 or 3.

At the 8 week review if nutrition goals are still not met, a referral should be initiated to the
Community Dietetic contact along with a copy of the MUST Step 5 documentation for that
resident.

Monitoring of ONS is essential to ensure they are effective and residents are managing to
take them as prescribed.
When completing the monitoring form always document the following:-

• The correct product and daily dose including any specific instructions on when or
  how to give the products as per the Dietitian’s instructions
• Any issues with tolerance or likes and dislikes with the ONS (if residents are not
  taking the full dose or refusing ONS always report this to the Dietitian supporting the
  clinical caseload in that home.
• In the actions required box try to document the reasons for continuing ONS e.g.
  continued weight loss, swallowing difficulties
• When any changes are made to product or dose and when they are discontinued

Please stock check before ordering supplements as this reduces wastage and avoids
stockpiling of ONS.

If you feel a resident no longer requires their supplements or could reduce their dose please
discuss with Community Dietitian.