Malnutrition Universal Screening Tool (MUST)

MUST Calculator

BMI Score

Unplanned Weight Loss in 3-6 Months

Acute Disease Effect

MUST Score: –

Score: 0

Default scoring assumes 0 for un-set fields.

Identifies patients who are malnourished or at risk of malnutrition.

Why Use

If untreated, malnutrition can lead to poorer health outcomes with increased morbidity and significantly reduced quality of life. Studies have shown that patients who are malnourished access health services more often in both acute hospital and primary care settings ( Murphy 2018 ). When admitted, patients who are malnourished have more complications, longer inpatient stays, and higher mortality rates ( NICE 2006 ). Routine use of this screening tool can objectively identify patients who are at risk of malnutrition or suffering from malnourishment. Subsequent intervention can mitigate poorer health outcomes.

When to Use

Patients at risk for malnutrition. Per BAPEN guidelines , patients should be screened at the following intervals: Hospital inpatients: weekly. Patients in community care homes: monthly. Outpatients: annually if low risk, monthly to every 3 months depending on clinical status if not low risk.

Formula

Addition of the selected points: Criteria Points BMI , kg/m 2 >20 0 18.5-20 1 <18.5 2 Unplanned weight loss in past 3-6 months <5% 0 5-10% 1 >10% 2 Patient is acutely ill and there has been or is likely to be no nutritional intake for >5 days No 0 Yes 2

Pearls / Pitfalls

If height cannot be measured, recently documented or self-reported height may be used, if reliable and realistic. If the patient does not know or cannot report their height, height may be estimated by one of the following: ulna length, knee height, demispan. If height and weight cannot be obtained, use mid-upper arm circumference (MUAC) in place of BMI. Training staff to correctly score MUST and to take appropriate next steps in management is an important barrier to universal and routine implementation of this scoring system. High nursing staff turnover can be an important confounding factor in MUST use. Simple behavioral methods of support can be used to encourage oral intake, such as encouraging patients to eat and/or eat in small portions, providing patients with favorite meals, and assisting patients with feeding. MUST is primarily used in the UK.

Management

For patients requiring nutritional support in hospital, a dietician should be involved at an early stage. Nutritional support can be categorized as oral nutritional supplements, enteral tube nutrition, and parenteral nutrition. Again, these methods are prescribed and monitored under specialist supervision, especially in the case of critically ill patients.

Critical Actions

For all risk categories, treat any underlying conditions while optimizing nutritional status. Record need for special diets, and provide help and advice on food choices, eating, and drinking when necessary. Always record the presence of obesity.

Advice

Per BAPEN guidelines , patients should be screened as follows: Low risk (MUST Score = 0) patients should have routine repeat screening according to the clinical setting: Hospital – weekly. Care homes – monthly. Community – annually, for special groups (e.g. those >75 years old). For medium risk (MUST Score = 1) patients, formally document dietary intake for 3 days if patient in hospital or care home. If improvement in the patient’s dietary intake and little clinical concern, then documentation may be discontinued. If there is no improvement with intake and/or clinical concern by staff, then dietician referral can be considered. Continue repeat screening as follows: Hospital – weekly. Care home – at least monthly. Community – at least every 2-3 months. For high risk (MUST Score ≥2) patients, refer to dietician in hospital or community dietician support team. Increase and document overall nutritional intake. Monitor and review care plan as follows: Hospital – weekly. Care home – monthly. Community – monthly. Even though increasing scores correlate with increased risk, clinical circumstances exist where lower scores are still very high risk, e.g. anorexia nervosa.

More Information

Interpretation: MUST Score Overall malnutrition risk Suggested management by BAPEN guidelines 0 Low Routine clinical care 1 Medium Observe; document dietary intake and if adequate/little concern, continue screening; if inadequate, improve and increase overall intake according to local policy ≥2 High Treat*; refer to dietitian, improve and increase overall intake, increase frequency of monitoring according to local policy *Unless detrimental or no benefit is expected from nutritional support, e.g. imminent death.