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Background:  Nutrition screening using evidence‐based clinical practice is important for identifying patients whose nutritional status may be compromised, so that they receive appropriate treatment. Introduction of the Malnutrition Universal Screening Tool (`MUST') in two wards in two Melbourne hospitals resulted in low screening completion rates by nursing staff. Nurses’ screening practices were explored to understand personal and workplace barriers to compliance. Methods:  Surveys of patients’ medical records and focus groups with nurses were used to gather data. Audio‐recorded group narratives were transcribed verbatim, and then coded thematically to develop understandings of response patterns. Results:  A survey of admitted patients (n = 46) showed low screening rates by ward (17% and 62%). Eighteen nurses in two wards participated in three focus groups. The five main themes that emerged were: ‘screening role’, ‘task priorities’, ‘recognition of evidence‐based practice’, ‘uncertainty of protocols’ and ‘degree of competence’. Screening completion was limited by workloads, uncertainty about screening policy and also individuals’ skill in use of the tool. Conclusions:  Application of `MUST' can be facilitated by increasing nurses’ competence through training and by the provision of ongoing support. When implementing nutrition risk screening, dietitians’ roles should include continually working with nurses to identify and reduce the barriers that prevent the adoption of universal screening. Enhancement of collaboration is essential to ensure that optimal nutrition care occurs.

Malnutrition is prevalent in hospitalised medical and surgical patients. Certain clinical factors should heighten awareness and prompt detection for malnutrition. Coding for malnutrition impacts favourably on casemix funding for a subset of malnourished patients.

NRS compliance improved at MH with strong governance support and formalised implementation; however, the overall compliance achieved appears to have been affected by the complexity and diversity of multiple healthcare sites. Ongoing education, regular auditing and establishment of NRS routines and ward practices is recommended to further improve compliance.

Prevalence of malnutrition in Australian hospitals is reported to be up to 50 % (1) , yet it often remains unrecognised and uncorrected. Implementation of a nutrition screening programme provides the means to identify malnutrition but few hospitals have such programmes. Nutritional screening was implemented in a 850-bed tertiary healthcare facility to identify patients at nutritional risk and commence appropriate nutritional therapy. This paper describes our experience with the implementation process of the Malnutrition Universal Screening Tool ('MUST') during two implementation phases.In phase one in 2005, a six-week trial of 'MUST' in a gastroenterology ward was initiated (by the ward dietitian and the nurse manager). A 'stand alone' nutritional screening chart was designed for nurses use incorporating the 'MUST', the reference charts, alternative measurements, management guidelines for treatment and a serial monitoring section. Compliance to the MUST was audited through regular spot and three-weekly audits while qualitative data were extracted from focus groups of the ward nurses. Improvements were made to the design of the tool following feedback and 'MUST' was then implemented across six wards by dietitians.However, low screening rates (25-70 %) and several barriers to the successful uptake of nutrition screening were identified (2) . Many of these barriers were addressed through a series of training, audit and feedback sessions. In order to further build capacity to incorporate nutrition screening into everyday nursing practice, it was proposed that 'MUST be integrated into the revised initial nursing and assessment document (phase two).The nursing and assessment document to be implemented shortly is an initiative to improve clinical practices by the organisation and designed to replace several other 'stand alone' documents hospital wide. The nutrition risk assessment section includes the 'MUST' tool only. Laminated reference charts, alternative measurements and management guidelines are to be located separately in each patient's end of the bed folder.Results of a survey of a random sample of ward nurses (n = 14) conducted prior to the piloting of the new nursing document indicate that 64 % of nurses feel they will face less barriers than previously highlighted to successfully completing nutrition screening. Some reasons given were that more time would be available due to the reduction of paper work and the simpler format of the tool. Data collected for evaluation during the second phase of implementation will be reported at the conference.The main lesson learnt is that collaboration and support of key players at the organisation level was integral to progressing with the nutrition screening implementation process in our facility.

Dietetic departments are challenged to assure and maintain staff competency in skills not learnt during university qualification. Subjective Global Assessment (SGA) is traditionally learnt on-the-job in most hospitals in Australia. This paper describes our experience in developing and evaluating an SGA training programme for dietitians.Literature review (1)(2)(3)(4) and consultation with those experienced in SGA, local and international, was conducted by two department experts. These experts underwent further training through a combination of methods and then performed tests of clinical reproducibility on six patients. Modules one and two were developed for department staff training. Module one included an in-depth instructional component, an interactive workshop and bed-side demonstration of the technique by the department experts. Trainees received a training package including written guidelines, relevant resources and a 'learner's version' of the SGA form.In module two, staff performed hands-on patient assessments (3-4 patients) in small groups, followed by review with the department expert to reach a consensus about each patient's nutritional status. After a minimum period of two weeks, department experts and staff performed bedside SGA in pairs independently on assigned unknown patients (1-2 patients). Competency standards were met if ‡ 80 % agreement was achieved between trainees and department experts in the overall ranking and when trainees had completed all listed tasks.Eleven dietitians completed module one of the above programme. Nine dietitians, half of them with more than 5 years clinical experience, completed the second module. There was 74.8% agreement between department experts and trainees in assessing the medical history features and 63.8% agreement in assessing the physical status of patients. Dietitians tended to over classify the physical examination rating more severely than did department experts. However, dietitians were in agreement with the department experts for the overall SGA ranking 100% of the time. Analysis of evaluation by participants indicated that the programme objectives were met; knowledge and understanding had increased and the experience of the bed-side physical assessment and group discussions were particularly valuable.SGA can be taught with a high degree of agreement in overall rating in a group of experienced dietitians using a structured training programme. Strategies recommended to improve precision and validity of assessing the individual features of the SGA include performing the tests of agreement on more patients regularly, routinely using SGA as part of day to day clinical practice and regular patient-case reviews during professional development activity times.To ensure that competency standards are maintained it is proposed to review staff performance in a format similar to Module two on an annual basis. A programme such as this will assist dietitians in their professional development to gain skills, knowledge and confidence in diagnosing malnutrition in approp...

explains cardiovascular disease in patients with end stage renal disease. The purpose of this study was to estimate the association between CRP and both carotid and femoral IMT in hemodialysis (HD) patients. The present crosssectional study is nested in the Sevelamer hydrochloride and ultrasoundmeasured femoral and carotid intima media thickness progression in end stage renal disease (SUMMER) clinical trial. Carotid (common, internal and bifurcation) and femoral arteries were visualized in B-mode ultrasonography. CRP was measured in serum. The study cohort included 177 HD patients (39.5% female, mean age 67.8711.5 years). All measures of both carotid and femoral IMT were significantly, positively associated with CRP. Compared to subjects without, subjects with PVD, coronary revascularization and hypertension had significantly higher CRP levels. Conversely, subjects treated with sevelamer hydrochloride had significantly lower CRP levels than those not exposed to this medication. CRP was significantly, positively associated with serum phosphorus, calcium and PTH, and significantly inversely associated with HDL. In conclusion, CRP is significantly, positively associated with both femoral and carotid IMT and suggests an association between inflammation and atherosclerosis in HD patients.http://dx.

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