Malnutrition remains a significant problem encountered by a proportion of surgical patients and may directly affect or even complicate their inpatient stay.12,13 Hospitalised patients, regardless of their body mass index (BMI), typically suffer from malnutrition because of their propensity for reduced food intake due to illness-induced poor appetite, gastrointestinal symptoms, reduced ability to chew or swallow or nil by mouth status for diagnostic and therapeutic procedures.14
Inadequate nutritional support has been shown to be associated with worse clinical outcomes in malnourished surgical patients,15,16,17 thus highlighting the importance of screening and identifying those patients who are at risk of malnutrition at admission. Early identification and nutritional assessment coupled with adequate and timely implementation of nutritional support have shown to positively affect the functional conditioning of the surgical patient.18,19,20
Patients requiring emergency laparotomy who are admitted acutely often have had periods of malnourishment in their peri-operative period due to their underlying surgical pathology. The stress response to surgery encompasses derangements of metabolic and physiological processes that induce perturbations in the inflammatory, acute phase, hormonal and genomic responses.21 Hypermetabolism and hyper-catabolism occur, leading to muscle wasting, impaired immune function and wound healing, organ failure and death.21
Our QIP demonstrated that the appropriate utilization and accurate scoring using the malnutrition risk assessment tool in patients undergoing emergency laparotomy could aid in their post-operative recovery and reduction of surgical complications rate by helping the surgical team identify patients who are at risk of malnutrition early and ensuring their nutritional optimisation peri-operatively.
There are multiple scoring tools that can be used to assess the nutritional status of a surgical patient, such as MUST, malnutrition screening tool (MST), short nutritional assessment questionnaire (SNAQ) and nutritional risk screening 2002 (NRS-2002). All these screening tools show satisfactory performance and similar accuracy in identifying patients at nutritional risk.22,23 MUST was developed to identify malnourished individuals in all care settings including primary care, hospitals, nursing homes and care homes, where it has been found to have excellent inter-rater reliability, concurrent validity with other tools and predictive validity.23
Literature review shows that the use of the MUST screening tool increases the dietician referrals by 30–40% and is subsequently validated by the dietician’s assessments of malnutrition.24 Moreover, it is an easy and reproducible tool to assess the patient’s nutritional status.24 In addition, the European Society of Clinical Nutrition and Metabolism (ESPEN) highlighted the importance of using a multi-disciplinary approach in the nutrition screening process which involves hospital management, physicians, nurses, dieticians and logistics and IT personnel.25
The MUST scores at admission predict the requirement for any in-hospital nutritional support. Clinicians have a responsibility to ensure accurate nutritional assessments are undertaken throughout hospital admission to identify those at risk and institute the appropriate nutritional treatment.26 The results of this project demonstrated the high prevalence of perioperative poor nutritional status in patients undergoing emergency laparotomy which was not adequately highlighted on admission, this may have resulted in a more complicated hospital journey. Following our recommendations and interventions in the current practice; the accuracy rate of MUST scores has significantly improved between the two cycles (27, 54% vs 29, 96.6%, P = 0.00005). This led to a marked improvement in the average referral time to the nutritional support team; with 53.3% being referred before the laparotomy to the dietitian in the second cycle, whereas only 8% were referred in the first. This difference was statistically significant (P = 0.00001).
Our audit is a reflection of how a slight adjustment in the team work can lead to a significant improvement in the quality and accuracy of the MUST score at admission after introducing a multi-disciplinary approach to complete the assessment using the online BAPEN MUST calculator. This improvement led to early dietician referral in our practice, and ultimately, optimal nutrition support starting peri-operatively.
Enteral feeding is considered to be associated with better recovery and less complications and is more cost effective than parenteral nutrition. Therefore, enteral feeding is the most desirable form for surgical patients and critically ill patients.27 A meta-analysis showed that oral nutritional support during the peri-operative period is associated with a 35% reduction in total surgical complications, which was found to be cost effective.28 Early enteral nutrition is recommended for critically ill patients. If enteral nutrition is insufficient or fails, parenteral nutrition should be instituted.29
There are around 30,000 emergency admissions for small bowel obstruction in the UK every year.30 Our study showed that bowel obstruction is the most common indication for laparotomy, this is consistent with NELA report 2020. These patients are at a very high risk of malnutrition as the majority have reduced oral intake for several days prior to admission, and enteral feeding is contraindicated due to bowel obstruction.
The use of early parenteral nutrition is still debatable. The ESPEN guidelines recommend that practitioners consider initiating parenteral nutrition within 2 days after admission to the intensive care unit (ICU) for patients who cannot be adequately fed enterally.31 In contrast, the American and Canadian guidelines recommend early initiation of enteral nutrition but suggest that parenteral nutrition not to be initiated concomitantly and be withheld for 1 week.32,33
A large randomised controlled multicentre trial compared early versus late parenteral nutrition in critically ill adults and showed that patients for whom early enteral nutrition was surgically contraindicated appeared to have a greater benefit from late initiation of parenteral nutrition than other patients.34 However, other observational studies showed that early achievement of nutritional targets improves the outcome for critically ill patients.35,36,37