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REVISED WATERLOW -USE OF MSTSeveral people have asked the question: Why has the nutritional element of the Waterlow pressure ulcer risk assessment scoring system used the Australian Malnutrition Screening tool ‘MST’1, in preference to the UK ‘MUST’2when it was revised earlier this year?To appreciate ‘why’, the background of the revision must be understood:1.Over 6 years ago, I was approached by Nancy Magazinovic a Director of Nursing at Prince Charles Hospital in Brisbane for permission to use ‘Waterlow’ in a Resource Guidelines which Queensland Health had been funded by the Queensland Government to produce3.2.They had selected ‘Waterlow’ after an internal review of Braden, Norton & Waterlow and had decided on the basis of the evidence that Waterlow wasthe most appropriate.3.As it is many years since Waterlow was designed they were intending to review the system in the light of modern nursing practices and asked me whether I would be willing to work with their team. I readily agreed and when Nancy was in Europe, presenting a paper at the European Wound Care Conference, she took the opportunity to come to England, where she stayed with me so we were able to spend a few days thoroughly going through the areas which we considered would benefit from a review.4.One of these areas was ‘Appetite’. Over the years I have been convinced that nutrition is an important parameter in any risk assessment system.5.A couple of years into the study I was in Australia visiting my daughter south of Sydney and was invited to fly up to Brisbane to meet the project team and discuss various aspects of the work in progress. I was also invited to give a talk on pressure ulcer prevention at the Prince Charles Hospital. 6.Not surprisingly Nancy and her team opted to use MST for the nutritional parameter to replace ‘Appetite’ when the validation process was conducted in various trials, in all areas, across Queensland. 7.The MST was developed by a team from the Centre for Public Health research, Queensland University of Technology Brisbane, the Nutrition Services Department, The Wesley Hospital Brisbane, and the Nutrition and Dietetics Department of the Radcliffe Hospital, Radcliffe, Australia1. The abstract of the research paper states that ‘convergent and predictive validity of the MST was established and the inter-rater reliability was high (93-97%)’8.Whether this is more, or less, accurate than MUST is irrelevant. What is important is that Nancy and her team have validated ‘revised Waterlow’ with the MST as a replacement for ‘Appetite’ onthe original scoring system.
9.In my opinion there should be no confusion. MUST should be used for what it was evaluated for –a comprehensive tool to identify a risk of poor protein-energy status. There is no evidence to suggest that it would, or would not, be a valid replacement for ‘Appetite’ in Waterlow.10.If we are talking in the practical world of the day to day care of people, rather than an academic discussion there will be very little difference between the Waterlow ‘risk status’ level if a MUST score is used as the nutritional element of the overall score whichever system is used. Using MST the score will cover a range of 0 –5. Using MUST the score will cover a range of 0 –6. The assessment of pressure ulcer risk, using Waterlow, should not be seen as just a mathematical summation of numbers. An assessment should be conducted, parameter by parameter, using professional judgement to determine whether any individual risk element can be alleviated. When a total score and risk status have been established, taking into account all the circumstances of the individual person, and the environment in which they are being cared for, action should be taken –and documented, to ensure, as far as is possible, that the development of a pressure ulcer is prevented.11.It has been suggested that if MUST is part of a Hospital Policy then patients cannot be assessed for their risk of developing pressure ulcers using Waterlow, because Waterlow uses MST. I find this quite surprising, as previous to the latest revision, there appeared to be no problem using MUST, with Waterlow when Waterlow had ‘Appetite’ as the nutritional parameter of the scoring system.References:1.Ferguson M, Capra S, Bauer J: Development of a valid and reliable malnutrition screening tool for adult acute hospital patients –Nutrition Vol.15, No.6, 1999 (More information can be obtained from Maree Ferguson mferguson@wesley.com.au)2.BAPEN 2003 ISBN 1 899467 70 X: The ‘MUST’ Report3.The State of Queensland, Queensland Health 2004 ISBN 0-7345-2982-1: Pressure ulcer prevention & management resource guidelines. (A presentation of the work leading up to the publication of the document is due to be made by Nancy Magazinovic Dir. Of Nursing at Prince Charles Hospital, Brisbane at the Australian Wound Management Association Conference in March 2006)