Appropriate First Line Prescribing of Oral Nutritional Supplements in the Treatment of Adult Malnutrition in Primary Care

Transcription

1 Cannock Chase Clinical Commissioning Group East Staffordshire Clinical Commissioning Group South East Staffordshire and Seisdon Clinical Commissioning Group Staffordshire and Stoke on Trent NHS Partnership Trust Stafford and Surrounds Clinical Commissioning Group Appropriate First Line Prescribing of Oral Nutritional Supplements in the Treatment of Adult Malnutrition in Primary Document Number Version V1 Ratified By and Date Area Prescribing Group 11/12/15 Name of Approving Body(s) and Formulae Working Group of the Allied Prescribing Dates Group Job Title of Document Author SSOTP Dietetic Team in Partnership and Allied Prescribing Group, Cannock Chase Clinical and East Staffordshire Commissioning Group Medicines Management Team Name of Responsible Committee Executive Director Date Issued Expiry Date (Maximum Two Years) Target Audience Allied Prescribing Group SSOTP Medicine Management Group Clinical Director of Pharmacy SSOTP GP s and Health Prescribers This document may be made available in a different format by contacting the Author of the Document Version Control - Review and Amendment Log Version Type of Change Date Description of Change V0 Development of document July to November 2015 Consultation with APG members and SSOTP Dietitians developed from Task and Finish Group on oral nutritional supplements involving UHNM dietitians, SSOTP Dietitians and North and South Medicine Management Team. V1 Draft Page 1

2 Version Type of Change Date Description of Change V1 Draft Page 2

3 Cannock Chase Clinical Commissioning Group East Staffordshire Clinical Commissioning Group South East Staffordshire and Seisdon Clinical Commissioning Group Staffordshire and Stoke on Trent NHS Partnership Trust Stafford and Surrounds Clinical Commissioning Group DOCUMENT SUMMARY Document Title Appropriate First Line Prescribing of Oral Nutritional Supplements in the Treatment of Adult Malnutrition in Primary Document Status New x Revision Date of Publication Key Points Malnutrition is estimated to affect at least three million adults in the UK at a cost of 13 billion annually. It may occur as a result of illness or from a variety of physiological and social co-factors. Oral Nutritional Supplements (ONS) are commercially produced products available as over the counter (OTC) products and prescribable products to support the treatment of malnutrition. ONS provide additional calories, protein, vitamins and minerals to improve the nutritional status of the malnourished individual to improve their clinical outcomes. ONS are highly beneficial for patients identified with malnutrition or for those who have a high risk factor for malnutrition. Despite this audit data indicates that ONS is often prescribed inappropriately in our community with a significant cost to the local health economy and no benefit to the patient. These guidelines aim to assist pharmacists, general practitioners (GP s), qualified district nurses, practice nurses and other appropriate community health professional prescribers with information on the use of prescribable oral nutritional supplements in the first line treatment of malnutrition. Available Support Medicine Management Team CCG Nutrition and Dietetics SSOTP V1 Draft Page 3

4 Contents Page 1. Introduction 4 2. Purpose Steps to Appropriate Nutritional in Adults 5 4. Advice on starting and stopping ONS prescriptions 9 5. References Appendices Appendix 1 MUST Malnutrition Universal Screening Tool Appendix 2 Quick Reference Guide 6 Steps to Appropriate Nutritional Appendix 3 A guide to assessing underlying causes of malnutrition and possible actions/solutions Appendix 4 - Make Every Mouthful Matter Appendix 5 Quick Reference Guide to First Line Prescribing on ONS Appendix 6 Monitoring and Compliance Colour Key used on the following pages: Over the counter products (OTC) to be used initially Prescribe as first-line Prescribe as second-line Prescribe in primary care only as recommended by Paediatric Dietitian or Paediatrician Should not routinely be prescribed V1 Draft Page 4

5 Cannock Chase Clinical Commissioning Group East Staffordshire Clinical Commissioning Group South East Staffordshire and Seisdon Clinical Commissioning Group Staffordshire and Stoke on Trent NHS Partnership Trust Stafford and Surrounds Clinical Commissioning Group Appropriate First Line Prescribing of Oral Nutritional Supplements in the Treatment of Adult Malnutrition in Primary 1. Introduction Malnutrition is estimated to affect at least three million adults in the UK at a cost of 13 billion annually. It may occur as a result of illness or from a variety of physiological and social co-factors. The consequences of malnutrition are: Impaired immune responses - increasing risk of infection Reduced muscle strength and fatigue Reduced respiratory muscle function - increasing the risk of chest infection and respiratory failure Impaired thermoregulation - predisposition to hypothermia Impaired wound healing and delayed recovery from illness Apathy, depression and self-neglect Increased risk of admission to hospital and length of stay Poor libido, fertility, pregnancy outcome and mother child interactions Oral Nutritional Supplements (ONS) are commercially produced products available as over the counter (OTC) products and prescribable products to support the treatment of malnutrition. ONS provide additional calories, protein, vitamins and minerals to improve the nutritional status of the malnourished individual to improve their clinical outcomes. ONS are highly beneficial for patients identified with malnutrition or for those who have a high risk factor for malnutrition. Despite this audit data indicates that ONS is often prescribed inappropriately in our community with a significant cost to the local health economy and no benefit to the patient. V1 Draft Page 5

6 2. Purpose of these Guidelines These guidelines aim to assist pharmacists, general practitioners (GP s), qualified district nurses, practice nurses and other appropriate community health professional prescribers with information on the use of prescribable oral nutritional supplements in the first line treatment of malnutrition. The guidelines are targeted at adults aged 18 years and over and should be read in conjunction with Staffordshire Nutrition Support Guidelines 017%20Staffordshire%20%20Nutrition%20Support%20Guidelines%20%20V1 %20Final.pdf. These guidelines do NOT replace individual dietetic consultation recommendations on prescriable ONS for patients who require specific dietary advice for the treatment of malnutrition and or any other clinical condition that would be supported by the dietetic team. These patients should be referred to dietetic services via the local referral pathway. The guidelines advise on: Food first approach with printable diet sheets Over-the-counter (OTC) ONS products Initiating prescribing Quantities to prescribe Which products to prescribe for different circumstances Triggers for reviewing and discontinuing prescriptions When onward referral for dietetic advice should be considered. If implemented as part of a health and social care economy wide approach then these guidelines should: Improve the management of patients who are malnourished or identified to be at risk of malnutrition Ensure appropriate cost effective prescribing Stop repeat prescriptions without regular review Reduce wastage 3. 6 Steps to Appropriate Nutritional in Adults All adult patients should be nutritionally screened using MUST (Malnutrition Universal Screening Tool) to assess their risk of malnutrition (Appendix 1). An app is also available for users of smartphones (search for BAPEN MUST ) which provides a simple to use MUST calculator. The 6 Steps to Appropriate Nutritional for Adults (Quick Reference Guide Appendix 2) provide guidance on:- 1. Who is at risk of malnutrition 2. Assessing underlying causes of malnutrition 3. Setting a treatment goal 4. Make Every Mouthful Matter - food first advice 5. Review - Initiating prescribing of oral nutritional supplements (ONS) if V1 Draft Page 6

7 no change 6. Treatment goal met? - Reviewing and discontinuing prescriptions Step 1 Identification of malnutrition NICE Clinical Guideline 32, Nutritional Support in Adults, suggests the following criteria are used to identify those who are malnourished or at nutritional risk. If one of these criteria is identified then continue to implement the pathway: MUST score of 2 or more Body mass index (BMI) less than 18.5kg/m 2 Unintentional weight loss more than 10% in the past 3-6 months Body Mass Index (BMI) less than 20kg/m 2 and an unintentional weight loss more than 5% in the past 3-6 months Those who have eaten little or nothing for more than 5 days Those who have poor absorptive capacity or high nutrient losses Referral to the dietetic service Those with MUST score of 3 or more Patients with a MUST of 2 or more who are failing to improve despite following the 6 Steps pathway Patients with a BMI of 16.5 kg. -2 or for whom supplements are a sole source of nutritional intake Those who require alternative feeding such as nasogastric (NG) or Percutaneous Endoscopic Gastrostomy (PEG) feeding Please use standardised Dietetic referral forms ( Step 2 - Assessing underlying causes of malnutrition Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Consider: Ability to chew and swallowing issues Impact of medication Physical symptoms e.g. pain, nausea, vomiting, constipation, diarrhoea Medical prognosis Environmental and social issues Psychological issues/low mood Tissue Viability/Skin integrity Substance or alcohol misuse Appendix 3 provides more detail on this assessment. Review the treatment plan in respect of these issues and if needed make appropriate referrals. Step 3 - Setting a treatment goal V1 Draft Page 7

8 Clear treatment goals and a care plan should be agreed with patients using a person centered approach. Treatment goals should be documented on the patient record and should include the aim of the nutritional support, timescale, and be realistic and measurable. This could include: Target weight or target weight gain or target Body Mass Index (BMI) over a period of time Weight maintenance where weight gain is unrealistic or undesirable Step 4 Make Every Mouthful Matter - food first advice Oral nutritional supplements (ONS) should not be used as first line treatment for patients identified as being at risk of malnutrition (MUST score 1-2). A food first approach should be used initially and taken in all scores of MUST 1-4. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements for those with a small appetite. The Daily Meal Planner can if implemented properly by the patient provide approximately an additional 1000kcal and 20g protein per day subject to their previous intake (Appendix 4 this and additional resources can be down loaded from here: If patients prefer and they do not meet the ACBS criteria but would still benefit from nutrition support, they can purchase OTC nutritional supplements such as Complan milkshakes or soups, Aymes, Meritene milkshakes or soups, or Nurishment milkshakes unless contraindicated (i.e. Poorly controlled diabetes, chronic kidney disease stage 3-4, liver disease. Seek advice from a dietitian). OTC products can also be useful store cupboard items for those who have variable appetites and oral intakes to stop them becoming nutritionally compromised. These products are available from some supermarkets and pharmacies subject and also from online pharmacies. Over the Counter (OTC) to be used initially Powdered Products Meritene Presentation 270g tin and 30 g sachets Vanilla, banana, strawberry, and chocolate flavours Not available routinely in Pharmacies but can be ordered in if requested by patients Nutritional content Per sachet mixed with 200ml full fat milk 200kcals 16g protein when mixed with 200ml semi skimmed milk V1 Draft Page 8

9 Complan 4 x 57g sachets Vanilla, banana, strawberry, chocolate and neutral flavours kcals 8.5g protein when mixed with water Aymes 4 x 38 g sachets Vanilla, strawberry, chocolate, banana. 265 Kcals 15g protein when mixed with whole milk Powdered Products Complan stir in Presentation Nutritional content per 100g powder 1 box of 450g neutral flavour 438kcals 15.3g protein Soups Presentation Nutritional content Per sachet mixed with 200mls water Meritene soup 1 box of 4 x 50g sachets Chicken, vegetable 207kcals 7g protein mixed with water Complan soup 1 box of 4 x 57g sachets of chicken flavour. 243kcals 8.7g protein mixed with water Aymes 4 x 49 g sachets Chicken flavour 207 kcals 7.7g protein mixed with water Liquid Presentation Products Nurishment 400g tin original Vanilla, banana, strawberry, raspberry, cherry and chocolate flavours Nurishment Extra 310ml bottle Vanilla, banana, strawberry and chocolate flavours Nutritional content per unit Per 400g can kcals 20g protein Per 310 bottle kcals 12g protein Complan Smoothie 250ml tetrapak Tropical and berry flavours Milkshakes ml chocolate and strawberry flavors Per 250 ml - 272kcals g protein Per 250 ml Kcal 8.9 g protein V1 Draft Page 9

10 Step 5 - Review - Initiating prescribing of ONS if no change in weight Patients should be reviewed within one month (after one week in community hospitals), by the person who initiated and offered this advice, to assess the progress with Make Every Mouthful Matter, food first approach. If there is a positive change towards meeting goals, the changes should be encouraged and maintained and a further review arranged until goals are met. If a food first approach has failed to achieve a positive change towards meeting the agreed goals after one month (one week for those in community hospitals) and there is clear evidence that all attempts have been made to optimize the food first approach consider prescribing ONS in addition to the food first Make Every Mouthful Matter changes which should be maintained. To prescribe ONS patients must meet at least one of the Advisory Committee for Borderline Substances (ACBS)* criteria below: Short bowel syndrome Intractable malabsorption Pre-operative preparation of patients who are undernourished Proven inflammatory bowel disease Following total gastrectomy Dysphagia Bowel fistulae Disease related malnutrition Continuous ambulatory peritoneal dialysis (CAPD) Haemodialysis Patients who do not meet ACBS prescribing criteria can also be advised to purchase OTC nutritional supplements as already discussed or prepare homemade nourishing drinks can be recommended unless contraindicated (i.e. Poorly controlled diabetes, renal disease stage 3-4, liver disease. Seek advice from a dietitian) (see recipe ideas Appendix 3 or 4. Advice on starting and stopping ONS prescriptions Appendix 5 provides a quick reference guide to first line prescribing of ONS in the treatment of malnutrition. To maximise their effectiveness and avoid spoiling appetite, patients should be advised to take the prescribed ONS between or after meals and not before meals or as a meal replacement. V1 Draft Page 10

11 To be clinically effective it is recommended that ONS are prescribed twice daily, which will provide an extra kcals/day. This ensures that calorie and protein intake is sufficient to achieve weight gain. NB some powdered products such as Scandishake, Enshake and Calshake are higher in calories so only 1 sachet is required to provide kcals A one week prescription or starter pack should always be prescribed initially to avoid wastage in case products are not well tolerated. Actively manage the patient and carers expectation that it is a prescribeable product subject to review of their progress Do not add prescriptions of ONS to the repeat template unless a short review date is included to ensure review against goals and prevent wasted prescribing. If the patient is not able to attend surgery for review then arrange with a health care professional such as a district nurse or a HCA to assess patients progress to ensure appropriate prescribing or to initiate a referral to the Dietetic Service Do not prescribe 1kcal/ml oral nutritional supplements which contain less nutritionally and are not as cost effective as 1.5kcal/ml products Patients with complex nutritional needs (i.e. renal disease, gastrointestinal disorders) may require specialist products and should be referred to local dietetic services these guidelines are only for first line prescribing in the treatment of malnutrition Patients with swallowing problems should be referred to Speech & Language services for assessment and prescribed the correct pre thickened ONS (Stage 1, 2 or 3). Do not advise ONS to be thickened with thickener Patients with Diabetes can be prescribed milk based or savoury supplements. Blood glucose levels will need monitoring and medication altered accordingly. Juice-style supplements (i.e. Ensure Plus Juce, Fortijuice, Resource Fruit) and Complan shake should be avoided due to their high sugar content homes should provide adequate quantities of good quality food. ONS should not be used as a substitute for the provision of high calorie, good quality food. Suitable high calorie, high protein snacks, food fortification as well as OTC products can be used to improve the nutritional intake of those at risk of malnutrition Palliative care patients should be assessed on an individual basis. Appropriateness of ONS will be dependent upon the patient s state and their treatment plan. Emphasis should always be on the enjoyment of nourishing food and drinks and maximising quality of life. Early palliative care patients who have months and years to live may V1 Draft Page 11

12 benefit from ONS to improve tolerance of treatment and quality of life. ONS can boost their nutritional intake and nutritional status. In late palliative care, aggressive feeding is contraindicated as it is not likely to be of any benefit and can cause distress and anxiety. The patient s condition will be deteriorating and they may be experiencing increasing symptoms such as nausea, pain and reduced appetite. The focus should be on quality of life with encouragement to eat and drink the foods that they enjoy. ONS at this stage is unlikely to improve nutritional status or prolong life. Substance misuse is NOT a specified ACBS indication for ONS prescription. Prescribing ONS for this patient group (alcohol and drug misusers) raises concern, due to the cost and lack of evidence on clinical benefit. This patient group have a range of nutrition related problems such as: Poor appetite and weight loss Nutritionally inadequate diet Constipation (drug misusers in particular) Dental decay (drug misusers in particular) Contributed to: Poor nutrition knowledge and skills Poor memory Poor access to food Drugs themselves can often cause poor appetite, acidic saliva leading to dental problems, constipation, craving sweet foods (drug misusers in particular) Poor dental hygiene (drug misusers in particular) Chaotic lifestyles Lack of interest in food and eating Irregular eating habits Low income, intensified by increased spending on drugs or alcohol Homelessness / poor living accommodation Infection with HIV or hepatitis B and C Eating disorders with co-existent substance misuse ONS prescribing in Substance Misusers often causes the following issues: Used to replace meals and therefore no benefit Once started the individual can become very reliant on them making it difficult to stop They may be given/sold to other members of the family/friends Only prescribe ONS for substance misusers if they meet ACBS criteria and are malnourished or at risk of malnutrition (MUST score of 2 or more). V1 Draft Page 12

13 First line Prescribing ONS Powdered nutritional supplements should be the first option to consider for patients that meet the following criteria: No dietary restrictions (They are not suitable for patients with cow s milk allergy or lactose intolerance) The patient can tolerate full fat/whole milk The patient can tolerate 200ml serving twice a day The patient has carer support or good finger dexterity to mix the ONS Can tolerate normal fluid Prescribing order ONS Unit Nutritional Profile Mixed with 200ml whole milk Cost per Unit (without milk) Cost per 100 kcal First Line Foodlink Complete Nualtra Neutral, Vanilla, Strawberry, Banana, Chocolate 57g sachet to be mixed with 200ml whole milk 385kcal 18.5g Protein Second Line Ensure Shake Abbott Nutrition Vanilla, strawberry, chocolate, banana 57g sachet to be mixed with 200ml whole milk 389kcal 17g protein Second Line AYMES Shake Vanilla, chocolate, banana, strawberry, neutral 57g sachet to be mixed with 200ml whole milk 387kcal 15.6g protein Prescribe in primary care only as recommended by Dietitian or Fresubin powder extra Fresenius Vanilla, strawberry, 62g Sachet to be mixed with 200ml 400Kcal 17.7g protein V1 Draft Page 13

14 Consultant Prescribe in primary care only as recommended by Dietitian or Consultant chocolate, neutral Complan Shake Nutricia vanilla, strawbery, chocolate, banana, neutral whole milk 57g sachet to be mixed with 200ml whole milk 387kcal 15.6g protein Ready to drink milk shake-style supplements 200ml Prescribing order ONS Unit Nutritional Profile Mixed with 200ml whole milk Cost per Unit (without milk) Cost per 100 kcal Prescribe in primary care only as recommended by Dietitian or Consultant AYMES Complete Banana, chocolate, strawberry, vanilla 200ml bottle 300kcal 12g protein Prescribe in primary care only as recommended by Dietitian or Consultant Ensure Plus milkshake style Abbott Nutrition banana, chocolate, coffee, fruits of the forest, neutral, orange, peach, raspberry, strawberry, vanilla 220ml bottle 330kcal 13.8g protein V1 Draft Page 14

15 Prescribe in primary care only as recommended by Dietitian or Consultant Fresubin Energy Fresenius Kabi chocolate, neutral, tropical Fruits, vanilla, banana, strawberry, cappuccino, lemon, blackcurrent 220ml bottle 300kcal 11.2g protein Prescribe in primary care only as recommended by Dietitian or Consultant Resource Energy Nestle chocolate, vanilla, banana, coffee, strawberry and raspberry 220ml bottle 303kcal 11.2g protein Prescribe in primary care only as recommended by Dietitian or Consultant Fortisip Bottle Nutricia neutral, vanilla, chocolate, caramel,, banana, orange, strawberry and chocolate 220ml bottle 300kcal 12g protein Fibre enriched supplements. Consider fibre enriched supplements for patients who have been taking non Fibre ONS and who are experiencing constipation or where ONS is the sole source of nutrition. V1 Draft Page 15

16 Second line Prescribing of ONS Ready to drink milk shake-style supplements suitable for the following patients: Like milkshake style drinks (Note: Lactose Free, please check products individually for other allergen information, or contact the Nutrition and Dietetic service for further advice Unable to make up powdered style ONS Unable to tolerate 200ml twice a day Can tolerate normal fluid Prescribing order ONS Unit Nutritional Cost per Unit (without milk) Cost per 100 kcal Second Line Second Line Nutriplen 125ml Nualtra Vanilla, Hazel chocolate, strawberry, banana Ensure Compact Abbott Nutrition Vanilla, strawberry, banana 125ml compact 125ml 300kcal 12g protein 300kcal 13g protein Second Line Prescribe only flavours not available above Fortisip compact 125ml Nutricia mocha, apricot, forest fruit, and neutral 125ml compact 300kcal 12g protein Juice-style Supplements Ready to drink juice style supplements are suitable for the following patients: That do not like milky drinks Can tolerate normal fluids May not be suitable for patients with diabetes due to high carbohydrate content Prescribing order ONS Unit Nutritional Cost per Unit Cost per 100 kcal V1 Draft Page 16

17 (without milk) Second Line Ensure Plus Juce Abbott Nutrition strawberry, peach, apple, lemon & lime, orange, fruit punch 200ml bottle 330kcal 10.6g protein Prescribe in primary care only as recommended by Dietitian or Consultant Fresubin Jucy Fresenius Kabi Apple, orange, pineapple, blackurrant, cherry 200ml bottle 300kcal 8g protein Prescribe in primary care only as recommended by Dietitian or Consultant Fortijuce Nutricia Lemon, apple, orange, strawberry, tropical, forest fruit, blackcurrent 200ml bottle 300kcal 8g protein Prescribe in primary care only as recommended by Dietitian or Consultant Resource Fruit Nestle apple, orange, raspberryblackcurrent, pear-cherry 200ml bottle 254kcal 8g protein Thickened Fluid for Patients with Dysphagia Ready to drink thickened supplements suitable for the following patients: That have been seen by a Speech and Language Therapist and instructed to have thickened fluids ONS do not thicken well or safely it is therefore recommended the only pre thickened ONS is prescribed for this patient group V1 Draft Page 17

18 Prescribing order ONS Unit Nutritional Cost per Unit (without milk) Cost per 100 kcal First Line Stage 1 First Line Stage 2 First Line Stage 3 Fresubin stage 1 Fresenius vanilla, wild strawberry Fresubin stage 2 Fresenius vanilla, wild strawberry Nutricrem stage 3 (Nualtra) 200ml 200ml 125g pot 300kcal 20g Protein 300kcal 20g Protein 225kcal 12.5g protein Vanilla, Strawberry, Orange chocolate Prescribe in primary care only as recommended by Dietitian or Consultant Nutilis Nutricia apple, strawberry 150g pot 206kcal 10.5g Protein Step 6 - Treatment goal met? - Reviewing and discontinuing prescriptions ONS is frequently prescribed whilst people are in hospital which they then continue to receive in the community. ONS are therefore sometimes continued for longer than may be required. ONS is usually only needed for a short period of time to overcome an acute illness or change in clinical condition. Patients on oral nutritional supplements (ONS) should be reviewed as follows: After 1 month if following a food first approach (one week in community hospitals). After 1 week if starting ONS prescribing to check tolerance After 1 month initially and then monthly to 3-6 months Three months after discontinuation of ONS to ensure that there is no V1 Draft Page 18

19 recurrence of the precipitating problem or sooner dependent on need Each review should assess progress towards agreed goals and whether there is a continued need for ONS on prescription. The following parameters should be monitored: Weight/Body Mass Index (BMI)/wound healing depending on goal set if unable to weigh the patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, clothes/rings/watch looser or tighter, visual assessment Changes in food intake and/or appetite Compliance with ONS and stock levels at home/care home When conducting general medication reviews, ONS should be included as above. Discontinue prescriptions when treatment goals are met. The patient should also have met all of the following criteria: 1. Food and fluid intake are satisfactory i.e. more than half of meals are being eaten, and they are managing to drink an adequate amount of fluid (8 cups per day) 2. BMI is above 18.5 kg/m2 3. The patient has maintained their current weight for the last 2 months or is gaining weight. Discontinue prescriptions if the patient no longer meets Advisory Committee for Borderline Substances (ACBS) criteria. If the patient still wishes to take ONS, suggest OTC products (page 7) and continue to promote a food first approach Make Every Mouthful Matter. If a patient continues to require nutritional supplements due to their clinical condition and or a MUST score of 2 with no improvement of MUST of 3 then refer to the dietetic team for assessment and review. 5 Further Reading and Resources British Association Parenteral and Enteral Nutrition (BAPEN) Combating Malnutrition; recommendations for action. Accessed online April 2012: British National Formulary, September 2015, Appendix 7, ACBS, Cochrane Collaboration (2007). Dietary advice for illness-related malnutrition in adults (review), The Cochrane Library. V1 Draft Page 19

20 Elia M., Stratton,R.J., Russell et al (2005). The cost of malnutrition in the UK and the economic case for the use of oral nutritional supplements (ONS) in adults. British Association Parenteral and Enteral Nutrition (BAPEN) Elia M., and Russell CA (Eds). Combating Malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN (2009). London Procurement Programme: A guide to prescribing oral nutritional supplements in nursing and care homes (2011). Managing Adult Malnutrition in the Community (including a pathway for the appropriate use of oral nutritional supplements (ONS). Produced by a multi-professional consensus panel including the RCGP, RCN, BDA, BAPEN, PCPA. (2012) National Institute for Health and Clinical Excellence (NICE) published Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition in February Accessed online: National Minimum Standards for Homes for Older People. Dept of Heallth (2003). Accessed online: Prescribing of Oral Nutritional Supplements (ONS) Guiding principles for improving the systems and processes for ONS use. National Prescribing Centre, V1 Draft Page 20

21 APPENDICES V1 Draft Page 21

22 Appendix 1 MUST V1 Draft Page 22

23 V1 Draft Page 23

24 V1 Draft Page 24

25 V1 Draft Page 25

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27 V1 Draft Page 27

28 Quick Reference Guide Appendix 2 6 Steps to Appropriate Nutritional for Adults - Pathway STEP 1 Identification of Nutritional Risk if there is a MUST score of 2 move to STEP 2 Refer to Dietetic service (and also commence pathway) if: MUST score of 3 or more On ONS as their sole source of nutrition Require artificial nutritional support eg Nasogastric/Percutaneous Endoscopic Gastrostomy STEP 2 Assess underlying causes of malnutrition and availability of adequate diet Make changes to treatment plan and refer to other services as needed. STEP 3 Set a treatment goal and devise a nutrition care plan STEP 4 MAKE EVERY MOUTHFUL MATTER - offer food first advice DAILY MEAL PLANNER advice STEP 5 Review after 1 month in community and 1 week in community hospital. Has there been progress towards goal set? Yes, there is progress towards goal set: Reinforce advice Reassess after 1-3 months in Continued progress or improvement: Reinforce advice Reassess after 1-3 months in community and 1-2 weeks community hospital, until goal met. STEP 6 Treatment goal met Discontinue ONS if prescribed on a phased approach Review after 3 months If problems reoccur return to start of flow chart. No progress towards goal set: Reinforce Make Every Mouthful Matter food first advice. Reassess underlying problems and treat/refer on as appropriate. Prescribe ONS as per guideline (if meets ACBS criteria) in addition to fortified foods. If does not meet ACBS criteria recommend over the counter supplements Reassess after 1 week trial of first line ONS and prescribe preferred flavour bd for 1-3 months then review. No progress or improvement refer to dietetic services nhs.uk/services/dietetics.htm) V1 Draft Page 28

29 Appendix 3 Guide to assessing causes of malnutrition A guide to assessing underlying causes of malnutrition and possible actions/solutions Medical conditions causing poor appetite, nausea etc e.g. cancer, COPD, diarrhoea, constipation GP and/or Community Matron and/or District Nursing management, consider appropriate medication Poor emotional or mental health e.g. depression, isolation, bereavement GP management, counselling, social clubs, day centres, mental health team Poor Poor dentation emotional or mental health e.g. depression, isolation, bereavement Refer to dentist and advise patient on appropriate /soft diet Difficulties with swallowing or unable to swallow Refer to Speech and Language Therapy Unable to do own shopping and/or cook and/or feed self Suggest home delivery of food and or refer to social service/casserole club and EatWell Experiencing financial difficulties Refer to social services Alcohol or other substance misuse Refer to Community Drug and alcohol services V1 Draft Page 29

30 Appendix Meal Planner and Recipe Ideas V1 Draft Page 30

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35 Appendix 5 V1 Draft Page 35

36 Appendix 6 Name of Procedural Document Monitoring Officer Reporting Arrangements Element to be Monitored - NSLA Criteria Ref Standard Criteria MONITORING COMPLIANCE Appropriate First Line Prescribing of Oral Nutritional Supplements in the Treatment of Adult Malnutrition in Primary Tool Change in Practice and Lessons to be Shared Timeframe 1 2 CCG prescribing of ONS CCG prescribing records Medicine Optimisation Teams (MOT) Nominated Lead CCG MOT V1 Draft Page 36

37 Appropriate Prescribing of Specialist Infant Formulae in Staffordshire Guidelines V1 Final Page 37