Guidelines for the Management of Malnutrition in Adults

Transcription

1 Guidelines for the Management of Malnutrition in Adults Reference No: G_CS_26 Version: 2 Ratified by: LCHS Trust Board Date ratified: 14 th June 2016 Name of originator/author: Name of responsible committee: Anne Duncan Date issued: June 2016 Quality Scrutiny Group Review date: May 2018 Target audience: All Lincolnshire Community Health Services staff Distributed via: LCHS Website Chair: Chief Executive: Elaine Baylis QPM Andrew Morgan 1

2 Version Control Sheet Guidelines for the Management of Malnutrition Version Section/Para Appendix Version/Description of Amendments Date Author/Amended by 1 Draft Document update in accordance with NICE. BAPEN guidance and the LP&CEB. January 2014 Anne Duncan 2 All Full review and update May 2016 Kim Barr Copyright 2016 Lincolnshire Community Health Services NHS Trust, All Rights Reserved. Not to be reproduced in whole or in part without the permission of the copyright owner. 2

3 Guidelines for the Management of Malnutrition Contents No Section Page i) Version Control Sheet 2 ii) Policy Statement 4 iii) Contents 3 1. Introduction 5 2. Rationale 5 3. Specific Responsibilities and Accountability Training Nutritional Screening Nutritional Support Flow Chart Nutritional Support Ethical and Legal Issues Measures to help Nutritional Intake First Line: Dietary Advice Second Line: Prescribing ONS or Sip Feeds Which Oral Nutritional Supplement? Eat Well, Feel Better Leaflet Guidance on Nutritional Support Malnutrition Universal Screening Tool ( MUST ) MUST Guidance Booklet Supplement Selection Chart NHSLA Monitoring Template Implementation Plan Template Equality Analysis 8.1 3

4 Guidelines for the Management of Malnutrition Policy Statement Background Statement Responsibilities Training Dissemination Resource Implication Consultation Malnutrition is a significant, and neglected, public health problem. It affects over 10% of people over the age of 65 and costs more than 7.3 billion per year. Malnutrition currently produces one of the highest spends in healthcare The causes of malnutrition are both social and clinical: they include underlying disease, decreased mobility and limited transport to local shops, social isolation and poverty. The National Institute for Clinical Excellence(NICE) recommends that nutritional screening should be carried out in all groups at risk of malnutrition (e.g. patients in community hospitals and residential care homes, patients with chronic diseases and the elderly). Nutritional screening should be undertaken using the Malnutrition Universal Screening Tool( MUST ). The purpose of these guidelines is to implement a co-ordinated and uniform approach to the management of malnutrition in adults in the community setting. The guidance has been updated and includes the process for the identification of adult patients at risk of and those with malnutrition and their subsequent management. These guidelines reflect the NICE recommendations stated in Nutrition Support in Adults and should be used in conjunction with them. The guidelines conform to Lincolnshire Community Health Service(LCHS) statutory and organisational requirements and national guidance to promote holistic and safe practice. Compliance with the guidance will be the responsibility of clinical LCHS staff. The guidance has been developed after consultation with Primary and Secondary Care Practitioners with the appropriate expertise. Practitioners undertaking nutritional screening should be competent with the requirements of this document. LCHS Website Workforce will require access to training via ESR. The guidance has been developed in line with the NHS Litigation Authority guidelines to provide a framework for staff within NHS organizations to ensure the appropriate production, management and review of organization wide policies. 4

5 Guidelines for the Management of Malnutrition INTRODUCTION These guidelines set out the process for the identification of adult patients in the community and community hospital setting with malnutrition using an evidencebased nutritional screening tool and guidance on their subsequent management. The purpose of the guidelines is to ensure that: Nutritional screening in accordance with British Association for Parenteral and Enteral Nutrition(BAPEN) guidance using the MUST tool is undertaken. It is a mandatory requirement for this to be completed for all new patients and, for those in the community, every subsequent three months or for those in hospital, every week; clinical indicators may require more frequent assessment. Those who are identified as being malnourished or at risk of malnutrition follow a pathway that begins with dietary advice and nutritional interventions, continuing with ongoing assessment. The Eat Well Feel Better (Appendix 1) leaflet is available to all practice, care home and community staff, clinicians, and patients to ensure that practical advice is readily available on the use of the Food First approach and improving nutrition. A clear pathway is defined where food is used as a first line measure, fortified food is second line (incorporating guidance on Complan and Build Up) and oral nutritional supplements(ons) are reserved for third line use. Guidance is given to ensure that where ONS are prescribed, the appropriate product is selected for the appropriate duration and with appropriate supportive care. RATIONALE Nutrition: Nutrition is defined as the process of providing or obtaining the food necessary for health and growth. A healthy, balanced diet is important for everyone. All heath care professionals have a public health role and duty of care to give positive and practical dietary advice and identify those at risk of malnutrition. Nutrition is also the study of nutrients in food, how the body uses nutrients and the relationship between diet, health and diseases. Good nutrition underpins the healing process and assists an earlier recovery. Malnutrition: Malnutrition is defined as the state of nutrition in which a deficiency or excess (or imbalance) of energy protein and other nutrients causes measureable adverse effects on tissue, body form, body function and clinical outcome. If undetected or overlooked the effects of malnutrition on patients well being can be deleterious. The NICE Quality Standard 24: Quality Standard for Nutritional Support in Adults indicates the requirement for nutritional screening for malnutrition in all care settings. It also includes the need for a management care plan to meet nutritional 5

6 Guidelines for the Management of Malnutrition requirements. People with the following characteristics are defined as malnourished: A body mass index (BMI) of less than 18.5 Kg/m 2 Unintentional weight loss greater than 10% within the last 3-6 months. A BMI of less than 20 Kg/m 2 and unintentional weight loss greater than 5% within the last 3-6 months. Having eaten little or nothing for more than 5 days and/or likely to eat little or nothing for the next 5 days or longer. Having a poor absorptive capacity and/or having high nutrient losses and/or having increased nutritional needs from causes such as catabolism. SPECIFIC RESPONSIBILITIES AND ACCOUNTABILITY The Trust: All staff to have access to an updated evidence based policy document. To ensure that appropriate training and updates are provided to all relevant staff groups. Staffs are made aware of any policy changes and new skills update followed by the appropriate training. All relevant staff groups have access to appropriate equipment that complies with safety and maintenance requirements according to Trust policies. The Staff To practice within their professional competency. To read and adhere to the Trust policy. To identify any areas for skill update or training requirement. To undertake clinical supervision and regular peer review. To obtain informed consent from the patient. The Manager Managers need to ensure that staff are aware and have access to clinical guidelines and that the appropriate education, supervision and mechanisms are in place to ensure safe practice. This will include education for all healthcare workers. Areas for training needs must be highlighted and addressed. This can be done through appraisal or supervision and a record of competencies kept for audit and standard purposes. Training 6

7 Guidelines for the Management of Malnutrition It is essential for all practitioners carrying out nutritional assessments to complete training on the following aspects of malnutrition in the community: Recognise the importance of and issues raised by malnutrition/poor nutrition Understand adverse effects of malnutrition/poor nutrition Appreciate healthcare and financial implication of malnutrition/poor nutrition Understand key policy guidelines Use the BAPEN Malnutrition Universal Screening Tool ( MUST ) to undertake nutritional screening Practitioners who delegate tasks to non-registered staff retain professional accountability. Training for nutritional screening is available via an e-learning package on ESR. NUTRITIONAL SCREENING PATIENTS COVERED This guideline applies to all adult LCHS patients who are at risk of malnutrition, have become malnourished or, due to clinical presentation or need, require nutritional screening and intervention. Patients who present with indicators of dysphagia should be referred to the appropriate specialists, such as Speech and Language Therapists and those recommended in NICE Guidance Para 1.6.1, & 1.8. The Malnutrition Universal Screening Tool (MUST). There is evidence that malnourished patients: have longer periods in hospital. have increased morbidity and mortality. have impaired wound healing. have poorer quality of life. cost the NHS in excess of 260 million a year. NICE recommends that nutritional screening should be carried out in all groups at risk of malnutrition (e.g. patients in community hospitals and residential care homes, patients with chronic diseases and the elderly). LCHS healthcare professionals are required to carry nutritional screening as a mandatory assessment using the MUST (Appendix 3) on all patients. MUST is a five step screening tool to identify adults who are malnourished, at risk of malnutrition (under-nutrition) or obese. Patients should be weighed to establish BMI and to monitor relative weight changes. In patients homes, where calibrated scales are not available, their own scales can be used to identify changes. In the event of patients being unable to stand, then it is possible to estimate BMI using a variety of alternative measures, such as using the mid upper arm circumference, shown in the MUST Explanatory Booklet(Appendix 7

8 Guidelines for the Management of Malnutrition 3). MUST screening classifies patients according to their overall risk of malnutrition (i.e. Low, Medium or High Risk). This includes the need for a management care plan that aims to meet nutritional requirements. Practitioners are required to inform the medical staff of patients identified as being at risk of malnutrition. Details of the assessment and care plan should be entered on SystmOne. Further details on MUST and a copy of the screening tool can be found on the website at the BAPEN website: Further Information can be found in detail in the MUST Explanatory Booklet (Appendix 3). The Nutritional Support Flow Chart should be followed once a patient has been identified as at risk of malnutrition. 8

9 NUTRITIONAL SUPPORT FLOW CHART for Patients at Risk of Malnutrition Guidelines for the Management of Malnutrition Undertake MUST Risk Assessment (Appendix 2) Medium/High Risk Overall risk of malnutrition identified using MUST. Refer hospital patients who score 2 or more to dietitian and inform doctor Low Risk Repeat screening in line with MUST guidelines. Record Patient Details on SystmOne Assess underlying problems and inform doctor Implement Care Plan (for allied professionals liaise with community nurses) Give first-line dietary advice and information. Give patient Information booklet Eat Well, Feel Well. How to Increase your Energy Intake (Appendix 1) Reassess according to MUST recommendations. CONTINUED RISK Reinforce dietary advice Reassess underlying problems and treat where possible Follow Second Line guidance REDUCED RISK Weight stable or increasing/eating improved Reinforce advice Monitor concordance with nutritional support Complete Food Charts/Diaries Risk Reduces Reassess weekly using MUST Reinforce concordance Risk increases When agreed weight has been reached and/or eating has returned to normal If on sip feeds, withdraw under supervision. Weigh according to MUST guidance If problems recur start at the beginning of flow chart Weight/eating continues to deteriorate Inform doctor. Refer to dietician or Speech and Language Therapist if dysphagia present. If patient is for palliative care consider appetite stimulants (contact palliative care team for further advice) 9

10 Guidelines for the Management of Malnutrition NUTRITIONAL SUPPORT NICE Guidelines Key Recommendations: Nutritional screening of all patients should be carried out using the BAPEN Malnutrition Universal Screening Tool ( MUST ) by healthcare professionals with appropriate training. Nutritional support should be considered in people who are malnourished or at risk of malnutrition. Healthcare professionals should consider using oral, enteral or parenteral nutrition support for either malnourished or at risk of malnutrition. Healthcare professionals should ensure that all people who need nutrition support receive co-ordinated care from a multi-disciplinary team. Information should be in languages and ways that are suited to the individual s requirements and circumstances. Where patients experience communication impairments alternative means of communication should be employed, e.g. pictures, stimuli, etc. Details of relevant support groups, charities and voluntary organisations should also be made available (NICE Guidance Para 1.9). The following methods are used to improve or maintain nutritional intake: Oral nutrition support. For example fortified food, additional snacks and/or sip feeds. Enteral tube Feeding. The delivery of nutrition directly into the gut via a tube. Community patients having enteral tube feeding should be supported by a co-ordinated multi-disciplinary team. Close liaison between members of the team, patients and carers is essential. Parenteral Nutrition. The delivery of nutrition intravenously. Community patients having parenteral tube feeding should be supported by a coordinated multi-disciplinary team. ETHICAL AND LEGAL ISSUES When undertaking nutritional screening and starting or stopping nutrition support practitioners are required to: Obtain consent Where patients lack capacity to provide consent practitioners should act in the patient s best interest in accordance with the Mental Capacity Act 2005 and LCHSt policies for MCA and DoLS. Be aware that the provision of nutrition support is not always appropriate. Decisions on withholding or withdrawing of nutrition support require a 10

11 Guidelines for the Management of Malnutrition consideration of both ethical and legal principles. In addition, it may be inappropriate to provide nutritional intervention where this would be in contravention of a patient s wishes expressed in an Advanced Decision to Refuse Treatment. When such decisions are being made, guidance issued by the General Medical Council ( or the Department of Health ( MEASURES TO HELP IMPROVE NUTRITIONAL INTAKE: Successful Mealtimes. Practitioners should ensure that patients are alert and in an upright position for all oral intake and for 30 minutes after meals. Where possible, patients should sit at a table to promote a good position for swallowing. The social aspect of mealtimes and overall quality of life should be considered as people with a positive outlook often eat better. If isolation is a problem lunch clubs or day care may be considered. Patients and carers often find mealtimes stressful due to concerns regarding eating. Reassurance should be offered that in the short-term, small meals are acceptable because energy requirements may be reduced due to a reduction in activity levels. Mealtimes should be made enjoyable for the patient rather than pressure to eat normal sized meals. When feeding patients with dementia, practitioners should employ hand over hand feeding and allow patients to see and smell the food they are offered. Protected meal times, both in hospital and at home, may need to be considered to avoid interruptions. A small glass of alcohol can be a very effective appetite stimulant take approximately half an hour before a meal, maintaining the social aspect of the drink rather than as another medicine. It is important to check a patient s history, medication leaflet, doctor or pharmacist to ensure that alcohol is not contraindicated. Cooking smells try to keep the patient away from cooking smells if they find this reduces their appetite. Where possible encourage exercise and access to fresh air as these may help to improve appetite and general feeling of well being. Consider use of pre-prepared meals such as those ranges of ready made meals available at supermarkets, or home delivery. Signpost to other organisations who might offer assistance with shopping, cooking and eating where appropriate, for example luncheon clubs, Age Concern, Day Centres etc. In community hospitals, family involvement in feeding and choice of food for patients is encouraged. DIETARY INTERVENTIONS Following clinical assessment, dietary counselling should recommend the use of energy and protein rich foods as the initial intervention BEFORE the prescription of sip feeds, if appropriate. 11

12 Guidelines for the Management of Malnutrition In all cases cultural or specific dietary needs should be given priority when considering nutritional advice. For instance, interventions might be dairy based products which would be unsuitable for vegan patients. In addition, nutritional interventions in some groups such as palliative care, patients undergoing cancer treatment, progressive neurological conditions and those in advanced stages of illness may not result in improvements in nutritional status, but may provide valuable support to slow decline in weight and function. Before providing specialised dietary advice to patients, practitioners should consult with the dietician or refer on for specialist input via the following contact numbers: Lincoln County Hospital(Dietetic Dept) Boston Pilgrim Hospital Grantham Hospital Louth County Hospital , Ext 1312 First Line: Dietary Advice Dietary counselling to encourage the use of energy and protein rich foods should be recommended first line in most circumstances taking account of recommendations made by the Speech and Language Therapist. There is usually no role for prescribed sip-feeds at this stage. Patients should be urged to take the following advice: Have nourishing snacks and drinks between meals and a snack supper before bed. Drink more milk based drinks (e.g. milky coffee, malted milk, hot chocolate and milkshakes). Consume at least one pint of full fat milk each day. Avoid low fat, low sugar products look for full-fat, high-sugar varieties to provide more calories. Enrich food and drinks such as cereals, milk puddings, canned fruit, potatoes, soups and vegetables with cream, evaporated milk, condensed milk, sugar, cheese, unsaturated margarines and oils. Consider purchasing proprietary food supplement products, such as Complan or Build-Up. These products can be used between meals to increase nutritional intake. Some patients may be reluctant to eat high-fat, high-sugar foods, so it is important to reinforce the message that the dietary needs of the under-nourished are different to that of the healthy population (i.e. general healthy eating messages do not apply to this group). Patients should be advised on the aim of their therapy (i.e. to improve their nutritional status, to reach or maintain an agreed weight or to slow the rate of weight loss). A patient information booklet entitled Eat Well Feel Better has been devised and is appended to these guidelines. 12

13 Guidelines for the Management of Malnutrition For patients at Medium or High Risk, first line treatment should be dietary advice and information to increase nutritional intake utilizing food first, fortified if necessary. If normal meals and snacks are insufficient to meet individual requirements, then food can be fortified to increase the energy/protein content. Detailed dietary advice and an updated version of the patient leaflet entitled Eat Well, Feel Better are enclosed. If this is insufficient then over the counter nutritional supplements (e.g. Complan or Build- Up) should be considered before ONS which should not be seen as a replacement for food. Second Line: Prescribing ONS or Sip Feeds Patients classified as Medium Risk by the MUST screening tool should usually be reassessed and weighed after four weeks of dietary advice as outlined above. Those at High Risk will need to be reassessed and weighed weekly or as clinically indicated. Where there is no improvement in nutritional status, dietary advice will need to be reinforced and the introduction of ONSs considered. Initially two per day in addition to a normal diet should be prescribed, although patients unable to eat normal food in sufficient quantities may require more. ONS should not be seen as a replacement for food and patients should be given clear instructions on how to take them. There are a number of key points that need to be taken into account when prescribing sip feeds: The use of sip feeds should usually only be considered when first-line dietary measures have failed to improve nutritional intake or status. For patients who present with dysphagia and risks of aspiration on normal fluids, syrup thick fluids may be recommended to reduce this risk. For these patients, Fresubin pre-thickened stage 1/stage 2 should be considered. For patients taking custard thick fluids, dessert style semi-solid supplements (for example: Forticremes) should be considered as detailed in the appendix. Sip feeds should only be prescribed for patient s suffering from conditions approved by the Advisory Committee on Borderline Substances (ACBS). The disease related malnutrition category is often a useful catch-all term that covers many of the patients under consideration, although malnutrition status will need to be assessed using the MUST tool. Unless supplements have already been tried and patient preferences established, the initial prescription should be for a 1 week supply only and marked mixed flavours (endorsed ACBS). This enables the pharmacist/ dispenser to dispense a selection of flavours for the patient to sample. Determining the patient s tastes in this way will avoid potential waste resulting from the patient being issued with large stocks of a product that they do not like and will not take. Once the patient s tastes have been confirmed this information can be used to inform further repeat prescribing. Patients may get flavour fatigue and wish to try new flavours or styles of sip feed; to overcome this, feeds can be mixed and matched (e.g. one milkshake style and one juice style each day). 13

14 Guidelines for the Management of Malnutrition Once the patient s preferred choice of product has been established, those in the community should be given 1 month s supply and those discharged from community hospital 7 day s supply. Usually 2 sip feeds per day, taken in addition to meals should be sufficient. In general, prescribing should be retained on acute prescription as this will highlight the need for regular review. More than 2 supplements a day may be required if the patient s dietary intake is very poor or if their nutritional requirements are very high. If this is the case long-term, a referral to a dietician for further assessment should be considered. Patients receiving sip feeds should be monitored using MUST on a weekly to monthly basis (depending on the level of risk previously identified) to assess whether the aim of therapy is being met. The management plan should be recorded on SystmOne with the following specific issues recorded: 1. weight/bm I/alternative measurements (use appropriate record chart); 2. changes in dietary intake following the advice given; 3. compliance with supplements. When the agreed target weight or aim of therapy is achieved, supplements should be gradually reduced and monitoring continued for at least 3 months after stopping. Oral nutritional supplements should only be prescribed within ACBS approved indications. For many patients, this equates to disease-related malnutrition. Where malnutrition is suspected, risk should be assessed using the MUST tool. Which Oral Nutritional Supplement? The information at Appendix 2 Guidance on Oral Nutritional Supplements", used in conjunction with the Treatment Algorithm and Supplement Selection Tables should help to facilitate clinical decision making and product selection within this notoriously difficult and confusing area. For patients with dysphagia and risk of aspiration on normal fluids, Stage 1 or Stage 2 pre-thickened supplements should be considered. References: NICE Clinical Guideline 32, Nutrition Support in Adults (February 2006) Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition, Malnutrition Universal Screening Tool accessible from Acknowledgements Many thanks to: Stephen Gibson, Head of Prescribing and Medicines Optimisation, Greater East Midlands Commissioning Support Unit. Katherine Green, Trust Lead Dietitian. ULH, Katy McMillan, Home Enteral Nutrition Team Leader, ULH, and all the members of the Home Enteral Feeding Group for their help in the preparation of this edition of the PACE Bulletin. 14

15 Appendix 1 Double click on this icon to expose whole document Eat Well, Feel Better draft.pdf Chair: Chief Executive: Elaine Baylis QPM Andrew Morgan 1

16 Appendix 2 GUIDANCE ON ORAL NUTRITIONAL SUPPLEMENTS Milk Based Complete Sip Feeds (Milkshake-style) Examples: Fresubin Energy Drink, Ensure Plus Milkshake Style, Ensure Plus Savory, Fortisip Bottle and Resource Energy These milkshake-style supplements all contain 1.5kcal/ml of energy, protein vitamins and minerals. The table below illustrates that they are all broadly comparable in terms of price, pack size, range of flavours, protein and energy content; selection should be made on the basis of availability and patient preference. In most cases that require an ONS, a milk based complete sip feed containing 1.5kcal/ml should be used first line, unless a dietitian specifically advises otherwise. The usual frequency of use is 2 cartons a day with a maximum frequency of 6 to 7 cartons per day. Products containing 1 kcal/ml, such as Fresubin Original Drink, Fortimel Regular and Ensure, do not have a high enough energy content and should only be used on the advice of a dietitian. Existing patients should be reviewed at their next scheduled appointment to confirm that the product is still indicated and to ensure that it meets the nutritional needs of the patient. Product name Fresubin Energy Drink (Fresenius Kabi) Ensure Plus Milkshake Style (Abbott) Ensure Plus Savoury (Abbott) Fortisip Bottle (Nutricia) Resource Energy (Nestle) Protein Energy content content 11.2g 300kcal in 200ml 1.5kcal/ml g 330 Kcal 13.75g 1.5kcal/ml 330 Kcal 1.5kcal/ml 12 g 300 kcal 1.5kcal/ml 11.2 g 300 kcal 1.5kcal/ml Pack size Flavours Cost Comments 200 ml carton Vanilla, Chocolate, Cappuccino, Tropical Fruit, Blackcurrant, Neutral, Banana, Lemon. 220 ml carton Vanilla, Banana, Orange, Neutral, Blackcurrant, Raspberry, Chocolate, Caramel, Fruits of the Forest, Peach, Coffee 220ml bottle Chicken, Mushroom 200ml bottle 200ml bottle Vanilla, Banana, Caramel, Chocolate, Orange, Toffee, Tropical Fruits, Neutral Strawberry-Raspberry, Vanilla, Banana, Chocolate, Coffee, Apricot 1.97 per 200ml pack 2.02 per 220ml Bottle 2.02 per 220 ml bottle 2.06 per 200ml bottle 1.92 per 200 ml bottle Lactose Free Gluten Free Gluten Free, Clinically Lactose Free. Gluten free Gluten Free Clinically Lactose Free Gluten Free Low Lactose Fibre Containing Sip Feeds Examples: Fresubin Energy Fibre, Ensure Plus Fibre and Fortisip Multi Fibre. A fibre containing sip feed can be useful as an aid to the prevention of constipation in patients with a fibre deficient diet. These milkshake style supplements contain 1.5kcal/ml of Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 2

17 Appendix 2 energy in addition to protein, fibre, vitamins and minerals. They are all comparable in terms of price, pack size, range of flavours, protein and energy content; selection should be made on the basis of availability and patient preference. The usual frequency is 2 cartons per day, with a maximum frequency of 6 to 7 cartons per day. Product name Fresubin Energy Fibre (Fresenius Kabi) Ensure Plus Fibre (Abbott) Fortisip Multi Fibre (Nutricia) Protein Energy content content 11.2g 300kcal 1.5kcal/ml 12.5g 310kcal 12g Yoghurt Style Sip Feeds 1.55kcal/ml 300 kcal 1.5kcal/ml Pack size Flavours Cost Comments 200ml bottle 200ml bottle Chocolate, Caramel, Cherry, Vanilla, Banana Banana, Chocolate, Raspberry, Vanilla 1.98 per 200ml bottle 2.02 per 200ml pack 200ml bottle Vanilla 2.09 per 200ml bottle Examples include: Ensure Plus Yoghurt and Fortisip Yoghurt Style Lactose Free Gluten Free Contains fish gelatin Gluten Free Clinically Lactose free. Gluten Free Clinically Lactose free If the patient likes yoghurt and suffers from flavour fatigue with milkshake-style products, a yoghurt-style sip feed should be considered. Both of the examples quoted contain 1.5 kcal/ml and are broadly comparable in terms of price, pack size, range of flavours, protein and energy content. Selection should be made on the basis of availability and patient preference. The usual frequency is 2 cartons per day with a maximum frequency of 6 to 7 cartons per day. Product name Ensure Plus Yoghurt (Abbott) Fortisip Yoghurt Style (Nutricia) Protein Energy content content 13.8 g 330 kcal 1.5kcal/ml 12 g 300 Kcal Fruit Juice Style Sip Feeds 1.5kcal/ml Pack size Flavours Cost Comments 220ml Bottle 200ml Bottle Orchard Peach, Strawberry Swirl Vanilla & Lemon, Peach & Orange, Raspberry 2.02per 220ml pack 2.02 per 200ml pack Gluten Free Clinically Lactose Free Gluten Free Examples include: Fresubin Jucy, Ensure Plus Juce, Fortijuce and Resource Fruit Drink. Fruit juice style sip-feeds can be useful for patients who do not like milk, although, in contrast to milk based alternatives, they are lacking in fat and essential fatty acids and are not nutritionally complete. They should be used with caution in patients with diabetes. These products are broadly comparable in terms of pack size and range of flavours, although energy content varies. Fresubin Jucy Drink and Ensure Plus Juce are lower in price than Fortijuce and are preferred; Resource Fruit Drink is also lower cost, but does not have the same energy content as competitors (1.25kcal/ml). Do not exceed 8 to 10 cartons per day; patients taking more than four a day need a dietetic review as their diet is in danger of becoming nutritionally compromised. Product name Fresubin Jucy Drink (Fresenius Kabi) Ensure Plus Juce (Abbott) Protein Energy content content 8 g 300 kcal 1.5kcal/ml 10.6 g 330 kcal 1.5kcal/ml Chair: Pack size Flavours Cost Comments 200ml bottle 220ml bottle Elaine Baylis QPM Apple, Pineapple, Cherry, Blackcurrant, Orange Apple, Fruit Punch, Lemon & Lime, Peach, Orange 1.82 per 200 ml bottle 1.97 per 220ml bottle Gluten Free Clinically Lactose Free Fat Free Fibre free Fat Free Gluten Free Clinically Lactose free Chief Executive: Andrew Morgan 3

18 Appendix 2 Fortijuce (Nutricia Clinical) Resource Fruit (Nestle) 8 g 300 kcal 1.5kcal/ml 8 g 250 kcal 1.25kcal/ml Lower cost products are highlighted in bold. 200 ml bottle Lemon, Apple, Orange, Tropical, Blackcurrant, Forest Fruits 200ml bottle Apple, Orange, Pear-Cherry, Raspberry- Blackcurrant 2.02 per 200ml bottle 1.84 per 200ml bottle Fat Free Gluten Free Clinically Lactose free. Fat Free Gluten Free, Low Lactose Powdered Milkshake-Style Supplements Powdered milkshake-style supplements are made up with whole milk or water and are only appropriate where the patient or carer can make up the reconstituted product for themselves. None of these products are nutritionally complete. The higher calorie products are: Calshake Powder, Enshake and Scandishake Mix; these 3 products are broadly comparable in terms of price, pack size, range of flavours, protein and energy content. Selection should be made on the basis of availability and patient preference. The patient should be advised to take one per day; do not exceed two without dietetic advice as these are not nutritionally complete. A savoury product called Vitasavoury is now available. This product is lower in energy that the sweet flavoured products. There is now a third group of products where the energy content is less, but the cost is significantly lower. These include: AYMES Shake, Complan Shake, Fresubin Powder Extra and Foodlink. The usual frequency is 1 or 2 per day; do not exceed two without specialist dietetic advice as these are not nutritionally complete. Product name Calshake (Fresenius Kabi) Protein content 3.74g per serving Energy content 430 kcal per serving Pack size Flavours Cost Comments 87g sachet Banana, Vanilla, Neutral, Chocolate 2.23 per 87g sachet Gluten Free Make up with 240mls whole milk Enshake (Abbott) Scandishake Mix (Nutricia) Vitasavoury (Vitaflo) AYMES Shake (AYMES) Complan Shake (Complan) Fresubin Powder Extra (Fresenius Kabi) 8.4g per serving 4g per serving cup - 4g sachet 6g 450 kcal per serving 425 kcal per serving cup-206kcal sachet- 309kcal 8.8 to 9.2g 248 to 253 kcal per serving g 246 to 251 kcal 100g sachet 85 g sachet 33g cup 57g sachet 57g sachet 1 7.5g 260kcal 62g sachet Banana, Chocolate, Vanilla Banana, Caramel, Chocolate, Unflavoured Chicken, Leek and Potato, Mushroom, Vegetable Neutral Vanilla Strawberry Banana, Chocolate, Original, Vanilla Chocolate, Neutral, Vanilla 2.16 per sachet 2.27 per 85g sachet Cup Sachet p per 57g sachet 95p per 57g sachet 80p Gluten free Make up with 240ml of whole milk Make up with 240mls of whole milk Make up with hot water Gluten free Make up with 200ml whole milk Make up with 200ml whole milk Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 4

19 Appendix 2 Foodlink Complete (Foodlink) 12.5g 249kcal 57g Banana, chocolate, neutral, strawberry 42p Make up with water High Protein Sip Feeds Examples include: Fresubin Protein Energy, Fortisip Extra and Resource Protein. These products are useful in patient with increased protein requirements (e.g. those with pressure ulcers or impaired wound healing). Higher energy, high protein products are recommended in these patient groups. Fresubin Protein Energy, and Fortisip Extra both contain 1.5 kcal/ml or more and are broadly comparable in terms of price, pack size, range of flavours and protein content; selection should be made on the basis of availability and patient preference. Resource Protein is lower cost, but has a lower energy content. The usual frequency is 2 cartons per day, with a maximum frequency of 3 to 4 cartons per day; particular risks exist around the use of these products in the elderly, those with lower protein requirements and those with renal impairment. Product name Fresubin Protein Energy (Fresenius Kabi) Fortisip Extra (Nutricia) Resource Protein (Nestle) Protein Energy content Content 20g 300kcal 1.5kcal/ml 20g 320kcal 1.6kcal/ml 18.8g 250kcal 1.25kcal/ml Pack size Flavours Cost Comments 200ml bottle 200ml bottle 200ml bottle Cappuccino, Chocolate, Tropical Fruits, Vanilla Chocolate, Forest Fruits, Mocha, Vanilla Apricot Chocolate Forest Fruits, Vanilla 1.97 per 200ml bottle 2.02 per 200ml bottle 1.59 per 200ml bottle Gluten free Clinically lactose free Fish gelatin Gluten-free Gluten free High Energy High Protein Sip Feeds Examples include: Ensure TwoCal, Fortisip Compact, Fortisip Compact Fibre, Fortisip Compact Protein, Fresubin 2kcal Drink, Fresubin 2kcal Fibre Drink and Resource 2.0 Fibre These products have similar protein content to the High Protein Sip Feeds listed above, but have significantly higher energy content. Care should be taken in renal impairment and in patients of low body weight who will have lower protein requirements. Normally 2 bottles per day are sufficient; higher amounts should only be given under dietetic supervision. Product Name Ensure TwoCal (Abbott) Fortisip Compact (Nutricia) Fortisip Compact Fibre (Nutricia) Protein content Energy content Pack Size Flavours Cost Comments 16.8g 400kcal 200ml Banana, 2.22 Gluten free Neutral, per Lactose free bottle Vanilla 12g 300kcal 125ml Apricot, 2.02 Clinically lactose Banana, per free Chocolate, 125ml Gluten free Forest fruits, bottle Mocha, Vanilla 11.75g 300kcal 125ml Mocha, banana 2.09 per 125ml bottle Gluten free Clinically lactose free Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 5

20 Appendix 2 Fortisip Compact Protein (Nutricia) Fresubin 2kcal Drink (Fresenius Kabi) Fresubin 2kcal Fibre Drink (Fresenius Kabi) Resource 2.0 Fibre (Nestle) 18g 300kcal 125ml Banana, Mocha, Vanilla 20g 400kcal 200ml Vanilla, Apricot-peach, Cappuccino, Neutral, Forest Fruits, Toffee 20g 400kcal 200ml Chocolate, Apricot-peach, Cappuccino, Lemon, Neutral, Vanilla 18g 400kcal 200ml Apricot, Coffee, Neutral, Summer fruits, Vanilla 1.94 Per bottle 1.85 per 200ml bottle 1.85 per 200ml pack 1.88 per 200ml bottle Gluten free Clinically lactose free Lactose Free Gluten Free Lactose Free Gluten Free Gluten free Low lactose Dessert-Style Semi-Solid Supplements Dessert-Style Semi-Solid Supplements are useful in patients with swallowing difficulties. There are a large number of products on the market which are broadly comparable in terms of energy and protein content, range of flavours and price (see table). Product Name Clinutren Dessert (Nestle) Ensure Plus Crème (Abbott) Forticreme Complete (Nutricia) Fortisip Fruit Dessert (Nutricia) Fresubin Creme (Fresenius Kabi) Fresubin YoCreme (Fresenius Kabi) Resource Dessert Energy (Nestle) Resource Dessert Fruit Protein content Energy content Flavours Cost Comments 12g 156kcal Caramel, Chocolate, 1.47 per Gluten free Peach, Vanilla 125g pot 7.1g 175kcal Banana, Chocolate, 1.88 per Gluten free Neutral, Vanilla 1 25g Lactose free Contains soya 12g 200kcal Vanilla, Chocolate, Banana, Forest Fruits 10.5g 200kcal Apple, Strawberry 1 2.5g 225kcal Cappuccino, Caramel, Chocolate, Praline, Vanilla 9.4g 187.5kcal Apricot-peach, Biscuit, Lemon, Raspberry 6g 200kcal Caramel, Chocolate, Vanilla 6.25g 200kcal Apple, Apple/peach, 1.96 per 1 25g pot 2.16 per 1 50g pot 1.87per 125g pot 1.87per 125g pot 1.59 per 1 25g pot 1.59 per 1 25g pot Gluten free Residual lactose Gluten free Lactose free Gluten free Gluten free Gluten free Gluten free (Nestle) Apple/strawberry Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 6

21 Appendix 2 Energy/Protein Supplements Examples include: Calogen liquid or Fresubin 5kcal Shot Drink for additional calories without protein and Pro-Cal Powder or Pro-Cal Shot for additional calories with protein. These are useful if the patient needs additional calories with or without protein. For those who do not tolerate sip feeds, they can be added to food or drink. These products do not contain vitamins or minerals and should be used under the supervision of, or in consultation with, a dietitian. Product name Calogen Liquid (SHS) Fresubin 5kcal Shot Drink (Fresenius Kabi) Pro Cal Powder (Vitaflo) Pro Cal Shot (Vitaflo) Protein content Energy Content Pack size Flavours Dose Cost 0g See flavours 200ml or 500 Unflavoured 30mls 4.36 per 200 ml ml (450kcal per three times per 500 ml 100ml), daily Banana (468kcal per100ml), Strawberry (467kcal per100ml), 0g 600kcal 120ml Neutral 2.65 per 120ml bottle Lemon 2g per 1 5g sachet 6.7g per 100ml 1 00kcal per 1 5g sachet 334 kcal per 100ml 15 g sachets 510g, 1.5kg, 12.5kg, 25kg tubs 250ml Unflavoured Neutral Banana Strawberry 1 5g four times daily added to food or drink 30m ls three times daily 25 x 1 5g sachets = (59p per sachet) 6 x 250ml bottles ( 4.79 each) Protein Supplements The following products should only be used with dietetic supervision: ProSource (Nutrinovo) Pro-Cal (Vitaflo) Casilan 90 (Heinz) Protifar (Nutricia) Vitapro (Vitaflo) Carbohydrate Supplements The following products must be taken in large amounts to be effective and have no vitamin, mineral or protein content. They should be used under dietetic supervision. Caloreen (Nestle) Vitajoule (Vitaflo) Maxijul (SHS) Polycal (Nutricia) Duocal (SHS) Fat Supplements The following products have a high calorie content but little or no protein and are not nutritionally complete. They should be used with dietetic supervision. Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 7

22 Appendix 2 Fresubin 5kcal Shot (Fresenius Kabi) Calogen (Nutricia) Quickcal (Vitaflo) All product information is taken from British National Formulary 65 March - September 2013 and MIMS November A sip feed selection algorithm is provided as an Appendix to this Bulletin to help with prescribing decisions. Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 8

23 Appendix 3: Malnutrition Universal Screening Tool ( MUST ) The MUST Screening Tool can be found at the following site: MUST.htm - or Double click on this page to expose whole document Appendix 2

24 Appendix 4 The MUST Guidance Booklet MUST Explanatory Booklet.pdf 4-1

25 Appendix 5 Supplement Selection Chart Patient requires prescribable nutritional supplement and meets indications for prescription. Normal protein requirements. Yes Patient enjoys milk based No Additional protein requirements and reduced protein intake. Yes Try Milk Based Complete Sip Feed: 2 cartons/day or Powdered Milkshake Style Supplement No Try Fruit Juice Style Sip Feeds 2 cartons/ day Patient dislikes flavours or has taste changes Consider High Protein Sip Feed Yes Try Yoghurt- Style Sip Feed or Fruit Juice Style Sip Feed No Continue A Fibre Containing Sip Feed may be useful, particularly with constipation. Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 5-11

26 Appendix 6 NHSLA Monitoring Template This template should be used to demonstrate compliance with NHSLA requirements for the procedural document where applicable and/or how compliance with the document will be monitored. Minimum requirement to be monitored Must Screening Assessment completed on all relevant patients Process for monitoring e.g. audit Responsible individuals/group /committee Monthly performance monitoring through each Business Units governance process and monthly by the Performance management meetings by the Board with the Business Units. Evidence taken from System1 Matrons/ Business Units Performance meetings and Board PMR meetings Monthly Frequency of monitoring /audit Responsible individuals / group / committee (multidisciplinary) for review of results Matrons/ Business Units Performance meetings and Board PMR meetings Responsible individuals / group / committee for development of action plan Matrons/Head of Clinical Services Responsible individuals / group / committee for monitoring of action plan Matrons/Heads of Clinical Services Business Units Performance meetings and Board PMR meetings 6-1 6

27 Appendix 7 Implementation Plan Template Implementation Plan (with timescales): Policy Ref: Policy Name: Name of Author/Originator: Date Ratified: Feedback: Amendments Required to Policy Completed By (Policy Lead): Date: Date: 7-7 1

28 Appendix 8 Equality Analysis Introduction The general equality duty that is set out in the Equality Act 2010 requires public authorities, in the exercise of their functions, to have due regard to the need to: Eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act. Advance equality of opportunity between people who share a protected characteristic and those who do not. Foster good relations between people who share a protected characteristic and those who do not. The general equality duty does not specify how public authorities should analyse the effect of their existing and new policies and practices on equality, but doing so is an important part of complying with the general equality duty. It is up to each organisation to choose the most effective approach for them. This standard template is designed to help LCHS staff members to comply with the general duty. Please complete the template by following the instructions in each box. Should you have any queries or suggestions on this template, please contact Qurban Hussain Equality and Human Rights Lead. Chair: Elaine Baylis QPM Chief Executive: Andrew Morgan 8-1 8

29 Appendix 8 Name of Policy/Procedure/Function* Policy for the Development and Management of Policies and Procedural Documents Equality Analysis Carried out by: Anne Duncan Date: January 2014 Equality & Human rights Lead: Rachel Higgins Director\General Manager: Kay Darby *In this template the term policy\service is used as shorthand for what needs to be analysed. Policy\Service needs to be understood broadly to embrace the full range of policies, practices, activities and decisions: essentially everything we do, whether it is formally written down or whether it is informal custom and practice. This includes existing policies and any new policies under development. 8

30 Appendix 8 A. Section 1 to be completed for all policies Briefly give an outline of the key objectives of the policy; what it s intended outcome is and who the intended beneficiaries are expected to be The purpose of this policy is to provide all staff with an approved framework for the creation, approval, ratification and dissemination of policies and procedural documents across the organization. It enables the implemention of a co-ordinated and uniform approach to strategic, operational or clinical management. LCHS will develop policies to fulfil all statutory and organizational requirements. These will be comprehensive, formally approved and ratified, disseminated through approved channels and implemented. B. C. D. Does the policy have an impact on patients, carers or staff, or the wider community that we have links with? Please give details Is there is any evidence that the policy\service relates to an area with known inequalities? Please give details Will/Does the implementation of the policy\service result in different impacts for protected? The effective production of all organizational policies and procedural documents have an impact on all staff, service users and carers. This policy sets out an approved framework through which this should be done. No Yes No Disability X Sexual Orientation X Sex X Gender Reassignment X Race X Marriage/Civil Partnership X Maternity/Pregnancy X Age X Religion or Belief X Carers X Equality Analysis Carried out by: Anne Duncan Date: January