Ipswich and East Suffolk Adult sip feed prescribing guidelines

Transcription

1 Ipswich and East Suffolk Adult sip feed prescribing guidelines Version 4.1 May 2017 Produced by the Medicines Management Team, Ipswich and East Suffolk Clinical Commissioning Group in conjunction with the Dietitians, The Ipswich Hospital NHS Trust 2017/18

2 Contents Aim and Objectives 2 Nutritional Screening 2 Nutrition Sip Feed Flow Chart 3 Advisory Committee on Border Substances (ACBS) guidance on FP10 prescribing 4 Key to colour coding of sip feeds 4 Sip feed formulary 5 Appendix 1: MUST Local Policy and Action Plan (excluding care home residents) 10 Appendix 2: Care Home MUST Local Policy and Action Plan 11 Appendix 3: Food First Guidelines 12 Appendix 4: Useful links 13 Acknowledgements Sarah E. Williams Louise Jordan Daisy Greenaway Professional Lead for Dietetics, The Ipswich Hospital NHS Trust Community Dietitian, The Ipswich Hospital NHS Trust Community Dietitian, The Ipswich Hospital NHS Trust All prices correct as per MIMS, May 2017 edition 1

3 Introduction Aim This document aims to provide clear guidance for prescribing nutritional sip feeds in adult patients (>18 years) in Ipswich and East Suffolk. It is intended for use by General Practitioners, Practice Nurses, Community Nurses and other community prescribers. This version provides an update to the products and prices since the fourth edition of June Objectives To improve the management of patients who are malnourished or identified as at risk of malnutrition To ensure appropriate cost-effective sip feed prescribing To reduce wastage through tailoring sip feed prescriptions to individual preferences To stop repeat prescriptions without regular review. Nutritional screening Nutritional screening should be the first step in identifying people at risk of malnutrition. Vulnerable groups include those with chronic diseases, older people, those recently discharged from hospital and those who are socially isolated. Malnutrition screening in the community implementing MUST The NICE guidelines for nutrition support in adults (2006) state the following should be considered when assessing the need for nutrition support: The patient s current BMI Percentage unintentional weight loss The length of time that (food) intake has been / or is likely to remain inadequate. The Malnutrition Universal Screening Tool (MUST) incorporates all of the above and has been validated across a range of settings including general practice, the community and care homes. It is consistent, reproducible and easy to use. In addition to identifying malnutrition risk, it provides nutritional care plans to enable health professionals and carers to respond immediately if a patient is identified as being malnourished or at risk of malnutrition. The tool is available to download from Community dietitians at the Ipswich Hospital NHS Trust and West Suffolk Foundation Trust have developed the accompanying MUST Local Policy and Action Plans (see Appendices 1 and 2) to provide guidelines for the management of these individuals. They also provide ongoing training to care home staff, Community Nurses, Local Care Teams and other care workers in Suffolk in using the MUST Tool and the food first approach. Contact Ipswich ( ) dietitians to access MUST training. 2

4 Nutrition Sip Feed Flow Chart (excludes residents in Care Homes see Appendix 2) Patient requires sip feeds as identified through MUST and MUST Local Policy (Appendix 1) Assess any underlying medical problems and establish aims of treatment, e.g. weight gain, prevent further weight loss, improved nutritional intake Food First advice has been given. See Provide NAGE leaflet So you Think You Have a Small Appetite or Eating well and keeping well with diabetes (see Appendix 4 for links) Check patient can potentially meet nutritional needs safely via the oral route Check patient s condition complies with ACBS guidelines for sip feeds (see page 4) Prescribe sip feed for one week trial. Reinforce Food First advice See page 5 for supplements of choice. Where these are contraindicated prescribe from first line alternatives (pages 6-9) Record weight If ACBS prescribing criteria is not met, Over The Counter (OTC) products can be recommended unless contraindicated, e.g. Complan, Meritene Energis, AYMES Retail, Nurishment, Nurishment Extra. Prescriptions should have clear directions for use, e.g. one to be taken twice daily between meals. As directed should not be used. After one week: Establish patient s preferences for sip feeds Weigh patient Establish any changes in patient s appetite If not tolerated choose alternative sip feed for further one week trial Prescribe 1-2 sip feeds per day in addition to usual food for one month as an acute prescription. Seek dietetic advice for patients unable to take usual diet who may require an increased number of sip feeds If sip feeds not tolerated or nutritional intake/weight declines refer to dietitian using MUST referral form as indicated in MUST Local Policy Continue to monitor patient monthly if not under care of dietitian using MUST and MUST Local Policy and check compliance with sip feeds If taste fatigue occurs, recipes (available from manufacturers) should be encouraged before an alternative prescription is provided. When target weight or aim of therapy achieved reduce sip feeds gradually and then discontinue. Monitor weight/must score for 3 months If any concerns regarding underlying conditions consider referral to GP or appropriate health care professional, e.g. Speech and Language Therapist, Palliative Care Team for further advice at any stage STOPPING SUPPLEMENTS When agreed goals are met or If all the following are met: Food intake is satisfactory (eating more than half their meals) BMI within healthy range (20 25kg/m 2 ) Maintained current weight for last 2 months or is gaining weight 3

5 Advisory Committee on Borderline Substances (ACBS) guidance on FP10 prescribing The Advisory Committee on Borderline Substances (ACBS) recommends the prescription of certain food products (such as enteral or sip feeds) on the basis that they are used as a treatment of the management of specified conditions. The prescription of sip feeds should only occur when the patient s condition falls into one or more of the ACBS approved categories: Standard ACBS indications Other ACBS indications Short bowel syndrome Intractable malabsorption Pre-operative preparation of patients who are malnourished proven Inflammatory bowel disease Following total gastrectomy Disease related malnutrition (DRM) Bowel fistulae Dysphagia Continuous Ambulatory Peritoneal Dialysis (CAPD) Haemodialysis Colour Coding Key The sip feeds listed in this document have been colour coded to denote the following: Green Amber Red Recommended first line products - provide the most cost-effective and optimum nutritional content Alternative products if there is a physical or medical reason that a patient cannot take the first line product or if the supplement is not tolerated from the green section Of limited nutritional content or a specialist product and therefore should only be prescribed under the guidance of a registered dietitian 4

6 Sip Feed Formulary This is not an exhaustive list. New products regularly become available. The BNF and MIMS provide the full list of oral nutritional supplements (ONS). Products not listed here are not recommended as first-line and dietetic guidance is recommended before prescribing them. The first line sip feeds of choice, unless contraindicated, are Foodlink Complete or AYMES Shake which provide kcal and 16-19g protein when mixed with 200ml whole milk. First Line Preferred Options * * (g) AYMES Shake (sweet flavours) 57g sachet Foodlink Complete 57g sachet Foodlink Complete with Fibre 63g vanilla flavoured sachet * * (g) Foodlink Complete Starter Pack 4 flavours of Foodlink Complete and 1 of / Foodlink Complete with Fibre AYMES Shake Starter Pack (sweet 5 flavours of AYMES Shake flavours) * when mixed with 200ml whole milk Suggested intake: 1-2 servings a day unless otherwise indicated by the clinician or dietitian. Contraindications: Limited dexterity & inability to make up the shake Cow s milk or soya allergy or intolerance Less than 6 years of age Galactosaemia Require thickened fluids Require ONS as a sole source of nutrition Require additional fibre via their ONS (Nb. Foodlink Complete with Fibre contains 4.6g fibre per serving) Not suitable for use with enteral feeding tubes Patients with renal disease should be assessed by a dietitian prior to prescribing any of the above. Patients with diabetes should have their oral intake assessed before an ONS is prescribed. Blood glucose levels should be monitored and treatment reviewed as necessary. If contraindicated, the sip feeds overleaf are recommended as a first-line choice of supplement. Some are available as Starter Packs intended as an initial 3-10 day supply to assess preference. 5

7 Alternative options Starter packs: Product Presentation Unit price Calories (g) * / 644* 30* Foodlink Complete Starter Pack 4 flavours of Foodlink Complete and 1 of Foodlink Complete with Fibre Complan Shake Starter Pack 5 flavours of Complan Shake AYMES Shake Starter Pack 5 flavours of AYMES Shake Ensure Plus Commence (1.5kcal/ml) 10 flavours of Ensure Plus AYMES Complete Starter Pack 4 flavours of AYMES Complete (1.5kcal/ml) Fortisip Compact Starter Pack 6 mixed flavours of Fortisip (2.4kcal/ml) Compact Altraplen Compact Starter Pack 4 flavours of Altraplen Compact (2.4kcal/ml) Nutricrem Starter Pack (1.8kcal/g) 3 mixed flavours of Nutricrem pudding style for dysphagia Vitasavoury Starter Pack (2kcal/g) 8 sachets, two of each flavour ** 194*** 3** 5*** Fortisip Compact Starter Pack 4 mixed flavours of Fortisip (2.4kcal/ml) Compact Fortisip Range Starter Pack (1.5kcal/ml) 4 Fortijuce, 4 Fortisip Bottles, Fortisip Yogurt Style Fortijuce Starter Pack (1.5kcal/ml) 4 flavours of Fortijuce Fortisip Compact Fibre Starter Pack (2.4kcal/ml) 4 mixed flavours of Fortisip Compact Fibre * when made up with 200ml whole milk, ** average serving with water, *** average serving with milk Milkshake style sip feeds: (g) Ensure Plus (1.5kcal/ml) 220ml bottle Nutricomp Drink Plus (1.5kcal/ml) 200ml bottle AYMES Complete (1.5kcal/ml) 200ml bottle Fresubin Energy (1.5kcal/ml) 200ml bottle Fortisip Bottle (1.5kcal/ml) 200ml bottle Ensure Compact (2.4kcal/ml) 125ml bottle Fortisip Compact (2.4kcal/ml) 125ml bottle Altraplen Compact (2.4kcal/ml) 125ml bottle Fresubin 2kcal (2kcal/ml)* 200ml bottle Fresubin 2kcal mini drink (2kcal/ml) 125ml bottle Fortisip 2kcal (2kcal/ml) 200ml bottle Ensure Plus Advance (1.5kcal/ml)** 220ml bottle Resource Energy (1.5kcal/ml) 200ml bottle Ensure (1 kcal/ml) 250ml can Fresubin Original (1kcal/ml) 200ml bottle * cost-effective option if prescribed once daily as opposed to two 1.5kcal/ml products. ** for patients over 65 years of age. 6

8 Juice-style sip feeds: An alternative for patients who do not like/tolerate milk or milk-based sip feeds. per (g) Ensure Plus Juce (1.5kcal/ml) 220ml bottle Fresubin Jucy (1.5kcal/ml) 200ml bottle Fortijuce (1.5kcal/ml) 200ml bottle Resource Fruit (1.25kcal/ml) 200ml bottle Yoghurt-style sip feeds: Less sweet, and useful for patients with taste fatigue or taste changes. Tend to be lower calorie than the 2kcal/ml milk based sip feeds. (g) Ensure Plus Yoghurt Style (1.5kcal/ml) 220ml bottle Fortisip Yogurt Style (1.5kcal/ml) 200ml bottle Savoury-style supplements: Best served warm as a soup or added to sauces. (g) AYMES Shake chicken (1 kcal/ml) 57g sachet * 13* Ensure Plus Savoury (1.5kcal/ml) 220ml bottle Vitasavoury (2kcal/ml) 50g sachet * 194** *when made up with water, ** when made up with whole milk. 3* 5** 7

9 Other nutritional supplements available on prescription (not an exhaustive list) Other energy and protein supplements are available in the form of powders, liquids and desserts. Powdered milkshake style drinks: These drinks are made up with fresh milk or water. They are high in calories. Mixing instructions can be obtained from the manufacturer s website. (g) AYMES Shake 57g sachet * 26* Foodlink Complete 57g sachet * 30* Foodlink Complete with Fibre 63g vanilla flavoured sachet * 28* Ensure Shake 57g sachet * 24* Complan Shake 57g sachet * 22* Fresubin Powder Extra 62g sachet * 23* Enshake 96.5g sachet ** 7** Calshake 87g-90g sachet ** 5** Scandishake 85g sachet ** 5** * when made up with 200ml whole milk. ** when made up with 240ml whole milk. High protein sip feeds: These are high in protein. Useful in patients with chronic wounds, burns or fistulae. Seek advice if any concerns with renal function. (g) Foodlink Complete 57g sachet * 30* Ensure Compact (2.4kcal/ml) 125ml bottle Altraplen (1.5kcal/ml) 200ml bottle Fresubin 2kcal (2kcal/ml) 200ml bottle Fresubin 2kcal mini drink (2kcal/ml) 125ml bottle Fortisip 2kcal (2kcal/ml) 200ml bottle Fortisip Compact (2.4kcal/ml) 125ml bottle Fortisip Extra (1.6kcal/ml) 200ml bottle Fresubin Energy (1.5kcal/ml) 200ml bottle * when made up with 200ml whole milk Fibre-containing sip feeds: Useful if patient is suffering with constipation. Shake well before drinking. (g) Foodlink Complete with Fibre 63g vanilla flavoured sachet * 28* Resource 2.0 Fibre (2kcal/ml) 200ml bottle Fresubin 2kcal Fibre (2kcal/ml) 200ml bottle Fresubin 2kcal Fibre mini drink (2kcal/ml) 125ml bottle Ensure TwoCal (2kcal/ml) 200ml bottle Ensure Plus Fibre (1.6kcal/ml) 200ml bottle Fresubin Energy Fibre (1.5kcal/ml) 200ml bottle Fortisip Compact Fibre (2.4kcal/ml) 125ml bottle * when made up with 200ml whole milk 8

10 Semi-solid desserts: Often used in patients with dysphagia. Nutricrem (1.8kcal/g) 125g pot Nutilis Complete Stage 2 (2.4kcal/ml) 125ml pot Fresubin 2kcal Crème (2.0kcal/g) 125g pot Resource Dessert Energy (1.6kcal/g) 125g cup Forticreme Complete (1.6kcal/g) 125g pot Fresubin YOcrème (1.5kcal/g) 125g pot Ensure Plus Crème (1.4kcal/g) 125g pot Nutilis Fruit Stage 3 (1.4kcal/g) 150g pot Pre-thickened milk-shake style: Used in patients with dysphagia. Fresubin Thickened Stage 1 (1.5kcal/ml) 200ml bottle (g) (g) Fresubin Thickened Stage 2 (1.5kcal/ml) 200ml bottle Nutilis Complete Stage 1 (2.4kcal/ml) 125ml bottle Modular supplements: Specialist products only to be prescribed under the guidance of a dietitian, e.g. Product Type Altrashot Calogen Calogen Extra Calogen Extra Shot Maxijul Super Soluble Pro-Cal Shot Pro-Cal Powder Fresubin 5kcal Shot ProSource ProSource Jelly ProSource Plus Fat, carbohydrate & protein liquid Fat emulsion Fat emulsion with protein, carbohydrate, vitamins and minerals Fat emulsion with protein, carbohydrate, vitamins and minerals Glucose polymer powder Fat, carbohydrate & protein liquid Fat, carbohydrate & protein powder Fat emulsion Collagen & whey protein liquid jelly Collagen & whey protein liquid 9

11 Appendix 1 MUST Local Policy and Action Plan for Community Nurses and GPs (Excluding Care Home residents) 0 : Low Risk 1 : Medium Risk 2 or more : High Risk Routine Clinical Care Observe Treat All risk categories: - Treat underlying condition - Check patient can potentially meet nutritional needs safely via oral route - Record favourite foods; provide assistance with food choices, eating and drinking as necessary - Record need for special diets and follow local policy Screen at initial contact and at least monthly for at risk groups e.g. people with chronic disease, older people - Commence food record chart for 3 days - Encourage: - eating and drinking - in-between meal snacks - milky drinks - Follow local Food First advice* and fortify diet - Commence food record chart for 3 days - Encourage : - eating and drinking - in-between meal snacks - milky drinks - fortify diet *Use Food First advice in the Nutrition Action Pack provided by your local Nutrition & Dietetics Department Referrals to the Dietitian All staff who have received training on MUST can refer directly to the local dietetic service by fax or post using the MUST referral form (see Appendix 4 for link) If no improvement with intake e.g. eating less than 50% of meals, or clinical concern Follow local Food First advice* - Fortify diet Repeat screening monthly & follow appropriate action plan If improved intake, e.g. eating more than 50% of meals and a snack/milky drink, and little clinical concern Repeat screening monthly & follow appropriate action plan If no improvement with intake e.g. eating less than 50% of meals, weight loss or clinical concern Trial of nutritional supplements (see Nutritional Sip Feed Flow Chart) Repeat screening weekly & follow appropriate action plan If improved intake, e.g. eating more than 50% of meals and a snack/milky drink, and little clinical concern Repeat screening weekly & follow appropriate action plan If scores 1 then continue as above If further clinical concern refer to the dietitian using MUST referral form If scores 2 then treat as High Risk with trial of nutritional supplements If trial of nutritional supplements unsuccessful or clinical concern, refer to the dietitian using MUST referral form 10

12 Appendix 2 - Care Home MUST Local Policy and Action Plan All risk categories: - Treat underlying condition - Check patient can potentially meet nutritional needs safely via oral route - Record favourite foods; provide assistance with food choices, eating and drinking as necessary - Record need for special diets and follow local policy MUST 0 - Low Risk Routine Clinical Care Screen at initial contact (within 48hrs) and then rescreen using MUST monthly. *Use Food First advice in the Nutrition Action Pack provided by your local Nutrition & Dietetics Department. Additional copies are available on our website: dietetics/ Referrals to the Dietitian All staff who have received training on MUST can refer directly to the dietitian using the MUST referral form. Referrals will be reviewed on receipt and if the action plan has not been followed or the referral is inappropriate, they will be returned MUST 1 Medium Risk Observe Commence food record chart for 3 days Commence Food First Principles: o Encourage eating and drinking o in-between meal nourishing snacks o One nourishing drink per day ( See Food First Pathway poster) o Food Fortification Consider providing daily over the counter multivitamin and mineral supplementation if intake has reduced to ensure all nutrient requirements are met. Rescreen weekly using MUST and follow appropriate action plan. If individual manages more than 75% of meals/drinks and little clinical concern, continue with Food First and rescreen weekly using MUST If individual manages less than 50% meals/drinks Follow High Risk action plan MUST 2 or more without high risk factors Treat Commence food record chart Increase Food First Principles : - o Encourage eating and drinking o in-between meal nutritious snacks o Fortify Food and drinks o Commence two nourishing drinks per day. See Food First Pathway poster o Trial over the counter sip feed up to twice per day i.e. Complan, AYMES, Meritene Energis Rescreen weekly using MUST Consider providing daily over the counter multivitamin and mineral supplementation if intake has reduced to ensure all nutrient requirements are met. Rescreen weekly using MUST & follow appropriate action plan. If no improvement after 1 month, or not tolerated, or develops high risk factors refer to dietitian using Care Home MUST referral form. Rescreen weekly using MUST If improved intake, e.g. eating more than 75% of meals/nourishing drinks, and weight increased, and little clinical concern Care home to wean off over the counter sip feed Monitor & repeat screening via MUST weekly & follow appropriate action plan. To refer to dietetic department if develops high risk factor. Rescreen weekly using MUST MUST 2 or more with high risk factors Treat Commence food record chart Increase Food First Principles : - o Encourage eating and drinking o in-between meal nutritious snacks o Fortify Food and drink o Commence two nourishing drinks per day. See Food First Pathway poster. Rescreen weekly using MUST Consider daily over the counter multivitamin and mineral supplementation if intake has reduced Refer to dietitian using a Care Home MUST referral form and rescreen weekly using MUST High Risk Factors Rapid weight loss (More than 10% in 3-6 months) Therapeutic Diet i.e. Renal, diabetes Breathing difficulties i.e. COPD Current increased nutritional requirements e.g. infection, pressure sores Trialed 2 different types of over the counter sip feed and no improvement in nutritional status Dysphagia/swallowing difficulties 11

13 Produced by the Medicines Management Team, Ipswich and East Suffolk Clinical Commissioning Group in conjunction with the Dietitians, The Ipswich Hospital NHS Trust. May Next review May

14 Appendix 4 Useful links AYMES Shake mixing instructions: Foodlink Complete mixing instructions: Malnutrition Universal Screening Tool (MUST), available to download from the British Association for Parenteral and Enteral Nutrition (BAPEN) website at MUST dietetic referral form, available to download from the dietetics page within Medicines Management at nagement/ccgformularies/dieteticsformulary.aspx Information on food first, the first-line treatment for malnutrition, available to download from: Fabulous Fortified Feasts. Food first recipes produced by PrescQIPP. Available to download from Do You Have a Small Appetite? A5 booklet produced by the Nutrition and Diet Resources UK (NDR-UK) and the Nutrition Advisory Group for the Elderly (NAGE) a specialist group of the British Dietetic Association (BDA) available to purchase from This booklet is not suitable for people with diabetes. Eating Well and Keeping Well with Diabetes, A5 booklet produced by the Nutrition and Diet Resources UK (NDR-UK) and the Nutrition Advisory Group for the Elderly (NAGE) a specialist group of the British Dietetic Association (BDA) available to purchase from Ipswich and East Suffolk CCG policy on Oral Nutritional Supplements in Care Homes and Information for Care Homes. Both available to download from Produced by the Medicines Management Team, Ipswich and East Suffolk Clinical Commissioning Group in conjunction with the Dietitians, The Ipswich Hospital NHS Trust. May Next review May