Birmingham Community Nutrition MUST * screening & the next steps

Transcription

1 Birmingham Community Nutrition MUST * screening & the next steps The identification of Birmingham undernutrition Community and the management of oral nutrition support for adults in the community First version issued: January 2014 Updated version: August 2018 Review Date: 3 years from date of issue Written by Birmingham Community Nutrition & Dietetic Service This user guide replaces Guidelines for the Management of Undernutrition in the Community * Malnutrition Universal Screening Tool 1

2 Title MUST screening & the next steps 1 Edition: 4 th Edition 2 Impact Assessments and Dates: Equality & Human Rights Analysis 25/07/ Approval History: BAPEN 31/01/12 Birmingham & Solihull Cluster MMC 29/05/12 Ratified by BCHC Adults & Communities Quality, Governance & Risk Committee 21/01/2014 Update approved by BCHC Patient Safety Express 24/01/18 Medicines Management Cross City CCG 28/03/17 Medicines Management South Central CCG 28/03/17 4 Name of Executive Director Lead: Sarah Monk, Joint Head of Service, Birmingham Community Nutrition, BCHC 5 Name of Lead Officer: Janet Gordon, Team Leader, Nutrition Support Team, Birmingham Community Nutrition 6 Date Issued: January 2014 Updated August Review Date: 3 Years from date of Issue 8 Target Audience: External organisations such as GP practices, care homes (residential and nursing) pharmacists 9 Is this policy new or a replacement for existing policies? 10 If no, which policies should be removed from the intranet? Replacement 11 Type of policy please circle Clinical Guidelines for the management of undernutrition in the community 12 Summary The timely identification of undernutrition and evidence based management of oral nutrition support in the community are essential in improving health and aiding recovery from illness, and in ensuring the most efficient use of resources. This policy aims to give guidance to all staff on how to use the nationally validated MUST screening tool and how to implement effective care planning based on the MUST score. 2

3 CONTENTS PAGE Introduction 4 The five steps of MUST 6 MUST flow charts and record chart 7 Implementation of the care plans including first line advice 10 Prescribing nutritional supplements 14 Withdrawing nutrition support 17 Palliative/end of life care 18 Referral Process and How to Contact a Dietitian 18 Recommended resources 20 References 21 Appendix 1 MUST reference charts 23 Appendix 2 Care plans for care homes 29 Appendix 3 Care plans for community care 31 Appendix 4 Identifying underlying causes of nutritional deficiencies 33 and action plans Appendix 5 Boosting the calories recipe adapting 35 Appendix 6 Increase the calories 36 Appendix 7 Types of first line nutritional supplement 37 Appendix 8 Dietetic referral criteria 38 Appendix 9 Dietetic referral form 39 Appendix 10 Subjective indicators of malnutrition 44 Appendix 11 Special considerations for ONS prescribing: substance misusers 45 Appendix 12 Homemade Food Booster Milkshake 47 Appendix 13 Dysphagia Snack Recipes 49 The Malnutrition Universal Screening Tool ( MUST ) is reproduced within these Guidelines with the kind permission of BAPEN (British Association for Parenteral and Enteral Nutrition). (Thank you to C.A. Russell of BAPEN who provided feedback and recommendations on the content of this document). Please note: This user guide is intended as guidance only and healthcare professionals remain responsible for the care given to their patients. The contents reflect evidence or consensus opinion. It is the responsibility of the healthcare professional to ensure that they keep up to date and that new information, evidence, consensus or national guidelines are taken into account when giving advice and when recommending or prescribing oral nutritional supplements. This user guide is intended for use with individuals who have the ability to eat and drink safely (with the use of modified consistencies where appropriate) and are not intended for use with individuals who have been advised to be nil by mouth. The suitability of enteral feeding should be considered, where appropriate, for individuals who are nil by mouth, but whose gastrointestinal tract functions, and this should be a multidisciplinary decision. 3

4 INTRODUCTION Who is this guidance for? GP s and practice staff, case managers, care home staff, and all other healthcare staff who are involved in the care of adult patients (16 years+, excludes those with learning disabilities) in their own homes or in care home beds (BCHC healthcare staff please refer to the BCHC How to use the malnutrition screening tool MUST for adults in the community and bedded units policy ) Why is guidance required? Early identification and appropriate management of patients with poor nutritional status, or who are at risk of malnutrition, will allow the most efficient use of resources and will increase health benefits and recovery. This guidance supports the national Harm Free Care 1 (NHS Safety Thermometer) and the Care Quality Commission regulation 14 Meeting Nutritional & Hydration Needs. Within the community setting a coordinated approach by a range of health care professionals is essential to identify, treat and monitor patients who are malnourished or at risk of becoming so. This guidance is based on the NICE Guideline for Nutrition Support in Adults (2006) 2 and the NICE Quality Standard 24 Nutritional Support in Adults (2012) 3 What is malnutrition? Malnutrition is defined as a state of nutrition in which a deficiency, excess or imbalance of energy, protein and other nutrients, causes measurable adverse effects on tissue/body structure and function and clinical outcome 4. For the purpose of these guidelines the term malnutrition will refer to a deficiency of energy, protein and/or micronutrients. The main causes of malnutrition 2 are:- Impaired intake Impaired digestion and/or absorption Altered metabolic requirements Excess nutrient losses If untreated, malnutrition has many consequences detrimental to physical function, disease outcomes and psycho-social wellbeing as well as healthcare costs. Examples are:- Increased admissions and re-admission to hospital Increased length of hospital stay Increased visits to GP Increased mortality Inability to cope with ill health resulting in a loss of independence and well being In the cost in the UK was estimated to be 19.6 billion a year 5. How is malnutrition identified? The Malnutrition Universal Screening Tool ( MUST ) has been designed to enable identification of adults who are malnourished or at risk of malnutrition, as well as those who are overweight or obese. MUST has not been designed to identify deficiencies in or excessive intakes of vitamins and minerals. MUST was developed by the Malnutrition Advisory Group (MAG), a standing committee of the British Association for Parenteral and Enteral Nutrition (BAPEN). Further information regarding 4

5 MUST can be obtained from 6 Online MUST training is available at: What is the role of healthcare professionals? It is the health professional s duty of care to consider the patient in a holistic manner. This includes the consideration of every patient s nutritional status. Health professionals are therefore expected to screen patients to identify malnutrition or risk of malnutrition using MUST (pages 7 or 8), implement a care plan which includes giving first line dietary advice and refer onto more specialist healthcare professionals e.g. dietitians, only when appropriate to do so. Care homes (nursing and residential) All patients must be screened for malnutrition on admission and then thereafter as indicated by the MUST flow chart on page 7 2. Community patients (patients in their own homes) (eg community nurse, GP, practice nurse, allied healthcare professional) Screening should be done at initial registration with a patients GP, at the first community nurse contact, when clinical concern and at other opportunities e.g. health checks, flu injections and thereafter as indicated by the MUST flow chart on page 8 2. What is the role of the dietitian? Registered dietitians 7 play a key role in addressing malnutrition; however dietitians are a limited resource. Primarily the dietitian s role is to: 1. establish a whole system approach to addressing malnutrition, for example, providing information and training on MUST, first line dietary advice and the appropriate use of prescribed nutritional supplements to health care professionals 2. use their expertise to see only those patients where a MUST implemented care plan requires dietetic referral, if a patient is receiving no oral nutrition at all, if there are complex dietary needs e.g. coeliac disease, Crohns disease or a modified texture is also required See appendices 8 & 9 for dietetic referral criteria and referral form. If you are uncertain whether to refer a patient, please phone the dietetic department for advice on

6 THE FIVE STEPS OF MUST See Appendix 1 of this document for relevant reference materials. Using the appropriate MUST flowcharts (page 7 or 8) obtain consent then complete the following steps: Step 1: Body Mass Index (BMI kg/m 2 ) score Establish the patient s BMI score using their height and weight measurements to calculate BMI. Note if the patient is dehydrated the BMI will be falsely lowered and will require re-checking after hydration. Conversely if there is fluid overload/oedema/ascites BMI will be falsely raised If unable to measure height use a recently documented or self-reported height (if reliable and realistic). If unable to obtain this measure ulna length (Appendix 1) If unable to obtain a weight a BMI score cannot be derived. See the section below on subjective criteria Step 2: Recent unplanned percentage weight loss score Establish the patient s weight loss score by exploring any unplanned weight loss experienced over the last 3-6 months. To calculate percentage weight loss: Percentage weight loss = (previous weight current weight) previous weight x 100 e.g. previous weight = 48kg current weight = 46kg (48 46 = 2) 48 x 100 = 4% Alternatively use the percentage weight loss chart in Appendix 1. Start with the patient s current weight in the non-coloured column on the left. Look horizontally across the chart until the previous weight is found. Look up to the column heading which will give the weight loss score If recent weight loss cannot be calculated, use self-reported weight loss if reliable and realistic N.B. If significant weight loss within the last 2 weeks consider if the patient could be dehydrated, or whether oedema that was present before has now resolved. Step 3: Acute disease effect score This is used if the patient is currently affected by an acute patho-physiological or psychological condition and there has been (or is likely to be) no nutritional intake for more than five days. This is unlikely to apply in the community apart from in those patients who have reached end of life and action may be inappropriate. Step 4: Overall risk of malnutrition score Establish the patients overall risk of malnutrition by combining the scores for steps 1, 2 and 3. The maximum score that can be achieved is 6. Step 5: Management Guidelines Once the overall risk of malnutrition has been detected, document the score on the MUST record chart (page 8) and implement an appropriate care plan (appendices 2 & 3). Subjective criteria If height, weight or BMI cannot be obtained, other criteria (see Appendices 1 and 10) which relate to them can assist professional judgment of the patient s nutritional risk category. Please note, these criteria should be used collectively, not separately, as alternatives to steps 1 and 2 and are not designed to assign a score. Mid upper arm circumference (MUAC) may be used to estimate BMI category only in order to support your overall impression of the patient s nutritional risk. 6

7 MUST SCREENING TOOL CARE HOMES Patient screened for risk of malnutrition on admission to a care home and then as indicated using MUST score. STEP 1 - BMI Score BMI (kg/m 2 ) Score >20 (>30 obese) = = 1 <18.5 = 2 NB: can be estimated from mid-upper arm circumference (MUAC) STEP 2 Weight Loss Score % Unplanned weight + + loss in past 3 6 months % Score <5 = = 1 >10 = 2 STEP 3 Acute Disease Effect Score If patient is acutely ill AND there has been or is likely to be no nutritional intake for >5 days SCORE 2 Otherwise score 0 STEP 4 Overall risk of Malnutrition (score 0 6) Add scores together to calculate overall risk of malnutrition Score 0 = LOW RISK Score 1 = MEDIUM RISK Score 2 or more = HIGH RISK Assess for underlying cause of malnutrition and refer if appropriate to members of the multidisciplinary team 0 LOW RISK Repeat screening every four weeks* and document on MUST record chart Re-screen immediately if patient s clinical condition changes 1 MEDIUM RISK Implement Medium Risk Care Plan (appendix 2) Repeat screening every four weeks* and document on MUST record chart 2 or MORE HIGH RISK Implement High Risk Care Plan (appendix 2) Repeat screening every four weeks* and document on MUST record chart 7

8 MUST SCREENING TOOL COMMUNITY NICE 32 (2006) recommends the patient is screened for the risk of malnutrition at initial registration with GP, however practically this is likely to be if there are initial clinical indications to do so (see appendix 10), if subsequent clinical concern, first contact with community nursing, or other opportunistic moments e.g. injections, health checks. STEP 1 - BMI Score BMI (kg/m 2 ) Score >20 (>30 obese) = = 1 <18.5 = 2 NB: can be estimated from mid-upper arm circumference (MUAC) STEP 2 Weight Loss Score % Unplanned weight loss in past months + % Score <5 = = 1 >10 = 2 STEP 3 Acute Disease Effect Score If patient is acutely ill AND there has been or is likely to be no nutritional intake for >5 days SCORE 2 Otherwise score 0 STEP 4 Overall risk of Malnutrition (score 0 6) Add scores together to calculate overall risk of malnutrition Score 0 = LOW RISK Score 1 = MEDIUM RISK Score 2 or MORE = HIGH RISK Assess for underlying cause of malnutrition and refer if appropriate to members of the multidisciplinary team 0 LOW RISK Repeat screening annually for special groups e.g. those >75 yrs Re-screen if clinical condition changes or if clinical concern 1 MEDIUM RISK Implement Medium Risk Care plan (appendix 3) Repeat screening every four weeks and document on MUST record chart 2 or MORE HIGH RISK Implement High Risk Care Plan (appendix 3) Repeat screening every four weeks and document on MUST record chart 8

9 Weight on admission or initial contact: Kg MUST RECORD CHART Developed for use with the Malnutrition Universal Screening Tool Name: Date of Birth: NHS Number: Address or Room Number: Weight 3 months before first recorded screening date OR recent stable weight: Kg Height (m)* or ulna length: Consent: Yes No If measuring MUAC use left arm** Date Current weight (kg) (record MUAC (cm) if unable to weigh) BMI kg/m 2 (wt/ht 2 ) if weight available STEP 1 BMI Score Previous weight 3-6 months ago (kg) (wt before wt loss) Amount of weight lost (kg) (previous wt minus current wt) STEP 2 Weight Loss Score STEP 3 Acute Disease Effect Score (nutrition intake) STEP 4 Overall MUST score (Step 1+2+3) STEP 4 Risk 0=low 1=medium 2+=high STEP 5 Care Plan updated/ continued Print name & Signature Special Instructions: E.G kg kg 5kg High A Smith *If height is unavailable, height can be estimated from ulna length (cm) (length between elbow and prominent bone in wrist) ** If unable to measure MUAC on left arm please state reason right arm was used: For more information on MUST see 9

10 IMPLEMENTATION OF THE CARE PLANS (Appendices 2 & 3) On obtaining a MUST score, or level of risk by subjective criteria, it is essential to TAKE ACTION: 1. Ensure any underlying conditions or problems affecting the patient s risk of malnutrition) are identified and treated (Appendix 4) 2. Ensure adequate hydration 3. Set an appropriate goal with the individual/carer When implementing any nutritional plan you should set a goal and monitor progress towards this goal. This goal should be reviewed each time the patient is screened or when there are changes in medical condition to ensure it is still appropriate. This will help you know when to start withdrawing nutritional therapy (please see flow chart on page 16). The goal you set will need to be specific to each patient and may be one or more of the following: Target BMI (20-25 Kg/m 2 is the healthy range, however for particular individuals a lower BMI e.g kg/m 2 may be more realistic). Please note that if your patient has a BMI over 25 when you implement a nutrition plan, you would need to aim for a stable BMI rather than aiming to reduce their BMI to the healthy range as they are already in a compromised nutritional state Target Weight. For some patients it would not be feasible to attain the healthy range BMI above. For these, set a target weight, e.g. the weight before they started losing weight Prevention of further weight loss Wound healing. Intervention may be withdrawn safely (see page 16) when the persons wound has healed Improved mobility Quality of life. This may be about maintaining current quality of life or improving quality of life. e.g. those with end stage dementia, at the end of life or receiving palliative care. In these cases provision of food for comfort, enjoyment or alleviation of symptoms should be encouraged, providing it is safe to do so, in order to slow the decline in nutritional status whilst being realistic about what can be achieved. It may not always be appropriate to MUST screen, commence supplements or refer for dietetic advice but this must be based on clinical judgment at the time, taking into account patient/carer wishes, and any decisions should be clearly documented.. See page 17 for further information. Maintenance of adequate nutritional intake When setting any goal, ensure it is: Specific Measurable Achievable Realistic Time Appropriate 4. Give first line dietary advice (see below) Advice should be provided to encourage the use of energy, protein and micronutrient rich foods in the patient s diet. This is the initial intervention, and should precede the prescription of nutritional supplements in all cases where the patient is able to take foods orally. The first line dietary advice overleaf is supported by the leaflet Advice to Boost Nutritional Intake or Your Guide to making the most of your food (available from which can be given to patients to reinforce the dietary advice provided. The professional providing the patient with first line advice should advise on the aim of therapy which is to improve or maintain nutritional status and avoid malnutrition. This advice must take into account religious and 10

11 secular beliefs and cultural influences on food intake. Care homes must ensure the food provided complies with this advice 5. Prescribe oral nutritional supplements as guided by the care plan 6. Monitor the intervention as guided by the care plan First Line Dietary Advice First line dietary advice should include the following: Use at least one pint of full fat (whole) milk each day fortified with dried milk powder (see appendix 5 for recipe) and use in drinks/food throughout the day Little and often have 2 high calorie snacks (appendix 6) or nourishing drinks between meals and a snack/supper before bed. Patients requiring altered texture modification (puree/fork mashable) also require suitable snacks (appendix 13) Enrich food and drinks such as cereals, milk puddings, canned fruit, potatoes, soups and vegetables with cream, butter, margarine, cheese, evaporated milk or sugar* (*unless patient has diabetes) Drink more milk based drinks made with the fortified milk e.g. milky coffee, malted milk, hot chocolate and milkshakes Avoid low fat, low sugar* products look for full fat, high sugar* varieties to provide more calories (*unless patient has diabetes) Care homes should be offering home-made nutritious milkshakes (see Appendix 12) Patients may be reluctant to eat high fat, high sugar foods, so it is important to reinforce the message that preventing weight loss and malnutrition is most important and that first line advice is only meant as a short term measure i.e. general healthy eating messages do not apply (N.B. Patients used to low fat diets may experience nausea if they introduce high fat foods too quickly, so encourage a gradual increase). First Line Advice suitable for a Vegan Diet First line advice should be followed substituting dairy options for suitable full fat vegan alternatives Ground almonds can be added to foods Nut butters e.g. peanut, cashew, hazelnut can be added to cereals, soups, curries, stews (it may help to thin these down with a little water to aid mixing into other foods) Use vegan cream in hot drinks, poured over fruit or added to desserts Vegan desserts are available from most supermarkets Plain chocolate can be given as a snack or used to cook with to add additional energy/protein to foods First Line Advice for patients needing a long term cardio protective diet The above information is designed to be used as a short term measure. For those needing to use food fortification as an ongoing measure and where heart health is a primary concern please use the following advice: Use at least one pint of semi skimmed milk each day fortified with Dried Skimmed Milk Powder (see Appendix 5 for recipe) and use in drinks/food throughout the day Drink more milk based drinks made with the fortified milk e.g. milky coffee, malted milk, hot chocolate and milkshakes Use Monounsaturated Fat sources where possible e.g. olive/vegetable oil, olive oil based spread o Use olive oil as dressings on salads and vegetables o Use olive oil based spreads on bread, in mash etc Aim to promote fruit and vegetable consumption as these provide a good source of vitamins and minerals o Try almond butter or mashed avocado on toast or crackers as a snack 11

12 o Add avocado to salads o Snack on dried fruit and nuts such as almonds, brazil nuts etc o Try vegetables such as peppers and carrots with dips as snacks Aim for 1-2 portions of oily fish per week (e.g. salmon, mackerel, sardines, pilchards, fresh tuna) Encourage snacks between meals (see appendix 6 for snack ideas) Vitamins and Minerals People requiring food fortification still need a balanced diet to ensure they meet their vitamin and mineral requirements. Vitamins and minerals are essential for lots of processes in the body including prevention of anaemia and wound healing. Food fortification is often high in calories and protein at the expense of fruit and vegetables. Try the following tips: Snack on dried fruit** and nuts Have fruit** as a dessert but serve with cream, custard or yoghurt Ensure vegetables present at main meals add salad dressings or olive oil or butter on vegetables Add fruit** to cereal Have a small glass of fruit juice** Try vegetables such as peppers and carrots with dips as snacks ** Be aware that if the patient has diabetes fruit consumption should be spaced out throughout the day to avoid raised blood glucose levels. Patients with diabetes are advised to have only one small glass of fruit juice per day and this should be taken separately to additional fruit. Should you be concerned about the vitamin and mineral status it would be advisable to advise they purchase their own standard multivitamin multimineral tablet. If, when following the appropriate flow chart, your patient starts prescribable nutritional supplements it is important to remember that these contain added vitamins and minerals. Additional points to consider when providing dietary advice: Assess fluid intake if intake is reduced, encourage the patient to drink more fluids. Explore practical ways of increasing fluid intake with the patient and carers. Nutritious fluids such as milkshake will count towards their daily intake. If the patient has a small appetite, taking fluids before mealtimes should be discouraged, as this can impact on appetite Stressful mealtimes patients and carers often find mealtimes stressful due to concern over poor intake. This should be discussed with those involved. Offer reassurance that in the short-term, small meals with an adequate fluid intake are acceptable because energy requirements may well be reduced due to a reduction in activity levels This situation may often arise in terminally ill patients again reassure that much can be achieved by making mealtimes enjoyable for the patient rather than trying to persuade them to eat larger quantities The social aspect of mealtimes should be maintained as people often eat better in company. If isolation is a problem, lunch clubs, day care or home helps may be considered 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. N.B. check alcohol is not a contraindication of medication or medical condition 12

13 Cooking smells try to keep the patient away from cooking smells if they find this makes them nauseous and reduces their appetite Exercise and fresh air often improve appetite and general feeling of well being 13

14 PRESCRIBING NUTRITIONAL SUPPLEMENTS The Advisory Committee on Borderline Substances (ACBS) recommends products on the basis that they may be used as drugs for the management of specified conditions. Prescribers should satisfy themselves that products can be safely prescribed, that patients are adequately monitored and that, where necessary, expert dietetic supervision is available. It is important that these products should not be excessively prescribed to discourage reliance on these rather than oral food intake. It is advised that once it is available the Birmingham, Sandwell, Solihull and environs APC Formulary or the Trust s own formulary should be referred to for recommended supplements. Procedure for Prescribing 1. The patient must have been screened using MUST and have been identified as requiring nutritional supplements (see MUST care plans, appendices 2 & 3). The patient should be following first line dietary advice as well. 2. Check that the patient s condition falls into one of the ACBS approved categories for prescribing sip feeds: a. Short bowel syndrome b. Bowel fistula c. Intractable malabsorption d. Pre-operative preparation of patients who are malnourished e. Proven inflammatory bowel disease f. Following total gastrectomy g. Dysphagia h. Disease related malnutrition (this could incorporate a range of conditions and is open to interpretation) For those who are substance misusers (drugs and/or alcohol) see Appendix Issue a prescription, available on FP10, for milk shake style supplements as follows: 2 sachets equivalent to kcal per day, taken between meals, to make a significant addition to nutritional intake Initial prescription for one starter pack * can be issued in order for the patient to try the supplements and ascertain up to 2-3 preferred flavours First line supplements are powdered milk shake sachets which are the most cost effective supplements, currently at half the price of ready made bottled supplements. Please note that they need to be made with 200ml full fat milk, although these supplements can be made with a smaller volume of milk ( ml) if it is clearly established that the patient cannot manage the volume when made with 200mlPowdered shakes are unsuitable for patients with CKD 4 or 5, lactose intolerance or hepato-biliary disease. Patients with dexterity problems may be unable to make up the shake themselves, and require family/carer support This first line supplement should always be used in care homes/bedded units where there is someone available to prepare it, unless contraindicated. Care homes must have demonstrated they have offered the resident an in-house milkshake (Appendix 12) prior to requesting first line supplements Some patients at home may find it difficult to prepare the supplement correctly, or may have difficulty accessing or affording 400ml milk per day for mixing A ready-made high energy milkshake (containing at least 1.5kcal/ml) can be used if the patient is unable to make up a powdered version with milk, and where volume 14

15 tolerance is a concern, a low-volume ready-made high energy milkshake should be prescribed. Again it is recommended a prescriber pack* is prescribed to ascertain tolerance and preferred flavours.if either of the powdered shakes or the ready-made high energy milkshakes are not appropriate, or not tolerated, please refer to the APC formulary or Trust formulary if available, or Appendix 7 for a list of other types of nutritional supplement * Prescribable starter packs provide a range of styles and flavours of supplements for the patient to try. This approach aids compliance and avoids wastage resulting from prescriptions for products that the patient will not take. Once decided, the patient should inform the prescriber of their preferred choice of flavour. Packs may offer recipe suggestions and patient preference cards to highlight which flavours are preferred for future prescriptions. Samples of products given by company representatives can only be given to patients by dietitians following the BCHC guidelines regarding samples. All other health professionals are to arrange prescription of a starter pack N.B. Product information contained in these guidelines is correct at the time of print. Please refer to the BNF or MIMS for updates. 4. Once preference is ascertained, a prescription can be issued for one month at a time for two nutritional supplements per day, taken in addition to meals and away from mealtimes. 5. Patients should be encouraged to take as much of their oral food as possible and not to use supplements as a meal replacement. 6. It should be made clear to the patient/carer that the supplement is only to be consumed by the patient. 7. Community pharmacists often deliver prescriptions which is helpful for some patients as a month s supply is bulky/heavy. 8. Patients receiving nutritional supplements should be monitored on a regular basis (see care plans in appendices 2 & 3) to assess the aim of therapy is being met. The GP should be notified of who will be responsible for monitoring the patient, and progress should be documented to assist review of supplement prescribing. The following should be checked: i. Weight (where possible) or Mid Upper Arm Circumference (if this changes by at least 10% then it is likely that weight and BMI will have changed by approximately 10% or more) ii. Changes in dietary intake following the dietary advice given iii. Compliance with nutritional supplements 9. When the agreed goal of therapy is achieved, nutritional supplements should be gradually reduced using the withdrawing input flowchart (page16). Additional Information Patients should have the reason why they are having nutritional supplements prescribed explained to them and that the intervention will be reviewed regularly to determine whether the prescription will continue. As with all drug treatments, good compliance with nutritional supplements is vital for a successful outcome. Compliance with nutritional supplements can be improved by: Explaining the need for, and importance of taking the recommended dose on a daily basis Ascertaining patient preference and prescribing suitable flavours 15

16 Taking the nutritional supplement between or after meals, not with or before meals Serving sweet drinks chilled through a straw Varying the flavours and type of nutritional supplement to help combat flavour fatigue Not all nutritional supplements are suitable for vegetarians and so guidance should be sought from the manufacturers or from the Dietitians. There are very few vegan nutritional supplements and it would be advisable to refer the patient to the Dietitian for specialist advice. As nutritional supplements contain sugar, which can contribute to dental caries, patients should be advised to have a sip of water after drinking these to rinse the mouth, and to brush their teeth twice daily with a fluoride containing toothpaste. Patients with diabetes can be given most milk-based supplements but blood glucose levels will need careful monitoring and diabetes medication may need to be altered. Juicestyle supplements are not usually advised for patients with diabetes as they are higher in sugar. Patients with special requirements e.g. Chronic Kidney Disease Stage 4-5, malabsorption etc., may require more specialised products and should be referred to acute dietetic services. Patients with swallowing difficulties who require a modified consistency diet (e.g. puree or thickened fluid) are highly likely to require nutritional supplements to maintain their nutritional requirements. Patients with neurological related swallowing difficulties should be referred to a Speech & Language Therapist who may recommend a modified texture diet and/or a thickening agent to be used or advise on pre-thickened products. The first line choices of supplement for stage 1 (syrup) and stage 2 (custard) thickness for dysphagia are powdered shakes which include a thickener. The powder is mixed with full fat milk according to instructions for a thickened shake. Ready-made pre-thickened supplements are available where powdered pre-thickened shakes are contraindicated (CKD 4 or 5, lactose intolerance) or cannot be prepared, and semi-solid supplements are also available for dysphagia Hospital Dietitians requesting that a patient continues on nutritional supplements post-discharge should give evidence of need e.g. MUST score and aims of treatment (with target weight or goal where appropriate) to the patient s GP, The GP may then refer on to another appropriate health professional to monitor or monitor the patient themselves. In the absence of any written correspondence from the hospital dietitians, patients should not be given nutritional supplements post-discharge until they have been reassessed using MUST and the appropriate care plan implemented. This can be carried out by GP, community nurses, care home staff etc. Ongoing care plans/ MUST screening Following an intervention with first line advice and/or prescription supplements, the care plans advise regular screening and review. Should the health professional e.g. community nursing, reach the end of their treatment episode and discharge the patient, they should hand over the ongoing MUST care plan for that patient to another health professional such as the patient s GP. 16

17 FLOW CHART FOR WITHDRAWING ORAL NUTRITIONAL SUPPLEMENTS AND/OR FIRST LINE DIETARY ADVICE This chart should only be used for those patients who are appropriate, as specified in MUST nutritional care plans. Is patient on oral nutritional supplements (ONS)? ONS Sole Source of Nutrition Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Repeat screening every four weeks and document on MUST record chart Oral Diet and ONS Decrease the number of ONS by one per day Continue first line dietary advice Repeat screening every four weeks and document on MUST record chart Zero ONS Decrease first line dietary advice actions Repeat screening every four weeks and document on MUST record chart Refer to appropriate MUST nutritional care plan if patient is identified to be at risk of malnutrition AFTER FOUR WEEKS Weight Loss Increase the number of ONS by one per day Continue first line dietary advice Repeat screening every four weeks and document on MUST record chart Weight Stable or Weight Gain Repeat screening every four weeks and document on MUST record chart If continues on ONS refer to oral diet and ONS box If on zero ONS refer to zero ONS box AFTER FOUR WEEKS Continue first line dietary advice Repeat screening every four weeks and document on MUST record chart Weight Loss Continue ONS and refer to appropriate MUST nutritional care plan Weight Stable Continue ONS Weight Increasing Restart withdrawing input flowchart refer to oral diet and ONS box Please Note Some patients will require first line dietary advice and/or oral nutritional supplement prescriptions on an ongoing basis in order to maintain their weight. The need for these should be reviewed every three months. 17

18 PALLIATIVE/END OF LIFE CARE NHS England s Actions for End of Life Care for adults (2014) 8 aims to improve access to high quality care based on the NICE Quality Standard for End of Life Care for Adults (2011) 9 This should include specialist input of a wider multi-disciplinary team for assessment of individual needs. Key areas of nutritional support within this group include: Sensitive nutritional screening/assessment taking into account both national and local screening tools Implementation of dietary changes to optimise nutrition related symptom management. This would include taste acuity, nausea, vomiting, and modified consistency. See Table 8.5, Chapter 8, Royal Marsden Nursing Procedures for further tips (BCHC staff only) Appropriate use of nutritional supplements and/or appetite stimulants and/or antiemetics which prove beneficial and are evidence based Provide practical nutritional advice including written information tailored to individual needs, prognosis and changing circumstances Provision of nutrition support to improve quality of life where it is warranted MDT decisions on role of enteral feeding and withdrawal of feeding within legal boundaries Emotional support for families coping with anxiety of food provision and hydration Any input should aim to promote effective communication between hospital, hospice, and community settings to ensure consistency of care. You may find the following useful reading: The National Council for Palliative Care Oral Feeding Difficulties and Dilemmas - Royal College of Physicians, January 2010 Oxford Textbook of Palliative Medicine Oxford University Press REFERRAL PROCESS AND HOW TO CONTACT A DIETITIAN To refer a patient to the Community Dietetic Service, please refer to the referral criteria (Appendix 8) and, if concordant, complete a Nutrition Support Referral Form, ensuring that all information is completed comprehensively, as this will enable a swifter response. The referral must be discussed with the patient and their consent given (or with the carer [best interest] if the patient is unable to consent). Guidance on referring: Patients should be nutritionally assessed using MUST, the relevant care plan implemented and monitored and referred to a Dietitian at the stage the care plan indicates Patients can be referred directly to a Dietitian, using a referral form, when a full, detailed nutritional assessment is necessary, or when advice on a specific therapeutic diet is also required i.e. diabetes, coeliac disease, renal insufficiency 18

19 Patients with swallowing difficulties can be referred to the Dietitian after a swallowing assessment by a Speech and Language Therapist has been completed. All referrals should be signed by a registered health professional unless the patient is referring themselves, or a carer is on their behalf. Criteria for a home visit A home visit is only available to those who: are bed-bound on O2 therapy have GP home visits as unable to attend appointments at the GP surgery All other patients will be given a local clinic appointment. The referral form is available in Appendix 9 or on our website and should be returned to: Nutrition Support Birmingham Community Nutrition 3rd Floor Priestley Wharf 1 Holt Street Birmingham B7 4BN Tel: Fax: If faxing a referral a receipt by fax or phone must be requested RECOMMENDED RESOURCES Recommended Reading BAPEN (2010). Malnutrition Matters Meeting quality standards in nutritional care. A toolkit for clinical commissioning groups and providers in England. Available at Care Quality Commission (2010) Essential Standards of Quality and Safety Available at Caroline Walker Trust (2004) Eating well for older people: practical and nutritional guidelines for food in residential and nursing homes and for community meals (2nd edition), Abbots Langley: Caroline Walker Trust. Available at National Institute of Clinical Excellence (NICE) (2010). Chronic obstructive pulmonary disease (updated) Department of Health National Institute of Clinical Excellence (NICE) (2006). Dementia. Supporting people with dementia and their carers in health and social care Department of Health National Institute of Clinical Excellence (NICE) (2006). Nutrition support in adults: oral supplements, enteral and parenteral feeding. Department of Health National Institute of Clinical Excellence (NICE) (2012) Nutrition support quality standard. Department of Health National Institute of Clinical Excellence (NICE) (2005). Pressure ulcers. The management of pressure ulcers in primary and secondary care. Department of Health 19

20 NHS National Patient Safety Dysphagia Diet Food Texture Descriptors (2011) Available at Royal College of Nursing (2007) Enhancing nutritional care- (Nutrition Now Campaign). Available at data/assets/pdf_file/0006/187989/ pdf Royal Marsden Hospital Manual of Clinical Nursing Procedures, Eighth Edition Available to BCHC staff only on the BCHC intranet in the policies section The Department of Health (2007) Dignity in Care - Mealtimes and nutritional care Department of Health The Department of Health and the Nutrition Summit Stakeholders group (2007) Nutrition Action Plan available at Useful Websites Age UK (Age Concern & Help the Aged) Birmingham Alzeimer s Society (resources and training) BAPEN (for MUST information) British Dietetic Association Diabetes UK Macmillan MENCAP Nutritional guideline for COPD The Stroke Association Parkinson s disease Society REFERENCES 1. NHS Harm Free care NHS England 2. NICE (2006). Guidance 32: Nutrition Support in Adults 3. NICE (2012) Quality Standard 24 Nutrition Support in Adults 4. Elia M. The MUST Report. Malnutrition Advisory Group (MAG), Standing committee of BAPEN. Maidenhead: BAPEN Elia M (2015) A report on the cost of disease-related malnutrition in England & a 20

21 budget impact analysis of implementing the NICE clinical guidelines/quality standard on nutritional support in adults. National Institute for Health Research, Southampton Biomedical Research Centre 6. British Association for Parenteral and Enteral Nutrition, Malnutrition Universal Screening Tool 7. The British Dietetic Association 8. NHS England (2014) NHS England s Actions for End of Life Care 9. NICE (2011) NICE Quality Standard for End of Life Care for Adults 21

22 APPENDIX 1 MUST REFERENCE CHARTS 22

23 23

24 24

25 25

26 26

27 Additional notes for using the MUST reference charts 1. The BMI values on the BMI charts provided with the MUST have been rounded to the nearest whole number. The yellow shaded area represents BMI values of kg/m 2. Therefore, values of 20 which lie above this shaded area represent values greater than 20 and less than 20.5 kg/m 2. Values of 18 which lie below this area represent values less than 18.5 and above 17.5 kg/m Care should be taken when interpreting the patient s BMI or percentage weight loss if any of the following are present: Fluid disturbances: i) BMI. More significant if underweight with oedema; subtract ~ 2 kg for barely detectable oedema (severe oedema is >10 kg; see The MUST Report); can use MUAC when there is ascites or oedema in legs or trunk but not arms; re-measure weight after correcting dehydration or over hydration; inspect the subject to classify as thin, acceptable weight, or overweight/obese. ii) Weight change. When there are large and fluctuating fluid shifts, a history of changes in appetite and presence of conditions likely to lead to weight change, are factors that can be used as part of an overall subjective evaluation of malnutrition risk (low or medium/high risk categories). Pregnancy: i) Pre-pregnancy BMI. Measured in early pregnancy; self reported or documented weight and height (or estimated using measurements in early pregnancy); MUAC at any time during pregnancy. ii) Weight change. Weight gains <1 kg (<0.5 kg in the obese) or >3 kg per month during the 2 nd and 3 rd trimester generally require further evaluation. See The MUST Report for further details. Lactation: i) BMI Measured BMI ii) Weight change As for oedema (above). Critical illness: Acute disease effect (and no dietary intake for >5 days). This generally applies to most patients in intensive care or high dependency units. Plaster casts: BMI Synthetic and plaster of paris casts for upper limb weigh <1 kg; lower leg and back kg depending on material and site. See The MUST Report for further details. Amputations: BMI Adjustments of body weight can be made from knowledge of missing limb segments: upper limb 4.9% (upper arm 2.7%; forearm 1.6%; hand 0.6%); lower limb 15.6% (thigh 9.7%; lower leg 4.5%; foot 1.4%). Calculations to obtain pre-amputation weights: Amputation Calculation Below knee Current weight (kg) x Full leg Current weight (kg) x 1.18 Forearm Current weight (kg) x Full arm Current weight (kg) x For those patients who are identified as being overweight or obese and are acutely ill, the need to address weight loss should be postponed until that individual is in a more stable clinical position. Contact the dietetic service if unsure. 27

28 Name: APPENDIX 2 CARE PLAN FOR CARE HOMES MUST Score 1 Medium Risk of Malnutrition MUST Score 1 Implement first line dietary advice (see page 11) Review hydration status (see page 31) Set a weight/dietary goal (see page 10) Repeat screening every four weeks and document on MUST record chart D.O.B./NHS Number: Details of Weight/Dietary Goal: Date: Print name: Signature: If No Improvement or Further Decline Continue current plan Trial with 1-2 nutritional supplements per day (see page 13) Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: AFTER FOUR WEEKS AFTER FOUR WEEKS Improved Nutritional Status i.e. eating more, weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Once patient reaches target set refer to withdrawing input flowchart Date: Signature: Print name: If No Improvement or Further Decline Not Compliant with Supplements Check timings of supplements Try different flavours, variety, type of supplement (see page 35) Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue with first line dietary advice Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Compliant with Supplements Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue current plan Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Improved Nutritional Status i.e. eating more, weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Once patient reaches target goal refer to withdrawing input flowchart Date Signature: Print name: 28

29 CARE PLAN FOR CARE HOMES MUST Score 2 or more High Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 2 or MORE Implement first line dietary advice (see page 11) Review hydration status (see page 31) Trial with 1-2 nutritional supplements per day (see page 13) Set a weight/dietary goal (see page 10) Repeat screening every four weeks and document on MUST record chart Details of Weight/Dietary Goal Date: Print name: Signature: AFTER FOUR WEEKS If No Improvement or Further Decline Not Compliant with Supplements Check timings of supplements Try different flavours, variety, type of supplement (see page 35) Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue with first line dietary advice Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Compliant with Supplements Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue current plan Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Improved Nutritional Status i.e. eating more, weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Once patient reaches target goal refer to withdrawing input flowchart Date: Signature: Print name: 29

30 APPENDIX 3 CARE PLAN FOR COMMUNITY PATIENTS MUST Score 1 Medium Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 1 Implement first line dietary advice (see page 11) Review hydration status (see page 31) Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: AFTER FOUR WEEKS If No Improvement or Further Decline Continue with first line dietary advice Prescribe 1-2 nutritional supplements per day (see page 13) Repeat screening every four weeks and document on MUST record chart Improved Nutritional Status i.e. eating more/weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Refer to withdrawing input flowchart Date: Print name: Signature: Date: Signature: Print name: AFTER FOUR WEEKS If No Improvement or Further Decline Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue current plan Repeat screening every four weeks and document on MUST record chart Date: Print name: Signature: Improved Nutritional Status i.e. eating more/weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Refer to withdrawing input flowchart Date: Signature: Print name: 30

31 CARE PLAN FOR COMMUNITY PATIENTS MUST Score 2 or MORE High Risk of Malnutrition Name: D.O.B./NHS Number: MUST Score 2 or MORE Implement first line dietary advice (see page 11) Review hydration status (see page 31) Ask GP to prescribe 1-2 nutritional supplements per day (see page 13) Review progress with care plan weekly Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: AFTER FOUR WEEKS If Clinically Concerned Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue current plan Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: If No Improvement or Further Decline Refer to Dietitian (fully complete referral form including weight history, supplements tried etc) Continue current plan Repeat screening every four weeks and document on MUST record chart Date: Signature: Print name: Improved Nutritional Status i.e. eating more, weight increasing/stable Continue current plan Repeat screening every four weeks and document on MUST record chart Refer to withdrawing input flowchart Date: Signature: Print name: 31

32 APPENDIX 4 IDENTIFYING UNDERLYING CAUSES OF NUTRITIONAL DEFICIENCIES, AND ACTION PLANS Underlying Cause Loss of Appetite: Medical Dehydration Fever Depression Recovery from infection Constipation Diarrhoea Nausea Taste changes Posture End of Life Environment Embarrassment at meal times Action Ensure daily fluid intake is 30ml/kg for 60yrs and over,35 ml/kg for < 60yrs Discuss treatment with patients GP/case manager i.e. laxative, anti-emetic, etc. A medication review could check if any medication is contributing to nausea, taste change, constipation etc Follow MUST flow charts (page 7 or 8) Consider referral to Occupational Therapist, Physiotherapist or Speech and Language Therapist for advice regarding seating and posture and swallowing difficulties Consider the dining habits of other people, providing adequate time, finger foods or adaptive cutlery to promote independence Smell Other people Ensure no offensive smells at meal times Ensure other people are not providing a distraction e.g. other residents. Try limiting visiting times at meal times. Conversely, they may eat better with other people around them. Food provision Difficulty Eating: Problems handling food e.g. arthritis, reduced dexterity Ensure appropriate foods offered are appealing and correctly portion sized for the person Discuss with Occupational Therapist Consider finger foods that do not require utensils to eat Problems with chewing e.g. poor dentures Refer to Dentist Unable to take solid food Investigate underlying cause Difficulty with swallowing Refer to Speech and Language Therapist BCHC staff, see Chapter 8, Royal Marsden Nursing Procedures for more information about dysphagia) Patient no longer able/inclined to feed themselves Advise carers Provide assistance with all food/drinks (BCHC staff, see Procedure Guideline 8.9, Royal Marsden Nursing Procedures) Problems with memory e.g. Promote regular scheduled meals 32

33 Alzheimer s Food diary Carers to prompt patient to eat Inability to retain or absorb food: Nausea or vomiting for >4 days Investigate cause and treat (take sample and send for investigation) Diarrhoea: loose stools >3 days Encourage adequate oral fluid intake Malabsorption Refer, via GP to a gastrointestinal unit for advice on management Disease state with implications for nutrition support: Inflammatory bowel disease, infection, major surgery, malignancy, pressure sores, leg ulcers Liver or renal disease Social Situation: Limited support for shopping, cooking or feeding e.g. 3-4 days per week or evenings only No support for shopping, cooking or eating Follow appropriate MUST flow chart (page 7 or 8) Refer to relevant specialist unit if necessary Chronic Kidney Disease (stage 4 and 5) needs to be seen by a renal specialist Dietitian (secondary care) Refer to Social Services for Meals Direct/Home Help/Day-Care/Lunch Clubs or other services Refer to Social Services for care package Using a multi disciplinary team approach will help improve your patients compliance and nutritional status. 33

34 APPENDIX 5 BOOSTING THE CALORIES RECIPE ADAPTING Adapting the recipe Energy Kcals (calories) Food item 1 portion Before After Milk 1 pint Add 4 heaped tablespoons dried skimmed milk (dsm) powder to 1 pint whole milk Custard Soup Porridge Mashed potatoes Large ladle (125mls) Large ladle (125mls) Large ladle (125mls) Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to custard made with whole milk Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to soup Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to porridge made with whole milk 1 scoop Add an extra 1 heaped teaspoon of margarine/butter and 1 tablespoon of cream to mashed potatoes Vegetables 2 tablespoons Add 1 heaped teaspoon of margarine/butter to vegetables. Allow to melt Ice cream 1 small scoop Pour 2 tablespoons of double cream over the ice cream Sponge pudding Breakfast cereal Milk pudding 2 tablespoons Place an extra 2 teaspoons of jam or syrup to the sponge when serving. Then serve with high calorie custard or ice cream Small serving (25g) Large ladle (125mls) Use fortified milk with 2 tablespoons double cream and 2 teaspoon sugar Add 1 heaped tablespoon dsm powder & 2 tablespoons double cream to the milk pudding made with whole milk serve with 2 teaspoons jam extra 106% extra 143% extra 250% extra 118% extra 170% extra 460% extra 100% extra 58% extra 115% extra 150% 34

35 Increasing the calories The foods listed below vary from approximately calories each and can be added to any appropriate meal, or eaten as a snack in between meals, to help you increase your calories. 100 calorie Savoury spreads and toppings Peanut butter (16g)* 1 level tbsp mayonnaise (15g) Average serving of salad cream (30g) 2 tbsp hummus (50g)* 1 heaped tbsp pesto (20g) Sweet spreads and toppings 1 heaped tbsp sugar (25g) 2 heaped tsp honey (35g) 2 heaped tsp golden syrup (35g) 2 heaped tsp lemon curd (35g) Dairy 2 tbsp skimmed milk powder (30g)* 150ml full fat milk* 1 scoop icecream (60g) 75ml evaporated milk* 30ml condensed milk 1 small pot full fat yogurt* 30ml coconut cream 1 medium slice cheddar cheese* Fruit and Nuts Small handful of peanuts (30g)* 5 Brazil nuts (15g)* Small handful cashew nuts (20g)* 1 heaped tbsp sultanas (35g) 2 dried apricots (50g) 2-3 dates (40g) 6 prunes (60g) Snacks 2 digestive biscuits 5 jelly babies 2 fingers of KitKat ½ a Crunchie 1 Fudge bar Bag of crisps APPENDIX calorie Ham sandwich (1 slice bread, butter and ham)* Fairy cake Malt loaf (1 slice with butter) ½ fruit scone/hot cross bun with butter and jam Medium size sausage roll* Meringue nest with whipped cream 250 calorie ½ Teacake/crumpet with butter and jam 1 slice sponge/fruit cake 1 medium pork pie* Jam/paste sandwich (1 slice bread, butter and jam/paste) Individual Bakewell tart/fruit pie 1 ring/mini doughnut Individual trifle 300 calorie Small slice of flapjack ½ fruit scone with jam, butter and cream 2 slices malt loaf with butter Cheese and biscuits (2 crackers with butter and cheese)* Danish pastry Chocolate bar (e.g. Twix, Mars) *Also a good source of protein (tbsp. = tablespoon, tsp = teaspoon) 35 (tbsp = tablespoon, tsp = teaspoon). * Also a good source of protein

36 APPENDIX 7 TYPES OF FIRST LINE PRESCRIBABLE NUTRITIONAL SUPPLEMENT Powdered shakes sweet flavours, milk-based (requires preparation). Powder, needs to be made with full fat milk. Sample packs contain a shaker. Unsuitable for patients with CKD 4 or 5, lactose intolerance or hepato-biliary disease. Patients with dexterity problems may be unable to make up the shake themselves and require family/carer support. Sweet, milk-based (ready to drink), comes in a ml bottle in various flavours, low lactose. Use when powdered supplements are unsuitable. Choose a product with a low volume, and high energy content (at least kcal/ml). Avoid those lower in calories (less than 1.5kcal/ml) Yoghurt Style (ready to drink) for patients with dysgeusia (taste changes such as persistent salty, rancid, or metallic taste in mouth) as it has a slightly sharper taste and useful for patients who find the milkshake style too sweet Fruit Juice Style(ready to drink). These supplements are not milk-free and are not nutritionally complete so not appropriate as a sole source of nutrition. They can be used for patients who dislike milktastingsupplements.. Please note: should not be used for patients with diabetes unless their blood sugars are being closely monitored or unless this supplement has been recommended by a dietitian. Sweet milk-shake style with added fibre/added protein these supplements can be used when recommended by a dietitian/when nutritional assessment indicates that dietary/other sources of fibre/protein do not meet the patient s requirements Savoury powder (requires preparation, have better nutritional value if made up with whole milk not water, needs to be warmed) useful for patients who do not like sweet supplements. Like other supplements, this should be used between meals, and not in place of meals Thickened, powdered* and ready to drink For those diagnosed with swallowing difficulties. Available in stage 1 and stage 2 textures Dessert Style Only for patients with dysphagia (requiring a modified texture diet) or on a fluid restriction often a pot with a mousse or a milk custard-like dessert. Note most varieties are lower in calories than the liquid supplements listed above Companies that make Nutritional Supplements Aymes Aymes Shake TM*, Aymes Complete TM* Fresenius Kabi the Fresubin range Nualtra Foodlink Complete TM*, Altraplen TM*, Nutricrem TM*, Altraplen protein TM Nutricia Complan TM*, Fortisip Compact TM* and Forti range Vitaflo - Vitasavoury TM Nestle Meritene Energis TM (not prescribable in community except for patients in liver failure, but available in bedded units) * Denotes supplements which are the most cost effective choices of their type at the time of writing (November 2017). Refer to the APC Formulary or Trust formulary for further guidance 36

37 APPENDIX 8 37 BIRMINGHAM COMMUNITY NUTRITION Experts in Nutrition Working Across Birmingham NUTRITION SUPPORT REFERRAL CRITERIA To make a referral please complete the Nutrition Support referral form as fully as possible after checking the criteria as below. Please follow the guidelines MUST screening and the next steps The identification of under nutrition and the management of oral nutrition support in the community for those malnourished or at risk of developing malnutrition. We accept referrals from/on behalf of consenting individuals (16 years +) who are ready to make dietary changes and who have a Birmingham GP. We aim to contact urgent referrals (as determined by the dietitian) within 5 working days and non urgent within 4 weeks. Before referring please consider: Is the patient ready and willing to make dietary changes? Please note: Home visits are only provided for those who are bedbound or require GP visits at home. All other patients will be given a clinic appointment local to them. Referral Criteria Exclusion Criteria BMI less than 18.5 kg/m 2 AND unintentional weight loss greater than 5% within the last 3-6 months Unintentional weight loss greater than 10% within the last 3-6 months MUST score of 2 or more post implementation of the correct care plan* Unintentional weight loss due to being on a texture modified diet post Speech and language therapy assessment Pressure ulcer grade 3 or above and not healing Needing enteral nutrition (tube feeding) in the community phone first to discuss Receiving established enteral nutrition (tube feeding) in the community and are medically stable, not in an active phase of treatment and receiving the majority of medical care from a GP For nursing home/community nursing patient referrals: All referrals should have a MUST score. A correct care plan* should have been implemented and monitored. Refer to the dietitian only when the care plan states this. For patients discharged from hospitals on oral nutritional supplements in the community/ care setting: The discharging dietitian needs to ensure a GP letter is done with clear guidelines on how long the supplements need to be prescribed for. Only those patients that meet the above criteria will be followed up in the community Specialist Nutrition Nurses will accept referrals for : PEG assessments Training for passing NG or replacement gastrostomies Removal of PEG s in the community Placement of nasal bridles Troubleshooting for enteral tube problems Patients with chronic kidney disease (stage 3b - if unstable, 4 or 5) Patients who are under regular review by a dietitian already Eating disorders (Please refer to our primary care team) Patients not consenting to see a dietitian Patients not willing to make dietary changes Patients who have a swallowing difficulty and have not been assessed by Speech and Language Therapy. * For information on Care plans and first line advice please refer to MUST screening and the next steps The identification of under nutrition and the management of oral nutrition support in the community Please contact the Nutrition Support Team if you would like to discuss the referral/patient or if you feel you require support regarding giving first line dietary advice on: (Priestley Wharf 1, Holt Street, Aston, Birmingham, B7 4BN). For information on MUST please visit:

38 APPENDIX 9 NUTRITION SUPPORT - ADULT REFERRAL All sections of this form must be completed for it to be processed. Thank you. For help with completing this form see our referral criteria at Before referring please consider: Has the patient consented to the referral? Is the patient ready, willing and able to make dietary changes? Please indicate what service you wish to refer to: Community Nutrition Support Team Dietitians Community Nutrition Nurses Section 1 Patient details: Patient Name: Address: NHS number: GP name: Practice Address: Post code: DOB: Sex: M F Telephone No: Post Code: Telephone No: Ethnicity details Ethnicity Code: (Please see below for list of codes) Home Language: Is an Interpreter required? Yes No Code Ethnicity Code Ethnicity A White British L Asian/Asian British Other Background B White Irish M Black/Black British Caribbean C White / Other White Background N Black/Black British African D Mixed White and Black Caribbean P Black/Black British Other E Mixed White and Black African R Chinese F Mixed White and Black Asian S Any Other Ethnic Group G Mixed Other Background T Eastern European H Asian/Asian British Indian NKN Not Known J Asian/Asian British Pakistani NS Not Specified K Asian/Asian British Bangladeshi Z Not stated Carer Details Family/Friend Agency Name: Telephone number: Section 2 - Relevant Medication: Medical Diagnosis / Condition: 38

39 Medical summary attached? YES / NO Enteral feeding regimen attached? YES / NO / NA Date of Homeward registration: (All new enteral feed patients discharged from hospital must be registered on Homeward) Section 3 Domiciliary Visit Risk assessment: Is the patient / carer able to open the door? If no, how can access be gained? Yes No Not sure Are there any safety/security issues involved in seeing this patient? If yes please provide details: Yes No Not sure Section 4 Additional information: Has patient been assessed by Speech and Language therapist? If yes, please give details of specific instructions given by SLT and a phone Number:: Yes No Not applicable Does a carer need to be present to understand and communicate effectively? If yes, please specify who and contact details: Yes No Not sure Has the patient consented to this referral? Yes No If no, does patient have capacity to consent? Yes No Best interest Is the patient able to attend a local clinic? Yes No Not sure Please note: Home visits by dietitians are only provided for those who are bed bound, on oxygen or require GP visits at home. All other patients will be offered a clinic appointment local to them. Referrer Details (MUST BE FULLY COMPLETED) Referred by: (please print name) Signature: Designation: Telephone number: Fax number: Referrer s full contact address, postcode: Base if not GP practice: Date: NUTRITION SUPPORT TEAM DIETITI AN REFERR AL Reason for referral/dietetic input: 39

40 REASON FOR DIETETIC INPUT: BMI less than 18.5 kg/m 2 AND unintentional weight loss greater than 5% within the last 3-6 months Unintentional weight loss greater than 10% within the last 3-6 months MUST score of 2 or more post implementation of the correct MUST care plan (only for those patients in care settings and for those under the care of the community nursing teams Complete Section below) Unintentional weight loss due to being on a texture modified diet post Speech and Language Therapy assessment Receiving established enteral nutrition (tube feeding) in the community, and are medically stable, not in an active phase of treatment and receiving majority of medical care from a GP. PLEASE ATTACH ENTERAL FEEDING REGIME Needing enteral nutrition (tube feeding) in the community (please phone first to discuss) Pressure ulcer grade 3 or above and not healing Other : For nursing home and community nursing patient referrals : Weight (kg) / MUAC (cm) Date Height/ulna length: BMI: MUST score: Date first line advice/ food fortification implemented: Date oral nutritional supplements commenced: Type of supplements and quantity: Care Homes please attach patients relevant MUST care plan Please return/fax the completed form to: Birmingham Community Nutrition, Nutrition Support Team, 3 rd Floor, Priestley Wharf 1, Holt Street, Birmingham B7 4BN Tel: Fax: referrals.nutrition@nhs.net All sections of this form must be completed and must include a copy of the discharge summary for it to be processed. Thank you. PLEASE COMPLETE PAGE 4 TO REFER ENTERAL FEEDING PATIENTS TO THE NUTRITION NURSE TEAM 40

41 NUTRITION SUPPORT TEAM NUTRITION NURSE REFERRAL PATIENT NAME: NHS NUMBER: REASON FOR NUTRITION NURSE INPUT: Ongoing tube care Needing enteral nutrition (tube feeding) in the community PEG assessment NG assessment NG to PEG assessment Training for patients/carers PEG removed Jejunostomy Other: Reason for tube insertion: Is the patient safe to take normal diet and fluids: (Please use comments box if more detail is required) Yes No Planned duration the tube is required for (e.g. long term or short term): Tube details: Tube Type: Tube Size Tube Brand: Date of insertion: Difficult insertion: (if yes please give details of any tube insertion problems in the comments) Yes No For NG patients NEX Measurement: Method of securing tube: On discharge: Who will provide care for this tube: Patient Family Member Carer Are there any plans for alternative feeding routes or follow up in the future? Patients usual ph value range: Care Agency/Nursing home At the time of discharge do you feel this tube can be changed in the community: Yes No Not applicable Have they been trained and are competent in all aspects of tube care? Balloon volume checking (RIG/BGT patients only) Advance and Rotate procedure Administration of medication Skin Care checking of gastric aspirate ph (NG only) Has a spare tube or plug like device been given to the patient: Yes No Has written information been given regarding what to do if the tube comes out? (if no confirm patient/family are aware of need to call community nurses or attend hospital) Yes No 41

42 Comments Please return/fax the completed form to: Birmingham Community Nutrition, Nutrition Support Team, 3 rd Floor, Priestley Wharf 1, Holt Street, Birmingham B7 4BN Tel: Fax: referrals.nutrition@nhs.net 42

43 APPENDIX 10 SUBJECTIVE INDICATORS OF MALNUTRITION In the absence of height and weight (measured or recalled) the following can be used collectively to identify individuals at risk of malnutrition: Unintentional weight loss, especially if progressive Fatigue and lack of energy Lack of appetite Fragile skin Poor wound healing Pressure ulcers Altered taste sensation Evidence of muscle wasting Depression Poor interest in life/low morale Clothes are very loose/too large Rings and jewelry is very loose/ill fitting Belts have new holes Ill-fitting or broken dentures, painful or broken teeth Dry sallow skin Poor immunity prone to pressure sores, chest infection, MRSA, C.difficile Impaired swallowing Prolonged inter-current illness Groups at risk of malnutrition in the community: Chronic disease: Chronic obstructive pulmonary disease (COPD), cancer, inflammatory bowel disease, gastrointestinal disease, renal or liver disease Chronic progressive disease: Dementia, neurological conditions (e.g. Parkinsons, MND) Debility: Frail, immobility, old age, depression, recent discharge from Hospital Social issues Poor support, housebound, inability to cook and shop, poverty If only using clinical judgment the following may act as a guide as to which care plan to implement: Unlikely to be at risk of malnutrition (low) Possible risk of malnutrition (medium) Likely malnourished (high) Physical appearance Not thin, weight stable or gaining weight (no unplanned weight loss), no change to appetite Thin as a result of disease/condition or history of unplanned weight loss in previous 3 6 months, reduced appetite/ability to eat Thin/very thin and/or substantial unplanned weight loss in previous 3 6 months Taken from 43

44 APPENDIX 11 SPECIAL CONSIDERATIONS FOR ORAL NUTRITIONAL SUPPLEMENT PRESCRIBING: SUBSTANCE MISUSERS Oral Nutritional Support (ONS) prescribing in substance misusers (drug and alcohol misuse) is an area of increasing concern, due to questions of effectiveness, and cost. Substance misuse is NOT a specified ACBS indication for Oral Nutritional Support (ONS) prescription. Local policies in the UK differ widely for ONS use in substance misusers the following recommendations may be helpful as a guide which you may wish to adapt according to the needs of the individual patient: It is recommended that ONS should NOT be prescribed for substance misusers unless ALL the following criteria are met: BMI<18kg/m 2 AND evidence of significant weight loss (>10%) AND co-existing medical condition which could affect weight or food intake AND after nutritional advice has been given by a healthcare professional and tried by the patient AND the patient is in a rehabilitation programme e.g. methadone or alcohol programme or on the waiting list to enter a programme If ONS is initiated: The patient should be weighed and measured, and nutritional goals set and monitored e.g. goal to improve food intake and prevent further weight loss or attain an acceptable weight (target BMI of 18.5 to 25kg/m 2, depending upon what is a realistic goal for the individual). If patient fails to attend on two consecutive occasions, ONS should be discontinued. Maximum prescription should be for kcal/day (i.e. a kcal supplement twice daily). A first line supplement should be offered initially such as Aymes Shake, or Foodlink Complete. These are cost effective powdered supplements, which the patient mixes with whole milk (unsuitable in lactose intolerance). Prescriptions should be on acute, not repeat, to facilitate monitoring and review. Prescribe on a short term basis only (i.e. 1-3 months). If there is no change in weight after three months, ONS should be reduced and discontinued. If weight gain occurs, continue until usual weight or acceptable weight (see above) is reached, and commence a withdrawal plan by reducing one supplement per day initially for one month, then discontinue ONS. If the individual is insistent on using a high energy supplement, recommend over the counter supplements such as Aymes, Complan, or Nurishment. 44

45 The following information has been documented to provide some awareness regarding the nutritional issues that may be relevant in substance misusers, reasons for them and problems that can arise from implementing oral nutritional supplements. Substance misusers may 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) Reasons for nutrition related problems include: The drugs themselves - can often cause poor appetite, reduced ph of saliva leading to dental problems, constipation, craving sweet foods (drug misusers in particular) Chaotic lifestyles Lack of interest in food and eating, and displacement of food by substance use Poor dental hygiene Irregular eating habits Poor memory Poor nutrition knowledge and skills Low income, intensified by increased spending on drugs or alcohol Homelessness / poor living accommodation Poor access to food Infection with HIV or hepatitis B and C Eating disorders with co-existent substance misuse Problems often created by prescribing ONS for Substance Misusers: Once started on ONS it can be difficult to stop the individual having them ONS may be taken instead of meals and therefore are of no benefit ONS may be given to other members of the family/friends ONS may be sold and used as a source of income Substance misusers can be poor clinic attendees therefore making it difficult to weigh them, monitor goals and re-assess need for ONS Adapted from ONS Guidelines, London Procurement Programme (2010) and Policy And Procedure For General Practitioners And Primary Care Staff Prescribing Oral Nutritional Supplements in Substance Misuse, NHS Grampian (2011) 45

46 APPENDIX 12 HOMEMADE FOOD BOOSTER MILKSHAKE Ingredients 170ml whole milk 30ml double cream 5 heaped teaspoons (15g) dried milk powder 3 heaped teaspoons (15g) milkshake powder, e.g. Nesquick or supermarket own brand (makes 200ml) Mix milk powder with enough whole milk to form a smooth paste, then add the remaining ingredients and whisk together well. The milk shake is: A palatable high energy, high protein shake Useful as a nutritious between meal drink for residents who have poor appetite or eating difficulties To be taken in addition to meals, never instead of meals as it is not nutritionally complete Around the same calorie and protein content as standard supplements on prescription Suitable for those residents for whom prescribed supplements are not indicated, but who do not eat well, and are in the healthy range for BMI ( kg/m2), with a MUST score for 0 Suitable for underweight residents with diabetes (monitoring of blood glucose recommended) May be used in place of a prescribed supplement, for example where compliance is a problem, with agreement of GP or Dietitian The milk shake is: NOT advised for overweight or normal weight patients who have a good appetite, have not lost weight and can easily meet their nutritional needs from food, due to its high calorie content. NOT suitable for residents with lactose intolerance since it contains milk and milk products NOT suitable for thickening with standard thickeners (Resource Clear, Thick and Easy) Nutritional Composition Chocolate Strawberry & Banana Energy (kcal) Protein (g) Vitamin D (µg) Calcium (mg)