Oral Nutrition Support Guidelines

Transcription

1 Brighton and Hove Clinical Commissioning Group High Weald Lewes Havens Clinical Commissioning Group Oral Nutrition Support Guidelines Introduction The purpose of this document is to provide guidance on the prescribing of oral nutritional supplements (ONS) for adult patients in Brighton and Hove CCG (BHCCG) and High Weald Lewes Havens CCG (HWLHCCG). ONS includes sip feeds and nutritional supplements. This guidance does not include enteral tube feeds. The guidance is intended for use by Brighton and Hove and High Weald Lewes Havens GP practices, care home staff and all primary care prescribers working within BHCCG, HWLHCCG, Sussex Community Foundation NHS Trust (SCFT), Sussex Partnership Foundation Trust (SPFT) and Brighton and Sussex University Hospitals NHS Trust (BSUH). Malnutrition is often under recognised and undertreated. Early identification and treatment of malnutrition can improve patient outcomes. The National Institute of Clinical Excellence (NICE CG32) has shown substantial cost savings can result from identifying and treating malnutrition. Cost savings are based on conservative estimates of reduced hospital admissions, length of stay for admitted patients and reduced demand for GP and outpatient appointments. The guidance aims to: Improve the management of patients who are malnourished or identified to be at risk of malnutrition Ensure appropriate cost-effective ONS prescribing Stop repeat prescriptions without regular review Reduce wastage Author David Broadbent, Advanced Prescribing Support Dietitian Issue date Jan 2017 Version 1 Editor Approved by Brighton APC Expiry date 5 years Supersedes n/a Reviewer To be reviewed before expiry date if warranted

2 How to use this guidance 1. Screen your patient using the MUST screening tool 2. Treat following the action plan linked to the MUST score 3. Monitor your patient. Are the goals set being achieved? E.g. regaining weight Always use Food as Treatment strategies before considering oral nutritional supplements. Food as Treatment leaflets to support the action plans for patients at medium and high risk can be found in appendix 1. If a supplement is required, use the oral nutritional support care pathway to identify the most appropriate product. All requests received by primary care prescribers to write an FP10 prescription for ONS should be accompanied by a MUST history and score, and be in line with the MUST action plan and the Oral Nutrition Support care pathway. ONS can only be prescribed on an FP10 prescription for specific indications as advised by the Advisory Committee on Borderline Substances (ACBS). All prescriptions for oral nutritional supplements should be endorsed with ACBS in such cases. Standard ACBS indications are: Disease-related malnutrition, intractable malabsorption, pre-operative preparations of malnourished patients, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short-bowel syndrome and bowel fistula. Other ACBS indications which may apply to specific products are: continuous ambulatory dialysis (CAPD) and haemodialysis. Advise patients with diabetes to drink supplements slowly and increase blood sugar monitoring. If you have any concerns, refer the patient to the dietitian. Where a prescriber considers a non-formulary ONS may be required for an individual patient they should seek dietetic advice. Discharges from secondary care Patients assessed by a dietitian in hospital requiring ongoing ONS in primary care will be discharged home with a 7 day supply of supplements. The dietitian will arrange follow up in the community and write to the GP to request an ongoing prescription and include a summary of care. Patients who are discharged from hospital on ONS with no on-going dietetic review process in place will not automatically require ONS on prescription once home. They may have required ONS whilst acutely unwell or recovering from surgery, but once home and eating normally the need is negated. Therefore it is recommended that ONS are not prescribed following hospital discharge without first assessing need in line ONS pathway. Where ONS are still required, a switch to first line community products is recommended. 2

3 Patients details Surname: Malnutrition Universal Screening Tool ( MUST ) First Name:... DOB:. Hosp No:.. NHS No: Complete the nutrition screening tool on first contact with patient. Admission Weight 3-6 Admission date Height (m) Weight (kg) months ago (kg) NOTE: < = less than > = greater than Date: Alternative measurements (if needed) Height - Ulna length (cm): BMI category - MUAC (cm): Scales used: S C H S C H S C H S C H S C H S C H Weight (kg): Step 1 BMI >20 (acceptable overweight) Score = 0 BMI (Thin) Score = 1 BMI < 18.5 (Very Thin) Score = 2 Refer to BMI reckoner Step 2 Unplanned weight loss in the past 3-6 months Step 3 < 5 % loss Score = % loss Score = 1 >10% loss Score = 2 Refer to weight loss reckoner Is the patient acutely ill and had no nutritional intake for > 5 days? likely to have no nutritional intake for > 5 days? If answer to either questions is yes, Score = 2 If answer to both of questions is no, Score = 0 Step 4 OVERALL SCORE (Add scores for step 1, 2 & 3) Step 5 Circle care plan to be implemented L M H L M H L M H L M H L M H L M H Step 6 Signature: Status: Score 0 Low risk no action needed nursing homes screen monthly community patients screen as part of routine clinical care or on concern ACTION / CARE PLAN Score 1 Medium risk provide and discuss Food as Treatment leaflet with patient/carer weigh and rescreen monthly Score 2 High risk provide and discuss Food as Treatment leaflet with patient/carer consider 1 month trial of ONS in line with ONS formulary. If no improvement after 1 month consider referral to Dietitian This is a malnutrition screening tool. Some patients will need referring to the dietitian due to clinical and nutritional problems even if they have a MUST score of less than 2 Referral to the Dietitian Food as Treatment leaflets and CCG specific referral forms can be found on page 8, page 10 (BHCCG) and page 11 (HWLHCCG) or ring the Dietitians on ext (BHCCG) or (HWLHCCG). Referrals for Brighton and Hove should be faxed to the Community Dietitians on Referrals for High Weald Lewes Havens should be ed to esh-tr.hscc@nhs.net using the HSCC referral form (appendix 3) 3

4 Monitor Treat Screen Oral Nutrition Support Care Pathway MUST Screen MUST=0 Low risk. Implement low risk action plan Re screen care homes - monthly. Community-annually MUST= 1 Medium Risk. Implement medium risk action plan Re-screen monthly. MUST 2 High risk. Implement high risk action plan Has MUST score improved after 1 month? MUST of 0 or 1 and improved - continue with action plan MUST of 2 and no improvement - prescribe 600 calories per day from supplements in line with high risk action plan Which supplements to prescribe to achieve 600 calories per day To improve compliance, ask patient which flavour they prefer First line-preferred option-powdered milkshake style made with 200ml of whole milk If patient able to prepare powdered milkshake or has carers/care home support. Prescribe 1 week initially* 1 st line: 1 sachet Complan shake b.d. 1 st line alternative: 1 sachet Aymes Shake or Ensure Shake b.d Alternative options If patient requires ready to drink supplement and is able to drink 2x200ml or 2x220ml milkbased supplement per day Milkshake style supplement Prescribe 1 week initially* 2 nd line: 200ml Fortisip Bottle b.d. 2 nd line alternative: 220ml Ensure Plus b.d. Juice style supplement (NB still contains milk proteins) Prescribe 1 week initially* 2 nd line: 200ml Fortijuce b.d. 2 nd line alternative: 220ml Ensure Plus Juce b.d. If patient requires ready to drink, low volume supplement and is able to drink 2x125ml milk based supplement Prescribe 1 week initially* 3 rd line: 125ml Fortisip Compact b.d. 3 rd line alternative:125ml Ensure Compact b.d. Monitor *Initial 1 week supply of supplements (prescribe either assorted flavours or individual flavours) - continue for 3 weeks if tolerated. Review prescription and MUST score monthly: MUST=0 MUST=1 MUST 2 Stop supplements, follow low risk action plan Stop supplements, follow medium risk action plan Continue supplements, follow high risk action plan 4

5 Guidance on prescribing ONS The formulary has been established in collaboration with BSUH. It therefore reflects the current enteral feeding contract terms, in turn supporting sustainability across the local health economy. Starting Prescriptions See ONS pathway for guidance on when to start prescriptions. Style Preparation Regimen Notes Powder Complan Shake 1 sachet Shakes b.d. Milkshake Other formulary powder shakes include Aymes Shake and Ensure Shake Fortisip Bottle 1 200ml bottle b.d. 1 st line choice Give starter pack to establish flavour preferences. Follow with monthly acute prescription of 2 sachets daily of preferred flavours (56 sachets or 14 boxes). Use as 2 nd line when a powder shake is not appropriate/tolerated and a milkshake style drink is preferred e.g. Unable to mix shake/and does not have relative/carer to do this Confirmed diagnosis of lactose intolerance Juice Other formulary choice milkshake is Ensure Plus Fortijuce 1 220ml bottle b.d ml bottle b.d. Prescribe initially 1 week (14 bottles) of preferred flavours. Follow with monthly acute prescription of 2 bottles daily (56 bottles/ 11200ml per month). Use as 2 nd line when a powder shake is not appropriate/tolerated and a juice style drink is preferred e.g. Unable to mix shake/and does not have relative/carer to do this Confirmed diagnosis of lactose intolerance Low volume Milkshake Other formulary choice juice is Ensure Plus Juce Fortisip Compact 1 220ml bottle b.d ml bottle b.d. Prescribe initially 1 week (14 bottles) of preferred flavours. Follow with monthly acute prescription of 2 bottles daily (56 bottles/ 11200ml per month). Use as 3 rd line when a powder shake and supplement with mls volume is not appropriate/tolerated e.g. Unable to mix shake/and does not have relative/carer to do this Confirmed diagnosis of lactose intolerance Lower volume feed needed Other formulary choice low volume milkshake is Ensure Compact 1 125ml bottle b.d. Give starter pack to establish flavour preferences. Follow with monthly acute prescription of 2 bottles daily (56 bottles/ 7000ml per month). Discontinuing Prescriptions When the treatment goals are achieved, ONS should be discontinued. At least one review, ideally after one month, is required after discontinuation of ONS to ensure that there is no recurrence of the precipitating problem. If patients wish to continue with a supplement once the prescription has ceased, OTC products should be suggested e.g. Meritine, Complan or Nurishment. 5

6 Inappropriate prescribing of ONS Care homes should provide adequate quantities of good quality food so that the use of unnecessary ONS is avoided. ONS should not be used as a substitute for the provision of food. Suitable snacks, food fortification as well as homemade milkshakes smoothies and over the counter products can be used to improve the nutritional intake of those at risk of malnutrition. Please refer to the food as treatment guidance for further information. Avoid prescribing less than the clinically effective dose of 2 sachets/bottles daily that will provide kcals/day. Once daily prescribing provides amounts that can be met with food fortification alone and will delay resolution of the problem. Patients with complex nutritional needs, e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes and gastrointestinal disorders may require specialist products and should be referred to local community dietetic services. Patients with swallowing problems will require assessment by a Speech and Language Therapist before Dietetic input. Patients with diabetes should not routinely be prescribed fruit juice based ONS. This is because these products have a higher glycaemic index, and blood glucose levels will need additional monitoring, with possible changes required to medication. Use of ONS in substance misuse Substance misuse is NOT a specified ACBS indication for ONS prescription. ONS prescribing in substance misusers (alcohol and drug misuse) is an area of increasing concern, due to both the cost and question of appropriateness. ONS should NOT be prescribed in substance misusers unless ALL the following criteria are met: BMI <18kg/m2 AND there is evidence of significant weight loss (>10%) AND there is a co-existing medical condition which could affect weight or food intake AND nutritional advice has been advised, tried and not been successful AND the patient is actively complying with a rehabilitation programme e.g. methadone or alcohol programme or on the waiting list to enter a programme. If ONS is initiated: It should be discontinued if they fail to attend their review appointments on two consecutive occasions. Maximum prescription should be for 600 kcal/day (twice daily ONS) NO repeat prescriptions Prescribed on a short term basis only (i.e. 1-3 months) If there is no change in weight after three months, ONS will be reduced and discontinued If weight gain occurs, continue until usual weight or healthy weight is reached. Then discontinue ONS. After healthy weight is reached, if the individual is insistent on using a high energy supplement recommend OTC supplements such as Meritine, Complan or Nurishment. 6

7 References Malnutrition Advisory Group A standing committee of Bapen. Explanatory notes for Screening Tool for adults at Risk of malnutrition. November National Institute for Health and Clinical Excellence (NICE CG32:) Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition February Accessed online: Costal West Sussex Clinical Commissioning Group, Western Sussex Hospitals NHS Foundation Trust, Sussex Partnership Foundation NHS Trust, Sussex Community Foundation NHS Trust, Oral Nutritional Supplements Formulary - for Adults, September 2015 Acknowledgements Food as Treatment used by kind permission of Department of Nutrition and Dietetics, BSUH 7

8 Appendix 1 For a printable version (just containing this document) please click here: Food as Treatment During periods of ill health it is not unusual to have a poor appetite and eat less food. If you continue to experience a poor appetite for a long time it can lead to weight loss. You have been given this leaflet because you are not eating enough and you have been losing weight. Following the advice in this leaflet will help you to increase your intake of calories and protein which should help you to gain weight. Aim to eat an additional 600 calories per day. Tips to increase your intake: Choose full fat or high energy foods, avoid low calorie or diet options. Eating 6 smaller meals or snacks may be easier than the traditional 3 meals per day. Don t drink close to a mealtime as this can fill you up. If you are struggling to prepare foods use convenience foods or ready meals. Add extra calories to your food using the table below Have snacks between meals, see table below for examples. Include nourishing drinks(see overleaf) If your food intake is limited a general multivitamin and mineral tablet can be taken. Adding extra calories to your food: Food type Quantity of serving Calories Double cream 2 tablespoons 140 Hard cheese 40g 165 Skimmed milk powder 25g 125 Butter or margarine 1 heaped teaspoon 75 Oil 1 tablespoon 100 Full cream milk 8 tablespoons/75mls 68 Jam/marmalade/honey 1 heaped teaspoon 50 Sugar 1 heaped teaspoon 25 Examples of high calorie snacks: approx calories each Slice of cake Scone with butter and jam Pork pie Sandwich with meat/fish/cheese/ peanut butter Cheese and biscuits Whole milk yoghurt Scotch egg Handful of dried fruit/nuts 8

9 Nourishing drinks: It is important to drink enough fluids during the day. Whilst fluids such as water and squash are hydrating they are not very high in calories (see chart below). Switch to full fat (whole) milk if you are not using it already as it contains more calories than other types of milk. Aim to have at least 2 milk based drinks per day such as milkshakes, smoothies, milky coffee, hot chocolate, malted drinks e.g. Horlicks or Ovaltine. Over the counter preparations: e.g. Complan and Meritine are available from most pharmacies and supermarkets. They come in a range of sweet, savoury and neutral flavours. Choose higher calorie drinks where possible: Approximate calorie content of various drinks Quantity Calories Water, tea, coffee, sugar free/diet drinks 200ml 0-50 Fruit juice (not reduced sugar variety) 200ml 100 Fizzy drinks (not sugar free) 330ml can Skimmed milk 200ml 65 Semi-skimmed milk 200ml 95 Full fat (whole) milk 200ml 135 Fortified full fat milk 200ml 210 Over the counter soups and milkshakes made with water various Over the counter soups and milkshakes made with full fat milk various Fortified Milk (to boost calories and protein) 1 pint full fat milk 5 tablespoons (about 32g) milk powder Mix the milk powder with a small quantity of milk to make a smooth runny paste, add the remainder of the milk and mix well. Fortified milk can be used as you would normal milk e.g. on cereal, to make milky drinks puddings and custard etc. Food as Treatment Shake (300 calories) 200mls full fat milk 2 heaped tablespoons dried milk powder Milkshake syrup or powder to taste Variations add: 1 tablespoon double cream 1 scoop of ice cream Pureed fruit such as strawberries or banana For further advice if you are continuing to lose weight please speak to your GP or other healthcare professional who may seek advice from/refer you to a Dietitian. Authored by: David Broadbent-Community Dietitian, The Department of Nutrition and Dietetics Brighton and Sussex University Hospitals NHS Trust The Royal Sussex County Hospital The Princess Royal Hospital Eastern Road Lewes Road Brighton Haywards Heath East Sussex BN2 5BE West Sussex RH16 4EX Tel: (01273) Ext Tel: (01444) Ext Ref number: DS190 V2 Publication Date: November 2016 Review Date: November

10 Appendix 2 DIETITIAN REFERRAL FORM Fax to or send to Department of Nutrition & Dietetics, Royal Sussex County Hospital, Room G1, Ground Floor, St Mary s Hall, Eastern Road, Brighton, BN2 5JJ Surname: First name(s): Title: NHS Number: Hospital Number: DOB: Address: Postcode: Telephone: Home Mobile Is the patient is aware of this referral? Yes No Current Weight: BMI: Reason for referral: Height: Weight History: Past Medical History /current medications/relevant biochemistry (can attach a print out): Is the patient under the mental health services? Yes No Has the patient got a confirmed or suspected eating disorder? Yes No Swallow problems? Yes No Has patient had SALT referral? Yes No MUST Score if documented: Has a nutrition care plan been completed (please attach) Yes No Has food as treatment/fortification been used? Yes No NA Have nutritional supplements been prescribed? Yes No Date: End of life care: Yes No Input required: Outpatient Clinic Nursing Home Visit Home Visit Health and Safety - 2 person visit recommended? Yes No Please give details Translator needed? Yes No Language Hospital transport needed Yes No Type: Escort Yes No Name and Title of Referrer: Address: Telephone Number: GP Name and Address: GP Authorising Signature (not needed for SCT please sign your name) 10

11 Appendix 3 HWLH referral form this is available on all GP clinical systems. HSCC Referral Form HWLH June

12 Appendix 4 Oral Nutritional supplements in this section are BLUE on the formulary therefore, they should only be prescribed on the NHS within BHCCG and HWLHCCG if recommended by a Dietitian. Yoghurt style sip feed Fortisip Yoghurt Style Ensure Plus Yoghurt Style Raspberry Vanilla and Lemon Peach and Orange Strawberry Swirl 200ml bottle ml bottle 300 High protein sip feed Fortisip Compact Protein Fortisip Extra Vanilla Banana Mocha Strawberry Peach and Mango Berries Vanilla Forest Fruit Strawberry 125 ml bottle ml botte 305 Fibre containing sip feeds Fortisip Compact Fibre Ensure Plus Fibre Strawberry Vanilla Mocha Strawberry Raspberry Chocolate Banana Vanilla 125 ml bottle ml bottle

13 High energy powdered milkshake style sip feed High in calories but not nutritionally complete Scandishake Strawberry Chocolate Vanilla Caramel Unflavoured Banana Chocolate Strawberry Vanilla Neutral Strawberry Vanilla Banana 85g sachet 600 Serving instructions Reconstitute with 240ml full fat milk Savoury high energy supplements Vitasavoury Vitasavoury Starter pack Leek and Potato Mushroom Golden Vegetable Chicken x each flavour 50g sachet 4x50g sachet Serving instructions Reconstitute with 150ml hot water Reconstitute with 150ml hot water Semi-solid desserts. Often used for patients with dysphagia. Nutritionally complete but not recommended as a sole source of nutrition. Forticreme Complete Chocolate Vanilla Banana Forest Fruit Nutilis Fruit Stage Apple Strawberry 125g pot 150g pot Pre-thickened milk-shake style used in patients with dysphagia. Nutritionally complete. Nutilis Complete Stage 1 Nutilis Complete Stage Strawberry Vanilla Chocolate Strawberry Vanilla Chocolate 125g pot g pot

14 Modular Supplements Fat or carbohydrate based: High energy, typically low protein. / unit dose Polycal Unflavoured 400g tin powder 20 (5g scoop) Neutral Orange 200ml bottle 494 Calogen Neutral Strawberry 500ml bottle Banana Neutral 135 (30ml) Strawberry 200ml bottle Banana Calogen Extra Neutral Strawberry 200ml bottle 160 (40ml) Calogen Extra Shots Neutral Strawberry 6x40ml shot 160 (40ml) Modular supplements Protein based: high protein. Protifar ProSource Liquid Protein Unflavoured Original Citrus Berry Orange Creme 225g tin 30ml sachet and protein / unit dose 9.5kcal and 2.2g protein (2.5g scoop) 100kcal and 10g protein (30ml sachet) Specialist supplements Renilon 7.5 Supportan Modulen IBD Apricot Caramel Cappuccino Tropical Fruits Neutral 125ml ml g tin Optifibre Neutral 250g tin Neutral 5g sachet 2000 (whole tin) 10 (5g scoop) 14

15 Thickeners and pre-thickened drinks Nutilis powder Neutral 300g tin Food thickener - not intended to contribute to kcals Nutilis Clear Neutral 175g tin Food thickener - not intended to contribute to Resource ThickenUp Clear kcals Neutral 125g tin Food thickener - not intended to contribute to kcals Instant Carobel Neutral 135g box Food thickener - not intended to contribute to kcals Slõ Milkshake+ sachets stage 1 Slõ Milkshake+ sachets stage Chocolate Strawberry Chocolate Strawberry 7 x 50g sachets 7 x 50g sachets Pre-thickened drink 197.5kcal (50g sachet) Pre-thickened drink 197.5kcal (50g sachet) 15