Quick reference guide to prescribing adults oral nutritional supplements (ONS)

Transcription

1 Quick reference guide to prescribing adults oral nutritional supplements (ONS) Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust August 2017

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

3 Sip feed formulary These are the first-line sip feeds recommended for use across West Suffolk, providing the most cost-effective and optimum nutritional content. Preferred option: Style Product Unit volume Unit price Powdered milkshake AYMES Shake 57g to be mixed with 200ml Foodlink Complete 57g 0.61 whole milk Foodlink Complete with Fibre (vanilla flavour) 63g 0.67 Foodlink Complete Starter Pack 57g / 63g 0.62 AYMES Shake Starter Pack (5 flavours of AYMES Shake) Contraindications: Limited dexterity and inability to make up the shake Cow s or soya milk allergy or intolerance Less than 6 years of age Galactosaemia Require thickened fluids 57g 0.96 Require oral nutritional supplements (ONS) as a sole source of nutrition Require additional fibre via their ONS (Nb. Foodlink Complete contains 4.6g fibre per serving) Not suitable for use with enteral feeding tubes Patients with renal disease should be assessed by a dietitian prior to prescribing any of the above. Patients with diabetes should have their oral intake assess before an oral nutritional supplement (ONS) is prescribed. Blood glucose levels should be monitored and treatment reviewed as necessary. Alternative options if the above are contraindicated or not tolerated: Style Product Unit volume Unit price Milkshake (use if unable to prepare powdered milkshakes) Ensure Plus Nutricomp Drink Plus AYMES Complete Fresubin 2kcal cost effective if prescribed once daily Ensure Compact useful if unable to manage a 200ml bottle 220ml 200ml 200ml 200ml 125ml Juice Ensure Plus Juce 220ml 1.97 (use if dislike / do not tolerate milk or milk-based sip feeds) Yoghurt (useful if taste fatigue / changes) Ensure Plus Yoghurt Style 220ml 1.12 High protein (useful for chronic wounds, burns, fistulae) seek dietetic advice if renal function concerns Fibre-containing (useful if constipated) Savoury (useful if prefer savoury flavours) Semi-solid desserts (use if dysphagic) Foodlink Complete Ensure Compact Altraplen Protein 57g 125ml 200ml Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust. August Next review due August Foodlink Complete with Fibre 63g 0.67 AYMES Shake chicken Ensure Plus Savoury 57g 220ml Nutricrem 125g 1.44 Resource Dessert Energy 125g 1.63 Fresubin Thickened Stage 1 or Stage 2 200ml 2.35 Pre-thickened milkshakes (use if dysphagic) All prices correct as per MIMS, August 2017 edition. The West Suffolk oral nutritional supplement (ONS) prescribing guidelines for adults produced by Medicines Management, West Suffolk CCG in conjunction with the Dietitians, the West Suffolk NHS Foundation Trust, should be consulted for further guidance on prescribing ONS, ACBS indications, food first advice and screening for malnutrition in adults using the MUST and NAGE leaflets. The guidelines are available at: For residents in care homes, see the ONS in care homes policy link on back page)

4 Appendix Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust. August Next review due August 2018.

5 Appendix Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust. August Next review due August 2018.

6 Appendix Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust. August Next review due August 2018.

7 Appendix Produced by the Medicines Management Team, West Suffolk Clinical Commissioning Group in conjunction with the Dietitians, West Suffolk NHS Foundation Trust. August Next review due August 2018.

8 Appendix

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

10 West Suffolk Community Local Action Policy for acceptance of referrals for residents in Care Homes Residents must meet one of the following criteria in order to be referred to Community Dietetics Referrals with a MUST score of 2 and above with a high risk factor e.g. Pressure areas, COPD, Poorly controlled diabetes and other high risk factors at Dietetic discretion If a resident continues to lose weight after the implementation of food fortification for 4 weeks. ALL referrals must be accompanied with A four week food diary including evidence of food fortification, snacks and high calorie drinks. (Example of food diary in Nutrition Support Action Pack) and a weekly record of residents weight. Evidence of over the counter supplements purchased Please see the Oral Nutritional Supplements (ONS) in care homes policy and the Oral Nutritional Supplements in Care Homes: Information for Care Home Staff for further guidance. See