NHS Trafford Guidelines on the Use of Oral Nutritional Supplements (ONS) in adults in Primary Care.
July 2012
Approved by: / Amendments to December 2011 guidelines approved by TPCCG Medicines Management GroupDate approved: / 17.07.2012
Expiry Date: / 31.12.2014
Review date: / 31.10.2014
CONTENTS
1.0 INTRODUCTION AND AIMS OF GUIDELINE 3
2.0 IMPORTANCE OF NUTRITIONAL SCREENING 3
3.0 NUTRITIONAL SCREENING TOOL 3
4.0 DOCUMENTATION 4
5.0 FIRST LINE NUTRITIONAL SUPPORT 4
6.0 PRESCRIBING SIP FEEDS 5
7.0 IMPLEMENTATION 7
8.0 REFERENCES 7
9.0 ACKNOWLEDGEMENT 7
APPENDIX 1 –MUST SCREENING TOOL 8
APPENDIX 2 NUTRITIONAL SUPPORT FLOW CHART AND SUPPORTING INFORMATION 14
1.0 INTRODUCTION AND AIMS OF GUIDELINES
1.1 The aim of this guideline is to offer best practice advice on patient-centred care of adults who are malnourished or at risk of malnutrition, whether they are in a care home or at home. They are intended to be used by all local clinicians so that they can determine which service users require nutritional support and that a coordinated multidisciplinary approach is adopted.
1.2 This guideline sets out the process for the identification of patients with nutritional problems using a nutritional screening tool and how to proceed with their subsequent management. They incorporate the principles set out in the guidance issued by the National Institute for Health and Clinical Excellence entitled ‘Nutrition support in adults’, issued February 2006.1 (www.nice.org.uk).
2.0 IMPORTANCE OF NUTRITIONAL SCREENING
2.1 Nutritional screening should be undertaken (as per NICE guidelines) on:
· All hospital inpatients on admission
· All outpatients at their first appointment
· All people in care homes on admission
· All people on first registration at GP surgeries
· All people where there is clinical concern, for example, unintentional weight loss, fragile skin, poor wound healing, wasted muscles, impaired swallowing and poor appetite.
Patients should be rescreened according to these guidelines (Appendix 2)
3.0 NUTRITIONAL SCREENING TOOL
3.1 Patients should be screened for the risk of malnutrition using the ‘Malnutrition Universal Screening Tool’ (‘MUST’) (Appendix 1). The ‘Malnutrition Universal Screening Tool’ (‘MUST’) is a five step screening tool to identify adults, who are malnourished, at risk of malnutrition (under nutrition), or obese. It has not been designed to detect deficiencies in or excessive intakes of vitamins and minerals.
3.2 MUST has been validated across various settings such as hospital wards, outpatient clinics, general practice, community settings and care homes. It was found that ‘MUST’ was quick and easy to use, and gave reproducible results. It can be used for patients in whom height and weight are difficult to obtain, as a range of alternative measures and subjective criteria are given to obtain the Body Mass Index (BMI).
3.3 Further details can be found on the BAPEN website at www.bapen.org.uk and copies of MUST can be downloaded and printed from this site.
3.4 This document acts as the ‘local policy’ referred to throughout the MUST document.
3.5 The Nutritional Support Flow chart (appendix 2) should be followed once a patient has been identified as at risk of malnutrition.
3.6 The aims of nutritional support should be agreed for each patient which take into account any ethnic preferences, family situation, social circumstances or disabilities.
4.0 DOCUMENTATION
4.1 GP practices should ensure that all relevant data, including the current MUST score, can be recorded and updated on the patient’s computer records. Read code 687C may be used.
4.2 Patients receiving oral nutritional supplements (ONS) should be managed and monitored according to the flowchart in appendix 2 or as directed by the dietician. The management plan should be recorded in the patient’s notes with the following specific issues documented:
· Current weight/BMI/alternative measurements (use appropriate record chart).
· Target BMI/ weight.
· Compliance with supplements.
· Document all advice / treatment given.
· MUST score
5.0 FIRST LINE NUTRITIONAL SUPPORT
5.1 Specialist nutritional support advice to encourage the use of a high calorie diet should be recommended as the initial intervention BEFORE the prescribing of oral nutritional supplements.
5.2 For those at low risk with a MUST score of 0, the importance of healthy eating should be emphasised. Fluid intake of 30-35ml per kg should also be encouraged.
5.3 Patients with a MUST score of 1 should be given the advice specified in 5.2 and encouraged to have healthy snacks and milky drinks. The “Achieving a balanced diet” leaflet can be provided. (Appendix 4).
5.4 For those with a MUST score of 2 or more, encourage an increase in overall nutritional intake by encouraging high calorie and protein meals, snacks and drinks. A copy of the leaflet “What can I eat?” can be provided (Appendix 5). This information should be given BEFORE prescribing oral nutritional supplements
6.0 PRESCRIBING SIP FEEDS
6.1 This section applies to patients identified as requiring oral nutritional supplements using the ‘Nutritional Support Flow Chart’ (Appendix 2). Patients should be managed according to the flow chart in Appendix 2. When starting or stopping nutrition support:
· act in the patient’s best interest and obtain consent
· be aware that nutrition support is not always appropriate
Decisions on withholding or withdrawing nutrition support require consideration of ethical and legal principles-follow guidance from the General Medical Council and the Department of Health(NICE CG32;2006)
6.2 Where oral nutritional supplements are indicated, over the counter Complan® or Build Up® (1-2 sachets per day in addition to usual meals) should be trialled initially, with the exception of patients with renal disease (CKD 4&5) who should be referred to the renal dietician. These supplements are available to purchase from supermarkets or pharmacies. They are included on the national list of drugs that cannot be prescribed on the NHS. Patients should be reassessed after two weeks and referred to a dietician if the MUST score remains 2 or above or where no improvement is seen.
6.3 Complan Shake® can be prescribed for patients who are awaiting a dietician referral (unless CKD 4&5 - see above) where the prescriber considers this appropriate. This should be after a 2 weeks trial of Complan or Build Up.
6.4 Complan Shake® should initially be prescribed as a starter pack to allow the patient to trial the different flavours available (vanilla, strawberry, chocolate, banana and original) and establish taste preferences. The patient should be instructed to inform the prescriber of their preferred choice of flavours, which should be specified on future prescriptions. Prescriptions should be for one weeks supply at a time whilst awaiting dietetic assessment.
6.5 Prescriptions for oral nutritional supplements should be issued as acute prescriptions only to highlight the need for constant review and should be issued in quantities of maximum 28 days supply only when taste preferences and need for longer term treatment are established.
6.6 Where oral nutritional supplements are commenced in patients with diabetes, blood sugars may alter, requiring closer monitoring and review of existing diabetes treatments.
6.7 Prior to the issue of each prescription a weight should be taken or requested from the patient where possible, and the MUST score recalculated and recorded. Where possible information on current food and fluid intake should be requested.
6.8 When the agreed treatment aim is achieved, patients should be reassessed and consideration should be given to stopping supplements. Where oral nutritional supplements are stopped, patients should be monitored as outlined in the Nutritional Support Flow Chart in appendix 2 and their MUST score recalculated.
6.9 Substance misusers should be managed as per the flow chart in appendix 2. To ensure the benefits of treatment are maximised and that the necessary monitoring takes place prescribers should consider only prescribing oral nutritional supplements when the following criteria are met:
· MUST score of 2 or above AND
· First line nutritional support advice has been given and reviewed.
Prescribing for these patients is of increasing concern for the following reasons:
· Patients can become dependent on oral nutritional supplements and it may be difficult to stop prescribing where this is not considered appropriate.
· Oral nutritional supplements are often taken instead of meals, rather than between meals negating the benefit of treatment.
· Oral nutritional supplements may be sold to supplement income.
· Oral nutritional supplements may be given to friends, family or pets.
· Poor clinic attendance can make monitoring and reviewing treatment difficult.
Oral nutritional supplements should only be continued where patients comply with treatment and derive clinical benefit.
6.10 Where any discharge summary (or other communication) suggests that sip feeds initiated in hospital should be continued by the GP, and communication from a dietician (detailing treatment aims or treatment length and the date for dietician follow up) has not been received within 7 days, GPs should refer the patient to the Primary Healthcare Dietician. Small quantities of supplements can be issued on acute prescriptions while the patient is awaiting this referral.
6.11 Where patients have been commenced on oral nutritional supplements in hospital and the discharge communication requests the GP to reassess the patient for ongoing need as discharge has occurred before an intended review by hospital dieticians, the prescriber may refer the patient to the Primary Healthcare Dietician if this is considered to be more appropriate.
6.12 Patients discharged from hospital on oral nutritional supplements taken prior to admission may not have had their ONS reviewed and should be managed as per appendix 2.
6.13 Patients prescribed oral nutritional supplements recommended by a dietician, should continue until the next dietetic review unless treatment aims have been achieved.
6.14 Patients prescribed oral nutritional supplements who are not under the care of a dietician should be reviewed as per Appendix 2 and referred to the dieticians where appropriate.
6.15 Patients who have not eaten, or are unlikely to eat, for more than 5 days, or who have had a prolonged period of poor nutritional intake, may be at risk of refeeding syndrome (severe electrolyte imbalances and metabolic disturbance). Patients should be assessed for the risk of refeeding syndrome using Appendix 3. Patients identified as high risk, should be managed in secondary care.
7.0 IMPLEMENTATION
7.1 Practices need to ensure their staff have read and understood these guidelines. Training on the MUST tool is available from the Primary Healthcare Dieticians.
8.0 REFERENCES
1. NICE guidelines, Nutrition support in adults, February 2006 http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
2. Malnutrition Universal Screening Tool (MUST)- British Association of Parenteral and Enteral Nutrition (BAPEN) http://www.bapen.org.uk/pdfs/must/must_full.pdf
9.0 ACKNOWLEDGEMENTS
1. British Association of Parenteral and Enteral Nutrition (BAPEN)
2. Management of Under Nutrition in Adults in the Community. Guidelines for General Practice. Worcestershire PCT
APPENDIX 2 - Nutritional Support flow chart
Should I prescribe an Oral Nutritional Supplement (ONS)?
STEP 1 STEP 2 STEP 3
BMI score % unplanned weight loss score Acute disease effect score
STEP 4
Overall risk of malnutrition
STEP 5
Management Guidelines
Low Risk MUST Score 0 Medium Risk MUST Score 1 High Risk MUST Score 2+
APPENDIX 2a
Management of Nutritional Support for Patients in their own homes- Further information
LOW RISK‘ MUST’ Score 0 / ROUTINE CLINICAL CARE
- Treat underlying condition
- Record need for special diets
- Check and advise patient has regular meals
- Identify any swallowing difficulties and refer to GP to consider Speech and Language Therapy assessment
- Respect any religious / ethnic dietary needs and personal preferences
- Ensure meal environment conducive to promoting appetite
- Ensure appropriate cutlery to aid self feeding and assistance is offered if required
- If chewing difficulties, ensure soft meal options are available and consider dental review
- If BMI more than 30, encourage weight loss to BMI 20-30
WEIGH CLIENT AND REPEAT SCREENING ANNUALLY.
If nutritional supplements are already being used, these may not be necessary: consider stopping. If continued repeat screening MONTHLY.
MEDIUM
RISK
‘MUST’
Score 1 / OBSERVE
- Treat underlying condition
- Record need for special diet
- Continue routine care as for Low risk
- Ensure times when appetite is good are optimised
- Ensure snacks and milky drinks are offered between meals
- Use a food record chart to document dietary intake for 3 days and review
= If managing all of meals but continuing to lose weight, consider medical review to
investigate any underlying condition
= If managing less than half of meals and snacks (see Food Record Chart) or
unintentional weight loss continues TREAT AS HIGH RISK
= If improved or adequate intake – little clinical concern
WEIGH CLIENT AND REPEAT SCREENING AT LEAST 2-3 MONTHLY
If nutritional supplements are already being used, these may not be necessary: consider stopping if managing all of meals and no recent weight loss
HIGH RISK
‘MUST’
Score 2+ / TREAT
Unless detrimental or no benefit is expected from nutritional support
- Treat underlying condition
- Record need for special diet
- Continue clinical care as for Low and Medium Risk
- Advise high protein, high calorie diet( see ’What can I eat’ and ‘Small appetite’ leaflet
- Offer Build-up, Complan shake drinks, twice a day
- If no improvement with High protein, High calorie diet within 2 weeks request GP review and referral to dietitian if appropriate.
WEIGHT CLIENT AND REPEAT SCREENING BEFORE EACH PRESCRIPTION ISSUED(monthly)
Obesity: record presence of obesity. For those with underlying conditions, these are generally controlled before the treatment of obesity.
Patients in care homes: Please see appendix 2b
Appendix 2b
Management of Nutritional Support in Care Homes- Further information
LOW RISK‘ MUST’ Score 0 / ROUTINE CLINICAL CARE
- Treat underlying condition
- Record need for special diets
- Protect meal times – ensure no meals are missed
- Identify any swallowing difficulties and refer to GP to consider Speech and Language Therapy assessment
- Respect any religious / ethnic dietary needs and personal preferences
- Provide environment conducive to promoting appetite
- Provide appropriate cutlery to aid self feeding and offer assistance if required
- If chewing difficulties, offer soft meal options and consider dental review
- If BMI more than 30, encourage weight loss to BMI 20-30
CARE HOME STAFF TO WEIGH CLIENT AND REPEAT SCREENING MONTHLY. If nutritional supplements are already being used, these may not be necessary: consider stopping.
MEDIUM
RISK
‘MUST’
Score 1 / OBSERVE
- Treat underlying condition
- Record need for special diet
- Continue routine care as for Low risk
- Optimise times when appetite is good
- Offer snacks and milky drinks between meals
- Document dietary intake for 3 days (Food record chart) and review
= If managing all of meals but continuing to lose weight, consider medical review to
investigate any underlying condition
= If managing less than half of meals and snacks (see Food Record Chart) or
unintentional weight loss continues TREAT AS HIGH RISK
= If improved or adequate intake – little clinical concern
CARE HOME STAFF TO WEIGH CLIENT AND REPEAT SCREENING AT LEAST MONTHLY
If nutritional supplements are already being used, these may not be necessary: consider stopping if managing all of meals and no recent weight loss
HIGH RISK
‘MUST’
Score 2+ / TREAT
Unless detrimental or no benefit is expected from nutritional support e.g: imminent death
- Treat underlying condition
- Record need for special diet
- Continue clinical care as for Low and Medium Risk
- Optimise times when appetite is good
- Offer snacks and fortified milky drinks between meals
- Document dietary intake for 3 days (Food record chart) and review
- Liaise with catering staff and initiate High protein, high calorie diet
- Offer Build-up, Complan shake drinks, twice a day
- If no improvement with High protein, High calorie diet within 2 weeks request GP review and referral to dietitian.
CARE HOME STAFF TO WEIGH CLIENT AND REPEAT SCREENING WEEKLY
Obesity: record Presence of obesity. For those with underlying conditions, these are generally controlled before the treatment of obesity.