Guidelines For The Use Of Oral Nutritional Supplements In The Community

Transcription

1 Guidelines For The Use Of Oral Nutritional Supplements In The Community 1. Nutrition Screening For All Mid- Essex Community Patients This policy has been produced in order to provide guidance for GPs, Community Nurses, and healthcare staff involved in assessing and monitoring the nutritional status of adult patients in community care homes and in their own homes. It is a guide for staff to identify those at risk of malnutrition and provides appropriate treatment plans based on the NICE Guidelines for Nutrition Support in Adults (2006) 1. The NICE Guidelines recommend that all adult patients in the community should be screened for malnutrition or the risk of malnutrition. WHO TO SCREEN Community patients in their own homes should be screened for the risk of malnutrition when they are seen in GP clinics or other community outpatient services when there is a clinical concern. Screening should be done using the Malnutrition Universal Screening Tool (MUST) 2. This tool is designed to detect those with low, medium or high risk of malnutrition. The MUST screening tool and action plan for patients in their own homes is shown in Appendix 1. Residents in Mid Essex Care Homes should be screened for malnutrition on admission and monthly thereafter using the MUST Tool. The MUST screening tool and action plan for residents in Care Homes is shown in Appendix FIRST LINE OF TREATMENT The Food First approach should be followed as the first line of treatment for patients at risk of malnutrition. Information and recipes are available in the Food First Leaflets and Fabulous Fortified Feasts. OralNutritionalSupplementsCommunityGUI201501v2.0final Page 1 of 12

2 Care Homes should either make home made nourishing drinks, such as high calorie milkshakes using full cream milk, ice cream, cream and blended fruits etc or purchase milkshake powders to make up with full cream milk. For patients in their own homes, the above nourishing drinks should be encouraged. 3. SECOND LINE OF TREATMENT After following the Food First approach for at least 4 weeks, oral nutritional supplements (ONS) can be considered for individuals requiring additional energy and protein. Patients should initially be advised to purchase supplements as part of a food first programme and prescribing should only be considered when this has failed. Patients should also be encouraged to take as much of their oral foods as possible and not to use supplements as a meal replacement. 3.1 Over The Counter (OTC) Nutritional Supplements OTC supplements can be purchased and are useful for those patients whose clinical condition is not eligible for prescribable supplements. Care homes should be encouraged to consider this option for such patients. Alternatively, home-made nourishing drinks can be prepared by care home cooks and chefs. OTC supplements are available from most supermarkets and some chemists. There are two varieties: Ready To Drink from the bottle or tin eg: Nurishment, & Nurishment Extra, Complan Smoothie and Complan Milkshake. Powdered, to mix with milk eg: Build Up, Complan. Full cream milk is preferable to use. 3.2 Prescribed Oral Nutritional Supplements Before considering prescribed supplements, the first line treatment should have been instigated. The Food First approach should be followed for 4 weeks before referral to the Dietitian or commencing supplements. Detailed food and fluid records should be completed and kept for this time. These should demonstrate that extra effort has been made to improve nutritional intake. Referrals will only be accepted on completion of the referral form Appendix 3 and are usually in cases where there has been no improvement despite ONS. The MUST score above 2 and evidence of weight loss should also be stated on the referral form. OralNutritionalSupplementsCommunityGUI201501v2.0final Page 2 of 12

3 Standard ACBS indications The Advisory Committee on Borderline Substances (ACBS) recommends that certain food products (e.g. prescribed ONS) should be regarded as drugs for use in the management of specific conditions. ONS should only be prescribed on FP10 for patients who meet the ACBS prescribing criteria (see below) and have been screened using the Malnutrition Universal Screening Tool (MUST) and deemed to be at nutritional risk. One or more of the following ACBS criteria should be present: Intractable malabsorption Pre-operative preparation of undernourished patients Proven inflammatory bowel disease Following total gastrectomy Bowel fistulas Dyspahagia Short-bowel syndrome Disease-related malnutrition Disease-related malnutrition encompasses a wide range of conditions that may result in a requirement for nutrition support. The prescriber should use their clinical judgement to determine when ONS is required and consider the individual needs/circumstances of the patient. Certain supplements may have further indications (e.g. dysphasia or dialysis). Details can be found in the BNF and MIMS. Patients for whom supplements are a sole source of nutrition should be referred to the Nutrition and Dietetic Department for assessment and on-going support. Patients with diabetes can be given most supplements. Do not use any glucose polymer based supplements. Please seek advice from a registered dietician if there is uncertainty on which supplement to use. The supplements should be given in small volumes throughout the day. Blood glucose levels should be carefully monitored and medication adjusted if necessary. Patients with complex clinical conditions e.g. advanced stages of renal impairment, may require dietetic intervention before commencing on oral nutritional supplements. First Line Choice of ONS (See Appendix 4 for a table of first line supplements.) Patients who are prescribed nutritional supplements should be initially commenced on COMPLAN SHAKE. Complan Shake is suitable for the majority of individuals and can be prescribed as per ACBS guidelines. This product is in powder form and requires mixing with water or milk before being consumed. Full cream milk should be used, unless it is medically contraindicated, to ensure maximum nutrition support. OralNutritionalSupplementsCommunityGUI201501v2.0final Page 3 of 12

4 There are several other prescribable powder-form, easy-to- mix, nutritional products available e.g.: Aymes Shake, Foodlink Complete, and Fresubin Powder Extra. Most of these are newer to the market and consumption will be dependent on personal preference and flavour. All other supplements other than Complan Shake or the powder-form prescribable feeds above should be prescribed only under dietetic supervision. Second line choice of ONS (see Appendix 5 for a table of second line supplements) If there are anticipated difficulties in preparing Complan Shake then FRESUBIN 2 KCAL should be prescribed. Fresubin 2Kcal is a milk based, ready to drink sip feed. If a fruit juice style supplement is required, FRESUBIN JUCY should be prescribed. Fresubin Jucy is a milk free, ready to drink sip feed. These supplements should only be prescribed once a day initially. These may then be increased to twice daily once tolerance is assessed and only if absolutely necessary. 4. Treatment review To assess the benefit of the prescribed nutritional supplements, individuals should be reviewed within 3-4 months of commencement by the clinician who initiated them. When the aim of starting prescribed supplements is achieved, the supplements should be discontinued. Patients in the final weeks of life are unlikely to benefit from prescription supplements. OTC supplements may be a better option due to palatability. 5. References 1. National Institute for Health and Care Excellence (2006) Nutrition Support In Adults CG British Association for Parenteral and Enteral Nutrition (BAPEN) 2012 MUST Tool. 3. NHS London Procurement Programme 4. Prescqipp ONS guidelines B68 v 2.0. Fabulous Fortified Feasts. 6. Appendices 1. MUST Score Action Plan For Adult Patients In Their Own Home OralNutritionalSupplementsCommunityGUI201501v2.0final Page 4 of 12

5 2. MUST Score Action Plan For Adult Patients In Care Homes 3. Referral form to Dietitian 4. First Line Recommended Nutritional Supplements 5. Second Line Recommended Nutritional Supplements OralNutritionalSupplementsCommunityGUI201501v2.0final Page 5 of 12

6 Appendix 1 MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) FOR ADULTS IN THEIR OWN HOMES STEP 1 + STEP 2 + STEP 3 BMI Score Weight Loss Score Acute Disease Score BMI kg/m² > < Unplanned weight loss in past 3-6 months <5% % 1 >10% 2 If the patient is acutely ill and there has been or is likely to be no intake for >5 days Score = 2 STEP 4 - Overall risk of Malnutrition Add scores together to calculate overall risk of malnutrition Score 0 = Low Risk Score 1 = Medium Risk Score 2 or more = High Risk STEP 5 - Care Plan MUST Score = 0 Low Risk If BMI>30kg/m² then suggest a healthy eating plan Repeat MUST Score annually or every 3-6months if there is clinical concern (e.g. neurological degenerative conditions) MUST Score = 1 Medium Risk Observe intake using a food and fluid. If oral intake is poor, then initiate Food First advice. Repeat MUST score monthly for 3 months. If oral intake is adequate and weight is stable, continue screening annually or more frequently as above if condition deteriorates MUST Score = 2 or more High Risk TREAT unless detrimental or no benefit expected from nutritional support e.g. terminal phase of illness. Observe intake using food and fluid chart. Initiate Food First advice. Monitor weight weekly. If no improvement after 4 weeks consider whether OTC nutritional supplements are Appendix suitable. 2 OralNutritionalSupplementsCommunityGUI201501v2.0final Prescribable supplements are only appropriate if the patient s clinical condition Page 6 of 12 meets the ACBS criteria. If there is a major clinical concern, refer to Community Nutrition Support Dietician using the department referral form.

7 Appendix 2 MALNUTRITION UNIVERSAL SCREENING TOOL (MUST) FOR ADULTS IN COMMUNITY CARE HOMES STEP 1 + STEP 2 + STEP 3 BMI Score Weight Loss Score Acute Disease Score BMI kg/m² > < Unplanned weight loss in past 3-6 months <5% % 1 >10% 2 If the patient is acutely ill and there has been or is likely to be no intake for >5 days Score 2 STEP 4 - Overall risk of Malnutrition Add scores together to calculate overall risk of malnutrition Score 0 = Low Risk Score 1 = Medium Risk Score 2 = High Risk STEP 5 - Care Plan MUST Score = 0 Low Risk If BMI>30kg/m² then suggest/offer a healthy eating plan ) Repeat MUST Score monthly in Care Home MUST Score = 1 Medium Risk Observe intake using a food and fluid If oral intake is poor, then initiate Food First advice If no improvement, then devise a nutrition care plan If oral intake is improved/adequate, repeat MUST score monthly or more frequently if condition deteriorates MUST Score = 2 or more High Risk TREAT unless detrimental or no benefit expected from nutritional support e.g. terminal phase of illness. Observe intake using food and fluid chart. Initiate Food First advice. Monitor weight weekly. If no improvement after 4 weeks consider whether OTC nutritional supplements are suitable. Prescribable supplements are only appropriate if the patient s clinical condition meets the ACBS criteria. If there is a major clinical concern, refer to Community Nutrition OralNutritionalSupplementsCommunityGUI201501v2.0final Support Dietitian using the department referral form. Page 7 of 12

8 Appendix 3 REFERRAL FORM FOR NUTRITION AND DIETETIC DEPARTMENT FOR CARE HOME RESIDENTS AND INDIVIDUALS REQUIRING HOME VISITS.THEY SHOULD BE REFERRED DUE TO SUSTAINED HIGH RISK OF MALNUTRITION USING MUST SCORE (MUST SCORE 2 OR ABOVE) PLEASE REFER TO MID ESSEX MUST TOOL GUIDELINES BEFORE COMPLETING THIS REFERRAL Fax To: Community Nutrition Support Dietitians at Mid-Essex Referral Centre Patients Name: NHS Number: Date of Birth: Male/Female (please circle) Address: Postcode: Contact number (s): Medical History/Diagnosis: Current MUST Score: Previous Month s MUST Score & date: Only MUST Score of 2 or above should be referred unless medical diagnosis requires dietetic intervention. Current diet (if any): Reason For Referral: Relevant Medication: Anthropometry or Biochemistry Information (With Relevant Dates) Height: Current Weight (date taken): BMI: Weight History over past 6-12 months including dates: Referral can only be accepted from a GP OR Community Matron Referrer s Details Name: Profession: Address: GP Details Name: Address: Tel No: OralNutritionalSupplementsCommunityGUI201501v2.0final Page 8 of 12

9 Date Form Completed: Date Form Received: OralNutritionalSupplementsCommunityGUI201501v2.0final Page 9 of 12

10 Appendix 4 Recommended First Line Supplements All cost prices are subject to change and should be checked in the latest edition of BNF. Prices as per BNF 68 September Nutritional value may vary with flavour, please consult product literature for further details. Product Unit Nutritional Profile Cost per Unit Complan Shake Foodlink Complete 57g sachet to be mixed with 200ml whole milk 3 heaped tablespoons (from a 450g carton) in 250ml water 387kcal 15.6g protein kcal 12.5g protein 0.46 Foodlink Complete with Fibre 4 heaped tablespoons (from a 450g carton) or 63g sachet in 250ml water 270kcal 12.3g protein 0.46 if carton prescribed if sachet prescribed Aymes Shake Fresubin Powder Extra Ensure Shake 57g sachet to be mixed with 200mls whole milk 62g sachet to be mixed with 200mls whole milk 57g sachet to be mixed with 200ml whole milk 388kcal 15.8g protein kcal 17.7g protein kcal OralNutritionalSupplementsCommunityGUI201501v2.0final Page 10 of 12

11 Appendix 5 Recommended Second Line Supplements All cost prices are subject to change and should be checked in the latest edition of BNF. Prices as per BNF 68 September Nutritional value may vary with flavour, please consult product literature for further details. Milkshake Style 2kcal/ml Product Unit Nutritional Profile Cost per Unit Fresubin 2kcal Drink 200ml 400kcal g protein Fresubin 2kcal Fibre 200ml 400kcal g protein Milkshake Style 1.5kcal/ml Product Unit Nutritional Profile Cost per Unit Fresubin Energy 200ml bottle 300kcal g protein Fresubin Energy Fibre 200ml bottle 300kcal 11.2g protein 1.98 (500ml 5.40) Aymes Complete 200ml bottle 300kcal 1.40 Fruit Juice Style 12g protein Product Unit Nutritional Profile Cost per Unit Fresubin Jucy Drink 200ml bottle 300kcal g protein OralNutritionalSupplementsCommunityGUI201501v2.0final Page 11 of 12

12 Title Guidelines for the use of Oral Nutritional Supplements in the Community Document reference OralNutritionalSupplementsCommunityGUI201501v2.0final Author Updated by Natalie Leong, Senior Pharmacist, Mid-Essex CCG Consulted with Pauline J Bird, Clinical Manager, Nutrition & Dietetic Service Millie Olu, Community Nutrition Support Dietician Reference: NICE Guidance Nutrition Support for Adults February 2006 Approved by Mid-Essex Area Prescribing Committee Date approved Jan 2015 Next review date Jan 2017 Previous version Guidelines for Nutrition screening and prescribing oral nutrition in the community Key Changes Document Management added. Updated MUST tool for patients at home & care homes. Formulary choices on oral nutritional supplements. OralNutritionalSupplementsCommunityGUI201501v2.0final Page 12 of 12