Download NHS Trafford CCG Guidelines on the use of Oral Nutrition

NHS Trafford Guidelines on the Use
of Oral Nutritional Supplements (ONS)
in adults in Primary Care.
July 2012
Approved by:
Date approved:
Amendments
to
December
2011
guidelines
approved
by
TPCCG
Medicines Management Group
17.07.2012
Expiry Date:
31.12.2014
Review date:
31.10.2014
NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL
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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
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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.
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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.
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
4.2
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)
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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.
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
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.
2.
NICE guidelines, Nutrition support in adults, February
http://www.nice.org.uk/nicemedia/live/10978/29981/29981.pdf
Malnutrition Universal Screening Tool (MUST)- British Association of
Parenteral and Enteral Nutrition (BAPEN)
http://www.bapen.org.uk/pdfs/must/must_full.pdf
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2006
9.0
ACKNOWLEDGEMENTS
1.
2.
British Association of Parenteral and Enteral Nutrition (BAPEN)
Management of Under Nutrition in Adults in the Community. Guidelines for
General Practice. Worcestershire PCT
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APPENDIX 2 - Nutritional Support flow chart
Should I prescribe an Oral Nutritional Supplement (ONS)?
STEP 1
STEP 2
BMI score
BMI kg/m2
> 20
18.5 -20
< 18.5
Score
=0
=1
=2
STEP 3
% unplanned weight loss score
Acute disease effect score
Unplanned weight loss in past
3-6 months - check for
treatable causes.
%
Score
< 5
=0
5 – 10
=1
> 10
=2
If patient is acutely ill &
there has been or is likely
to be no nutritional intake
for > 5 days score 2.
*NB Refeeding risk!
STEP 4
Overall risk of malnutrition
Add scores for steps 1, 2 and 3 together to calculate overall risk of malnutrition
Score 0 = Low Risk
Score 1 = Medium Risk
Score 2 or more = High Risk*
STEP 5
Management Guidelines
Low Risk MUST Score 0
Encourage to eat 3
healthy meals per day &
aim for 30-35mls per Kg
of fluid / day.
Repeat screening:
Care homes monthly
Community annually
For greater detail on the
recommendations for all
MUST scores please see
Appendices 2a & 2b
Where sip feeds have
been discontinued GPs
may wish to reassess
patients sooner according
to the patient’s clinical
need.
* NB. If patient at risk of
refeeding syndrome. see
Appendix 3
Medium Risk MUST Score 1
High Risk MUST Score 2+
Continue clinical care as for
low risk
Continue clinical care as for low
and medium risk.
Treat unless detrimental or no
benefit
is
expected
from
nutritional support.
Improve & increase overall
nutritional
intake
by
encouraging high calorie and
protein meals, snacks and
drinks see “What can I eat”
leaflet (appendix 11)
Advise patient to purchase &
consume 1-2 sachets of OTC
Complan / Build up per day in
addition to usual meals except
renal patients with CKD stage
4/5 who should be referred to
a renal dietician. Review in 2
weeks (weekly if in care
home).
If MUST score
remains 2 or above refer to
dietetics.
If GPs feel there is a need to
initiate ONS whilst patient is
being referred to dietetics then
an acute script for Complan
Shake starter pack should be
issued initially. Prescribe only 7
days supply until
flavour
preferences are established &
to facilitate monitoring. ONS
should not be put on repeat.
Patients with diabetes will need
their blood sugar monitored and
managed accordingly.
Repeat screening:
Care homes – weekly
Communitybefore
each
prescription issued (monthly
once stable)
Establish
recent
dietary
intake & document intake if
possible for 3 days.
If managing all meals but
continuing to loose weight
consider medical review to
investigate any underlying
condition.
If managing less than half of
meals and snacks refer to
the leaflet ‘Achieving a
balanced diet’ (see appendix
10). If unintentional weight
loss continues treat as HIGH
RISK.
Repeat Screening:
Care homes - at least
monthly.
Community - at least every
2-3 months.
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APPENDIX 2a
Management of Nutritional Support for Patients in their own homes- Further
information
ROUTINE CLINICAL CARE
LOW RISK
‘ MUST’ Score 0
-
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.
OBSERVE
MEDIUM
RISK
‘MUST’
Score 1
-
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
TREAT
Unless detrimental or no benefit is expected from nutritional support
HIGH RISK
‘MUST’
Score 2+
-
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
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Appendix 2b
Management of Nutritional Support in Care Homes- Further information
ROUTINE CLINICAL CARE
LOW RISK
‘ MUST’ Score 0
-
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.
OBSERVE
MEDIUM
RISK
‘MUST’
Score 1
-
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
TREAT
Unless detrimental or no benefit is expected from nutritional support e.g: imminent
death
HIGH RISK
‘MUST’
Score 2+
-
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.
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APPENDIX 3
IDENTIFYING PATIENTS AT HIGH RISK OF REFEEDING
What is Refeeding Syndrome?
Refeeding syndrome is defined as the potentially fatal shifts in fluids and electrolytes e.g.
hypophosphataemia; abnormal sodium and fluid balance; changes in glucose, protein, and
fat metabolism; thiamine deficiency; hypokalaemia; and hypomagnesaemia. During the
period of prolonged starvation, several intracellular minerals become severely depleted;
however serum concentrations may remain normal. During refeeding, glycaemia leads to
increased insulin secretion which stimulates the absorption of potassium, magnesium and
phosphorous (and water by osmosis) into cells which results in severe electrolyte
deficiencies and can result in life threatening clinical symptoms. Cofactors such as
thiamine can also become depleted.
Which patients are at risk?
The possibility of refeeding syndrome should be considered in patients who have not
eaten little or nothing for more than 5 days or those who are chronically undernourished.
Patients are at high risk of refeeding problems if:
7.1.1.1 Either the patient
has one or more of
the following:
7.1.1.2 Or the patient has
two or more of the
following:

Body mass index (kg/m2) <16

Body mass index <18.5

Unintentional weight loss >15%

Unintentional weight loss >10%
in the past three to six months

Little or no nutritional intake for
in the past three to six months

>10 days

Low levels of potassium,
Little or no nutritional intake for
>5 days

History of alcohol misuse or
phosphate, or magnesium
drugs, including insulin,
before feeding
chemotherapy, antacids, or
7.1.1.3
diuretics
7.1.1.4
How should patients who are high risk of refeeding syndrome be managed?
NICE advises that people at high risk of developing refeeding problems should be cared
for by health professionals who have skills and training and expert knowledge of nutritional
requirements and nutrition support. NICE also advises that nutritional support should be
introduced at a slower rate, which mineral supplements should be given and, in some
cases that cardiac monitoring is undertaken. Patients identified as being at high risk
should therefore be managed by secondary care.
If refeeding syndrome is detected, the patient should be urgently referred to Refer to the
full NICE guidance at: http://www.nice.org.uk/guidance/index.jsp?action=byID&r=true&o=10978
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APPENDIX 4
Patient information leaflet for those with a MUST score of 1: “Achieving a balanced diet”
leaflet produced by the department of Nutrition and Dietetics, Trafford Provider Services.
Contact 0161 9808041
APPENDIX 5
Patient information leaflet for those with a MUST score of 2 or more: “What can I eat?”
leaflet produced by the department of Nutrition and Dietetics, Trafford Provider Services.
Contact 0161 9808041
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