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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 Page 1 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 2 of 18 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. NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 3 of 18 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) NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 4 of 18 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. NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 5 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 6 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 7 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 8 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 9 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 10 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 11 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 12 of 18 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 13 of 18 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. NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 14 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 15 of 18 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. NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 16 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 17 of 18 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 NHS Trafford Guidelines on the use of Oral Nutritional Support (Sip Feeds) in Adults June 2012 FINAL Page 18 of 18