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Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Oral Nutritional Supplement (Sip Feed) Guidelines for Adults October 2013 VERSION CONTROL Version Date D1 31.12.10 D2 8.10.10 Author SS SS Status Draft Draft Comment D3 28.1.11 SS Draft D4 31.1.11 ss Draft D1 21.2.11 SS Draft Circulated for comment Circulated for comment Circulated for comment D18 2.3.11 SS Final Draft Circulated for comment Final 12.5.11 D19 Final 22.10.13 SS 1st revision 09.03.15 SS/AR Minor update By whom Final Approval CityCare QualityAssurance Forum CityCarePatient Safety Committee Nottinghamshire APC Committee Nottinghamshire APC Committee Include formulary update and links to MUST tool IMPORTANT NOTICE: If the review date of any policy or procedure has expired staff should seek advice form their clinical lead or manager regarding the appropriate action to be taken. Page 1 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines CONTROL RECORD Title Oral Nutritional Supplement (Sip Feed) Guidelines Reference Purpose To ensure that oral nutritional supplements are used, prescribed and reviewed appropriately across the health community Audience Issue NHS Nottinghamshire County, Nottingham CityCare, County Health Care Paternership., Nottingham University Hospitals, Nottinghamshire CCGs Issue date 25.10.13 Version V 19 Date 15.4.11 Status Review date 01.02.15 Owner Nottingham Community Nutrition and Dietetic Service Author Nottingham Community Nutrition and Dietetic Service and NHS Nottingham City Medicines Management Team Development group Nottinghamshire Sip Feed Guideline Review Group Approved by Area Prescribing Committee Date Approved by CityCare Quality Assurance Forum Date Ratified by CityCare Patient Safety Committee Date Target audience All Clinical Staff across Nottinghamshire Health Community Distribution list All Clinical Staff across Nottinghamshire Health Community Method Paper copies Archived Date Intranet Other Location Access Page 2 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Page 3 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Contents Page 1 Introduction 4 2 Purpose 4 3 Role of the Registered Dietitian 4 4 Background 5 5 Risk Management 6 6 Equipment List 6 7 Patient Assessment Malnutrition Universal Screening Tool (MUST) 8 Nutritional Screening and the provision of first line dietary advice 9 Prescription of Sip Feeds and the review process 7-8 10 Sip Feed formulary 8-9 11 Education and Training Programme 9 12 Implementation and dissemination 9 13 Monitoring 9 14 Equality and Diversity Statement 9 15 References and additional supporting documents 6-7 7 10-12 Appendices Appendix 1 –Malnutrition Universal Screening Tool (‘MUST’ Tool) 13 Appendix 2 – Food and Fluid Checklist 14 Appendix 3 –“Little and Often” Information Sheets for patient/carers 15&16 Appendix 3 – Sip Feed Implementation Pathway 17 Appendix 4 – Sip Feed Formulary 18 Appendix 6 - “Using a Sip feed” Information Sheet for patient/carers 19 Page 4 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines 1. INTRODUCTION Prescribable oral nutritional supplements (sip feeds) are liquid nutrient formulations containing the complete range of nutrients, which generally are administered by mouth to supplement or to provide the complete nutritional requirements for an individual. These guidelines have been developed to provide clear evidence based guidance about how and when to use oral nutritional supplements effectively in adults. Their content is based on NICE guidance for nutrition support in adults, a review of current literature, particularly two systematic reviews suggesting positive benefits when using oral nutritional supplements with patients who are underweight (BMI < 20) and local good practice discussions with GP’s and Community Nurses. 2. PURPOSE The guidelines should be considered as an aid to good practice and not a rigid protocol. Using this guidance will ensure: Nutritional risk screening of all adults using a validated nutrition risk screening tool (Appendix 1). Effective multidisciplinary working. The appropriate and cost effective prescribing of sip feeds in the community. Patients’ nutritional needs are evaluated correctly and reviewed regularly. Patients will be prescribed products only for as long as is necessary. Patients will be prescribed the most appropriate product to meet their nutritional needs Patients will only be prescribed flavours and forms of nutritional supplement that are acceptable to that patient. Repeat prescriptions are not generated without regular review. Ensuring sip feeds are prescribed appropriately will minimise waste, and potentially provide a cost saving to the CCGs. 3. ROLE OF THE REGISTERED DIETITIAN Patients meeting the following criteria should be referred to the appropriate Nutrition and Dietetic Department. Patients with Stage 3-4 Pressure Ulcers Patients scoring 4 or above on the Malnutrition Universal Screening Tool (‘MUST’) Patients scoring 2-3 or above if there has been no significant improvement in condition, following the provision of Food First advice and 1-2 months on 1.5 Kcal/ml sip feeds. Patients with complex medical conditions and/or complex nutritional needs. For patients whose GP practice is in the Nottingham City and South of the County please Community Nutrition and Dietetic Service. All referrals should be made via the Nottinghamshire Health Care Action Point wither by phoning 0300 300 3333 or using the on-line referral form which can be accessed via Nottingham CityCare website. For patients whose GP practice is in the North of the County please contact Nottinghamshire County Nutrition and Dietetic Service on 01623 676025 The Dietitian will assess a patient’s current nutritional status whilst also considering their medical condition and the provision of nutrients from their current diet. Previous medical, social and nutritional information will also be considered. Appropriate anthropometrics will be taken when possible. The Dietitian will re-enforce advice already given, to improve a patient’s nutritional intake through the use of normal foods and non-prescribable products. Prescribed nutritional supplements will be recommended, in addition to this advice, when these methods have not been sufficient to meet their Page 5 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines treatment goals. The patient must meet the standard Advisory Committee on Borderline Substances (ACBS) indications. The Dietitian will initially review the needs of the patient (frequency of review will be determined on an individual basis) and will liaise with all relevant healthcare/ medical professionals regarding changes in nutritional status. When appropriate the dietitian will discharge the patient either to the referring health professional or to their GP for monitoring. 4 BACKGROUND Reported prevalence of malnutrition varies according to the method of assessment. Using the criteria of weight status, the proportion of underweight adults in the UK ranges from 10-40% in hospitals and care homes, ≤5% in the general population and >10% in those with chronic diseases living at home. 1 The Nutrition Screening Survey (BAPEN, 2008) found that 42% of recently admitted residents in care homes were malnourished. 2 The consequences of malnutrition include vulnerability to infections, delayed wound healing, impaired function of heart and lungs, muscle weakness and depression. Individuals who are malnourished consult their GP more frequently and have a higher rate of hospital admissions for longer periods. This is compounded by higher complication and mortality rates for similar conditions. 1, 5 There has been concern regarding the significant expenditure on oral nutritional supplements across Nottingham City and County. Oral nutritional supplements are a valuable resource to reduce the burden of disease related malnutrition and associated health care costs; they may however represent a significant waste of resources if they are being inappropriately prescribed or poorly monitored. In 2003 the cost of malnutrition and associated disease to the NHS was estimated at £7.3 billion. The majority of this expenditure was related to hospital admissions, length of stay and long-term care facilities. Small contributions arose from GP visits, outpatient visits, parenteral and enteral nutrition and oral nutritional supplements in the community3,5. In 2007 the cost to the NHS was estimated at in excess of £13.0 billion, about 80% of which was in England1. The majority of those identified as being either malnourished or at risk of malnutrition were living in the community 3,4,5. There is evidence that malnourished patients Visit their GP more often. Need more prescriptions Have more hospital admissions and remain in hospital for longer Have increased morbidity and mortality Reduced quality of life The causes of malnutrition are multi-factorial therefore its management may require a team approach involving a number of health care professionals and / or support workers to identify the underlying issues, and to develop and support implementation and monitoring of nutritional care strategies. These may include adapted eating / drinking utensils, modified food and or fluid texture, practical advice relating to eating patterns or food and fluid choices, help with eating or food preparation, food and fluid enrichment, oral nutritional supplements and tube feeds. 3,4,5 NICE guidance on Nutrition Support for Adults was produced in 2006 1 and the key clinical priorities for implementation which are relevant to community settings are listed below: Screening for malnutrition or the risk of malnutrition should be carried out by healthcare professionals with appropriate skills and training. Page 6 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Nutrition support should be considered in people who are malnourished, as defined by any of the following: o A body mass index (BMI) of less than 18.5 kg/m² o Unintentional weight loss greater than 10% within the last 3 – 6 months o A BMI of less than 20 kg/m² and unintentional weight loss greater than 5% within the last 3 – 6 months. Nutrition support should be considered in people at risk of malnutrition, as defined by any of the following: o o o Have eaten little or nothing for more than 5 days and/or are likely to eat little or nothing for the next 5 days or longer Have a poor absorptive capacity and/or have high nutrient losses and/or have increased nutritional needs from causes such as catabolism. Potential swallowing problems should be taken into account. A reference list of further supporting evidence can be found in appendix 7. The Nottingham Guidelines provide additional local guidance on the specific issue of the use of oral nutritional supplements (sip feeds). The guidance will help to improve good practice by supporting healthcare professionals to correctly identify patients who require nutritional intervention along with implementation of the most appropriate method of nutritional support. 5. RISK MANAGEMENT If the guidelines are not used there is a risk that service users requiring nutritional intervention would not be identified and thereby be at greater risk of all the complications associated with malnutrition. The risk of not using the guidelines could be inappropriate prescribing of nutritional supplements with increased costs to the health community. 6. EQUIPMENT LIST Equipment required for monitoring A means of measuring patients height e.g. height stick, tape measure Suitable sit on, stand on or hoist digital scales should be used, which must be calibrated on a regular basis according to the manufacturer’s recommendations to reduce the risk of inaccuracies. Health professionals and local authority run Care homes should use Grade 3 class scales and it is recommended that all other Care homes should also be using this type of scales for weighing residents. If it is difficult or impossible to weigh the patient, due to their condition either make a visual assessment or see the ‘MUST’ Explanatory Booklet for alternative measurements ( http://www.bapen.org.uk/must_notes.html) 7. PATIENT ASSESSMENT MALNUTRITION UNIVERSAL SCREENING TOOL (‘MUST’) See Appendix 1 ‘MUST’ Tool One of the critical components of raising awareness of the risks of malnutrition in the community is to ensure that the means to detect and treat malnutrition are in place and properly communicated to all stakeholders in the community. Page 7 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Detecting malnutrition requires a screening tool. NICE guidance1 suggests that screening should assess Body Mass Index and percentage unintentional weight loss and should also consider the time over which nutrient intake has been unintentionally reduced and/or the likelihood of future impaired intake. It suggests that the Malnutrition Universal Screening Tool (MUST) http://www.bapen.org.uk/screening-formalnutrition/must-calculator is an example of a validated tool, which can be used. ‘MUST’ has been advocated for use in the community and has been validated in a range of settings e.g. general practice, community settings including care homes, and outpatient clinics. It has proved to be quick and easy to use and give reproducible results. The ‘MUST’ tool identifies adult patients who are malnourished, at risk of becoming malnourished by means of a score. The ‘MUST’ score is used to classify patients into one of three groups either: low risk, medium risk or high risk. These groups are used to determine the actions the clinician/ patient/ carer should take in order to manage the patient, Details of these actions are given in Appendix 1 MUST Tool and Appendix 3 Supplement Pathway 8. NUTRITIONAL SCREENING AND PROVISION OF FIRST LINE DIETARY ADVICE See Appendix 2. Food and Fluid Checklist Appendix 3 Little and Often advice leaflet The Food and Fluid Checklist enables the health professional to evaluate the current nutritional intake of the patient and highlights any problem areas in their diet. This will allow for practical tips to be given to improve nutritional intake in conjunction with Appendix 5 “Little and Often” information leaflet. Where further information is required this can be provided by the completion of a 3-day food diary by the patient or carer. 9. PRESCRIPTION OF SIP FEEDS AND REVIEW PROCESS See Appendix 4. Supplement Pathway Outlines the process of and prescribing and reviewing sip feeds for a patient with a MUST score of 1 and above. It enables the health professional to follow a clear step wise approach to prescribing supplements when Food First advice, using the Little and Often patient information leaflet, has not been sufficient to improve the patients nutritional status and achieve treatment aims. Patients with a MUST score of 4 or above or those with Stage 3-4 pressure ulcers should be referred for Specialist Dietetic advice. For patients whose GP practice is in Nottingham City or South of the County need to be referred to Nottingham Community Nutrition and Dietetic Service. All referrals should be made via the Nottinghamshire Health Care Action Point wither by phoning 0300 300 3333 or using the on-line referral form which can be accessed via Nottingham CityCare website. For patients whose GP practice is in the North of the County please contact Nottinghamshire County Nutrition and Dietetic Service on 01623 676025 If the patient is alert and has swallowing problems please discuss with the relevant Speech & Language Therapy Service. For patients with a County GP please ring 0115 9691169 ext.55350 For Patients with a City GP please ring 0115 8834707 and Fax – 0115 8834755) Page 8 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines If the patient has dexterity problems relating to meals please refer to Occupational Therapy Service, via Health Care Access Point referral system. Contact numbers CityCare 0300 300 300: County 08449 808080 Important points to consider The aims of treatment should always be identified at the onset of prescribing any supplement. We would normally expect supplements to be prescribed on an acute basis. However there will be some patients whose condition dictates that they require a repeat prescription. For further information regarding the review process please see Appendix 3. Patients need to be reviewed on a regular basis (within 3 months) to ensure the patient’s continued compliance with the supplements and that treatment aims/goals are being met. Where the aims/goals are not being achieved or the patient’s condition deteriorates they should be referred for specialist dietetic advice. People who have eaten little or nothing for more than 5 days should have nutrition support introduced at no more than 50% of requirements for the first 2 days. Increase feeding rates to meet full needs if clinical and biochemical monitoring reveals no re-feeding problems.1 10. SIP FEED FORMULARY Specified ACBS indication conditions are: Disease related malnutrition including o Head, neck and oesophageal tumours o Severe COPD – FEV1<30% and MUST score of 2 or more o Patients with a complex chronic conditions requiring specialised feeds e.g. Stage 4 Pressure Ulcers (N.B. These patients must be referred for Specialist Dietetic advice) Dysphagia related to : o Stroke o Neurological conditions e.g. MND, MS. Pre-operative preparation of malnourished patients Following Total Gastrectomy Intractable malabsorption Proven Inflammatory bowel disease Short bowel syndrome Bowel fistulae Renal failure on CAPD or haemodialysis Appendix 5. Supplement Formulary Provides details of suitable 1.5/1.75 kcal/ml sip feeds and powder style feeds which need to be made up with full cream milk, that can be initiated by any health care professional for patients who score 3 or above on the MUST tool, without seeking dietetic advice. Ideally milk or yoghurt style supplements should be trialled first as these have a higher nutritional value then juice style versions. Powder style feeds can be more palatable as they are made with fresh full cream milk. However consideration needs to be made with regard to an individuals ability to make them up, their ability to consume an entire sachet as they have greater volume 1 x BD and should be used with caution for patients with diagnosed renal impairment stage 4 and above Where possible patients with diabetes should be prescribed milk/yoghurt style as juice style have a higher sugar content. They should be advised to sip drinks slowly, blood sugars should be closely monitored and medication changed if necessary. For queries about supplements suitable for patients with specific dietary requirements e.g. Halal, food allergies or vegan, please contact your local Dietetic Department. Page 9 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines A variety of other nutritional support products are available on prescription, however the nutritional content of these products varies considerably. Therefore they have not been included in the formulary and should be prescribed under the advice of a Registered Dietitian. They include: Specialised sip feeds (e.g. high protein sip feeds, 2 kcal/ml sip feeds) Semi-solid desserts High energy fat emulsions Soluble Glucose polymers Liquid and powder supplements, providing calories and protein Appendix 6 “Using a sip feed” This leaflet should be provided and discussed with all patients and/or their carers who require sip feeds. In particular highlighting the need to drink supplements slowly, to have them between meals and to feedback problems re compliance to the relevant health professional involved in their care 11. EDUCATION / TRAINING PROGRAMMES BAPEN have an excellent web site with free resources which can be down loaded for use in training on use of the MUST tool. http://www.bapen.org.uk/musttoolkit.html To discuss training opportunities please contact your relevant dietetic team: City and south of the County staff Nottingham Community Nutrition and Dietetic Service: 0115 8834327 Department of Nutrition and Dietetics City Hospital Campus Community Outreach team 0115 9691169 ext 54103 / 54008 North County staff: Nottinghamshire County Nutrition and Dietetic Service: 01623 676025 12. IMPLEMENTATION AND DISSEMINATION The guidelines will be available to view and download on the Nottinghamshire Area Prescribing Committee Website and via the routes for clinical guideline dissemination in each healthcare organisation. 13. MONITORING Audit Criteria Is there documented assessment of patient’s needs (MUST Tool) recorded in the medical records? Is there a record of the condition for which oral nutritional supplement prescribed? Has the oral nutritional supplement been prescribed for an approved condition? Is there an explicit nutritional goal/aim identified in the medical records? Is there a specified review interval? Is there evidence that review has been undertaken in relation to set goals/aims? Have first line dietary measures been tried (‘Little & Often’, food first) as well as prescribing oral nutritional supplements? Do prescriptions contain clear instructions about the dose and quantity to be used? Does the prescribing interval correlate with the intended frequency and quantity? Page 10 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines 14. EQUALITY AND DIVERSITY STATEMENT No impact on equality issues were identified using the Equality Assessment Tool for NHS Nottingham City, Nottingham CityCare or County Health Partnerships 15. REFERENCES AND ADDITIONAL SUPPORTING DOCUMENTS 1. NICE December 2012 Clinical Guideline Nutrition Support in Adults 2. British Association for Parenteral and Enteral Nutrition (BAPEN) (2008) Nutrition Screening Survey in the UK in 2008: Hospitals, care homes and mental health units 3. BAPEN (2005) The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements in adults 4. BAPEN (2009) ‘Combating Malnutrition’: Recommendations for Action 5. Pennington Lecture, Proceedings of the Nutrition Society (2007), 66, 522–529. Dr R. J. Stratton “Malnutrition: another health inequality?” 6. Managing Adult Malnutrition in the Community2012. Document produced by a multi professional consensus panel and endorsed by a wide range of professional bodies e.g. RCGP, BDA, RCN, PCPA, BAPWN, BPNG, PCSG, and RPS. N.B. This includes a pathway for the appropriate use of ONS, which mirrors the pathway in the Nottinghamshire Sip Feed Guidelines. 7. Elia M et al. The cost of disease-related malnutrition in the UK and economic considerations for the use of oral nutritional supplements (ONS) in adults. A report by BAPEN. 2005. 8. National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding principles on improving the systems and processes for ONS use. Paper 1: Title: Collins C.E, Kershaw J, Brockington S (2005) Effect of nutritional supplements on wound healing in home-nursed elderly: A randomized trial. Nutrition, 21: 147-155. Main findings: Home-nursed elderly with wounds represent a vulnerable population group in whom malnutrition is common. This group demonstrated a high acceptance of oral nutritional supplements. Improvements in some indicators of wound healing and cognition were observed in those who received the energy, protein and nutrient dense supplements. Paper 2: Title: Heyman H, Van De Looverbosch D.E.J, Meijer E.P, Schols J.M.G.A (2008) Benefits of an oral nutritional supplement on pressure ulcer healing in long-term care residents. Journal of Wound Care, 17 (11): 476-80. Main findings: After nine weeks the average pressure ulcer area significantly decreased. A high protein oral nutritional supplement enriched with arginine, vitamin C, vitamin E and zinc when used with standard pressure ulcer care significantly reduced the mean pressure ulcer area of long term nursing residents. Paper 4: Title: Schols J. Heyman, H., Meijer, EP., (2009), Nutritional support in the treatment and prevention of pressure ulcers: an overview of studies with an arginine enriched Oral Nutritional Supplement. Journal of Tissue Viability. Page 11 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Main findings: * Cubitan specific * A review of practice-based studies with the specific ONS specifically developed for patients with pressure ulcers show positive effects of ONS on pressure ulcer healing. In addition the ONS might potentially reduce the risk of developing pressure ulcers. Paper 5: Title: Faxen-Irving G, Andren-Olsson B, af Geijerstam A et al (2002). The effect of nutritional intervention in elderly subjects residing in group-living for the demented. Eur J Clin Nutr 56:221–227. 19. Main findings: Being underweight was common in those who had dementia and was related to low cognitive capacity. After five months of oral supplementation and education of the personnel the weight increased by about 3kg (6%) which was lost about nine months after the withdrawal of the liquid supplement. Paper 6: Title: Smith KL, Greenwood CE. Weight loss and nutritional considerations in Alzheimer disease. J Nutr Elder. 2008;27(3-4):381-403. Weight loss and nutritional considerations in Alzheimer disease. (Smith & Greenwood, 2008) Main findings: Supplementation is generally effective but tends to be least beneficial for those with the lowest body mass index. Paper 8: Title: Stratton R.J and Elia M (2007) A review of reviews: A new look at the evidence for oral nutritional supplements in clinical practice. Clinical Nutrition Supplements, 2: 5-23. Main findings: This review of reviews found largely consistent clinical benefits with oral nutritional supplements in meta-analysis of trials across patient groups. Benefits included significant reductions in mortality and complication, e.g. infections and pressure ulcers, particularly in acute settings and acutely ill geriatrics. Across reviews of all patient groups, oral nutritional supplements consistently improved total nutritional intake, with little suppression of food intake. In general, reviews indicated improvements in weight (weight gain or less weight loss) with oral nutritional supplements. Paper 9: Gary P. Hubbard, Marinous Elia, Anne Holdaway and Rebecca J Stratton 2011 Elsevier LTD and European Society for Clinical Nutrition and Metabolism A systemic review of compliance to oral nutritional supplements Main Findings: This systemic review suggests that compliance to ONS is good, especially with higher energy-density ONS, resulting in improvements in patients’ total energy intakes that have been linked with clinical benefits. Paper 10 Peter F Collins, Rebecca J Stratton and Marinous Elia. Nutritional support in chronic obstructive pulmonary disease: a systemic review and Meta analysis. American Journal of Clinical Nutrition 2012 Main findings: Conclusion: this systemic review and meta-analysis showed that nutritional support. Mainly in the form of ONS, improves total intake, anthropomorphic measures and grip strength in COPD. These results contrast with the results of previous analyses that were based on only cross-sectional measures at the end of intervention trials Paper 11 Floor Neelmaat, Judith E. Bosmans, Abel Thijs, Jaap C. Seidell, Marion A.E. van der Schueren Oral Nutritional support in malnourished elderly decreases functional limitations with no extra costs Page 12 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Main findings: Conclusions: A multi-component nutritional intervention for malnourished elderly patients for 3 months after hospital discharge led to significant improvement in functional limitations and is neutral in cost. Paper 12 Sharon Carey, Susie Ferrie, Jane Young, Margaret Allman-Farinelli 2011Long term nutritional support in gastrointestinal disease- A systemic review of the evidence Main findings Results; Overall evidence supports the use of ONS for improving outcomes such as weight, function, calorie intake and quality of life. Conclusion: there is strong evidence to support the use of ONS in a long term setting for gastrointestinal patients. Page 13 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 1 BAPEN Validated MUST tool Page 14 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 2 – Food and Fluid Check List Information from this will highlight problem areas and influence advice given to patient/carer. Name NHS number Do you eat? Please give details e.g. meal examples Breakfast Yes No Sometimes Lunch/midday meal Yes No Sometimes Tea/evening meal Yes No Sometimes Snacks between meals Yes No Sometimes Do you have a cooked meal daily? Yes No Sometimes Please give details e.g. who supplies or cooks the meals Do you have a drink? With every meal Between meals During the evening Please give details e.g. what type of drinks do you have? Do you use a cup or mug? Yes Yes Yes No No No Sometimes Sometimes Sometimes Do you have any difficulties eating? e.g. nausea, chewing and swallowing or dexterity problems Yes No Please give details e.g. texture modification, amount of assistance needed Are you on a therapeutic diet because of a medical problem? Yes No Please give details Are you taking any food, drink or vitamin supplements? (e.g. Complan, Build Up, Fortisip) Yes No Please give details Do you drink alcohol, if so how much in a week ………………………………………………….…..……………………………… ………………………..… Please give details Page 15 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 3. 2 Page Little and often Advice leaflet If you have lost weight unintentionally or have a small appetite it is important that what you do eat is as nourishing as possible. You will need to eat a variety of foods, choosing higher calorie options whenever you can. This information will give you ideas for food and drinks to have when your appetite is small and suggest ways to increase the amount of nourishment in your meals. Include the following each day 3 small meals + 2-3 snacks or milky drinks Bread, rice, pasta, cereal, chapatti or potatoes at each meal Meat, chicken, fish, eggs, cheese, yoghurt, nuts, lentils or beans twice a day Fruit, vegetables or fruit juice at each meal Use one pint of full cream milk each day or ½ pint of fortified milk ( see recipe below) 8 cups of fluid Adding extra nourishment to your food Fortified milk: mix 2 tablespoons of milk powder into half a pint of full cream milk. Use this fortified milk in place of ordinary milk or water to make up coffee, packet soup, condensed soup, sauces, mousses, milk puddings, porridge and other breakfast cereals. Breakfast Cereals: add one or more of the following - fortified or evaporated milk, cream, thick and creamy yoghurt, fresh or dried fruit, nuts, syrup, honey or sugar. If you have diabetes, please ask your dietitian or diabetes healthcare team before adding extra sugar, syrup and honey to foods and drinks. Soups and Sauces: add one or more of the following - grated or cream cheese, cream, milk powder, fortified or evaporated milk, crème fraîche, thick and creamy yoghurt, fried onions, margarine, butter, croutons, lentils or pasta. Potatoes and Vegetables: roasting potatoes and vegetables in olive, rapeseed or sunflower oil will provide more energy than boiling them. Or add one or more of the following to potatoes or vegetables - grated cheese, cream, milk based sauces, margarine, butter, mayonnaise, salad cream or fried onions. Puddings and cakes: add one or more of the following - cream, evaporated milk, crème fraîche, thick and creamy yoghurt, custard, ice cream, jam, honey, syrup, treacle, chocolate or fruit sauces, dried fruit. If you have diabetes, please ask your dietitian or diabetes healthcare team before adding extra sugar, jam, syrup, treacle, honey and chocolate or fruit sauces to foods and drinks. Using convenience foods such as frozen, chilled or packet ready meals can help if your appetite is affected by cooking smells or you are unable to stand for long periods of time. As well as considering food, other simple measures may help to stimulate your appetite. Fresh air, gentle exercise and eating in company may be helpful. Page 16 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines * Meal Ideas * Breakfast Porridge or other breakfast cereal with fortified milk and sugar and a glass of fruit juice. Cereal with full fat yoghurt and fresh or dried fruit. Toast, crumpets, croissants or bagel with extra butter, jam, marmalade, honey, lemon curd, chocolate spread, peanut butter, or spreading cheese, and a glass of fruit juice. Scrambled egg, fried bacon and tomato with buttered toast. Boiled, scrambled or poached egg with buttered toast and a glass of fruit juice. Light Meals Soup with a buttered bread roll. Make up condensed or packet soup with full cream milk, or add a swirl of cream or grated cheese to home made or tinned soup. Sandwiches or toasties filled with cheese, egg, meat or tinned fish with added mayonnaise, or salad cream, and salad (such as tomato, cucumber, beetroot or lettuce). Baked beans or tinned ravioli on buttered toast topped with grated cheese. Omelette (such as cheese and tomato, or ham and mushroom) with buttered bread. Macaroni cheese with extra cheese and sliced tomato. Jacket potato with lots of butter and fillings such as baked beans, tuna mayonnaise and sweetcorn, or cheesy coleslaw. Puddings Individual chilled desserts such as thick and creamy yoghurts, fromage frais, trifles, cheesecakes or mousses. Tinned fruit in syrup with evaporated milk, cream or ice cream. Fruit crumble with cream, custard or ice cream. Tinned or home made rice pudding. Sponge or tart with custard . Gateau with cream. Snack Ideas Crisps, nuts or dried fruit Crackers with cheese or dips with breadsticks or vegetable sticks Sausage rolls, bhajis or samosas Naan bread Toast, crumpets, bagels or teacakes with butter, peanut butter or cream cheese Breakfast cereals with fortified milk (good at any time) or cereal bars Chocolate or shortbread biscuits Ice creams - try chocolate bar ones for extra calories Cream or fruit cakes, muffins, doughnuts, scones with cream and jam Sweet or toffee flavoured popcorn Drinks Milky tea or coffee made using fortified milk, and sugar Fruit juice Smoothies Fruit squash Milky drinks e.g. full cream or fortified milk, flavoured milk drinks (strawberry, chocolate, or banana milk), hot chocolate, Horlicks®, Ovaltine®, Complan®, or Build Up® milkshakes If you have diabetes, please ask your dietitian or diabetes healthcare team before adding sugar cereal or having sugary, sweet snacks and drinks. Page 17 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 4 Supplement Pathway BMI kg/m² Score >30 obese >20 18.5 – 20 <18.5 =0 =0 =1 =2 Unplanned weight loss in past 3 months % Score <5 =0 5 – 10 =1 >10 =2 Score = Score = Patient has acute illness and there has been and is likely to be a significantly decreased nutritional intake for > 5 days Score 2 NB these criteria only apply to patients who have suffered a severe CVA traumatic brain injury or similar Score = 0 Total malnutrition risk MUST*score = Score 1 = medium risk score 2-3 = high risk Score 4 = Very high risk MUST calculator tool is available at www.bapen.org.uk/screening-for-malnutrition/must-calculator or on SystemOne Key points: 1. Food First - SIP feeds are supplements and should not usually be used as a substitute for food, MANAGING MEDIUM RISK PATIENTS MUST SCORE 1 Set treatment goal: e.g. prevent further weight loss/ promote weight gain, improve nutritional status and /or promote wound healing. Record ‘MUST’ score in patients’ notes. Read code 687C Check for underlying causes: e.g. control pain/nausea; treat any constipation/diarrhoea, check for medications that may affect appetite etc. Use the Food First approach. Talk through “Little & Often” sheets with patient and /or carer MANAGING HIGH RISK PATIENTS MUST SCORE 2 -3 As medium risk plus: MUST= 2 Recommend over the counter (not FP10) Complan, Build Up drinks etc and document agreed actions. Ensure useage and overall dietary intake is monitored either in own home or Care Home. If there is no improvement after 2-3 weeks OR MUST =3 Initiate 1 week’s trial prescription for Sip Feeds as detailed overleaf 1 x BD. N.B. patient should meet ACBS indications- see over Use milk based sip feeds in preference to juice based ones as these have a higher nutritional content Juice style can be used if patients dislike milky drinks, or cannot tolerate milk based varieties. N.B. Juice based sip feeds should only be used for patients with diabetes if their blood glucose levels can be adequately monitored and their medication adjusted appropriately. Talk through “Using a Sip feed” leaflet with patient and /or carer to improve compliance. If supplement is tolerated, arrange acute prescription for 1 month’s supply of preferred flavours, review 3 monthly. If a brand is not tolerated continue trialling different brands until a suitable supplement has been identified. MANAGING HIGH RISK PATIENTS MUST SCORE 4 + OR WITH STAGE 3-4 PRESSURE ULCERS As all above, plus refer for Specialist Dietetic Advice: CityCare area/South of the County - Nottingham Community Nutrition and Dietetic Service 0300 33 33 North of the County - Nottingham County Health Partnership Nutrition and Dietetic Service 01623 676025 The Dietitian will review the needs of the patient, provide them with specialist advice and support and update all relevant healthcare/ medical professionals involved in their care. When appropriate, the dietician will discharge the patient either to the referring health professional or to their GP for monitoring. ON GOING MANAGEMENT AND REVIEW If the treatment goal is achieved: Supplements should be reduced gradually to ensure progress is maintained. Continue to monitor for 3 months. If the treatment goal is not achieved: There will be some patients with long term conditions who will continue to have an on-going need for supplements as defined in the ACBS criteria. These patients should be reviewed every 3-4 months to ensure compliance. If necessary refer for Specialist Dietetic advice. Page 18 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 5 Sip feed formulary Specified ACBS indication conditions for the prescription of nutritional supplements are: Disease related malnutrition including - Head, neck and oesophageal tumours - Severe COPD – FEV1<30% and must score 2 or more - Patients with complex chronic conditions requiring specialised feeds Dysphagia related to: Stroke and other Neurological conditions e.g. MND, MS. Pre-operative preparation of malnourished patients Following Total Gastrectomy, Intractable malabsorbition, Proven Inflammatory bowel disease, Short bowel syndrome, Bowel fistulae Renal failure on CAPD or haemodialysis 1.5 Kcal/ml OR **2.4 Kcal Sip Feed Formulary Milk/Yoghurt style/ Fibre rich NB Flavour ranges may change Nutriplen ** Compact Sip feed, Vanilla, Strawberry Fortisip Bottle Neutral, Vanilla, Toffee, Orange, Strawberry, Banana, Tropical fruit, Chocolate Fortisip Compact ** Strawberry, Vanilla, Apricot, Banana, Mocha, Forest Fruit Fresubin Energy Vanilla, Strawberry, Chocolate, Blackcurrant, Banana, Neutral, Lemon, Tropical Fruits, Cappuccino Ensure Plus Milkshake Banana, Blackcurrant, Caramel, Chocolate, Coffee, Fruits of the Forest, style Neutral, Orange, Peach, Raspberry, Strawberry, Vanilla. (starter packs are available) Savoury version – Chicken mushroom Ensure compact ** Banana, Strawberry, Vanilla Resource Energy Apricot, Chocolate, Strawberry & Raspberry, Banana, Coffee, Vanilla Fortisip Yoghurt style Raspberry, Peach & Orange, Vanilla & Lemon Ensure plus yoghurt Strawberry swirl, Orchard peach, Pineapple twist, Orange burst Fresubin Energy Fibre Strawberry, Chocolate, Cherry, Caramel, Vanilla, Banana Fortisip MultiFibre Vanilla, Strawberry, Orange, Chocolate, Banana, Chicken Ensure Plus Fibre Banana, Chocolate, Forest Fruits, Raspberry, Strawberry, Vanilla Powder sachets Each sachet needs to be made up with 200 mls full cream milk Complan Shake Box contains 24 sachets of either: Vanilla, Strawberry, Chocolate, or Banana flavoured powder. (starter Fresubin Powder Extra Box contains 7 sachets of either Chocolate, Strawberry, Vanilla, Neutral. Aymes Shake Box contains 7 sachets of either Banana, Vanilla, Strawberry, Chocolate, Neutral. Ensure Shake Box contains 7 sachets of Banana, Vanilla, Strawberry or Chocolate Juice Style Should only be used for diabetic patients if their blood glucose levels can be adequately controlled Ensure Plus Juce Apple, Fruit punch, Grapefruit, Lemon & lime, Orange, Peach, Pineapple, Strawberry. Resource Fruit Apple, Pear & Cherry, Orange, Raspberry and Blackcurrant Fortijuce Blackcurrant, Forest Fruit, Orange, Lemon, Apple, Strawberry, Tropical Fresubin Jucy Apple, Orange Pineapple, Blackcurrant, Cherry Other prescribed Nutritional Supplements A variety of other nutritional support products are available on prescription, however the nutritional content of these products varies considerably. Therefore, they have not been included in the formulary and should be prescribed under the advice of a Registered Dietitian. They include: Specialised sip feeds (e.g. high protein sip feeds, 2 kcal/ml sip feeds, pre thickened sip feeds Milk shake powders Semi-solid deserts High energy fat emulsions Soluble glucose polymers Liquid and powder supplements, providing calories, protein and other micronutrients Page 19 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016 Nottinghamshire Oral Nutritional Supplement (sip feeds) Guidelines Appendix 6 – Using a Sip feed Using a sip feed…… Sip feeds are prescribable drinks that provide extra nourishment in an easy to take form. The following information contains ideas on how to make the most of them… Patients name ………………………………… Sip Feed ………………………… Number to take per day ……………………… Date for review …………………. The person recommending sip feeds should have provided information about how many bottles or sachets (which should be made up with full cream milk) to take each day. Drink sip feeds slowly, it should take 20 -30 minutes to drink one bottle Sip feeds are most effective if they are taken every day as prescribed. Take sip feeds after or between meals so they don’t put you off eating meals. Sip feeds should not replace ordinary food – meals and snacks should be eaten as well. If the sip feeds cannot be taken as prescribed or you think that they are no longer required, please contact the person who recommended them for more advice. Sip feeds come in many flavours – ask to try other flavours. Shake the bottle first before taking. Sip from the bottle or pour into a glass. Many sip feeds taste better chilled. Some can even be frozen to make ice-cream or ice-lollies for a delicious change. Sip feeds can be warmed but remember not to boil them. Try warmed chocolate, coffee or soup flavours. Sip feeds can be used in cooking. Companies producing sip feeds can usually provide recipe booklets. Storing your sip feed Some chemists will deliver sip feeds. Remember to ask when you hand in the prescription. Store sip feeds in a cool place. Do not store them next to radiators or other sources of heat. If you want chilled sip feeds, keep those needed for the next few days in the fridge. Once opened, store the sip feed in the fridge for up to 24 hr Page 20 of 20 Document Owner: Nottingham Community Nutrition and Dietetic Service Please see Section 15 for full references and further reading Date of Issue: July 2011 Approved by APC November 2013 Date of review: November 2016