Download Prescribing Sip Feeds In Adults A Guide to Nutritional Screening

Prescribing Sip Feeds In Adults
A Guide to Nutritional Screening and Appropriate
NHS Prescribing of Oral Nutritional Supplements
Produced in consultation with GHT Department of Nutrition and Dietetics
Date of Publication: Oct 2013
Review Due Date: Oct 2015
This guidance is available online at the Gloucestershire ‘CCG Live’ intranet site in the section:
Clinical Support/Medicines Management/Prescribing Guidance.
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NHS Gloucestershire Clinical Commissioning Group
Purpose of this Guidance
During the financial year 2012-2013 sip feeds prescribed in primary care cost the NHS more than
£1 million. The purpose of this guidance is ensure that Oral Nutritional Supplements (ONS) are
prescribed appropriately and cost effectively.
Using this guidance will ensure that:
 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 be prescribed flavours and forms of nutritional supplement that are acceptable to
that patient.
 Repeat prescriptions are not generated without regular review.
 Waste will be minimised.
Key questions this guidance answers are:
1) Is the patient suffering from malnutrition?
2) If yes, how can the patient obtain nutrition without the need for sips feeds?
3) IF the patient is indicated for sips on the NHS – what are the most cost effective choices?
This guidance recommends that patients prescribed sips feeds are reviewed every 28 days and
therefore repeat prescriptions are not indicated.
How to Use This Guidance:
These guidelines have been written to use alongside the Malnutrition Universal Screening
Tool ‘MUST’ (Appendix 1). Follow the flow chart on Page 3, and refer to the supporting
information to assist with the use of the flow chart.
Contents:
Flow chart guidance on the appropriate prescribing of sip feeds
 Supporting information
 Screening for malnutrition
 Assessment of any underlying causes
 Food first
 Treatment goals
 Prescribing advice
Sip Feed product choices
Further information and references
 MUST – Malnutrition Universal Screening Tool
 NICE clinical guidelines
 ACBS NHS prescribing guidance
 Local advice contacts
Patient/Carer/Homes information
 Food First Advice
 Nourishing Snack Ideas
 Food Boosters for diet fortification
 Nourishing drink recipes
 Making the most of sip feeds
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NHS Gloucestershire Clinical Commissioning Group
Screen Adult patients for Malnutrition using MUST
Step 1: BMI score + Step 2: weight loss score + Step 3: acute disease score
= Step 4 Overall risk of malnutrition (see Appendix 1)
Patient identified At Risk of Malnutrition: MUST Score = 1 or More
No
Yes


Assess & investigate any underlying causes.
Assess medical issues, side effects of medications, oral health or
swallowing problems, social issues, mental health issues which may
affect nutritional intake.
Monitor adequacy of food and fluid intake.
Is support from other services required?
Yes
Routine Screening
Care Home – Monthly
Community – annually
or upon clinical concern
No
Give First Line Dietary Advice: Use first line dietary advice (Appendix 2) to improve intake - see patient
information leaflet. Agree and document aims of treatment.
After 2 weeks (high risk) - 4 weeks (medium risk) evaluate & review goals of treatment:
Use MUST score to evaluate if first line dietary advice is promoting weight gain &/or improving oral intake.
No improvement
Loosing weight/intake
remains poor
Is nutritional support of
benefit to the patient?
No
Improvement
Improving intake &/or weight stable.
Monitor and repeat MUST screening:
 Medium Risk (Score 1): after 1 month in care homes
and after 2 – 3 months in the community
 High Risk (Score 2+): after 1 week in care homes and
after 1 month in the community.
Have aims been achieved?
Yes
Does the patient meet ACBS criteria? (see page 6) Consider using sip feeds in addition to first line
dietary advice.
Select 1.5kcal/ml sip feed depending on patient preference. E.g. juice/milk/yoghurt style. Provide a 7 day
trial (2 per day). Specify mixed flavours on prescription or prescribe a starter pack. See attached Sip Feed menu.
After one week: Review patient tolerance and preference for sip feeds
If tolerated provide a 28 day prescription of 2 per day in addition to meals and snacks. Indicate the dose
to be taken daily. N.B - An increased number of sip feeds may be required if patients dietary intake is
very poor and/or nutritional requirements are very high – seek dietetic advice.
Monitor weight, food and fluid intake monthly using MUST and check tolerance of sip feeds. Patient is
reviewed every 28 days therefore repeat prescriptions are not appropriate.
No improvement
No
Improvement
Reduce sip feeds gradually and continue to
monitor for at least 3 months after stopping
Has target weight or aim of therapy been
achieved?
Refer to other services
 Consider referral to community based services or specialist team if support from these services will
address underlying cause for weight loss.
 Consider referral to dietitian: if patient has complex nutritional needs, patient remains on sip feeds
for more than 3 months or care pathway has been followed and goals of treatment are not being
met. Unless detrimental or no benefit is expected from nutritional support.
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NHS Gloucestershire Clinical Commissioning Group
Yes
Supporting Information
1. Screening for Malnutrition: Refer to Appendix 1 for BMI and weight loss ready reckoner charts with
accompanying MUST tool (www.bapen.org.uk/must_tool.html). Risk score and weight should be documented in
patient records.
You may also need to assess overall malnutrition risk subjectively and estimate a malnutrition risk score based on
your evaluation:
 If unable to assess BMI – use clinical impression to establish if an individual is thin, an acceptable weight
or overweight. Obvious wasting (very thin) and obesity (very overweight) can be noted.
 If unable to assess weight – use subjective observation. This can include checking for signs of weight
loss e.g. do clothes appear loose? Have previously fitting rings/watches/dentures become loose? Do arms
and legs look wasted? Is there a history of reduced food intake/appetite over 3 - 6 months?
 Consider increased nutritional needs – nutritional requirements are usually increased following a recent
trauma e.g. head injury, major surgery, if patient has sepsis, active cancer or any underlying disease
affecting absorption
Important: All patients recently discharged from hospital on sip feeds that have not been requested by a
dietitian should be re-assessed for nutritional risk using the screening flow chart to determine whether they
are still indicated before a further prescription is issued.
2. Assess & investigate any underlying causes:









Oral health and swallowing problems - refer to Dentist or to Speech and Language Therapist for swallowing
assessment.
Visual problems affecting cooking and feeding skills - refer to Optician.
Altered taste and smell - check medications or investigate potential underlying problem.
Reduced mobility and difficulty preparing, eating or handling food- refer to Occupational Therapist
Poor positioning - refer to Physiotherapist
Underlying medical cause/complication - investigate cause and treat
Disease states with nutritional implication - follow nutrition action flow chart and refer to Dietician
Social Situation - refer to Social Services for signposting advice or assessment
Poly-pharmacy - clinical medication/medicines use review
Monitor adequacy of food and fluid - Encourage patient / carer to record meals/snacks and drinks for 3 days or
take 24 hour recall if more appropriate. If intake is poor (less than half of all meals and snacks eaten) and
unintentional weight loss continues treat as high risk.
3. Food First Approach:
Provide patients with first line dietary advice on improving their nutritional intake supported by the Food First
information leaflets (Appendix 2) advising them to:
 Increase their intake by use of 3 small meals and 2 – 3 nourishing snacks daily
 Use 1 pint of full fat milk enriched to make nourishing drinks e.g. homemade milkshakes, hot chocolate
 Enrich one dish at each meal to provide extra energy to their diet
4. Agree and document goals of treatment:
E.g. weight maintenance or gain, improve calorific value of food, hydration, wound healing, and pressure area care
NB: Caution is required in patients that have eaten little or nothing for 5 days or more as they are at a greater risk of
developing re-feeding syndrome (see hospital policy
http://ghnhst/C10/C6/Departmental/Policy%20Library%20Pages/Nutrition%20and%20Dietetics%20Policy%20Index.aspx ).
5. Prescribing Sip Feeds – If there is little improvement in nutritional intake and patient is not
maintaining/gaining weight following first line dietary advice after 2 weeks (high risk) or 4 weeks (medium risk) and
meets the ACBS criteria consider prescribing sip feeds. Use the Sip Feed Menu on page 5 to help the patient to
choose styles and flavours that appeal to them, with the first choice local recommendation being Fresubin Powder
Extra. Start with a 7 day trial. If sip feeds are tolerated prescribe a further 28 days acute script. Review the patient’s
weight and progress every 28 days and offer a choice of products from the menu at each review. Repeat
prescriptions are not appropriate.
6. Refer to other Services: If there is no improvement in patient’s nutritional status after following this process
consider referring the patient to either an appropriate specialist team – see point 2 - or to a dietitian.
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NHS Gloucestershire Clinical Commissioning Group
Primary Care Formulary Sip Feed Choices
The products listed in the below table are recommended as choices of supplement. These all
provide 1.5 -1.7kcal/mL and are nutritionally complete.
For general use, the Gloucestershire recommended first sip feed for general use in
primary care when necessary (vs ‘food first’) are the powdered products:
Fresubin Powder Extra
www.fresubinpowderextra.co.uk
80p per sachet in boxes of 7 x 62g
Volume 240ml after addition of 200ml of whole milk.
Flavours available: Neutral, Vanilla, Strawberry, Chocolate
Starter pack contains 2 sachets of each flavour + shaker.
The Fresubin Powder Extra starter pack (includes shaker) is NOT currently prescribable on FP10. It is sent
to the patient free of charge to the NHS if the prescriber registers the patients name and address online at
www.fresubinpowderextra.co.uk for a starter pack delivery .Consent should be obtained from the patient
before passing the patients name and address outside the NHS for their starter pack delivery.
Complan
Shake
95p per sachet in boxes of 4 x 57g
Volume 237ml after addition of 200ml whole milk.
Flavours available: Original, Vanilla, Strawberry, Chocolate, Banana
Starter pack (FP10 prescribable) contains 5 sachets assorted flavours + shaker
Both the above products require patients to add their own milk and are significantly lower
cost than readymade sip feeds.
Alternative choices if the above products are not suitable:
Milkshake Style
Juice Style
Yogurt Style
Savoury Style
Drinks
Fresubin Energy
Drink 200ml
£1.97
Fresubin
Jucy Drink
£1.82
Fresubin
Yo-Crème
£1.87
Fortisip Bottle
200ml
£1.98
Ensure Plus
Milkshake Style
220ml
£2.02
Resource Energy
200ml
£7.30 per pack of
4 (£1.92 each)
Fortijuce
200ml
£1.94
Ensure Plus
Juce 220ml
£1.97
Fortisip Yoghurt
Style 200ml
£2.02
Ensure Plus
Yoghurt Style
220ml
£2.02
Ensure Plus
Savoury 220ml
£2.02
Containing
Fibre
Fresubin
Energy Fibre
Drink 200ml
£1.98
Fortisip Multi
Fibre 200ml
£2.09
Ensure Plus
Fibre 200ml
£2.02
Prices correct September 2013.
N.B. Juice Style sip feeds are not nutritionally complete but may be an option for patients who do
not like milk or have taste fatigue with milk-based sip feeds.
Other Supplements Available on Prescription
There are other powders, liquids and desserts available on prescription such as Calshake,
Enshake, Resource Dessert, Fortisip Compact, Fresubin 5kcal shot, Calogen and Pro Cal. These
products are not always nutritionally complete and should therefore only be used in accordance
with specialist Dietetic advice
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NHS Gloucestershire Clinical Commissioning Group
Further Information and References
1. MUST – Malnutrition Universal Screening Tool (Appendix 1)
Nutrition screening is the first step in identifying patients who may be at risk of malnutrition and
benefit from nutrition intervention. Early detection is essential to highlight those at risk of
malnutrition and to improve their health status.
Remember to consider overweight/obese adults may also be at risk of malnutrition – plan care in
line with MUST score.
The Malnutrition Universal Screening Tool (MUST) is a five-step, clinically validated screening tool
that can be used to identify adults who are malnourished, at risk of malnutrition (undernutrition) or
obese. It has been evaluated for use with all adult patent groups across all care settings –
hospitals, care homes and in the community by GPs and practice nurses.
The evidence base for MUST is summarised in the MUST Report and Explanatory Booklet, copies
of both are available at www.bapen.org.uk
2. NICE Clinical Guidance 32 Nutritional Support for Adults February 2006 available at
www.nice.org.uk states that:
Considered nutritional support for people who are malnourished, as defined by any of the
following:
 A body mass index (BMI) of less than 18.5 kg/m2
 Unintentional weight loss greater than 10% within the last 3–6 months
 A BMI of less than 20 kg/m2 and unintentional weight loss greater than 5% within the last
3–6 months.
Or
For people at risk of becoming malnourished as defined by any of the following:
 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.
3. Who should be screened?
All new care homes residents, all new patients at GP surgeries, older people (especially those
70+), those with chronic neurological conditions, mental illness, stroke, inflammatory bowel
disease, cancer, respiratory disease and those recently discharged from hospital.
Patients of clinical concern include those with: unexplained weight loss, fragile skin, poor wound
healing, apathy, muscle wasting, poor appetite, impaired swallowing and loose fitting clothes/rings.
4. Department of Health 2001 Essence of Care:
A tool to help practitioners take a patient-focused and structured approach to sharing and
comparing their practice. Patients, carers and professionals worked together to agree and
describe good quality care and best practice. This resulted in benchmarks covering eight areas of
care: one of which is food and nutrition. Further information is available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH
_4005475
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NHS Gloucestershire Clinical Commissioning Group
5. The Caroline Walker Trust: Eating Well for Older People (Second edition, 2004).
Provides practical and nutritional guidelines for older people in residential and community care and
is available at: www.cwt.org.uk
6. The Advisory Committee on Borderline Substances (ACBS)
The Drug Tariff part XV – borderline substances (http://www.nhsbsa.nhs.uk/924.aspx) states that
in certain conditions some foods have characteristics of drugs. The circumstance in which such
substances may be regarded as drugs is advised by the ACBS. An alphabetical index of these
products is listed along with a list of the conditions for which each is suitable.
The Drug Tariff reminds General Practitioners that the ACBS recommends products on the basis
that they may be regarded as drugs for the treatment of specified conditions. Doctors should
satisfy themselves that the products can be safely prescribed, that patients are adequately
monitored and that, where necessary, expert hospital supervision is available.
An example of the Drug Tariff entry for ENSURE liquid nutrition is below:
ENSURE
As a necessary nutritional supplement prescribed on medical grounds for:
Disease-related malnutrition, intractable malasorption, total gastrectomy, proven inflammatory
bowel disease, and pre-operative preparation of patients who are undernourished. Not to be
prescribed for any child under two years; use with caution for young children up to five years of
age.
For More Specialist Advice
Contact details for the GHT Dietitians:
Department of Nutrition and Dietetics
Beacon House
Gloucestershire Royal Hospital
Great Western Road
Gloucester
GL1 3NN
Phone: 0300 422 5506
Fax: 0300 422 6457
Department of Nutrition and Dietetics
Cheltenham General Hospital
Sandford Road
Cheltenham
GL53 7AN
Phone: 0300 422 3460
Fax: 0300 422 4494
Contact Details for the Medicines Management Team:
NHS Gloucestershire Clinical Commissioning Group
Sanger House
5220 Valiant Court
Gloucester Business Park
Brockworth
GLOUCESTER
GL3 4FE
Phone: 0300 422 1982
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NHS Gloucestershire Clinical Commissioning Group
Appendix 2
Food First Advice
Tips to help make the most of your food
If you have lost weight or have a poor appetite, it is important to make the most of
the food and drink you are taking. The tips below contain ideas for nourishing
snacks, drinks and ideas to help you gain weight or prevent further weight loss.
 Always try to eat full fat and full sugar products.
 Eat when you feel the need to rather than having set meal times,
see ‘nourishing snacks’ for ideas.
 Try to have small and frequent meals and nourishing snacks by
taking something every 2-3 hours.
 Make the most of times when you feel hungry. If this is in the
morning try having a cooked breakfast
 If you are unable to manage a meal try having a nourishing drink
instead e.g. hot chocolate, milkshake, milky coffee and malted milk.
 Try not to fill up on drinks in between or with meals instead of eating
nourishing foods.
 As well as food, think about other ways to help stimulate your
appetite. A small glass of alcohol half an hour before meals may
help to improve the appetite (if appropriate, check with your doctor
first). Fresh air may also help or eating in company
 Take your time to relax and enjoy your meals rather than rushing them.
If you need more detailed advice or if you are following a special diet that makes it
difficult to make these changes, please ask your doctor to refer you to a registered
dietitian.
If you have been advised to have thickened fluids or modified texture diet by a Speech and
Language Therapist please continue.
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NHS Gloucestershire Clinical Commissioning Group
Nourishing Snack Ideas
Try to eat two to three nourishing snacks between meals each day.
 Bowl of cereal/porridge made with milk or fortified milk and sugar.
 Cheese, baked beans or sardines on toast.
 Cheese and crackers
 Sandwiches of tuna and cucumber, cheese and tomato, ham and pickle.
 Bowl of creamy soup and a roll.
 Peanut butter on toast
 Scones, toasted teacakes, crumpets or muffins. Top with butter, jam,
honey, cheese or cream.
 Danish pastry, doughnut, individual bakewell tart/fruit pie
 All cakes, such as fruit cake, flapjack, sponge cake and cream cakes, malt
loaf.
 2-3 biscuits – shortbread, cream or chocolate biscuits or plain biscuits with
butter/margarine
 Nuts, any type, or mixed fruit and nuts.
 Crisps and dips
 Milkshake. Try adding fresh fruit and icecream for a “thick shake”
 Malted drink made with milk and 2-3 plain biscuits
 Individual desserts such as trifle, crème caramel, rice pudding, milk jellies,
thick and creamy yoghurt, egg custard, fromage frais, mousse, fruit fool,
cheese cake
 Mini pies, sausage roll, pizza slice
Use generous amounts of butter/margarine on snacks
If you have been advised to have thickened fluids or modified texture diet by a Speech and
Language Therapist please continue.
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NHS Gloucestershire Clinical Commissioning Group
Food Boosters: Fortifying your diet
If you have a poor appetite and have lost weight you may find the following ideas helpful on making small
additions of everyday foods to fortify meals, snacks and drinks to increase your energy intake.
Food
Portion
Ideas to increasing calories
Full cream
milk
1 pint
Add 4-5 tablespoons of dried milk powder
– mix milk powder with some milk to make
a runny paste and add to the remainder of
the pint. Use to make up condensed or
packet soups, in blancmange, milk jellies,
cheese sauce, white or savoury sauces
Custard
1 ladle
(125ml)
Soup
1 ladle
(125ml)
Porridge
Calories
before
Calories
after
375
630
Add 1 heaped tablespoon of milk powder
and 2 tablespoons of double cream to
custard made with full cream milk
140
270
Add 1 heaped tablespoon of milk powder
and 2 tablespoons of double cream. You
could also add grated cheese.
80
350
Add 1 heaped tablespoon of milk powder
and 2 tablespoons of double cream to
porridge made with full cream milk
170
440
Mashed
potato
1 scoop
Add an extra teaspoon of margarine or
butter and 1 tablespoon of double cream
to mashed potato.
70
250
Vegetables
2
tablespoons
Add 1 teaspoon of margarine or butter to
vegetables and allow to melt.
15
90
Ice-cream
1 scoop
Pour 2 tablespoons of double cream over
the ice-cream
115
335
Sponge
pudding/cake
2
tablespoons
Place an extra 2 teaspoons of jam or
syrup on the sponge when serving. Then
serve with fortified custard or ice-cream
425
525
Small serving Use fortified milk and add 2 teaspoons of
(25g)
sugar and perhaps 2 tablespoons of
double cream
195
465
195
465
Breakfast
cereal
Milk puddings
1 ladle
(125mls)
Add 1 heaped tablespoons of milk powder
and 2 tablespoons of double cream to the
milk pudding made with full cream milk
If you have been advised to have thickened fluids or modified texture diet by a Speech and
Language Therapist please continue.
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NHS Gloucestershire Clinical Commissioning Group
Try These Nourishing Drinks
Nourishing coffee • 350 calories per serving
• 150mls milk
• 1 heaped tablespoon milk powder
• 1 teaspoon coffee powder
• 2 tablespoons of cream
Nourishing drink • 450 calories per serving
• 150mls milk
• 1 heaped tablespoon milk powder
• 3 teaspoons of malted drink powder e.g. Ovaltine or Horlicks
• 2 tablespoons of cream
Nourishing Cup-a-Soup • 300 calories per serving
• 200mls milk
• 1 heaped tablespoon milk powder
• 1 packet of Cup-a-Soup
Nourishing hot chocolate • 450 calories per serving
• 150mls milk
• 1 heaped tablespoon milk powder
• 2 tablespoons cream
Homemade Milkshake • 300 calories per serving
• 200mls milk
• 2 heaped tablespoons milk powder
• Milkshake syrup or powder to taste
Pineapple or banana yoghurt drink • 300 calories per serving
• 300mls milk
• 1 heaped tablespoon milk powder
• 1 pot (150g) thick and creamy yoghurt
• 3 pineapple rings or 1 ripe banana
• Liquidise all the ingredients and serve chilled.
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Tips for adding extra calories:
Always use full cream milk
Always use double cream or whipping cream
Mix milk powder to a runny paste with milk or cream to help it mix well
Add 1 scoop of ice-cream to cold drinks
There are many high calorie nourishing drinks which can be bought at most chemists or
supermarkets. For example Build Up, Complan or shop own brand are useful options
If you find recipes to creamy replace 1 tablespoon of cream with 4 tablespoons of full
cream milk
Information for diabetics: use sugar free milkshake syrup for milkshakes and Highlights or
Options to make hot chocolate.
If you have been advised to have thickened fluids or modified texture diet by a Speech and
Language Therapist please continue.
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NHS Gloucestershire Clinical Commissioning Group
Make the most of your sip feed
Below are some ideas to help you to enjoy and make the most of the sip feed you
have been prescribed.
 Sip feeds should not normally replace meals but should be taken in
addition to meals.
 Continue to eat as much food or snacks as you can and take your sip
feeds between meals.
 Sip feeds can be used to make various meals and snacks. Ideas and
recipes are available on the websites of the companies that make
these products.
 Sip feeds are versatile and are available in a variety of styles and
flavours.
 Neutral flavoured sip feeds can be used instead of milk to make for
example: Porridge, Milk puddings, Custard, Rice pudding, Sweet or
savoury sauces
 Neutral sip feeds can be flavoured for example with coffee, cocoa or
other flavourings.
 Savoury sip feeds such as chicken or mushroom flavours are best
served heated and taken as a soup or warm drink. Make sure it does
not boil.
 Sweet flavoured sip feeds are best served chilled. They can also be
frozen to make ice cream or can be served hot. Make sure it does not
boil.
 Fruit juice type sip feeds can be frozen into ice cubes or ice lollies.
They can also be diluted with, for example, lemonade as long as the
full amount of the sip feed is taken during the day.
 Sip feeds may be sipped in small amounts through the day or taken as
a whole drink.
If you have been advised to have thickened fluids or modified texture diet by a Speech and
Language Therapist please continue.
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NHS Gloucestershire Clinical Commissioning Group