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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. Page 1 of 12 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 Page 2 of 12 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. Page 3 of 12 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. Page 4 of 12 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 Page 5 of 12 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 Page 6 of 12 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 Page 7 of 12 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. Page 8 of 12 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. Page 9 of 12 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. Page 10 of 12 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. 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. Page 11 of 12 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. Page 12 of 12 NHS Gloucestershire Clinical Commissioning Group