Checked: 15-01-2016 by
vicky.ryan Next Review: 19-01-2018
Prescribing Oral Nutritional Supplemetns NS MOM
Scope of pathway - adults over 18 requiring oral nutritional support.
Malnutrition can often be very difficult to recognise, particularly in patients who are overweight or obese to start with. Malnutrition can happen very gradually, which can make it very difficult to spot in the early stages.
Some of the symptoms and signs to watch out for include:
Loss of appetite
Weight loss – clothes, rings, jewellery, dentures may become loose
Tiredness, loss of energy
Reduced ability to perform normal tasks
Reduced physical performance – for example, not being able to walk as far or as fast as usual
Altered mood – malnutrition can be associated with lethargy and depression
It is important to remember that some ONS prescriptions prescribed at discharge are for acute illness requiring short-term nutritional support. If these are to be continued it is important to confirm ongoing need by re-assessing Malnutrition Risk using the Malnutrition in Adults Pathway.
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Efforts are made to ensure the accuracy and agreement of these guidelines. However, we cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties
For any queries regarding referrals contact the SALT department at the NSCP Community Neuro Service: 01275 546561
NSCP SALT referral form is available as an EMIS template
anticipated rapid clinical deterioration to dietetics- refer to dietetics
If patient is unable to eat at all/ has severe dysphagia-refer to SALT
Unexpected weight loss (weight loss may be an indication of an underlying condition requiring medical investigation) - see Two Week Wait Information NSCCG guidelines
Treat any underlying conditions which may affect oral intake (e.g. nausea, vomiting, constipation, diarrhoea, low mood).
Check that the discharge information specifies the indication and expected duration for the ONS.
The product specified should comply with the BNSSG Formulary where possible.
Patients discharged from Weston General Hospital or Southmead Hospital:
GP's will receive a letter from the dietetic department about all patients discharged from hospital who have been under the care of the dietitian. This will outline the indication and duration for the ONS prescription.
If the GP does not receive a letter from the department within 1-2 weeks, then it is likely that the patient was not seen by a dietitian during their stay in the hospital. These patients should be reviewed by the GP so that a management plan can be formulated.
Bristol Hospital BRI:
If patients are discharged on an ONS and the dietitian has liaised with the prescribing discharge doctor, this will be added on to the discharge summary. However, some patients may also have been prescribed an ONS without dietetic input and this would also be added on to the discharge summary.
Local administrative information
For any queries for Weston General Hospital dietetics team: 01934 636304
For any queries for Southmead Hospital dietetics team: 0117 414 5428
For any queries for BRI dietetics: 0117 342 3030
Consider issuing 2-4 week, 'acute' prescriptions to give practices the opportunity to ensure whether patient is engaging with dietetic services and their management plan.
Where patients are identified as not engaging with dietetic services, practices should review the need for ONS by undertaking MUST score/ weight reviews (e.g. start assessment by following the Malnutrition in Adults Pathway on Map of Medicine).
It is important to remember that some ONS prescriptions that are prescribed at discharge are for acute illness requiring short-term nutritional support. If these are to be continued it is important to confirm on-going need by re-assessing Malnutrition Risk using the Malnutrition in Adults Pathway.
If details at discharge are inadequate to assess the appropriateness of continued ONS:
Consider issuing a 2-4 week, 'acute' Rx
Agree a review date in 4 weeks so that the MUST score can be assessed before issuing any further prescriptions, as patient may only require these short-term. It is recommended to document this date in the dosage instructions to prompt review of the ONS.
At review, follow the Malnutrition Risk Screening Pathway.
ONS are prescribable on an FP10 prescription if the following criteria is met:
Patient's MUST score is appropriate (2 or more) - see Malnutrition in Adults Pathway for more information
Patient's condition is Advisory Committee on Borderline Substances (ACBS) approved: disease-related malnutrition, intractable malabsorption, pre-operative preparation of patients who are undernourished, dysphagia, proven inflammatory bowel disease, following total gastrectomy, short bowel syndrome, bowel fistula.
In addition, ONS may assist in the treatment of pressure ulcers.
Set SMART goals and document these in the consultation notes so that they can be assessed at review: Specific: (e.g. weight gain, BMI within healthy range) Measurable: (e.g. kg, BMI, pressure ulcer grading) Achievable Realistic Timely
Note: Nutritional support should be cautiously introduced in people at high risk of developing refeeding problems (see 1.4.6 for criteria in NICE CG32 guidance) .