Prescribing Oral Nutritional Supplemetns

 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
• Poor concentration.

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

• BNSSG Formulary- 'Food First Advice':

http://www.bnssgformulary.nhs.uk/includes/documents/foodfirst.pdf

• BNSSG Formulary- Oral Nutrition:

https://www.bnssgformulary.nhs.uk/95-Nutrition/

• NICE CG32: Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition:

http://www.nice.org.uk/guidance/CG32

• BAPEN: Introduction to Malnutrition:

http://www.bapen.org.uk/about-malnutrition/introduction-to-malnutrition

• BAPEN: Introducing Malnutrition Universal Screening Tool (MUST):

http://www.bapen.org.uk/screening-for-malnutrition/must/introducing-must

• GMC Guidance for End of Life Care: clinically assisted nutrition and hydration:

http://www.gmc-uk.org/guidance/ethical_guidance/end_of_life_clinically_assisted_nutrition_and_hydration.asp

• Managing Adult Malnutrition in the Community:

http://www.malnutritionpathway.co.uk/

 ONS NSCCG sign off form

 https://www.bnssgformulary.nhs.uk/95-Nutrition/

 Patients receiving feeds through an enteral feeding tube are under the care of the Home Management Service at UHB.

Local administrative information

 Local administrative information

 
NSCP SALT referral form is available as an EMIS template

 Refer for:

• 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

• 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.

 See:  https://www.bnssgformulary.nhs.uk/95-Nutrition/

•  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) .

http://www.nice.org.uk/guidance/cg32/chapter/1-Guidance#oral-nutrition-support-in-hospital-and-the-community

Prescribing an ONS in the community should be in accordance with the BNSSG Formulary guidelines (see link below) and be prescribed in addition to Food First Advice: 

https://www.bnssgformulary.nhs.uk/95-Nutrition/

 https://www.bnssgformulary.nhs.uk/95-Nutrition/

 Once trialled, the GP must specify one preferred flavour for the patient and amend the prescription accordingly.

'Mixed flavour' prescriptions incur multiple dispensing fees and increase prescribing costs. As long as 1 flavour is specified, the flavour can always be changed every so often as preferred.

For on-going prescriptions, prescribe a maximum of 2-4 weeks supply to allow regular review.

 Document in consultation notes: MUST, weight, BMI, changes in condition affecting dietary intake and progress towards goals (e.g. stabilised weight loss, weight gain, improved oral intake, reduced MUST score, improved wellbeing).

• Reinforce dietary advice
• Add ONS on 'acute' to prevent uncontrolled repeats without monitoring
• Set review date with patient for monitoring of MUST Score/ weight to assess response
• Continue to monitor until goals achieved 

 Discontinue ONS when patient is stable and:

• Adequate oral intake is established
• Intervention targets are achieved and the individual is no longer at malnutrition risk (e.g. a MUST score below 2).

If tapering of discontinuation is preferred, consider decreasing supplements to 1 a day for 2-4 weeks and then stop ONS.

When ONS has been discontinued, re-assess malnutrition risk after 4 weeks and re-assess accordingly to clinical concern.

 Review Treatment Plan

Check that patient is compliant with ONS by considering:

• do they like the flavours prescribed?
• any flavours they don't like and don't take?
• do they drink the whole bottle/ glass?
• how many do they take each day and when?
• are they having any difficulties to swallow the drinks?

Reassess clinical condition and consider/ treat any underlying conditions which may affect oral intake (e.g. nausea, vomiting, constipation, diarrhoea, low mood, dysphagia, poor-fitting dentures).

Remember: weight loss may be an indication of an underlying condition requiring medical investigation.

 The Positive Steps referral form is available as an EMIS template

  The PCLS referral form is available as an EMIS template

 Refer patients who can attend an outpatient clinic in North Somerset to the Department of Nutrition and Dietetics at Weston General Hospital.

Refer patients who:

• have an eating disorder
• are unable to eat at all/have severe
  dysphagia
• have anticipated rapid clinical deterioration
• require a full nutritional assessment based on clinical judgement
• require specialist nutritional advice following diagnosis (e.g. renal disease, coeliac disease)
• supplements as a sole source of nutrition.

Local administrative information

 The WAHT Dietetic service referral form is available as an EMIS template

 Refer patients who meet the following referral criteria to the North Somerset Community Partnership Dietitians Team (with patient’s consent):

Patients aged 18 years or above who are housebound or living in a care home and who are at high risk of high malnutrition:

• MUST≥2
• Patients with a Grade 3-4 pressure sore

Local administrative information

 Refer to NSCP Dietetics Service via EMIS Managed Referrals

 Local administrative information

 The referral form for NSCP CTPLD is available as an EMIS template