Standards and Criteria - NICE



NICE Shared Learning Awards

Submission Title: Clinical and Cost Effective Prescribing of Oral Nutritional Supplements for Adults in the Community

Supporting Information:

1. Audit Standards & Criteria ………………………………………………………………………………………………………….Page 2-3

2. ‘Flow Chart for Prescribing ONS ……………………………………………………………………………………………………Page 4

3. Flow chart to aid review of patients currently prescribed ONS …………………………………………………………………Page 5

4. Procedure for prescribing oral nutritional supplement for adults in the community ………………………………………….Page 6-7

5. ONS Formulary Table ………………………………………………………………………………………………………………Page 8

Audit Standards & Criteria

▪ A standard describes the level of care we expect patients to receive

▪ A criterion is an explicit statement describing the area of care that is being measured

▪ For each criterion you will need to set compliance targets

▪ Exceptions: there may be acceptable reasons for not meeting the criteria, either due to unforeseen circumstances or to meet the individual clinical needs of the patient

|Standard |Criteria |Compliance |Exceptions |

|1. Patient documented to be at risk of |Risk of malnutrition is medium or high using the ‘MUST’ (malnutrition |100% |Where ONS have been requested under supervision of a Dietitian (should be documented |

|malnutrition using validated nutritional screening|universal screening tool) | |by Dietitian) |

|tool | | | |

|2. Patient documented to have been given verbal |The Leaflet “Build yourself up” / “food first” for improving nutrition or|100% |Where ONS have been requested under supervision of a Dietitian (should be documented |

|and/ or written “Build yourself up” advice to |appropriate alternative | |by Dietitian) |

|improve nutritional intake | | | |

|3. The indication for prescribing ONS is |ACBS criteria include short bowel syndrome, intractable malabsorption, |100% |Where ONS have been requested under supervision of a Dietitian (should be documented |

|documented |preoperative preparation of undernourished patients, proven inflammatory | |by Dietitian) |

| |bowel disease, total gastrectomy, bowel fistulas, and disease related | | |

| |malnutrition | | |

| | | | |

| | | | |

|4. The aims of treatment are documented when |Aims of treatment include weight maintenance or gain, improved |100% |Either documented in GP records or on Dietitian’s letter |

|starting ONS on prescription |nutritional intake, hydration, wound healing, pressure area care, | | |

| |improvements in psychological and / or physical health | | |

|5. The prescription is for 2 x 1.5kcal/ml ONS |Suitable products include Resouces Energy, Fortisip, Fresubin Energy, |100% |Where different ONS / products have been requested under supervision of a Dietitian. |

|daily or suitable alternative |Ensure Plus, Fortisip Multi-fibre, Fresubin Energy Fibre, Ensure Plus | |For patients with dysphagia, dessert-style supplements (Forticreme Complete, Fortisip|

| |Fibre, Fortisip Yoghurt Style, Ensure Plus Yoghurt Style, Fortijuce, | |Fruit Dessert, Fresubin Crème, Resource Energy Dessert, Resouce Fruit Dessert) are a |

| |Resource Fruit, Provide Extra, Ensure Plus Juce Style, Scandishake, | |suitable alternative. |

| |Calshake, Enshake, Complan Shake | | |

|6. The first prescription was for a 2 week trial |Sample pack (Ensure Commence, Fortisip Range, Enmix Plus Commence or |100% |Where ONS have been requested under supervision of a Dietitian (should be documented |

| |Ensure Plus Commence | |by Dietitian) |

|7. Each prescription is issued as “acute” |Repeat of batch prescribing not acceptable |100% |Where a longer duration of supplement use is indicated and has been documented with |

| | | |clear timescale for review. |

|8. Prescription includes clear directions for use |E.g. “one to be taken twice daily” or “twice daily between meals”. NOT |100% |None |

| |“as required” or “as directed” | | |

|9. Patient on prescribed ONS is reviewed monthly |To include weight, compliance with ONS, progress towards aims of |100% |Where patient is under regular review by a Dietitian (e.g. Dietitians letter |

|before further prescription is issued |treatment | |indicates planned follow up) |

|10. Aims of treatment and need for ONS reviewed |If improved, ONS are reduced or discontinued. If not improved, Dietitian |100% |Documented clinical reason for continuing ONS (e.g. further improvement / benefit |

|after 3 months |is contated for advice if appropriate | |anticipated) |

|11. Any patients for whom a Dietitian has |Letter or other communication details indication for ONS, patients |100% |Where the requesting Dietitian is employed other than NHS Swindon, GWH NHS |

|requested ONS on prescription should have |weight, aims of treatment, expected duration of treatment and follow up | |FoundationTrust, Wiltshire PCT |

|documented indication, aims of treatment, weight, |arrangements | | |

|expected duration of treatment and follow up | | | |

|arrangements from the Dietitian | | | |

Oral Nutritional Supplements (ONS) Flow Chart (Adults)

‘MUST’ Screening Score

Score 0 Score 1 Score 2+

Re-screen annually First line advice (food first) First line advice and

or on clinical concern Provide ‘Food First Booklet’ consider supplements

Encourage regular meals and nourishing snacks

Food fortification and nourishing drinks between meals

Encourage patient to monitor weight weekly

After a month

Is patient still losing weight?

No Yes

Encourage to continue with Consider nutritional supplements to have between

‘food first’ approach until weight meals – prescribe 2 a day initially

stable Provide booklet ‘Ideas for using Nutritional Supplements’

see ONS TABLE for products

1. Prescribe a starter pack to determine style and taste preferences.

2. Milky based liquid sip feeds i.e. milkshake style or yoghurt style, should be offered as a first choice.

3. If patient dislikes milky drinks consider a fruit juice based supplement

4. Does the patient prefer desserts, or require a semi-solid consistency. If yes, consider a supplement from the semi solid range – both milky based or fruit based dessert options available.

Monitor weight and compliance with supplements monthly

Does patient continue to lose weight?

Continue to monitor No Yes

weight until weight stable

Refer to Dietitian

Flow chart to aid review of patients currently prescribed [pic]

Oral Nutritional Supplements (ONS)

To be used to aid reviewing patients currently being prescribed ONS. To be done when a prescription for continued ONS is requested by the patient

‘MUST’ Screening Score

(Use Community Nutrition Screening Tool)

Procedure for Prescribing Oral Nutritional Supplements (ONS) for Adults in the Community

To be read in conjunction with the ‘ONS Flow Chart (Adults)’ and guide to oral nutritional supplements available on FP10 (ACBS)

• Patient’s must have been appropriately identified, by the use of nutritional screening tool (use Malnutrition Universal Screening Tool – MUST), as being nutritionally at risk and nutritional risk score (MUST Score) and weight must be documented in patient records.

• Patient’s with a nutritional risk (MUST Score) of 2 should be given first line dietary advice on improving their nutritional intake supported by the information booklet ‘Food First Information Booklet’ and little improvement in nutritional intake and status observed after 2 weeks (for high nutritional risk) or 4 weeks (for medium nutritional risk).

• Patient’s clinical condition should fall within the Advisory Committee on Borderline substances (ACBS) approved categories for prescribing nutritional supplements:

o Short Bowel Syndrome

o Intractable malabsorption

o Pre-operative preparation of undernourished patients

o Proven inflammatory bowel disease

o Following total gastrectomy

o Bowel fistulas

o Disease related malnutrition

Refer to BNF for more specific indications applicable to individual products (such as dysphagia and age related restrictions.

• Nutritional supplements should only be prescribed if conventional dietary intervention to improve nutritional status had failed, ‘Food First Information Booklet’ provided.

• The aim and expected outcome of using the nutritional supplement must be identified and recorded at the beginning of treatment e.g. to prevent further weight loss, increase weight, aid wound healing, improve oral intake, improve well being.

• When oral nutritional supplements (ONS) are indicated, all patients should be prescribed 2 x 1.5kcal supplements daily, unless otherwise advised by a Dietitian or if patient has been identified to be at risk of refeeding syndrome1. Refer to the guide to Oral nutritional supplements available on FP10 for a range of suitable supplements.

• The first prescription, to establish taste preferences, should be for no more than 2 weeks and marked mixed/assorted flavours and endorsed ‘ACBS’, excluding any flavours the patient does not wish to try (refer to ONS sip feed table for available flavours). Alternatively, starter/initiation packs are available on prescription from the following companies: Nutricia (Fortisip Range Starter Pack) and Abbott Nutrition (Enmix Plus Commence or Ensure Plus Commence). Refer to ‘ONS Table Adults’ or The guide to Nutritional Supplements available on FP10.

• Once the patient’s preferred choice of product and flavours has been established prescriptions should be provided MONTHLY and issued as ACUTE2.

• All patients should be reviewed monthly (weight, MUST score, nutritional intake and compliance) before further prescriptions are issued2 and until treatment aims are achieved3. Nutritional supplements should not be given as repeat medication unless there are exceptional circumstances.

• All prescriptions for oral nutritional supplements should have clear directions for use e.g. daily dose, timings (between meals) or incorporation into meals and how best served. ‘Ideas for using Nutritional Supplements’ booklet should be used as supporting information. Avoid using ‘use as directed’, ‘as required’ or ‘as needed’.

• All patients should be referred to a Dietitian for assessment if ‘disease specific’ or ‘macronutrient only’ supplements are indicated (refer to sip fed table).

• Where patients have been referred for dietietic assessment as an inpatient or in an outpatient clinic, and have commenced nutritional supplements as a result, the Dietitian should write to the GP within 2 weeks of patient’s discharge or outpatient appointment to advice concerning ongoing requirement for nutritional supplements and any follow-up arrangements.

• All other patients who are discharged from hospital on nutritional supplements not requested by a Dieititian should be reassessed to determine whether nutritional supplements are still indicated before a further a prescription is issued. The ‘Food First Information Booklet’ should be given if appropriate.

• All patients should discontinue oral nutritional supplements once treatment goals have been achieved3, or if advised by the Dietitian. Consider reducing nutritional supplements gradually at first e.g. daily for a designated time frame.

• If, after 3 months, patients are not progressing toward treatment goals, aims of treatment should be reassessed before continuing treatment.

1 Refer to NICE CG32 9p.19 of Quick Reference Guide) or contact Dietitian for advice on identifying and managing refeeding syndrome.

2 Repeat or batch prescriptions should be avoided as compliance can be difficult o monitor and unnecessary costs are incurred

3 Aims of treatment include weight maintenance or gain, improved nutritional intake, hydration, wound healing, pressure area care, improvements in psychological and/ or physical pain.

| | |

| | |

|Oral Nutritional Supplements (ONS) available on FP10 (ACBS) - August 2010 ONS TABLE (Adults) | |

| | | | | |

|Green = First Line|Blue - Second Line | | | |

| | | | | |

|Supplement |Product |Company |Flavours |Comments |

|Starter Packs |Fortisip Range Starter Pack |Nutricia |4 x Fortisip (Milkshake STYLE), 4 x Fortijuce (Juice Style), 2 x Fortisip Yogurt Style (Yogurt Style) |Intended as an initial |

| |(Milk, Juice & Yoghurt styles) | | |5-10 day supply to |

| |Ensure Plus Commence |Abbott Nutrition |10 Mixed Flavours (Milkshake Style) |assess preference |

| |(Milkshake Flavours) | |(Banana, Blackcurrent, Chocolate, Fruits of Forest, Neutral, Orange, Peach, Raspberry, Strawberry, Vanilla) | |

|Milkshake Style |Resource Energy |Nestle Nutrition |Apricot, Chocolate, Banana, Coffee, Vanilla, Strawberry/Raspberry |Nutritionally balanced |

|1.5kcal/ml |Fortisip |Nutricia |Strawberry, Banana, Chocolate, Toffee, Tropical Fruits, Neutral, Orange, Vanilla |Can be used for people |

| |Fresubin Energy |Fresenius Kabi |Vanilla, Strawberry, Blackcurrant, Chocolate, Neutral, Banana, Lemon, Cappuccino, Tropical Fruits |with diabetes if sipped |

| |Ensure Plus Milkshake Style |Abbott Nutrition |Neutral, Banana, Blackcurrant, Caramel, Chocolate, Coffee, Fruits of Forest, Orange, Peach, Raspberry, Strawberry, |slowly over 1/2 hour |

| | | |Vanilla | |

|High Fibre |Fortisip Multi-Fibre |Nutrica |Strawberry, Banana, Chocolate, Orange, Vanilla, Cream of Chicken, Cream of Tomato |Nutritionally balanced |

|Milkshake Style |Fresubin Energy Fibre |Fresenius Kabi |Vanilla, Strawberry, Chocolate, Banana, Cherry, Toffee-Caramel |May help maintain |

|1.5kcal/ml |Ensure Plus Fibre |Abbott Nutrition |Vanilla, Chocolate, Fruits of the Forest, Raspberry, Strawberry and Banana |normal bowel function |

|Yoghurt Style |Fortisip Yoghurt Style |Nutricia |Raspberry, Blackcurrant, Pineapple, Peach & Orange, Vanilla & Lemon |Nutritionally balanced |

|1.5kcal/ml |Ensure Plus Yogurt Style |Abbott Nutrition |Orange Burst, Orchard Peach, Pineapple Twist, Strawberry Swirl | |

|Fruit Juice Style |Fortijuce |Nutricia |Lemon & Lime, Peach & Orange, Forest Fruit, Apple & Pear, Blackcurrant, Apricot, Pineapple |Nutritionally incomplete |

|1.5kcal/ml |Resource Fruit |Nestle Nutrition |Apple, Orange, Pear-Cherry, Raspberry/Blackcurrant |in vitamins and minerals |

| |Provide Extra |Fresenius Kabi |Lemon & Lime, Cherry, Blackcurrent, Citrus Cola, Orange & Pineapple, Apple, Melon, Tomato, Carrot-Apple | |

| |Ensure Plus Juce Style |Abbott Nutrition |Apple, Fruit Punch, Grapefruit, Lemon and Lime, Orange, Peach, Pineapple, Strawberry | |

|High Protein |Fortisip Extra |Nutrica |Strawberry, Chocolate, Vanilla, Forest Fruits, Apricot, Mocha |Should be prescribed |

|Milkshake Style |Fortimel |Nutrica |Forest Fruits, Strawberry, Vanilla, Chocolate |post assessment |

| |Fresubin Protein Energy |Fresenius Kabi |Wild Strawberry, Vanilla, Chocolate, Neutral |by a Dietitian |

|Semi solid |Forticreme Complete |Nutricia |Chocolate, Banana, Forest Fruits, Vanilla |Suitable for patients |

| |Fortisip Fruit Dessert |Nutricia |Apple |with dyshagia |

| |Ensure Plus Crème |Abbott Nutrition |Banana, Chocolate, Vanilla, Neutral | |

| |Fresubin Creme |Fresenius Kabi |Wild Strawberry, Vanilla, Cappuccino, Chocolate, Praline | |

| |Resource Energy Dessert |Nestle Nutrition |Caramel, Chocolate, Vanilla | |

| |Resource Fruit Dessert |Nestle Nutrition |Apple, Apple-Strawberry, Apple-Peach | |

|Powdered |Scandishake |Nutricia |Unflavoured, Vanilla, Chocolate, Strawberry, Banana, Caramel |Nutritionally incomplete |

| |Calshake |Fresenius Kabi |Banana, Chocolate, Strawberry, Vanilla, Neutral |in vitamins and minerals |

|Use as prescribed |Enshake |Abbott Nutrition |Strawberry, Banana, Vanilla, Chocolate | |

|by Dietitian |Complan Shake |Complan Foods |Strawberry, Vanilla, Chocolate, Banana, Milk |Advised to make with |

| | | | |full cream milk |

| | | | | |

|Disease Specific |ProSure (Abbott Laboratories); Forticare (Nutricia); Resource Support (Nestle Nutrition); Elemental 028 (SHS); E028 Extra (SHS) |Use as prescribed |

|Supplements |Modulen (Nestle); Renilon (Abbott Nutrition); Nepro (Abbott Nutrition); Suplena (Abbott Nutrition) |by Dietitian |

|Macro-nutrient |Polyal, Caloreen, Polycose, Vita-joule, Duocal, Maxijule, Calogen, Liquigen, Protifar, Vita-pro, Pro-Cal Shot, Vita-savoury, Quick cal | |

|Supplements | | | | |

|Document created by: Natalie Kominek and Kate Ashman, Community Dietitians. Nutrition and Dietetic Department, GWH. |

|Tel: 01793 605149 |

|Aug-10 |

-----------------------

1.

[pic]

Score 0

With the patient’s left arm hanging loose, measure around the upper arm at the marked mid-point. Ensure that the tape measure is snug, but not tight. Decontaminate tape measure after use.

If MUAC is less than 23.5cm, BMI is likely to be less than 20kg/m2

If MUAC is greater than 32.0cm, BMI is likely to be greater than 30kg/m2

[pic]

[pic]

Bend the patient’s left arm at the elbow at a 90 degree angle with the upper arm held parallel to the side of the body. Measure the distance between the bony protrusion on the shoulder (acromion) and the point of the elbow (olecranon process) Mark the mid-point.

Measure between the point of the elbow (olecranon process) and the midpoint of the prominent bone of the wrist (styloid process) (left side if possible).

Decontaminate tape measure after use.

[pic]

[pic]

[pic]

Score 2+

Score 1

-Negotiate with patient and stop ONS.

-Discuss with patient and explain ONS are not needed any more due to patient having a normal BMI, and minimal or no weight loss within the last 3-6 months

-Re-screen annually or on clinical concern

-Make sure ONS – 2x 1.5kcal/ml (unless recommended by Dietitian)

-Use Formulary and Prescribing Guidelines for appropriate prescribing

- Change ONS prescription to monthly Acute

-Provide ‘Food First Booklet’

Encourage regular meals and nourishing snacks

Food fortification and nourishing drinks between meals

Encourage patient to monitor weight weekly

-Provide booklet ‘Ideas for using Nutritional Supplements’

-Negotiate with patient and stop ONS

-First line advice (food first)

-Provide ‘Food First Booklet’:

Encourage regular meals and nourishing snacks

Food fortification and nourishing drinks between meals

Encourage patient to monitor weight weekly

Refer to Dietitian

After a month – is patient still losing weight?

Yes

Follow Score 2+ Management guidelines

No

Is patient still losing weight?

No

Yes

Link to ‘MUST’, booklets, ONS formulary, flow chart, guidelines for prescribing ONS under 9.4.2 Enteral Nutrition

Document created by: Kate Ashman and Natalie Kominek Community Dietitians

Tel: 01793605149

May 2010 Updated November 2010

Monitor weight and compliance with supplements monthly

Continue to monitor weight until weight stable

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