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 malnutrition using validated nutritional screening tool / Risk of malnutrition is medium or high using the ‘MUST’ (malnutrition universal screening tool) / 100% / Where ONS have been requested under supervision of a Dietitian (should be documented by Dietitian)
2. Patient documented to have been given verbal and/ or written “Build yourself up” advice to improve nutritional intake / The Leaflet “Build yourself up” / “food first” for improving nutrition or appropriate alternative / 100% / Where ONS have been requested under supervision of a Dietitian (should be documented by Dietitian)
3. The indication for prescribing ONS is documented / ACBS criteria include short bowel syndrome, intractable malabsorption, preoperative preparation of undernourished patients, proven inflammatory bowel disease, total gastrectomy, bowel fistulas, and disease related malnutrition / 100% / Where ONS have been requested under supervision of a Dietitian (should be documented by Dietitian)
4. The aims of treatment are documented when starting ONS on prescription / Aims of treatment include weight maintenance or gain, improved nutritional intake, hydration, wound healing, pressure area care, improvements in psychological and / or physical health / 100% / Either documented in GP records or on Dietitian’s letter
5. The prescription is for 2 x 1.5kcal/ml ONS daily or suitable alternative / Suitable products include Resouces Energy, Fortisip, Fresubin Energy, Ensure Plus, Fortisip Multi-fibre, Fresubin Energy Fibre, Ensure Plus Fibre, Fortisip Yoghurt Style, Ensure Plus Yoghurt Style, Fortijuce, Resource Fruit, Provide Extra, Ensure Plus Juce Style, Scandishake, Calshake, Enshake, Complan Shake / 100% / Where different ONS / products have been requested under supervision of a Dietitian. For patients with dysphagia, dessert-style supplements (Forticreme Complete, Fortisip Fruit Dessert, Fresubin Crème, Resource Energy Dessert, Resouce Fruit Dessert) are a suitable alternative.
6. The first prescription was for a 2 week trial / Sample pack (Ensure Commence, FortisipRange, Enmix Plus Commence or Ensure Plus Commence / 100% / Where ONS have been requested under supervision of a Dietitian (should be documented 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 “as required” or “as directed” / 100% / None
9. Patient on prescribed ONS is reviewed monthly before further prescription is issued / To include weight, compliance with ONS, progress towards aims of treatment / 100% / Where patient is under regular review by a Dietitian (e.g. Dietitians letter indicates planned follow up)
10. Aims of treatment and need for ONS reviewed after 3 months / If improved, ONS are reduced or discontinued. If not improved, Dietitian is contated for advice if appropriate / 100% / Documented clinical reason for continuing ONS (e.g. further improvement / benefit anticipated)
11. Any patients for whom a Dietitian has requested ONS on prescription should have documented indication, aims of treatment, weight, expected duration of treatment and follow up arrangements from the Dietitian / Letter or other communication details indication for ONS, patients weight, aims of treatment, expected duration of treatment and follow up arrangements / 100% / Where the requesting Dietitian is employed other than NHS Swindon, GWH NHS FoundationTrust, Wiltshire PCT

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

stableProvide 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 monitorNo Yes

weight until weight stable

Referto Dietitian

Flow chart to aid reviewof patients currentlyprescribed

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:
  • Short Bowel Syndrome
  • Intractable malabsorption
  • Pre-operative preparation of undernourished patients
  • Proven inflammatory bowel disease
  • Following total gastrectomy
  • Bowel fistulas
  • 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, Vanilla / slowly over 1/2 hour
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