Appropriate provision of prescribable oral nutritional supplements in hospital (G095)

This guidance is applicable to:

1. All patients commencing on prescribed oral nutritional supplements.
2. All members of the multidisciplinary ward based teams involved in the direct provision of oral nutritional supplements to patients;
   • Registered Nurses
   • Health Care Support workers
   • Dietitians
   • Dietetic Assistant Practitioners/ Support Workers
   • Speech and Language Therapists
   • Domestic/Housekeeping Staff
   • Other AHP staff, as appropriate
3. Members of the catering and portering staff responsible for the issue and distribution of prescribed oral nutritional supplements to ward areas.

The provision of adequate nutritional care and hydration:

• should be regarded as an important component of the overall care for all patients.
• is as essential to care as all prescribed medication and other types of treatment.
• can increase the rate of recovery, reduce the risk of any complications and can result in an earlier discharge for patients.

The use of prescribed oral nutritional supplements (ONS) may be deemed necessary for patients who are taking an inadequate food and fluid intake to enable them to meet their nutritional requirements, whether this is due to an inability to consume sufficient nutrition or increased nutritional requirements due to clinical status. However it is important that ONS are used appropriately.

The role of ONS is to compliment other oral nutritional intake and should not be used as a substitute for adequate provision of normal food. ONS can only be prescribed where there are clear clinical indications and where the Advisory Committee on Borderline Substances (ACBS) prescribing criteria can be met. This should be for less than 6 months.

All patients admitted to hospital in NHS Ayrshire and Arran should be screened for undernutrition using the Malnutrition Universal Screening Tool (MUST). Patients identified by the screening process as being undernourished, or who are at risk of undernutrition (MUST≥2), should be referred to the Dietitian for a full nutritional assessment.

Patients with dysphagia (swallowing difficulties) may require modification to food texture or drink thickness. Patients with longstanding dysphagia will already have food texture and drink thickness recommendations that must be followed. Any patients with new or increasing swallowing difficulties should be referred to the Speech and Language Therapist (SLT) for assessment or review, before Dietetic input. The SLT will recommend the most appropriate texture of food texture and drink thickness using the IDDSI framework. Pre-thickened prescribable ONS may be utilised as part of the treatment plan.

When sufficient energy intake cannot be achieved via a consumption of normal foodstuffs or dietary fortification the use of oral nutritional supplements can be considered. Only where the ACBS prescribing criteria can be met, will the use of prescribable ONS be recommended.

In NHS Ayrshire and Arran, ONS should only be prescribed on the recommendation of a Dietitian. All patients in receipt of ONS will remain under dietetic review.

Whilst in hospital, prescribed ONS will be issued on an individual patient basis as indicated by the Dietitians recommendations. Each supplement will be labelled with the patients name and the date of issue and, if appropriate, dosage.

NOTE – It is of the utmost importance that the ‘Best Before’ date (BBD) on all proprietary supplements is checked;

• at delivery,
• prior to issue from the kitchen,
• prior to being given to the patient at ward level.

It is imperative that oral nutritional supplements are viewed as an essential part of the treatment plan for the patients who have been prescribed them.

Supplements are most often prescribed between meals i.e. mid-morning, mid-afternoon and evening. At these times a member of the nursing team should be given the responsibility to undertake this role.

Patients should be given encouragement to consume their supplements. This may require additional explanation and/or assistance. The focus should be on the important beneficial role that supplements have on their nutritional and clinical status.

Supplement drinks are usually best served following a period of refrigeration. Warm supplement drinks will be less appetising and will be less likely to be consumed. Patients should therefore be encouraged to drink them when cold. Assistance may be required to decant the drink into a glass or place the straw into the bottle/ carton.

Documentation

It is imperative that a team approach is taken and that documentation and communication methods employed ensure that patients receiving supplements can be easily identified and supported. This includes;

• bed boards
• pantry ‘nutritional information’ boards
• ‘dietetic recommendations’ chart
• completion of ‘nutritional intake record charts’
• relevant documentation on ‘fluid balance’ charts.

As a result of nutritional screening, patients with MUST≥2 will be referred to the dietitian.
On receipt of referral, the dietitian will assess each patient individually and recommend the nutritional supplements the patient to be commenced on.

The assessment will be based on patient's:

• physical ability to eat/drink
• mental status
• personal preferences
• cultural or religious constraints
• relevant biochemical parameters
• relevant drugs
• clinical condition(s)
• estimated nutritional requirements
• nutritional status, including weight/ BMI and any weight loss
• prescribing criteria
• most appropriate product.

The Dietitian will assess the best treatment plan suitable for the patient’s needs. A ‘Food First’ approach will be followed as the first line management of those with or at risk of malnutrition. Patients are encouraged to eat ‘little and often’, grazing throughout the day on small nourishing snacks and drinks. Where required, food fortification advice will be provided to help increase calories, protein and nutrient value in existing food and drink choices.

Over the counter (OTC) products can be effective and are particularly useful for those patients whose appetite or weight loss is likely to be short term or for use with patients who do not meet the Advisory Committee on Borderline Supplements (ACBS) criteria for prescribed ONS. These can be used first line.

The ACBS criteria for prescribed ONS includes:

• short bowel syndrome
• intractable malabsorption
• pre-operative preparation of patients who are undernourished
• proven inflammatory bowel disease
• following total gastrectomy
• dysphagia
• bowel fistulae
• disease related malnutrition (chronic or acute)

At ward level the Dietitian/ Dietetic Assistant Practitioner/ Dietetic Support Worker will:

• Discuss the proposed treatment plan with the named nurse on duty at the time of the assessment.
• Complete a Dietetic Recommendations Chart.
• Record the patient’s needs on the Nutritional Information Board (or ward snack list on some long stay wards), noting the patients name, the name of the supplement(s) and the time(s) that the patient should receive their supplement(s).
• Where available, information should also be updated on the Bed Board at the patient’s bedside.
• Complete the MUST Multidisciplinary Care Plan recording the supplement(s) name and frequency.
• Put a ‘Nutritional Intake Record Chart’ in place for completion by nursing colleagues.

Local procedures are employed in some areas to reflect the Dietetic Service available e.g. visiting services. In these instances the Dietitian may advise the treatment to be commenced following a telephone consultation with ward staff, which will then be required to written up at ward level by nursing staff.

Patients who require to continue taking oral nutritional supplements at home should be given a 7-10 day supply (consideration should be given to discharges occurring at the weekend or over public holidays) when discharged from hospital. Care will be transferred onto the Community Dietitian for continued management.

Speech and Language Therapists (SLTs) are the professionals who assess, diagnose and manage dysphagia (swallowing difficulties). They have a key role in the identification and management of dysphagia and work closely with other members of the team. The SLT takes a lead role in the development of a management plan and will discuss the nature of the intervention with the individual (where possible), the multidisciplinary team, carers and the family. Further information is available within the Adult Dysphagia Policy (G125 NHS A&A 2021).

Where a modified consistency of food texture and drink thickness is recommended, this requires to be considered when nutritional supplements and snacks are issued to the patient. Commercially available pre-thickened nutritional supplements may be required.

N.B: Thickeners should not to be added to supplement drinks.

• A member of catering personnel will print the daily supplement labels.
• Each label will identify the date, the patient's name and the name of the item for issue. Labels on some sites also state when the supplement is due to be consumed (e.g. mid-morning, mid-afternoon, evening)
• A designated member of the catering staff e.g. Diet Cook will ensure that the documented supplement is issued to the correct ward at the correct time having checked the “best before” date (BBD) and that the seal is intact prior to distribution.
• On the majority of sites the nutritional supplements will be placed on top of the designated ward meal trolley by a member of the catering staff. Some sites will employ local procedures.

Any supplements not issued to patients and returned to the Catering Department will be monitored.

• On the majority of sites portering staff will collect the meal trolley from the catering department and transport it to the designated ward. Site specific procedures should be followed for transportation of meal trolleys.
• Care should be taken to ensure that trolleys are transported in a safe manner ensuring that supplements and snacks are not disturbed on top of the trolley.
• Ward staff should be notified when the meal trolley is delivered to the ward.

In most areas the Domestic/Housekeeping staff will be responsible for removing the supplements from the meal trolley when it arrives on the ward and storing them appropriately e.g. in the ward fridge.

In some smaller community hospitals nursing staff are responsible for removing the supplements from the trolley and storing them appropriately.

The nurse is responsible for ensuring that each patient receives and is given encouragement to consume the correct supplement at the most appropriate time and temperature.

• The Nutritional Information Board in the ward pantry will identify the patients who are due to receive nutritional supplements. The name of the supplement drink to be given will be noted next to the patient’s name.
  Individual ward arrangements may be employed.
  Out of hours and at weekends this board will be updated where necessary by the
  ward nurse.
• The nurse will commence a ‘Nutritional Intake Record Chart’ noting the supplements that the patients is due to be given at the top of the chart.
• The nurse will remove the required nutritional supplements in the ward fridge. Supplements must only be given to the patient named on the label. Labels should not be removed.
• Dependent patients may require nursing assistance to open, hold or consume the supplements.
• Attention should be paid to patients receiving texture modified diets whom may require a pre-thickened supplement.
• The "Best before" date (BBD) must be checked prior to issue to the patient.
• In bottle type presentations where there is foil seal under the cap and this has been broken or has been removed, the drink should not be used.
• The nurse should give positive encouragement to the patient to consume the nutritional supplement prescribed.
• The amount of supplement taken should be documented on the ‘Nutritional Intake Record Chart’ and assessed against the Dietetic Recommendations chart.
• If appropriate, fluid intake from nutritional supplement drinks should be documented on the Fluid Balance Chart.
• Some patients may find they are unable to tolerate certain supplements or may find them unpalatable. This should be recorded on the Nutritional Intake Record Chart and communicated to the Dietitian/ Dietetic Assistant Practitioner/ Dietetic Support Worker and other members of the multidisciplinary team as necessary.
• All supplements which remain unopened or not issued to patients should be returned to the kitchen within 24hours, with the patient label still attached.
• Ongoing nutritional care issues, including supplement consumption and tolerance should be updated in the MUST Multidisciplinary Care Plan.
• The nurse has responsibility for ensuring that the ward dietitian is informed when a patient is being discharged home on ONS to ensure that the patient is given a 7-10 day supply of the required supplements to take home.
• The ‘Nutritional Intake Record Chart’ should be filed in the patient’s medical case notes on discharge beside other nursing documentation.

• Use of nutritional supplements can maintain/ improve the nutritional status of malnourished patients.
• Dietitians will assess patients on an individual basis and recommend appropriate nutritional supplements as required.
• Patients with dysphagia should be referred to the Speech and Language Therapist for assessment.
• ONS should be given to the individual named on the affixed label only, at the time and in the quantity advised.
• Nutritional Intake Record Charts should be commenced and completed for all patients in receipt of ONS.
• Patients should be given encouragement to consume their nutritional supplements.
• Intake and/or problems should be reported to the dietitian and other members of the multidisciplinary team including medical staff.
• Supplements which remain unopened/ not issued should be returned to the kitchen with the patient label still attached at the next mealtime or within one day at the most.

N.B. - It is a clinical risk to issue supplements to patients who have not been assessed by a Dietitian.

Fresubin 5kcal Shot is a high energy fat emulsion oral supplement.

Presentation is in a 120ml plastic bottle.

The dosage will be directed by the Dietitian and recorded on the medicine prescription sheet or Hospital Electronic Prescribing and Medicines Administration (HEPMA) system by a suitably qualified prescriber e.g. 40ml three times daily.

Fresubin 5kcal Shot will be issued on an individual named patient basis.

Staff should read all labels carefully, as with all medications/ dietary supplements.

When using the 120ml bottle presentation the date and time of first use must be documented on the label on the outer side of the bottle. Once opened, the lid should be replaced and the bottle should be stored in the ward fridge and used within 14 days.

Fresubin 5kcal Shot must not be stored in the drug fridge. This is a food supplement and not a drug. Drugs must be stored separate from food - this includes the fridge or the drug trolley, in accordance with the Code of Practice for Medicines Governance.

From time to time some patients may bring their own oral nutritional supplements in from home when they are admitted to hospital. These patients must still be referred to the Dietitian for provision and assessment as appropriate.

If the patient is to continue with these nutritional supplements, they will be supplied by the hospital. The patient’s own supply should be returned to the patient/ relatives and should be taken home.

If the specific supplement required needs to be ordered by the hospital the patient’s own supply may be used until it is in stock.