Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team...

22
Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group East Staffordshire Clinical Commissioning Group Page 1 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019 Approved By Medicine Optimisation Group: July 2017 Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify all adult patients prescribed oral nutritional supplements (ONS), including sip-feeds, and review to determine whether prescribing is appropriate, evidence based and cost-effective, in line with local and national guidance. Patients will be switched to more cost effective alternative, where there is no difference in terms of clinical effect and patient factors and there is a significant cost differential. Prescribing of Oral nutritional supplements (ONS) will be stopped if not indicated to continue. Rationale Oral nutritional supplements (ONS) represent a significant cost to the NHS so ensuring that they are only used where clinically appropriate and when ‘food first’ strategies have been sufficiently employed first, will help to ensure that limited NHS resources are used in the best way possible. Furthermore, ONS are only considered suitable for prescribing for medicinal purposes for patients who meet the ACBS (Advisory Committee on Borderline Substances) criteria. Patients must meet at least one of the ACBS criteria below to be eligible for prescribed ONS: 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. In addition, some supplements and food products are prescribable for those receiving continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis, or are specifically prescribable for individual conditions. These products would normally be requested by a dietitian and should not be routinely started in primary care. The initial aim will to be review and discontinue inappropriate prescribing of ONS. Where it is not appropriate to stop prescribing, patients will be reviewed to formulary products. One of the main switches will be from ready made products to powdered products which need reconstitution with whole milk where suitable. Advantages of a powder based ONS: • They tend to taste better. This is based on local Dietetic taste tests. • They can be easily added to meals and as such promotes a “Food First Policy”. • They are half the price of ready-made milkshakes • They can be prescribed as a sample pack so the patient can trial flavours • A shaker is provided by the company to assist with reconstitution. • The local first link product has a vanilla flavour which contains 4.6g of fibre per sachet, which is beneficial to bowel function especially in the elderly population & care home residents.

Transcript of Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team...

Page 1: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Cannock Chase Clinical Commissioning Group South East Staffordshire and Seisdon Peninsula Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group East Staffordshire Clinical Commissioning Group

Page 1 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Medicines Optimisation Team Standard Operating Procedure Audit:

Oral Nutritional Supplements for Adults

Aim To identify all adult patients prescribed oral nutritional supplements (ONS), including sip-feeds, and review to determine whether prescribing is appropriate, evidence based and cost-effective, in line with local and national guidance. Patients will be switched to more cost effective alternative, where there is no difference in terms of clinical effect and patient factors and there is a significant cost differential. Prescribing of Oral nutritional supplements (ONS) will be stopped if not indicated to continue.

Rationale Oral nutritional supplements (ONS) represent a significant cost to the NHS so ensuring that they are only used where clinically appropriate and when ‘food first’ strategies have been sufficiently employed first, will help to ensure that limited NHS resources are used in the best way possible. Furthermore, ONS are only considered suitable for prescribing for medicinal purposes for patients who meet the ACBS (Advisory Committee on Borderline Substances) criteria. Patients must meet at least one of the ACBS criteria below to be eligible for prescribed ONS: • 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. In addition, some supplements and food products are prescribable for those receiving continuous ambulatory peritoneal dialysis (CAPD) and haemodialysis, or are specifically prescribable for individual conditions. These products would normally be requested by a dietitian and should not be routinely started in primary care. The initial aim will to be review and discontinue inappropriate prescribing of ONS. Where it is not appropriate to stop prescribing, patients will be reviewed to formulary products. One of the main switches will be from ready made products to powdered products which need reconstitution with whole milk where suitable.

Advantages of a powder based ONS:

• They tend to taste better. This is based on local Dietetic taste tests. • They can be easily added to meals and as such promotes a “Food First Policy”. • They are half the price of ready-made milkshakes • They can be prescribed as a sample pack so the patient can trial flavours • A shaker is provided by the company to assist with reconstitution. • The local first link product has a vanilla flavour which contains 4.6g of fibre per sachet, which is beneficial to bowel function especially in the elderly population & care home residents.

Page 2: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 2 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Powder-based ONS may not be suitable in certain patients (needs to be decided on a case-by-case basis).

Audit criteria

Inclusion criteria All adult patients (those 16 years and over) currently prescribed oral nutritional supplements, branded or generic, as an acute or repeat prescription within the previous 6 months, unless they fall under any of the exclusion criteria (see specific exclusion criteria’s) General Review Process (see review process section for discontinuation) 1. Patients will be reviewed to identify if there is a documented plan in place in relation to their ONS

prescription with an agreed treatment goal. Patients should fulfil the ABCS criteria if not it should be recommended that their ONS prescription is discontinued.

2. The use of an appropriate screening tool e.g Malnutrition Universal Screening Tool (MUST)

(Appendix 3) should be documented upon initiation. It is expected that only individuals with a MUST score of 2 or more who have failed a trial of four weeks food fortification (unless food fortification inappropriate, e.g. swallowing difficulties) should have been initiated on ONS. If not these patients should be recommended for discontinuation of ONS.

3. There will then be a check to ensure the patient has had a regular review. a) For any patient with no up to date weight (within the previous month for care home patients or

the previous 3 months for domiciliary patients where it is possible to weigh the patient), request an up to date weight is taken and recorded..

b) Recalculate the the patients BMI and MUST score based on current situation, i.e. is disease no longer active (See appendix 1 for MUST score). Review with GP as to whether those that have now decreased to MUST scores less than 2 require a review to discontinuing ONS, or where very high quantities being issued these can be reduced.

c) Assess whether patient has met treatment goal - if this is the case discontinue the ONS. 4. Certain patient groups should be highlighted for referral to dietician a) Any patient with a body mass index (BMI) of 16kg/m² or less and no dietetic referral – refer without delay. b) Any patient who has had little or no nutritional intake for the last 10 days and has had no dietetic referral – refer without delay. c) Any patient who has lost more than 15% body weight within the last 3-6 months, except patients at the end of their lives, with no dietetic referral – refer without delay. d). Any patient where ONS is their sole source of nutrition, with no dietetic referral – refer without delay e) Any patient with complex nutritional needs who haven’t been reviewed by a dietician - e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes, eating disorder gastrointestinal disorders – refer to prescriber to arrange referral to local community dietetic service. 5. Need to consider whether a patient being reviewed is already under a dietician or secondary care in relation to their ONS prescription and who has recommended a specific product (e.g. product with additional fibre or protein) to meet their individual need, where there is no suitable formulary alternative – exclude. Where there is an alternative and actively reviewed contact dietician prior to change.

Page 3: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 3 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

General exclusions

Any patient who is excluded by the prescriber. Patients on enteral feeds i.e. PEG tube, RIG, NJ, jejunostomy, any ONS these patients have needs

discussing with dietician reviewing patient prior to change. Exclude patients from review to formulary powdered ONS where: 1. Is there any factors that need to be taken into consideration with regards to whether a powdered

shake would be appropriate e.g. dexterity issues or fragility where there is no carer or individual who could aid with this. For those who live alone and have no assistance (carers or relatives) in food preparation prescribe ENSURE COMPACT. If a patient is in a nursing home prescribe powdered ONS.

2. A history of not liking any of the flavours that come as powdered shakes. 3. Patients on juice based supplements (these patients only suitable to review to discontinue). 4. Patients on compact (125ml) products - if not suitable to discontinue review to formulary

compact product (Ensure Compact) instead where it is cost effective. 5. Patients with an intolerance to soya , allergies to soya or milk protein . 6. Patients with galactoseamia. 7. Patients who have failed a previous switch of medication i.e. caused undue distress. 8. Patients already on a powdered shake even if non formulary as very similar composition and cost. 9. Anyone who needs lactose free products as the recommended formulary products contain

lactose. (For full lists of allergen and religious information for Nualtra® products refer to (Appendix 8).

10. Patients currently under review by the dietician, please liaise with the dietician regarding the suitability. Specific Patient Groups for caution/exclusion as indicated

1. Any patient with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes, gastrointestinal disorders or eating disorders- should really be under a dietician as above.

2. Any patient who is a substance misuser – refer to Appendix 2 for advice. 3. Recent change in risk e.g. co-morbidity or oncology should be incorporated into recalculation of

MUST score. 4. Is the patient receiving palliative care? If early stage – review in line with the below. If late stage

palliative care (final days or weeks of life), discontinue ONS as nutritional content is no longer of prime importance.

5. Unstable diabetes due to the carbohydrate content - ideally should be reviewed by diabetes nurse specialist, less suitable for powdered ONS. Nutricrem® may be more appropriate but this would need assessment.

6. Renal disease - due to the phosphate & potassium levels if the patient is on electrolyte restrictions. If a Dietitian is not involved in the patients care, prescribe Ensure® Plus Juice & refer to a renal Dietitian

Cautions- where further clarification is needed 1. Patients who do not appear to be taking the existing medication that is being proposed to switch

as prescribed (e.g. due to inconsistency in the pattern of ordering their repeat prescription) - refer to prescriber to determine appropriateness to change or to archive and exclude.

2. Patients on repeat dispensing – highlight for review before next batch issued OR discuss with practice and decide what course of action is to be taken for such patients.

Page 4: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 4 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

3. Patients/carers for whom the method of communication outlined in the SOP may not be appropriate (e.g. patients who are deaf, illiterate etc.) - refer to prescriber to determine appropriateness to change.

4. Any patient that those involved in the switch feel is unsuitable for the mentioned change in medication – refer to prescriber for clarification or exclude and highlight as appropriate. For example, vulnerable patients might require a face-to-face or telephone discussion with the prescriber. This reason must be documented on the data collection form.

5. Any patient with no up to date weight- within the previous month for care home patients or the previous 3 months for domiciliary patients where it is possible to weigh the patient - ask for a new weight as per review process.

6. Any patient without a documented nutrition treatment goal – refer to prescriber to request this. 7. Any patient who is a substance misuser – refer to the prescriber to assess in line with PrescQIPP

guidance. 8. Any patient prescribed less than 2 oral nutritional supplement doses per day – refer to prescriber

to assess whether they can increase their intake to the recommended dosage or whether it is more appropriate to discontinue.

Method

1. Search the practice clinical system for all adult patients (using the standardised search) currently prescribed oral nutritional supplement defined within this SOP as an acute or repeat item (initially focus mainly on 2kcal/mL products) – branded or generic, repeat or acute items. Following review of each patient’s electronic medical record, record all relevant data using the data collection form (appendix 1) or similar, for each patient identified.

2. Exclude patients according to the specific exclusion criteria. Any patient excluded from the switch should have a relevant read code and explanation added to their electronic medical record for audit purposes and any future work.

3. Refer patients requiring clarification or individual authorisation at this stage, to the relevant prescriber.

4. Invite patients who require a review of their oral nutritional supplements to a clinic (nurse/pharmacist/GP led) to be assessed for suitability, using the patient letter in appendix 2. Practices may prefer to send a letter informing patients of their switched or discontinued treatment, where this doesn’t require review – see appendices 3 and 4.

5. Switch or discontinue ONS for those who are suitable. If the change is made on a different day to the data collection due to referral of queries to the prescriber etc., ensure that there has been no clinically significant change to a patient’s circumstances and/or medication immediately prior to undertaking the change (i.e. all information recorded on the data collection form is still accurate). Add a relevant code to the additional information/pharmacy box to record that this has been carried out.

6. Carry out the change for all suitable patients by: - Adding the new ONS product to the patient’s list of medicines, if suitable to switch. Where

there is a starter pack for the preferred product (for example powdered ONS) add this to the acute (should explain to prescription clerks that needs issuing first and then removing from prescription once requested). Alternatively the starter pack could be given out at clinic appointment.

- Archiving the previous ONS into past drugs, adding “formulation switch” or “ONS stopped”, as appropriate.

- Creating an entry in patient consultation/journal notes confirming the change. Use wording ‘ONS review as per CCG policy, letter sent to patient’. READ codes for changing or stopping medication should be used:

Inappropriate medication stopped 8B1w

Page 5: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 5 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Medication changed 8B316 - Creating and printing the relevant patient letter using the template previously downloaded

onto the GP system (appendices 4, 5 and 6 ). If the patient is a care home resident – a letter should be sent to the care home to advise them of the change (appendix 7).

7. Provide details of the total number or a list of patients changed to their community pharmacy, as appropriate.

Page 6: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 6 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Review process- preferred product switches

Switching to a preferred product: Patients prescribed non-formulary ONS where there is a cost effective alternative – assess for suitability to switch to a formulary alternative, in line with local guidance.

ONS TYPE Brand name- 200ml unless

specified FP10

price* Flavours

PROTEIN AND CALORIE CONTENT PER BOTTLE/POT

Notes

ENERGY

ENSURE PLUS (237ml) 1.12 Vanilla, strawberry, dark chocolate, milk chocolate, butter pecan

350 kcal (1.5 kcal/ml) 15 g protein

Substitute with FOODLINK COMPLETE powdered ONS

FORTISIP 1.4 Banana, orange, strawberry, toffee caramel, tropical, vanilla, chocolate, neutral

300kcal and 12g protein

FRESUBIN ENERGY 1.4 Chocolate, Neutral, Tropical Fruits, Vanilla, Banana, Strawberry, Cappuccino, Lemon and Blackcurrant.

300kcal and 11.2g protein

AYMES COMPLETE 1.12 Vanilla, Strawberry ,Banana, Chocolate, 300kcal and 12g protein

RESOURCE ENERGY 1.92 Apricot, Chocolate, Strawberry/Raspberry, Banana, Coffee and Vanilla

300 kcal and 11.2g protein

FOODLINK Complete 0.61 Vanilla (added fibre),Natural, Strawberry,Banana, Chocolate

386kcal,18.3g Protein- based on strawberry flavour

HIGH ENERGY

FORTISIP COMPACT (125ml)

1.45 Vanilla, Strawberry, Banana and Mocha 300kcal and 12g protein

Substitute with ENSURE COMPACT where cost effective

ALTRAPLEN COMPACT (125ml)

1.45 Vanilla, Strawberry, Banana, Hazel Chocolate 300kcals, 12g Protein

FRESUBIN 2 KCAL 1.98 Vanilla, Fruits of the Forest, Apricot-Peach, Cappuccino, Neutral and Toffee

400kcals, 20g protein

ENSURE TWOCAL 2.22 Banana, neutral, strawberry and vanilla 399kcals, 16.8g protein

FRESUBIN 2KCAL MINI (125ml)

1.25 Vanilla, fruits of the forest, apricot and peach 250kcals, 12.5g protein

FORTISIP 2KCAL 2.14 Vanilla and strawberry 400kcals, 20g protein

Page 7: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 7 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

ENSURE COMPACT (118ml)

1.35 Milk chocolate, vanilla 300 kcal (2.4 kcal/ml) 13 g protein

FIBRE ENRICHED

FORTISIP COMPACT FIBRE (125ml)

2.09 Mocha, vanilla, strawberry 300kcal, 12g protein and 4.5g fibre per bottle

Substitute with FOODLINK COMPLETE with added fibre

powdered ONS

ENSURE PLUS FIBRE 2.02 Vanilla, Strawberry, Banana, Chocolate, Raspberry 310kcals, 13g Protein and 5.0g fibre

FRESUBIN 2KCAL FIBRE 1.98 Chocolate, Lemon, Cappuccino, Vanilla, neutral and Toffee.

400kcals, 20g protein

FRESUBIN ENERGY FIBRE 2.05 Chocolate, Vanilla, Strawberry, Banana, Caramel and Cherry

300kcals, 11g protein and 4g fibre

RESOURCE 2.0 FIBRE 1.88 Vanilla, Summer Fruits, Strawberry, Apricot, Neutral and Coffee

400 kcal, 18g protein and 5g Substitute with

FOODLINK COMPLETE with added fibre powdered ONS fibre

FRESUBIN 2KCAL FIBRE MINI (125ml)

1.25 Chocolate and vanilla 250kcals, 12.5g protein and 2g fibre

FOODLINK W/FIBRE 0.67 VANILLA ONLY 399kcals, 18.6g Protein

STD ENERGY

ENSURE CANS (250ml) 2.26 Vanilla, Chocolate, Coffee 251kcals, 10g Protein

Substitute with FOODLINK COMPLETE- note double calories and protein may reduce quantity

FRESUBIN ORIGINAL 2.14 Mocha, Blackcurrant, Peach,Nut, Vanilla, Chocolate 200kcals, 10g Protein

FOODLINK Complete 0.61 Vanilla (added fibre),Natural, Strawberry,Banana, Chocolate

386kcal,18.3g Protein- based on strawberry flavour

PROTEIN ENRICHED

FORTISIP COMPACT PROTEIN (125ml)

2 Berry, Mocha, Vanilla ,Strawberry, Banana, peach & mango,

300kcal and 18g protein Subsitute with ALTRAPLEN PROTEIN

FORTSIP EXTRA 2.22 Vanilla, strawberry 320kcal and 20g protein

Page 8: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 8 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

ENSURE PLUS ADVANCE (220ml)

2.02 Vanilla, Strawberry, Banana, Chocolate, coffee 330kcals, 20g protein

FRESUBIN PROTEIN ENERGY

2.08 Vanilla, chocolate, wild strawberry, tropical fruits and cappuccino

300kcals, 20g protein

ALTRAPLEN PROTEIN 1.49 Vanilla, Strawberry 300kcals, 20g protein

DESSERTS

FORTICREME COMPLETE (125g)

1.96 Vanilla, Banana, Chocolate, forest fruits 200kcals, 11.9g Protein

Substitute with NUTRICREM

FRESUBIN CREME & 2KCAL (125g)

1.96 Vanilla, wild strawberry, cappuccino, praline and chocolate.

200kcals, 12.5g Protein

ENSURE PLUS CRÈME (125g)

1.88 Vanilla, Neutral, ,Banana, Chocolate 171kcals, 7.1g Protein

RESOURCE DESSERT ENERGY (125g)

1.63 Vanilla, Chocolate and Caramel 200kcals, 6g Protein

NUTILIS FRUIT STAGE 3 (150g)

2.36 Strawberry. Apple 206kcals, 10.5g Protein

FRESUBIN YOCREME (125g)

2.04 Neutral, Lemon, Apricot-peach, Raspberry and Biscuit

187Kcals, 9.3g Protein

NUTRICREM 1.44 Vanilla ,Strawberry, Chocolate orange 225kcals, 12.5g Protein

MODULES- most available as 120ml bottles with cups to measure 30ml-40ml servings

PRO-CAL SHOTS (30ml serving)

2.41 Neutral, strawberry and banana 100kcals, 2g Protein

Substitute with ALTRASHOT- WHEN PRODUCT LAUNCHED- April 2017-note significant increased calories

and protein so may reduce quantity

CALOGEN INCL EXTRA (40ml serving)

2.99 Neutral, strawberry 160kcals, 2g Protein

FRESUBIN 5KCAL SHOT (30ml serving))

2.8 Neutral, Lemon 150Kcals and 0g protein

ALTRASHOT (30ml serving)

2.1 Vanilla, Strawberry 105KCals, 1.5g protein

Notes

* Source: MIMS April2017

Ensure Plus and Ensure compact prices dropped april 2017

Indicates products for review to discontinuation only as little cost-effectiveness from switch to formulary alternatives

Indicates preferred product

Page 9: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 9 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

References: 1. PrescQIPP NHS Programme. Guidelines for the appropriate use of ONS for adults in primary care. Version 2.0. Bulletin 68. June 2014. Available at

https://www.prescqipp.info/ons-guidelines/finish/235-ons-guidelines/1348-b68-ons-guidelines. 2. Appropriate Prescribing of oral nutritional supplements in the first line treatment of adult malnutrition in primary care 2015. Available at

http://www.southstaffordshirejointformulary.nhs.uk/docs/apg/Nutrition-and-Blood/Appropriate%20Prescribing%20of%20oral%20nutritional%20supplements%20in%20the%20first%20line%20treatment%20of%20adult%20malnutrition%20in%20primary%20care%20V1%2015-12-15.pdf

3. Malnutrition Universal Screening Tool (MUST). Available at http://www.bapen.org.uk/must_tool.html

Page 10: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 10 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 1 – data collection form

Practice support data collection form:

Practice Name

Surn

ame

DO

B

Ge

nd

er

Age

NA

ME

of

curr

en

t O

NS

Dai

ly D

OSA

GE

of

curr

en

t O

NS

Typ

ical

Mo

nth

ly Q

uan

tity

(u

nit

s -

i.e

. sac

he

ts/

bo

ttle

s) p

resc

rib

ed

Ind

icat

ion

fo

r Tr

eat

me

nt

Last

re

cord

ed

He

igh

t (m

ete

rs)

Dat

e

Last

re

cord

ed

we

igh

t (K

g)

Dat

e

Last

re

cord

ed

BM

I

Dat

e

MU

ST S

core

in P

atie

nt

Re

cord

s

Re

sid

en

tial

In

stit

ute

or

Ho

use

bo

un

d

Dia

be

tic

(Ye

s/ N

o)

Mo

st r

ece

nt

GFR

(m

L/m

inu

te/1

.73

m2

)

NOTES (Any

relevant)

MEE

TS M

UST

CR

ITER

IA (

Y/N

/Ukn

)

AC

TIO

N T

ake

n:

Ch

ange

d t

o A

C, C

han

ged

to

AS,

St

op

, Exc

lud

e…

Incr

eas

ing/

De

cre

asin

g Q

uan

tity

issu

ed

(In

c/D

ec)

Pro

ject

ed

Qu

anti

ty (

un

its)

th

e n

ext

mo

nth

(sac

he

ts/

bo

ttle

s)

Furt

he

r A

sse

ssm

en

t/ R

evi

ew

Re

qu

ire

d b

y

Pra

ctic

e/D

ieti

cian

(P

rac/

Die

t)

Co

st p

er

mo

nth

be

fore

re

vie

w

Co

st p

er

mo

nth

aft

er

revi

ew

Eff

icie

ncy

sav

ings

pe

r m

on

th

Pro

ject

ed

An

nu

al E

ffic

ien

cy S

avin

gs

Usu

al G

P

Summary

Total number of patients identified

Total number of patients Discontinued

Total number of patients switched

Work completed by: <insert name and job title> Date completed: <insert date>

Page 11: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 11 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 2 – Advice on patients with substance misuse Substance misuse is NOT a specified ACBS indication for ONS prescription. Prescribing ONS for this patient group (alcohol and drug misusers) raises concern, due to the cost and lack of evidence on clinical benefit. This patient group have a range of nutrition related problems such as:

Poor appetite and weight loss

Nutritionally inadequate diet

Constipation (drug misusers in particular)

Dental decay (drug misusers in particular) This is due to a number of reasons, including:

Poor nutrition knowledge and skills

Poor memory

Poor access to food

Drugs themselves – can often cause poor appetite, acidic saliva leading to dental problems, constipation, craving sweet foods (drug misusers in particular)

Poor dental hygiene (drug misusers in particular)

Chaotic lifestyles

Lack of interest in food and eating

Irregular eating habits

Low income, intensified by increased spending on drugs or alcohol

Homelessness / poor living accommodation

Infection with HIV or hepatitis B and C

Eating disorders with co-existent substance misuse

ONS prescribing in Substance Misusers often produces the following issues:

Used to replace meals and therefore is of no benefit

Once started the individual can become very reliant on them making it difficult to stop

They may be given/sold to other members of the family/friends Only prescribe ONS for substance misusers if they meet ACBS criteria and are malnourished or at risk of malnutrition (MUST score of 2 or more).

Page 12: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 12 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Page 13: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 13 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 3 MUST SCORE

Page 14: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 14 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Page 15: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 15 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Page 16: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 16 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 4 – Example patient letter – invitation for review

Page 17: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 17 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name

IMPORTANT INFORMATION REGARDING YOUR REPEAT PRESCRIPTION

As part of a review of prescribing, we are currently reviewing patients prescribed oral nutritional supplements in line with both local and national guidance. These products are not medications but support many patients to maintain a healthy weight and nutritional balance in their diet. They are suitable for prescribing on the NHS for patients with certain conditions, who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone. Some of the available products are more cost-effective or have a better balance of nutrients. Consequently, we have reviewed these alongside national guidance and come up with a list of preferred products for our local patients and when they should be prescribed on the NHS, when they should be purchased over-the-counter and when they are no longer needed. After careful review of your records, we are writing to advise that you need to come in for a review of your oral nutritional supplements before your next supply. If you have any queries regarding this letter please contact the practice. Yours sincerely

Appendix 5 – Example patient letter – switching of ONS

Page 18: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 18 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name

IMPORTANT INFORMATION

REGARDING YOUR REPEAT PRESCRIPTION

As a practice we are committed to ensuring all of our patients are receiving the best possible care

and that we are prescribing effectively and cost-efficiently. We are currently reviewing patients who

have been prescribed oral nutritional supplements.

You currently receive a prescription of an oral nutritional supplement. These products are not

medications but support many patients to maintain a healthy weight and nutritional balance in their

diet. They are suitable for prescribing on the NHS for patients with certain conditions, who meet

specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone.

Some of the available products are more cost-effective or have a better balance of nutrients.

Consequently, we have reviewed these alongside national guidance and have produced local

preferred products for prescribing to our patients.

After reviewing and updating your care plan, we have changed your current prescription as follows:

Foodlink Complete/Nutriplen/Ensure Compact/ (*delete as appropriate) is an alternative to [insert

current product used].

All other items on your prescription remain the same and have not changed.

Your new product will be prescribed as assorted flavours on the prescription so you will need to

inform the pharmacy which flavours you prefer. A starter pack will be issued so that you can try all of

the flavours and advise the pharmacy on your preferred choices.

(Foodlink complete- only).

Your new product comes as a powder sachet which requires making up with 200ml of fresh whole

milk in the shaker which will be provided with your initial prescription for Foodlink complete. Many

patients prefer this as the drinks have a fresh taste similar to a normal milkshake and the sachets are

compact for storage purposes, as well as having a higher nutritional content then many of the ready-

to-drink products.

Page 19: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 19 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

This product contains milk and soya protein, lactose (Food link complete sachets only- delete as

appropriate) so if this is an issue let the surgery know. The strawberry flavour is not vegetarian/halal

or Kosher as it contains colouring E120, which is also known as cochineal or carmine. All other

flavours are vegetarian and the products do not contain any ingredients that are forbidden in halal

or kosher diets.

Please do not hesitate to contact your local pharmacist or GP if you would like more information.

Yours sincerely

On behalf of

Page 20: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 20 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 6 – Example patient letter – discontinuation of ONS

Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name

IMPORTANT INFORMATION

REGARDING YOUR REPEAT PRESCRIPTION

Dear

As a practice we are committed to ensuring all of our patients are receiving the best possible care

and that we are prescribing effectively and cost-efficiently. We are currently reviewing patients who

have been prescribed oral nutritional supplements.

You currently have a prescription of an oral nutritional supplement. These products are not

medications but support many patients to maintain a healthy weight and nutritional balance in your

diet. They are only suitable for prescribing on the NHS for patients with certain conditions, who

meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet

alone.

After reviewing and updating your care plan, we have removed your oral nutritional supplements

from your prescription as it is no longer necessary for you to receive these from us. All other items

on your prescription remain the same and have not changed.

Please do not hesitate to contact your local pharmacist or GP if you would like more information.

Yours sincerely

On behalf of

Page 21: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 21 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

Appendix 7 – Example Care home standard letter

Date as Postmark Title Initial Last Name Home Full Address (stacked) Dear Calling Name

IMPORTANT INFORMATION

REGARDING THE PRESCRIBING OF ORAL NUTRITIONAL SUPPLEMENTS

Dear

As a practice we are committed to ensuring all of our patients are receiving the best possible care and that

we are prescribing effectively and cost-efficiently. We are currently reviewing patients who have been

prescribed oral nutritional supplements.

You will be aware of your residents receiving a prescription for an oral nutritional supplement. These

products are not medications but support many patients to maintain a healthy weight and nutritional

balance in their diet. They are only suitable for prescribing on the NHS for patients with certain conditions,

who meet specific criteria, during times where their nutritional needs cannot be met by a fortified diet alone.

Where a “food first” strategy is more appropriate, patients have met their nutritional target or they are no

longer indicated, oral nutritional supplements have been removed from patient’s prescriptions.

Patients still requiring an oral nutritional supplement will be switched to the most cost-effective alternative

that meets their needs. We have reviewed the available products alongside national guidance and come up

with a list of preferred products for our local patients.

PLEASE SEE INIDVIDUAL LETTERS (ENCLOSED) OF THE PROPOSED CHANGE FOR EACH PATEINT.

In order to help us assess ongoing eligibility for prescribed oral nutritional supplements, we will require a

monthly MUST (malnutrition universal screening tool) score – available online at

http://www.bapen.org.uk/must_tool.html. For new patients, we will require a recorded MUST score and

weight loss, 3 days of documented dietary and fluid intake and evidence of a ‘food first’ approach being used

for the previous four weeks and a completed Nutritional Assessment Form.

Useful information on food fortification and ‘Making Every Mouthful matter’ are available at

http://www.southstaffordshirejointformulary.nhs.uk/docs/apg/Nutrition-and-Blood/

Please do not hesitate to contact us if you would like any more information.

Yours sincerely

Page 22: Medicines Optimisation Team Standard Operating Procedure ... · Medicines Optimisation Team Standard Operating Procedure Audit: Oral Nutritional Supplements for Adults Aim To identify

Page 22 of 22 Version 2.0 Revised by Mary Johnson May 2017 To be revised: May 2019

Approved By Medicine Optimisation Group: July 2017

On behalf of

Appendix 8 – Religious and allergen information -Nualtra®

.

Head of Medicine Optimisation SESSP, SAS & CC CCG’s

Sam Buckingham

Date 5th July 2016

GP Prescribing Lead

Mo huda

Date 5th July 2016

Document Change History

Version Date Editor Details of significant changes

2 April 2017 M Johnson Addition of MUST Score & Nualtra Product switches