Developing evidence based strategies and tools for the use of oral nutritional support in the community Vera Todorovic Consultant Dietitian in Clinical Nutrition Doncaster and Bassetlaw Hospitals NHS Foundation Trust [email protected]
Developing evidence based strategies and tools for the use of
oral nutritional support in the community
Vera Todorovic
Consultant Dietitian in Clinical Nutrition
Doncaster and Bassetlaw Hospitals NHS Foundation Trust
Common issues for primary care and the community
Every PCT will indicate that there have been increases in the volumes of oral nutritional supplements prescribed for patients and this is reflected in increased costs.
There is an assumption that inappropriate prescribing occurs and that there are no ‘controls’ in place.
practitioners are unclear as to who should receive oral nutritional supplements and what the benefits of these are.
Robust guidance to help clinicians make informed decisions is not always available
Building the evidence for nutritional support in the community
identify key policy initiatives nationally and locally that could have an impact on the nutritional care of patients
Profile the local health and social care community
identify clinical evidence that demonstrates the burden of malnutrition in the community and the benefits that can be associated with nutritional support.
work in partnership with other staff and different agencies
to identify high risk patient groups
link all elements together to develop best practice and evidence based strategies and guidelines for patient care.
Key policy drivers
GMS contract- chronic disease management– COPD, stroke, cancer, mental health
Payment by results - tariff system for commissioning care for patients
New Pharmacy contract and enhanced services
Major national initiatives Essence of Care ( hospital and community )
– pressure ulcers- assessment– food and nutrition
National Service Frameworks ( NSF’s)
NICE Guidelines– Nutrition support in adults:oral supplements, enteral
and parenteral feeding (first draft May 2005 )– The NICE guidance on the management of patients with
COPD ( 2004 ) Long term conditions and new ways of working -
case managers Supplementary prescribing
National Service Frameworks
Older people - falls, stroke, mental health, intermediate care, single assessment, promotion of health
Cancer,- dietitians have a valuable role
Long term conditions - multidisciplinary approach to improve care
Coronary heart disease - heart failure, CABG
National Institute of Clinical Excellence ( NICE ) guidelines
The NICE guidance on the management of patients with COPD ( 2004 ) recognises the importance of addressing poor nutrition
in vulnerable individuals with COPD and highlights the importance of carrying out nutritional screening on these individuals. For those individuals with a low BMI it suggests commencing them on nutritional supplements.
NICE guidelines
Nutrition support in adults:oral supplements, enteral and parenteral feeding (first draft May 2005 )
Key elements nutritional screening on admission to care homes, at hospital out-patients,
when patients register with general practices nutrition support and patient selection snacks and supplements offered to patients should aim
to ensure that overall nutritient intake is balanced in energy, protein, minerals and vitamins
Key driversPerformance Monitoring
Healthcare Commission- Standards for Health Patient Environment Action Team ( PEAT) Essence of Care QIS- Quality Improvement Scotland
Food, Fluids and Nutritional Care in Hospitals
Welsh Risk Pool
National minimum standards for care homes for older people ( 8.9 )
Essence of Care Nutrition Benchmark
10 factors
Screening and assessment-patients ‘at risk’ are given a full assessment
planning, implementation and evaluation of care
a conducive environment to eat in patients are given assistance to eat
and drink when they require it. obtaining food-patients have sufficient
information to obtain food food provided meets the needs of
individual patients food is available for patients at all
times and replacements are offered. Food presentation is appealing patients food intake is monitored patients are encouraged to eat to
promote their own health
Links to
PEAT
Healthcare Commission Standards
Patient Environment Action Team - (PEAT)
Reviewing quality issues in England relating to cleanliness, ward environment and food
now includes a standard on nutritional care
50% patients to have a recorded nutritional risk score and body weight
50% wards observing protected meal times.
Healthcare commission- Assessment for Improvement-the annual health
check Standards to performance
monitor all Organisations in England that provide care for patients
core standards reflect expected basic standards of care
standard C15 focuses on food and nutrition
key elements where food is provided
patients are provided with a balanced diet and one that meets their nutritional, personal and clinical dietary requirements
assessors will expect to see evidence from a variety of sources eg
Essence of care Patient meal survey Protected
mealtimes PEAT
Local profiling
Factors for consideration Rationale
Population with age profiles To identify local characteristics Including ethnic minority groups
Geographical layout eg rural, urban, transport systems
Gives an overview of locality eg access to shops, problems with isolation,
Deprivation index Highlights eg degree of poverty, percentage of individuals working, long term sickness
Health and social care provision Highlights support available eg hospitals, care homes, day centres, Leisure facilities
Health of the population Identifies the problem areas eg proportion of long term illnesses eg COPD, cancers, mental illness
Prevalence of malnutrition in the community
Malnutrition in patients in the community with a BMI<20 kg/m2
Prevalence of up to (%)
COPD
30
Fractured neck of femur 50
Cancer 35
CVA/stroke 31
Other neurological problems 60
Elderly patients with a variety of conditions
36
Stratton et al. Disease related malnutrition: an evidence based approach to treatment.2003. Cabi Publishing
Costs of malnutrition
Malnutrition in the UK is an important clinical and public health issue
Underweight individuals (BMI <20kg/m2)
have been shown to consume more healthcare resources than those with a BMI between 20 and 25kg/m2
require more prescriptions (9%) have more GP visits (6%) have more hospital admissions (25%) have higher death rates
Source: Martyn et al. Effect of nutritional status on healthcare resources by clients with chronic disease living in the community. Clin Nutr. 1998 (17):119-23
Significant functional and clinical outcome improvements – hospital and community patients receiving
oral nutritional supplements Disease/patient group Functional/clinical outcome
COPD Improved respiratory muscle function Improved hand grip strength Improved walking distance
Older people Immunological benefits Reduced number of falls Increased activities of daily living
HIV/AIDS Improved cognitive function
Liver disease Lower incidence of severe infections Lower frequency of hospitalisation
Malignancy Immunological benefits
Pressure ulcers Improved healing
Pre and postoperative lower gastrointestinal tract surgery
Lower minor complications
Source: Stratton et al. Disease related malnutrition: an evidence based approach to treatment.2003. Cabi Publishing
Smedley et al Randomised controlled trial of the effects of preoperative and postoperative oral nutritional supplements on clinical course and cost of care. Br J Surg (2004)91(8):983-90
Clinical outcome improvements in the community for patients
using oral nutritional supplements
Systematic reviews by Stratton and Elia
Reduction in rates of infection, frequency of hospitalisation, reduction in the length of hospital stay, mortality.
Improvement in energy and nutrient intake,some evidence to suggest suppression of food intake but overall increase.
Improvements in body weight, greater with patients with BMI <20kg/m2 or BMI >20kg/m2 but weight losing.
Stratton RJ, Elia M. A critical systematic analysis of the use of oral nutritional supplements in the community. Clin. Nutr. 1999; 18(2):1-84
Unintentional weight loss over three to six months
<5% body weight: normal intra-individual variation loss 5% body weight:
less energeticdecrease in voluntary physical activityincrease in fatigue
loss 10% body weight: changes in muscle functiondisturbances in thermoregulationpoor response or outcome to surgery and chemotherapy
Formulating a plan
nutritional screening to identify ‘at risk’ patients
determine goals and outcomes
care planning and treatment options
monitoring
Who requires nutritional support?
Offer nutritional support to individuals who:
have unintentional weight loss of >10% over previous 3-6 months or
have a BMI < 20 with unintentional weight loss of >5% or
have a BMI < 18.5 or
no nutritional intake for 5 days and not likely to be eating in the near future
NICE (2005)
Defining outcomes
functional eg improvements in respiratory muscle function increase walking distances increase activities of daily living Decrease in falls
body composition eg improve muscle mass fat mass
dietary eg improve qualitative and quantitative aspects of diet
Care planning Weight goals
Maintain Prevent further loss Increase
Dietary goals Continue Improve Increase
Dietary interventions– Improve– Enrich– Use of supplements
Vera Todorovic
Rationale for use of oral nutritional sip
feeds/supplements Supplement current oral intake to improve
nutritional intake , aiming to meet nutritional requirements. Evidence suggests ONS’s are additive to food.
Sole source of nutrition ,replacing oral intake where nutritional intake is poor.
Improves clinical outcomes for the patient.
What to give? Fortified foods, snacks, texture modified and dietary
counselling Limited data available to suggest what daily quantities of
ONS’s confer benefits for patients but a daily intake of 250-600kcal has been shown to be of value( Delmi et al 1990;Larson et al
1990;Rana et al 1992 ) individuals with a BMI<20kg/m2 or with a BMI >20kg/m2 but
losing weight are more likely to benefit from the provisional of ONS’s ( Stratton and Elia 1999; Stratton et al 2003 )
when choosing supplements it is probably more effective to choose a variety of different flavours, textures and consistencies to avoid taste fatigue ( Stratton and Elia 1999)
New legislation in the form of The European Commission Directive 1999/21/EC on Dietary Foods for Special Medical Purposes has formalised the categorisation of nutritional products into 3 principal groups ( Article 1.3 ):
1. “Nutritionally complete foods with a standard nutrient formulation
which……may constitute the sole source of nourishment”
2. “Nutritionally complete foods with a nutrient adapted formulation specific
for a disease, disorder or medical condition which …..may constitute the
sole source of nourishment”
3. “Nutritionally incomplete foods with a standard formulation or a nutrient-
adapted formulation……not suitable to be used as the sole source of
nourishment”
Some examples of prescribable sip feeds and supplements ( Taken from Todorovic 2004, Nurses’ Index of Medicines and Products) . Type of supplement
Category of product
Examples Nutritional profile
Comments
Milk tasting 1 Fortisip , Fortisip savoury, Ensure Plus, Clininutrin 1.5, Resource Shake, Fresubin energy
1.5-1.75kcal/ml
most commonly used sip feeds
Milk tasting Fibre enriched
1 Fortisip Multi Fibre, Enrich Plus Fresubin Energy Fibre
1.5 kcal/ml Useful for individuals with constipation or clinical conditions affecting bowel action
Specialist feeds and supplements
2
Juice tasting
3 Fortijuce, Enlive, Provide Xtra , Clinutren Fruit, Resource Fruit Flavour Drink
1.25-1.5 kcal/ml Most suitable for individuals who do not like milk
High protein 3 Fortimel, Fortisip Protein, Protifar ( powder ), Forceval protein ( powder )
Approx 20g protein in 200ml
Modular Energy supplements
3 Polycal, Maxijul, Caloreen, Calogen, Calsip, Polycose, Pro-Cal, Scandishake, Calshake
mainly carbohydrate or fat or mixtures of both
These are more appropriate for use with individuals who need to increase their energy intake but cannot tolerate other supplements or in renal patients where fluid intake needs to be restricted.
What to monitor?
clinical and nutritional status
functional goals
acceptability of diet and supplements
review after stopping supplements to see if any deterioration
Care pathway for nutritionally at risk patients
food fortific ation
monitor to assess ifgoals being met.
If met s top s ip feedsIf not met refer to d ietitian
c hoos ing s ip feeds-1-2 p lus d iet-c ategory 1 ( nut c omp lete)- mixed flavours as may need for months
food fortific ationand sip feeds
sip feedsas sole sourc e of
nutrition(c onsult dietitian )
Dec ide on the typeof nutritionalintervention
S et goals for treatment eg weight gain improve overall nutritional intake
Develop a c linic a l c are p lan- patients in med ium and high r isk
c ategories w ill need some form of nutr itiona l intervention.H igh r isk may need d ietetic intervention
Identify nutr itiona lly at r isk patientsthrough use of a nutritional sc reening tool
'MU S T '
DiqPCT\copd\nutritional pathwyaDi
Nutritional Management of Individuals with COPD
Low risk Score = 0
Medium risk Score = 1
High risk Score = 2
Management Plan
Monitor weight and weight changes at visits. If changes – consider appropriate action
Management Plan Encourage use of
higher energy foods
Initiate use of oral nutritional supplements 1-2/day (300 – 600 kcal) For examples consult Nurses Index 2004 Select from Category 1 products
Review monthly If weight
decreases refer to dietitian
Management plan Encourage use
of higher energy foods
Commence oral nutritional supplements as per med risk
Refer to dietitian for full assessment
Nutritional Screening using the ‘Malnutrition Universal Screening Tool’( ‘MUST’ )
Conclusion
Using a variety of sources of data and information helps to build robust strategies for the nutritional management of patients in the community
nutritional protocols will differ depending on the patient group and should be customised to meet their needs.
Working in partnership with other staff and agencies is key in defining the nutritional needs of their population.