staffordshire nutrition support guidelines · staffordshire nutrition support guidelines . 6 steps...

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SSOTP – Staffordshire Nutrition Support Guidelines V1 Produced in collaboration with East Staffordshire Clinical Commissioning Group V2.2

Staffordshire Nutrition Support Guidelines

6 Steps to Appropriate Nutritional Care for Adults And

“Make every Mouthful Matter” food first tool

Guidelines for early identification of malnutrition, first line nutritional support and appropriate use of oral nutritional supplements (ONS).

Guidelines/Gateway Number:

PP-017

Version Number: V2.2 Name of Ratification Committee:

Nutrition Effectiveness Group Safety and Effectiveness Sub Committee

Date Ratified: 22 August 2014 29 August 2014 12 May 2017

Title of Guideline Author: SSOTP Steering Group for Managing Malnutrition in the Community

Title of Guidelines Lead: Professional Lead Dietetics Date Issued: December 2017 Next Date of Review: December 2018 Date of First Issue: September 2014 Target audience: All staff

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CONSULTATION AND RATIFICATION SCHEDULE

NAME TITLE DATE CONSULTED

Nutrition Effectiveness Group

Staffordshire Nutrition Support Guidelines V0

29 May 2014

Malnutrition Matters Task and Finish Group

Staffordshire Nutrition Support Guidelines V0

09 June 2014

South CCG Area Prescribing Group

Staffordshire Nutrition Support Guidelines V0.1

13 – 20 June 2014

Staffordshire and Stoke on Trent Partnership Trust


18 June -19 July 2014

Patient and Carer Group members


27 June – 19 July 2014

Eat Well Staffordshire Project, Age UK.


27 June – 19 July 2014

Nutrition and Dietetic Service, University

Hospital North Staffordshire


27 June – 19 July 2014

SSOTP Quality Governance Committee


16 July 2014

Commission Quality Review Meeting


31 July 2014

Malnutrition Matters Task and Finish Group


5 August 2014

Nutrition and Effectiveness Group


May 2017

Guidelines APPROVED BY: DATE OF

APPROVAL Area Prescribing Group 13 June 2014

Nutrition Effectiveness Group 22 August 2014 Safety and Effectiveness Sub Committee 29 August 2014

Policy Group 12th May 2017 VERSION CONTROL

Guidelines: Staffordshire Nutrition Support Guidelines

VERSION VALID FROM VALID TO DOCUMENT PATH/NAME

V0.1 January 2014 May 2014 Draft V0.2 June 2014 June 2014 Draft V0.3 June 2014 July 2014 Draft V0.4 July 2014 August 2014 Final V2.0 April 2017 May 2017 Draft V2.1 May 2017 December 2018 Final V2.2 December 2017 December 2018 Final

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CONTENTS

PAGE 1. Introduction 4 2. Purpose

4 3. 6 Steps to Appropriate Nutritional Care for Adults. 5 STEP 1- Identification of nutritional risk – MUST and refeeding syndrome 5 STEP 2- Assessment of causes of malnutrition. 6 STEP 3- Setting a treatment goal. 6 STEP 4- Offering food first advice – ‘MAKE EVERY MOUTHFUL MATTER’. 7 STEP 5 - Review - Prescribing Oral Nutritional Supplements (ONS) if no change. 8 STEP 6- Treatment Goal Met? reviewing and discontinuing oral nutritional supplements (ONS).

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4. Inappropriate prescribing of oral nutritional supplements (ONS). 10 5. Over the counter oral nutritional supplements (ONS). 11 6. Oral nutritional supplements (ONS) to prescribe as first line 12 7. Oral nutritional supplements (ONS) which should not routinely be initiated in

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8. Further reading and resources 13 9. Acknowledgements 14

10. Appendices 15

1. Standard Assessment Forms for Nutrition 15

2. Quick reference guide 6 Steps to appropriate nutritional care for adults

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3. Guide to assessing causes of malnutrition 17

4. Make Every Mouthful Matter resource pack

5. Malnutrition Universal Screening Tool (MUST)

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1. Introduction These guidelines advise on the screening process and intervention to support the nutritional journey of adults at risk of malnutrition within the population we serve.

They are based on evidence based guidance as detailed in Managing Adult Malnutrition in the community (2012), including a pathway for the appropriate use of oral nutritional supplements (ONS).

2. Purpose

The guidelines aim to assist health and social care professionals and third sector colleagues with the early identification of malnutrition and first line Nutritional support. The guidance also supports value based commissioning through a process which support the appropriate use of oral nutritional supplements (ONS) by prescribers and those responsible for monitoring progress. Other members of the community care team including dietitians, community nurses and matrons, community geriatricians, end of life nurses and other specialist nurses, should also refer to this information in making recommendations to support those identified as requiring nutritional support. These guidelines may not be appropriate for people who are in the final days of life. Please refer to specialist support services for advice. It is the duty of care of those who are using these guidelines to ensure they are competent to adhere to the guidelines. Please contact the Nutrition and Dietetic Service for support if required http://www.staffordshireandstokeontrent.nhs.uk/Services/dietetics_2.htm

Advice is also offered within the guidelines on inappropriate prescribing and when it is appropriate to refer to community dietetic services.

The Malnutrition Universal Screening Tool (MUST) is a validated screening tool for malnutrition and is used throughout the NHS in primary and secondary care. It was developed by a multi-disciplinary group of healthcare professionals. It includes appropriate care plans and so can influence clinical outcomes. This tool should be used to identify the risk of malnutrition within the pathway.

It can be accessed at www.bapen.org.uk/screening-for-malnutrition/must-calculator. An ‘app’ is also available for users of smartphones (search for ‘BAPEN MUST’) which provides a simple to use MUST calculator. Please contact the Nutrition and Dietetic Service for support if required.

http://www.staffordshireandstokeontrent.nhs.uk/Services/dietetics_2.htm

http://www.bapen.org.uk/screening-for-malnutrition/must-calculator

http://www.bapen.org.uk/screening-for-malnutrition/must-calculator

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3. 6 Steps to Appropriate Nutritional Care for Adults

Adapted from 6 Steps to Appropriate Prescribing ONHS, NHS Hertfordshire (June 2010)

STEP 1 - IDENTIFICATION OF NUTRITIONAL RISK

NICE Clinical Guideline 32, Nutritional Support in Adults, suggests the following criteria are used to identify those who are at nutritional risk or are malnourished. If one of these criteria is identified then implement the pathway:

• Must Score of 1 or more • Body mass index (BMI) less than 18.5kg/m2 • Unintentional weight loss more than 10% in the past 3-6 months

• Body Mass Index (BMI) less than 20kg/m2 and an unintentional weight loss more than 5% in the past 3-6 months

• Those who have eaten little or nothing for more than 5 days • Those who have poor absorptive capacity or high nutrient losses

Referral to the dietetic service: Refer to the dietitians if one of the following criteria are met:

• MUST score of 2 with no improvement following ‘the 6 Steps to Appropriate Nutritional Care’

• MUST score of 3 or more • Patients for whom supplements are a sole source of nutrition • Those who require alternative feeding such as nasogastric (NG) or Percutaneous

Endoscopic Gastrostomy (PEG) feeding. Please use standards Dietetic referral forms available from: https://www.staffordshireandstokeontrent.nhs.uk/Services/dietetics_2.htm continue to follow the 6 Steps to Appropriate Nutritional Care offering food first advice as outlined in Step 4. Patients at high risk of developing re-feeding problems should be referred to their GP to ensure adherence of NICE 32. The criteria for determining this is one or more of the following:

• Body Mass Index (BMI) less than 16kg/m2 • Unintentional weight loss greater than 15% within the last 3-6 months • Little or no nutritional intake for more than 10 days • Low levels of potassium, phosphate or magnesium prior to feeding.

Or patient has two of more of the following: • Body Mass Index (BMI) less than 18.5 kg/m2 • Unintentional weight loss greater than 10% within the last 3-6 months. • Little or no nutritional intake for more than 5 days • A history of alcohol abuse or drugs including insulin, chemotherapy, antacids or diuretics

https://www.staffordshireandstokeontrent.nhs.uk/Services/dietetics_2.htm

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STEP 2 - ASSESSMENT OF CAUSES OF MALNUTRITION

Once nutritional risk has been established, the underlying cause and treatment options should be assessed and appropriate action taken. Consider: • Ability to chew and swallowing issues • Impact of medication • Physical symptoms e.g. pain, nausea, vomiting, constipation, diarrhoea • Medical prognosis • Environmental and social issues • Psychological issues / low mood • Tissue viability / skin integrity • Substance or alcohol misuse

Review the treatment plan in respect of these issues and if needed make appropriate referrals. See Appendix 3 - A Guide to Assessing Underlying Causes of Malnutrition and Treatment Options.

STEP 3 - SETTING A TREATMENT GOAL

Clear treatment goals and a care plan should be agreed with patients using a person centered approach. Treatment goals should be documented on the patient record and should include the aim of nutritional support, timescale, be realistic and measurable. This could include:

• Target weight, or target weight gain, or target Body Mass Index (BMI) over a period of time

• Wound healing if relevant, e.g. pressure ulcer management • Weight maintenance where weight gain is unrealistic or undesirable

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STEP 4 - MAKE EVERY MOUTHFUL MATTER – offering food first advice

(Please refer appendix 4) Oral nutritional supplements (ONS) should not be used as first line treatment. A ‘food first’ approach should be used initially. This means offering advice on food fortification to increase calories and protein in everyday foods. Additional snacks will be needed to meet requirements for those with a small appetite. Please follow the 3 – 2 – 1 DAILY MEAL PLANNER advice

3 Aim for 3 fortified meals a day ie. breakfast, lunch and evening meal.

These meals should be fortified by adding extra goodness

• Add full fat milk to porridge and breakfast cereal* • Add sugar to drinks and cereals* • Add jam to cereal / porridge / toast* • Add butter to bread, potatoes and vegetables* • Add full fat mayonnaise/salad cream to sandwich fillings/salads* • Add cheese to soups and potatoes*

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At least 2 high energy snacks each day

Cheese and crackers with butter* Full fat yoghurt* Crisps* Custard pots* Cake* Milky drinks* Biscuits (not plain), chocolate covered, flapjacks, cake* Toast with butter and jam / peanut butter / chocolate spread /cheese / full fat

cheese spread. Scone or bun or teacake with butter Sandwich with butter and meat / fish / cheese/ peanut butter Mini pork pie, sausage roll, cocktail sausage, mini scotch egg, quiche Any nuts

*Available in our Community Hospitals 1

USE 1 PINT of fortified milk daily

To make fortified milk add 4 heaped tablespoons of dried skimmed milk powder to 1 pint of whole (full fat) milk, stir well or whisk to dissolve. Use this on cereal, in tea/coffee, in milky drinks ie milkshake, hot chocolate, coffee, Horlicks, in puddings, in milk based soups and sauces. In community hospitals where milk powder may not always be available use full fat milk. Encourage Meritene® Soups and milkshakes available from Catering/Sodexo. If patients prefer, they can purchase over the counter products such as Meritene®Complan® Nurishment Extra®, Aymes milkshakes or soups. Nutritional content of these products are shown on page 11.

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STEP 5 – R E V I E W

PRESCRIBING ORAL NUTRITIONAL SUPPLEMENTS (ONS) IF NO CHANGE. Patients MUST care plan and treatment goal should be reviewed within one month in the community and after one week in community hospitals, ideally by the person who initiated assessment. If there is a positive change towards meeting goals, the changes should be encouraged and maintained and a further review arranged until goals are met. If a ‘food first’ approach has failed to achieve a positive change towards meeting goals after one month, one week for those in community hospitals and there is clear evidence that all attempts have been made to optimize this approach consider prescribing oral nutritional supplements (ONS) in addition to the ‘food first’ changes which should be maintained.

Patients must meet at least one of the Advisory Committee for Borderline Substances (ACBS)* criteria below to be eligible for prescribed oral nutritional supplements (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

Patients who do not meet ACBS prescribing criteria can also be advised to purchase supplements over the counter or prepare homemade nourishing drinks.

Advice on starting prescribed ONS To maximise their effectiveness and avoid spoiling appetite, patients should be advised to

take oral nutritional supplements (ONS) between or after meals and not before meals or as a meal replacement

To be clinically effective it is recommended that oral nutritional supplements (ONS) are prescribed twice daily. This ensures that calorie and protein intake is sufficient to achieve weight gain

A one week prescription or starter pack should always be prescribed initially to avoid

wastage in case products are not well tolerated. In community hospitals patients should only be offered the exact ons prescribed for that patient. If a patient is refusing their supplements they should be reviewed by the Dietitian/prescriber. Please follow Community Hospitals Care Management Pathway for Declined Prescribed ONS.

Avoid adding prescriptions for oral nutritional supplements (ONS) to the repeat template unless a short review date is included to ensure review against goals

*NHS England and Wales Drug tariff www.ppa.org.uk/ppa/edt_intro.htm List in section XV of the drug tariff refers to Advisory Committee Borderline Substances (ACBS).

http://www.ppa.org.uk/ppa/edt_intro.htm

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STEP 6 – T R E A T M E N T G O A L M E T ?

REVIEWING AND DISCONTINUING ORAL NUTRITIONAL SUPPLEMENTS (ONS) Patients on oral nutritional supplements (ONS) should be reviewed regularly following the advice in these guidelines, to assess progress towards goals and whether there is a continued need for oral nutritional supplements (ONS) on prescription. The following parameters should be monitored:

• Weight/Body Mass Index (BMI)/wound healing depending on goal set – if unable to weigh

patient, record other measures to assess if weight has changed e.g. mid-upper arm circumference, clothes/rings/watch looser or tighter, visual assessment

• Changes in food intake and / or appetite • Compliance with oral nutritional supplements (ONS) and stock levels at home/care home

When conducting general medication reviews, oral nutritional supplements (ONS) should be included as above.

Advice on discontinuing prescriptions

• When treatment goals are met, discontinue prescriptions • Review three months after discontinuation of oral nutritional supplements (ONS) or sooner

dependent on need to ensure that there is no recurrence of the precipitating problem

If the patient no longer meets Advisory Committee for Borderline Substances (ACBS) criteria, or goals are met, but still wishes to take oral nutritional supplements (ONS), suggest over the counter products e.g. Aymes, Meritene®, Complan® or Nurishment Extra®. Information regarding nutritional content are shown on page 11.

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4. Inappropriate Prescribing of Oral Nutritional Supplements (ONS)

Care homes should provide adequate quantities of good quality food to avoid unnecessary nutrition support. Oral nutritional supplements should not be used as a substitute for the provision of food. Suitable snacks, food fortification as well as homemade milkshakes and smoothies and over the counter products can be used to improve the nutritional intake of those at risk of malnutrition. Patients who are discharged from hospital on oral nutritional supplements with no ongoing dietetic review process in place will not automatically require oral nutritional supplements on prescription once home. They may have required oral nutritional supplements whilst acutely unwell or recovering, but once home and eating normally the need is negated. Therefore it is recommended that oral nutritional supplements are not prescribed following hospital discharge without first assessing need in line with the 6 steps to appropriate nutritional care. Where oral nutritional supplements are still required, a switch to first line community products is recommended following locally agreed prescribing guidelines unless specific recommendations in a discharging letter have been made by Hospital Dietitian. The ons recommended and treatment plan should then be prescribed and followed. Avoid prescribing less than the clinically effective dose of 2 sachets/bottles daily which will provide 600-800kcals/day. Once daily prescribing provides amounts which can be met with food fortification alone and will delay resolution of the problem. Patients with complex nutritional needs e.g. renal disease, liver disease, swallowing problems, poorly controlled diabetes and gastrointestinal disorders may require specialist products and should be referred to local community dietetic services. Patients with swallowing problems will require assessment by a Speech and Language Therapist before dietetic input. Patients with diabetes should not routinely be prescribed fruit juice based oral nutritional supplements i.e. Fresubin Jucy®, Resource Fruit®, Fortijuce®, Ensure Plus Juce®. These products have a higher glycaemic index, and blood glucose levels will need monitoring, with possible changes required to medication. Patients in the final days or weeks of life are unlikely to benefit from oral nutritional supplements. Over the counter products can be recommended if required.

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5. Over The Counter Oral Nutritional Supplements

If patients prefer and or do not meet the ACBS criteria and cannot meet their additional nutritional requirements through a food first approach alone, they can purchase over the counter nutritional supplements such as Complan®

milkshakes or soups, Aymes®, Meritene®, Nurishment® milkshakes or soups, or unless contraindicated (i.e. Poorly controlled diabetes, chronic kidney disease stage 3-4, liver disease (Seek advice from a dietitian). Over the counter products can also be useful store cupboard items for those who have variable appetites and oral intakes to stop them becoming nutritionally compromised. These products are available from some supermarkets, pharmacies and also from online pharmacies.

These products are not suitable as sole source of nutrition and should not be used as tube feeds.

Powdered Products

Presentation Nutritional content Per sachet mixed with

200ml full fat milk Meritene®

270g tin and 30 g sachets Vanilla, banana, strawberry, and chocolate flavours Not available routinely in Pharmacies but can be ordered in if requested by patients

200kcals 16g protein when mixed with 200ml

semi skimmed milk

Complan®

4 x 57g sachets Vanilla, banana, strawberry, chocolate and neutral flavours

241-244kcals 8.5g protein

when mixed with water

Aymes 4 x 38 g sachets

Vanilla, strawberry, chocolate, banana.

265 Kcals 15g protein

when mixed with whole milk

Powdered Products

Presentation Nutritional content per 100g powder

Complan® stir in

1 box of 450g neutral flavour 438kcals 15.3g protein

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Soups Presentation Nutritional content Per sachet mixed with

200mls water Meritene®

soup

1 box of 4 x 50g sachets Chicken, vegetable

207kcals 7g protein

mixed with water

Complan®

soup

1 box of 4 x 57g sachets of chicken flavour.

243kcals 8.7g protein mixed

with water

Aymes®

4 x 49 g sachets – Chicken flavour 207 kcals 7.7g protein

mixed with water

Liquid Products

Presentation Nutritional content per unit

Nurishment ®original

400g tin Vanilla, banana, strawberry,

raspberry, cherry and chocolate flavours

Per 400g can - 380-424kcals 20g protein

Nurishment® Extra

310ml bottle Vanilla, banana, strawberry

and chocolate flavours

Per 310 bottle - 329-335kcals 12g protein

Complan® Smoothie

250ml tetrapak Tropical and berry flavours

Milkshakes - - 250ml – chocolate and strawberry flavors

Per 250 ml - 272kcals 9.8 – 10 g protein

Per 250 ml -214 – 222Kcal 8.9 g protein

6. Oral Nutritional Supplements to be Prescribed as First Line Please refer to local prescribing agreements. Prescribe supplements which have a minimum 1.5kcal/ml or above.

7. Oral Nutritional Supplements Which Should Not Routinely

Be Initiated In Primary Care.

Dietitians may make clinical decisions to use other oral nutritional supplements where first line products are not sufficient to meet individual patients’ nutritional needs. However these patients should always be under review by the dietitians. The list includes:

Low calorie products i.e. 1kcal/ml since these are not cost effective Milkshake style oral nutritional supplements which are not first or second

line products in primary care Modular supplements which do not provide a balance of nutrients Specialist products which may be required for particular patient

groups e.g. renal patients, or those with bowel disorders, those with

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pressure ulcers, or those with dysphagia Puddings or soups as it should usually be possible for suitable

homemade products to be fortified It is not a fully comprehensive list. Please discuss with your local Dietitian for further advice. 8. Further Reading And Resources

British National Formulary. www.bnf.org.uk

Cochrane Collaboration (2007). ‘Dietary advice for illness-related malnutrition in adults (review)’, The Cochrane Library. www.cochrane.org

Elia M. (Chairman and Ed 2003) MUST Report : Nutritional screening of adults : a multi-disciplinary approach.

Elia M., Stratton,R.J., Russell et al (2005). The cost of malnutrition in the UK

and the economic case for the use of oral nutritional supplements (ONS) in adults. British Association Parenteral and Enteral Nutrition (BAPEN) www.bapen.org.uk

Elia M., and Russell CA (Eds). Combating Malnutrition; Recommendations for Action. A report from the Advisory Group on Malnutrition, led by BAPEN (2009).

London Procurement Programme: A guide to prescribing oral nutritional supplements in nursing and care homes (2011). www.lpp.nhs.uk

Malnutrition Universal Screening Tool (MUST). www.bapen.org.uk

Managing Adult Malnutrition in the Community (including a pathway for the appropriate use of oral nutritional supplements (ONS) . Produced by a multi-professional consensus panel including the RCGP, RCN, BDA, BAPEN, PCPA. (2012) www.malnutritionpathway.co.uk

Manual of Dietetic Practice.5

th ed. Blackwell Publishing Ltd. (2014) MIMS monthly prescribing guide. www.mims.co.uk National Institute for Health and Clinical Excellence (NICE) Clinical Guideline 32 ‘Nutrition support in adults: oral nutrition support, enteral tube feeding and parenteral nutrition’ updated in August 2017 www.nice.org.uk National Institute for Health and Clinical Excellence (NICE). Cost saving

guidance. www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidan

ce.jsp

http://www.bnf.org.uk/

http://www.cochrane.org/

http://www.bapen.org.uk/

http://www.lpp.nhs.uk/

http://www.bapen.org.uk/

http://www.malnutritionpathway.co.uk/

http://www.mims.co.uk/

http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidan%09ce.jsp

http://www.nice.org.uk/usingguidance/benefitsofimplementation/costsavingguidan%09ce.jsp

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National Institute for Health and Clinical Excellence (NICE) Quality standard for nutrition support in adults. NICE QS24 Nov 2012. www.guidance.nice.org.uk/qs24

National Minimum Standards for Care Homes for Older People. Dept of Health (2003). www.dh.gov.uk

National Prescribing Centre. Prescribing of adult oral nutritional supplements (ONS). Guiding principles for improving the systems and processes for ONS use. www.npc.nhs.uk/quality/ONS/resources/borderline_substances_final.pdf

Prescribing Toolkit provided by NHS Prescription Services. Information provided by the Information Centre for Health and Social Care, October 2011

PrescQIPP NHS Midlands and East. Fabulous Fortified Feasts (2012) a collection of fortified recipes. www.clingov.eoe.nhs.uk/prescqipp/index.php/gg-fabulous-fortified-feasts

Royal College of General Practitioners (2006). ‘Prescribing in Primary Care’ Accessed online: www.rcgp.org.uk

Stratton RJ, and Elia M. Encouraging appropriate, evidence based use of oral nutritional supplements. Proc Nut Soc 2010; 69(4):477-487

9. Acknowledgements

6 Steps to Appropriate Nutritional Care for Adults - Care Pathway has been adapted from 6 Steps to Appropriate Prescribing ONHS, NHS Hertfordshire (June 2010)

The following healthcare professionals contributed to the original development of this document as part of the Steering Group:

o Dr Joanne Fillingham, Professional Head of Allied Health Professions, SSOTP

o Gillian Rudge, Prescribing Support Lead Dietitian, ESCCG and SSOTP

o Charlotte Jackson, Specialist Dietitian, SSOTP o Laura Hill, Specialist Dietitian, SSOTP o Marie Skerry, Advanced Dietitian, SSOTP o Cath Babington, Dietetic Assistant SSOTP

http://www.guidance.nice.org.uk/qs24

http://www.dh.gov.uk/

http://www.npc.nhs.uk/

http://www.clingov.eoe.nhs.uk/prescqipp/index.php/gg-fabulous-fortified-feasts

http://www.rcgp.org.uk/

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10. Appendices

Appendix 1 Standard Assessment Forms Community MUST Nutrition Screening Form: http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0046-DTC%20DIT%20Community%20Must%20Nutrition%20Screen%20V2.0.pdf Community MUST monitoring Form: http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0047-DTC%20DIT%20Community%20Must%20Nutritional%20Assessment%20Monitoring.pdf Community Hospital Nutritional Assessment Form: Community Hospital Food Diary: http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0726-CH%20Food%20Diary%20Chart%20V2.0.pdf Make Every Mouthful Matter Leaflet: http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0049-DTC%20Make%20Every%20Mouthful%20Matter.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0046-DTC%20DIT%20Community%20Must%20Nutrition%20Screen%20V2.0.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0046-DTC%20DIT%20Community%20Must%20Nutrition%20Screen%20V2.0.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0047-DTC%20DIT%20Community%20Must%20Nutritional%20Assessment%20Monitoring.pdf



http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0726-CH%20Food%20Diary%20Chart%20V2.0.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0726-CH%20Food%20Diary%20Chart%20V2.0.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0049-DTC%20Make%20Every%20Mouthful%20Matter.pdf

http://ssotp.ns.xnsht.nhs.uk/cp/sa/shared/A-0049-DTC%20Make%20Every%20Mouthful%20Matter.pdf

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Appendix 2 Quick Reference Guide 6 Steps to Appropriate Nutritional Care for Adults - Care Pathway

STEP 1 – Identification of Nutritional Risk – if there is a MUST score of 1 move to STEP 2 Refer to Dietetic service (and also commence pathway) if:

• MUST score of 2 or more with no improvement following 6 Steps to Appropriate Nutritional Care

• On ONS as their sole source of nutrition • Require artificial nutritional support eg Nasogastric/Percutaneous Endoscopic

Gastrostomy Patients at high risk of developing re-feeding problems should be referred to their GP to ensure adherence of NICE 32 – see pg. 5

STEP 2 – Assess underlying causes of malnutrition and availability of adequate diet Make changes to treatment plan and refer to other services as needed.

STEP 3 – Set a treatment goal and devise a nutrition care plan

STEP 4 – MAKE EVERY MOUTHFUL MATTER - offer food first advice 3 – 2 – 1 DAILY MEAL PLANNER advice

STEP 5 – Review after 1 month in community and 1 week in community hospital. Has there been progress towards goal set?

Yes, there is progress towards goal set: • Reinforce advice • Reassess after 1-3 months in community

and 1 week community hospital.

Continued progress or improvement: • Reinforce advice • Reassess after 1-3 months in community

and 1-2 weeks community hospital, until goal met.

STEP 6 – Treatment goal met • Discontinue ONS if prescribed on a

phased approach • Review after 3 months • If problems reoccur – return to start of flow

chart.

No progress towards goal set: • Reinforce Make Every Mouthful

Matter ‘food first’ advice. • Reassess underlying problems and

treat/refer on as appropriate. • Prescribe ONS as per guideline (if

meets ACBS criteria) in addition to fortified foods. If does not meet ACBS criteria recommend over the counter supplements

• Reassess after 1 week trial of first line ONS and prescribe preferred flavour bd for 1-3 months then review.

No progress or improvement – refer to dietetic services

www.staffordshireandstokeontrent.nhs.uk/services/dietetics.htm)

http://www.staffordshireandstokeontrent.nhs.uk/services/dietetics.htm

http://www.staffordshireandstokeontrent.nhs.uk/services/dietetics.htm

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Appendix 3 Guide to assessing causes of malnutrition

A guide to assessing underlying causes of malnutrition and possible actions/solutions

PP

Refer to dentist and advise patient on appropriate /soft diet

Alcohol or other substance misuse

Refer to Community Drug and alcohol services

Refer to social services

Suggest home delivery of food and or refer to social service/Casserole club and EatWell

Refer to Speech and Language Therapy

GP management, counselling, social clubs, day centres, mental health team

GP and/or Community Matron and/or District Nursing management, consider appropriate medication

Experiencing financial difficulties

Unable to do own shopping and/or cook and/or feed self

Difficulties with swallowing or unable to swallow

Poor dentation

Poor emotional or mental health e.g. depression, isolation, bereavement

Medical conditions causing poor appetite, nausea etc e.g. cancer, COPD, diarrhoea, constipation

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Appendix 4 Make Every Mouthful Matter Leaflet

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Appendix 5 MUST Screening Tool

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