Sip feeds: dietetic prescribing

do dietitiAnS need to Be SiP feed PreSCriBerS?

dimple thakrar Prescribing Support dietitian, bolton clinical commissioning group (ccg)

dimple works with Bolton gPs and onS prescribers to advise and provide training on appropriate onS prescribing and food first. She is also a member of the BdA Prescribing Support dietitians, neurosciences Specialist, freelance dietitians groups and a BdA media spokesperson.

looking at the sip feed Project in Bolton

Malnutrition can be defined as: ‘a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein and other nutrients causes measurable adverse effects on tissue/body form (body shape, size and composition) and function and clinical outcome’ (1).

The cost of disease-related malnutrition is in excess of £13 billion per year, of which ~93 percent live in the community (2). Tackling malnutrition can improve nutritional status, clinical outcomes and reduce healthcare use (2). The National Institute for Health and Clinical Excellence (NICE CG32) has shown that substantial cost savings can result from identifying and treating malnutrition, CG32 is ranked third in the top clinical guidelines shown to produce savings (3).

Sip feeds are often used to treat malnutrition; however, they should only be considered when diet alone has proved to be, or clearly will be, insufficient to sustain or improve oral intake (4). Sip feeds are also referred to as oral nutritional supplements (ONS).It has been documented that ONS are often prescribed without involvement of a dietitian and with no attempt to improve oral intake by conventional dietary methods (4).

the ProJect PurPoSe Over the last two years there has been a significant rise in spend on ONS in Bolton. In 2011/12 the amount spent was in the region of £1.4m and in 2012/13 it was £1.5m (sourced from 5). This represents an average growth of nine percent year on year to Bolton Clinical Commissioning Group (CCG).

The purpose of this project was to establish the current prescribing practices of sip feeds within Bolton CCG to ensure the NHS commitment to providing best value for taxpayers money and the most effective, fair and sustainable use of finite resources (6). The prescribing of ONS has a significant impact on local prescribing budgets which are often prescribed inappropriately due to of lack of dietetic assessment (4). In order to identify if the CCG was spending inappropriately on ONS, a Medicine Optimisation Dietitian (MOD) was employed with the aims discussed below.

ProJect AIMS • Identify and evaluate current inappropriate ONS prescribing within the CCG for adults in Bolton Community, who are not under the care of a dietitian. • Audit the presence of nutritional screening by GPs or in care homes prior to prescribing ONS. • Stop and reduce inappropriate prescribing by investing in dietetic support. • Support GPs with screening, assessing and treating malnutrition appropriately. • Develop guidance on nutritional screening and prescribing of ONS for adults in Bolton community. • Educate prescribers of ONS on appropriate prescribing and the principles of ‘food first’

Food first, being defined as ‘using everyday foods to increase protein and/ or energy density of the diet, including drinks’, is often achieved through adding high fat/carbohydrate/protein foods/ drinks to the diet in food and/or drinks. It is not intended to achieve nutritional completeness for micronutrients.

figure 1: Summary of data collected and cost savings

subject

Stopped sip reduced sip changed sip

Increased sip

Started on sip feeds referred to community dietetics take patient off community dietetic waiting list no further dietetic intervention needed referred back to the gP for monitoring referred back to hospital consultant

Calculated rounded monthly cost savings

Calculated rounded annual savings

PIlot ProJect delIvery All patients who met the project criteria (see below) were assessed by the dietitian. Those who did not attend were assessed by telephone consultation. Appropriate nutritional care plans were agreed with all patients, including advice on ONS. Individual GP practice data was collated and then summarised for the seven practices detailed in Figure 1.

ProJect IncluSIon crIterIA • Over 18 years old • Currently being prescribed a ONS and not under the supervision of a dietitian • Not enterally tube fed • Not on palliative care register • Not diagnosed with an eating disorder

The cost saving/avoidance has been calculated from the sum of the cost of the ONS discontinued and is only indicative of that moment in time and will be referred to as cost saving in this article.

reSultS Total number of patients seen: 117 (see Fig. 1).

concluSIon • 88 percent of the sip feeds being prescribed were inappropriate at the time of dietetic review. • The cost of the inappropriate prescribing calculated though cost avoidance was in the region off £156,000/annum.

total no patients total in %

103 88

1

12 0.85

10

1 0.85

0 0

1

2 0.85

1.7

54

32 46

27

0 0

~£12,000 ~£156,000 ~53% from total annual spend

• Over half of the spending on ONS prescribing could be saved with appropriate prescribing. • Though this was not collated, there was little evidence of nutritional screening, assessment, or monitoring of patients on ONS from the documentation.

Anecdotal evidence suggests that the reasons for the inappropriate ONS prescribing were often due to: • unclear written or verbal communication as to clinical reasoning for starting and stopping ONS; • GPs lack of knowledge/confidence with food first and criteria for use of ONS; • lack of patient monitoring on ONS; • high volume of requests for ONS from care homes without establishing adequate food first techniques; • lack of dietetic involvement when ONS are commenced; • GPs welcomed the input from the dietitian and acknowledged the above.

recoMMendAtIonS • To extend the project for the whole of the Bolton population. • The need for GP and staff Training GP on: 1. appropriate sip feed prescribing 2. food first • To collect data on nutritional screening and

ONS initial prescribing source.

Source: nhS business Services Authority december 2014, Advisor: Jole hannan, clinical effectiveness Pharmacist, bolton ccg

MAIn ProJect Project design: The project was extended in the same format for 12 months, to cover the remaining 43 GPs. In addition, Prescribing Guidelines for the appropriate use of oral nutritional supplements (ONS) in the community (adults) (PGONS), July 2014, were developed to support GPs and provide food first handouts for patients.

Following the patient assessment phase, an individual GP practice training programme was developed for all practice staff. This included: • a Practice Patient Data Summary Report, aiming to ensure that the training was relevant and pertinent to each practice; • a cost saving and incidence analysis of inappropriate ONS prescribing presentation; • a food first interactive game aiming to raise awareness of food first and increase knowledge of ONS nutritional contents and appropriate prescribing; • guidance on implementing the PGONS; • personalised practice recommendations aiming to provide future guidance; • a simple two-part project evaluation questionnaire.

reSultS: Forty GP practices were included in the project. Two had no patients that met the criteria and one practice refused to participate. 154 patients received dietetic review (average age 71 years old). The total cost savings were in the region of £152,000 per annum for the 40 practices; which equates to an average of approximately £1,000/ patient/annum.

Only one out of 154 showed evidence of appropriate screening, i.e. MUST and % weight loss recorded in the GP patient notes. However, it is common practice for care homes to collect MUST scores and body mass index (BMI), but there was no documented evidence of this on request for ONS.

There were no differences found in prescribing trends of ONS in care homes compared to patients in their homes. However, there was a greater incidence of under usage of ONS in patients in their own home, i.e. patients not taking their full prescribed dose of ONS. This suggests that patients when unmonitored by trained staff struggle to tolerate the directed dose of ONS as their food intake increases. This highlights the need for close monitoring, while a patient is on ONS to support the weaning off process and reduce wastage as per the PGONS.

The majority of GPs were trained on food first and the PGONS with the exception of three who either declined or were unable to complete the training within the project time frame.

The PGONS was made available to all GPs and hospital prescribers with the aim to reduce further inappropriate ONS prescribing and promote food first.

Figure 2 demonstrates the impact of dietetic intervention (started January 2014) on cost savings compared to Greater Manchester and National trends.

Qualitative data gathered following the practice training was very positive and in summary staff reported the following: • The training to be greatly needed and to be provided annually. • Very practical and easy to apply to practice. • The Food First Patient leaflets were well received. • Staff felt more confident to use food first as a first line approach over prescribing ONS. • Appreciated the importance of monitoring patients regularly.

The limitations of this project are: • True cost savings over time were not collected due to the short project time, i.e.12 months. • Due to the limited dietetic funding, patients could not be reviewed and, while detailed instructions on monitoring and reviewing nutritional status was given to the GP and/or practice nurse, clinical outcomes could not be measured.

concluSIonS Specialist dietetic intervention has been shown to reduce inappropriate spending on ONS in Bolton and achieved the aims of this project. It was evident from GP feedback that the training was a crucial part of the project, which will need to be continued to ensure sustainable and clinically safe cost savings. Further dietetic input is needed to continue to support clinically safe, cost savings in ONS prescribing, particularly in assisting prescribers to maintain safe and appropriate nutritional care, as well as enabling clinical outcomes to be measured and reported over a greater period than 12 months.

nutrItIonAl recoMMendAtIonS for gPS And other onS PreScrIberS • Assess nutritional status appropriately and set nutritional measurable goals. • Treat early signs of malnutrition with food first if appropriate. • Avoid ONS on repeat prescriptions. • Monitor, review and act upon nutritional changes. • Stop ONS when nutritional goals have been achieved. Recommendations for dietitians: • When communicating with GPs state clearly and concisely when and by whom review and monitoring of nutritional status should be completed. • Always consider food first as first line approach. • When first recommending ONS, ensure clear goals are agreed with the patient, carers, staff and prescriber, including how long the patient should expect to remain on

ONS. • Be aware of the cost of ONS in Primary care. • Indicating clearly with dates, where possible, when ONS should be discontinued. • Promote dietetics by optimising on (ad hoc) training opportunities with GPs, i.e. in practice meetings or in passing when discussing patients.

future thoughtS It is clear from this project that those patients on ONS who aren’t under the supervision of a dietitian need close monitoring to ensure that their nutritional needs are being met appropriately and cost effectively, thus ensuring that the NHS runs efficiently.

Is it time to pass ONS prescribing over to dietitians and use the cost saving demonstrated in this project to invest in dietitians? Let’s use every opportunity to fly the flag for dietetics. We are the nutrition experts!

references 1 www.guidelinesinpractice.co.uk/eguidelinesmains/index/page/5/www.gov.uk/www.dh.gov.uk/about_gip 2 Managing adult Malnutrition in the Community. Including a pathway for the appropriate use of oral nutritional supplements (ONS). www. Malnutrtionpathway.co.uk 3 NICe CG32 4 Manual of Dietetic Practice (2007) 5 Health and social Care Information Centre (Dec 2014) 6 The NHS Constitution (2013)

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