CLINICAL
IMPROVING ONS UPTAKE ON THE WARDS This article explores ways to increase uptake of ONS amongst patients on wards, featuring top tips from other dietitians working in the clinical setting. Oral nutrition supplements (ONS), sometimes referred to as sip feeds, are often prescribed for hospital or community patients who are struggling to meet their nutritional requirements through an oral diet alone.1 ONS products typically contain a mix of macronutrients (protein, carbohydrate and fat) and micronutrients (vitamins, minerals and trace elements), and in large enough quantities (this varies between brands), they are nutritionally complete. However, they are designed to complement oral dietary intake rather than serving as a meal replacement. These specially formulated nutrition supplements are used for medical purposes in patients who meet the Advisory Committee on Borderline Substances (ACBS) prescribing criteria (see Table 1), who have been screened using a validated malnutrition screening tool such as ‘MUST’ and who have been deemed to be at nutritional risk. ONS should be given under medical supervision and must be used appropriately. ONS products are sterile and often come in liquid, powders, or semi-solid textures, meaning there are plenty of options available for patients with different medical and
nutritional needs. For example, texturemodified supplements (such as prethickened liquids or pudding-texture supplements) are available for patients with dysphagia, whilst semi-elemental sip feeds are available for patients with malabsorption/maldigestion. There is a huge variety of options available, with a choice of different energy and protein densities, flavours and volumes. However, they are only effective if they are consumed. Studies have shown that dietary counselling given with or without ONS is effective in increasing nutritional intake and weight.3 Therefore, ONS and a food-first approach are often used in combination.
Harriet Smith Registered Dietitian and Health Writer Harriet is Founder of Surrey Dietitian providing private dietetic consultations and consultancy services, offering evidence-based nutritional advice, backed up by the latest research on food, health and disease. Harriet has written for national, consumer and industry media. www.surrey dietitian.co.uk @SurreyDietitian
APPROPRIATE PRESCRIBING
Recent audit data indicates between 57-75% of oral nutrition prescriptions are inappropriate.4 ONS can seem like an obvious choice for a malnourished hospital patient who is struggling to eat enough; however, it is important to ensure that the patient meets the prescribing criteria mentioned above and that food-first advice has been given. Ensure that a clinically beneficial dose is prescribed (many Trusts consider this to be two sachets/bottles
REFERENCES Please visit the Subscriber zone at NHDmag.com
Table 1: ACBS Indications for ONS2 • Short bowel syndrome
• Disease-related malnutrition (chronic/acute)
• Dysphagia
• Proven inflammatory bowel
• Intractable malabsorption
• Continuous ambulatory peritoneal dialysis (CAPD)
• Bowel fistulas • Pre-operative preparation of patients who are undernourished
• Following total gastrectomy • Haemodialysis
www.NHDmag.com April 2019 - Issue 143
15
CLINICAL
Offer a variety of flavours and always ask the patient if they have a preference regarding milkbased or juice-based supplements.
per day, which provides approximately 500-600 calories per day).5 One bottle could probably be met through food fortification techniques alone. Where appropriate, use an energy-dense high-protein version, as studies have shown that highest compliance with ONS is associated with high-energy sip feeds.6 CHECK SUITABILITY
Standard hospital sip feeds may not be suitable for patients with religious, ethical or cultural requirements who require kosher, halal or vegan supplements. You may need to contact the sip-feed manufacturer to confirm whether the product is appropriate for your patient, and if it isn’t, you may need to source alternative options. Similarly, if your patient has complex medical needs, such as dysphagia, renal disease, or malabsorption, they may require a specific type of sip feed (such as pre-thickened liquids or a semi-elemental sip feed). For patients at risk of refeeding syndrome, the volume of ONS given may need to be built up over several days and refeeding bloods may need to be monitored closely. For diabetic patients, broadly-speaking, it is recommended that they have milk-based or savoury supplements rather than juice-based supplements (which have a higher glycaemic 16
www.NHDmag.com April 2019 - Issue 143
load). However, there may be instances where juice-based ONS is indicated (for example, if the patient has an aversion to milk) and, therefore, regular monitoring of blood sugar levels will be required.1 ENCOURAGE UPTAKE
Dr Clare Shaw, Specialist Consultant Oncology Dietitian at the Royal Marsden, says, “We used to run a cocktail round using ONS and it was loved by patients.” Sian Shepherd, Specialist Gastroenterology Dietitian, added, “It was essentially adding fruit juice/fresh fruit/coffee/ ice cream to different flavoured ONS. Service was really important and we used cocktail glasses and umbrellas to increase uptake.” Sadly, this is no longer offered on a regular basis, but Dr Shaw believes that if the resources are available, it gives ONS uptake a boost. AnnMarie Jones, a Registered Dietitian at University Hospital Southampton, recommends that dietitians ensure the ONS is within reach for the patient and that if the patient can’t open it/feed themselves, they should receive assistance. MDT APPROACH
Build relationships with all the staff on your ward(s) who are involved in food service. For example, ward hostesses can assist with food fortification and opening lids for patients, whilst HCAs, nurses and dietetic assistants can assist with encouraging uptake of sip feeds
CLINICAL and recording consumption on food and fluid charts. Gemma Holloway, Prescribing Support Dietitian, recommends working closely with ward staff to ensure that sip feeds get handed out in the first place. She says, “A good matron is worth their weight in gold for ensuring this happens.” Rachel Whitehall, Registered Dietitian, told me that when she reviews ward patients on ONS, she always tries to bring them a chilled flavour of their choice at the end of their consultation, as it’s one less job for the busy nurses. PATIENT PREFERENCE
Offer a variety of flavours and always ask the patient if they have a preference regarding milk-based or juice-based supplements. Amy Williams, a dietetic student, says that she always double checks which flavours patients prefer and tries to match preferences as much as possible. If patients are not consuming their ONS, ask them why and determine if there is a way to improve uptake. For example, would the patient like to try an alternative flavour, or would they like to have the ONS mixed into a glass of full-fat milk? EDUCATE THE PATIENT
It’s important to explain to patients what ONS is and why it’s needed. Lindsey Allen, Registered Dietitian, recommends teaching ward staff and doctors about the importance of ONS and using a dietetic assistant to help with compliance and encouragement. Claire Irlam, Registered Dietitian at Manchester Royal Infirmary, suggests talking to the patient and explaining the importance of ONS with respect to their priorities. Claire says that patients often don’t care about ONS increasing calories, so, instead, she focuses on the role of ONS in terms of “getting stronger”, “getting home quicker” or “helping your body to heal”. MONITOR
All ONS patients should be regularly monitored to assess whether ONS remains clinically indicated. For example, a patient coming towards the end of their life may not require ONS. Similarly, if oral intake remains poor on
ONS and a patient’s nutritional status continues to decline, enteral feeding may be required.1 Your review might involve monitoring anthropometric changes (such as weight, BMI, handgrip strength, etc),1 speaking with the MDT and asking the patient about oral consumption and ONS compliance. If consumption is poor, work with the patient to come up with strategies to maximise their compliance (such as serving ice with the supplement, or offering alternative flavours). Ensure that you set clear goals and a care plan for all patients on ONS and if ONS is no longer clinically appropriate, it should be discontinued. PLAN AHEAD
Finally, it’s important to think about the aftercare that your patient will require once discharged from hospital. The acute setting also offers an excellent opportunity for you to deliver nutrition education (ie, food fortification advice) to relatives and/or carers on the importance of eating well at home. Given that 93% of malnourished individuals live in the community and 1.3 million are over the age of 65,7 it is important that we line up ongoing nutritional support in the community where indicated. ONS may be included on drug discharge summaries and some patients might be given a small supply to take home. However, if a patient requires ongoing nutritional support, they will likely require a letter to their GP asking for a repeat prescription for ONS, and ideally a referral to the community dietitians. Whilst this is being arranged, you could organise for a sample delivery of ONS to be delivered to their home, as well as provide advice on additional mealtime support (ie, Meals on Wheels). Whilst ONS is clinically effective and is widely used in hospital and community settings, it is not a replacement for oral intake and we shouldn’t underestimate the importance of a food-first approach. Evelyn Newman, Registered Dietitian, told me that in the Highlands, they are actively working to reduce the need for any ONS by proactively promoting a food-first approach by working with caterers to deliver personcentred nutritional support. www.NHDmag.com April 2019 - Issue 143
17
Coming in the May issue:
• Probiotics & paediatric gut health • Tube, naso-gastric & bolus feeding • IMD tyrosinaemia • Short bowel syndrome • Ketogenic diet therapy • Community dietetics • Mental health & depression • Palliative care guidelines _______ Check whether you are eligible for a FREE subscription to
Network Health Digest (NHD) at wwwNHDmag.com . . . Don’t miss a single issue!