NHD clinical -
- sip feeds
by Alison Smith Specialist Dietitian, Peterborough Community Services
Alison Smith specialises in oral nutrition support in elderly care homes and in nutrition support in progressive neurological conditions. She is PR Officer for NAGE (a post that she also held between 2003 and 2007).
Sip feeds: a subject for debate?
Sip feeds are undoubtedly an important weapon in our fight against malnutrition, a problem which is only going to get worse as the population ages and the elderly population increases. But how cost effective are they and can wastage be managed?
At the BDA Conference on the 23rd of this month (June) a session entitled ‘The Big Debate’ will argue that ‘This house believes that dietitians should promote ‘food first’ as an ef- fective approach to the treatment of malnutrition’. The argu- ments for and against the use of food first are, quite cor- rectly, around the evidence of its effectiveness. On one side is the claim that the evidence we have demon- strates that sip feeds are an effective treatment of malnutri- tion and that the evidence for food first does not demonstrate this. On the other side is the claim that it is not that evidence for food first shows it is ineffective as a treatment, but more that the evidence is simply not there, as food first has not been adequately researched. It would therefore be very good to see a well-designed research trial conducted that looks at comprehensive food first advice versus sip feed use, but of course funding for this could be an issue.
Cost effectiveness
Sip feeds are undoubtedly an important weapon in our fight against malnutrition, a problem which is only going to get worse the elderly population increases. However, it is essential that we are as cost-effective in our use of these products as possible.
under frequent scrutiny from community trusts. Pharmacy teams and GPs must bear the cost of sip feed prescribing in the community, including those initiated in acute care. It is no real surprise then that GPs may not always be willing to prescribe sip feeds when requested to do so, as they can be viewed as expensive and unnecessary, due partly to past experience of inappropriate requests for sip feeds.
NICE guidelines
'Wasted sip feeds have a big cost implication for the NHS as under current guidance most areas of the country are unable to re-use sip
feeds which have been dispensed, even if they remain unopened.'
There is often a disparity between the cost of sip feeds in hospitals compared to those products within the community. In many hospitals, contracts with nutrition companies mean that sip feeds cost as little as 1p per bottle, making them a very cost-effective way of dealing with malnutrition in acute care with or without input from a dietitian. This low cost also demonstrates why there may be a lack of motivation for hos- pitals to adopt food first approaches. Sip feeds available this cheaply will always be more cost-effective than any amount of ‘real’ food, as the latter requires staff time and preparation and is therefore infinitely more expensive to provide. However, when the patient who has been on sip feeds in hospital is discharged into the community with a request for continued prescription, the cost of these same sip feeds suddenly rockets (the cost of the same 200ml 1.5 kcal/ml sip feed in the community is £1.55 to £1.91 per bottle). In these cash strapped times, GPs prescribing can be
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NICE has recently issued guidance on the implementa- tion of its guidelines which will potentially deliver the most cost savings – ‘CG 32 Nutrition support in adults’ comes third on the list, beaten only by ‘Hypertension’ and ‘Long acting reversible contraception’. NICE states: ‘Costs aris- ing from this guideline included improving systematic screen- ing, assessment and treat- ment of malnourished patients. If this was fully implemented and resulted in better nour- ished patients then this would lead to reduced complications such as secondary chest infec- tions, pressure ulcers, wound abscesses and cardiac failure.
Conservative estimates of reduced admissions and reduced length of stay for admitted patients, reduced demand for GP and outpatient appointments indicate significant savings are possible.’
Choice of sip feed
It is therefore essential that when considering a sip feed, we as dietitians must have cost effectiveness uppermost in our minds and be able to demonstrate why the product we are requesting is a cost effective choice.
One of the first things to consider is the nutritional require- ments of the patient balanced by what they are physically able to take. Having a ‘one size fits all’ policy of using just one sip feed may not mean totally cost effective prescribing, as wastage is likely to be high. For example, if a patient’s fluid intake is very low (a situ- ation not uncommon for the very elderly in any setting), it is quite probable that they would be entirely unable to manage 2 x 200ml bottles of a sip feed each day. So in this case a low
NHDmag.com June '10 - issue 55
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