Practiguide | Prescribing of ONS ‘
The two-year project in NHSG revealed that approximately 50 per cent of patients receiving ONS in care homes were not known to the any dietitian.
Expected outcomes • Patients requiring nutritional support are referred to the CDD before ONS are prescribed
•
Inappropriate prescribing is reduced leading to an overall reduction in ONS use
Results To date 71 per cent of practices have received awareness training and three per cent declined due to time commitments or other pressures. The remainder have sessions arranged.
’
Outcomes (see Table One) The number of patients referred for nutritional support increased from 37 per cent to 77 per cent. Of those patients referred to the CDD, approximately 40 per cent were managed without the need for ONS. The number of items prescribed decreased by six per cent. The cost associated with ONS prescribing continued to rise. However, the rate of increased spend increased by only four per cent compared to 20-30 per cent in previous years (see Figure 1). Some of the increase in cost could be accounted for by an increase in the community price of some ONS.
Comment Overall the awareness sessions have proved very positive. The majority of GPs from each practice have attended the sessions as well as some community nurses. The sessions have provided the opportunity to highlight the availability of the guidelines, discuss the issues of inappropriate prescribing, the costs involved, signpost staff to appropriate resources and examine ONS prescribing in their own practice. This has resulted in an improvement in the referral rate to the CDD. It would also suggest that one-to-one meetings with GPs are more effective in implementing guidelines rather than simply circulation.
2. Nutritional screening and food fortification training for care home staff
Background The two-year project in NHSG revealed that approximately 50 per cent of patients receiving ONS in care homes were not known to the any dietitian. The use of ‘MUST’ ('Malnutrition Universal Screening Tool') had resulted in an increase in the number of referrals to the CDD. However, many of these were considered inappropriate. Some were made simply to request ONS, while others were made for residents at end of life because they had a score of >2. In addition, where CDD recommended a fortified diet, implementation of this was inconsistent and variable.
An 11-month project to investigate food
provision and the use of ONS in care homes in NHSG highlighted poor menu planning and poor knowledge of nutrition screening and food fortification. In 25 per cent of the care homes, energy provision was less than recommendations.3
Initiative A planned programme of training for cooks, care staff and managers to improve understanding of the screening process, raise awareness of the value and significance of food fortification and improve the provision of food fortification in care homes was implemented. There were two elements to the training:
Nutrition screening (‘MUST’) This included the correct use of ‘MUST’ but mainly focused on action taken based on the results of screening. The management guidelines for Grampian care homes recommend food fortification measures to provide 400- 600kcal/day for eight weeks or four weeks for scores of 1 and 2 respectively, before referring to the CDD. Paperwork for referring to CDD was
developed specifically to reflect action taken. Any incomplete paperwork was returned to the referring care home. Care homes were recommended to refer directly to the CDD rather than request a referral via their GP. This helped ensure the correct processes were implemented and reduced the likelihood of staff requesting ONS directly from the GP. GPs and community staff were also made aware of the correct processes.
Food Fortification Training addressed the importance of appropriate food fortification measures in the treatment and prevention of malnutrition and included a practical session to prepare, taste and compare fortified foods to non-fortified foods. A food fortification information booklet was
used to support the training. This outlined a range of food fortification options, including home made nutrient dense drinks, which the carers can choose from, depending upon the needs and preferences of their residents.
Expected outcomes • Correct referral paperwork completed with evidence of food fortification, where appropriate, prior to referral to CDD
• Reduction in dietetic caseload as a result of more appropriate use of food fortification
• Reduced use of ONS
Table One: Outcomes of the Initiative Patients referred to
Pre-awareness sessions Post-awareness sessions
CDD for ONS 37% 77%
Number of ONS items Rate of increase in prescribed/year
19,979 18,649
spend on ONS 20-30% 4%
30 | Complete Nutrition Vol.10 No.6 December/January 2010/11
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68 |
Page 69