NICE Shared Learning Awards
Submission Title: Clinical and Cost Effective Prescribing of Oral Nutritional Supplements for Adults in the Community
Supporting Information:
1.
2.
3.
4.
5.
Audit Standards & Criteria ………………………………………………………………………………………………………….Page 2-3
‘Flow Chart for Prescribing ONS ……………………………………………………………………………………………………Page 4
Flow chart to aid review of patients currently prescribed ONS …………………………………………………………………Page 5
Procedure for prescribing oral nutritional supplement for adults in the community ………………………………………….Page 6-7
ONS Formulary Table ………………………………………………………………………………………………………………Page 8
Audit Standards & Criteria




A standard describes the level of care we expect patients to receive
A criterion is an explicit statement describing the area of care that is being measured
For each criterion you will need to set compliance targets
Exceptions: there may be acceptable reasons for not meeting the criteria, either due to unforeseen circumstances or to meet the
individual clinical needs of the patient
Standard
1. Patient documented to be at
risk of malnutrition using
validated nutritional screening
tool
2. Patient documented to have
been given verbal and/ or
written “Build yourself up” advice
to improve nutritional intake
3. The indication for prescribing
ONS is documented
4. The aims of treatment are
documented when starting ONS
on prescription
5. The prescription is for 2 x
1.5kcal/ml ONS daily or suitable
alternative
6. The first prescription was for
Criteria
Risk of malnutrition is medium or high using the
‘MUST’ (malnutrition universal screening tool)
The Leaflet “Build yourself up” / “food first” for
improving nutrition or appropriate alternative
ACBS criteria include short bowel syndrome,
intractable malabsorption, preoperative
preparation of undernourished patients, proven
inflammatory bowel disease, total gastrectomy,
bowel fistulas, and disease related malnutrition
Aims of treatment include weight maintenance
or gain, improved nutritional intake, hydration,
wound healing, pressure area care,
improvements in psychological and / or physical
health
Suitable products include Resouces Energy,
Fortisip, Fresubin Energy, Ensure Plus, Fortisip
Multi-fibre, Fresubin Energy Fibre, Ensure Plus
Fibre, Fortisip Yoghurt Style, Ensure Plus
Yoghurt Style, Fortijuce, Resource Fruit, Provide
Extra, Ensure Plus Juce Style, Scandishake,
Calshake, Enshake, Complan Shake
Sample pack (Ensure Commence, Fortisip
Compliance
100%
100%
Exceptions
Where ONS have been requested under supervision of a
Dietitian (should be documented by Dietitian)
Where ONS have been requested under supervision of a
Dietitian (should be documented by Dietitian)
Where ONS have been requested under supervision of a
Dietitian (should be documented by Dietitian)
100%
Either documented in GP records or on Dietitian’s letter
100%
100%
100%
Where different ONS / products have been requested
under supervision of a Dietitian. For patients with
dysphagia, dessert-style supplements (Forticreme
Complete, Fortisip Fruit Dessert, Fresubin Crème,
Resource Energy Dessert, Resouce Fruit Dessert) are a
suitable alternative.
Where ONS have been requested under supervision of a
a 2 week trial
7. Each prescription is issued as
“acute”
8. Prescription includes clear
directions for use
9. Patient on prescribed ONS is
reviewed monthly before further
prescription is issued
10. Aims of treatment and need
for ONS reviewed after 3
months
11. Any patients for whom a
Dietitian has requested ONS on
prescription should have
documented indication, aims of
treatment, weight, expected
duration of treatment and follow
up arrangements from the
Dietitian
Range, Enmix Plus Commence or Ensure Plus
Commence
Repeat of batch prescribing not acceptable
Dietitian (should be documented by Dietitian)
100%
E.g. “one to be taken twice daily” or “twice daily
between meals”. NOT “as required” or “as
directed”
To include weight, compliance with ONS,
progress towards aims of treatment
If improved, ONS are reduced or discontinued. If
not improved, Dietitian is contated for advice if
appropriate
Letter or other communication details indication
for ONS, patients weight, aims of treatment,
expected duration of treatment and follow up
arrangements
Where a longer duration of supplement use is indicated
and has been documented with clear timescale for
review.
None
100%
100%
100%
Where patient is under regular review by a Dietitian (e.g.
Dietitians letter indicates planned follow up)
Documented clinical reason for continuing ONS (e.g.
further improvement / benefit anticipated)
Where the requesting Dietitian is employed other than
NHS Swindon, GWH NHS FoundationTrust, Wiltshire
PCT
100%
Oral Nutritional Supplements (ONS) Flow Chart (Adults)
‘MUST’ Screening Score
Score 0
Re-screen annually
or on clinical concern
Score 1
Score 2+
First line advice (food first)
Provide ‘Food First Booklet’
Encourage regular meals and nourishing snacks
Food fortification and nourishing drinks between meals
Encourage patient to monitor weight weekly
After a month
First line advice and
consider supplements
Is patient still losing weight?
No
Encourage to continue with
‘food first’ approach until weight
stable
Yes
Consider nutritional supplements to have between
meals – prescribe 2 a day initially
Provide booklet ‘Ideas for using Nutritional Supplements’
see ONS TABLE for products
1. Prescribe a starter pack to determine style and taste preferences.
2. Milky based liquid sip feeds i.e. milkshake style or yoghurt style,
should be offered as a first choice.
3. If patient dislikes milky drinks consider a fruit juice based supplement
4. Does the patient prefer desserts, or require a semi-solid consistency.
If yes, consider a supplement from the semi solid range – both milky
based or fruit based dessert options available.
Monitor weight and compliance with supplements monthly
Does patient continue to lose weight?
Continue to monitor
weight until weight stable
No
Yes
Refer to Dietitian
Flow chart to aid review of patients currently prescribed
Oral Nutritional Supplements (ONS)
To be used to aid reviewing patients currently being prescribed ONS. To be done when a prescription
for continued ONS is requested by the patient
‘MUST’ Screening Score
(Use Community Nutrition Screening Tool)
Score 0
Score 2+
Score 1
-Negotiate with patient and
stop ONS.
-Discuss with patient and explain
-Negotiate with patient and stop
ONS
-First line advice (food first)
ONS are not needed any more
due to patient having a normal
BMI, and minimal or no weight
loss within the last 3-6 months
-Provide ‘Food First Booklet’:
Encourage regular meals and
nourishing snacks
Food fortification and nourishing drinks
between meals
Encourage patient to monitor weight
weekly
-Re-screen annually or on
clinical concern
After a month – is patient still
losing weight?
Continue to monitor
weight until weight stable
No
-Make sure ONS – 2x 1.5kcal/ml
(unless recommended by Dietitian)
-Use Formulary and Prescribing
Guidelines for appropriate prescribing
- Change ONS prescription to monthly
Acute
-Provide ‘Food First Booklet’
Encourage regular meals and nourishing
snacks
Food fortification and nourishing drinks
between meals
Encourage patient to monitor weight
weekly
-Provide booklet ‘Ideas for using
Nutritional Supplements’
Monitor weight and compliance with
supplements monthly
Yes
Follow Score 2+ Management
guidelines
Is patient still losing weight?
No
Yes
Refer to Dietitian
Document created by: Kate Ashman and Natalie Kominek
Community Dietitians
Tel: 01793605149
May 2010
Updated November 2010
Link to ‘MUST’, booklets, ONS formulary, flow chart, guidelines for prescribing ONS
under 9.4.2 Enteral Nutrition
http://www.gwh.nhs.uk/SMNHS/Departments/Pharmacy/Formulary-New.aspx
Procedure for Prescribing Oral Nutritional Supplements (ONS) for Adults in the
Community
To be read in conjunction with the ‘ONS Flow Chart (Adults)’ and guide to oral nutritional supplements
available on FP10 (ACBS)
 Patient’s must have been appropriately identified, by the use of nutritional screening tool (use
Malnutrition Universal Screening Tool – MUST), as being nutritionally at risk and nutritional risk
score (MUST Score) and weight must be documented in patient records.

Patient’s with a nutritional risk (MUST Score) of 2 should be given first line dietary advice on
improving their nutritional intake supported by the information booklet ‘Food First Information
Booklet’ and little improvement in nutritional intake and status observed after 2 weeks (for high
nutritional risk) or 4 weeks (for medium nutritional risk).

Patient’s clinical condition should fall within the Advisory Committee on Borderline substances
(ACBS) approved categories for prescribing nutritional supplements:
o
o
o
o
o
o
o
Short Bowel Syndrome
Intractable malabsorption
Pre-operative preparation of undernourished patients
Proven inflammatory bowel disease
Following total gastrectomy
Bowel fistulas
Disease related malnutrition
Refer to BNF for more specific indications applicable to individual products (such as dysphagia and
age related restrictions.
 Nutritional supplements should only be prescribed if conventional dietary intervention to
improve nutritional status had failed, ‘Food First Information Booklet’ provided.

The aim and expected outcome of using the nutritional supplement must be identified and
recorded at the beginning of treatment e.g. to prevent further weight loss, increase weight, aid
wound healing, improve oral intake, improve well being.

When oral nutritional supplements (ONS) are indicated, all patients should be prescribed 2 x
1.5kcal supplements daily, unless otherwise advised by a Dietitian or if patient has been
identified to be at risk of refeeding syndrome1. Refer to the guide to Oral nutritional
supplements available on FP10 for a range of suitable supplements.

The first prescription, to establish taste preferences, should be for no more than 2 weeks and
marked mixed/assorted flavours and endorsed ‘ACBS’, excluding any flavours the patient does
not wish to try (refer to ONS sip feed table for available flavours). Alternatively, starter/initiation
packs are available on prescription from the following companies: Nutricia (Fortisip Range
Starter Pack) and Abbott Nutrition (Enmix Plus Commence or Ensure Plus Commence). Refer
to ‘ONS Table Adults’ or The guide to Nutritional Supplements available on FP10.

Once the patient’s preferred choice of product and flavours has been established prescriptions
should be provided MONTHLY and issued as ACUTE2.
1

All patients should be reviewed monthly (weight, MUST score, nutritional intake and
compliance) before further prescriptions are issued2 and until treatment aims are achieved3.
Nutritional supplements should not be given as repeat medication unless there are exceptional
circumstances.

All prescriptions for oral nutritional supplements should have clear directions for use e.g. daily
dose, timings (between meals) or incorporation into meals and how best served. ‘Ideas for
using Nutritional Supplements’ booklet should be used as supporting information. Avoid using
‘use as directed’, ‘as required’ or ‘as needed’.

All patients should be referred to a Dietitian for assessment if ‘disease specific’ or
‘macronutrient only’ supplements are indicated (refer to sip fed table).

Where patients have been referred for dietietic assessment as an inpatient or in an outpatient
clinic, and have commenced nutritional supplements as a result, the Dietitian should write to
the GP within 2 weeks of patient’s discharge or outpatient appointment to advice concerning
ongoing requirement for nutritional supplements and any follow-up arrangements.

All other patients who are discharged from hospital on nutritional supplements not requested
by a Dieititian should be reassessed to determine whether nutritional supplements are still
indicated before a further a prescription is issued. The ‘Food First Information Booklet’ should
be given if appropriate.

All patients should discontinue oral nutritional supplements once treatment goals have been
achieved3, or if advised by the Dietitian. Consider reducing nutritional supplements gradually at
first e.g. daily for a designated time frame.

If, after 3 months, patients are not progressing toward treatment goals, aims of treatment
should be reassessed before continuing treatment.
Refer to NICE CG32 9p.19 of Quick Reference Guide) or contact Dietitian for advice on identifying and managing refeeding syndrome.
Repeat or batch prescriptions should be avoided as compliance can be difficult o monitor and unnecessary costs are incurred
3
Aims of treatment include weight maintenance or gain, improved nutritional intake, hydration, wound healing, pressure area care, improvements in
psychological and/ or physical pain.
2
Oral Nutritional Supplements (ONS) available on FP10 (ACBS) - August 2010
ONS TABLE (Adults)
Green =
First Line
Supplement
Starter Packs
Blue - Second Line
Milkshake Style
1.5kcal/ml
Product
Fortisip Range Starter Pack
(Milk, Juice & Yoghurt styles)
Ensure Plus Commence
(Milkshake Flavours)
Resource Energy
Fortisip
Fresenius Kabi
Abbott Nutrition
High Fibre
Milkshake Style
1.5kcal/ml
Yoghurt Style
1.5kcal/ml
Fruit Juice Style
Fresubin Energy
Ensure Plus Milkshake
Style
Fortisip Multi-Fibre
Fresubin Energy Fibre
Ensure Plus Fibre
Fortisip Yoghurt Style
Ensure Plus Yogurt Style
Fortijuce
Nutrica
Fresenius Kabi
Abbott Nutrition
Nutricia
Abbott Nutrition
Nutricia
Vanilla, Strawberry, Blackcurrant, Chocolate, Neutral, Banana, Lemon, Cappuccino, Tropical Fruits
Neutral, Banana, Blackcurrant, Caramel, Chocolate, Coffee, Fruits of Forest, Orange, Peach, Raspberry,
Strawberry, Vanilla
Strawberry, Banana, Chocolate, Orange, Vanilla, Cream of Chicken, Cream of Tomato
Vanilla, Strawberry, Chocolate, Banana, Cherry, Toffee-Caramel
Vanilla, Chocolate, Fruits of the Forest, Raspberry, Strawberry and Banana
Raspberry, Blackcurrant, Pineapple, Peach & Orange, Vanilla & Lemon
Orange Burst, Orchard Peach, Pineapple Twist, Strawberry Swirl
Lemon & Lime, Peach & Orange, Forest Fruit, Apple & Pear, Blackcurrant, Apricot, Pineapple
1.5kcal/ml
Resource Fruit
Nestle Nutrition
Apple, Orange, Pear-Cherry, Raspberry/Blackcurrant
Provide Extra
Ensure Plus Juce Style
Fortisip Extra
Fortimel
Fresubin Protein Energy
Forticreme Complete
Fortisip Fruit Dessert
Ensure Plus Crème
Fresubin Creme
Resource Energy Dessert
Resource Fruit Dessert
Scandishake
Fresenius Kabi
Abbott Nutrition
Nutrica
Nutrica
Fresenius Kabi
Nutricia
Nutricia
Abbott Nutrition
Fresenius Kabi
Nestle Nutrition
Nestle Nutrition
Nutricia
Lemon & Lime, Cherry, Blackcurrent, Citrus Cola, Orange & Pineapple, Apple, Melon, Tomato, Carrot-Apple
Apple, Fruit Punch, Grapefruit, Lemon and Lime, Orange, Peach, Pineapple, Strawberry
Strawberry, Chocolate, Vanilla, Forest Fruits, Apricot, Mocha
Forest Fruits, Strawberry, Vanilla, Chocolate
Wild Strawberry, Vanilla, Chocolate, Neutral
Chocolate, Banana, Forest Fruits, Vanilla
Apple
Banana, Chocolate, Vanilla, Neutral
Wild Strawberry, Vanilla, Cappuccino, Chocolate, Praline
Caramel, Chocolate, Vanilla
Apple, Apple-Strawberry, Apple-Peach
Unflavoured, Vanilla, Chocolate, Strawberry, Banana, Caramel
Calshake
Fresenius Kabi
Banana, Chocolate, Strawberry, Vanilla, Neutral
Enshake
Abbott Nutrition
Strawberry, Banana, Vanilla, Chocolate
Complan Shake
Complan Foods
Strawberry, Vanilla, Chocolate, Banana, Milk
High Protein
Milkshake Style
Semi solid
Powdered
Use as
prescribed
by Dietitian
Disease Specific
Supplements
Macro-nutrient
Supplements
Company
Nutricia
Flavours
4 x Fortisip (Milkshake STYLE), 4 x Fortijuce (Juice Style), 2 x Fortisip Yogurt Style (Yogurt Style)
Abbott Nutrition
10 Mixed Flavours (Milkshake Style)
(Banana, Blackcurrent, Chocolate, Fruits of Forest, Neutral, Orange, Peach, Raspberry, Strawberry, Vanilla)
Apricot, Chocolate, Banana, Coffee, Vanilla, Strawberry/Raspberry
Strawberry, Banana, Chocolate, Toffee, Tropical Fruits, Neutral, Orange, Vanilla
Nestle Nutrition
Nutricia
ProSure (Abbott Laboratories); Forticare (Nutricia); Resource Support (Nestle Nutrition); Elemental 028 (SHS); E028 Extra (SHS)
Modulen (Nestle); Renilon (Abbott Nutrition); Nepro (Abbott Nutrition); Suplena (Abbott Nutrition)
Polyal, Caloreen, Polycose, Vita-joule, Duocal, Maxijule, Calogen, Liquigen, Protifar, Vita-pro, Pro-Cal Shot, Vita-savoury, Quick cal
Document created by: Natalie Kominek and Kate Ashman, Community Dietitians. Nutrition and Dietetic Department, GWH.
Tel: 01793 605149
Aug-10
Comments
Intended as an initial
5-10 day supply to
assess preference
Nutritionally balanced
Can be used for
people
with diabetes if sipped
slowly over 1/2 hour
Nutritionally balanced
May help maintain
normal bowel function
Nutritionally balanced
Nutritionally
incomplete
in vitamins and
minerals
Should be prescribed
post assessment
by a Dietitian
Suitable for patients
with dyshagia
Nutritionally
incomplete
in vitamins and
minerals
Advised to make with
full cream milk
Use as prescribed
by Dietitian
If MUAC
Measure
With
Bend
the
the is
less thanleft
patient’s
between
the
23.5cm,
arm
point
hanging
at
ofthe
the
BMI
isat a
loose,
elbow
likely
to be
measure
90
(olecranon
degree
less
than
around
angle
process)
with
the
2
20kg/m
upper
the
and
upper
thearm
at
If
MUAC
is
the
arm
midpoint
marked
held of
greater
mid-point.
parallel
the
to
than
Ensure
the
prominent
sidethat
of
32.0cm,
the
bone
tape
body.
of the
BMI
is
measure
Measure
wrist
(styloid
the
is
likely
to be
snug, but
distance
process)
greater
not tight.
between
(left
side the
if
Decontami
than
bony
possible).
2
nate tape
30kg/m
Decontami
protrusion
measure
nate
on
thetape
after use.
measure
shoulder
after
use.
(acromion)
and the
point of the
elbow
(olecranon
process)
Mark the
mid-point.