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Type and Title of Submission


Title:

Prescription of oral nutritional supplements

Description:

A clinical audit of the use of nutritional supplements and monitoring of people having nutritional support on inpatient wards.

Does the submission relate to the general implementation of all NICE guidance?

No

Does the submission relate to the implementation of a specific piece of NICE guidance?

Yes

Full title of NICE guidance:

CG32 - Nutrition support in adults

Is the submission industry-sponsored in any way?

No


Description of submission


Aims and objectives

To assess and improve the current practice of the prescription of oral nutritional supplements across the Trust.

Context

Malnutrition is estimated to affect at least three million adults in the UK and costs 13 billion annually (BAPEN, 2008). People suffering from malnutrition may be admitted to hospital more often, stay in hospital for longer and visit their GP more frequently. Oral Nutritional Supplements (ONS) may be used to treat malnutrition. Research suggests ONS can reduce death rates and complications, as well as reduce length of stay and weight gain in a variety of clinical conditions (NICE Clinical Guideline 32, 2006). However, London audit data indicates some ONS are prescribed to patients who do not need them. Findings from the audit revealed that an estimated 16.2 million would be spent on ONS in 2010/2011 and expenditure is set to exceed 20million by 2013/2014 (London Procurement Clinical Oral Nutritional Support Document, 2009). In the past 5 years 65 million was spent on adult ONS with roughly 37-49 million estimated to be inappropriate (London Procurement Clinical oral Nutritional Support Document, 2009). Examples of such issues identified from the London audit data were as follows:
- Poor communication between acute and community services
- Patients not assessed or monitored by dietitians
- Patients kept on ONS for too long

Methods

A pilot clinical audit was carried out on the general medical and care of the elderly wards in July 2011; 12 wards in total. The sample was all patients on the ward although some could not be included (they were being assessed by the medical team, had left the ward for investigations or other reasons). The total sample size was 266. Verbal consent was received from patients prior to gathering data. The standards were taken from CG32 Nutritional support for adults:
- People having nutrition support in hospital should be monitored by healthcare professionals with the relevant skills and training in nutritional monitoring
- Healthcare professionals should refer to the protocols for nutritional, anthropometric and clinical monitoring, when monitoring people having nutrition support in hospital
Data gathering involved:
- asking the patient if they had been given any nutritional supplements throughout their hospital stay
- checking the drug kardex for the prescription of any nutritional supplements
- checking the food chart
- observing bed side for any nutritional supplements.

The clinical audit was then rolled out to the whole trust in October 2011. 12 wards at Queen Elizabeth Hospital (n=266), 4 wards at Queen Mary's Hospital (n=63) and 21 adult wards at Princess Royal University Hospital (n=407) were included. The total sample size was 736 patients. Again, all patients actually on the ward were included, verbal consent was obtained prior to collecting data and data gathering involved:
- asking the patient if they had been given any nutritional supplements throughout their hospital stay
- checking the drug chart for the prescription of any nutritional supplements
- checking the food chart
- observing bed side for any nutritional supplements.

Results and evaluation

In the pilot phase based on 237 patients carried out at Queen Elizabeth Hospital, 65% of patients were not prescribed supplements, 23% were prescribed them by a doctor, 4 % by a dietitian and 9% were receiving supplements which had not been prescribed.

In the trustwide audit, 74% of patients had not been prescribed supplements. 12% of patients had been prescribed supplements by a doctor and dietitians ordered them for 8% of patients. 6% were receiving supplements that had not been prescribed. This shows an increase in supplements ordered by a doctor or dietitian and reduction in people receiving supplements that had not been prescribed. In total, 26% of patients were prescribed or given oral nutritional supplements (n=191) which was felt to be high. 44 patients in the trustwide audit were receiving supplements that were not prescribed. Only 8% of the supplements given to patient were ordered by the dietitian (n=59).

CG32 states that there should be clear documentation of which healthcare professional has been involved in the prescription, administration and monitoring of the patient and this was not always clear. All TTOs for supplements at one of the hospitals require dietitian approval before being dispensed and this is being discussed as a trustwide protocol.

Training for doctors and nurses is to highlight the appropriate prescribing of supplements. The message that any supplements given to patients need to be prescribed will be re-enforced at ward level, and the control of supply and labelling will be improved. The Malnutrition Universal Screening Tool will be used more effectively by nursing staff.

Key learning points

Carrying out the clinical audit across 3 sites highlighted the cultural differences between them. There were differences across the sites in the procedures for supplying supplements. In one site pharmacy hold the stock and in the other two it is held by the catering department.

When some patients were due to be discharged, supplements were listed on the TTO. NICE recommends monitoring of patients receiving supplements but this was not happening for patients discharged with supplements that were not prescribed by a dietitian.

Contact Details

Name:Patricia Murphy
Job Title:Deputy Head of Dietetics
Organisation:South London Healthcare NHS Trust
Address:Queen Elizabeth Hospital, Stadium Road
Town:Woolwich
County:London
Postcode:SE18 4QH
Phone:020 8836 5062
Email:patriciamurphy@nhs.net
Website:http://www.slh.nhs.uk

 

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This page was last updated: 20 July 2012

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Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.