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Are oral nutritional supplements being prescribed inappropriately?
Oral nutritional supplements (ONS) are a common treatment for malnutrition, and have been shown to have clinical benefit when prescribed appropriately. The increasing drive to improve nutritional management of service users in care homes has led to some improvement in menus and screening for malnutrition, but the use of ONS may still be an area where awareness is lacking and they can be inappropriately prescribed.
An interesting article by a Prescribing Support Dietitian in West Sussex in the latest edition of NHD, the Dietitians magazine, explored the use of ONS in care home settings.
Food as first line treatment
Food should be first-line treatment, although lack of knowledge, historical use and inconsistent messages may promote care home staff to regard ONS as the panacea for malnutrition. Thus ONS, are often prescribed in care homes without adequate assessment, goals or treatment plan defined, and before other recommended first-line methods such as dietary counselling and simple food fortification have been tried.
However, the use of ONS should be largely based on meeting Advisory Committee of Borderline Substance (ACBS) criteria after first line dietary measures have been unsuccessful in achieving goals of treatment.
In the NHD review of ONS prescriptions in eight care homes in West Sussex, it was reported that around 75% of prescriptions were inappropriate for reasons including:
- Nutritional assessment that indicated low risk of malnutrition (MUST score of 0)
- ACBS criteria for prescription of ONS were not met
- Food First advice was not being consistently implemented
Commencing supplements may not always be the right decision
The review noted that in some cases, such as service users with advanced dementia, whilst ONS may have been commenced inappropriately, this was done with good intentions. For example, they could have been started to deal with challenging food behaviours like food refusal, or simply to be seen as to be doing something for the service user’s nutritional care.
Importantly, although once commenced, it may be challenging or distressing to discontinue prescriptions, and in such circumstances this may not be appropriate. These decisions should rely on dietetic experience, and highlight the importance of involving expertise where necessary.
The review also reflected on some of the nutritional issues within care homes, particularly in the area of documentation. It was noted that care staff know their service users in great detail but this was not reflected in nutrition care plans or in food and fluid charts, which may not have been completed or neglected.
Poor documentation was further noted for MUST score where whatever the calculated score there was no difference in the subsequent care plans. This may suggest that such assessments have become viewed as a ‘tick box’ exercise, and merely something that CQC would want to see.
Staff training with dietitians may improve nutritional care of service users
It may be time for a review of all service users who receive ONS in your care homes, but this should only be undertaken with advice from the relevant health professionals such as GPs and dietitians. By following stricter procedures, significant cost savings could be made. Working together with dietitians and ensuring appropriate training to care home staff may be a way to facilitate better nutritional care. The answer may not just be oral nutritional supplements.
Ayela Spiro, British Nutrition Foundation – QCS Expert Nutrition Contributor