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Ten steps to manage nutritional supplements

Anita Sharma gives ten tips - including what to do with a MUST score - on nutrition and supplement management

1. Search

Do a computer search and identify all patients on nutritional supplement, whether on acute or repeat within the last twelve months. Do not hesitate to ask help from the prescribing support pharmacist/technician of your PCT.

2. Review

List the names of these patients and document who initiated the supplements. Remember you do not have to continue with the prescriptions if a patient is discharged on supplements. Check whether there is a record of height/weight and BMI. Check whether there is a record of MUST (Malnutrition Universal Screening Tool) score. Check the caloric value of the type of supplement and make sure whether it is clinically effective.

3. Meet

Have a practice meeting and agree on your prescribing policies as to who will qualify for the supplements. Remember nothing will be achieved unless this is taken in a structured way. It is a good idea to have a GP prescribing lead in your practice.

Agree with all the prescribers the clinical indications where this prescription would be justified. The specific patients should be: Terminally ill patients (1Z0), cancer patients undergoing chemotherapy (8BAD)/radiotherapy/post surgery, alcoholic liver disease (J613), patients on home detoxification, end stage COPD (H39), heart failure (G58), advanced dementia (E00-97), patients in the last days of life and some stroke patients (G66). Nursing home or residential home patients do not necessarily justify a prescription except some frail older people.

4. Assess

The lead GP should authorise as to who will do the assessment and what should the assessment include. This could be a district nurse, Macmillan nurse, nursing home matron or a specialist dietician. A referral should be made to these professionals. All professionals must agree with practice policy of assessment, identifying treatment goals, length of treatment and regular review.

5. Indicate

Enter an indication for prescribing. Enter height (229), weight read code (22A), BMI (22K) read code. Enter MUST score read code (687C). MUST score should be used in patients who have a chronic illness, is over 70 years old, is at a risk of developing pressure sore/ (39C0) has a pressure sore and where the practitioner's assessment indicates malnutrition - see below for the formula.

Patients with disease related malnutrition - severe COPD (H39), heart failure (G58) can be assessed by community matron, Macmillan nurses are better suited to assess cancer patients. Anorexia nervosa (E271), IBD (J4-2), coeliac disease (J690) patients should be referred to a dietitian. Enter read code on those where the treatment has been stopped. All practitioners must agree as to what to prescribe and when.

6. Investigate

Some patients may need routine blood tests for example FBC (424), ferritin (42R4), B12 (42T), TFT (442), blood sugar (44T1), renal (451) and liver function tests (44D). Agree on the simple principle of who will be doing these tests and who will be actioning the results.

7. Identify

Find patients who qualify for prescription. This depends on the results of the MUST assessment score.

8. Act

MUST score 0 - Offer a hand out, 'Making the most of a small appetite'.

MUST score 1 - Offer a hand out, 'How to fortify foods'. For example: one pint of full fat milk daily enriched with four tablespoons of skimmed milk powder, chilled desserts – mousses, trifles, rice pudding, home made milk shakes, add butter/cream/grated cheese, nibbling nuts and dried fruits, buy build-ups or Complan from supermarket.

Advise fresh air and gentle exercises to increase appetite. Keep leaflets of fortifying your food, nourishing food and drinks, choosing the right type of food, snacks in each consulting room. Get these from your hospital dietician.

MUST score 2+ - High risk. Refer to the dietician (8H76).

A patient discharged from the hospital on nutritional feeds must be assessed using the MUST score and decision made on continued prescribing depending on the score.

9. Prescribe

Only if MUST score is 2 or more: Complain shake 1 sachet twice daily can be prescribed for 1-2 months until assessment is undertaken by the Dietetic team.

Follow ACBS guidance of nutrition supplements. I use oral nutritional support code (8B78). Nutritional support (PC0058) can be used

10. Follow up

Do not enter nutritional supplements on repeat prescribing. Patient should be followed up monthly and MUST score must be taken again. Once the target weight is reached stop the prescriptions (8B396).

DO NOT FORGET:

  • To update your locum prescribing folder

  • To inform local pharmacy about your action plan

  • To inform the patient by sending a letter explaining the reasons for the change.

  • Do an audit and present in your practice and locality and mark yourself 20 credits. This goes in your appraisal folder ready for revalidation.

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