OUR SITES: Centre for Sustainable Healthcare | Sustainable Action Planning | NHS Forest | Mapping Greener Healthcare | Carbon Addict

Minimising Inappropriate Use of Dietary Supplements - Nutrition and Dietetics

By: Royal Devon and Exeter NHS Foundation Trust

Goal: The aims of the project were to reduce the inappropriate use of oral nutritional supplements (ONS)

Background: ONS are easily accessible to ward staff and there has been very little monitoring or control over their distribution. The dieticians postulated that ONS were often given to patients, without a review by a dietician. This was confirmed by an audit in December 2017 that showed a discrepancy between the number of dietician prescriptions for ONS per week and the number ordered by the catering department.

Inappropriate use of ONS has the potential to have a negative impact on patient health, for example if sugarcontaining ONS are given to diabetic patients (ONS were given out by catering staff who do not have training on diabetes) or if patients are not assessed adequately and given professional advice on diet and nutrition (for example drinking milk rather than using ONS in patients less ‘at risk’ of malnutrition).

Furthermore, if patients are discharged to the community with inappropriately dispensed ONS this has the potential to incur large costs for GPs as ONS are cheap for hospitals to provide (1p each) but much more expensive to provide in the community. The prescriptions are sometimes, but not always, reviewed in the community. Where prescriptions are not reviewed unused ONS may accumulate in patient’s homes and go to waste.

Approach: establish a more effective management system for the supply and storage of ONS at the RD&E Wonford Hospital at ward level



Designing a system:

• the team were aiming to devise a simple, reliable and uniform system to supply ONS to all wards, regulating distribution but also allowing for large volumes of ONS to be available for patients being discharged with little advanced notice.

• part of streamlining the system involved reducing the number of different ONS supplied by wards. It has been difficult to gain consensus on which reduced range of ONS to use in different locations and this work continues.

• When piloting the system, the Datix system was used to log any problems encountered. 

• Prior to the launch information was disseminated about the new system by arranging meetings open to clinical stakeholders (e.g. matrons, registered nurses, HCA’s, ward housekeepers, dietitians, logistics, catering). Meetings were poorly attended and some email addresses were out of date.

Launching the system: The ‘Top Up’ ordering system for ONS was launched in September 2018. Under the new system:

• all ONS ordered can be tracked and monitored using bar codes.

• The dieticians complete prescription forms for the ward housekeepers so that the housekeepers know which patients are prescribed ONS, which ONS are due and how frequently they should be given.

• There is also a section on the prescription form to help the ward housekeeper manage ward stock levels.

• The forms will also be used for monitoring. They will be returned monthly to the dietetics manager who repeat the audit carried out in December 2017 to see if the new system and communications with different teams has reduced the number of ONS being supplied to patients without dietetics advice.


Results: The re-audit is yet to take place, so results are awaited. The team have been learning about managing change including running a consultation process, decision-making in a large, diverse organisation and that disseminating information about change in an organisation is challenging and requires a multi-faced communication strategy.

Savings: In the long term it is hoped that the ‘Top-Up’ system will be embedded and that most ONS will be prescribed by dieticians. It is expected that this regulated distribution will have the down-stream effect that fewer patients will be discharged on inappropriately dispensed ONS, reducing the cost to NHS North, Eastern and Western Devon Clinical Commissioning Group and reduce the waste of unused ONS.

The Centre for Sustainable Healthcare runs the Green Ward Competition as a clinical engagement programme for NHS Trusts wishing to improve their environmental sustainability and reduce their carbon footprint.

Olivia Bush, olivia.bush@sustainablehealthcare.org.uk