Early dietetic assessment and intervention in managing the nutrition of hip fracture patients at a Melbourne hospital has improved rates of malnutrition, pressure injuries and length of stay.

Austin Health has introduced a new nutritional care guideline that requires all hip fracture patients to receive a dietetic assessment within 48 hours of admission, with dietary strategies then implemented to prevent or treat malnutrition.

Research evaluating the impact of the new guideline, which was presented at the Dietitians Association of Australia’s (DAA) recent National Conference and published in Nutrition and Dietetics, found dietetic intervention occurred an average of three days earlier.

The intervention also decreased length of hospital stay an average of five days for acute and subacute patients, significantly reduced the incidence and severity of pressure injuries, and decreased the number of malnourished patients.

The intervention has been such a success, the health service has since introduced another dietetic initiative to further improve the nutritional status of hip fracture patients.

Research shows hip fracture patients have a high prevalence of malnutrition and pressure injuries. Most hip fracture patients are older people who are more likely to be at risk of malnutrition or malnourished on admission to hospital.

There’s also a strong link between nutrition and pressure injuries, with annual audits at Austin Health indicating about 60 per cent of hip fracture patients with pressure injuries are malnourished.

Immobility due to injury and surgery, incontinence problems which put patients at risk of skin breakdown, and poor nutrition leads to pressure injuries - all are common issues for older hip fracture patients.

Accredited Practising Dietitian (APD) Jacqui Bailey, a senior dietitian at Austin Health, who worked with a study team including research nutritionist Haydn Klemm, says the intervention was prompted by a rise in hospital-acquired pressure injuries in the subacute ward in 2012.

“On top of that, dietitians at the subacute site expressed concerns about patients being transferred to the subacute ward who were quite malnourished,” she says.

“Questions were raised about why these patients had not been referred to the acute dietitian despite the existence of nutrition risk screening, and a care pathway for hip fracture patients that involved minimising unnecessary fasting for patients awaiting surgery, and monitoring food intake of patients.”

At the time, nutrition risk screening was based on the Malnutrition Universal Screening Tool (MUST).

Ms Bailey says the previous standard care pathway for hip fracture patients involved nursing-initiated food charts to monitor food intake.

“It was hoped that this would prompt nursing staff to refer to a dietitian when intake was notably low. However, the completion rate of the food charts was poor, and those that were documented still relied on interpretation by staff with no nutrition expertise.

“Dietitians responded to referral only, relying upon referral by other staff, and nursing staff completing a risk assessment. This risk assessment was poorly completed and rates of referral were low and/or delayed by many days, even when the nutrition risk was correctly identified.”

An audit showed less than 20 per cent of patients who were detected as being at risk of malnutrition were actually referred. 

In addition, Ms Bailey says the screening tool failed to detect patients with chronic malnutrition.

“For instance, if patients were already malnourished, the screening tool did not prompt a referral if they had been recently weight stable, even if the weight was very low.”

Ms Bailey says Austin Health dietitians developed the clinical nutrition guideline for hip fracture patients, which was implemented in January 2014.

The research team examined and compared data between 110 patients admitted with a hip fracture between January and June, 2013, in the pre-guideline group and 113 patients admitted with a fractured hip between January and June, 2014, for the post-guideline group.

Mr Klemm says the team, which used a proxy measure of length of stay, found earlier dietetic assessment and intervention decreased the incidence of pressure injuries from 41 per cent pre-guideline to 29 per cent post-guideline, while the number of pressure injuries per patient also fell, and there were significantly fewer malnourished patients in the post-guideline group.

“Over this time, there was no change in surgical or nursing care, so we feel that this change can be related to the guideline,” he says.

Ms Bailey says Austin Health has since amended the guideline to further reduce patient delays to receiving optimal nutrition.

“We found that in the majority of cases where dietetic intervention occurred, it included the provision of additional menu options, snacks or supplements,” she says.

“Rather than wait until a dietitian has seen a patient, we now initiate the offer of high-protein dairy-based snacks to all patients with the diagnosis of a fractured hip on our orthopaedic ward. 

“We aim to screen all patients, explain the reason for mid-meal snacks they are being offered and encourage patients to accept them.”

Dietitians tailor the snacks to suit personal preference or special dietary needs where required while written information is left at the bedside for patients, to alert both staff and visiting family members to encourage oral intake.

“We aim to empower patients and their families to fuel their recovery by eating small, frequent meals and requesting assistance when they have concerns about nutrition,” Ms Bailey says.

A full nutritional assessment takes place when the patient is considered to be at risk of nutritional decline or when the patient has a compromised nutritional status.

The study also collected data on mealtime practices of the ward that affected patients’ oral intake, including the provision of appropriate positioning for meals, mealtime assistance, and mealtime disruptions.

The mealtime audit found 38 per cent of patients were not in a position to eat when their meal was delivered, 27 per cent of patients’ meal trays were left out of patient reach, while 53 per cent of patients had unnecessary interruptions to eating their meals.

Ms Bailey says following in the footsteps of the NHS implementation of Protected Mealtimes in the UK, dietitians are now leading a move to minimise non-urgent interruptions to patients’ meals at Austin Health.

“It’s a concept where all non-urgent clinical work stops at mealtimes and all hands are on deck to encourage patients to eat well, so it’s about minimising barriers to patients eating well on the ward because we have such busy environments.

“As dietitians, that’s our number one frustration in hospitals is that we do a lot of work trying to optimise what the patient gets on their tray but the food doesn’t necessarily get into the patient’s mouth for a multitude of reasons, and a common reason just is a lack of attention to the importance of mealtimes in hospitals,” she says.

“Another area we’d like to do a bit more work on in the coming years is getting the mealtimes conducive to good oral intake for patients.”