The Evidence Based Continuum Of Care For Nutrition Management Post-Hip Fracture


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Judi Porter, Dietetics Manger, Eastern Health delivered this presentation at the 2012 Hip Fracture Management conference in Australia. The only regional event to discuss practical innovations and improvement processes for the management of hip fractures in the hospital setting. For more information on the annual conference, please visit the website:

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The Evidence Based Continuum Of Care For Nutrition Management Post-Hip Fracture

  1. 1. Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health Members of Eastern Health: Angliss Hospital, Box Hill Hospital, Healesville & District Hospital, Maroondah Hospital, Peter James Centre, Turning Point Alcohol & Drug Centre, Wantirna Health, Yarra Ranges Health and Yarra Valley Community Health The evidence based continuum of care for nutrition management post-hip fracture Dr Judi Porter, AdvAPD Dietetics Manager
  2. 2. The evidence based continuum of care for nutrition management post-hip fracture Content of this presentation: – Nutrition screening, triage, assessment and intervention in acute and sub-acute settings – Evidence based nutrition models of care – Case examples from the workplace
  3. 3. The care continuum for hip fractures Fall/event Admission usually via ED Acute admission Subacute admission Discharge home or to a facility
  4. 4. Nutrition screening • Using validated screening tools appropriate for the clinical setting to identify patients who are malnourished or at risk of malnutrition. • What screening process can be used to identify adults at risk of malnutrition? Reference: Dietitians Association of Australia. (2009) Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutrition & Dietetics. 66 (Supp 3).
  5. 5. Who screens? • Systematic review soon to be published in Journal of Human Nutrition & Dietetics exploring barriers and enablers to nutrition screening (authors unknown). • Qualitative study of nurses undertaken at Southern Health, Victoria Five main themes emerged: – Screening role – Task priorities – Recognition of evidence based practice – Uncertainty of protocols – Degree of competence
  6. 6. Nutrition screening issues • Screening completion limited by workloads • Uncertainty of screening policies • Individual skill in tool use • Recommendations for nurse led screening: – Facilitation of nurse competence through training and ongoing support – Dietitians need to work with nurses to identify and reduce barriers – Collaboration is essential • Alternatives include allied health led nutrition screening Reference: Porter et al (2009) Exploring issues influencing the use of the Malnutrition Universal Screening tool by nurses in two Australian Hospitals. Journal of Human Nutrition & Dietetics.
  7. 7. Dietetic triage • ‘Triage’ and ‘prioritisation’ are terms used to describe systems and tools which support clinicians to allocate their services. • Triage systems can be used across the spectrum of health care to assess the needs of individuals to determine how, if and when clinical and staffing resources are allocated. • Triage aims to balance the considerations of need with other priority considerations including ability to benefit, relative cost, and ease of access.
  8. 8. Benchmarking study aims • To compare the triage guidelines in use in a sample of Australian dietetic departments. • To gather demographic information describing the dietetic department and its scope of service provision. • To obtain feedback from dietetic managers on the benefits/disadvantages of their triage guidelines.
  9. 9. Inpatient priorities for dietetic assessment Category/ priority 1 conditions Category/ priority 2 conditions Category/priority 3 conditions Enteral and parenteral nutrition Food allergies (anaphylaxis) Newly diagnosed Type 1 diabetes or frequent hypoglycaemic episodes Newly diagnosed coeliac disease Refeeding syndrome Hyperkalaemia Burns Significant weight loss Failure to thrive Chyle leaks Post major gastric surgery Commencing texture modified food or fluids Multi trauma Malnutrition Newly diagnosed Type 2 diabetes New/non-compliant coeliac disease Malnutrition/ risk of malnutrition Chronic renal failure Dialysis Pancreatic disease Inflammatory bowel disease Cystic fibrosis Pressure injury Liver disease Poor oral intake Texture modified food Cancer cachexia Overweight/obesity Pre-existing diabetes Hypertension Lipid lowering/ cardiovascular disease Vitamin K education on warfarin Chronic GI conditions Gout Healthy eating advice Vegetarianism Existing coeliac disease
  10. 10. Triage issues in dietetics • Benefits: – “Helps staff to prioritise their workload and it is standardised for all staff members”. – “Identifies the highest priority referrals well”; “provides staff with permission to prioritise patients” • Weaknesses: – “Does not give guidelines for incorporating prioritisation of reviews against new patients. Implementation has been hospital wide but nursing staff tend to ignore them because they have different priorities”. – “Not really helpful for staff – too vague. But I do want to leave a degree of professional judgment with our dietitians, and not write a recipe for this process. Also, it doesn’t include non-clinical work priorities so... staff aren’t able to make decisions between patient referrals and other types of work that needs to be done”. • Lack of validity and reliability of tools currently in use Reference: Porter J and Jamieson R (2012). Triaging in dietetics: do we prioritise the right patients? Nutrition & Dietetics, 69. DOI 10.1111/j.1747-0080.2012.01637/x
  11. 11. Dietetic assessment: Subjective global assessment • Medical History (60%) – Weight change – Dietary intake – GI symptoms – Functional impairment • Physical Examination (40%) – Loss of subcutaneous fat – Muscle wasting – Oedema and ascites Reference: Detsky et al. (1987) What is subjective global assessment of nutritional status. Journal of Parenteral and Enteral Nutrition, 11(1).
  12. 12. Assessment • Importance of dietary assessment – Pre-hospital admission – In hospital – including food record charts – History obtained from patients and their family • Consideration of pressure injury risk in the hip fracture population
  13. 13. Physical examination Patients are classified as: – A Well nourished – B Mildly/moderately malnourished – C Severely malnourished Fat stores Muscle stores
  14. 14. Intervention Reference: Notes from a hospital bed – Traction man
  15. 15. Intervention Reference: Notes from a hospital bed – Traction man
  16. 16. Intervention Eastern Health visual menu project
  17. 17. Intervention Eastern Health visual menu project
  18. 18. Meta-analysis of calcium intake and hip fracture risk • This study assessed the relation of calcium intake to the risk of hip fracture. • Included 7 prospective cohort studies of women and 5 for men, and 9 clinical trials. • Pooled results suggested that calcium intake is not significantly associated with hip fracture risk in women or men. • Pooled results from RCTs showed no reduction in hip fracture risk with calcium supplementation, and an increased risk is possible (poor statistical power noted). • Authors suggested a range of reasons for the results, including that other deficiencies, eg vitamin D deficiency and phosphate deficiency due to low protein intake should also be corrected. Reference: Bischoff-Ferrari et al, Am J Clin Nutr 2007; 86:1780-90.
  19. 19. Clinical benefits of ONS in elderly hip fracture patients • RCT of an oral nutritional supplement + hospital diet (n=65) vs control of hospital diet only (n=61) • Both groups received usual rehabilitation , oral calcium and Vit D supplementation • Outcomes measured at discharge and 4 weeks post-discharge • Significant differences in BMI (reduction less in intervention group), and LOS (3.80 days) in intervention group. No differences observed in serum albumin, FIM or EMS scores. ONS Oral nutritional supplementation Reference: Myint et al, Age Ageing 2012
  20. 20. Interventions: evidence based nutrition models of care • Protected mealtimes • Feeding assistance • Communal dining • The “red tray” initiative Practitioners assume that employing these nutritional models-of –care will improve dietary intake and decrease malnutrition, however the evidence to support associations remains unclear. Reference: Wade K and Flett M (2012) Nutrition & Dietetics 69. In press.
  21. 21. Malnutrition intervention in the workplace • Drink me! • Med-pass program with education sticker
  22. 22. Acknowledgements The fabulous team of dietitians at Eastern Health, including those who contributed work to this presentation: • Melissa Corken • Melanie Flett • Rachel Jamieson • Kathleen Wade • Anita Wilton