Background: Malnutrition is common in older patients with hip fracture and impacts recovery. Guidelines recommend screening hospitalized patients for malnutrition and providing nutritional support, including oral nutritional supplements (ONS).
Aims: This study assessed whether increasing intervention levels (prompting medical staff to screen and act on malnutrition risk) improved adherence to best practice guidelines and increased identification and support for at-risk patients. Secondary aims included evaluating whether malnutrition diagnosis or prolonged fasting affected length of stay (LOS), complications, readmission, or mortality.
Methods: A quality improvement study using the Plan-Do-Study-Act (PDSA) model was conducted on 192 hip fracture patients (≥65 or ≥45 years if Aboriginal/Torres Strait Islander) at John Hunter Hospital. After a 13-week baseline (n=115), two PDSA cycles were implemented: Cycle 1 (n=39) introduced an infographic and staff training; Cycle 2 (n=38) added an orthogeriatrics proforma prompting screening and dietitian referral.
Results: All patients were screened for malnutrition, with 82%, 72% and 71% identified at risk respectively at Baseline, Cycle 1 and Cycle 2. Dietitian referrals increased (33% baseline, 32% Cycle 1, 56% Cycle 2), as did ONS prescription (25% baseline, 18% Cycle 1, 45% Cycle 2). Malnutrition diagnosis improved (18% baseline, 10% Cycle 1, 37% Cycle 2) and was associated with increased LOS (+6 days), infection, and 120-day mortality.
Conclusions: A high proportion of patients with hip fracture are at risk of malnutrition. The AOG proforma improved dietician referrals and prescription of ONS. Our data has since been used in various presentations and quality improvement rollouts.