ANZHFR Sprint Audits

ANZHFR Sprint Audits

A Sprint Audit involves additional questions or variables that are temporarily added to the routine registry data collection. Sprint Audits allow us to get a ‘close up’ view of one aspect of care in a short period of time.

Click on the titles below to find a summary of our ANZHFR Sprint Audit projects, findings and recommendations.

Nutrition: ANZHFR Sprint Audit (2021)

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Patient Level Results

Background

Malnutrition is the most costly comorbidity in hip fracture and the one most likely to prolong length of stay [1]. It is a stronger predictor of 12-month mortality than ASA grade, Charlson Comorbidity Index, time to surgery, or type of surgery [2]. Malnutrition is observed across all BMI ranges, and in overweight or obese patients is a very strong predictor of 12-month mortality [3]. It has been widely established that multidisciplinary, multimodal nutrition care can improve outcomes [4].

As reported in the ANZHFR Annual Report (2021):

In New Zealand, 46% of patients had an assessment for malnutrition
In Australia, 69% of patients had an assessment for malnutrition
In both countries, a large proportion of patients not assessed suggests malnutrition may be under reported.

The ANZHFR Sprint Audit sought to gain greater insight into the current provision of nutrition care to patients with a hip fracture in Australia and New Zealand.

Audit Population

Thirty hospitals across Australia and New Zealand voluntarily contributed patient-level data to the ANZHFR Sprint Audit on malnutrition. This resulted in a study population of 450 patients with a hip fracture aged 50 years and over admitted to a participating hospital between 1 - 31 August 2021.

Thirty-six hospitals voluntarily contributed facility-level data to the ANZHFR facility-level Nutrition Sprint Audit.

Findings

Nearly 3 in 10 patients were diagnosed with malnutrition, although the proportion of patients not assessed suggests malnutrition remains under-reported

Improvement opportunities:

Evidence suggests that all patients with a hip fracture should have their nutritional status assessed early in the hospital stay and throughout their admission [3, 5-7].
Nutritional assessments should be conducted using a validated assessment tool [8, 9].

5 in 10 patients did not receive any form of nutrition support

Improvement opportunities:

Multimodal, multidisciplinary nutritional interventions should be provided to all hip fracture patients to support adequate dietary intake, maintain or increase body weight, and improve patient and health care outcomes [4, 7, 10-12].

Only 3 in 10 patients received oral nutrition supplements

Improvement opportunities:

Offer all older patients with hip fracture oral nutritional supplements in order to improve dietary intake and reduce the risk of complications [7].

Less than 2 in 10 patients received prescribed oral nutrition supplements

Improvement opportunities:

Prescribing 80ml of a 2-cal/ml supplement, 3 times/day as part of a multimodal nutrition care program for all admitted hip fracture patients can improve nutritional intake and outcomes [4].

In all patients recruited across Australia and New Zealand, only two received enteral tube feeding, and two received parenteral nutrition

Improvement opportunities:

Where oral intake is expected to be impossible for more than three days or expected to be below half of energy requirements for more than one week, consider enteral nutrition [9, 13-16]. This should be done in collaboration with the patient/carer, and aligned with patient-centred goals and treatment intent.
Supplementary overnight tube feeding should not be offered to older patients with hip fracture unless enteral nutrition is indicated for other reasons [7].

3 in 10 patients were on a dietary restriction

Improvement opportunities:

Dietary restrictions that may limit dietary intake are potentially harmful and should only be prescribed where considered essential [7]. This should be done in collaboration with the patient and/or carer.
Any restrictions should be reviewed regularly.

5 in 10 patients diagnosed with malnutrition were not provided with diagnostic advice and a treatment plan

Improvement opportunities:

People with malnutrition or who are at risk of malnutrition should be offered nutritional information, education, and be engaged in treatment planning [7].

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Facility Level Results

Findings

Thirty-four hospitals used a tool /method to screen for nutrition risk. The most common approaches were the Malnutrition Screening Tool, ‘blanket risk’ (all hip fracture patients considered at risk), and the Malnutrition Universal Screening tool.

Improvement opportunities:

Given the high prevalence of malnutrition and inadequate post-operative protein and energy intakes, all hip fracture patients should be considered at nutritional risk and undergo nutrition assessment and intervention [9].
Where resources are limited, offer all patients nutrition care interventions, including oral nutrition supplements [9, 20].

Twenty-nine hospitals used at least one tool/method to routinely determine protein/energy malnutrition status. The most common approaches were the Subjective Global Assessment, ICD coding criteria, and clinical judgement.

Improvement opportunities:

There is no gold standard for diagnosing malnutrition in patients with hip fracture in the clinical setting. The most commonly reported approaches have reasonable predictive validity. Other tools such as the Global Leadership Initiative on Malnutrition (GLIM criteria) or Mini Nutritional Assessment Short form (MNA-SF) may also be considered [21].
BMI and blood tests (e.g. Albumin, Prealbumin) should not be relied upon as stand-alone diagnostic measures.

The most common facility-level fasting time for clear fluids was 2-3 hours. Eight hospitals fasted clear fluids for ≥ 4 hours.

Improvement opportunities:

Reducing fasting times for clear fluids to 2 hours is recommended for most patients [22].
A number of sites allow clear fluids less than 2 hours prior to theatre. Although further evidence is required, programs such as ‘Sip Til Send’ may be appropriate to consider [23]

Twenty-six hospitals fasted solids between 6 and 7 hours; almost all other hospitals fasted solids between 8 and 9 hours.

Improvement opportunities:

Reducing fasting times for solids to 6 hours is recommended for most patients [22].

Twenty-three hospitals often or always provide additional food or fluid options to increase protein/energy intake

Improvement opportunities:

Hip fracture patients should be offered food-based fortification, finger foods, snacks, non-standard menus, or non-prescribed supplements to support adequate dietary intake [4, 5, 9]

Further Reading

For more information on systematised, interdisciplinary opportunities for nutrition care in hip fracture, consider these freely available resources:

Tune in to ANZHFR's podcast series Hipcast to listen to Dr Jack Bell and Dr Ólöf G. Geirsdóttir discuss their open access textbook Interdisciplinary Nutritional Management and Care for Older Adults | An Evidence-Based Practical Guide for Nurses
Nutritional Care of the Older Patient with Fragility Fracture: Opportunities for Systematised, Interdisciplinary Approaches Across Acute Care, Rehabilitation and Secondary Prevention Settings

We would like to sincerely thank all of the teams who contributed to this ANZHFR Nutrition Sprint Audit. Your efforts are greatly appreciated.

Bone Medication Protection: ANZHFR Sprint Audit (2021)

Acute Rehabilitation: ANZHFR Sprint Audit (2022)