A baseline audit to evaluate the quality of nutritional provision delivered to fractured neck of femur inpatients

Abstract

Background: Fractured neck of femur patients are often malnutrition (Lumbers et al., 2001). Studies have found 30–50% of patients are malnourished on admission, and dietary intake during recovery in hospital is frequently suboptimal resulting in a deterioration of nutritional status, and impaired recovery. The aim was to baseline the nutritional care given to this patient group, and objectives were set to evaluate initial nutritional screening, nutritional interventions delivered and nutritional monitoring. Methods: Data were collected on all fractured neck of femur patients present on an orthopaedic ward on two separate dates in February 2010. Audit standards were set for clinical care, and data were collected using information from the medical/ nursing notes, as well as from observations made on the ward throughout the day. The audit form was designed to capture data on use of nutrition screening and monitoring, delivery of nutritional care and dietetic referrals. In addition, an estimate of the energy and protein intake of each patient was made for the day of the audit, and this was compared with the estimated requirement based on 125 kJ kg−1 (30 kcal kg−1) and 1g protein kg−1. Results: A total of 33 patients were included, the mean age was 83 years (range 49–94 years), 85% were female, and 24% had dementia. Twenty-seven (81%) patients had an initial Malnutrition Universal Screening Tool (MUST) score (BAPEN, 2003) calculated. It was calculated using a measured weight in 18% of these, and nine patients had a previous weight recorded for score calculation. Of these, 51% (17 patients) were given an initial MUST score of zero, indicating a low risk of malnutrition. First-line nutritional care was poorly documented, and often not observed. Assistance was given to 11 (33%) patients but not all these had a red tray. Fifteen (45%) patients were referred to the dietitian. Of those not referred 74% were taking ≤50% of their daily energy requirement; 78.5% patients referred to the dietitian were seen within two working days of referral. Oral nutritional supplements (ONS) were prescribed for 39% patients; this was following dietetic referral in all cases. Fourteen (42%) patients had food record charts in their notes to monitor food intake, and 60% of patients with a MUST score ≥1 were monitored in this way. Only 14% patients who were inpatients for more that 7 days had weight and MUST score repeated weekly. Twenty-one (63%) patients were getting ≤50% of their daily energy requirement, and 45% patients were getting ≤50% of their daily protein requirement on the day of the audit. Discussion: This audit showed that many of the standards of nutritional care were not met, and many patients were not consuming enough energy or protein on the day of the audit. Although evidence suggests that routine supplements are of benefit in this patient group (Volkert et al., 2006), 61% did not have ONS prescribed. These findings were used to devise a dedicated nutritional care pathway, in the form of a flow diagram, to highlight the importance of nutrition in this patient group throughout their hospital stay, and promote best practice in nutritional assessment, delivery and monitoring, as well as trigger routine blanket ONS twice a day, an extra daily snack, and appropriate dietetic referral. Conclusions: This audit has highlighted nutritional care in this high-risk group of patients and that greater dietetic involvement is needed to improve their nutritional status.