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Abstract
Malnutrition is common in older people with fragility fractures and is associated with poor clinical outcomes and increased risk of complications. The UK National Health Service has published national standards for food and drink for patients, staff and visitors, in hospitals. These standards describe the methods to ensure quality and sustainability.
We assessed these standards and report the nutritional status of older (70 years of age) patients admitted to hospital with fragility fracture, and weighed food trolley and plate waste after lunch and supper for five days.
There were 19 older patients with fragility fractures on the trauma and orthopaedic ward. The mean intake for 'nutritionally well' was 1592 kcal/day and 65.7 g/day protein; the mean intake for 'nutritionally vulnerable' was 643 kcal/day and 24.8 g/day protein.
Although all key characteristics of good nutrition and hydration care for patients in hospital were achieved, energy and protein intake was poor in the nutritionally vulnerable group. Further interventions are necessary to improve dietary intake in hospital, particularly in those who are nutritionally vulnerable.
- Hip Fractures
- Standards of care
- Quality measurement
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Background
Malnutrition is common in older people with fragility fractures. It is estimated that approximately 25% of patients presenting with a hip fracture in the UK are malnourished.1 Malnutrition is associated with poor clinical outcomes and increased risk of complications.2 Furthermore, malnutrition has been shown to be a strong independent risk factor for recurrent falls and subsequent fracture.3 Optimising nutritional care is important. The UK National Health Service (NHS) has recently published national standards for food and drink for patients, staff and visitors, in hospital. This was developed by the Healthcare Food Standards and Strategy Group, set up by the NHS and describes the methods to ensure quality and sustainability, how they should be applied and monitored, as well as recommending future improvement aspirations and actions.4 The 10 key characteristics from these standards identified as ‘good nutrition and hydration care for patients’ are shown in box 1.
Ten key characteristics of ‘good nutrition and hydration care’ for patients in hospital
Screen all patients and service users to identify malnourishment or risk of malnourishment and ensure actions are progressed and monitored.
Together with each patient or service user, create a personal care/support plan enabling them to have choice and control over their own nutritional care and fluid needs.
Care providers should include specific guidance on food and beverage services and other nutritional and hydration care in their service delivery and accountability arrangements.
People using care services are involved in the planning and monitoring arrangements for food service and drinks provision.
Food and drinks should be provided alone or with assistance in an environment conducive to patients being able to consume their food (Protected Mealtimes).
All healthcare professionals and volunteers receive regular training to ensure they have the skills, qualifications and competencies needed to meet the nutritional and fluid requirements of people using their services.
All care providers to have a nutrition and hydration policy centred on the needs of users, which is performance managed in line with local governance, national standards and regulatory frameworks.
Facilities and services providing nutrition and hydration are designed to be flexible and centred on the needs of the people using them, 24 hours a day, every day.
Food, drinks and other nutritional care are delivered safely.
Care providers should take a multidisciplinary approach to nutrition and hydrational care, valuing the contribution of all staff, people using the service, carers and volunteers working in partnership.
We report the findings of an assessment of these 10 key characteristics and dietary nutritional intake in fragility fracture patients, in a large teaching hospital, in the UK.
Methods
We undertook an assessment of each of the key characteristics as listed in box 1, followed by a 3-day dietary (food-only) intake and plate waste assessment, of older (≥70 years of age) patients admitted to hospital with fragility fracture, across a single ward. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetic Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for 5 days. Where additional oral nutritional supplements (ONS) were prescribed (Fortisips Compact Protein), in addition to meals, we measured patient compliance (weighing the bottles before and after consumption).
Results
The ward met all of the 10 key characteristics of good nutrition and hydration care for patients care standards (box 2).
Ten key characteristics of ‘good nutrition and hydration care for patient hospital ward assessment
1. Screen all patients and service users to identify malnourishment or risk of malnourishment and ensure actions are progressed and monitored.
Routine use of the Malnutrition Universal Screening Tool
2. Together with each patient or service user, create a personal care/support plan enabling them to have choice and control over their own nutritional care and fluid needs.
Catering staff visit each patient, every morning and offered a menu, food recorded on a tablet device
3. Care providers should include specific guidance on food and beverage services and other nutritional and hydration care in their service delivery and accountability arrangements.
Each meal is specially prepared by the catering team with recorded nutritional values
4. People using care services are involved in the planning and monitoring arrangements for food service and drinks provision.
The hospital has a patient and public involvement group dedicated to nutritional care
5. Food and drinks should be provided alone or with assistance in an environment conducive to patients being able to consume their food (Protected Mealtimes).
Protected mealtimes and assisted meals with the use of red trays
(A red tray is used on the wards, in hospital to help staff identify which patients need extra attention when eating, or need foods that have a modified texture)
6. All healthcare professionals and volunteers receive regular training to ensure they have the skills, qualifications and competencies needed to meet the nutritional and fluid requirements of people using their services.
Hospital training package for nurses to complete
7. All care providers to have a nutrition and hydration policy centred on the needs of users, which is performance managed in line with local governance, national standards and regulatory frameworks.
National framework used as part of standard hospital operating procedure
8. Facilities and services providing nutrition and hydration are designed to be flexible and centred on the needs of the people using them, 24 hours a day, every day.
Nurses have access to the ward kitchen which allows preparation of snacks as required
9. Food, drinks and other nutritional care are delivered safely.
Specialist catering team employed within the hospital
10. Care providers should take a multidisciplinary approach to nutrition and hydrational care, valuing the contribution of all staff, people using the service, carers and volunteers working in partnership.
High-risk patients identified referred to specialist dietetics service in the hospital
There were 19 older patients on the trauma and orthopaedic ward with fragility fractures. Food diaries were collected from all 19 patients (68% hip fractures), mean age 84 years (9 female and 10 male). Mean (SD) intake for ‘nutritionally well’ (n=4) was 1592(257) kcal/day and 65.7 (8.5) g/day protein; ‘nutritionally vulnerable’ (n=15) 643(354) kcal/day and 24.8 (14.0) g/day protein.
Plate waste for ‘nutritionally well’ was 4.1 (5.8) % at main meals and 1.7 (3.4)% at pudding; ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. Extrapolating this to the whole 25 bedded ward, over 12 months, equates to the 4526 kg (4.5T) of waste per year.
Discussion
Despite achieving all of the key characteristics of good nutrition and hydration care for patients in hospital, energy and protein intake was poor in the nutritionally vulnerable group, mean (SD) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Despite the recognition of and changes in practice, this still remains poor and similar to previous studies over 10–20 years ago.5 6 The European Society for Clinical Nutrition and Metabolism advocates the use of ONS for all hip fracture patients in hospital, with those at high risk of malnutrition continuing to receive ONS for at least 1-month postdischarge.7 However, compliance with ONS was poor in our study, with a mean consumption of 28.3% of the total volume. Further, interventions are necessary to improve dietary intake in hospital, particularly in those who are nutritionally vulnerable, and to further explore the acceptability of alternative ONS food/drink styles, such as a high energy protein based Ice Cream, which have shown to be beneficial.8
Ethics statements
Patient consent for publication
Acknowledgments
We are grateful to the patients and staff on the trauma and orthopaedic wards who supported, took part in thus quality improvement project.
Footnotes
Twitter @n/a
Contributors All of the authors contributed to the design, collection of data and writing of the manuscript.
Funding This study was funded by Nottingham University Hospitals NHS Trust (no award/grant number).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.