The fractured neck of femur pathway

1. The fractured neck of femur pathway Malnutrition and the role of oral nutritional supplements in hip fracture recovery Robyn Collery Older Persons Specialist Dietitian & Clinical Educator

2. Hip fractures in the UK Contents Major health issue due to increasingly aged population Difficult to ascertain the exact prevalence of hip fractures Projections suggest that, incidence will rise from 70,000 per year in 2006 to 91,500 in 2015 to 101,000 in 20201 Hip fractures nearly always require hospitalisation, 50% of patients are permanently disabled & only 30% fully recover2 1 in 10 patients die within a month 1 in 3 patients die within a year3 1. Department of Health. Hospital episode statistics (England) 2006. 2. Sernbo I, Johnell O (1993). Consequences of a hip fracture: a prospective study over 1 year. Osteoporosis International 3: 148–53. . 3. NICE, 2017. www.nice.org.uk/guidance/cg124 [09.08.18].

3. Cost of UK hip fractures Contents Direct medical costs from UK fragility fractures, the majority being hip fractures, were estimated to be £1.8 billion in 2000, with the potential to increase to £2.2 billion by 20251 This one injury carries a total cost equivalent of about 1% of the entire NHS budget Hip fracture patients occupy over 4,000 beds at any one time across England, Wales & Northern Ireland Patients may remain in hospital for a number of weeks, leading to 1.5 million bed days each year 1. Burge RT, Worley D, Johansen A, et al. The cost of osteoporotic fractures in the UK: projections for 2000–2020. Journal of Medical Economics 4: 51–52.

4. Hip fracture patients are some of the frailest & sickest patients, with complex medical problems and comorbidities, who have to overcome the additional physiological challenges posed by trauma and surgery4 • 4. Riemen and Hutchison. Orthop Trauma. 2016;30(2):117-22.

5. The pathology of nutritional decline after hip fracture Contents Prognosis is primarily dependent on how well a patient progresses as an inpatient following a fracture however many nutritional factors can inhibit recovery

6. Pre-existing malnutrition in #NOF patients Contents Malnutrition is associated with adverse clinical outcomes after hip fracture Up to 63% of hip fracture patients are at risk of malnutrition on admission to hospital1 Prolonged recovery time3 Impaired immune function (increased risk of post-op infection)5 Delayed wound healing5,6 Increased risk of developing pressure ulcers5,7 Reduced function & increased disability3,8 Increased risk of recurrent falls and fractures9,10 Increased hospital readmissions8 Increased mortality6,8 1. Murphy, et al. Eur J Clin Nutr. 2000;54:556-562. 2. Avenell, et al. Cochrane Database Syst Rev. 2016;11. 3. Lumbers, et al. Clin Nutr. 1996;15;101-107. 4. Li, et al. Br J Nutr. 2007;98(2):237-252. 5. Dorner, et al. Adv Skin Wound Care. 2009;22(5):212-21. 6. Patterson, et al. J Bone Joint Surg AM. 1992;74(2)251-260. 7. Baumgarten, et al. JAGS, 2009;57:863-870. 8. Koren-Hakim, et al. Clin Nutr. 2012;31(6);917-921. 9. Lloyd, et al. J Gerontol A Biol Sci Med Sci. 2009;64A(5);599-609. 10. Harvey, et al. ANZ J Surg. 2018;88(6):577-581.

7. Increased nutritional requirements in #NOF patients Contents • Increased nutritional requirements are often unrecognised • Trauma induced inflammatory stress response & catabolism1 • Fracture repair2 • Immune response2,3 • Wound healing4 & pressure damage4,5 • Rehabilitation and physiotherapy6 • Energy and Protein requirements in #NOF • - Energy7: • BMR + 20% Stress Factor + 15-20% Activity Factor • - Protein8: • >1.5 g per kg per day 1. Hedström, et al. Acta Orthopaedica, 2006;77(5);741-747. 2. Schurch, et al. Ann Intern Med. 1998;128:801-809. 3. Li, et al. Br J Nutr. 2007;98(2):237-252. 4. Dorner, et al. Adv Skin Wound Care. 2009;22(5):212-21. 5. Baumgarten, et al. JAGS, 2009;57:863-870. 6. Bauer, et al. J Am Med Dir Assoc. 2013;14(8):542-59. 7. PENG A pocket Guide to Clinical Nutrition 2011. 8. ESPEN - Deutz, et al. Clin Nutr. 2014;33(6):929–36.

8. Decreased nutritional intake of #NOF patients in hospital Contents • Decreased nutritional intake • Nutritional status may further decline due to poor intake1,2 • Average food intakes are less than 75% of that recommended, particularly among the elderly3 • Why don't people eat in hospital?3 • Communication difficulties in ordering food • Communication breakdown between staff • Poor menu choice • Poor appearance, presentation & palatability of food • Disrupted meal times • Patients who require assistance with eating are not identified • The ward environment can often put patients off eating 1. Murphy, et al. Eur J Clin Nutr. 2000;54:556-562. 2. Avenell, et al. Cochrane Database Syst Rev. 2016;11 3. BAPEN (2012) https://www.bapen.org.uk/resources-and-education/education-and-guidance/clinical-guidance/hospital-food-as-treatment?showall=1

9. The pathology of nutritional decline after hip fracture Contents Result in nutritional deficit of protein, energy & micronutrients

10. Electronic Voting: Do you have a Specialist Orthopaedic Dietitian in your department?

11. Dietetics in Orthopaedics Contents Orthopaedic patients are usually managed as part of a busy rotation rather than a specialist area with a dedicated dietitian Little dietetic time dedicated to these patients despite significantly high risk of malnutrition Orthopaedic ward is a busy ward where physiotherapy and mobilisation are often the focus Poor source of referrals despite the high risk patient group To overcome these barriers, a nutritional supplement pathway was introduced on the orthopaedic wards in Gateshead

12. Gateshead Health NHS Trust’s • #NOF Pathway Contents What It is a ward based ONS pathway for #NOF patients during their inpatient stay How A literature review of evidence was carried out and the pathway was developed from its findings Why To provide nutrition support to a high risk patient group who were often being missed

13. Choosing a supplement for the pathway Contents • The ideal ONS for a hip fracture patient should meet their specific needs and characteristics • Nutrient densehigh protein, • high energy & micronutrients Ready to drink Accessible and practical for frail patients with poor functionality Low volume(125ml) compliance is better in low volume ONS

14. Gateshead Health NHS Trust’s #NOF Pathway Contents

15. Gateshead Health NHS Trust’s #NOF Pathway Contents *Exclusions:

16. Strengths & Weakness of the #NOF pathway Contents

17. Electronic Voting: At first audit, what percentage of #NOF patients do you think received the pathway?

18. Implementation of the pathway Contents Education on wards is essential Bite size education on the ward works best Target junior doctors who will prescribe the ONS and nursing staff who will dispense the ONS Pathway posters provide a visual reminder Consider regular pathway update at point of junior doctor switchover Regular audits to monitor compliance with pathway

19. Electronic Voting: At second audit, what percentage of #NOF patients do you think received the pathway?

20. The fractured neck of femur pathway Where are we now?

21. Where are we now? Contents Pathway has now been adopted by Trust across UK & Ireland Building evidence to support continuation of pathway for period of 3 months post discharge Injury-induced catabolic state may last for up to 3 months after surgical correction of fracture1 The evidence base for high protein ONS in hip fracture is largely based on studies where prescription was continued post hospital discharge, for a mean period of ~3 months5-10 Raise the profile of dietetics in orthopaedics and older people 1. Hedström, et al. Acta Orthopaedica, 2006;77(5):741-747. 5. Malafarina, et al. Maturitas. 2017;101:42-50. 6. Delmi, et al. Lancet. 1990;335:1013-1016. 7. Tkatch, et al. JACN. 1992;11(5):519-525. 8. Schurch, et al. Ann Intern Med. 1998;128:801-809. 9. Tidermark, et al. Clin Nutr. 2004;23:587-596. 10. Flodin, et al. BMC Geriatrics. 2015;15:149.

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