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位置: eLearning Site of APLCGG > e-Learning > Oct 22-28, 2012,Geriatrics Fellowship Teaching Schedule > Measuring change and nutrition

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by aplcgg, 2012-11-12 19:50, 人氣(2520)

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標題

1. Hip fracture outcome- measuring changeAntony JohansenConsultant Orthogeriatrician – Cardiff Trauma UnitHon. Senior Lecturer in Public Health – Swansea University

2. Slide 2

3. Designing an outcome instrumentWe need a hip fracture dataset that provides:1.Key data that informs - clinical assessment - prediction of prognosis2.Outcome measure for - the individual patient- Trauma Unit performance

4. Slide 4

5. Slide 5

6. Clinical assessment Cognitive status is a key outcome predictorAMT score on admission

7. Length of StayAcute and Overall LOS- excludes patients with discharge outside the index year, or if LOS >1 year

8. Surgery in 48 hoursExcludes patients who were: - in hospital pre-fracture- died before 48 hours- managed conservatively - medically unfit at 48 hours

9. Slide 9

10. Return to own home by 30 days

11. Slide 11

12. The literature

13. Hip Fracture – evidence from the Cochrane Library Trials Evidenceorthogeriatric rehabilitation 9+?hospital at home 5 -nerve blocks 8+?spinal vs. general anaesthesia22+?pre-operative traction10 -operation vs. conservative care 5 -implant types and surgical approach73++thromboprophylaxis31+?antibiotic prophylaxis22++post-operative mobilisation 5 - delirium management 5 +nutritional supplementation21 +

14. Nutritional supplementation and hip fracture aftercare Cochrane Database of Systematic Reviews 2006 A Avenall, HHG Handoll21 trials including 1,727 participants Poor quality issues (allocation concealment, assessor blinding, intention to treat analysis, limited availability of outcome data)

15. Nutritional supplementation and hip fracture aftercare Cochrane Database of Systematic Reviews 2006 A Avenall, HHG HandollOral multi-nutrient feeds – 8 trials – ‘no statistically significant effect on mortality’ but ‘may reduce unfavourable outcome (combining mortality or complications) 14/66 vs. 26/73: RR 0.52, 95% CI 0.32-0.84’

16. Dietary supplementation in elderly patients with fractured neck of femur. Delmi et al. Lancet 1990; 335: 1013-16 59 patients aged 60+, randomised to: conventional feeding+/- 250ml oral supplement of 254kcal + 20g protein significantly higher albumin at 2-4 weeks after surgery ‘favourable outcome’ observed more frequently (p<0.05) fewer deaths at 6 months (24% vs. 37%, p=ns)

17. Nutritional supplementation and hip fracture aftercare Cochrane Database of Systematic Reviews 2006 A Avenall, HHG HandollOral multi-nutrient feeds – 8 trials – ‘no statistically significant effect on mortality’ but ‘may reduce unfavourable outcome (combining mortality or complications) 14/66 vs. 26/73: RR 0.52, 95% CI 0.32-0.84’Oral protein supplements – 4 trials – ‘may have reduced number of long-term complications, but did not make a difference to mortality’NG feeding – 4 trials –‘did not seem to make a difference to mortality’

18. Benefits of supplementary tube feeding after fractured hip: a randomised controlled trialBastow et al. BMJ 1983;287:1589-92 122 women with hip fracture (exclusions: dementia or stroke) Randomised to: conventional nutrition +/- overnight NG-feeding providing 1000kcal and 28g protein no effect on mortality time to ‘independent mobility with aids’ halved (p=0.02)

19. The real world

20. 1. Nutritional state predicts hip fracture outcome

21. 2. How does a simple validated risk assessment compare with MNA in women with hip fracture? Duncan, Hood, Beck, Johansen Proc Nutrition Soc 2001

22. 3. Routine nutritional support on the Trauma UnitIn response to this evidence we: - routinely provide oral multi-nutrient supplements - routinely perform nutritional risk assessment - encourage NG feeding and other support for those identified as being at 'high risk'

23. 4. Quantifying nutritional intake after hip fracture

24. 5. Consider hospital food as ‘treatment’ Improving intake by re-engineering hospital menus:

25.

26. 4. Quantifying nutritional intake after hip fracture

27.

28. 5. Consider hospital food as ‘treatment’ Improving intake by re-engineering hospital menus:

29.

30. 6. Reducing nutritional risk in hospital; the red tray Bradley and Rees. Nursing Standard 2003 17.26 33-37

31. Slide 28

32. Slide 29

33. 7. Dietetic Assistants Role – what would my mother do? - collect information to aid assessment by the dietitian - help those the dietitian identifies as being at high risk - check individual personal/cultural food preferences - coordinate meal orders with catering staff - order nutritional supplements if necessary - help at mealtimes with food choice, portion size etc. - sit with, encourage and feed the frailest patients

34. Slide 29

35. 7. Dietetic Assistants Role – what would my mother do? - collect information to aid assessment by the dietitian - help those the dietitian identifies as being at high risk - check individual personal/cultural food preferences - coordinate meal orders with catering staff - order nutritional supplements if necessary - help at mealtimes with food choice, portion size etc. - sit with, encourage and feed the frailest patients

36.

37. Slide 32

38. Patient satisfaction with nutrition in hospital

39.

40. Slide 35

41.

42. Slide 35

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