Background: Older adults with malnutrition (≥65 years) require coordinated nutrition care during hospital-to-home transitions. A key purpose of integrated electronic medical record (iEMR) systems is to support clinicians in ensuring continuity of care across settings, yet little is known about their use in nutrition care discharge practices. This study explored how clinical dietitians use the iEMR to support nutrition care discharge practices for older adults with malnutrition and identified opportunities for optimisation to enhance care continuity. Methods: Semi-structured interviews were conducted with 16 clinical dietitians (11 frontline clinicians, 5 senior leaders) from 10 public hospitals across Queensland, Australia. Analysis combined deductive coding using the Consolidated Framework for Implementation Research 2.0 with inductive thematic analysis to identify system-level, organisational and behavioural influences on iEMR use and optimisation opportunities. Results: Four themes and ten subthemes were identified. System fragmentation, policy constraints and documentation burden limited dietitians’ ability to coordinate discharge care. Workarounds were common and reflected both practical adaptation and conditional trust in iEMR. Discharge practices were also shaped by local culture, professional norms and variable expectations for iEMR use. Despite these constraints, participants expressed aspirations for an optimised iEMR with embedded referral tools, real-time alerts and analytics to support improved service delivery. Conclusions: This study identified key factors influencing iEMR use by clinical dietitians to support nutrition care transitions for older adults with malnutrition. While current systems present significant challenges, optimising iEMR alongside organisational and policy enablers holds potential to strengthen nutrition care discharge practices and care continuity.

BACKGROUND:Nutrition care continuity after hospital discharge is critical for supporting recovery in older adults with malnutrition, yet evidence suggests significant variability in nutrition care discharge practices. This study explored clinical dietitians' experiences, perspectives, and approaches to nutrition care discharge practices for older adults with malnutrition transitioning home from hospital. METHODS:Semi-structured interviews were conducted with clinical dietitians from two public hospitals in one health service in Queensland, Australia. Interviews, informed by the Theoretical Domains Framework and a recent chart audit conducted at the health service, explored current practices and factors influencing nutrition care continuity. Data were analysed using inductive thematic analysis following Braun & Clarke's six-step framework. RESULTS:Ten clinical dietitians were interviewed. Participants acknowledged the practice gaps identified in the chart audit were reflective of their current practice environment. Four core elements characterising nutrition care discharge practices were identified: dietitians positioned themselves as advocates for nutrition care continuity; practice evolved through clinical experience rather than formal guidance; comprehensive discharge planning was selectively implemented; and documentation and communication approaches varied. Factors influencing practice operated at individual (patient engagement, dietitian capabilities), process (workflow complexities, service coordination), and system levels (healthcare environment and structure, resource constraints and organisational culture). CONCLUSIONS:Variability in nutrition care discharge practices reflects the interplay between system constraints, workflow challenges and dietitian adaptations. Addressing these dynamics presents opportunities for system- and practice-level improvements, including standardising documentation workflows, optimising electronic medical record functionality, and strengthening care pathways between acute and community settings to support continuity of nutrition care.

BACKGROUND:Hip fractures generate high biomedical, social, functional, organisational, and economic costs. There are various quality indicators to guide its management. One of them is surgery within 48-72 h. In Chilean public health system, this indicator has out-of-standard results. This situation could have organizational causes: after hip fracture diagnosis, many older patients are first referred to general hospitals, whilst waiting an orthopedic surgical bed. OBJECTIVE:To evaluate the effects of a protocol of immediate-admission to the surgery hospital on organisational and economic indicators of hip-fractured older patients. DESIGN:Before-and-after study, between 01/01/2017-09/30/2019; 12 months before and 21 months after implementation. SETTING:Regional surgical hospital responsible for 87 % of the older population in its assigned territory, in the more aged region of Chile. PARTICIPANTS:Anonymised data of 902 hip-fractured older adults (≥ 60 years). INTERVENTION:Implementation of a protocol that requires immediate admission to the surgical hospital of all older hip-fractured patients at the time of diagnosis. MEASUREMENTS:Number of hip-fractured patients with no immediate admission, time to surgery, total in-hospital time, and economic costs. Normality tests (Kolmogorov-Smirnov), non-parametric tests (Chi-squared), Mann-Whitney and Kruskal-Wallis tests were performed. Measures of central tendency (medians and percentiles) were used. RESULTS:After protocol there was a significant reduction in the proportion of patients referred to general hospitals in both, first and second year (pre=37,8 %; post 1 = 27,3 %; post 2 = 23,3 %, p = 0,000). Time to surgery was also significantly reduced (medians bed days pre=15, post 1 = 11, post 2 = 10, p = 0,000). Total in-hospital time decreased 21 % (3395 bed days), and there was also a significant decrease in costs from USD130,000 to USD35,000 (p = 0,000). CONCLUSION:Immediate admission to orthopedic surgical hospital of older adults with hip fractures significantly decreases inter-hospital transfers, time to surgery, total in-hospital time, and direct hospital costs.

Background: Malnutrition predicts poor outcomes following hip fracture, affecting patient recovery, healthcare performance, and costs. Evidence-based guidelines recommend multicomponent, interdisciplinary nutrition care to improve intake, reduce complications, and enhance outcomes. This study examines global variation in oral nutrition support for older (65+ years) hip fracture inpatients. Methods: A global survey was conducted as part of a broader program to improve interdisciplinary nutrition care. The protocol was based on evidence-based guidelines, reviewed by experts, and piloted for validity. Recruitment used snowball sampling to achieve diversity across income levels, countries, and healthcare roles. Results: The survey (July-September 2023) recruited 308 participants from 46 countries across five global regions. Respondents primarily worked in acute teaching (57.5%) and non-teaching (17.5%) hospitals, representing medical (48.4%), nursing (28.2%), and allied health (17.9%) roles. Findings revealed a global knowledge-to-practice gap in multicomponent nutrition care, across providing high-protein/energy food and fluids (median: "half the time"), post-operative provision of oral nutritional supplements (median: "half the time") and continuation for one month with assessment (median: "not very often"), and nutritional education (median: "not very often"). Only 17.9% of respondents reported routine provision ("often" and "nearly always or always") of high-protein/energy food, supplements, and education. Substantial regional variation showed Western Pacific respondents perceiving the lowest provision across multicomponent processes. Interdisciplinary, multicomponent interventions were seen as a potential opportunity requiring further exploration. Conclusions: Major gaps persist in implementing evidence-based, interdisciplinary, multicomponent nutrition care for older adults with hip fractures. A targeted implementation approach is the next step to addressing the knowledge-to-practice gap.

Care transitions from hospital to home for older adults with malnutrition present a period of elevated risk; however, minimal data exist describing the existing practice. This study aimed to describe the transition of nutrition care processes provided to older adults in a public tertiary hospital in Australia. A retrospective chart audit conducted between July and October 2022 included older (≥65 years), malnourished adults discharged to independent living. Dietetic care practices (from inpatient to six-months post-discharge) were reported descriptively. Of 3466 consecutive admissions, 345 (10%) had a diagnosis of malnutrition documented by the dietitian and were included in the analysis. The median number of dietetic visits per admission was 2.0 (IQR 1.0–4.0). Nutrition-focused discharge plans were inconsistently developed and documented. Only 10% of patients had nutrition care recommendations documented in the electronic discharge summary. Post-discharge oral nutrition supplementation was offered to 46% and accepted by 34% of the patients, while only 23% attended a follow-up appointment with dietetics within six months of hospital discharge. Most patients who are seen by dietitians and diagnosed with malnutrition appear lost in transition from hospital to home. Ongoing work is required to explore determinants of post-discharge nutrition care in this vulnerable population.

Objectives: To examine patient, surgical and hospital factors associated with Day-1 postoperative mobility after hip fracture surgery in older adults. Methods: A cohort study using Australia and New Zealand Hip Fracture Registry was conducted. Participants were aged older than 50 years and underwent hip fracture surgery between 1 January 2020 and 31 December 2020 inclusive. The outcome was standing and step transferring out of bed onto a chair and/or walking Day-1 after hip fracture surgery. Results: Mean age was 82 years and 68% were women. Of 12,318 patients with hip fracture, 5981 (49%) actually mobilised Day-1. Odds of actual first-day mobilisation were lower for individuals usually walking with either stick or crutch (OR = 0.71, 95% CI 0.62-0.82) or two aids or frame (OR = 0.57, 95% CI 0.52-0.64) or wheelchair/bed bound (OR = 0.24, 95% CI 0.17-0.33); who had impaired cognition preadmission (OR = 0.57, 95% CI 0.51-0.64); from aged care facilities (OR = 0.59, 95% CI 0.52-0.67); had an American Society of Anaesthesiologists grade 2 (OR = 0.63, 95% CI 0.41-0.97), 3 (OR = 0.31, 95% CI 0.20-0.47) or 4 or 5 (OR = 0.21, 95% CI 0.14-0.32); surgery delay >48 h (OR = 0.81, 95% CI 0.71-0.91); and restricted/non-weight-bearing status immediately postoperatively (OR = 0.53, 95% CI 0.42-0.67). Conclusions: Both non-modifiable and modifiable patient and surgical factors influence first-day mobilisation after hip fracture surgery. Reducing time to surgery might assist future quality improvement efforts to increase Day-1 postoperative mobility.

BackgroundThe aim of this study was to pilot a protocol for prospective validation of the Global Leadership Initiative on Malnutrition (GLIM) criteria in hospital patients and evaluate its feasibility and patient acceptability.MethodsThe validation protocol follows the GLIM consortium's rigorous methodological guidance. Protocol feasibility was assessed against criteria on recruitment (>= 50%) and data collection completion (>= 80%); protocol acceptability was assessed via patient satisfaction surveys and interviews. Adult inpatients in a tertiary hospital underwent four nutrition assessments (each by a different assessor); two Subjective Global Assessments (SGAs) and two GLIM assessments. All five GLIM criteria were assessed with bioelectrical impedance analysis used for muscle mass. Interrater reliability, criterion validity, and predictive validity were reported to detect trends.ResultsAll primary feasibility criteria were met (consent rate 76%; data for GLIM criterion validity collected on 83% participants). Of predictive outcome data, 100% of hospital-related data, 82% of 6-month mortality data, and 39% of 6-month health-related quality of life data were collected. The mean (SD) age of participants was 61.0 +/- 16.2 years, and 51.5% were male. The median (interquartile range) length of stay and body mass index were 7 (4-15) days and 25.6 (24.2-33.0) kg/m2, respectively. GLIM criteria diagnosed 70% of the patients as malnourished vs 55% with SGA. Most patients found the data collection acceptable with minimal burden.ConclusionThe methods outlined in this rigorous GLIM validation protocol are feasible to undertake in hospitals and acceptable to patients. This paper provides practical methodological guidance for future prospective GLIM validation studies.

Background/Objectives: Evidence-based guidelines and care standards recommend offering oral nutrition supplements to all older adults with hip fracture, not just those already malnourished. This study aimed to identify the proportion of inpatients in a sample of hospitals in two countries that were provided with oral nutritional supplementation (ONS) following a hip fracture and to identify factors associated with ONS provision. Methods: An analysis of prospectively collected data from a bi-national Hip Fracture Registry nutrition sprint and registry audit data limited to older adults (≥65 years) undergoing surgical intervention for a fractured hip from 1 to 31 August 2021. Multivariable logistic regression was used to identify factors associated with providing ONS. Results: Patient-level data was available for 385 older adults (median 85 years; 60.5% female) admitted to twenty-nine hospitals. Less than half (n = 47.3%) of the audited inpatients were provided ONS. After adjusting for covariates, ONS was more likely to be provided to older adults who were identified as malnourished on formal testing (OR 11.92; 95%CI 6.57, 21.69). Other factors associated with prescription of ONS included those who did not have a preoperative medical assessment (OR 2.26; 95%CI 1.19, 4.27) or were cognitively impaired (OR 1.83; 95%CI 1.01, 3.32), severely frail, or terminally ill (OR 3.17; 95%CI 1.10, 9.17). Conclusions: ONS was provided in line with evidence-based recommendations for less than half of the older adults with a hip fracture in 29 hospitals in two countries. A structured approach to implementation may be required to reduce complications and improve outcomes for all older adults after a hip fracture, not just those assessed as cognitively impaired, frail, and/or malnourished.

OBJECTIVE:Despite the protective effect of obesity on mortality in older patients, the dual diagnosis of obesity and malnutrition may worsen outcomes. This study aimed to investigate whether obese patients aged 65 years and over with a diagnosis of malnutrition have different outcomes to obese, non-malnourished peers. METHODS:This retrospective study of inpatients included 9 years of data from annual Malnutrition Audits (2011-2019). Obesity was defined as Body Mass Index (BMI) > 30 kg/m2; malnutrition was defined by Subjective Global Assessment (SGA) category B or C. Logistic regression analyses were used to consider the association between a concurrent diagnosis of malnutrition and obesity and outcomes including: 12-month mortality, prolonged length of stay (defined as >50th centile, very prolonged as >75th centile) and hospital readmission within 12 months. RESULTS:326 obese patients aged 65 years and over were included. Median patient age was 76.1 years, with 51.8 % female. 37 patients (11 %) were malnourished and obese, with a median BMI of 32.9 kg/m2. Malnutrition increased the odds of prolonged length of stay (OR:3.30, 95 % CI 1.58-6.91, p = 0.002) and very prolonged length of stay (OR: 4.17, 95 % CI 1.89-9.21, p = <0.001), as well as increased 12-month mortality (OR: 2.89, 95 % CI 1.40-5.96, p = 0.004). Malnutrition was not associated with increased hospital presentations within 12 months (p = 0.531). CONCLUSION:Older patients with a dual diagnosis of obesity and malnutrition have worse outcomes than their obese but non-malnourished peers. The presence of obesity should not preclude the assessment of nutritional status in older patients.

AimsThis scoping review aimed to identify and map the available information on the nutrition care process in older adults with delirium to analyse and summarise key concepts, and gaps, including the barriers and enablers to providing nutrition care for this group.DesignScoping review.MethodsThis review was conducted in accordance with the JBI methodology for scoping reviews. Published and grey sources in English were considered.Data sourcesDatabases searched were CINAHL, Medline, Embase, JBI Evidence-based Practice, Scopus, ProQuest and Google. The initial search was conducted from October 2021 to March 2022 and repeated in October 2023.ResultsThe database search identified 1561 articles, 186 underwent full-text review and 17 articles were included. The grey literature search identified eight articles. Malnutrition and delirium were identified as mutually reinforcing, and nutrition strategies were included as part of multicomponent interventions for delirium management. There was no mention of barriers or enablers to nutrition care and minimal descriptive or empirical data available to guide nutrition care processes in this group.ConclusionThis scoping review revealed a need for further research into nutrition care processes in older patients with delirium, in particular the barriers and enablers, to inform appropriate management strategies in this vulnerable group.Implications for the profession and patient careProviding nutrition care for older patients with delirium is important and further practical guidance could help patients, healthcare staff and families.ImpactThis scoping review yielded instructive data suggesting that delirium is an important risk factor for malnutrition and vice versa, which leads to poor patient and health service outcomes.Reporting methodThis scoping review adhered to relevant EQUATOR guidelines and used the Preferred Reporting Items For Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR).Patient of public contributionNo patient or public contribution.

AIMS:To explore adult inpatients' perceptions, understanding and preferences regarding the term 'malnutrition' and to identify the terms that adult inpatients report are used by themselves and health workers to describe malnutrition. DESIGN:This qualitative study was conducted using data collected for a separate qualitative study that investigated factors that influence the dietary intake of long-stay, acute adult inpatients. METHODS:Semi-structured interviews were conducted with a purposive sample of current inpatients. Data were analysed using inductive content analysis. RESULTS:Nineteen interviews were included (mean age 64 years (standard deviation ±17), 10 female (53%), 12 malnourished (63%)). Four categories were identified. 'Variation in patients' recognition of malnutrition' represents the differing abilities of patients to understand and identify with the term 'malnutrition'. 'Recognising individuals' needs and preferences' highlights patients' varying beliefs regarding whether 'malnutrition' is or is not an appropriate term and participants' suggestion that health workers should tailor the term used to each patient. 'Inconsistencies in health workers' and patients' practice regarding malnutrition terminology' encapsulates the multiple terms that were used to describe malnutrition by health workers and patients. 'Importance of malnutrition education' summarises patients' views that health workers should provide patient education on malnutrition prevention, management and complications. CONCLUSION:Findings highlight variations in patients' perceptions and understanding of the term 'malnutrition' and differences in the terms used by patients and health workers to describe malnutrition. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE:The terminology used by health workers to describe malnutrition risk or malnutrition to their patients can influence patients' recognition of their nutritional status and thus the multidisciplinary management of the condition. To ensure that patients receive information about their malnutrition risk or diagnosis in a way that meets their needs, health workers' practices must be revised. To do this, it is imperative to conduct further collaborative research with patients and health workers to identify optimum terms for 'malnutrition' and how health workers should communicate this to patients. IMPACT:There is a disparity in patients' perceptions, understanding and preferences for the term 'malnutrition' and there are inconsistencies in how health workers communicate malnutrition to patients. To support patients' recognition and understanding of their nutritional status, it is imperative for health workers to consider how they discuss malnutrition with patients. REPORTING METHOD:Adheres to the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007). PATIENT OR PUBLIC CONTRIBUTION:No Patient or Public Contribution.

To determine the relationship between three postoperative physiotherapy activities (time to first postoperative walk, activity on the day after surgery, and physiotherapy frequency), and the outcomes of hospital length of stay (LOS) and discharge destination after hip fracture. A cohort study was conducted on 437 hip fracture surgery patients aged ≥ 50 years across 36 participating hospitals from the Australian and New Zealand Hip Fracture Registry Acute Rehabilitation Sprint Audit during June 2022. Study outcomes included hospital LOS and discharge destination. Generalised linear and logistic regressions were used respectively, adjusted for potential confounders. Of 437 patients, 62

BACKGROUND:Malnutrition is prevalent across health care settings and has adverse outcomes for patients and the health system. However, some patients do not recall being informed about their malnutrition risk/diagnosis. OBJECTIVE:This meta-synthesis of qualitative studies aimed to identify and synthesize patient, carer, and health worker perceptions and understanding of the terminology used by health workers for malnutrition risk/malnutrition. METHODS:Four databases were searched (Medline, Cumulated Index in Nursing and Allied Health Literature, PsycINFO, and Embase) up until August 2023. Title, abstract, and full text screening were independently completed by 2 reviewers. The quality of the included studies was assessed using the Critical Appraisal Skills Programme Qualitative Studies Checklist. Data were analyzed by the review team using thematic synthesis. The resulting themes informed review findings. The confidence in each finding was assessed using GRADE-Confidence in the Evidence from Reviews of Qualitative Research. RESULTS:Seventeen studies were included, contributing perspectives from patients (n = 7 studies), health workers (n = 5 studies), or both patients and health workers (n = 5 studies); no studies included carer perspectives. There were 5 themes: patients have differing understanding, interpretation of, and identification with, malnutrition risk and malnutrition terminology (very low confidence); health workers perceive that patients do not identify with or understand malnutrition risk and malnutrition terminology (low confidence); Patients do not routinely perceive their malnutrition risk or malnutrition diagnosis as problematic (low confidence); health workers use varied terminology for malnutrition risk and malnutrition (low confidence); and action is required to improve malnutrition diagnostic communication (low confidence). CONCLUSIONS:Findings highlighted disparity in patients' perspectives regarding the terms used for malnutrition risk and malnutrition. Varied terms were used by health workers, and patients did not often associate these terms with a health condition that required treatment. Health workers and patients called for action to improve the communication of malnutrition. To do this, further research exploring malnutrition terminology and the broader concept of malnutrition communication is required with patients, carers and health workers.

Rationale: Inpatient malnutrition is a longstanding issue. More-2-Eat (M2E) is an implementation study designed to improve nutrition care practices to prevent, detect, and treat malnutrition in Canadian hospitals. The purpose was to determine the feasibility of spreading and scaling of M2E.

Abstract Nutrition and hydration are fundamental aspects of healthcare, especially in the care of older people, particularly those in hospitals or in long-term care facilities. Worldwide, nurses are ‘best-placed’ coordinators of interdisciplinary nutritional management and care processes. Even so, it is essential that nurses collaborate with other healthcare specialists as an interdisciplinary team to provide high-quality care that reflects patients’ needs for assessment, intervention, and health promotion. When an interdisciplinary team work collaboratively, care is more successful, improves patient outcomes, and reduces the risk of in-hospital and long-term mortality. The care process begins with screening and monitoring of the nutritional status and fluid intake of all older people within 24 h of admission. In the case of positive screening, comprehensive assessment and involvement of other team members should undertake to understand the underlying problem. Appropriate food and appealing meals, snacks, and drinks should be available and offered with recommended amounts of energy, protein, vitamins, minerals (particularly calcium), and water. This should be complemented with supplementary drinks if intake is not adequate. The prescription of vitamin D and calcium should be discussed. Patient-centred and evidence-based information should provide and interventions in the case of end-of-life care should be appropriate discussed. Educating, informing, and involving patients and families increases their level of health literacy. Malnutrition and/or dehydration management should be included in the discharge plan. The aim of this chapter is to increase awareness of nurses’ responsibility, within a multidisciplinary team, for assessment and intervention of nutrition and hydration, examine the issues pertaining to nutrition and fluid balance in older people and outline the nature, assessment and interventions relating to malnutrition and dehydration.

We are delighted to bring to you this special supplement on quality improvement (QI) initiatives to provide better care for older people experiencing fragility fractures. The Fragility Fracture Network (FFN) is a learning organisation committed to a global ‘call to action’ to improve the care of people who experience a fragility fracture. Achieving this ‘call to action’, requires multidisciplinary clinical systems which focus on excellence in acute care, rehabilitation and secondary prevention—with the formation of national alliances to promote policy change that supports the staff within these clinical systems to respond to the call for excellence. The FFN’s mission aligns well with the British Medical Journal Open Quality (BMJOQ) mandate to publish high quality peerreviewed content relevant to all those who strive for excellence in improvement science across the world. The articles in this special edition come from around the globe and stretch across all four pillars of acute care, rehabilitation, secondary prevention and policy change, fulfilling the BMJOQ and FFN shared vision of enacting a ‘call to action’. Teams of academics, clinicians and clinical academics needed to work together to continually collect data, identify potential improvements, make a change and importantly, evaluate that change. In this way, by constantly integrating data monitoring and promoting a positive quality improvement culture, improving quality and safety can become a routine part of how organisations work. This edition contains the cumulative work of authorship teams (many of them led by early career clinical academics who are FFN members), with contributions from countless more patients, carers, administrative staff, governance and audit teams and healthcare service managers. The authors depict improvement efforts, which require teamwork, sensitivity and determination to overcome the welldocumented challenges in patient safety and improvement work. These interventions are deceptively complex as even simple QI interventions requires an indepth appreciation of context, implementation and evaluation strategy and theories of organisational change. In 2016, McCulloch writes: ‘[creating] change is associated with a mix of intensive, strenuous, stressful and sometimes coercive training and the immersive experience of more subtle but equally strong social pressures over a considerable period’. We are inclined to agree that even now in 2023, the stark reality is that changing organisational culture is a huge task. Added to this, there are still some conceptual discussions on what constitutes improvement and it can be incredibly challenging to target interventions that will provide the most ‘leverage’ and become both ‘scalable’ and ‘sustainable’—rather than producing a ‘one hit wonder’ in one place for a short time. Added to this complexity, the authors represented within this special edition are trying to serve a population, which commonly includes vulnerable, frail and older people and their families/ carers in highly resourcediverse settings. The authors presented in this special collection have attempted to select interventions which are capable of having enough ‘leverage’ to impact individual patients, healthcare cost and provider wellbeing across a breadth of topics including: new models of care; early mobilisation; innovations in nutritional supplementation and understanding what ‘good’ looks like in nutritional support; decision support tools; quality registry; implementing a fragility fracture database in a lowtomiddle income country; and Fracture Liaison Services. The fragility fracture patient population is growing in volume along with the global ageing population. Thus, to attempt to change organisational culture to benefit these patients and introduce new and valuable interventions with lasting benefit is a truly laudable endeavour. We salute the authors of the work represented here and all others involved in its production, as they give accurate descriptions of each improvement effort and its context, and thoughtful learning points that could be generalised to fragility fracture services around the world. To cite: Sutton E, Bell JJ, Beaupre LA. Fragility Fracture Network: innovations in healthcare improvement. BMJ Open Quality 2023;12:e002609. doi:10.1136/ bmjoq-2023-002609