Background: Acute hip fracture inpatients are predominantly elderly, female, multimorbid, and prone to malnutrition and inadequate post-operative protein and energy intake. Protein-energy malnutrition is now recognised as the most costly comorbidity in patients with acute hip fracture and is associated with poor nutrition, patient and healthcare outcomes. Nutrition intervention studies have demonstrated inconsistent results and overall evidence supporting nutrition care in hip fracture has been considered at best weak by a recent Cochrane review. This may imply a patient group resistant to nutrition intervention. However, highly explanatory interventional study designs may be unsuitable to investigate and evaluate multidisciplinary and multimodal interventions which are required to effectively treat complex patients in routine clinical practice. A multiphase, pragmatic, action research based approach was therefore developed to identify and overcome barriers to nutrition care in hip fracture.
Design: Four sequential action research cycles built upon baseline data including 614 acute hip fracture inpatients and 30 purposefully sampled clinicians involved in treating them. Phase I considered nutrition screening and assessment in hip fracture including two diagnostic accuracy studies and a prospective, consecutive case series. Phase II reported a further prospective, consecutive case series investigating protein and energy intakes post hip fracture and inpatient barriers to intake. Phase III built on earlier results including an explanatory mixed methods study and presented additional patient and clinician barriers and facilitators to nutrition care. Subsequent changes to routine clinical practice were developed and implemented by the treating team between Phase III and IV; these were implemented as a new multidisciplinary, multimodal nutrition model of care. A controlled before and after study was then used to compare the new model of care to individualised nutrition care. Ethics approvals for all phases were obtained.
Results: The publications resulting from this study have highlighted novel barriers and facilitators to nutrition care. Engagement of the multidisciplinary team in a multiphase, pragmatic action research intervention significantly reduced observed and reported barriers, doubled energy and protein intake, tripled the return home discharge rate, and effected a 75% reduction in nutrition deterioration during admission in a reflective cohort of hip fracture inpatients when compared with the individualised nutrition care model.
Discussion: This research approach allowed research to be conducted as part of routine clinical practice, captured a more reflective patient cohort than reported in previous studies, and facilitated exploration of barriers and engagement of the multidisciplinary healthcare workers to identify and implement practical solutions. Publications resulting from this study have demonstrated substantially different results to those previously reported and findings are considered highly relevant to clinical practice. Similar study designs should be considered to identify, overcome, and report barriers and facilitators to nutrition care in other elderly, multimorbid inpatient populations.