Identifying and overcoming barriers to nutrition care in hip fracture.

An ethics approved before and after study evaluating changes to routine clinical practice for patients admitted to an acute hip fracture inpatients unit for surgical intervention of a hip fracture. Observed and reported barriers to nutritional care were identified; improvements to routine nutritional care were then identified, developed and implemented by the treating team as part of usual service improvement practices using an action research framework. The new multi-disciplinary, multi-modal nutritional model of care was then developed by the multidisciplinary treating team and embedded into routine clinical practice for all patients. Key improvements implemented were adopting a medicalisation of nutrition approach (medical scripting of supplements, supported medical diagnosis of malnutrition and patient education, consideration of whether enteral tube feeding was considered in the patients best interest), a coordinated multidisciplinary approach including delegation of activities to nutrition assistant staff, enhancements to the hospital foodservice system, and multimodal strategies to improve staff and patient knowledge and awareness. These changes were then evaluated using the same measures conducted during the first phase. The duration of assessment of the model of care changes was over two 10 week periods; however the total duration of data collection for the entire multiphase study including identification of barriers to intake was conducted from September 2011-July 2012. Pragmatic outcomes measures were only included that were collected as part of routine clinical practice audit; nil additional measures or interventions apart from those applied as changes to routine clinical practice were undertaken. Strategies used to monitor adherance were not applicable in response to the pragmatic trial design.