The present study showed that our ICP was associated with a significantly shorter hospital stay, i.e. the number of care days was reduced by half compared with the comparison group. Despite a shorter hospital stay, the intervention group had better physical functioning and a higher ADL level. In the intervention group 25% more patients reached or approached their pre-fracture ADL level. Moreover, the intervention group was less dependent on walking aids, equal in gait capacity and more of the intervention patients returned to their former residence (Figures 1 and 2). These latter differences approached statistical significance and would likely have reached significance with a larger patient sample. A noteworthy fact was that it was possible to achieve this result without allowing a running-in period.
The randomised controlled trial design is considered the gold standard for evaluating interventions; however, its use in studies of this kind is somewhat problematic because such a design involves interactions between the patients and nurses. If two wards are used, it is difficult to know whether it was the change of actions or the interactions between the nurses and patients that contributed to any differences. In most studies a before-and-after design is preferred. The present study was carried out using a nonrandomized prospective design in which an intervention group was compared with a standard care group . A disadvantage of this design is that it precludes conclusions regarding the true effects of an intervention, i.e. to know whether between-group differences are due to the intervention or to other factors. However, most studies of ICPs in patients with hip fractures have been conducted using this method [13–16].
The results of the present study are largely consistent with those reported in similar studies of ICPs in patients with a hip fracture [13, 14, 16, 23]. In a controlled, prospective study Choong et al.  found that ICPs reduced the length of hospital stay without increasing the risk of complication or readmission rates. In another study Tarling et al.  noted that ICPs could reduce the length of hospital stay by 33%. Similarly, in a study comparing a fast track group to an ICP group Gholve et al.  found that ICPs could reduce the length of hospital stay by four days. On the other hand, Roberts et al.  found that whereas hospital stay increased, the quality of care was improved.
ICPs, which are designed to streamline and standardise various aspects of patient care, are structured multidisciplinary care protocols defining and specifying critical steps and progress in the care of various patient groups . In implementing an ICP for acute hip fractures the most difficult component of the care trajectory in which to affect change are the steps from admission to first ambulation because so many different professionals are involved. Several studies have shown a correlation between waiting time for surgery and prolonged hospital stay [25, 26], usually stating that more than 48 h of waiting will increase the hospital stay. In one study it was found that when the waiting time increased from 9 h to 16 h, the hospital stay increased by 19% . It appears reasonable to keep the waiting time short because patient suffering can be relieved and precious time will be saved. For this reason, we made concerted efforts here and accomplished significant changes in two out of three outcomes. The continuity of caregivers and care content was maintained simply by eliminating transfers for other than medical reasons. Consequently, no transfers were made in the intervention group.
When the ICP protocol in the present study was developed, it was decided to build on the patients' engagement from an earlier study . The hospital period is only the beginning of the rehabilitation process and it is important to facilitate a healthy transition process. In contrast to the care of younger patients, the care of elderly patients is more complex with more factors involved (such as health status, co-morbidities, motivation and cognitive functioning). It was believed that early improvements in the care path may start a positive chain reaction that can be kept going. An example is the earliest first ambulation that was planned either on the day of surgery or the next morning. Thus, the aim was to achieve a daily progress, which could be accomplished by being sensitive to the patients' resources (such as motivation) as well as being aware of physical limitations, i.e. ensuring a balance between training and rest. The early mobilisation and the strict training protocol reduced the number of pressure wounds. Moreover, the caregivers focused attention on each patient's status may have played a role in reducing the number of medical complications. In addition, early ambulation probably helped the patients to realise that they would be able to fully regain their ability to walk and thus their autonomy at an earlier stage.