Cahill Naomi E, Murch Lauren, Cook Deborah, Heyland Daren K
Crit Care. 2014 May 11;18(3):R96. doi: 10.1186/cc13867.
Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. However, there is inadequate data to inform the optimal method or level of tailoring. Consequently, we conducted the PERFormance Enhancement of the Canadian nutrition guidelines by a Tailored Implementation Strategy (PERFECTIS) study to determine the feasibility of a multifaceted, interdisciplinary, tailored intervention aimed at improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.
A before-after study was conducted in seven ICUs from five hospitals in North America. During a 3-month pre-implementation phase, each ICU completed a nutrition practice audit to identify guideline-practice gaps and a barriers assessment to identify obstacles to practice change. During a one day meeting, the results of the audit and barriers assessment were reviewed and used to develop a site-specific tailored action plan. The tailored action plan was then implemented over a 12-month period that included bi-monthly progress meetings. Compliance with the tailored action plan was determined by the proportion of items in the action plan that was completely implemented. We examined acceptability of the intervention through staff responses to an evaluation questionnaire. In addition, the nutrition practice audit and barriers survey were repeated at the end of the implementation phase to determine changes in barriers and nutrition practices.
All five sites successfully completed all aspects of the study. However, their ability to fully implement all of their developed action plans varied from 14% to 75% compliance. Nurses, on average, rated the study-related activities and resources as 'somewhat useful' and a third of respondents 'agreed' or 'strongly agreed' that their nutrition practice had changed as a result of the intervention. We observed a statistically significant 10% (Site range -4.3% to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5% to 17.9%) and 4% (-8.3% to 18.2%) increase in the adequacy of total nutrition from calories and protein, respectively.
The multifaceted tailored intervention appears to be feasible but further refinement is warranted prior to testing the effectiveness of the approach on a larger scale.
ClinicalTrials.gov NCT01168128. Registered 21 July 2010.
针对已确定的变革障碍量身定制干预措施，可能是实施指南并改进实践的有效策略。然而，目前尚无足够的数据来确定最佳的定制方法或程度。因此，我们开展了一项名为“通过定制实施策略提高加拿大营养指南的执行效果（PERFECTIS）”的研究，以确定一项多方面、跨学科的定制干预措施的可行性，该干预旨在提高对提供肠内营养的重症监护营养指南的依从性。
在北美五家医院的七个重症监护病房进行了一项前后对照研究。在为期3个月的实施前阶段，每个重症监护病房完成一次营养实践审核，以确定指南与实践之间的差距，并进行一次障碍评估，以识别实践变革的障碍。在为期一天的会议上，对审核结果和障碍评估结果进行了审查，并用于制定针对特定地点的定制行动计划。然后，在为期12个月的时间内实施该定制行动计划，其中包括每两个月召开一次进展会议。通过行动计划中完全实施的项目比例来确定对定制行动计划的依从性。我们通过工作人员对一份评估问卷的回答来检验干预措施的可接受性。此外，在实施阶段结束时，重复进行营养实践审核和障碍调查，以确定障碍和营养实践的变化。
所有五个地点均成功完成了研究的各个方面。然而，它们全面实施所有已制定行动计划的能力各不相同，依从率从14%到75%不等。护士平均将与研究相关的活动和资源评为“有些有用”，三分之一的受访者“同意”或“强烈同意”他们的营养实践因干预措施而发生了变化。我们观察到总体障碍得分在统计学上显著下降了10%（各地点范围为-4.3%至-26.0%），而热量和蛋白质方面的总营养充足率分别有不显著的6%（各地点范围为-1.5%至17.9%）和4%（-8.3%至18.2%）的增加。
多方面的定制干预措施似乎是可行的，但在更大规模上测试该方法的有效性之前，有必要进一步完善。
ClinicalTrials.gov NCT01168128。于2010年7月21日注册。
