Centre for Dietetics Research, School of Human Movement and Nutrition Sciences, University of Queensland (UQ), St Lucia, Queensland, Australia.
Nutrition and Dietetics Department, Royal Brisbane and Women's Hospital (RBWH), Brisbane, Queensland, Australia.
Nutr Diet. 2018 Sep;75(4):353-362. doi: 10.1111/1747-0080.12464. Epub 2018 Aug 28.
To describe prospective application of an implementation framework to guide and evaluate a quality improvement (QI) project to improve adherence to evidence-based postoperative diet guidelines (consistent with Enhanced Recovery After Surgery, ERAS) in older surgical patients.
A hybrid mixed methods study guided by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework was used. A pre-implementation audit identified gaps in nutrition-related care practices against ERAS guidelines for older surgical patients. Qualitative interviews explored barriers to practice change, informing development of the facilitated implementation strategy. Iterative facilitation interventions were identified by field notes and classified using i-PARIHS facilitator's tool-kit. Post-implementation audit measured implementation outcomes, and clinical processes and outcomes using controlled before-after comparative study.
Implementation involved 17 discrete facilitation activities. Early postoperative diet upgrade was acceptable, well adopted (79%) and appropriate for 89% of patients. Fidelity (i.e. protocol delivered as intended) was 59%, with loss of fidelity primarily because of incorrect diet codes. Clinical processes and outcome evaluation (n = 155) compared data pre-implementation (intervention: n = 45, control: n = 27; mean age 73 (SD 6) years, 60% male) and post-implementation (intervention: n = 47, control: n = 36; mean age 74 (SD 6) years, 57% male). Patients on the intervention ward had higher odds of receiving early nutrition post-implementation (adjusted odds ratio [95% CI]: 6.5 [1.9-22.4], P = 0.01).
Prospective application of an implementation framework supported planning and successful implementation in this QI project. Multi-level evaluation of facilitation strategies, implementation outcomes, and clinical processes and outcomes helps to understand areas of success and continuing challenges.
描述一个实施框架的前瞻性应用，以指导和评估一项质量改进（QI）项目，以提高老年手术患者对循证术后饮食指南（符合增强术后恢复，ERAS）的依从性。
采用混合混合方法研究，以综合促进健康服务研究实施的方法（i-PARIHS）框架为指导。实施前审核确定了与老年手术患者 ERAS 指南相关的营养相关护理实践中的差距。定性访谈探讨了实践改变的障碍，为制定促进实施策略提供了信息。通过现场记录和使用 i-PARIHS 促进者工具包对迭代促进干预措施进行了分类。实施后审核使用对照前后比较研究测量了实施结果以及临床过程和结果。
实施涉及 17 项离散的促进活动。早期术后饮食升级是可以接受的，很好地采用了（79%），并且适合 89%的患者。保真度（即按照预期提供的方案）为 59%，保真度的丧失主要是由于饮食代码不正确。临床过程和结果评估（n=155）比较了实施前（干预组：n=45，对照组：n=27；平均年龄 73（SD 6）岁，60%为男性）和实施后的数据（干预组：n=47，对照组：n=36；平均年龄 74（SD 6）岁，57%为男性）。接受早期营养干预的患者术后接受早期营养的可能性更高（调整后的优势比[95%置信区间]：6.5[1.9-22.4]，P=0.01）。
实施框架的前瞻性应用支持了这项 QI 项目的计划和成功实施。对促进策略、实施结果以及临床过程和结果的多层次评估有助于了解成功和持续挑战的领域。
