Nutrition in Clinical Practice最新文献

We conducted a quality improvement (QI) initiative to increase documentation of energy goals within 48 h of admission to the pediatric intensive care unit (PICU) for all children. Malnutrition remains one of the most prevalent issues in the PICU. Research shows early estimation and documentation of energy goals in the electronic health record (EHR) is associated with higher daily energy intake. Energy goals are often not documented early in patient admission, which can be improved. By revising critical care progress notes to prompt providers to estimate an energy goal when no goal has been documented within the first 48 h we expected an increased rate of goal documentation. A QI initiative was performed from May 2021 to April 2022 using the Plan-Do-Study-Act methodology. Interventions included (1) an automated smart-text element on the EHR progress note template and (2) a review of calculated and documented energy goals in calories by registered dietitians. A review team monitored the rate of documentation of energy goals monthly. Before the QI interventions, the baseline rate of documentation of an estimated energy goal was 44%. After adding standardized prompts to the EHR system, the rate of a documented energy intake goal within 48 h of admission by critical care providers increased to >90%. Using automated prompts in EHRs resulted in an increased frequency of energy goal documentation exceeding 90% monthly. Establishing a standardized prompting system within the EHR directly led to an overall increased frequency of energy goals documented in calories.

Quality improvement is utilized to improve system issues within healthcare. Although many models have been identified for quality improvement, the Plan-Do-Study-Act (PDSA) model is used commonly. The PDSA cycle is a quality improvement tool that has produced numerous system-wide changes. Since its conception, the PDSA has been used in a variety of nutrition-related quality improvement initiatives. Furthermore, the PDSA cycle has been applied in implementation science to bridge the gap between the literature and clinical nutrition practice. Implementation science using the PDSA cycle can be beneficial in the introduction of the Global Malnutrition Composite Score (GMCS) to identify, diagnose, and treat malnutrition in hospitalized patients. This manuscript describes the PDSA cycle in detail with direct application to GMCS implementation.

Background: A broader project translated evidence for a Mediterranean-style dietary pattern (MDP) into clinicians' routine dietary care for type 2 diabetes and coronary heart disease in a public health service in Australia. This study aimed to determine sustainment of practice and what predicts clinicians' routine use of an MDP approach 2 years after facilitated implementation.

Methods: May 2021-October 2022 implementation strategies targeted multidisciplinary clinicians involved with dietary care. In October 2024 clinicians were surveyed using an adapted 14-item Normalization Measure Development (NoMAD) questionnaire. Sustainment was defined as self-rating ≥7 on a scale from 0 (not at all) to 10 (always) that recommending MDP is a "normal part of your work." Exploratory analyses, including logistic regression, identified whether clinician characteristics, NoMAD items, and theoretical constructs predicted sustainment.

Results: Six dietitians and 61 other clinicians completed surveys, of which 100% and 52% self-reported MDP practice sustainment, respectively. Multivariable models in the total cohort found that the odds of sustainment increased with higher scores in NoMAD items related to the perception that using an MDP approach was legitimately within the clinicians' role (odds ratio [OR], 15.7; 95% CI, 3.23-224), shared understanding of supporting evidence (OR, 3.79; 95% CI, 1.35-15.8), and the constructs cognitive participation (OR, 6.12; 95% CI, 1.78-27.9) and collective action (OR, 5.7; 95% CI, 1.48-30.1). Twenty-seven clinicians commenced in the setting ≤2 years prior; within this group, MDP practice sustainment was significantly higher if MDP handover/orientation was received (71% vs 29%, P = 0.012).

Conclusion: These data provide novel insights into impacts on sustainment of implemented evidence-based dietary practice in the context of a multidisciplinary workforce with high turnover.

Background: Vitamin C deficiency (VCD) is common in adult inpatients in high-income countries and is associated with moderate to severe frailty, cognitive impairment, and scurvy signs and symptoms. However, clinical practice associated with vitamin C status has not been explored in this setting. This study aims to describe current vitamin C clinical practices and explore barriers and enablers that influence nutrition care delivered to adult hospitalized patients within routine clinical practice.

Method: This study was conducted across General Medicine units at a tertiary health service in Melbourne, Australia. Using an explanatory, sequential mixed methods design, data across each stage of the Nutrition Care Process (NCP) was triangulated from three phases involving analysis of clinical guidelines, file review data of patients with VCD (n = 100) according to plasma vitamin C levels, and focus groups informed by the Theoretical Domains Framework.

Results: Triangulated data revealed that barriers to vitamin C nutrition care include infrequent assessment, influenced by environmental factors, beliefs about consequences, clinical priority, and healthcare professionals' (HCPs') knowledge. Enablers include strong belief in nutrition care capability and belief that vitamin C nutrition care is within HCPs' roles. Low suspected VCD diagnosis and low intervention and discharge planning rates were also observed. The single vitamin C clinical guideline lacked detail across specific stages of the NCP.

Conclusion: Limited vitamin C nutrition care potentially occurs in adult inpatients, hindered predominantly by assessment barriers. To achieve improvements in clinical practice, a theoretically driven implementation strategy targeted to healthcare systems, clinician behavior, and national quality standards is required.

The literature is inconsistent regarding differences in infection risk between central venous catheter types used for home parenteral nutrition (HPN). Our goal was to determine if significant differences exist in rates of infection and other complications between peripherally inserted central catheters, tunneled central venous catheters, and implanted ports, as well as between single and multiple lumen catheters used for HPN. Data were collected for 141 central venous catheters placed in 89 adults receiving HPN provided by Continuum home health company affiliated with University of Virginia health system. The catheters were 63% peripherally inserted, 27% tunneled, and 10% implanted ports, with 25,273 total catheter days and 15,474 HPN days. Central line-associated bloodstream infection (CLABSI) rates were 0.91 episodes per 1000 total catheter days overall, 1.91 for peripherally inserted, 0.63 for tunneled, and zero for ports. CLABSI rates per 1000 HPN days were 1.49 overall, 2.61 for peripherally inserted, and 0.76 for tunneled catheters. CLABSI rates were significantly greater for peripherally inserted than for tunneled catheters per total (P = 0.023) and per HPN (P = 0.011) catheter days. CLABSI rates were greater, but not significantly so, for multiple than for single lumen catheters. The rate of noninfectious complications was not significantly different between tunneled and peripherally inserted central catheters and was zero for ports. HPN CLABSI rates were significantly lower with implanted ports and tunneled central venous catheters as compared with peripherally inserted central catheters.

Background: Older adults with dementia are at heightened risk of malnutrition, but nutrition screening is an uncommon practice in this population. This study aimed to determine the feasibility of malnutrition screening and to determine nutrition risk prevalence in an outpatient memory care clinic.

Methods: This quality improvement project used the eight-item Seniors in the Community: Risk Evaluation for Eating and Nutrition screener to determine nutrition risk. The Organizational Readiness to Change Assessment (ORCA) determined providers' views on readiness for change.

Results: During the 12-week trial, 15.3% of eligible memory care clinic patients were screened. Of these, 58.3% (n = 123) had high nutrition risk. Lack of staffing was the most significant barrier to completion of nutrition screening. Clinic staff responses on the ORCA indicated moderate agreement that screening among persons with dementia is evidence based (mean = 3.7 of 5; SD = 0.26) and strong agreement for evidence of organizational support (mean = 4.12 of 5; SD = 0.38). A majority of patients and/or caregivers reported nutrition screening was easy (n = 79 of 211) or extremely easy (n = 44 of 211). A total of 69 patients (33.7%) who completed the screener indicated interest in a nutrition consultation. The most common barriers to nutrition services reported by caregivers and/or patients were difficulty accessing the clinic and unwillingness to use nutrition services.

Conclusions: This study detected barriers and facilitators to administering nutrition screening in a memory care clinic. These preliminary findings suggest further efforts to implement nutrition screening in outpatient memory care clinics are warranted.

Background: To develop, implement, and evaluate a structured discharge preparation and guidance checklist for patients requiring home enteral nutrition (HEN).

Methods: The HEN discharge preparation and guidance checklist was developed through a multiphase process by literature review, qualitative interview, and Delphi consultation. A randomized controlled trial was conducted with 90 patients (45 intervention, 45 control) requiring HEN at a tertiary hospital in China. The intervention group received checklist-assisted discharge education, whereas the control group received conventional verbal instructions. Outcomes were assessed using validated tools: Quality of Discharge Teaching Scale (QDTS), Readiness for Hospital Discharge Scale (RHDS), Patient Satisfaction Questionnaire-18 (PSQ-18), NutriQoL, Self-Rating Anxiety Scale (SAS), 30-day unplanned readmission rates, and patient-initiated inquiries.

Results: The intervention group demonstrated significant improvements in QDTS total scores (P < 0.001), content received (P < 0.001), and delivery skills and effects (P = 0.007). RHDS scores for personal status, knowledge, perceived coping ability, and expected support were significantly higher in the intervention group (all P < 0.05). PSQ-18 (P < 0.001) and daily life and social activity domains of NutriQoL (P = 0.036) also improved. However, no significant differences were observed in physical functioning domains of NutriQoL (P = 0.217), SAS (P = 0.160), or unplanned readmission rates (P = 0.343). The intervention group reported fewer online searches for HEN management (P = 0.035).

Conclusion: The HEN discharge preparation and guidance checklist effectively standardized discharge education, enhanced patient preparedness, and improved satisfaction. Although short-term physiological and psychological outcomes showed limited effects, the tool addresses critical gaps in transitional care. Future studies should explore long-term impacts and integrate financial/psychosocial support.

Background: The Knowledge-to-Action (KTA) framework was first developed in 2006 and has become a widely used tool to support translating evidence into practice. Despite its broad application, no systematic review has examined its use in studies of nutrition research translation. This systematic review (PROSPERO ID: CRD42024613147) aims to describe the characteristics of nutrition translation studies that use the KTA, the application of the KTA stages, and the actors involved in the knowledge translation effort and study quality.

Methods: Searches were performed across four databases to include original nutrition studies in English that cite and apply the KTA from 2006 to April 2025. Data were extracted by two independent reviewers. The appraisal of the study quality used the Mixed Methods Appraisal Tool.

Results: Twenty-three studies met the inclusion criteria, and most were conducted in a hospital setting (n = 15) by multidisciplinary teams targeting change in healthcare workforce practices. Studies addressed a range of evidence-practice gaps in topics such as malnutrition (n = 5), postsurgical feeding or enteral nutrition (n = 5), infant feeding (n = 2), and dietary patterns (n = 2). The KTA was used flexibly either partly or as a complete cycle, often with integration of other implementation frameworks and mixed methodologies, tailored to project context. Although the quality of studies was generally high, the lack of quantitative baseline data in most studies limited assessment of effectiveness.

Conclusion: The KTA framework is an adaptable and valuable tool that has been used to address evidence-practice gaps across broad topics related to nutrition and dietetics.

Food insecurity is a prevalent yet overlooked issue within the inpatient setting. Despite food insecurity being predictive of poor health outcomes and increased hospital readmission rates, the development of efficient screening protocols remains a gap in care for high-risk, hospitalized patients. As part of a community health needs assessment (CHNA), a screening protocol for food insecurity has been implemented within a long-term acute care hospital (LTACH). This is a multistep protocol in which each newly admitted patient is asked pertinent questions related to food insecurity during the initial nutrition consult, led by a registered dietitian, followed by dissemination of a nutrition-resource packet upon positive screening. The packet includes a registry of county-based community nutrition resources and samples of recommended oral nutrition supplements. Additionally, the interdisciplinary team is informed of positive food insecurity status during weekly rounding to facilitate appropriate coordination of care in preparation for patient discharge. During the first year of implementation, 2022-2023, an average 95% of identified food insecure LTACH patients per the CHNA screening protocol were provided the appropriate nutrition-related resources during admission. This was improved upon from 2023-2024 as 100% of LTACH patients identified as food insecure received appropriate CHNA nutrition resources. Further, 93% of food insecure patients captured from 2023-2024 reported living within geographical proximity, or within the same county as this healthcare facility. As this protocol continues to be refined, future considerations include embedding a brief, validated food insecurity questionnaire within the initial nutrition consult as well as tracking metrics related to protocol effectiveness.

The safe use of enteral nutrition (EN) for patients of all ages in the healthcare setting is often taken for granted. However, an increasing body of literature highlights potential failure points even when using ready-to-feed (RTF) enteral formulas. Potential risks include administering a wrong, expired, or recalled formula which could result in patient harm including under or over nutrition, allergic reactions, gastrointestinal intolerance, metabolic or electrolyte disturbances, and/or consequences related to contamination. This quality improvement project reviewed the frequency of having the wrong RTF EN formula scanned for the wrong individual (defined as a near miss) in pediatric patients 1-18 years of age. During the time of this evaluation, a total of 48,044 RTF EN formula feeding attempts were recorded. Of those attempts, 46,648 were successful, with the RTF EN formula matching the patient's EN order when the patient's armband and EN bar code were scanned. The remaining 1396 attempts represented near misses in which the product being scanned was not the correct product for the patient (a rate of 2.9%). Although this rate may seem low, the number of near misses during this time frame means that, on average, 48 times per month or 1.6 times per day, the bar code scanning system is preventing a pediatric patient from receiving the wrong EN formula. The data from this performance improvement initiative support the organization's decision to scan EN formulas at the time of administration and underscores the importance of following protocols to ensure that scanning occurs every time when administering formulas to reduce risk of error.