Nutrition in Clinical Practice最新文献

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.

Attempts at behavior change have been shown to be more effective when interventions are based on evidence linked to an implementation framework. The Theoretical Domains Framework (TDF) and Behavior Change Wheel (BCW) provide a systematic way to map effective implementation strategies to address barriers and enablers to behavior change. This paper aims to outline the steps involved in designing and evaluating an intervention using the TDF and BCW, including (1) identifying barriers and enablers (TDF); (2) mapping barriers and enablers to the Capabilities, Opportunities, Motivation hub; and (3) identifying key interventions and specific strategies that are known to bring about behavior change. Real world gaps in the implementation of malnutrition screening and implementation of a preoperative prehabilitation clinic are used as examples to highlight the functionality of the framework. Given the TDF and BCW have been designed specifically to change clinician behavior, it is an ideal framework for addressing evidence-practice gaps in nutrition support.

Implementation science is a growing field, affecting disciplines such as nutrition and dietetics. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework is an evaluation framework used to assess outcomes of interventions. The Practical, Robust Implementation and Sustainability Model (PRISM) is an extension of RE-AIM, further assessing contextual factors. This paper reviews the RE-AIM framework's composition and history, its application in nutrition research and practice, and its implications for future endeavors of nutrition and dietetics. Sources of information contributing to the findings of this narrative review include systematic reviews, original research articles, and web-based resources. Articles were grouped by purpose, area of specialization, and framework use. Within each group, studies were analyzed by examining the application of RE-AIM and findings yielded from each study. Synthesis of these articles revealed many systematic reviews covering the use of RE-AIM and PRISM in clinical and community interventions. Whereas RE-AIM has been thoroughly used to evaluate nutrition interventions in clinical and community settings, PRISM has been underused, specifically in community-based research. Additionally, both frameworks have consistent use in the evaluation of programs but are found to be underused in program design and implementation. With more consistent use across settings and phases, RE-AIM and PRISM frameworks will contribute to the field of implementation science, informing best clinical practices for dietary interventions, as well as the applicability and scalability of public health interventions.

Theoretical approaches can help to plan, guide, and evaluate implementation projects that target real-world practice problems. This paper provides an overview of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework and summarizes its use in nutrition and dietetics research and practice. A narrative summary of its use was compiled from the published literature based on citations from two key reference sources of the i-PARIHS framework. Searches were performed in Web of Science Core Collection, Scopus, and PubMed. Data were extracted about the study characteristics and the application of i-PARIHS. Thirty articles from 20 implementation studies were included, with studies mostly originating from Australia (n = 9) and focused on adult patients/clients (n = 17) in the hospital setting (n = 13) and other practice settings. Studies included diverse clinical areas categorized as malnutrition (n = 9) or nutrition-related chronic disease (n = 10). Studies used i-PARIHS across phases of planning, implementing, and evaluating (n = 6 planning only, n = 6 evaluating only, n = 8 a combination of phases, and n = 5 across all three phases) and often in combination with other theoretical approaches (n = 10). The facilitation process and/or role were a common feature of implementation and evaluation studies. The framework's ability to aid comprehensive identification of barriers and enablers across the constructs was highlighted as a strength. The i-PARIHS framework can be a useful tool to support all phases of implementation in nutrition practice and research, particularly where facilitation is a core component of the implementation process. Two case studies are presented to demonstrate how it might be practically applied.

Background: Excessive fasting for tests and procedures within the hospital setting remains commonplace, despite clear evidence of the benefits related to reduced fasting. There is minimal research addressing the issue of prolonged preoperative fasting. The aim of this study was to undertake a pre/post implementation study using multifaceted interventions to reduce excessive fasting on acute surgical wards within a quaternary hospital in Sydney, Australia, using the behavior change wheel (BCW) framework.

Methods: The BCW was used to identify key strategies to address barriers to implementing evidence-based fasting guidelines. A pre/post implementation study using multifaceted interventions to reduce excessive fasting on acute surgical wards was implemented over a 3-month period. The primary outcome was preoperative fasting time in hours. Clinician interviews were conducted to assess the benefit of each of the interventions within the study.

Results: On completion of preimplementation data collection, strategies were implemented including ward education, guideline promotion, patient stories, patient-facing flyers, and audit and feedback. There was no significant difference between fasting times pre and post intervention. Clinician interviews showed increased awareness and increased confidence.

Conclusion: This pre/post implementation study was unable to significantly reduce fasting times, but did show increased clinician awareness and a trend towards improved patient-reported outcomes. Future research needs to ensure a larger sample size, as well as incorporating emerging strategies such as "sip-to-send" or "think-drink."

Background: Registered dietitian nutritionists (RDNs) use clinical practice guidelines (CPGs) to inform evidence-based practice. Despite the availability of CPGs, guidelines are not always translated into practice. This challenge is central to implementation science (IS), which seeks to understand how evidence can be adopted and sustained.

Methods: The Gestational Diabetes Mellitus (GDM) Registry Study was a multiphase, multisite hybrid implementation study that explored guideline implementation using quality improvement (QI) methods grounded in the Model of Improvement and guided by Plan-Do-Study-Act (PDSA) cycles. Following a baseline period, RDNs completed training, conducted a gap analysis, and identified 2 CPG implementation aims. Sites completed iterative PDSA cycles. Deidentified nutrition care data were entered into the GDM Study Registry and manually audited to evaluate process outcomes. RDNs participated in a closing interview. Qualitative data were analyzed using a constructivist approach and reflexive thematic analysis, supported by artificial intelligence (AI)-assisted qualitative software.

Results: Six themes were identified, highlighting the value of assessing current practices and the flexibility of PDSA as an implementation strategy. Themes were mapped against the Normalization Process Theory and Consolidated Framework for Implementation Research and showed alignment between PDSA and implementation principles. The registry audit demonstrated improved process measures. The median normalization score across RDNs (9.00) and sites (9.42) was high, suggesting normalization.

Conclusion: PDSA facilitated the work of normalization and enabled practice changes. This study contributes to IS by demonstrating how QI strategies, such as PDSA can help RDNs translate evidence into everyday nutrition care.

Malnutrition among community-dwelling older adults (OAs) is prevalent, particularly in groups using healthcare services. Malnutrition burdens health, social, and aged-care systems in terms of expenses for hospital admissions and care in nursing homes and home care settings. Effective management requires early identification and multimodal interventions; however, studies report a significant gap between recommended nutrition interventions and current healthcare practices. Therefore, this study aimed to identify, present, and map existing evidence on barriers and facilitators in the implementation of nutrition interventions among OAs living in noninstitutional municipal healthcare settings. A scoping review following the Joanna Briggs Institute guidelines and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews checklist were conducted. The study included evidence from bibliographic databases and gray-evidence sources that identify barriers and/or facilitators from stakeholder perspectives that influence the implementation of nutrition interventions for malnutrition prevention or treatment among OAs (≥65 years) in noninstitutional municipal healthcare settings. Stakeholders were OAs, informal caregivers, or healthcare professionals (HCPs). Thirty-seven articles were included and 10 categories identified. Barriers were (1) lack of knowledge and awareness among HCPs, (2) lack of resources, (3) lack of collaboration and communication, (4) missing links between healthcare settings, and (5) poor insight among OAs and caregivers. Facilitators were (1) education and training of HCPs, (2) self-care, (3) person-centered care, (4) technology in nutrition care, and (5) social and psychological factors. Findings from this review indicate an imperative need for targeted implementation strategies for developing evidence-based nutrition home care practice.

Many nutrition interventions and innovations are supported by strong evidence; however, their adoption, implementation, and long-term sustainability in real-world healthcare settings too frequently remain a challenge. Implementation science offers methodologies to equip practitioners with tools to identify and address the contextual factors that influence implementation success in health settings (e.g., adoption, implementation, sustainability). Among the various frameworks and theories used in implementation science, the Consolidated Framework of Implementation Research (CFIR) is one of the most widely used. The CFIR synthesizes constructs from multiple behavioral and implementation theories into a comprehensive tool that can be used to systematically assess the barriers and facilitators that influence implementation outcomes. The framework enables practitioners and researchers to identify context-specific implementation determinants and to design tailored implementation strategies across diverse contexts and settings. Given its adaptability, the CFIR is highly relevant to the field of nutrition and dietetics to support sustained adoption and delivery of nutrition innovations (e.g., screening tools, educational programs, quality improvement initiatives); but it is relatively underutilized in nutrition practice. This article provides an overview of the CFIR and illustrates how it can be used to guide the implementation of nutrition innovations in clinical practice through two pragmatic case studies. We highlight the potential of the CFIR to be used as a guiding framework to advance the adoption, implementation, and sustainability of nutrition innovations and improve nutrition care and patient outcomes.

Introduction: A 1-day cross-sectional study at our hospital found that only 22% of patients with hip fractures at nutrition risk met their energy and protein requirements during hospitalization. This study aimed to test whether closer collaboration between a clinical dietitian and ward staff, guided by the Model for Improvement, could optimize nutrition care for hospitalized older patients with hip fractures at nutrition risk.

Method: A dietitian was embedded to facilitate staff-led enhancements in nutrition care at an orthopedic ward in from September to December 2024. Two Plan-Do-Study-Act cycles were implemented. Cycle 1 focused on nutrition documentation. Cycle 2 targeted nutrition intake. The primary outcome was the proportion of patients meeting individual energy and protein requirements (≥80%). Secondary process indicators were (1) ≥80% of patients screened using Nutrition Risk Screening 2002, and (2) ≥80% of at-risk patients with intake documented in the medical record. Preintervention data served as the baseline.

Results: The primary outcome was achieved, with 80% (8 of 10) of patients meeting both energy and protein requirements, a significant improvement from 22% (2 of 9) at baseline (P < 0.05). Documentation of nutrition risk increased from 10% (1 of 10) to 80% (8 of 10) (P < 0.01), and intake documentation improved from 30% (3 of 10) to 100% (10 of 10) (P < 0.01).

Conclusion: This quality improvement study demonstrates that applying the Model for Improvement to integrate a clinical dietitian into ward practice strengthened interdisciplinary nutrition care and led to measurable gains in screening, documentation, and nutrition intake among older patients with hip fractures at nutrition risk.

In clinical cancer settings, malnutrition can go undiagnosed and patients often receive nutrition care only after they have lost substantial weight or developed severe side effects. Neglecting to provide nutrition care to a patient in a timely manner can lead to increased difficulties in supporting them and to poorer clinical outcomes. The aim of this review was to identify the barriers to timely nutrition support for patients with cancer before and during medical treatment. PubMed and CINAHL platforms were used to search for relevant published literature in June 2022. The search was updated in January 2025. Advanced search was used using the terms "cancer," "malnutrition," "nutritional support," and their synonyms in combination with "under-recognition" and associated synonyms. The protocol was prospectively registered on OSF Open Science. A total of 4584 records were identified in the databases, and 41 abstracts were selected for full article screening. A total of 19 articles were included in the review. Evidence from the studies indicates that malnutrition identification and dietetic support are not always implemented in current practice. Identified barriers were grouped into four interconnected macro themes: educational barriers, communication barriers, resource barriers, and sociocultural barriers. This scoping review identifies four barriers to early nutrition support in oncological settings and discusses their implications and how they influence each other. Clinical governance should consider and look to address all barriers when trying to implement dietetic support or design pathways in a timely and efficient manner.