Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies

Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.     

Nutrition and dietetics in aged care

Aim: The global trends of rapid population ageing and increased risk of malnutrition among older people have a tremendous impact on nutrition care for the elderly. The present paper offers an overview of the challenging nutritional needs and problems of the elderly and explores strategies related to nutrition and dietetics to improve care for this particular segment of the population. Methods: A narrative review on monitoring malnutrition and improving food services was undertaken with reference to the literature and drawing on the experience of the author. Results: There is a wide range of problems associated with malnutrition in the elderly that have implications on strategies of intervention for addressing these problems. Conclusions: The current challenges for dietitians include identifying and monitoring the nutritional needs and malnutrition problems of the elderly, improving the quality of food services in health‐care facilities, and initiating innovative approaches to nutrition and dietetic services in the community.     

国际儿童营养政策的发展历程及其启示

儿童营养问题是困扰发展中国家的重大公共卫生问题。儿童营养政策经历了早期跨部门营养计划、"营养孤立主义"和以战略目标为导向的营养行动三个时期。在总结归纳儿童营养政策发展历程的基础上,我们结合一些发展中国家在基础营养项目等国际项目和本国营养计划中加强政治承诺、整合政策措施等的做法,对我国制定儿童营养政策提出对策,如制定国家营养战略要注意的方面,从干预人群、干预项目的选择和加强营养政策或项目的执行等方面完善营养项目的设计。     

An evaluation of a public health nutrition workforce development intervention for the nutrition and dietetics workforce

Background: Workforce development is a key element for building the capacity to effectively address priority population nutrition issues. On‐the‐job learning and mentoring have been proposed as strategies for practice improvement in public health nutrition; however, there is limited evidence for their effectiveness. Methods: An evaluation of a mentoring circle workforce development intervention was undertaken. Thirty‐two novice public health nutritionists participated in one of three mentoring circles for 2 h, every 6 weeks, over a 7‐month period. Pre‐ and post‐intervention qualitative (questionnaire, interview, mentor diary) and quantitative (competence, time working in public health nutrition) data were collected. Results: The novice public health nutritionists explained the intervention facilitated sharing of ideas and strategies and promoted reflective practice. They articulated the important attributes of the mentor in the intervention as having experience in and a passion for public health, facilitating a trusting relationship and providing effective feedback. Participants reported a gain in competency and had an overall mean increase in self‐reported competence of 15% (range 3–48% change; P < 0.05) across a broad range of competency elements. Many participants described re‐orienting their practice towards population prevention, with quantifiable increases in work time allocated to preventive work post‐intervention. Conclusions: Mentoring supported service re‐orientation and competency development in public health nutrition. The nature of the group learning environment and the role and qualities of the mentor were important elements contributing to the interventions effects. Mentoring circles offer a potentially effective strategy for workforce development in nutrition and dietetics.     

Challenges of Maintaining Optimal Nutrition Status in COVID-19 Patients in Intensive Care Settings

The coronavirus disease 2019 (COVID-19) pandemic has threatened patients, healthcare systems, and all countries across the globe with unprecedented challenges and uncertainties. According to the latest literature, most patients with COVID-19 have mild symptoms that do not require hospital admissions, and only a small percentage of those hospitalized require intensive care. In the intensive care unit (ICU), a registered dietitian nutritionist (RDN) assists the critical care team by formulating, executing, and monitoring the nutrition strategies and interventions to meet the unique requirements of extremely sick patients. However, because of the novelty of COVID-19, the situation is fluid and guidelines continue to be developed and updated. This article discusses the interim guidelines available for the nutrition support of ICU COVID-19 patients and the challenges the critical care team and RDN may face from a nutrition standpoint.     

What Is “Best Achievable” Practice in Implementing the Enhanced Protein‐Energy Provision via the Enteral Route Feeding Protocol in Intensive Care Units in the United States? Results of a Multicenter,Quality Improvement Collaborative

Background: The purpose of this study was to determine what was “best achievable practice” with the implementation of a novel enteral feeding protocol (Enhanced Protein‐Energy Provision via the Enteral Route Feeding Protocol [PEP uP protocol]). Methods: This study was a multicenter quality improvement collaborative wherein we describe nutrition practices and outcomes within PEP uP sites. We report the minimum, average, and maximal site‐level performance on aspects related to nutrition practices and outcomes. Results: In 2014, 7 intensive care units (ICUs) in the United States implemented the PEP uP protocol. On average, over the first 5 ICU days, patients received 35% (site range, 26%–53%) of their prescribed energy requirements and 42% (site range, 29%–66%) of their prescribed protein requirements from enteral nutrition. In PEP uP sites, 71% (site range, 58%–95%) of patients received a semidigested formula within 72 hours of admission to the ICU, 72% had a volume‐based goal as the initial feeding strategy (site range, 47%–100%), 56% had prophylactic protein supplements (site range, 0%–100%), and 19% received prophylactic motility agents (site range, 0%–85%). Conclusions: There was variable success with the implementation of the different components of the PEP uP protocol. Improving the implementation of the various components may further increase nutrition delivery.     

Developments in personalised nutrition

Food4Me is a 4‐year multi‐partner project under the European Union Seventh Framework Programme (FP7), investigating the potential of, and public attitudes towards, personalised nutrition. Food4Me has gathered an international group of experts to survey the current understanding of personalised nutrition and to explore the application of individualised nutrition advice. The Food4Me project will also investigate consumer attitudes and produce new scientific tools for implementation. The project, which started in 2011, expects among its outcomes and achievements a comprehensive assessment of the opportunities and challenges for future personalised nutrition business models; new scientific tools that use dietary, genetic and phenotypic data for personalised nutrition; and a validation of the impact of different levels of personalised nutrition advice to consumers, be they dietary, phenotypic or genetic. It will also report on the attitudes and beliefs of European consumers to all aspects of personalised nutrition, describe the ethical and legal implications, as well as produce best practice guidelines for communicating information on the issue. This will be the first study of its kind in the world, designed to mimic a fully internet‐delivered, personalised nutrition service.     

Are doctors nutritionists? What is the role of doctors in providing nutrition advice?

Diet and nutritional status impact on health outcomes. The global rise of diet‐related non‐communicable diseases plus the double burden of obesity and malnutrition means that it is imperative more than ever that all healthcare professionals are able to provide at least basic evidence‐based nutrition advice. Improving an individual's diet requires more than just information provision, it requires consistent and long‐term support to change and maintain new behaviours. Doctors acknowledge that nutrition plays a crucial role in health and agree that providing nutrition advice is part of their role. However, providing sufficiently detailed nutrition advice that is relevant to a patient's health goals, useful for the patient, and that results in measurable changes, is not common in practice settings. Numerous challenges and barriers have been identified for why doctors do not provide nutrition recommendations to their patients. A lack of nutrition education and training, time constraints during appointments, and patients who have access to an ever‐growing body of nutrition and health information via the Internet and social media, together may explain why doctors tend not to include nutrition advice in their care plans. This paper outlines both short‐ and long‐term strategies for improving doctors' engagement with nutrition interventions and collaborative working with dietitians in the context of collaborative care. Having doctors support and advocate for evidenced‐based nutrition practice is a crucial element of the World Health Organization's Decade of Action on Nutrition achieving measurable success.     

Nutritional management of cystic fibrosis in Australia and New Zealand

Aim:  To document current practice in the nutritional management of cystic fibrosis in Australia and New Zealand and to examine changes in practice since 1996.
Methods:  Thirty-four cystic fibrosis services in Australia and New Zealand responded to a survey that examined current nutritional management practices and dietetic staffing levels. The questionnaire was based on a previous survey conducted in 1996.
Results:  Cystic fibrosis dietetic staffing levels were low. No service met the staffing level recommended by the UK Cystic Fibrosis Trust. Minor practice variations existed in nutrition assessment and monitoring: nutrition support and vitamin supplementation. Changes in the management of pancreatic enzyme replacement therapy and cystic fibrosis-related diabetes were reported since 1996.
Conclusion:  This survey highlights that improvements in consistency of nutrition management have been achieved since 1996 and reflect adherence to available clinical guidelines for pancreatic enzyme replacement therapy. While there are many areas of agreement in nutrition care for people with cystic fibrosis around Australia and New Zealand, there are still practice differences, implying that Australian- and New Zealand-specific clinical guidelines are warranted. The implementation of the Australasian Clinical Practice Guidelines for Nutrition in Cystic Fibrosis will be important in standardising and improving cystic fibrosis care.     

Mongolian Health Sector Strategic Master Plan (2006‐2015): A foundation for achieving universal health coverage

Nearly half of the countries in the world are in the process of reforming and strengthening their health care systems. More recently, even low‐income and middle‐income countries such as Mongolia have focused increasing attention on achieving universal health coverage (UHC). At this critical point, it is necessary to track recent progress and adjust health care strategies and planning. Therefore, this study analyzed changes in the health sector toward achieving UHC based on relevant literature, government documents, and framework analysis. We also investigated how basic principles of UHC were incorporated and reflected in Mongolia's Health Sector Strategic Master Plan. This study clarified the achievements of and challenges facing the health sector that remain or emerged during the plan's implementation over the last decade. Furthermore, all of the reviewed Master Plan strategies were underpinned by basic principles of UHC. However, strategies set out in the next Master Plan will require adjustments and innovative measures to respond to current challenges. This study may be used as a reference for other developing countries to track UHC achievements and serve as a guide to establishing a nation‐wide strategic plan.     

Thailand's national strategic plan on antimicrobial resistance: progress and challenges

Antimicrobial resistance is a serious threat that affects all countries. The Global Action Plan on antimicrobial resistance and the United Nations Political Declaration on antimicrobial resistance set standards for countries to resolve antimicrobial resistance challenges under the One Health approach. We assess progress and challenges in implementing Thailand’s national strategic plan on antimicrobial resistance 2017–2022, discuss interim outcomes and share lessons learnt. Major progress includes: establishing a national governance mechanism that leads high-impact policy on antimicrobial resistance and consolidates actions and multisectoral collaboration; creating a monitoring system and platform to track implementation of the strategic plan; and converting strategies of the strategic plan into actions such as controlling the distribution and use of antimicrobials in humans and animals. Interim results indicate that antimicrobial consumption in animals has nearly halved (exceeding the national goal of a 30% reduction) whereas other goals have not yet reached their targets. We have learnt that elevating antimicrobial resistance to high-level visibility and establishing a national governance mechanism is an important first step, and a monitoring and evaluation system should be developed in parallel with implementation. Securing funds is crucial. Policy coherence is needed to avoid duplication of actions. Highly ambitious goals, although yet to be achieved, can advance actions beyond expectations. Political commitment and collaboration across different sectors will continue to play important roles but might not be sustained without a well-designed governance structure to support long-term actions to address antimicrobial resistance.     

Comparing Hospital Staff Nutrition Knowledge,Attitudes, and Practices Before and 1 Year After Improving Nutrition Care: Results From the More‐2‐Eat Implementation Project

Background: Staff play key roles in the prevention, detection, and treatment of hospital malnutrition. Understanding staff knowledge, attitudes, and practices (KAP) is important for developing and evaluating change management strategies. Methods: The More‐2‐Eat project improved nutrition care in 5 Canadian hospitals by implementing the Integrated Nutrition Pathway for Acute Care (INPAC). To understand staff views before (T1) and after 1 year of implementation (T2), a reliable KAP questionnaire, based on INPAC, was administered. T2 included questions about involvement in implementation. The mean difference between T2 and T1 responses was calculated, and t tests were used for comparisons. Results: The questionnaire was completed at T1 (n = 189) and T2 (n = 147) (unpaired); 57 staff completed both questionnaires (paired). A significant increase in total score was seen in unpaired results at T2 (from 93.6/128 [range, 51–124] to 99.5/128 [range, 54–119]; t = 5.97, P < .0001), with an increase in knowledge/attitudes (KA) (t = 2.4, P = .016) and practice (t = 3.57, P < .0001) components. There were no statistically significant changes in paired responses. Seventy percent (n = 102/147) noticed positive changes in practices, 12% (n = 18) noticed positive/negative changes, 1% (n = 1) noticed negative change, and 17% (n = 25) noticed no change. Fifty‐nine percent (n = 86) felt involved in the change, and these staff had higher KA and KAP scores than those who did not feel involved. Conclusion: Staff involvement is important in the implementation process for improving nutrition care.     

Multitargeted Feeding Strategies Improve Nutrition Outcome and Are Associated With Reduced Pneumonia in a Level 1 Trauma Intensive Care Unit

Background: Factors impeding delivery of adequate enteral nutrition (EN) to trauma patients include delayed EN initiation, frequent surgeries and procedures, and postoperative ileus. We employed 3 feeding strategies to optimize EN delivery: (1) early EN initiation, (2) preoperative no nil per os feeding protocol, and (3) a catch‐up feeding protocol. This study compared nutrition adequacy and clinical outcomes before and after implementation of these feeding strategies. Methods: All trauma patients aged ≥18 years requiring mechanical ventilation for ≥7 days and receiving EN were included. Patients who sustained nonsurvivable injuries, received parenteral nutrition, or were readmitted to the intensive care unit (ICU) were excluded. EN data were collected until patients received an oral diet or were discharged from the ICU. The improvement was quantified by comparing nutrition adequacy and outcomes between April 2014–May 2015 (intervention) and May 2012–June 2013 (baseline). Results: The intervention group (n = 118) received significantly more calories (94% vs 75%, P < .001) and protein (104% vs 74%, P < .001) than the baseline group (n = 121). The percentage of patients receiving EN within 24 and 48 hours of ICU admission increased from 41% to 70% and from 79% to 96% respectively after intervention (P < .001). Although there were fewer 28‐ay ventilator‐free days in the intervention group than in the baseline group (12 vs 16 days, P = .03), receipt of the intervention was associated with a significant reduction in pneumonia (odds ratio, 0.53; 95% confidence interval, 0.31–0.89; P = .017) after adjusting sex and Injury Severity Score. Conclusions: Implementation of multitargeted feeding strategies resulted in a significant increase in nutrition adequacy and a significant reduction in pneumonia.     

The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study

Background: The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. Methods: The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e‐mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. Results: Twenty‐six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. Conclusion: Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.     

The Effects of Community Demands,Resources, and Strategies on the Nature and Consequences of the Work‐Family Interface: An Agenda for Future Research

Abstract: This article presents a broad conceptual framework that suggests ways in which community demands, resources, and strategies influence relationships between work demands, resources, and family well‐being. Within‐domain and boundary‐spanning community demands and resources are proposed to combine with work demands and resources in relation to work‐family conflict and facilitation. Boundary‐spanning community strategies are expected to mediate and moderate relationships between work‐family conflict and facilitation and family well‐being. The paper closes with an agenda for future research and a strategy for policy and practice.     

Nutrition policies for schools

In Britain, Canada and the United States, the impetus for initiating school nutrition policies has come primarily from health, not education, agencies. These agencies define the nutrition problems of school students as both under‐ and over‐nutrition, and, to solve them, advocate the development and implementation of policies to combat health and learning problems associated with poor nutrition. Health, rather than educational, agencies are also more likely to formulate school nutrition policies; such policies commonly address the dietary principles of access, adequacy, and moderation. Within countries, the adoption of school nutrition policies varies considerably. Moreover, the degree to which such policies have been implemented is unclear, because of a lack of research to evaluate their process and impact. To enhance the successful development and implementation of school nutrition policies, greater partnership between health and education agencies is recommended throughout the policy process.     

Health professionals' views of the effectiveness of nutrition care in general practice setting

Aim: The current qualitative study aimed to explore the perceptions of key health professionals relating to the effectiveness of nutrition care provided in the general practice setting. Methods: Twenty‐eight health professionals across a range of disciplines (general practitioners (n = 11), practice nurses (n = 3), dieticians (n = 5), naturopaths (n = 5) and exercise physiologists (n = 4)) individually participated in a semistructured telephone interview, guided by an inquiry logic informed by the literature. Interviews were transcribed verbatim and analysed thematically using a constant comparison approach. Results: Health professionals, including general practitioners, perceived that nutrition care provided in the general practice setting was mostly ineffective at improving patient nutrition behaviour. This was reported to be due to nutrition care competency deficits among general practitioners, a general practice reimbursement system that encourages practices inconsistent with quality nutrition care, and a low prioritisation of nutrition care in general practice. Tensions were apparent between health professional groups, which may be hindering the successful implementation of interdisciplinary nutrition care for patients with chronic disease in this setting. Conclusion: Without systematic changes to Australian primary health care model, the demand on general practitioners as primary providers of nutrition care will continue, therefore mandating support for general practitioners providing care in this context. Further research is required to identify strategies to improve nutrition care and opportunities to facilitate integrated health care provided to the general public within the general practice setting.     

Health system performance assessment in small countries: The case study of Latvia

Managing the complexity that characterizes health systems requires sophisticated performance assessment information to support the decision‐making processes of healthcare stakeholders at various levels. Accordingly, in the past few decades, many countries have designed and implemented health system performance assessment (HSPA) programmes. Literature and practice agree on the key features that performance measurement in health should have, namely, multidimensionality, evidence‐based data collection, systematic benchmarking of results, shared design, transparent disclosure, and timeliness. Nevertheless, the specific characteristics of different countries may pose challenges in the implementation of such programmes. In the case of small countries, many of these challenges are common and related to their inherent characteristics, eg, small populations, small volumes of activity for certain treatments, and lack of benchmarks. Through the development of the case study of Latvia, this paper aims at discussing the challenges and opportunities for assessing health system performance in a small country. As a result, for each of the performance measurement features identified by the literature, the authors discuss the issues emerging when adopting them in Latvia and set out the potential solutions that have been designed during the development of the case study.