Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study
Prospective application of an implementation framework to improve postoperative nutrition care processes: Evaluation of a mixed methods implementation study
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DOI：
10.1111/1747-0080.12464
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发表时间：
2018-09-01
影响因子：
3.1
通讯作者：
Bauer, Judy
中科院分区：
文献类型：
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作者：
Byrnes, Angela;Young, Adrienne;Bauer, Judy
目的描述实施框架的前瞻性应用，以指导和评估质量改进（QI）项目，以提高老年外科患者对循证术后饮食指南的依从性（符合术后增强恢复，ERAS）。方法采用综合卫生服务研究实施促进行动（i-PARIHS）框架指导下的混合方法研究。一项实施前审计确定了针对老年外科患者的ERAS指南在营养相关护理实践中的差距。定性访谈探讨了实践变革的障碍，为促进实施战略的发展提供了信息。通过现场记录确定迭代促进干预措施，并使用i-PARIHS促进者工具包进行分类。实施后审计使用前后对照研究测量了实施结果，临床过程和结果。结果实施过程涉及17项独立的促进活动。术后早期饮食升级是可接受的，被很好地采用（79%），对89%的患者是合适的。保真度（即按照预期交付的方案）为59%，保真度的丧失主要是因为不正确的饮食编码。临床过程和结果评价（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（干预组：n=47，对照组：n=36，平均年龄74 （SD 6）岁，57%为男性）的数据。干预病房的患者在实施后接受早期营养的几率更高（校正优势比[95% CI]: 6.5 [1.9-22.4]， P=0.01）。结论实施框架的前瞻性应用支持了该QI项目的规划和成功实施。对促进策略、实施结果、临床过程和结果的多层次评估有助于了解成功领域和持续的挑战。
AimTo 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.MethodsA 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.ResultsImplementation 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).ConclusionsProspective 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.