title: Improving feeding practices and intakes among patients who have undergone surgery using a knowledge translation approach
Creators: name: Rattray, Megan E
Publisher: name: Griffith University
Year: 2019
Subjects: subject: early oral feeding
subject: Knowledge to Action
subject: nutrition practices
subject: surgery

description: A convincing body of evidence exists supporting the reintroduction of liquids and solids within 24 hours after surgery. This practice is defined as early oral feeding and has been associated with faster recovery of gastrointestinal function, improved quality of life and reduced morbidity among various patient populations. In addition, the rapid reintroduction of nutrition after surgery is important for reducing the risk of malnutrition and its associated consequences. Hence, nutrition recommendations have been incorporated into evidence-based guidelines for postoperative care among gynaecologic, hepatic, pancreaticoduodenal, gastrectomy, colorectal, rectal and pelvic patients. Despite clear guidelines, it is well known that the adoption of research findings into clinical practice is often a slow process, with evidence taking up to two decades to be established in habitual practice. Indeed, international and national surveys have reported a gap between evidence-based recommendations and practice for initiating and progressing patients onto nutritionally adequate solid diets following surgery. Collectively, this evidence provides a strong rationale for interventions targeting improved nutrition care following surgery. Integrated knowledge translation has emerged as an effective method for translating research findings into habitual practice across a range of healthcare settings. As such, this thesis describes how an integrated knowledge translation approach and the Knowledge to Action framework was used to guide the design a four-phased, multimethod program of research, aiming to improve nutrition practices and intakes among patients who have undergone surgery. Six studies were generated within this four-phased program of research. A programmatic approach was applied so that each phase (and study) informed the next. Studies 1-2 were undertaken in Phase 1: ‘Identify the problem’. Study 1, a systematic review including 29 articles, was conducted to identify and quantify the prevalence of delayed postoperative feeding across different healthcare settings and patient groups. Study 2, an observational investigation of 100 postsurgical patients, was conducted to precisely identify the prevalence of delayed and inadequate feeding, the contributing factors, and the patient group in greatest need of intervention. Collectively, these studies demonstrated that delayed diet prescription and delivery in conjunction with patient-related factors contributed to suboptimal feeding practices and nutritional intakes. Further, patients who had undergone lower gastrointestinal surgery were identified as the highest risk group, with the greatest disparity between recommendations and current practice. Hence, the knowledge generated in Phase 1 suggested an intervention targeting professional, organisational and patient factors was warranted among individuals who have undergone colorectal surgery. Studies 3-5 were undertaken in Phase 2: ‘Adapting knowledge to local context and assess barriers to new knowledge use’. Study 3, a qualitative investigation involving 16 patients who had undergone colorectal surgery, was conducted to provide an in-depth understanding of the issues that individuals face immediately following surgery. Studies 4 and 5 focused on exploring staffs’ perceptions of nutrition among patients who have undergone colorectal surgery. Specifically, Study 4 was conducted to identify factors that multidisciplinary hospital staff (n = 18) perceived to influence timely and adequate feeding, while Study 5 was undertaken to explore the factors influencing doctors’ (n = 21) decision-making regarding postoperative nutrition prescription. Study findings generated from this phase indicated that providing simple, clear and encouraging dietary-related information to patients, introducing a flexible feeding protocol, supporting doctors’ knowledge around clinical nutrition and gaining buy-in from senior medical staff may be effective strategies to improve nutrition practices and dietary intakes among patients who undergo colorectal surgery. Phase 3 involved ‘selecting, tailoring and implementing an intervention’ designed to improve nutrition practices and intakes among patients who undergo elective colorectal surgery. Consultation with knowledge users in the local setting and findings generated from Phases 1-2 (Studies 1-5) informed the selection and tailoring of the intervention. A multifaceted intervention including staff- and patient-related strategies was designed and implemented. Phase 4: ‘Monitor and evaluate outcomes’ involved evaluating the intervention through a pilot study (Study 6). This mixed methods investigation included pre- (n = 30) and post-intervention (n = 34) patients and was undertaken to evaluate a) the processes underpinning intervention implementation; and b) the outcomes of the intervention. Significant improvements in times to first diet prescription, delivery and intake; and patients’ nutritional intakes for the first 2 days after surgery were observed. However, times to first solid diet prescription, delivery and intake, and the overall proportion of patients who met their nutritional requirements for at least one day while in hospital, did not significantly differ from pre- to post-intervention. These findings are likely explained by the variable uptake of intervention strategies (0-100%). Overall, this body of research has significantly contributed to existing knowledge around nutrition practices and intakes among patients who undergo surgery and provides useful insights for clinicians and researchers seeking to implement evidence-based nutrition guidelines in their own setting.