NIHR CLAHRC for South Yorkshire

1. National Institute for Health Research NIHR CLAHRC for South Yorkshire Enhancing the quality of oral nutrition support to hospitalised patients using the Knowledge to Action cycle Kate Gerrish PhD MSc B.Nurs RN Professor of Nursing, CLAHRC Implementation Lead, Sara Laker PhD BA(Hons) RN CLAHRC Project Manager Sheffield Teaching Hospitals NHS Foundation Trust & Sheffield Hallam University, United Kingdom • Background • Risk of malnutrition among hospitalised patients with long-term conditions is a widespread problem leading to adverse health outcomes (Ferreira et al 2009). There is evidence to suggest that under-nutrition delays recovery and lowers resistance to medical complications, with links observed between under-nutrition and lengthened hospital stay, morbidity and mortality (NICE 2006). Despite efforts targeted at improving the nutritional status of patients and the quality of nutrition support in hospitals, under-nutrition remains widespread among in-patients in the UK. • Aim • To enhance the quality of oral nutrition support provided by the multi-disciplinary team to adult patients with long-term conditions through the implementation of a malnutrition screening tool (MUST+) and associated care guidelines (MUST - Malnutrition Universal Screening Tool) • Objectives • To trial and evaluate two interventions designed to facilitate the uptake of MUST+ and care guidelines • Ward-based nutrition champions • Facilitation of the multi-disciplinary team by a dietitian • To evaluate the implementation of MUST+ and care guidelines in terms of the impact on patients and on staff • To develop the capacity of the multi-disciplinary team to provide effective nutritional support to patients with / at risk of developing malnutrition • Setting • Medical wards in two hospitals within an English Teaching Hospitals NHS Trust • 3 evaluation wards for each intervention • Approach • Action research strategy embedded within Knowledge to Action cycle (Graham et al 2006) • Multi-disciplinary project team involving KT team and lead clinicians who design and oversee the project • Participatory approach in which clinical staff and patient representatives become active collaborators with the KT team • Front-line nurses and dietitians seconded to work as KT facilitators • Project management group involving KT team, front-line staff, senior clinicians, middle managers and patient representatives who provide advice and help shape the project • Knowledge to Action cycle • Provides direction to process of implementation • Easily understood by all collaborators • Iterative rather than cyclical process • Each step requires elaboration – other frameworks can be useful • PARHIS framework (Rycroft Malone et al 2004) • Consolidated Framework for Implementation Research (Damschroeder et al 2009) • Knowledge creation stage required for selecting implementation strategies • Does not explicitly address roll-out and transfer of learning Knowledge Inquiry Systematic reviews oral nutrition support Knowledge synthesis Tailoring knowledge Knowledge products NICE guidance Joanna Briggs best practice Nutrition screening tools Care guidelines Professional expertise • Multi-level problem identification by • Health service commissioners • Trust Board and Executive managers • Trust Multi-disciplinary Nutrition Steering Group (NSG) • Front-line staff Ongoing audit to monitor sustainability Roll out of interventions and disseminate learning Understand macro, meso and micro context Secure ownership of need for change at all levels of the organisation Appraise MUST Develop MUST+ to include additional questions Confirm face validity with NSG & front-line staff Review guidelines using AGREE framework Phased withdrawal of facilitation Baseline data collected by means of observation of practice, audit of nutrition support and patient records Action research approach Measure patient and staff outcomes for oral nutrition support Evaluate intervention strategies Survey of knowledge, attitudes and barriers to oral nutrition support among the multi-disciplinary team Feedback baseline data & survey results to ward teams Repeat audit of oral nutrition support and patient records Feedback from facilitators ,clinical staff and patient representatives via Project Advisory Group Develop intervention strategies by drawing upon reviews of effective interventions. Tailor interventions to local context. Actively facilitate implementation of interventions in collaboration with front-line staff Modify interventions in response to changes in local context References AGREE Collaboration (2001) The Appraisal Guidelines for Research and Evaluation (AGREE) Instrument. London, The AGREE Trust Damschroeder et al (2009) Fostering implementation of health services research findings in practice: a consolidated framework for advancing implementation science. Implementation Science 4:50 Ferreira Iet al (2009) Nutritional supplementation for stable chronic obstructive pulmonary disease. The Cochrane Collaboration. Oxford, Wiley Graham I et al(2006) Lost in knowledge translation: Time for a map. Journal of Continuing Education in the Health Professions 26:1 13–24 NICE (2006) Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition. London, NICE Rycroft-Malone J (2004) The PARIHS framework: a framework for guiding the implementation of evidence-based practice. Journal of Nursing Care and Quality 19: 297-304 This project forms part of the NIHR CLAHRC for South Yorkshire: to find out more please contact kate.gerrish@sth.nhs.uk or sara.laker@sth.nhs.uk or go to www.clahrc-sy.nihr.ac.uk