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Best nutrition practice across the stroke care continuum: Using PEN & other evidence-based information sources. E Eppler, Vancouver, British Columbia. Introduction/Background.

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Best nutrition practice across the stroke care continuum: Using PEN & other evidence-based information sources

E Eppler, Vancouver, British Columbia

introduction background
Introduction/Background

Best practices are recommendations that are supported by research evidence andinformed by expert perspective, judgment and experience. Best practices produce effective health outcomes.

Stroke Care Best Practices describe the most effective policies, processes and interventions for stroke prevention, treatment and rehabilitation (1, 2). This poster describes a dietitian's experiences using the evidence-based practice cycle to determine best nutrition practice across the continuum of stroke care.

Figures 1 & 2, below,depict the evidence-based practice cycle and best practice, respectively.

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Figure 1. Evidence-Based Practice Cycle

Assess

Ask

Apply

Appraise

Acquire

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Figure 2: Best Practice

Define

Implement

Disseminate

Research generates evidence used in developing best practice

  • Standards
  • Guidelines
  • Protocols
  • Education
  • Care Paths

Best Practice Resources

Connect research and practice

Expert judgment is used in conducting systematic reviews and applying the evidence-based practice cycle.

The dietitian applies and adapts resources to the specific context; e.g. Acute neurosciences unit, rehab facility.

process results
Process & Results
  • The evidence-based practice cycle (EBPC) was applied to determine best nutrition practice across the continuum of stroke care. The Canadian Stroke Strategy (CSS) identifies these phases of the continuum:
    • Primary Prevention
    • Pre-hospital/Hyper-acute
    • Acute/In-hospital
    • Stroke Rehabilitation,
    • Secondary Prevention
    • Community Care/Re-engagement
  • In the “asking and acquiring” steps of the EBPC, Dietitians of Canada’s Practice-Based Evidence in Nutrition (PEN) tool (3) was the first resource consulted. The results of several basic and advanced searches are listed in Table 1. Figures 3, 4 & 5 depict PEN’smethod of organizing and presenting information.
figure 3 a pen knowledge pathway is the route to information

Ask

Apply

Figure 3. A PEN Knowledge Pathway is the route to information

Practice Guidance Summary

Background

Practice Questions

Evidence Summary

Tools & resources

Key Practice Points

Evidence

References

figure 4 sample pen results for search term cardiovascular disease
Figure 4. Sample PEN results for search term “cardiovascular disease”

1) Achieve and maintain a BMI < 25 2) exercise3)  fruit and vegetable intake 4) Restrict simple CHO5) Fat intake:  proportion of MUF and PUF;  proportion of SF and trans fats to <7% of total kcal;  intake of omega-3 FA from fish and plant sources.

Practice Guidance Summary

Ask

Practice Question

What nutrition strategies can prevent cardiovascular disease (CVD)?

  • Evidence Summaries
  • CVD
  • Dyslipidemia
  • CVD – Natural Health Products

BackgroundOmega-3 fatty acids, fish oil, alpha-linolenic acid

This document provides a grading of evidence for the effects of omega-3 fatty acids, fish oil, alpha-linolenic acid for a variety of conditions (e.g….stroke….).

Key Practice Point

Achieving and maintaining a healthy Body Mass Index (18.5-24.9), appropriate waist circumference (88 cm F; 102 m M) and waist-to-hip ratio (0.85 F; 0.90 M) can prevent CVD.

  • Tools & resources
  • Current Issues: The Health Benefits of Soy
  • Heart Healthy recipes
  • Heart and Stroke Foundation

Evidence

Apply

References

figure 5 sample pen results for search terms stroke and hypertension
Figure 5. Sample PEN results for search terms “stroke” AND “hypertension”

1) Follow DASH Diet Guidelines2)  sodium intake to 2400 mg (100 mmol) per day 3)  fibre intake to 25 to 30 grams per day especially foods rich in soluble fibre 4) A diet rich in potassium, calcium and magnesium is encouraged 5) …there is currently insufficient evidence to promote folic acid supplementation… 6) Maintain a healthy BMI and waist circumference 7) alcohol consumption to a maximum 2 drinks per day

Practice Guidance Summary –

excerpts from Prevention of Hypertension

Practice Question

Does an adult with hypertension, who adheres to healthy lifestyle practices … have better blood pressure control and therefore a lower risk or delayed incidence of stroke?

Ask

Evidence Summary

A summary of the graded evidence supporting the prevention and treatment of hypertension.

Background

Information on hypertension, including causes, diagnosis, and management

Key Practice Point

Lifestyle modifications can reduce the use and hence cost of antihypertensive medications and should be continued in conjunction with drug therapy. (A)

  • Tools & resources
  • 2007 Hypertension Public Recommendations
  • Facts About the DASH Eating Plan
  • Low sodium (salt) eating
  • Increasing Your Fibre Intake

Evidence

References

Apply

process results continued
Process & Results (continued)

Next, the CSS’s Best Practice document (1) and several key references listed in the CSS’s Best Practices and Standards Environmental Scan Report(2)were accessed via the Web and evaluated for their nutrition content (see Table 2 and Figure 6).

figure 6 sample content from selected key best practices documents

“Diet has an impact on a number of risk factors and can provide additional benefits to pharmacological

interventions in people with vascular disease.”

Figure 6. Sample content from selected key best practices documents

Management of patients with stroke: Identification and management of dysphagia (SIGN)

Canadian Best Practice Recommendations for Stroke Care: 2006

“All patients with stroke should have their swallow screened prior to initiating oral intake of fluids or food utilizing a simple valid reliable bedside testing protocol.”

“Early and regular screenings of patients for undernutrition is important.”

Best Practice Guidelines (Ontario)

Clinical Guidelines for Stroke Rehabilitation & Recovery (Australia)

“Determine feeding method based on swallowing

assessment or monitoring.

Implement safe diet texture and therapeutic diet.”

Nutrition element from acute care guide, day 2

Section on secondary prevention

summary
Summary
  • PEN has more than 120 up-to-date resources on stroke and cardiovascular disease risk factors (e.g., hypertension, dyslipidemia).
  • At present, most of PEN’s stroke resources apply to the prevention stage of the stroke care continuum.
  • New Critical Care and Dysphagia Knowledge Pathways soon will be added to PEN. They will provide information applicable to other stages in the continuum (e.g., acute care, rehabilitation).
  • Key resources recommended by the CSS (2)supplement PEN by providing nutrition standards across the continuum (4), dysphagia management guidelines (5), and templates for tools such as care paths (8).
  • This survey of PEN and CSS-recommended resources is ongoing.
next steps
Next steps

The information gathered from these best practice resources will be applied to these three current projects:

  • Vancouver Acute Clinical/Care Redesign for Stroke (CMG 13 & 14)
  • Vancouver Coastal Regional Care Path for Stroke
  • Vancouver Coastal Regional Stroke/High Risk TIA Emergency Department Orders (section on diet and dysphagia screening)/
literature cited
Literature cited

1. Best Practices and Standards Working Group, The Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: 2006. <http://www.canadianstrokestrategy.ca/technical_docs.htm>. Accessed 26 April 2007.

2. Best Practices and Standards Working Group, The Canadian Stroke Strategy. Best Practices and Standards Environmental Scan Report <http://www.canadianstrokestrategy.ca/technical_docs.htm>. Accessed 26 April 2007.

3. Dietitians of Canada’s Practice-Based Evidence in Nutrition: PEN.<http://www.dieteticsatwork.com/pen/>. Accessed 26 April 2007.

4. Heart and Stroke Foundation of Ontario, Ontario Stroke System. Best Practice Guidelines. <http://209.5.25.171/Page.asp?PageID=122&ContentID=932&CategoryID=73>. Accessed 26 April 2007.

5. Scottish Intercollegiate Guidelines Network. Management of patients with stroke. Identification and management of dysphagia. September 2004. <http://www.sign.ac.uk/guidelines/published/index.html>. Accessed 26 April 2007.

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6. National Stroke Foundation, Australia. National Clinical Guidelines for Acute Stroke Management. <http://www.strokefoundation.com.au/pages/article.aspx?id=1&articleid=ArticleID2006526135335&pageId=159&HandlerId=1>. Accessed 26 April 2007.

  • National Stroke Foundation, Australia. National Clinical Guidelines for Stroke Rehabilitation and Recovery. <http://www.strokefoundation.com.au/pages/article.aspx?id=1&articleid=ArticleID200652614320&pageId=159&HandlerId=1>. Accessed 26 April 2007.
  • 8. National Stroke Foundation, Australia. Stroke Care Pathway: A Resource for Health Professionals. <http://www.strokefoundation.com.au/pages/image.aspx?assetId=RDM38992.4311924884> Accessed 26 April 2007.

Acknowledgment

Photo used in Figure 2: Under the bridge by MissBeckles. Posted on Flickr under a Creative Commons Attribution-NonCommercial-ShareAlike 2.0 license. <http://www.flickr.com/photos/missbeckles/3375396/>. Accessed 22 April 2007.