Abstract：
BACKGROUND: Evidence-based guidelines (EBGs) in the nutrition management of advanced liver disease and enhanced recovery after surgery recommendations state that normal diet should recommence 12-24 h following liver transplantation. This study aimed to compare postoperative nutrition practices to guideline recommendations, explore clinician perceptions regarding feeding after transplant surgery, and implement and evaluate strategies to improve postoperative nutrition practices.
METHODS: A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated.
RESULTS: An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%.
CONCLUSIONS: This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.
METHODS: A pre-post multimethod implementation study was undertaken, guided by the knowledge-to-action framework. A retrospective chart audit of postoperative dietary practice and semistructured interviews with clinicians were undertaken. Implementation strategies were informed by the Consolidated Framework for Implementation Research-Expert Recommendations for Implementing Change matching tool and then evaluated.
RESULTS: An evidence-practice gap was identified, with the median day to initiation of nutrition (free-fluid or full diet) on postoperative day (POD) 2 and only 25% of patients aligning with the EBGs. Clinician interviews identified belief in the importance of nutrition, with variation in surgical practice in relation to early nutrition, competing clinical priorities, and vulnerabilities in communication contributing to delays in returning to feeding. An endorsed postoperative nutrition protocol was implemented along with a suite of theory- and stakeholder-informed intervention strategies. Following implementation, the median time to initiate nutrition reduced to POD1 and alignment with EBGs improved to 60%.
CONCLUSIONS: This study used implementation frameworks and strategies to understand, implement, and improve early feeding practices in line with EBGs after liver transplant. Ongoing sustainability of practice change as well as the impact on clinical outcomes have yet to be determined.
摘要：
背景：晚期肝病营养管理的循证指南（EBGs）和手术后恢复的建议指出，肝移植后12-24小时应重新开始正常饮食。这项研究旨在将术后营养实践与指南建议进行比较，探索临床医生对移植手术后进食的看法，并实施和评估改善术后营养实践的策略。
方法：进行了多方法实施前研究，以知识到行动框架为指导。对术后饮食实践进行了回顾性图表审核，并与临床医生进行了半结构化访谈。实施战略由实施研究综合框架-实施变更匹配工具的专家建议提供信息，然后进行评估。
结果：发现了证据与实践的差距，在术后第2天（POD）开始营养（自由液体或完全饮食）的中位天数，只有25％的患者与EBG保持一致。临床医生访谈确定了对营养重要性的信念，随着早期营养的外科手术实践的变化，相互竞争的临床优先事项，通信中的漏洞导致延迟返回喂食。实施了认可的术后营养方案以及一套理论和利益相关者知情的干预策略。实施后，开始营养的中位时间减少到POD1，与EBG的一致性提高到60%。
结论：本研究使用实施框架和策略来理解，工具，并根据肝移植后的EBG改善早期喂养方法。实践变化的持续可持续性以及对临床结果的影响尚未确定。
方法：进行了多方法实施前研究，以知识到行动框架为指导。对术后饮食实践进行了回顾性图表审核，并与临床医生进行了半结构化访谈。实施战略由实施研究综合框架-实施变更匹配工具的专家建议提供信息，然后进行评估。
结果：发现了证据与实践的差距，在术后第2天（POD）开始营养（自由液体或完全饮食）的中位天数，只有25％的患者与EBG保持一致。临床医生访谈确定了对营养重要性的信念，随着早期营养的外科手术实践的变化，相互竞争的临床优先事项，通信中的漏洞导致延迟返回喂食。实施了认可的术后营养方案以及一套理论和利益相关者知情的干预策略。实施后，开始营养的中位时间减少到POD1，与EBG的一致性提高到60%。
结论：本研究使用实施框架和策略来理解，工具，并根据肝移植后的EBG改善早期喂养方法。实践变化的持续可持续性以及对临床结果的影响尚未确定。
