Investigating the nutritional status and care of older (≥65 years) general surgical patients: a multiphase, action research study

Abstract

Introduction: The Australian population is ageing. Older adults, who are more vulnerable to the deleterious effects of hospitalisation, are increasingly undergoing surgery. Better adherence to quality of care indicators, such as evidence-based practice guidelines, has been shown to improve outcomes in older patients. The Royal Brisbane and Women’s Hospital Internal Medicine Research Unit and Nutrition and Dietetics Department have a history of implementing collaborative, systems-based approaches aimed at improving care of older adults, spanning over a decade. These efforts have predominantly been focused on medical settings, with limited work undertaken targeting the care of older adults in the surgical setting prior to this thesis. Therefore, the overarching aim of this thesis is to improve perioperative nutrition care of older general surgical patients by increasing adherence to evidence-based practice guidelines; more specifically, the Enhanced Recovery After Surgery (ERAS) perioperative care guidelines.Methods: In this pragmatic, multiphase Action Research study, mixed methods were used to: investigate validity of hand grip strength as an objective method of malnutrition screening and adjusted weighed plate waste as an objective method of measuring impact of nutrition interventions (assessment method testing); observe current practice to identify gaps in practice in the nutrition-related care of patients ≥65 years admitted to general surgical wards at the Royal Brisbane and Women’s Hospital (Action Research Phase I: Observe); qualitatively explore clinician perspectives and identify barriers and enablers to practice change (Phase II: Reflect); develop a guideline tailored to the local setting (Phase III: Plan); and achieve practice change using a facilitative implementation approach (Phase IV: Act). Each phase of the study and facilitated implementation were prospectively informed by the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation framework.Results: This study makes multiple contributions to the field and literature in terms of nutrition knowledge and practice, measurement methods and implementation of complex interventions. Some of the key findings are highlighted over the following paragraphs. In assessment method testing, hand grip strength was not found to be valid in screening for malnutrition, nor was calculating intake using an adjusted weighed plate waste method feasible for measuring impact of nutrition interventions outside of funded research in the clinical setting. Older patients were, however, found to eat poorly postoperatively, with few having an oral intake adequate to meet ≥50% theoretical requirements. No patient on a fluid diet met ≥50% of estimated protein requirements.Over half (59%) of admissions in older patients to general surgical wards were emergency admissions, a third (32%) of patients were at nutrition risk, with a quarter (25%) malnourished as per the Patient Generated Subjective Global Assessment (PG-SGA global rating B/C). Poor adherence to four nutrition care practices from ERAS guidelines (1. preoperative carbohydrate loading; 2. fasting from fluids limited to 2-4 hours; 3. fasting from solid food limited to 6-8 hours; and 4. diet upgraded to full ward diet either day of surgery or postoperative day one) identified gaps in practice, including prolonged preoperative fasting and delayed return to oral diet postoperatively.From qualitative interviews with multidisciplinary clinicians, three major themes presenting barriers to practice change were identified, including: a) complexity of the context (e.g. unpredictable theatre times, requirement for flexibility, and large, multidisciplinary workforce); b) strong decision making hierarchy, as well as lack of knowledge, confidence or authority of junior and non-surgical staff to implement change; and c) poor communication and teamwork (within and between disciplines). This highlighted the need for any intervention to be tailored to the local context to address these barriers to change.A facilitative implementation approach was successful in increasing the proportion of patients receiving early nutrition by 26% (from 53% pre-implementation to 79% post-implementation, P = 0.01) on the intervention ward, with associated odds (Adjusted OR [95% CI]) of receiving early nutrition post-implementation of 6.45 [1.86–22.40] (P = 0.01). Measuring implementation outcomes identified lower than expected fidelity (59%) and ongoing issues with feasibility, suggesting a need for further efforts to address these if practice change is to be sustained.Implications: Objective, easy to use methods for assessing nutrition risk and measuring impact of nutrition interventions remains a gap in the literature. Due to the pragmatic approach used in this thesis, the findings are directly applicable to the clinical setting. Additionally, the structured approach to achieving practice change in the clinical setting described by this thesis can be used by clinicians when undertaking complex interventions as part of research or quality improvement activities. An improvement in processes related to timeliness of postoperative diet upgrades on the intervention ward was observed; however, it was identified that further work to improve feasibility and fidelity is required, highlighting the importance of considering implementation outcomes when evaluating interventions.