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      The Sustain and Spread Framework: strategies for sustaining and spreading nutrition care improvements in acute care based on thematic analysis from the More-2-Eat study

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          Abstract

          Background

          Successful improvements in health care practice need to be sustained and spread to have maximum benefit. The rationale for embedding sustainability from the beginning of implementation is well recognized; however, strategies to sustain and spread successful initiatives are less clearly described. The aim of this study is to identify strategies used by hospital staff and management to sustain and spread successful nutrition care improvements in Canadian hospitals.

          Methods

          The More-2-Eat project used participatory action research to improve nutrition care practices. Five hospital units in four Canadian provinces had one year to improve the detection, treatment, and monitoring of malnourished patients. Each hospital had a champion and interdisciplinary site implementation team to drive changes. After the year (2016) of implementing new practices, site visits were completed at each hospital to conduct key informant interviews ( n = 45), small group discussions (4 groups; n = 10), and focus groups (FG) (11 FG; n = 71) (total n = 126) with staff and management to identify enablers and barriers to implementing and sustaining the initiative. A year after project completion (early 2018) another round of interviews ( n = 12) were conducted to further understand sustaining and spreading the initiative to other units or hospitals. Verbatim transcription was completed for interviews. Thematic analysis of interview transcripts, FG notes, and context memos was completed.

          Results

          After implementation, sites described a culture change with respect to nutrition care, where new activities were viewed as the expected norm and best practice. Strategies to sustain changes included: maintaining the new routine; building intrinsic motivation; continuing to collect and report data; and engaging new staff and management. Strategies to spread included: being responsive to opportunities; considering local context and readiness; and making it easy to spread. Strategies that supported both sustaining and spreading included: being and staying visible; and maintaining roles and supporting new champions.

          Conclusions

          The More-2-Eat project led to a culture of nutrition care that encouraged lasting positive impact on patient care. Strategies to spread and sustain these improvements are summarized in the Sustain and Spread Framework, which has potential for use in other settings and implementation initiatives.

          Trial registration

          Retrospectively registered ClinicalTrials.gov Identifier: NCT02800304, June 7, 2016.

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          Most cited references12

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          Implementing evidence-based interventions in health care: application of the replicating effective programs framework

          Background We describe the use of a conceptual framework and implementation protocol to prepare effective health services interventions for implementation in community-based (i.e., non-academic-affiliated) settings. Methods The framework is based on the experiences of the U.S. Centers for Disease Control and Prevention (CDC) Replicating Effective Programs (REP) project, which has been at the forefront of developing systematic and effective strategies to prepare HIV interventions for dissemination. This article describes the REP framework, and how it can be applied to implement clinical and health services interventions in community-based organizations. Results REP consists of four phases: pre-conditions (e.g., identifying need, target population, and suitable intervention), pre-implementation (e.g., intervention packaging and community input), implementation (e.g., package dissemination, training, technical assistance, and evaluation), and maintenance and evolution (e.g., preparing the intervention for sustainability). Key components of REP, including intervention packaging, training, technical assistance, and fidelity assessment are crucial to the implementation of effective interventions in health care. Conclusion REP is a well-suited framework for implementing health care interventions, as it specifies steps needed to maximize fidelity while allowing opportunities for flexibility (i.e., local customizing) to maximize transferability. Strategies that foster the sustainability of REP as a tool to implement effective health care interventions need to be developed and tested.
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            Towards understanding the de-adoption of low-value clinical practices: a scoping review

            Background Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. Methods MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed ‘related articles’ function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. Results From 26,608 citations, 109 were included in the final review. Most citations (65 %) were original research with the majority (59 %) published since 2010. There were 43 unique terms referring to the process of de-adoption—the most frequently cited was “disinvest” (39 % of citations). The focus of most citations was evaluating the outcomes of de-adoption (50 %), followed by identifying low-value practices (47 %), and/or facilitating de-adoption (40 %). The prevalence of low-value practices ranged from 16 % to 46 %, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41 %) that demonstrate harm (73 %) and/or lack of efficacy (63 %) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. Conclusions This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices. Electronic supplementary material The online version of this article (doi:10.1186/s12916-015-0488-z) contains supplementary material, which is available to authorized users.
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              Malnutrition and poor food intake are associated with prolonged hospital stay, frequent readmissions, and greater in-hospital mortality: results from the Nutrition Care Day Survey 2010.

              The Australasian Nutrition Care Day Survey (ANCDS) ascertained if malnutrition and poor food intake are independent risk factors for health-related outcomes in Australian and New Zealand hospital patients. Phase 1 recorded nutritional status (Subjective Global Assessment) and 24-h food intake (0, 25, 50, 75, 100% intake). Outcomes data (Phase 2) were collected 90-days post-Phase 1 and included length of hospital stay (LOS), readmissions and in-hospital mortality. Of 3122 participants (47% females, 65 ± 18 years) from 56 hospitals, 32% were malnourished and 23% consumed ≤ 25% of the offered food. Malnourished patients had greater median LOS (15 days vs. 10 days, p < 0.0001) and readmissions rates (36% vs. 30%, p = 0.001). Median LOS for patients consuming ≤ 25% of the food was higher than those consuming ≤ 50% (13 vs. 11 days, p < 0.0001). The odds of 90-day in-hospital mortality were twice greater for malnourished patients (CI: 1.09-3.34, p = 0.023) and those consuming ≤ 25% of the offered food (CI: 1.13-3.51, p = 0.017), respectively. The ANCDS establishes that malnutrition and poor food intake are independently associated with in-hospital mortality in the Australian and New Zealand acute care setting. Copyright © 2012 Elsevier B.V. and NIPR. All rights reserved.
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                Author and article information

                Contributors
                cvlaur@uwaterloo.ca
                Jack.Bell@health.qld.gov.au
                rfvalait@uwaterloo.ca
                s.ray@nnedpro.org.uk
                hkeller@uwaterloo.ca
                Journal
                BMC Health Serv Res
                BMC Health Serv Res
                BMC Health Services Research
                BioMed Central (London )
                1472-6963
                4 December 2018
                4 December 2018
                2018
                : 18
                : 930
                Affiliations
                [1 ]ISNI 0000 0000 8644 1405, GRID grid.46078.3d, Faculty of Applied Health Sciences, , University of Waterloo, ; Waterloo, Canada
                [2 ]ISNI 0000 0000 9320 7537, GRID grid.1003.2, School of Human Movement and Nutrition Sciences, , The University of Queensland and The Prince Charles Hospital, ; Chermside, Australia
                [3 ]ISNI 0000000121885934, GRID grid.5335.0, NNEdPro Global Centre for Nutrition and Health, St. John’s Innovation Centre, ; Cambridge, UK
                [4 ]ISNI 0000 0000 8644 1405, GRID grid.46078.3d, Schlegel-University of Waterloo Research Institute for Aging, , University of Waterloo, ; Waterloo, Canada
                Author information
                http://orcid.org/0000-0001-7782-8103
                Article
                3748
                10.1186/s12913-018-3748-8
                6278089
                30509262
                34dab869-99bd-4a49-b82d-cd92a71d913e
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 9 August 2018
                : 21 November 2018
                Funding
                Funded by: Canadian Frailty Network
                Award ID: SIG2014-08
                Award Recipient :
                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

                Health & Social care
                nutrition,sustainability,spread,implementation,knowledge translation,participatory research,acute care,hospital

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