Evidence supporting the important role of nutrition therapy in surgical patients has evolved, with several randomized trials and metaanalyses of randomized trials clearly demonstrating benefits of Nutrition Quality Improvement. Despite this evidence, surgeons and anesthesiologists have been slow to adopt recommended practices and the traditional dogma of delaying the initiation of and restricting the amount of nutrition during the postoperative period persists. Consequently, the nutrition therapy received by surgical patients remains suboptimal; thus, patients suffer worse clinical outcomes. Knowledge translation (KT) describes the process of moving evidence learned from clinical research, and summarized in clinical practice guidelines, to its incorporation into clinical and policy decision making. In this paper, we apply Graham et al’s knowledge-to-action model to illuminate our understanding of the issues pertinent to KT and Nutrition Quality Improvement in surgical nutrition. We illustrate various components of this model using empirically derived research, commentaries, and published studies from both critical care and surgical nutrition. Barriers to improving surgical nutrition practice may be related to (1) the nature of the underlying evidence and clinical practice guidelines; (2) guideline implementation factors; (3) characteristics of the health system, hospital, and surgical team; (4) provider attitudes and beliefs; and (5) patient factors (e.g. type of surgery, underlying disease, and nutrition status). Interventions tailored to overcoming these barriers must be developed, evaluated, and implemented. A system of audit and feedback must guide this process and evaluate improvements over time so that every patient undergoing major surgery will have the opportunity to be optimally assessed and managed according to best nutrition practices.
Despite its importance, little research has been conducted on the process of sustainability, but the process is conceptually similar to the initial implementation and monitoring of the change. Thus, the sustainability phase triggers a “feedback loop” through the subsequent steps of the action cycle, with a review of emerging evidence, monitoring of knowledge use, identification of problem areas, evaluation of barriers, and implementation or reinforcement of change strategies. Partnership with the ERAS program, NSQIP, or SCOAP in which we imbed nutrition modules into these existing data collection systems may be the most efficient way to monitor and evaluate on going progress (or lack thereof). The long-term sustainability of these data collection tools will need to be considered, as these tools will be essential to monitor changes in nutrition practices over time.
There is a tremendous opportunity to improve surgical patient outcomes by improving perioperative nutrition therapy so as to achieve Nutrition Quality Improvement. To drive this improvement process forward, there is a need to synthesize and define what the “body of knowledge” is to be translated (i.e. need for current, North American, evidence-based guidelines). Once there are guidelines available, the development of large-scale international audits would help define specific opportunities for improvement. An assessment of barriers to improving these identified opportunities would need to be conducted, using the frameworks that are provided in this paper. Finally, tailoring specific interventions to overcome these determined barriers may be the most efficient strategy to improve care. However, more research to determine the most effective interventions to change the current dogma, whether by targeting individual providers (e.g. peer-to-peer influence, education during training), by the local process of care through tools that integrate nutrition into daily practice (e.g. surgical nutrition bundles), or by targeting higher level system change (e.g. regulations that enforce/prioritize nutrition), is warranted.