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Background A large evidence-practice gap exists regarding provision of nutrition to patients following surgery. The aim of this study was to evaluate the processes supporting the implementation of an intervention designed to improve the timing and adequacy of nutrition following bowel surgery. Methods A mixed-method pilot study, using an integrated knowledge translation (iKT) approach, was undertaken at a tertiary teaching hospital in Australia. A tailored, multifaceted intervention including ten strategies targeted at staff or patients were co-developed with knowledge users at the hospital and implemented in practice. Process evaluation outcomes included reach, intervention delivery and staffs’ responses to the intervention. Quantitative data, including patient demographics and surgical characteristics, intervention reach, and intervention delivery were collected via chart review and direct observation. Qualitative data (responses to the intervention) were sequentially collected from staff during one-on-one, semi-structured interviews. Quantitative data were summarized using median (IQR), mean (SD) or frequency(%), while qualitative data were analysed using content analysis. Results The intervention reached 34 patients. Eighty-four percent of nursing staff received an awareness and education session, while 0% of medical staff received a formal orientation or awareness and education session, despite the original intention to deliver these sessions. Several strategies targeted at patients had high fidelity, including delivery of nutrition education (92%); and prescription of oral nutrition supplements (100%) and free fluids immediately post-surgery (79%). Prescription of a high energy high protein diet on postoperative day one (0%) and oral nutrition supplements on postoperative day zero (62%); and delivery of preoperative nutrition handout (74%) and meal ordering education (50%) were not as well implemented. Interview data indicated that staff regard nutrition-related messages as important, however, their acceptance, awareness and perceptions of the intervention were mixed. Conclusions Approximately half the patient-related strategies were implemented well, which is likely attributed to the medical and nursing staff involved in intervention design championing these strategies. However, some strategies had low delivery, which was likely due to the varied awareness and acceptance of the intervention among staff on the ward. These findings suggest the importance of having buy-in from all staff when using an iKT approach to design and implement interventions.

Ensuring inpatients with dysphagia receive and consume the correct texture-modified diet and thickened fluid prescriptions is challenging, and errors can result in significant complications for patients and increased costs to hospitals. The aim of this study was to investigate underlying factors that help or hinder receipt and consumption of correct dietary prescriptions for people with dysphagia in the hospital setting then implement and evaluate a range of strategies to address identified issues. A mixed-methods study design, using an integrated knowledge translation approach, was conducted in three phases. In Phase 1, clinical incident data (i.e., documented incidents of diet/fluid errors, with errors defined as the provision or consumption of any food/fluid not appropriate for a patient's dietary prescription) were analyzed, and staff, patients, and family members were interviewed using the Theoretical Domains Framework to identify factors contributing to errors. In Phase 2, health professionals assisted with the development and implementation of interventions targeted at micro (patient/family), meso (staff), and macro (organizational) levels to address factors identified in Phase 1. In Phase 3, outcomes including the change in number of dietary clinical incidents pre- to post-intervention, meal accuracy error rates from mealtime audits post-intervention, and follow-up interviews were evaluated using quantitative and qualitative measures. Post-intervention, there was a 50% reduction in clinical incidents, and a 2.3% meal accuracy error rate was observed. Staff reported most interventions were acceptable and feasible within their workload, although some interventions were not well embedded in everyday practice. This study highlights the value in using an integrated knowledge translation approach to inform tailored interventions targeting improved dietary accuracy in the hospital setting.

Supervised pelvic floor muscle training (PFMT), weight loss and exercise are recommended for overweight/obese women with urinary incontinence (UI). This study aimed to implement and evaluate the feasibility, acceptability and effectiveness of a 12-week group exercise and healthy eating program (ATHENA) for overweight/obese women with UI. This study, using an implementation-effectiveness hybrid type 3 design, was conducted within a Women’s Health Physiotherapy outpatient service at an Australian tertiary public hospital. Intervention feasibility and acceptability were assessed through process evaluation of implementation, while clinical effectiveness was assessed via pre-/post-clinical and quality of life surveys. Process data were analyzed using descriptive statistics and effectiveness data were compared pre-/post-intervention using inferential statistics. Of 156 eligible patients, 37 (24%) agreed to participate; 29 (78%) completed the ATHENA program. Median (IQR) age and body mass index were 53 (47–65) years and 30.8 (29.1–34.8) kg/m2 respectively. ATHENA was feasible to implement, with all components delivered as intended and high participant satisfaction. Ninety-seven percent of participants reported improved UI symptoms (global rating of change) and significant improvements in overall pelvic floor dysfunction and quality of life utility scores (p = 0.001). While weight did not change, significant improvements were found in body-food choice congruence (intuitive eating scale-2; p

Summary Background & aims Promoting patient participation in health care is a worldwide health care priority. When patients participate in their nutrition care during hospitalisation, they are more likely to meet their dietary needs. Patient participation is a potential solution to hospital malnutrition, for which inadequate dietary intake is the major modifiable risk factor. Our team developed a health information technology (HIT) intervention aiming to improve patients' dietary intakes during hospitalisation by engaging them in their nutrition care. The aim of this study was to explore patient perceptions and acceptability of the intervention. Methods This qualitative descriptive study was conducted at a tertiary teaching hospital in Australia. Participants were a subset of patients from a larger feasibility study, selected using maximum variation purposive sampling to include a broad representation of patients in terms of age, gender and experience with technology. All patients had used the HIT intervention to participate in their nutrition care in hospital, through nutritional goal setting and dietary intake monitoring. A semi-structured interview guide was used to collect qualitative data on patients' perceptions of the intervention, focusing on acceptability. Data were analysed thematically. Findings 11 patients participated in interviews, from which two main themes emerged. The first captured patients' experiences and perceptions of using technology to participate in their nutrition care. Patients found it easy to use, useful and valuable, but still valued interaction with researchers and hospital staff. The second theme portrayed the spectrum of participation, from simply learning about nutrition, to self-monitoring and evaluating, to changing behaviour. Participants enjoyed gaining new knowledge and awareness around nutrition. Most self-monitored their food intake and evaluated their goals, and some changed what foods they ordered based on what they had learned. Conclusions Patients responded positively to the intervention, likely because they found it valuable and easy to use. These findings are promising for potential future use of HIT to engage hospital patients in care. Future research should investigate the effects of HIT interventions on patient-centred outcomes in hospital.

Introduction Surgical wound care requires an interprofessional approach; however, there is considerable variation in practice and a lack of robust evidence to guide clinicians. Thus, it is important to identify priority areas from the perspectives of end-users to target efforts to both generate and implement high quality evidence. Objective To rank the top four priority questions in wound management across two health districts to inform future research and implementation efforts in wound care. Methods A multisite modified nominal group technique was used to build consensus. Two interactive two-hour workshops were held across two health services districts. Participants were recruited from nursing, allied health and medicine. In preparation for the workshops, a standard operating procedure was developed, and 25 wound care priority questions identified, a priori. Descriptive statistics were used to analyse workshop data. Results Across districts, 38 health professionals participated in the workshops. From a list of 25 clinical questions, the top 10 were determined, and from these, the top four. The number one priority question identified by 23/38 (60.5%) participants across districts related to patients’ understanding/knowledge of their wound treatment. The number two priority question 15/38 (39.5%) participants voted on focussed on patient involvement in wound care. Conclusions Overall, the priority questions reflect the need to encourage patient participation in wound care. These wound care priorities can be used to inform future research and improvement efforts in wound care.

Background People with cancer are at high risk of malnutrition. Nutrition education is an effective strategy to improve patient outcomes, however, little is known regarding the impact of family and/or carer involvement in nutrition education and requires investigation. The purpose of the study was to evaluate PIcNIC (Partnering with families to promote nutrition in cancer care) intervention acceptability from the perspective of patients, families and health care providers. Methods A descriptive qualitative study was undertaken at an inpatient and an outpatient hospital setting in Australia and an outpatient/home setting in Hong Kong. A patient-and-family centred intervention including nutrition education, goals setting/nutrition plans, and food diaries, was delivered to patients and/or families in the inpatient, outpatient or home setting. Semi-structured interviews were used to explore perceptions of the intervention. 64 participants were interviewed; 20 patients, 15 family members, and 29 health care professionals. Data were analysed using deductive and inductive content analysis. Results Two categories were identified; 1) ‘context and intervention acceptability’; and 2) ‘benefits of patient- and family-centred nutrition care’. Within each category redundant concepts were identified. For category 1 the redundant concepts were: the intervention works in outpatient settings, the food diary is easy but needs to be tailored, the information booklet is a good resource, and the intervention should be delivered by a dietitian, but could be delivered by a nurse. The redundant concepts for category 2 were: a personalised nutrition plan is required, patient and family involvement in the intervention is valued and the intervention has benefits for patients and families. Converging and diverging perceptions across participant groups and settings were identified. Conclusions In this paper we have described an acceptable patient- and family-centred nutrition intervention, which may be effective in increasing patient and family engagement in nutrition care and may result in improved nutrition intakes. Our study highlights important contextual considerations for nutrition education; the outpatient and home setting are optimal for engaging patients and families in learning opportunities.

Background: After lower gastrointestinal surgery, few patients start eating within timeframes outlined by evidence‐based guidelines or meet their nutrition requirements in hospital. The present study explored hospital staffs’ perceptions of factors influencing timely and adequate feeding after colorectal surgery to inform future interventions for improving postoperative nutrition practices and intakes. Methods: This qualitative exploratory study was conducted at an Australian hospital where Enhanced Recovery After Surgery guidelines had not been formally implemented. One‐on‐one semistructured interviews were conducted with hospital staff who provided care to patients undergoing colorectal surgery. Interviews lasted from 21 to 47 minutes and were audio recorded and transcribed verbatim. Data were analyzed using inductive thematic analysis. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation. Results: Eighteen staff participated in interviews, including 9 doctors, 5 nurses, 2 dietitians, and 2 foodservice staff. Staffs’ responses formed 3 themes: (1) variability in perceived acceptability of postoperative feeding; (2) improving dynamics and communication within the treating team; and (3) optimizing dietary intakes with available resources. Conclusion: Staff and organizational factors need to be considered when attempting to improve postoperative nutrition among patients who undergo colorectal surgery. Introducing a feeding protocol, enhancing intraprofessional and interdisciplinary communication, and ensuring the availability of appropriate, nutrient‐dense foods are pivotal to improve nutrition practices and intakes.

Aims and objectives Describe and compare current surgical wound care practices across two hospitals in two health services districts, Australia. Background Surgical site infections (SSI) are a complication of surgery and occur in up to 9.5% of surgical procedures, yet they are preventable. Despite the existence of clinical guidelines for SSI prevention, there remains high variation in wound care practice. Design Prospective comparative design using structured observations and chart audit. Methods A specifically developed audit tool was used to collect data on observed wound care practices, documentation of wound assessment and practice, and patients’ clinical characteristics from patients’ electronic medical records. Structured observations of a consecutive sample of surgical patients receiving wound care with a convenience sample of nurses were undertaken. The manuscript adheres to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement. Results In total, 154 nurses undertaking acute wound care and 257 surgical patients who received wound care were observed. Across hospitals, hand hygiene adherence after dressing change was lowest (Hospital A: 8/113, 7%; Hospital B: 16/144, 11%; χ 2: 8.93, p = .347). Most wound dressing practices were similar across sites, except hand hygiene prior to dressing change (Hospital A: 107/113, 95%; Hospital B: 131/144, 91%; (χ2: 7.736, p = .021) and use of clean gloves using nontouch technique (Hospital A: 88/113, 78%; Hospital B: 90/144, 63%; χ 2: 8.313, p = .016). The most commonly documented wound characteristic was wound type (Hospital A: 43/113, 38%; Hospital B: 70/144, 49%). What nurses documented differed significantly across sites (p

Malnutrition, frailty and sarcopenia are becoming increasingly prevalent among community-dwelling older adults; yet are often unidentified and untreated in community settings. There is an urgent need for community-based healthcare professionals (HCPs) from all disciplines, including medicine, nursing and allied health, to be aware of, and to be able to recognise and appropriately manage these conditions. This paper provides a comprehensive overview of malnutrition, frailty and sarcopenia in the community, including their definitions, prevalence, impacts and causes/risk factors; and guidance on how these conditions may be identified and managed by HCPs in the community. A detailed description of the care process, including screening and referral, assessment and diagnosis, intervention, and monitoring and evaluation, relevant to the community context, is also provided. Further research exploring the barriers/enablers to delivering high-quality nutrition care to older community-dwelling adults who are malnourished, frail or sarcopenic is recommended, to inform the development of specific guidance for HCPs in identifying and managing these conditions in the community.

Urinary incontinence (UI) affects many women and impacts quality of life. Group-based interventions may be an effective and efficient method for providing UI care; however, interventions must be acceptable to patients to have an impact. This study aimed to explore patients’ perceptions of an exercise training and healthy eating group program (ATHENA) for overweight and obese women with UI. This qualitative descriptive study involved semi-structured interviews with a subset of participants sampled from a feasibility study of ATHENA. The ATHENA intervention was co-developed with end-users and implemented in Women’s Health Physiotherapy services at an Australian hospital. Interviews were recorded, transcribed and analysed thematically. Eleven female patients participated (mean ± SD age 54.2 ± 9.9 years; body mass index 30.5 ± 3.25 kg/m2). Participants found ATHENA highly acceptable, with three themes emerging from interviews: (1) Participants’ journey of change through ATHENA, describing the shifts in knowledge, attitudes, behaviours and symptoms participants experienced; (2) High satisfaction with ATHENA, including educational content, exercise components and delivery style; and (3) Group setting integral to ATHENA’s success, with participants providing support, building friendships, and facilitating each other’s learning. Overall, ATHENA was acceptable to participants, who provided each other with peer support; an unexpected moderator to ATHENA’s success.

Empowering patients to participate in nutrition care during hospitalisation may improve their dietary intakes and associated outcomes. This study tested the acceptability and feasibility of a technology-based intervention to engage hospital patients in nutrition care at a tertiary teaching hospital in Australia. The hospital used an electronic foodservice system (EFS), by which patients ordered meals via bedside computers. Adults at nutritional risk received the nutrition technology (NUTRI-TEC) intervention, involving nutrition assessment, education on nutrition requirements and training on using the EFS to enter food intakes and monitor nutrition goals. Acceptability was assessed using patient satisfaction and engagement surveys. Feasibility was assessed by evaluating the intervention delivery/fidelity and patient recruitment/retention. Patients&rsquo, dietary intakes were observed daily to indicate the intervention&rsquo, s effects and assess the accuracy of the patient-recorded intakes. Descriptive and inferential statistics were used to analyse the data. Of the 71 patients recruited, 49 completed the study (55% male, median (IQR) age 71 (65&ndash, 78) years, length of stay 10 (7&ndash, 14) days). Patient satisfaction with NUTRI-TEC was high. Intervention delivery and fidelity targets were met but recruitment (&ge, 50%) and retention (&ge, 75%) targets were not, only 31% of patients agreed to participate and 69% completed the study (mostly due to unexpected/early discharge). Patient- and researcher-recorded dietary intakes correlated strongly, indicating patients can record food intakes accurately using technology. This study highlights the important role technology is likely to play in facilitating patient engagement and improving care during hospitalisation.

Background Confident Body, Confident Child (CBCC) is an innovative, evidence-based program providing parenting strategies to promote healthy eating, physical activity and body satisfaction in children aged 2–6 years. This study aimed to explore Child Health Nurse (CHN) experiences with using CBCC in their community health clinics with parents of young children. This work is part of a larger study involving tailoring, implementing and evaluating CBCC in a community child health setting. Methods This qualitative descriptive study was conducted within community child health centres at a public health service in Queensland, Australia. Participants included CHNs who had recently attended a tailored CBCC training workshop providing training/education, group activities/discussions and CBCC resources for CHN use in clinical practice. Semi-structured interviews were conducted to explore CHN perceptions of CBCC training, content and resources; and how CBCC was used in practice. Interviews were recorded and transcribed verbatim and analysed thematically. Results Eleven CHNs participated in interviews, with three themes emerging from the data. In Theme 1, High CHN satisfaction with CBCC messages, resources and utility, nurses expressed CBCC was highly valuable, useful and easy to enact in their practice. In Theme 2, Effects of CBCC on CHN knowledge, behaviour and practice, CHNs said they experienced increased awareness around body image, improved confidence in addressing issues with clients, and positive changes in their own behaviour and practice after attending CBCC training. In Theme 3, CHNs discussed Ideas for future implementation of CBCC, including challenges and considerations for practice, ongoing education/training for CHNs and broadening the target audience for wider CBCC dissemination. Conclusions This study found CHNs were highly accepting of CBCC as it was useful and valuable in practice, increased their awareness and confidence around body image issues, and positively affected their attitudes and behaviours. CHNs’ suggestions for making CBCC delivery more efficient and broadening its reach in the community were valuable and will likely inform local policy and future research. Further research is required on the wider dissemination of CBCC to parents of young children for promoting positive body image and healthy eating, ultimately for the long-term prevention of eating disorders.

Digital health is transforming the delivery of health care around the world to meet the growing challenges presented by ageing populations with multiple chronic conditions. Digital health technologies can support the delivery of personalised nutrition care through the standardised Nutrition Care Process (NCP) by using personal data and technology-supported delivery modalities. The digital disruption of traditional dietetic services is occurring worldwide, supporting responsive and high-quality nutrition care. These disruptive technologies include integrated electronic and personal health records, mobile apps, wearables, artificial intelligence and machine learning, conversation agents, chatbots, and social robots. Here, we outline how digital health is disrupting the traditional model of nutrition care delivery and outline the potential for dietitians to not only embrace digital disruption, but also take ownership in shaping it, aiming to enhance patient care. An overview is provided of digital health concepts and disruptive technologies according to the four steps in the NCP: nutrition assessment, diagnosis, intervention, and monitoring and evaluation. It is imperative that dietitians stay abreast of these technological developments and be the leaders of the disruption, not simply subject to it. By doing so, dietitians now, as well as in the future, will maximise their impact and continue to champion evidence-based nutrition practice.

Objectives Timely and adequate nutrition after surgery is important. The aim of this study was to evaluate the effects of an intervention, developed using an integrated knowledge translation approach, designed to improve oral intake among postoperative colorectal patients. Methods A pre/post, mixed-methods pilot study was undertaken at a tertiary teaching hospital in Australia. Patients who had undergone elective colorectal surgery and were admitted to the ward where 10 nutrition-related strategies had been implemented were included. Quantitative data, including patient demographics, timing and type of nutrition consumed, and protein and energy intake were collected pre- and post-intervention via chart audits, direct observations, and verbal clarification. Qualitative data on patient (n = 18) responses to the intervention were collected through one-on-one, semistructured interviews and analyzed using inductive content analysis. Results Sixty-four patients were observed (30 pre- and 34 post-intervention). Significant improvements were seen for the following outcomes (presented as median [interquartile range], pre- versus post-intervention): time (h) to first dietary intake (15.7 [7.4–22.5] versus 4.9 [3.7–14.2]); patient energy intakes (kJ) on day 1 (1719 [947–2200] versus 3530 [2192–5169]) and day 2 (2506 [1071–3749] versus 4144 [2987–5889]); and patient protein intake (g) on day 1 (3.3 [1.8–11.2] versus 30.3 [20–45]) and day 2 (10.8 [3.5–29.9] versus 39.6 [30.7–59]). Prescription of free fluids as first diet type increased from 13% to 79% pre- and post-intervention, respectively. There were no significant differences in time (h) to first solid dietary intake (86.1 [60.1–104] versus 69.2 [46.1–115.5]) and overall proportion of patients who met both their estimated energy and protein requirements while in hospital pre- and post-intervention (22 versus 37%). Patients reported positive experiences with the intervention. Conclusion A multifaceted intervention developed using an integrated knowledge translation approach has the potential to improve oral intake in patients who undergo colorectal surgery. A larger-scale trial is required to confirm these findings and assess the effects of the intervention on clinical outcomes and costs.

Aim: Evidence-based guidelines recommend early oral feeding (EOF) as prescription of an unrestricted diet within 24 hours after colorectal surgery. The present study aimed to understand local postoperative feeding practices after colorectal surgery; identify barriers to EOF implementation; select, tailor and implement stakeholder engagement strategies to facilitate EOF uptake; and evaluate changes to practice. Methods: A longitudinal, mixed methods study was undertaken, guided by the knowledge-to-action framework. Phase 1 assessed the nature of the problem using postoperative diet Audits 1 and 2. In Phase 2, staff interviews identified barriers to EOF implementation. Results from Phases 1 and 2 were fed back to inform Phase 3 strategies. Knowledge uptake was monitored in Audits 3 and 4. Phase 4 evaluated outcomes from Audit 5. Results: In Phase 1, median time to commencement of full diet was postoperative Days 4 and 3 in Audits 1 and 2, respectively. Phase 2 identified EOF barriers, including disparities in diet upgrade practices and variable understanding of hospital diets. In Phase 3, planned strategies were implemented to improve EOF (i) educational session describing local hospital diets; (ii) consultant decision to prescribe a full diet on operation notes; and (iii) educational sessions with nursing staff describing changes to EOF practice. In Phase 4, median time to commencement of full diet improved to postoperative Day 0. Patients prescribed a full diet on operation notes increased from 0% to 82%. Conclusions: The present study successfully identified and overcame local barriers to improve EOF practices to align with guideline recommendations.

Background Malnutrition is frequent in patients with cancer, particularly those in advanced stages of the disease. The aim of the present study was to test the feasibility of a family-centred nutritional intervention, based on the Family Systems theory and past research. Methods This was a single-arm trial assessing feasibility (eligibility, recruitment and retention rates); acceptability by patients, family caregivers and health professionals; intervention fidelity, and energy/protein intake (in one site only). Two sites were involved; one each in Australia (AUS) and Hong Kong (HK), with one site delivering the intervention to oncology patients receiving curative treatments in the hospital, and the other to advanced cancer patients in the home. Results The sample included 53 patients (23 from AUS and 30 from HK), 22 caregivers (3 from AUS and 19 from HK) and 30 health professionals (20 from AUS and 10 from HK). Recruitment was difficult in the acute inpatient oncology care setting (AUS) and feasibility criteria were not met. Sufficient recruitment took place in the home care setting with advanced cancer patients in HK. Patients, family members and health professionals found the intervention helpful and acceptable, and patients and families indicated they would take part in the future in a similar study. Energy and protein intake improved from baseline to end of intervention (mean 22 kcal/kg/day to 26 and 0.9 g/kg/day to 1.0 respectively). Conclusion The new intervention is feasible in a home setting when delivered to patients with advanced cancer, acceptable to patients and families, and has the potential to improve nutritional status in patients. A large randomised trial is warranted in the future. Electronic supplementary material The online version of this article (10.1186/s12904-018-0306-4) contains supplementary material, which is available to authorized users.

Background Early oral feeding after surgery is best practice among adult, noncritically ill patients. Evidenced-based guidelines (EBG) recommend commencing liquid and solid feeding within 24 h of surgery to improve patient (e.g. reduced morbidity) and hospital (e.g. reduced length of stay) outcomes. Whether these EBG are adhered to in usual clinical practice remains unknown. The present study aimed to identify the time to commencement of first oral feed (liquid or solid) and first solid feed among postoperative, noncritically ill, adult patients. Methods MEDLINE, CINAHL, SCOPUS and Web of Science databases were searched from inception to June 2016 for observational studies reporting liquid and/or solid feeding practices among postoperative patients. Studies reporting a mean/median time to first feed or first solid feed within 24 h of surgery or where ≥75% of patients were feeding by postoperative day one were considered in-line with EBG. Results Of 5826 articles retrieved, 29 studies were included. Only 40% and 22% of studies reported time to first feed and time to first solid feed in-line with EBG, respectively. Clear and free liquids were the first diet types commenced in 86% of studies. When solids were commenced, 44% of studies reported using various therapeutic diet types (e.g. light) prior to the commencement of a regular diet. Patients who underwent gastrointestinal procedures appeared more likely to experience delayed postoperative feeding. Conclusions Our findings demonstrate a gap between postoperative feeding evidence and its practical application. This information provides a strong rationale for interventions targeting improved nutritional care following surgery.

Background Pressure ulcers place a significant burden on patients and hospitals. Our team developed and tested a pressure ulcer prevention care bundle (PUPCB) in a cluster randomized trial. As part of the process evaluation conducted alongside the trial, we explored patients’ perceptions of the intervention. Aims To identify patients’ perceptions and experiences of a PUPCB in hospital. Methods This qualitative descriptive study explored the perceptions of a subset of patients who participated in a trial testing the PUPCB across four intervention hospitals. A trained interviewer conducted semistructured interviews, which were digitally recorded, transcribed, and analyzed using thematic analysis. Findings Nineteen patients were interviewed across the four hospitals. Three main themes emerged: (a) importance of personal contact in PUPCB delivery; (b) understanding pressure ulcer prevention (PUP) enhances participation; and (c) individual factors impact patients’ engagement in PUP. Discussion The extent to which patients adopted the intervention appeared to be influenced by the complexity of education materials, compatibility with patients’ existing knowledge and beliefs, and perceived advantage of the intervention; ability for human interaction; and patient-related facilitators and barriers to participating in PUP care. Linking Evidence to Action This study found patients accepted a PUPCB that encouraged participation in care, particularly as it involved personal and positive interactions with nurses and provision of information that was easy to understand and resonated with patients.

Hospital-acquired malnutrition is a significant issue with complex aetiology, hence nutrition interventions must be multifaceted and context-specific. This paper describes the development, implementation and process evaluation of a complex intervention for improving nutrition among medical patients in an Australian hospital. An integrated knowledge translation (iKT) approach was used for intervention development, informed by previous research. Intervention strategies targeted patients (via a nutrition intake monitoring system), staff (discipline-specific training targeting identified barriers), and the organisation (foodservice system changes). A process evaluation was conducted parallel to implementation assessing reach, dose, fidelity and staff responses to the intervention using a mixed-methods design (quantitative and qualitative approaches). Staff-level interventions had high fidelity and broad reach (61% nurses, 93% foodservice staff and all medical staff received training). Patient and organisation interventions were implemented effectively, but due to staffing issues, only reached around 60% of patients. Staff found all intervention strategies acceptable with benefits to practice. This study found an iKT approach useful for designing a nutrition intervention that was context-specific, feasible and acceptable to staff. This was likely due to engagement of multiple disciplines, identifying and targeting specific areas in need of improvement, and giving staff frequent opportunities to contribute to intervention development/implementation.

Background Enhanced Recovery After Surgery (ERAS) guidelines recommend early oral feeding with nutritionally adequate diets after surgery. However, studies have demonstrated variations in practice and poor adherence to these recommendations among patients who have undergone colorectal surgery. Given doctors are responsible for prescribing patients’ diets after surgery, this study explored factors which influenced medical staffs’ decision-making regarding postoperative nutrition prescription to identify potential behaviour change interventions. Methods This qualitative study involved one-on-one, semi-structured interviews with medical staff involved in prescribing nutrition for patients following colorectal surgery across two tertiary teaching hospitals. Purposive sampling was used to recruit participants with varying years of clinical experience. The Theoretical Domains Framework (TDF) underpinned the development of a semi-structured interview guide. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and sub-themes were discussed by all investigators to ensure consensus of interpretation. Results Twenty-one medical staff were interviewed, including nine consultants, three fellows, four surgical trainees and five junior medical doctors. Three overarching themes emerged from the data: (i) Prescription preferences are influenced by perceptions, experience and training; (ii) Modifying prescription practices to align with patient-related factors; and (iii) Peers influence prescription behaviours and attitudes towards nutrition. Conclusions Individual beliefs, patient-related factors and the social influence of peers (particularly seniors) appeared to strongly influence medical staffs’ decision-making regarding postoperative nutrition prescription. As such, a multi-faceted approach to behaviour change is required to target individual and organisational barriers to enacting evidence-based feeding recommendations. Electronic supplementary material The online version of this article (10.1186/s12913-019-4011-7) contains supplementary material, which is available to authorized users.

Background: Despite strong evidence for supervised pelvic floor muscle training (PFMT) for women with urinary incontinence (UI), and weight loss and exercise for overweight and obese women with UI, implementation literature on these combined interventions is limited. This paper aimed to describe the rigorous and systematic processes involved in the collaborative development, implementation, refinement and evaluation of a novel, holistic 12 week exercise training and healthy eating group program (ATHENA) for overweight and obese women with UI. Methods/Design: This intervention description paper is part of a larger mixed-methods feasibility study of implementing the ATHENA intervention within a physiotherapy service at a public hospital in Australia. The collaborative intervention design had input from clinicians, researchers and a consumer representative. Results: The intervention involved four evidence-based components&mdash, (1) supervised PFMT, (2) general exercise training, (3) pelvic health education, and (4) healthy eating education&mdash, delivered face to face over a 12 week period. Supporting resources developed included a Facilitator&rsquo, s Guide and Participant Workbook. Conclusion: ATHENA is an evidence-based, multifaceted, group-based intervention targeting exercise training and healthy eating for management of UI for overweight and obese women. The structured development process and transparency of intervention content and resources aims to enhance practical application and success in future studies.

Aim This study assessed the accuracy (including sources and reasons for errors) and adequacy (of patients’ intakes relative to requirements) among patients prescribed therapeutic diets in the hospital setting. Methods This observational study was conducted across six wards in a metropolitan tertiary hospital over 14 consecutive days. Meal accuracy was assessed by comparing each individual food or fluid item provided to each patient to items allowed on their specific diet code. Errors were defined by severity (critical or non-critical threat to patient safety) and source (foodservice system, staff or patient). Nutritional adequacy was determined by comparing patients’ daily energy and protein intakes to individually estimated requirements. Intakes were considered adequate if consumption was ≥75% of requirements. Results Meals of 67 patients (31 females, aged 60.0 ± 19.4 years) were assessed for accuracy for up to two days. Of the total 347 therapeutic meals observed, 69 (19.9%) were inaccurate. A large proportion of these errors were critical (64.8%). Foodservice errors were the most common source. Of the 48 patients with complete dietary intake data, mean energy and protein intakes were 3192 ± 2220 kJ and 33 ± 27 g protein, respectively. Only five and seven patients consumed adequate energy and protein to meet their estimated requirements, respectively. Conclusion Patients requiring therapeutic diets during hospitalisation are frequently exposed to food and/or fluid errors that may pose an acute threat to their safety. In addition, prescription of these diets may result in patients being unable to adequately meet their nutritional requirements.

Background Many patients who undergo lower gastrointestinal surgery neither recommence feeding within timeframes outlined by evidence-based guidelines, nor meet their nutrition requirements in hospital. Given that the success of timely and adequate post-operative feeding is largely reliant on patient adherence, the present study explored patients' perceptions of recommencing feeding after colorectal surgery to determine areas of improvement to meet their needs and expectations. Methods This qualitative study involved one-on-one, semi-structured interviews with patients receiving care after colorectal surgery in an Australian tertiary teaching hospital. Purposive sampling was used to ensure maximal variation in age, sex, procedural type and post-operative nutrition care experience. Interviews were audio recorded, with data transcribed verbatim before being thematically analysed. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation. Results Sixteen patients were interviewed (female 56%; age 61.5 ± 12.3 years). Three overarching themes emerged from the data: (i) patients make food-related decisions based on ideologies, experience and trust; (ii) patients appreciate the opportunity to participate in their nutrition care; and (iii) how dietary information is communicated influences patients' perceptions of and behaviours towards nutrition. Conclusions Enabling patients to select from a wide range of foods from post-operative day 1 (by prescribing an unrestricted diet in line with evidence-based practice guidelines) in conjunction with delivering clear, simple and encouraging dietary-related information may facilitate patient participation in care and increase oral intakes among patients who have undergone colorectal surgery.

BACKGROUND: Evidence-based guidelines (EBG) recommend recommencing oral feeding (liquids and solids) ≤24 hours after surgery. The aims of this study were to determine time to first diet (any) and solid-diet prescriptions, delivery, and intakes among adult, non-critically ill, postoperative patients. METHODS: This prospective cross-sectional study included 100 postsurgical patients. Demographic and perioperative dietary-related data were collected from patients' medical records or via direct observation. Dietary intakes were observed for the duration patients were enrolled in the study (from end of surgery to discharge). The amount of energy (kcal) and protein (g) consumed per patient per day was analyzed and considered adequate if it met ≥75% of a patient's estimated requirements. RESULTS: 89 and 52 patients consumed their first intake and first solid intake ≤24 hours after surgery, respectively. For their first intake, 53% of patients had clear or free liquids. Median times to first diet prescription (range: 1.3-5.7 hours), delivery (range: 2.1-12.5 hours), and intake (range: 2.2-13.9 hours) were ≤24 hours after surgery for all patient groups. Time to first solid-diet prescription (range: 1.3-77.8 hours), delivery (range: 2.1-78.0 hours) and intake (range: 2.2-78.2 hours) varied considerably. Urologic and gastrointestinal patients experienced the greatest delays to first solid-diet prescription and first solid intake. Only 26 patients met both their energy and protein requirements for ≥1 day during their stay. CONCLUSION: While practice appears consistent with EBG recommendations for commencing nutrition (any type) after surgery, the reintroduction of adequate diet requires improvement.

Background Surgical site infections (SSI) occur in up to 10% of surgeries. Wound care practices to prevent infections are guided by Clinical Practice Guidelines (CPGs), yet their contribution to improving patient outcomes relies on their quality and adoption in practice. We critically evaluated the quality of CPGs for SSI prevention during pre-, intra- and post-operative phases of care. Methods We systematically reviewed the literature from 1990–2018 using the Cochrane Library, CINAHL, EMBASE, MEDLINE, ProQuest databases and five guidelines repositories. We extracted characteristics of each guideline using purposely-developed data collection tools. We assessed overall quality using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool. Results Combined searches of databases and repositories yielded 5,910 citations. Of these, we reviewed 215 full text documents. The final sample included 15 documents: 6 complete CPGs, 3 CPG updates, and 6 supplementary documents. The overall %mean scores across AGREE II domains for CPGs were: 1) scope and purpose (%mean ± SD = 86.3±23.5); 2) stakeholder involvement (%mean ± SD = 64±31.0); 3) rigour of development (%mean ± SD = 68.7±30.6); 4) clarity and presentation (%mean ± SD = 88.5±16.7); 5) applicability (%mean ± SD = 44±30.2); and, 5) editorial independence (%mean ± SD = 61±37.6). Based on individual AGREE II domains and overall scores, we appraised 4 out of 6 CPGs (inclusive of updates) as “recommended” for use in practice. Overall agreement among appraisers was excellent (ICC 0.86 [95%CI 0.73–0.94] - 0.98 [95%CI 0.96–0.99]; p

Background Pressure ulcers are serious, avoidable, costly and common adverse outcomes of healthcare. Objectives To evaluate the cost-effectiveness of a patient-centred pressure ulcer prevention care bundle compared to standard care. Design Cost-effectiveness and cost-benefit analyses of pressure ulcer prevention performed from the health system perspective using data collected alongside a cluster-randomised trial. Settings Eight tertiary hospitals in Australia. Participants Adult patients receiving either a patient-centred pressure ulcer prevention care bundle (n=799) or standard care (n=799). Methods Direct costs related to the intervention and preventative strategies were collected from trial data and supplemented by micro-costing data on patient turning and skin care from a 4-week substudy (n=317). The time horizon for the economic evaluation matched the trial duration, with the endpoint being diagnosis of a new pressure ulcer, hospital discharge/transfer or 28days; whichever occurred first. For the cost-effectiveness analysis, the primary outcome was the incremental costs of prevention per additional hospital acquired pressure ulcer case avoided, estimated using a two-stage cluster-adjusted non-parametric bootstrap method. The cost-benefit analysis estimated net monetary benefit, which considered both the costs of prevention and any difference in length of stay. All costs are reported in AU$(2015). Results The care bundle cost AU$144.91 (95%CI: $74.96 to $246.08) more per patient than standard care. The largest contributors to cost were clinical nurse time for repositioning and skin inspection. In the cost-effectiveness analysis, the care bundle was estimated to cost an additional $3296 (95%CI: dominant to $144,525) per pressure ulcer avoided. This estimate is highly uncertain. Length of stay was unexpectedly higher in the care bundle group. In a cost-benefit analysis which considered length of stay, the net monetary benefit for the care bundle was estimated to be −$2320 (95%CI −$3900, −$1175) per patient, suggesting the care bundle was not a cost-effective use of resources. Conclusions A pressure ulcer prevention care bundle consisting of multicomponent nurse training and patient education may promote best practice nursing care but may not be cost-effective in preventing hospital acquired pressure ulcer.

Background Advancements in technology are enabling patients to participate in their health care through self-monitoring and self-management of diet, exercise and chronic disease. Technologies allowing patients to participate in hospital care are still emerging but show promise. Our team is developing a program by which hospitalised patients can participate in their nutrition care. This study explores hospital staffs’ perceptions of using this technology to engage patients in their care. Methods This qualitative study involved semi-structured interviews with hospital staff providing routine nutrition care to patients (i.e. dietitians, nutrition assistants, nurses, doctors and foodservice staff) from five wards at a tertiary metropolitan teaching hospital in Australia. The hospital currently uses an electronic foodservice system (EFS) for patient meal ordering, accessed through personal screens at the bedside. Participants were shown the EFS program on an iPad and asked about their perceptions of the program, with questions from a semi-structured interview guide. Staff were interviewed individually or in small focus groups. Interviews lasted 15–30 min and were audio recorded and later transcribed. Data were analysed using thematic analysis. Results Nineteen staff participated in interviews. Overall, they expressed positive views of the EFS program and wanted it to be implemented in practice. Their responses formed three themes, each with a number of subthemes: 1) Enacting patient participation in practice; 2) Optimising nutrition care; and 3) Considerations for implementing an EFS program in practice. Staff thought the program would improve various aspects of nutrition care and enable patient participation in care. Whilst they raised some concerns, they focused on overcoming barriers and facilitating implementation if the program were to be adopted into practice. Conclusions Staff found an EFS program designed to engage patients in their nutrition care acceptable, as they saw benefits to using it for both patients and staff. Staff recognised characteristics of the program itself, as well as allocation of roles and responsibilities in operationalising it, were pivotal for successful implementation in practice. Their perspectives will inform program and intervention design, and implementation and evaluation strategies. Electronic supplementary material The online version of this article (doi:10.1186/s12911-017-0495-4) contains supplementary material, which is available to authorized users.

Background Patient participation in health care is associated with improved outcomes for patients and hospitals. New technologies are creating vast potential for patients to participate in care at the bedside. Several studies have explored patient use, satisfaction and perceptions of health information technology (HIT) interventions in hospital. Understanding what works for whom, under what conditions, is important when considering interventions successfully engaging patients in care. This realist review aimed to determine key features of interventions using bedside technology to engage hospital patients in their care and analyse these in terms of context, mechanisms and outcomes. Methods A realist review was chosen to explain how and why complex HIT interventions work or fail within certain contexts. The review was guided by Pawson’s realist review methodology, involving: clarifying review scope; searching for evidence; data extraction and evidence appraisal; synthesising evidence and drawing conclusions. Author experience and an initial literature scope provided insight and review questions and theories (propositions) around why interventions worked were developed and iteratively refined. A purposive search was conducted to find evidence to support, refute or identify further propositions, which formed an explanatory model. Each study was ‘mined’ for evidence to further develop the propositions and model. Results Interactive learning was the overarching theme of studies using technology to engage patients in their care. Several propositions underpinned this, which were labelled: information sharing; self-assessment and feedback; tailored education; user-centred design; and support in use of HIT. As studies were mostly feasibility or usability studies, they reported patient-centred outcomes including patient acceptability, satisfaction and actual use of HIT interventions. For each proposition, outcomes were proposed to come about by mechanisms including improved communication, shared decision-making, empowerment and self-efficacy; which acted as facilitators to patient participation in care. Overall, there was a stronger representation of health than IT disciplines in studies reviewed, with a lack of IT input in terms of theoretical underpinning, methodological design and reporting of outcomes. Conclusion HIT interventions have great potential for engaging hospitalised patients in their care. However, stronger interdisciplinary collaboration between health and IT researchers is needed for effective design and evaluation of HIT interventions.

Background Active patient involvement in nutrition care may improve dietary intakes in hospital. Our team is developing an innovative programme allowing patients to self-assess and self-monitor their nutrition at the bedside. The present study aimed to assess usability and patient perceptions of an electronic foodservice system (EFS) for participating in nutrition care. Methods This qualitative study was conducted in an Australian tertiary hospital. Participants were sampled purposively and included patients who were able to provide informed consent and communicate in English. Patient interviews were conducted at the bedside and consisted of: (i) usability testing of the EFS using ‘Think Aloud’ technique and (ii) questioning using a semi-structured interview guide to understand perceptions of the EFS. Interview data were analysed using inductive content analysis. Results Thirty-two patients were interviewed. Their perceptions of using the EFS to participate in nutrition care were expressed in five categories: (i) Familiarity with technology can affect confidence and ability but is not essential to use EFS; (ii) User interface design significantly impacts EFS usability; (iii) Identifying benefits to technology increases its acceptance; (iv) Technology enables participation, which occurs to varying extents; and (v) Degree of participation depends on perceived importance of nutrition. Conclusions Patients found the EFS acceptable and acknowledged benefits to its use. Several factors appeared to influence usability, acceptability and willingness to engage with the system, such as user interface design and perceived ease of use, benefits and importance. The present study provides important insights into designing technology-based interventions for engaging inpatients in their nutrition care.

Background: As pressure ulcers contribute to significant patient burden and increased health care costs, their prevention is a clinical priority. Our team developed and tested a complex intervention, a pressure ulcer prevention care bundle promoting patient participation in care, in a cluster-randomised trial. The UK Medical Research Council recommends process evaluation of complex interventions to provide insight into why they work or fail and how they might be improved. This study aimed to evaluate processes underpinning implementation of the intervention and explore end-users’ perceptions of it, in order to give a deeper understanding of its effects. Methods: A pre-specified, mixed-methods process evaluation was conducted as an adjunct to the main trial, guided by a framework for process evaluation of cluster-randomised trials. Data was collected across eight Australian hospitals but mainly focused on the four intervention hospitals. Quantitative and qualitative data were collected across the evaluation domains: recruitment, reach, intervention delivery and response to intervention, at both cluster and individual patient level. Quantitative data were analysed using descriptive and inferential statistics. Qualitative data were analysed using thematic analysis. Results: In the context of the main trial, which found a 42% reduction in risk of pressure ulcer with the intervention that was not significant after adjusting for clustering and covariates, this process evaluation provides important insights. Recruitment and reach among clusters and individuals was high, indicating that patients, nurses and hospitals are willing to engage with a pressure ulcer prevention care bundle. Of 799 intervention patients in the trial, 96.7% received the intervention, which took under 10 min to deliver. Patients and nurses accepted the care bundle, recognising benefits to it and describing how it enabled participation in pressure ulcer prevention (PUP) care. Conclusions: This process evaluation found no major failures relating to implementation of the intervention. The care bundle was found to be easy to understand and deliver, and it reached a large proportion of the target population and was found to be acceptable to patients and nurses; therefore, it may be an effective way of engaging patients in their pressure ulcer prevention care and promoting evidence-based practise.

Background: Pressure ulcer prevention is a critical patient safety indicator for acute care hospitals. An innovative pressure ulcer prevention care bundle targeting patient participation in their care was recently tested in a cluster randomised trial in eight Australian hospitals. Understanding nurses’ perspectives of such an intervention is imperative when interpreting results and translating evidence into practice. As part of a process evaluation for the main trial, this study assessed nurses’ perceptions of the usefulness and impact of a pressure ulcer prevention care bundle intervention on clinical practice. Methods: This qualitative descriptive study involved semi-structured interviews with nursing staff at four Australian hospitals that were intervention sites for a cluster randomised trial testing a pressure ulcer prevention care bundle. Four to five participants were purposively sampled at each site. A trained interviewer used a semi-structured interview guide to question participants about their perceptions of the care bundle. Interviews were digitally recorded, transcribed and analysed using thematic analysis. Results: Eighteen nurses from four hospitals participated in the study. Nurses’ perceptions of the intervention are described in five themes: 1) Awareness of the pressure ulcer prevention care bundle and its similarity to current practice; 2) Improving awareness, communication and participation with the pressure ulcer prevention care bundle; 3) Appreciating the positive aspects of patient participation in care; 4) Perceived barriers to engaging patients in the pressure ulcer prevention care bundle; and 5) Partnering with nursing staff to facilitate pressure ulcer prevention care bundle implementation. Conclusions: Overall, nurses found the care bundle feasible and acceptable. They identified a number of benefits from the bundle, including improved communication, awareness and participation in pressure ulcer prevention care among patients and staff. However, nurses thought the care bundle was not appropriate or effective for all patients, such as those who were cognitively impaired. Perceived enablers to implementation of the bundle included facilitation through effective communication and dissemination of evidence about the care bundle; strong leadership and ability to influence staff behaviour; and simplicity of the care bundle.

Malnutrition affects up to 50% of hospitalised patients (Ray et al., 2014; Barker et al., 2011) and has severe consequences for patients and the health care system. Malnutrition increases the risks of mortality (Lim et al., 2012) and complications like pressure injuries (Banks et al., 2010), infections (Schaible and Stefan, 2007) and falls (Vivanti et al., 2011) and is associated with increased length of stay, readmissions and higher hospital costs (Lim et al., 2012). Inadequate dietary intake is the major modifiable risk factor for malnutrition and the majority of patients fail to meet their nutritional needs in hospital (Thibault et al., 2011). Improving dietary intakes among hospitalised patients is difficult as the problem is complex and multifactorial. Patient related factors include poor appetite; nutrition impacting symptoms such as nausea or constipation; problems with self-feeding; chewing or swallowing problems; increased nutrition requirements; older age and individual preferences (Sanson et al., 2018; Vanderwee et al., 2010; Kubrak and Jensen, 2007). Hospital related factors encompass nutrition care practices, hospital foodservice and the mealtime environment (Kubrak and Jensen, 2007).

Malnutrition is a common and complex problem in hospitals. This study used an integrated knowledge translation approach to develop, implement, and evaluate a multifaceted, tailored intervention to improve nutrition care, delivery, and intake among acute medical inpatients. This observational, pre-post study was conducted in a medical ward at a public hospital in Australia. The intervention was co-developed with key stakeholders and targeted three levels: individuals (nutrition intake magnets at patient bedsides), the ward (multidisciplinary hospital staff training), and the organisation (foodservice system changes). Observational data were collected pre- and post-intervention on patient demographics, food intakes, and the mealtime environment. Data were entered into SPSS and analysed using descriptive and inferential statistics. Ethical approval was gained through the hospital and university ethics committees. A total of 207 patients were observed, 116 pre- and 91 post-intervention. After intervention implementation, patients&rsquo, mean energy and protein intakes (in proportion to their estimated requirements) were significantly higher and the number of patients eating adequately doubled (p &lt, 0.05). In summary, a multifaceted, pragmatic intervention, tailored to the study context and developed and implemented alongside hospital staff and patients, seemed to be effective in improving nutrition practices and patient nutrition intakes on an acute medical ward.

Pressure injury guidelines recommend regular repositioning yet patients' mobility and repositioning patterns are unknown. An observational study using activity monitors was undertaken to describe the 24 h activity patterns of 84 hospitalized patients at risk of developing a pressure injury. The vast majority of participants' time was spent in the sedentary activity range (94% ± 3%) followed by the light range (5% ± 4 %). Patients changed their posture a median of 94 (interquartile range 48) time in the 24-h period (range 11-154), or ≈ 3.8 times per hour. Although a main focus for pressure injury prevention has been on repositioning, this study shows that patients with restricted mobility are actually moving quite often. Therefore, it might be appropriate to focus more attention on other pressure injury prevention strategies such as adequate nutrition, appropriate support surfaces and good skin care.

Objective: The purpose of this study was to investigate the effects of pre-exercise and protein coingestion on the glycemic response to carbohydrates. Methods: Twenty-one volunteers (13 males and 8 females) aged 22 y (� 3.8 y) participated in four trials in random order. These included: 1) glucose ingestion at rest (RG), 2) glucose and protein ingestion at rest (RGP), 3) glucose ingestion after exercise (EG), and 4) glucose and protein ingestion after exercise (EGP). Exercise consisted of 45 min of cycling at 60% of participants’ agepredicted maximum heart rate. Test drinks contained 50 g glucose or 50 g glucose with 20 g whey protein. Venous blood samples were taken at baseline and subsequently every 15 min for 2 h after drink consumption. Blood plasma was subsequently analyzed for glucose and insulin. Results: Plasma glucose concentration was significantly lower in the RGP group than in the RG group at 30, 45, 60, and 75 min and in the EGP group than in the EG group at 30, 45, and 60 min (P < 0.05). Plasma insulin area under the curve was significantly higher in the RGP group than in the RG group and in than in the EGP group than in the EG group (P < 0.05). No significant effect of exercise was seen on glycemic or insulinemic responses. Conclusions: Coingestion of protein with carbohydrate reduces glycemic response and increases insulinemic response in healthy subjects, whereas pre-exercise seems to have no effect.

Objective Nutrition is an important part of recovery for hospitalized patients. The aim of this study was to assess the nutritional adequacy of meals provided to and consumed by patients prescribed a therapeutic diet. Methods Patients (N = 110) prescribed a therapeutic diet (texture-modified, low-fiber, oral fluid, or food allergy or intolerance diets) for medical or nutritional reasons were recruited from six wards of a tertiary hospital. Complete (24-h) dietary provisions and intakes were directly observed and analyzed for energy (kJ) and protein (g) content. A chart audit gathered demographic, clinical, and nutrition-related information to calculate each patient's disease-specific estimated energy and protein requirements. Provisions and intake were considered adequate if they met ≥75% of the patient's estimated requirements. Results Mean energy and protein provided to patients (5844 ± 2319 kJ, 53 ± 30 g) were significantly lower than their mean estimated requirements (8786 ± 1641 kJ, 86 ± 18 g). Consequently, mean nutrition intake (4088 ± 2423 kJ, 37 ± 28 g) were significantly lower than estimated requirements. Only 37% (41) of patients were provided with and 18% (20) consumed adequate nutrition to meet their estimated requirements. No therapeutic diet provided adequate food to meet the energy and protein requirements of all recipients. Patients on oral fluid diets had the highest estimated requirements (9497 ± 1455 kJ, 93 ± 16 g) and the lowest nutrient provision (3497 ± 1388 kJ, 25 ± 19 g) and intake (2156 ± 1394 kJ, 14 ± 14 g). Conclusion Hospitalized patients prescribed therapeutic diets (particularly fluid-only diets) are at risk for malnutrition. Further research is required to determine the most effective strategies to improve nutritional provision and intake among patients prescribed therapeutic diets.

Background Hospital-acquired pressure ulcers are a serious patient safety concern, associated with poor patient outcomes and high healthcare costs. They are also viewed as an indicator of nursing care quality. Objective To evaluate the effectiveness of a pressure ulcer prevention care bundle in preventing hospital-acquired pressure ulcers among at risk patients. Design Pragmatic cluster randomised trial. Setting Eight tertiary referral hospitals with >200 beds each in three Australian states. Participants 1600 patients (200/hospital) were recruited. Patients were eligible if they were: ≥18 years old; at risk of pressure ulcer because of limited mobility; expected to stay in hospital ≥48h and able to read English. Methods Hospitals (clusters) were stratified in two groups by recent pressure ulcer rates and randomised within strata to either a pressure ulcer prevention care bundle or standard care. The care bundle was theoretically and empirically based on patient participation and clinical practice guidelines. It was multi-component, with three messages for patients’ participation in pressure ulcer prevention care: keep moving; look after your skin; and eat a healthy diet. Training aids for patients included a DVD, brochure and poster. Nurses in intervention hospitals were trained in partnering with patients in their pressure ulcer prevention care. The statistician, recruiters, and outcome assessors were blinded to group allocation and interventionists blinded to the study hypotheses, tested at both the cluster and patient level. The primary outcome, incidence of hospital-acquired pressure ulcers, which applied to both the cluster and individual participant level, was measured by daily skin inspection. Results Four clusters were randomised to each group and 799 patients per group analysed. The intraclass correlation coefficient was 0.035. After adjusting for clustering and pre-specified covariates (age, pressure ulcer present at baseline, body mass index, reason for admission, residence and number of comorbidities on admission), the hazard ratio for new pressure ulcers developed (pressure ulcer prevention care bundle relative to standard care) was 0.58 (95% CI: 0.25, 1.33; p=0.198). No adverse events or harms were reported. Conclusions Although the pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration, there was a high degree of uncertainty around this estimate and the difference was not statistically significant. Possible explanations for this non-significant finding include that the pressure ulcer prevention care bundle was effective but the sample size too small to detect this. National Health and Medical Research Council project grant number 1058963

Background: Participation in a clinical trial is believed to benefit patients but little is known about the post-trial effects on routine hospital-based care. Objectives: To describe (1) hospital-based, pressure ulcer care-processes after patients were discharged from a pressure ulcer prevention, cluster randomised controlled trial; and (2) to investigate if the trial intervention had any impact on subsequent hospital-based care. Methods: We conducted a retrospective analysis of 133 trial participants who developed a pressure ulcer during the clinical trial. We compared outcomes and care processes between participants who received the pressure ulcer prevention intervention and those in the usual care, control group. We also compared care processes according to the pressure ulcer stage. Results: A repositioning schedule was reported for 19 (14.3%) patients; 33 (24.8%) had a dressing applied to the pressure ulcer; 17 (12.8) patients were assessed by a wound care team; and 20 (15.0%) were seen by an occupational therapist. Patients in the trial’s intervention group were more likely to have the presence of a pressure ulcer documented in their chart (odds ratio (OR) 8.18, 95% confidence intervals (CI) 3.64–18.36); to be referred to an occupational therapist OR 0.92 (95% CI 0.07; 0.54); to receive a pressure relieving device OR 0.31 (95% CI 0.14; 0.69); or a pressure relieving mattress OR 0.44 (95% CI 0.20; 0.96). Participants with Stage 2 or unstageable ulcers were more likely than others to have dressings applied to their wounds (p = < 0.001) and to be referred to an occupational therapist for protective devices (p = 0.022). Conclusion: Participants in the intervention group of a clinical trial were more likely to receive additional post trial care and improved documentation compared with those in the control group but documentation of pressure ulcer status and care is poor.

OBJECTIVE: To evaluate the cost-effectiveness of nutritional support compared with standard care in preventing pressure ulcers (PrUs) in high-risk hospitalized patients. DESIGN: An economic model using data from a systematic literature review. A meta-analysis of randomized controlled trials on the efficacy of nutritional support in reducing the incidence of PrUs was conducted. PATIENTS: Modeled cohort of hospitalized patients at high risk of developing PrUs and malnutrition simulated during their hospital stay and up to 1 year. INTERVENTIONS: Standard care included PrU prevention strategies, such as redistribution surfaces, repositioning, and skin protection strategies, along with standard hospital diet. In addition to the standard care, the intervention group received nutritional support comprising patient education, nutrition goal setting, and the consumption of high-protein supplements. MAIN OUTCOMES MEASURES: The analysis was from a healthcare payer perspective. Key outcomes of the model included the average costs and quality-adjusted life years. Model results were tested in univariate sensitivity analyses, and decision uncertainty was characterized using a probabilistic sensitivity analysis. MAIN RESULTS: Compared with standard care, nutritional support was cost saving at AU $425 per patient and marginally more effective with an average 0.005 quality-adjusted life years gained. The probability of nutritional support being cost-effective was 87%. CONCLUSIONS: Nutritional support to prevent PrUs in high-risk hospitalized patients is cost-effective with substantial cost savings predicted. Hospitals should implement the recommendations from the current PrU practice guidelines and offer nutritional support to high-risk patients.

Background Pressure injuries are a significant clinical and economic issue, affecting both patients and the health care system. Many pressure injuries in hospitals are facility acquired, and are largely preventable. Despite growing evidence and directives for pressure injury prevention, implementation of preventative strategies is suboptimal, and pressure injuries remain a serious problem in hospitals. Objectives This study will test the effectiveness and cost-effectiveness of a patient-centred pressure injury prevention care bundle on the development of hospital acquired pressure injury in at-risk patients. Design This is a multi-site, parallel group cluster randomised trial. The hospital is the unit of randomisation. Methods Adult medical and surgical patients admitted to the study wards of eight hospitals who are (a) deemed to be at risk of pressure injury (i.e. have reduced mobility), (b) expected to stay in hospital for ≥48h, (c) admitted to hospital in the past 36h; and (d) able to provide informed consent will be eligible to participate. Consenting patients will receive either the pressure injury prevention care bundle or standard care. The care bundle contains three main messages: (1) keep moving; (2) look after your skin; and (3) eat a healthy diet. Nurses will receive education about the intervention. Patients will exit the study upon development of a pressure injury, hospital discharge or 28 days, whichever comes first; transfer to another hospital or transfer to critical care and mechanically ventilated. The primary outcome is incidence of hospital acquired pressure injury. Secondary outcomes are pressure injury stage, patient participation in care and health care costs. A health economic sub-study and a process evaluation will be undertaken alongside the trial. Data will be analysed at the cluster (hospital) and patient level. Estimates of hospital acquired pressure injury incidence in each group, group differences and 95% confidence interval and p values will be reported. Discussion To our knowledge, this is the first trial of an intervention to incorporate a number of pressure injury prevention strategies into a care bundle focusing on patient participation and nurse–patient partnership. The results of this study will provide important information on the effectiveness and cost-effectiveness of this intervention in preventing pressure injuries in at-risk patients. If the results confirm the utility of the developed care bundle, it could have a significant impact on clinical practice worldwide. Trial registration This trial is registered with the Australian New Zealand Clinical Trials Registry, ACTRN12613001343796.

The current study explored the impact of global landmarks, landmarks that are visible from a distance, and local landmarks, ones that are only visible from a short distance. Participants searched for targets in a virtual cityscape including either global or local landmarks. Way-finding performance was measured in addition to spatial memory using sketch maps. The findings indicate precedence of global landmarks during way-finding; however the impact of local landmarks increased with experience. Map sketches indicated that the impact of global and local landmarks was dependent on their location within and around the virtual environment. Theoretically, the findings help distinguish between the visibility and location aspects of global and local landmarks. Practically, the findings can inform the design of virtual environments with consideration to user tasks and requirements.

Current interactive systems are criticized for having complex interfaces that overload users with information. Two possible solutions to manage overload are automatic interfaces that augment user capabilities, and user-controlled systems that provide support. These two types of interfaces introduce a trade-off: On the one hand, automatic interfaces alleviate workload but create performance problems associated with the absence of control. On the other hand, user-controlled interfaces afford users more control, which may come with additional workload. Based on the analysis of adaptive user interfaces and automation, a model is proposed where automatic and user interface adaptation are in a multidimensional and continuum-based space, allowing for modelling dynamic changes to the roles the human and machine play at various stages of interaction.

One of the more remarkable feats of the human visual system is the apparent stability of the objects and events in the world. Regardless of the source of motion, objects within the visual field cohere and maintain their identity, despite the confusing and constant smear of spatial and temporal ambiguity that crisscrosses the retina, much akin to a small toddler playing with a camcorder. This derived stability is certainly valuable in interpreting the ever-changing landscape of dynamic visual events in the environment. Any highly mobile diurnal animal likely shares this same need. Perceiving and recognizing the actions of organized perceptual “objects,” such as predators, conspecifics, or obstacles, seems critical to interacting appropriately with the world, at least at the spatial scale occupied by animals like birds and mammals. With the added dimension of flight, birds may be especially adept at processing motion and using it to build object-based perceptual representations of the world. Because of the past and vast concentration on studying the visual processing of static images in nonhuman animals, how they perceive, process, and interpret the continuous stream of information that truly constitutes reality is a still poorly described and understood phenomenon. The experiments in this article contribute to correcting this oversight by looking at how pigeons process different types of object-based motion. Recent advances in video and computer animation technology have started to close this empirical and theoretical gap in the analysis of dynamic stimuli, as both psychologists and biologists increasingly use these powerful techniques to examine how animals perceive and react to extended sequences of images that can recreate the temporal and spatial properties of the real world (Cavoto & Cook, 2006; Dittrich & Lea, 2001). Three general approaches have been used. The first approach has used videos of actual behavior as playback stimuli to examine their capacity to

Objective The aim of the present study was to describe the research activities being undertaken by health service employees within one Australian health service and explore their experiences with undertaking research. Methods The present mixed-methods study was conducted across one health service in Queensland, Australia, and included a cross-sectional online survey and interviews with healthcare service employees. The anonymous survey was a self-administered online questionnaire, distributed to all 6121 employees at the health service via email, asking about research activity and engagement. Willing participants were also interviewed on their perceptions and experiences with research and capacity building. Results In all, 151 participants responded to the survey and 22 participated in interviews. Three-quarters of respondents reported actively participating in research over the past 6 years and several research outputs, such as publications, conference presentations and competitive grant funding, were displayed. Four concepts emerged from interview findings, namely collaborative partnerships, skilled mentorship, embedding research and organisational support, which represented the overall theme ‘opportunities for a research-infused health service’. Conclusion Employees of the health service recognised the importance of research and had a range of research skills, knowledge and experience. They also identified several opportunities for building research capacity in this service. What is known about the topic? Building research capacity among healthcare professionals is important for enabling the conduct of high-quality research in healthcare institutions. However, building research capacity is complex and influenced by the uniqueness of organisational context. In order to successfully build research capacity among employees at any health service, current research activity, skills and experience, as well as staff perceptions around building research capacity in that setting, should first be explored. What does this paper add? Healthcare services should incorporate teaching and research with clinical care to optimise outcomes for consumers. Support for research can be diminished in favour of clinical care and reduced emphasis on the importance of research can negatively influence research activity and expansion of clinician-led research. Highlighting the perceptions and experience of clinicians with enabling research and capacity building is a context-specific but necessary process to ensure that strategies, processes and resources are targeted to maintain support for research activity while overcoming barriers. What are the implications for practitioners? Participants in this study identified several ways to build research capacity in their health service, many of which may be applicable to other settings and contexts. Building research collaborations and academic partnerships are important to enable and drive research. Structural processes, such as organisational support and opportunities for skilled mentorship, may be necessary to build health service employees’ research knowledge, skills and confidence. Finally, embedding research into everyday practice is important to foster a positive research culture within health services.

Aim Existing practice strategies for actively involving patients in care during hospitalisation are poorly understood. The aim of this study was to explore how healthcare professionals engaged patients in communication associated with care transitions. Method An instrumental, collective case study approach was used to generate empirical data about patient transitions in care. A purposive sample of key stakeholders representing (i) patients and their families; (ii) hospital discharge planning team members; and (iii) healthcare professionals was recruited in five Australian health services. Individual and group semi-structured interviews were conducted to elicit detailed explanations of patient engagement in transition planning. Interviews lasted between 30 and 60 minutes and were digitally recorded and transcribed verbatim. Data collection and analysis were conducted simultaneously and continued until saturation was achieved. Thematic analysis was undertaken. Results Five themes emerged as follows: (i) organisational commitment to patient engagement; (ii) the influence of hierarchical culture and professional norms on patient engagement; (iii) condoning individual healthcare professionals' orientations and actions; (iv) understanding and negotiating patient preferences; and (v) enacting information sharing and communication strategies. Most themes illustrated how patient engagement was enabled; however, barriers also existed. Conclusion Our findings show that strong organisational and professional commitment to patient-centred care throughout the organisation was a consistent feature of health services that actively engaged patients in clinical communication. Understanding patients' needs and preferences and having both formal and informal strategies to engage patients in clinical communication were important in how this involvement occurred.

Pressure ulcers are a major cause of mortality, morbidity, and increased healthcare cost. Nutritional support may reduce the incidence of pressure ulcers in hospitalised patients who are at risk of pressure ulcer and malnutrition. To evaluate the cost-effectiveness of nutritional support in preventing pressure ulcers in high-risk hospitalised patients, and to assess the value of further research to inform the decision to implement this intervention using value of information analysis (VOI). The analysis was from the perspective of Queensland Health, Australia using a decision model with evidence derived from a systematic review and meta-analysis. Resources were valued using 2014 prices and the time horizon of the analysis was one year. Monte Carlo simulation was used to estimate net monetary benefits (NB) and to calculate VOI measures. Compared with standard hospital diet, nutritional support was cost saving at AU$425 per patient, and more effective with an average 0.005 quality-adjusted life years (QALY) gained. At a willingness-to-pay of AU$50,000 per QALY, the incremental NB was AU$675 per patient, with a probability of 87 % that nutritional support is cost-effective. The expected value of perfect information was AU$5 million and the expected value of perfect parameter information was highest for the relative risk of developing a pressure ulcer at AU$2.5 million. For a future trial investigating the relative effectiveness of the interventions, the expected net benefit of research would be maximised at AU$100,000 with 1,200 patients in each arm if nutritional support was perfectly implemented. The opportunity cost of withholding the decision to implement the intervention until the results of the future study are available would be AU$14 million. Nutritional support is cost-effective in preventing pressure ulcers in high-risk hospitalised patients compared with standard diet. Future research to reduce decision uncertainty is worthwhile; however, given the opportunity losses associated with delaying the implementation, “implement and research” is the approach recommended for this intervention.

Aim Nutrition is important for pressure ulcer prevention. This randomised control pilot study assessed the feasibility of conducting a larger trial to test the effectiveness of a patient-centred intervention for improving the dietary intakes of patients at risk of pressure ulcer in hospital. Methods A 3-day intervention targeting patients at risk of pressure ulcer was developed, based on three main foundations: patient education, patient participation and guided goal setting. The intervention was piloted in three wards in a metropolitan hospital in Queensland, Australia. Participants were randomised into control or intervention groups and had their oral intakes monitored. A subset of intervention patients was interviewed on their perceptions of the intervention. Feasibility was tested against three criteria: ≥75% recruitment; ≥80% retention; and ≥80% intervention fidelity. Secondary outcomes related to effects on energy and protein intakes. Results Eighty patients participated in the study and 66 were included in final analysis. The recruitment rate was 82%, retention rate was 88%, and 100% of intervention patients received the intervention. Patients viewed the intervention as motivating and met significantly more of their estimated energy and protein requirements over time. Conclusion This pilot study indicates that the intervention is feasible and acceptable by patients at risk of pressure ulcer. A larger trial is needed to confirm the effectiveness of the intervention in the clinical setting.