Construction And Application Of Perioperative Nutrition Support Management Program In Patients Undergoing Pancreaticoduodenectomy

ObjectiveThis study aimed at building a management scheme of pancreaticoduodenal resection(PD)patients with perioperative nutritional support and verifing the clinical application effect,in order to promote the transformation of evidence,improve the quality and promote patients postoperative rehabilitation.Specific purposes include:(1)evaluate,comprehensive evidence-based evidence of perioperative nutritional support in PD patients and select suitable evidence for clinical practice;(2)describe current situation,analysis what the stakeholder groups(doctors,nurses,dieticians,managers)perceive barriers and promote evidence-based practice factors,and the patient experience of perioperative nutrition support and demand;(3)construct management plan of perioperative nutritional support in PD patients;(4)evaluate the clinical application effect of the scheme.MethodBased on KTA(Knowledge to Action)model,evidence on PD patients perioperative nutritional support was appraised and synthesized by a evaluation of guidelines and systematic review,and by a research on nutritional evaluation tool in PD patients.Through expert meeting,select suitable evidence of clinical practice and establish the standard censorship.In-deep interview and a survy were conducted to explore the current practice and the promote and hinder factors Evidence Based Practice.Through expert meeting,build the perioperative nutrition support management plan,ane through before and after control test in medical care personnel and non-parallel control study in PD patients to obtain the effect.Result1.Through evidence searching,bring into 5 guidelines.Through the study of preoperative nutritional assessment tools used in 100 PD patients,NRS2002,PG-SGA,NRI,PNI,BMI,NRS2002 and PG-SGA are related to postoperative outcomes and nutritional laboratory indexes and have medium forecast of postoperative complications,PD patients can select NRS2002 preferentially,combining PG-SGA.Through the above research,obtain the best evidence of perioperative nutritional support of PD patients.2.Evidence about the feasibility and suitability,clinical significance and effectiveness,through expert meetings,PD patients perioperative nutritional support best evidence,including preoperative nutritional evaluation and preoperative nutritional support,choice of postoperative nutritional support,supplements,nutrition management mode of five modules,a total of 9 evidence,and formulate 7 practice examination article.3.There is a big gap between clinical practice and best evidence in perioperative nutritional support in Pilot wards,which is influenced by many factors.3.1 The status of the evidence-based practice in Pilot wards:poor auditing standards implementation,lack of nutrition management system and process.3.2Through interviewing 15 medical staff,the obstacles of evidence-based practice include the evidence,application process,organization and management factors,patients,doctors,and the promoting factors include nutrition training,establishing a multidisciplinary nutrition support team,nutrient management system,and the support of the leadership.3.3 Through 10 PD patients qualitative research,these patients experience diet pressure and pain of tube feeding,and the feeble hospital nutrition support system and incomplete nutrition education may increase the negative experience.4.Through expert meeting,the management solution of perioperative nutritional support of PD patients was build,including perioperative nutritional support specification,perioperative nutrition support process nutrition support team,nutritional support auxiliary text and energy calculation software.Taking the plan step by stages,the evidence gradually will be introduced into clinical practice.5.Implement the scheme and effect assessment5.1 Implement the scheme: the plan was launched in September 2016,through three stages,namely the training phase,project commissioning stage,project application stage.5.2 Effect assessment5.2.1 Through before-and-after controlled trial in pilot ward,during the period of five months of intervention,the implementation rate of audit criteria by staff was significantly higher than the control group rate before the intervention(P<0.05).5.2.2 Through non-parallel controlled trial,the postoperative days and total hospitalization days were shorter compared with control group.The incidence of complications were reduced,as well as the weight drop-out value and the mean of daily medicine-cost(P<0.05).The total bilirubin value of postoperative 1 days was lower compared with control group,difference have statistical significance(P<0.05).The total protein,albumin values and prealbumin of postoperative 1,3,7 days in the two groups were with no statistical significance(P>0.05).5.2.3 The experience of Medical staff in the process of plan implementation was doubt and expecting,refusing and initiative,reflection and of innovation.The supervise,incentives,constraints and strengthen can improve medical staff to adherence to plan and inspire their creativity.Conclusion1.This study summarizes the best evidence of perioperative nutritional support in PD patients,including nutritional tools NRS2002 and PG-SGA,preoperative nutritional support,postoperative nutritional support,supplements and nutrition management model,which provide a reference for PD patients.2.KTA model was used in perioperative nutritional support of PD patients,which can effectively promote the transformation of the evidence,shorten the gap between the evidence and the practice.3.The perioperative nutritional support management scheme of PD patients is established on the basis of evidence-based,considering with clinical situation and patients' demand.