Best nutrition practice across the stroke care continuum: Using PEN

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Best nutrition practice across the stroke care
continuum Using PEN other evidence-based
information sources

• E Eppler, Vancouver, British Columbia

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Introduction/Background
Best practices are recommendations that are
supported by research evidence and informed by
expert perspective, judgment and experience. Best
practices produce effective health outcomes.
Stroke Care Best Practices describe the most
effective policies, processes and interventions
for stroke prevention, treatment and
rehabilitation (1, 2). This poster describes a
dietitian's experiences using the evidence-based
practice cycle to determine best nutrition
practice across the continuum of stroke care.
Figures 1 2, below, depict the evidence-based
practice cycle and best practice, respectively.
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Figure 1. Evidence-Based Practice Cycle
Assess
Ask
Apply
Appraise
Acquire
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Figure 2 Best Practice
Define
Implement
Disseminate
Research generates evidence used in developing
best practice

• Standards
• Guidelines
• Protocols
• Education
• Care Paths

Best Practice Resources Connect research and
practice


Expert judgment is used in conducting systematic
reviews and applying the evidence-based practice
cycle.
The dietitian applies and adapts resources to the
specific context e.g. Acute neurosciences unit,
rehab facility.
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Process Results

• The evidence-based practice cycle (EBPC) was
  applied to determine best nutrition practice
  across the continuum of stroke care. The Canadian
  Stroke Strategy (CSS) identifies these phases of
  the continuum
• Primary Prevention
• Pre-hospital/Hyper-acute
• Acute/In-hospital
• Stroke Rehabilitation,
• Secondary Prevention
• Community Care/Re-engagement
• In the asking and acquiring steps of the EBPC,
  Dietitians of Canadas Practice-Based Evidence in
  Nutrition (PEN) tool (3) was the first resource
  consulted. The results of several basic and
  advanced searches are listed in Table 1. Figures
  3, 4 5 depict PENs method of organizing and
  presenting information.

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Table 1. Selected results of PEN searches using
stroke and related terms.
Search terms Results () Sample full knowledge pathways, practice questions, and tools resources
cardiovascular disease 121 What dietary and lifestyle modifications are recommended to manage specific dyslipidemias? Cardiovascular Disease Practice Guidance Summary Cardiovascular Disease Evidence Summary
stroke 24 CSS Canadian Best Practice Recommendations for Stroke Care 2006
hypertension 76 Hypertension Evidence Summary Hypertension Current Issues Backgrounder
stroke AND hypertension 5 Does an adult with hypertension, who adheres to healthy lifestyle practices (other than dietary), have better blood pressure control and therefore a lower risk or delayed incidence of CVD complications, ischemic heart disease and stroke? Are individuals with poorly or uncontrolled blood pressure at higher risk of developing other cardiovascular disease complications?
dyslipidemia 11 Dyslipidemia Evidence Summary
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Figure 3. A PEN Knowledge Pathway is the route
to information
Practice Guidance Summary
Background
Practice Questions
Evidence Summary
Tools resources
Key Practice Points
Evidence
References
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Figure 4. Sample PEN results for search term
cardiovascular disease
1) Achieve and maintain a BMI lt 25 2) ?
exercise3) ? fruit and vegetable intake 4)
Restrict simple CHO5) Fat intake ? proportion
of MUF and PUF ? proportion of SF and trans
fats to lt7 of total kcal ? intake of
omega-3 FA from fish and plant sources.
Practice Guidance Summary
Ask
Practice Question What nutrition strategies can
prevent cardiovascular disease (CVD)?

• Evidence Summaries
• CVD
• Dyslipidemia
• CVD Natural Health Products

BackgroundOmega-3 fatty acids, fish oil,
alpha-linolenic acid This document provides a
grading of evidence for the effects of omega-3
fatty acids, fish oil, alpha-linolenic acid for a
variety of conditions (e.g.stroke.).
Key Practice Point Achieving and maintaining a
healthy Body Mass Index (18.5-24.9), appropriate
waist circumference (88 cm F 102 m M) and
waist-to-hip ratio (0.85 F 0.90 M) can prevent
CVD.

• Tools resources
• Current Issues The Health Benefits of Soy
• Heart Healthy recipes
• Heart and Stroke Foundation

Evidence
Apply
References
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Figure 5. Sample PEN results for search terms
stroke AND hypertension
1) Follow DASH Diet Guidelines2) ? sodium intake
to 2400 mg (100 mmol) per day 3) ? fibre intake
to 25 to 30 grams per day especially foods rich
in soluble fibre 4) A diet rich in potassium,
calcium and magnesium is encouraged 5) there is
currently insufficient evidence to promote folic
acid supplementation 6) Maintain a healthy BMI
and waist circumference 7)? alcohol consumption
to a maximum 2 drinks per day
Practice Guidance Summary excerpts from
Prevention of Hypertension
Practice Question Does an adult with
hypertension, who adheres to healthy lifestyle
practices have better blood pressure control
and therefore a lower risk or delayed incidence
of stroke?
Ask
Evidence Summary A summary of the graded
evidence supporting the prevention and treatment
of hypertension.
Background Information on hypertension, including
causes, diagnosis, and management
Key Practice Point Lifestyle modifications can
reduce the use and hence cost of antihypertensive
medications and should be continued in
conjunction with drug therapy. (A)

• Tools resources
• 2007 Hypertension Public Recommendations
• Facts About the DASH Eating Plan
• Low sodium (salt) eating
• Increasing Your Fibre Intake

Evidence
References
Apply
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Process Results (continued)
Next, the CSSs Best Practice document (1) and
several key references listed in the CSSs Best
Practices and Standards Environmental Scan Report
(2) were accessed via the Web and evaluated for
their nutrition content (see Table 2 and Figure
6).
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Table 2. CSS Best Practice Recommendations
Other CSS-Recommended Key Resources
Resource Ref Nutrition elements
Canadian Best Practice Recommendations for Stroke Care 2006 1 Lifestyle modifications including diet dysphagia assessment and management education across the care continuum
Best Practice Guidelines (Ontario) 4 Nutrition standards are in all seven modules based on the continuum of care
Management of patients with stroke Identification and management of dysphagia (SIGN) 5 Assessment and management of dysphagia nutrition screening, assessment and support
National Clinical Guidelines for Acute Stroke Management (Australia) 6 Dysphagia assessment and management
National Clinical Guidelines for Stroke Rehabilitation and Recovery (Australia) 7 Evidence-based guidelines for lifestyle modification for secondary prevention of stroke
Stroke Care Pathway A Resource for Health Professionals (Australia) 8 Interdisciplinary care path that be used with the previous 2 resources.
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Figure 6. Sample content from selected key best
practices documents
Canadian Best Practice Recommendations for Stroke
Care 2006
Management of patients with stroke
Identification and management of dysphagia (SIGN)
All patients with stroke should have their
swallow screened prior to initiating oral intake
of fluids or food utilizing a simple valid
reliable bedside testing protocol.
Early and regular screenings of patients for
undernutrition is important.
Best Practice Guidelines (Ontario)
Clinical Guidelines for Stroke Rehabilitation
Recovery (Australia)
Determine feeding method based on
swallowing assessment or monitoring. Implement
safe diet texture and therapeutic diet.

Nutrition element from acute care guide, day 2
Section on secondary prevention
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Summary

1. PEN has more than 120 up-to-date resources on
   stroke and cardiovascular disease risk factors
   (e.g., hypertension, dyslipidemia).
2. At present, most of PENs stroke resources apply
   to the prevention stage of the stroke care
   continuum.
3. New Critical Care and Dysphagia Knowledge
   Pathways soon will be added to PEN. They will
   provide information applicable to other stages in
   the continuum (e.g., acute care, rehabilitation).
4. Key resources recommended by the CSS (2)
   supplement PEN by providing nutrition standards
   across the continuum (4), dysphagia management
   guidelines (5), and templates for tools such as
   care paths (8).
5. This survey of PEN and CSS-recommended resources
   is ongoing.

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Next steps
The information gathered from these best practice
resources will be applied to these three current
projects

• Vancouver Acute Clinical/Care Redesign for
  Stroke (CMG 13 14)
• Vancouver Coastal Regional Care Path for Stroke
• Vancouver Coastal Regional Stroke/High Risk TIA
  Emergency Department Orders (section on diet and
  dysphagia screening)/

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Literature cited
1. Best Practices and Standards Working Group,
The Canadian Stroke Strategy. Canadian Best
Practice Recommendations for Stroke Care 2006.
lthttp//www.canadianstrokestrategy.ca/technical_d
ocs.htmgt. Accessed 26 April 2007. 2. Best
Practices and Standards Working Group, The
Canadian Stroke Strategy. Best Practices and
Standards Environmental Scan Report
lthttp//www.canadianstrokestrategy.ca/technical_do
cs.htmgt. Accessed 26 April 2007. 3. Dietitians
of Canadas Practice-Based Evidence in Nutrition
PEN.lthttp//www.dieteticsatwork.com/pen/gt.
Accessed 26 April 2007. 4. Heart and Stroke
Foundation of Ontario, Ontario Stroke System.
Best Practice Guidelines. lthttp//209.5.25.171/Pag
e.asp?PageID122ContentID932CategoryID73gt.
Accessed 26 April 2007. 5. Scottish
Intercollegiate Guidelines Network. Management of
patients with stroke. Identification and
management of dysphagia. September 2004.
lthttp//www.sign.ac.uk/guidelines/published/index
.htmlgt. Accessed 26 April 2007.
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• 6. National Stroke Foundation, Australia.
  National Clinical Guidelines for Acute Stroke
  Management. lthttp//www.strokefoundation.com.au/pa
  ges/article.aspx?id1articleidArticleID200652613
  5335pageId159HandlerId1gt. Accessed 26 April
  2007.
• National Stroke Foundation, Australia. National
  Clinical Guidelines for Stroke Rehabilitation and
  Recovery. lthttp//www.strokefoundation.com.au/page
  s/article.aspx?id1articleidArticleID20065261432
  0pageId159HandlerId1gt. Accessed 26 April
  2007.
• 8. National Stroke Foundation, Australia. Stroke
  Care Pathway A Resource for Health
  Professionals. lthttp//www.strokefoundation.com.au
  /pages/image.aspx?assetIdRDM38992.4311924884gt
  Accessed 26 April 2007.

Acknowledgment
Photo used in Figure 2 Under the bridge by
MissBeckles. Posted on Flickr under a Creative
Commons Attribution-NonCommercial-ShareAlike 2.0
license. lthttp//www.flickr.com/photos/missbeckles
/3375396/gt. Accessed 22 April 2007.