Implementation of the Canadian Clinical Practice Guidelines for Nutrition Support: A Multiple Case Study of Barriers and Enablers

Abstract

Background: The Canadian Nutrition Support Clinical Practice Guidelines (CPGs), published in 2003, were designed to improve nutrition support practices in intensivecare units (ICUs). However, their impact to date has been modest. This study aimed to identify important barriers and enablers to implementation of these guidelines. Methods: Case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each site. During the interviews, the key informants were asked about their perceptions of the barriers and enablers to implementation of the Canadian Nutrition Support CPGs. Interview transcripts were analyzed qualitatively, using a framework approach. Results: Resistance to change, lack of awareness, lack of critical care experience, clinical condition of the patient, resource constraints, a slow administrative process, workload, numerous guidelines, complex recommendations, paucity of evidence, and outdated guidelines were cited as the main barriers to guideline implementation. Agreement of the ICU team, easy access to the guidelines, ease of application, incorporation into daily routine, education and training, the dietitian as an opinion leader, and open discussion were identified as the primary enabling factors. Although consistent across all sites, the influence of these factors seemed to differ by site and profession. Conclusions: Our findings suggest that implementation of the Canadian Nutrition Support CPGs is profoundly complex and is determined by practitioner, patient, institutional, and guideline factors. Further research is required to quantify the impact of each barrier and enabler and the mechanism by which they influence guideline adherence.

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References

Heyland DK, Schtoter-Noppe D, Drover JW. Nutrition support in the critical care setting: current practice in Canadian ICUs–opportunities for improvement. JPEN J Parenter Enteral Nutr. 2003 ;27:74– 83.

Rice TW, Swope T, Bozeman S, Wheeler AP. Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition. 2005 ;21:786– 792.

Institute of Medicine. Clinical Practice Guidelines: Directions for a New Program. Washington, DC: National Academy Press; 1990.

Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27:355– 373.

Thomson R, Lavender M, Madhok R. How to ensure that guidelines are effective. BMJ. 1995 ;311:237– 242.

Jain M, Heyland DK, Dhaliwal R, et al. Dissemination of the Canadian clinical practice guidelines for nutrition support: results of a cluster randomized trial. Crit Care Med. 2006 ;34:2362– 2399.

Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458– 1465.

Yin RK. Case Study Research: Design and Methods. 3rd ed. Thousand Oaks, CA: Sage Publications;2003 .

Krueger RA. Developing Questions for Focus Groups. Thousand Oaks, CA: Sage Publications Inc;1998 .

10.

McDonnell A, Jones ML, Read S. Practical considerations in case study research: the relationship between methodology and process. J Adv Nurs. 2000;32:383– 390.

11.

Pope C, Ziebland S, Mays N. Analysing qualitative data. BMJ. 2000;320:114– 116.

12.

Slomka J, Hoffman-Hogg L, Mion LC, Bair N, Bobek MB, Arroliga AC. Influence of clinicians' values and perceptions on use of clinical practice guidelines for sedation and neuromuscular blockade in patients receiving mechanical ventilation. Am J Crit Care. 2000 ;9:412– 418.

13.

Ricart M, Lorente C, Diaz E, Kollef MH, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med. 2003 ;31:2693– 2696.

14.

Jones N, Dhaliwal R, Day AG, Ouellette-Kuntz H, Heyland DK. Factors predicting adherence to the Canadian clinical practice guidelines for nutrition support in mechanically ventilated critically-ill adult patients [abstract]. Appl Physiol Nutr Metab. 2006 ;31:328 .

15.

Halm EA, Lee C, Chassin MR. Is volume related to outcome in health care? A systematic review and methodological critique of the literature. Ann Intern Med. 2002 ;137:511– 520.

16.

Kahn JM, Goss CH, Heagerty PJ, Kramer AA, O'Brien CR, Rubenfeld GD. Hospital volume and the outcomes of mechanical ventilation. N Engl J Med. 2006;355:41– 50.

17.

Glance LG, Li Y, Osler TM, Dick A, Mukamel DB. Impact of patient volume on the mortality rate of adult intensive care unit patients. Crit Care Med. 2006 ;34:1925– 1934.

18.

Davies HTO, Nutley SM, Mannion R. Organisational culture and quality of health care. Qual Health Care. 2000 ;9:111– 119.

19.

Shortell SM, Zimmerman JE, Rousseau DM, et al. The performance of intensive care units: does good management make a difference? Med Care. 1994;32:508– 525.

20.

Zimmerman JE, Shortell SM, Rousseau DM, et al. Improving intensive care: observations based on organizational case studies in nine intensive care units: a prospective, multicenter study. Crit Care Med. 1993;21:1443– 1451.

21.

Fox MY. Toward a zero VAP rate: personal and team approaches in the ICU. Crit Care Nurs. 2006 ;29:108– 114.

22.

Clemmer TP, Spuhler VJ, Oniki TA, Horn SD. Results of a collaborative quality improvement program on outcomes and costs in a tertiary critical care unit. Crit Care Clin. 1999 ;27:1768– 1774.