Implementing Guidelines in the ICU

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By: Lisa Moloney MS RD LDN

Dietitians are faced with the daunting challenge of keeping up with constant influx of new information and research in nutrition and dietetics. This is certainly no exception for clinical dietitians. It is essential for clinical dietitians to provide evidence based practice in the critical care setting to provide the best possible patient care. According to the BMJ, “evidenced based practice is conscientious, explicit and judicious use of current best evidence in making decision about the care of individual patients”.   

As clinical dietitians we know that we should be using evidence-based practice, and fortunately there are clinical practice guidelines (CPGs) to guide us in our decision making regarding nutrition support. Implementation of CPGs in theory should provide uniformity in nutrition practices across Intensive Care Units (ICUs). However, despite the availability of CPGs, nutrition practice varies among ICUs. Unfortunately, CPGs do not provide guidance on how to actually implement the practices in the critical care setting. Beyond implementing guidelines, actually achieving adherence to guidelines is beyond complex due to various factors. The November 2010 issue of JPEN focused on the multiple issues surrounding clinical practice guidelines. Cahill etal developed a five part framework for adherence to clinical practice guidelines in the ICU based on multiple case studies.

#1 Guideline Characteristics. One difficulty in implementing CPGs is the variation of recommendations among different sets of CPGs, so which set do you follow? The sets include the American Society for Parenteral and Enteral Nutrition, European Society for Clinical Nutrition and Metabolism and the Australasian Society for Parenteral and Enteral Nutrition. Recommendations supported by high grade evidence are consistent among each set of CPGs. Guidelines that are clear statements, supported by high-level evidence have increased rates of adherence. So bottom line – start with guidelines that are clear, easy to understand, and backed by reputable research.

#2 Implementation Process. Ideally the best way to implement new practices in the ICU would be to first begin with educational sessions for care givers in the ICU. As we know this is much easier said than done, time constraints are always an issue. Per Cahill and colleagues, using multiple education strategies tailored to the specific needs of the ICU may increase adherence to guidelines. Some of these strategies may include incorporating guidelines into routine practice, such as checklists or daily rounds. Another strategy may be to meet one-on-one with key leaders to present the rationale and supporting evidence for the guidelines.

#3 Institutional Factors. Hospital and ICU structure, hospital processes, resources and the ICU culture all have an impact on adherence to guidelines. It is key to identify enablers as well as barriers in your institution. Studies have found that specific aspects of ICU culture such as interdisciplinary collaboration, effective communication, and leadership support can improve quality of care. Cahill etal suggest that manipulating these aspects may be one strategy for improving guideline adherence.

#4 Provider Intent. Six factors that affect health care provider’s intention to adhere to guidelines were identified. The factors are familiarity, awareness, outcome expectancy, self-efficacy, motivation and agreement. These factors were the same for all professions; however the degree of influence of each factor did vary.

#5 Patient Characteristics. Across the ICU sites studied, the characteristics of the individual patients were the main barrier to adherence. Guideline adherence was found more difficult in patients with a poor prognosis or if there were other more urgent priorities of care.

Cahill etal found that in order to achieve guideline adherence, focus should not only be on individual behavior but also interactions amongst the care giver, surroundings and the patient. This five part framework can assist health care providers in identifying enablers as well as barriers in their facility. Addressing these factors can then help implement and improve adherence to CPGs in the ICU, resulting in improved patient care.

1. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996; 312:71-72.) Managing constant new information.

2. Cahill NE, Suurdt J, Ouellette-Kuntz HO, Heyland DK. Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework. JPEN J Parenter Enenteral Nutr. 2010;34:616-623.