Kami Benoit offers dietitians encouragement and motivation in overcoming clinical guideline hurdles.

By A.S.P.E.N. member Kami Benoit, MS, RD, CNSC, LD

Being inundated with nutrition headlines is nothing new for most of us: from emails, to tweets, to news bites, we hear it nonstop. As nutrition professionals, we have developed a “sixth sense”, if you will, of how to accept, pursue, or disregard the constant headlines. Entering into the daily realm of bedside practice we continue to hear it again in the steady undertone of clinical speak: “practice guidelines, standards of care, evidence-based practice”. We read it, understand it, believe in it, and are ready to implement all guidelines for our patients with gusto! And patient after patient, we hit obstacles and road blocks as we try to “follow the rules”.

As clinical dietitians, rest assured, we are not alone. Healthcare practitioners across the globe are studying strategies to make guideline use more practical. There is an actual “implementation science” dedicated to studying optimal ways to develop, disseminate, and execute clinical practice guidelines.¹  Specific to nutrition, multicenter observational studies have shown wide variations between guidelines and actual practice.²,³  The variance between how clinical practice guidelines state we should provide nutrition support versus how we actually provide support continues to be studied. More recent strategies are evaluating whether implementation should be individualized or tailored rather than a standard one-size-fits-all approach.⁴  Specific to the critical care arena, tools and questionnaires have been developed to help us identify when, why, and how we can tackle site-specific barriers to the provision of nutrition support.⁵

That being said, the purpose of this post is not to give dietitians a magic wand to wave that will make our implementation of guidelines flawless. The intricate web of factors playing into optimal clinical practice guideline implementation is being vigorously and scientifically studied. Instead, this is an opportunity to offer encouragement and motivation to dietitians enduring the day-to-day struggles and to provide suggestions of how we may overcome our obstacles and hurdles one at a time while the larger clinical practice guideline picture unfolds.

Solidify Our Foundation

I think the first thing we can do is commit ourselves to thoroughly understanding the guidelines. How many times have we referred to the guidelines or found ourselves saying “well, the practice guidelines state…” but then stumbled for answers when questioned more specifically about the actual studies upon which the guidelines were based? Familiarizing ourselves with the trials and being able to refer others to them creates confidence for both ourselves and our inquisitors. Refreshing ourselves helps solidify our expertise when we do make these recommendations. We can go back to the basics and ask ourselves these things:

• What is the overall strength of the recommendation?
• How were these recommendations derived?
• What studies were included?
• How closely does our patient population resemble the study subjects?
• What recent studies have been published to dispute or support these guidelines?

As we gain a better understanding of the guidelines, do we enhance our clinical judgment skills? Do we add yet another tool to our skill set of physical assessment, lab interpretation, years of experience, etc.? I believe we should. And in doing so, we can position ourselves to make positive progress.

Display the Data

Another component of guideline implementation that can seem overwhelming is participation in quality improvement measures. We may ask ourselves, “Why bother collecting the data?” Don’t we already know that we have room for improvement? We may think that team members are tired of hearing us nearly beg to start nutrition support. Surely they understand that we can adhere to guidelines more closely. So why do we need to bog ourselves down with quality initiatives?

Photo by Frits Ahlefeldt-Laurvig via Flickr Creative Commons.

As dietitians, this is where we have an opportunity to step up and tackle the data. When we collect it and willingly share it, we quantitatively display our strengths and weaknesses to other practitioners. Although we may think the healthcare team already knows this information, the numbers will descriptively highlight our adherence to clinical practice guidelines. The nice reality is that many of us are already routinely collecting some form of quality data.

So, for some institutions, “displaying our data” may begin on a small scale, as something we are already recording. Perhaps it is a weekly audit that is performed and reported to a quality committee. Or maybe we have moved on to something more large scale, such as an IRB–approved retrospective or observational study. The bottom line is that we are in pursuit of data, regardless of how grand our efforts seem. Then, as suggested elsewhere,³ we can determine which area of improvement is most modifiable. Is it a culture of practice that will take time to shape and reform, or is it a simple misunderstanding by staff that requires an easy manipulation? For example, does Surgeon X always prescribe PN post-op despite multiple discussions? Or is the night shift unfamiliar with the EN protocol regarding hold times for elevated gastric residual volumes?

Over time, ongoing studies will show us if prioritizing our specific deficits and treating those most malleable will be the optimal way to approach guideline implementation. In the meantime, we can embrace the idea that tackling our deficits in small steps may help us gain momentum. It is motivation, if you will, to continue ongoing evaluation and assessment efforts without feeling overwhelmed.

Take Ownership

Data collected during quality improvement initiatives can be quite revealing. Did we, on average, start enteral feeds 72 hours after mechanical ventilation? Or did we surprise ourselves and use PN more appropriately than we thought? Whether it is a strong performance or an area that needs improvement, we can now share the numbers to those throughout the treatment team. As most of us understand, providing actual numbers can give us more legitimacy than just our opinion. And because the results are collected by us and fall within the nutrition arena, I challenge that we accept them as our own and use that information to better own our own decisions. We should take a step back and ask ourselves if we are playing the blame game.

Do we find ourselves saying or hearing the following? “Administration says…” Or, “if only we had a tube team we could…” Or, “that physician will never let us advance feeds.” If so, then we may have a case of the blame game going around.

Can redirecting how we approach our deficits point us in a positive direction? These are nutrition provision deficits, so let’s solidify our knowledge base, use our collected data, and set out to overcome our hurdles one at a time, while trying to avoid pointing fingers. Perhaps we will find that we have again positioned ourselves and ideally others on the treatment team to stay motivated by the clinical practice guidelines.

Call on Our Allies

Overcoming our hurdles of clinical practice guideline implementation will require the help of others. I like to think of this as aligning with our allies. Does elicited support from others keep up our momentum to rise above obstacles? Does a team of allies create a sense of accountability that drives us to find more opportunities to spread the word about our clinical practice guideline implementation strategies? We can consider the following steps:

• Identify specific team members who show interest in nutrition support and those who seek our input:
  • Nurses
  • Mid-level practitioners
  • Physicians
  • Pharmacists

• Use these allies when we seize opportunities to spread the word:
  • Suggest or submit nutrition articles for review at interdisciplinary journal clubs.
  • Create a nutrition lunch and learn.
  • Review story boards with evening shift workers (RNs, CNPs, residents, etc.)
  • Offer to speak to nurses during unit orientation.
  • Do not shy away from speaking up at interdisciplinary conferences.
  • Ask to join daily rounds (even if only 1-2 times per week.)

I believe that as we gain rapport with our treatment team members, we also gain exciting momentum that propels us to tackle the next obstacle. We have support as we collectively strategize how to better adhere to clinical practice guidelines and improve our quality metrics.

It is clear that clinical practice guideline implementation is an ongoing international effort being studied in multiple facets of healthcare. Will the best way to implement clinical practice guidelines ever be revealed? Certainly time will tell. But in the meantime, as we work on the “front lines” of patient care, we can find ourselves using the clinical practice guidelines as they were intended. Hopefully we can stay abreast of the research and tools being offered to help our clinical practice guideline implementation process. And hopefully, beyond dwindling adherence deficits and improved quality metrics, we will see what we set forth to accomplish each day: better patient outcomes.

References

1.  http://www.fic.nih.gov

2. Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK. Nutrition therapy in the critical care setting: What is “best achievable” practice? An international multicenter observational study. Crit Care Med. 2010;38(2):395-401.

3. Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:1-72.

4. Cahill NE, Murch L, Cook D, Heyland DK. Improving the provision of enteral nutrition in the intensive care unit: A description of a multifaceted intervention tailored to overcome local barriers. Nutr Clin Pract. 2014;29(1):110-117.

5. King J, Dhaliwal R, Heyland DK. The Right Approach to Nutrition Care in ICU Pamphlet. http://www.criticalcarenutrition.com

 The views expressed in this post are those of the author, and do not necessarily reflect the views of A.S.P.E.N.