How to Implement Guidelines Best –
The Role of a Multidisciplinary Nutrition Team
Frank Dörje, Ph.D.
Dept. of Pharmacy, Erlangen University Hospital, D-91054 Erlangen, Germany
phone +49-9131-85-33591, fax +49-9131-85-39045, e-mail:frank.doerje@apotheke.imed.uni-erlangen.de
Learning Objectives
 To list the rationales for clinical guidelines as an important part of clinical practice
 To describe different multidisciplinary approaches to provide nutrition support
 To develop the elements of the conceptual framework for implementing clinical practice
guidelines
 To identify professional dissemination and implementation strategies for clinical guidelines
Introduction
Over the past decade, clinical guidelines have increasingly become a familiar part of clinical practice. In the field of nutrition and metabolic support multidisciplinary, professional
and scientific societies like ESPEN and ASPEN as well as organizations, e.g. the American Joint Commission on Accreditation of Healthcare Organizations (JCAHO), have developed clinical practice guidelines and standards to promote quality in nutrition care including specialized nutrition support [1,2].
The diverse professional membership of ESPEN and ASPEN (health care professionals
representing the fields of medicine, nursing, pharmacy and dietetics) emphasizes the basic
importance of nutrition to optimal medical practice and the multidisciplinary team approach
to sound nutrition.
ASPEN defines nutrition care as “intervention and counseling of individuals on appropriate
nutrition intake by integrating information from the nutrition assessment. Nutrition therapy,
a component of medical treatment, includes oral, enteral and parenteral nutrition” [3]. As a
component of patient care, the nutrition care process consists of screening, assessment,
and reassessment, planning, ordering, preparing and distributing or administering, and
monitoring. Clinical algorithms for the use of parenteral and enteral nutrition should be
used as part of the assessment to determine the appropriate route of delivery of nutrition
support [1]
A standard is defined as “the benchmark representing a range of performance of competent care which should be provided to assure safe and efficacious nutrition care (i.e. parenteral or enteral nutrition therapy)” [3]. As defined by the American Institute of Medicine,
clinical guidelines are “systematically developed statements to assist practitioner and
patient decisions about appropriate health care for specific clinical circumstances” [4].
Clinicians, policy makers, and payers see guidelines as a tool for making care more consistent and efficient and for closing the so called “knowledge-performance gap” between
what clinicians do and what scientific evidence supports. Clinical practice guidelines can
improve the quality of clinical decisions. They can support quality improvement activities.
The first step in designing quality assessment tools (standing orders, reminder systems,
algorithms, audits, peer reviews etc.) is to reach agreement on how patients should be
treated. Guidelines are a common point of reference for prospective and retrospective
audits of clinicians’ or hospitals’ practices: the indication for treatments and treatment
goals recommended in guidelines provide ready process measures for rating compliance
with best care practices [5]. However, a fundamental problem is that evidence-based
guidelines as developed by professional societies, e.g. ASPEN may do little to change
practice behavior on a local care level. As guidelines spread in medical practice, there are
important lessons to learn from the firsthand experience of those who develop, implement,
evaluate, and use them [6].
How to Implement Guidelines Best?
Implementation - a Multidisciplinary Task
Organization of nutrition support for hospitalized patients varies across countries and
health care systems. Delivery of nutrition care services requires coordination of work and
collaboration among departments and professional groups. The current emphasis is on
teamwork rather than teams and the recognition that quality nutrition outcomes result from
collaboration. This collaboration may be accomplished by having a specific nutrition support service responsible for providing specialized nutrition support or by multiple discipline
involvement integrated with the patient care team not necessarily existing as a team. If a
nutrition support service is not present, as is the case in most European care settings, it is
important to assure that staff are competent to perform nutrition support functions and a
system is in place to monitor process and outcome indicators that reflect the quality of
patient care being provided [7].
One possibility to achieve the goal of a “multidisciplinary delivery of high quality nutrition
care” is the committee approach. As a subcommittee of the local Pharmacy & Therapeutics Committee the nutrition committee “nutrition team” incorporates members from a variety of departments (e.g. Medicine/Surgery, Dietetics, Nursing, Pharmacy) and establishes
written policies and standards for nutrition care including the provision of parenteral and
enteral nutrition on a local level. One “change concept” approach to improve the nutrition
support on a local level could be the implementation of clinical practice guidelines along
with the standardization of care. Although committee members may not necessarily see
patients, they monitor the adherence to the implemented standards, respectively guidelines. They also give feed back on compliance with the institutions policy to the primary
care team.
The development of good guidelines does not ensure their use in practice. Systematic
reviews of strategies for changing professional behavior show that relatively passive
methods of disseminating and implementing guidelines, e.g. by mailing them to the targeted healthcare professionals – rarely lead to changes in professional performance on a
local level. Therefore, to maximize the likelihood of a clinical guideline being used we need
coherent dissemination and implementation strategies to capitalize on known positive factors and to deal with obstacles of the implementation that have been identified [8].
Conceptual Framework for Implementing Clinical Practice Guidelines
Implementing a guideline is similar to implementing any other new program or system in
an organization. The organization and the people involved will have to change, and many
will resist. Success is difficult, if not impossible, without planning who will do what in which
timeframe, without budgeting resources to carry out the plan, and without active support
for the change and the multidisciplinary implementation team (e.g. the P&T “nutrition subcommittee” as implementation team) by managers and the clinical staff. The introduction
and implementation of guidelines requires knowledge on the theoretical basis of behavior
changes among healthcare professionals and evidence on the effectiveness of different
dissemination and implementation strategies at an organizational level as well as good
interpersonal skills and knowledge on guideline development and appraisal. Specific skills
for monitoring the use of guidelines may also be needed.
There are certain elements needed in a conceptual framework for successful guideline
implementation as stated by Feder et al. and Cretin [8,9]:

Prioritizing Clinical Topics (Create Tension for Change)
Guidelines are hard to implement if the clinicians do not perceive that there is a problem with the current care. For example, criteria for prioritizing clinical topics could include assessment of unexpected variations in performance. A clinical topic where
there is a perceived performance gap should be picked. In application to nutrition support, questions like “Is the clinical indication for nutrition support demonstrated before
treatment begins?” or “Is the route of administration for nutrition support appropriate?”
could be used to review their own clinical performance data with clinicians, thereby
creating tension for change.

Finding Valid Guidelines to Use, Appraising Guidelines
(Identify an Effective Alternative)
Are there valid guidelines for the clinical indication of nutrition support? When the
group has identified relevant guidelines, it should appraise their validity before deciding whether to adopt their recommendations. Clinicians in the organization should
agree that the recommendations in the guideline are consistent with the best medical
evidence.

Adapting Valid Guidelines (Tailoring a Guideline to Local Conditions)
Once the group has identified guidelines of acceptable quality, these need to be
adapted for use within the local healthcare setting. Evidence-based guidelines are not
to be considered as “one size fits all”. Rather, they are dependent on the level of
training of the provider or the technical means of the site. The task of the “nutrition
team” is to adapt the guideline and then plan the presentation, use, and evaluation of
the guideline within the local setting and its services.

Dissemination and Implementation (Provide, Develop, and Build Support)
Guidelines can be presented as a full text version, summary sheets of all or parts of
the guideline, or reminder sheets or computer templates embedded in patient records.
The nutrition order forms could be designed to encourage the gathering of appropriate
clinical data. Thus, supporting the sound clinical decision-making process before
treatment begins. In addition, clinical algorithms may de used.
Since there is no single effective way to ensure the use of guidelines in practice, the
“nutrition team” should use a multifaceted intervention approach to disseminate and
implement guidelines. Dissemination and implementation strategies include various
professional strategies to overcome specific barriers. For instance, educational
approaches (seminars, workshops, “academic detailing”) may be useful where barriers
are related to the healthcare professional’s knowledge. Audit and feedback may be
useful when clinicians are unaware of suboptimal practice. Social influence
approaches (local consensus processes, educational outreach, opinion leaders, marketing, etc.) may be useful when barriers are related to the existing culture. Reminders
may be useful when healthcare professionals forget to follow the guideline. Organiza-
tional interventions would include expanding the role of the nutrition team, e.g. in the
consultant model, nutrition support could be provided by team members upon request
from the patient’s attending physician.

Evaluation (Include a Mechanism for Feedback)
Continuos evaluations help to ensure that the process of care reflects guideline recommendations. Guidelines can also be used as instruments for self assessment and
to learn about gaps in performance. This is particularly relevant whenever recommendations include specific measurable criteria.
To systematically determine whether the objectives of the guidelines have been
achieved and guideline implementation has resulted in improvements of performance,
a measurement system is needed. For monitoring the quality of nutrition support the
following criteria could be used [10]:
Measure and track the percentage of patients for whom nutrition support is indicated
based on the implemented guidelines.
Measure and track the percentage of nutrition support patients for whom the proper
route of administration is used to administer nutrition support.
Conclusions
The implementation of clinical guidelines within a local care setting requires time, commitment and resources. Local multidisciplinary teams (e.g. the P&T “nutrition subcommittee”)
should adopt pre-existing valid guidelines. Great care needs to be taken to ensure their
use within clinical practice. However, the implementation of guidelines should be seen as
only one strategy that can improve the patients’ quality of care [8].
References
1. A.S.P.E.N. Board of directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parent Enteral Nutr 1993; 17 (Suppl): 1SA-56SA
2. JCAHO Board of Directors. 1995 Comprehensive Accreditation Manual for Hospitals. Oakbrook, IL, 1994
3. Definition of terms used in A.S.P.E.N. guidelines and standards. J Parent Ent Nutr 1995; 19: 1
4. Field MJ, Lohr KN, eds. Clinical practice guidelines: directions for a new program. Washington, DC: National Academy Press, 1990
5. Agency for Health Care Policy and Research. Using clinical practice guidelines to evaluate quality of care. Vol 1.
Issues. Rockville, MD: US Department of Health and Human Services, Public Health Services (AHCPR publication
No 95-0045), 1995
6. Field MJ, Lohr KN, eds. Guidelines for clinical practice: from development to use. Washington, DC: National Academy Press, 1992
7. Schneider PJ, Mirtallo JM. The value of organized nutritional support service in intensive care unit care. In: Pichard
C and Kudsk KA (eds). From nutrition support to pharmacologic nutrition in the ICU. Berlin: Springer, 2000: 104-114
8. Feder G, Eccles M, Grol R, Griffiths C, Grimshaw J. Using clinical guidelines. Br Med J 1999; 318: 728-730
9. Cretin S. Putting clinical guidelines into practice. In: Margolis CZ, Cretin S (eds). Implementing clinical practice
guidelines. Chicago IL: AHA press, 1999: 99-120
10. Schneider PJ, Bothe A , Bisognago M. Improving the nutrition support process: assuring that more patients receive
optimal nutrition support. NCP 1999; 14: 221-226
Further reading

Freemantle N, Harvey E, Grimshaw JM, Wolf F, Bero L, Grilli R, et al. The effectiveness of printed educational materials in changing the behaviour of health care professionals. In Cochrane Collaboration. Cochrane Library. Issue 3.
Oxford: 1996, Update Software

Bero L, Grilli R, Grimshaw JM Oxmann AD, eds. The Cochrane Effective Practice and Organisation of Care Review
Group. The Cochrane Database of Systematic Reviews. Issue 3. Oxford: 1998, Update Software