Barriers and enablers to the adherence of the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients.

摘要

Background. Clinical Practice Guidelines (CPGs) have emerged as a beneficial strategy of integrating evidence into practice. The Canadian Nutrition Support CPGs, published in 2003, sought to improve nutrition support practices in Intensive Care Units (ICUs) in Canada. However, their impact to date has been modest.;Objectives. The aim of this study was to identify the barriers and enablers to guideline adherence in general, and to the Canadian Nutrition Support CPGs specifically, and to create a comprehensive framework for adherence to CPGs in the ICU.;Methods. A mixed methods approach was employed. Part 1 was a quantitative analysis of existing data from a survey of nutrition support practices in fifty-eight Canadian ICUs, grouped into fifty cluster ICUs. Multi-level modeling techniques were used to examine the association between adherence to the Canadian Nutrition Support CPGs and various hospital, ICU and patient characteristics. Part 2 consisted of multiple case studies in four Canadian ICUs. Semi-structured interviews were conducted with seven key informants at each of the four ICU sites, and documents pertaining to nutrition support practices were reviewed. Interview transcripts and supporting documents were analyzed qualitatively using a framework approach.;Results. In Part 1, hospital type (academic vs. community), admission category of the patient (medical vs. surgical), and sex were found to be significantly associated with adherence to the Canadian Nutrition Support CPGs. These quantitative results were corroborated in Part 2 of the thesis, where organizational and patient characteristics were identified as key components of the developed framework for guidelines adherence in the ICU, together with characteristics of the CPGs, the implementation process, and the individual provider. These five key components represented numerous itemized factors that further contributed to guideline adherence either as barriers or enablers. The magnitude of influence of each of these factors appeared to vary by specific practitioner and site characteristics.;Conclusions. Our findings suggest that guideline adherence in the ICU is profoundly complex and is determined by practitioner, patient, institutional and guideline factors. The proposed framework facilitates a holistic understanding of this problem and represents a useful template for further research. Future studies should attempt to quantify the impact of each barrier and enabler, and the mechanism by which they influence guideline adherence for individual guidelines and at individual sites.