Clinical Nutrition 31 (2012) 602e608

Contents lists available at SciVerse ScienceDirect

Clinical Nutrition
journal h om epage: http: / / www. e ls evier . c o m / l o c a
te/c lnu

Review

Guidelines recommendations on care of adult patients receiving

home parenteral nutrition: A systematic review of global practicesq
a, *
Mira Dreesen , Veerle Foulon b, Kris Vanhaecht c, Lutgart De Pourcq a, Martin Hiele d, Ludo Willems a
a
Pharmacy Department, University Hospitals, Leuven, Belgium
b
Pharmacy Department, Research Centre for Pharmaceutical Care and Pharmaco-economics, Catholic University Leuven, Belgium
c
Center for Health Services and Nursing Research, School of Public Health, Leuven, Belgium
d
Department of Gastroenterology, University Hospitals, Leuven, Belgium

a r t i c l e i n f s u m m a r y
o
Background & aims: Because home parenteral nutrition (HPN) in adult patients can give rise to a variety
Article history: of complications, good guidance is necessary. To achieve this, clarity and consistency in guidelines are
Received 20 July 2011 essential. The aim of this review is to identify and compare evidence-based guidelines, and to compile
Accepted 23 February 2012
a list of main recommendations, according to their evidence-based grade.
Methods: We searched Medline and the international guideline database for HPN guidelines, performed
Keywords: a content analysis of retrieved guidelines, and evaluated their quality. We then compiled a comparative
Home parenteral nutrition
table of guideline recommendations along with their assigned level of evidence.
Practice guidelines
Summary of results: Six systematically developed evidence-based guidelines and one expert opinion-
Adults
based standard for home care were retrieved. Of these guidelines, two were exclusively devoted to
HPN. Although the guidelines generally covered the same topics, most did not provide information on
intravenous medication, bone metabolic disease, and indications in patients with malignant disease.
Moreover, we found grading discrepancies among various guidelines, as identical recommendations
were often labeled with different grades.
Conclusion: Our comparison of guidelines and standards for HPN revealed substantial differences among
recommendations. Identication of these discrepancies and omissions should facilitate the development
of more comprehensive and better justied guidelines in the future.
2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.

1. Introduction
Parenteral nutrition (PN) is provided to patients who are unable
to maintain their nutritional status by oral or enteral intake
because of intestinal failure. Since the 1960s and 1970s, patients
receiving
PN can be treated at home.1 This is usually referred to as home
parenteral nutrition (HPN), which can be a life-saving or life-
extending therapy. In Europe, the most common indications for
long-term HPN are Crohns disease, mesenteric vascular disease,
cancer, and radiation enteritis.2 These indications are similar to
those in the United States (U.S.).3
The treatment of patients on HPN is not without risks. Catheter-
related infections, liver disease, and metabolic bone disease are the
q Conference presentation: none.
* Corresponding author. Pharmacy Department, University Hospitals, Herestraat
49, P.O. Box 7003, 3000 Leuven, Belgium. Tel.: 32 16342338; fax: 32 16343084.
E-mail address: mira.dreesen@uzleuven.be (M. Dreesen).
most common complications related to long-term PN.3 The prev-
alence of catheter-related bloodstream infections ranges between
0.38 and 0.50 episodes per catheter year.4 The weighted average of
catheter occlusion has been estimated to be 0.071 episodes per
catheter year and 0.027 for central vein thrombosis.4 In addition to
catheter-related complications, substantial liver damage and ulti-
mately end-stage liver disease can also occur in patients on HPN.5
The cause of this complication is complex and remains unclear
but may involve patient-related and nutrition-related factors.
Abnormal liver function tests have been reported in 48% of
patients6 on HPN, with elevated alkaline phosphatase levels being
the most common nding. Finally, HPN patients may experience
metabolic bone disease in the form of osteomalacia or osteoporosis,
or both.7 Several factors can contribute to this complication, such as
underlying disease, presence of bone-toxic products (e.g.,
aluminum) in the total parenteral nutrition (TPN) mixture, or lack
of essential nutrients for bone homeostasis in the TPN mixture.8
To minimize these complications, patients require careful
monitoring. Effective patient monitoring requires applying clear

0261-5614/$ e see front matter 2012 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2012.02.013
and comprehensive guidelines not only at the start of therapy but
also during home care and follow-up. Hence, the aim of this review
is to gain evidence-based insight into how patients on HPN should
be managed. To this end, we searched in the medical literature for
HPN guidelines, compared these, and composed a comprehensive
list of the most important recommendations based on the level of
evidence.
2. Methods
Medline and the international guideline database of the Belgian
Cochrane Centre (CEBAM)9 were searched for published evidence-
based guidelines on adult HPN patients. The following search string
was used: ((total parenteral nutrition, home OR home parenteral
nutrition OR parenteral nutrition, home OR home total parenteral
nutrition) AND (practice guideline)) AND (parenteral nutrition OR
home care services OR home care OR home parenteral nutrition).
The search strategy was restricted to English and Dutch language
articles. Relevant articles cited in the bibliographies of primary
candidate articles were culled for further review.
Two independent researchers assessed the quality of the
process and reporting of the guideline development using the
Appraisal of Guidelines Research and Evaluation (AGREE) instru-
ment.10 Overall assessment and domain scores were calculated as
instructed in the AGREE manual. Guidelines were included if the
majority of items scored high (3 or 4) and if most of the domain
scores (4 or 5) were above 60%.
We performed a content analysis of the guidelines, focusing on
whether guidelines mentioned certain themes concerning HPN for
adult patients. Guidelines with sections providing general infor-
mation on PN were screened as a whole for relevant words such as
long-term parenteral nutrition, home-specialized nutrition
support, nancial, or education.
Next, we categorized the guidelines according to their themes
and compiled a comparative table of guideline recommendations. A
distinction was made between recommendations from guidelines
exclusively devoted to HPN and guidelines providing more general
information on HPN. Recommendations were included in the
comparative table if they were present in all the guidelines exclu-
sively devoted to HPN. However, if one of the two guidelines
exclusively devoted to HPN did not include a specic topic or
theme, e.g., bone metabolic bone disease, the guidelines providing
more general information on HPN were also taken into account. A
particular recommendation was then only included in the table if
(1) all the general guidelines agreed on the recommendation of the
HPN-specic guideline, or (2) if at least 30% of the general guide-
lines gave the recommendation a C grade.
3. Results
3.1. Guideline inclusion
Of the 38 candidate papers initially identied in Medline, 3 met
our criteria and were included for review. These were two
evidence-based guidelines exclusively devoted to HPN, one from
the European Society of Parenteral and Enteral Nutrition (ESPEN
2009)11 and one from the Australasian Society of Parenteral and
Enteral Nutrition (AuSPEN 2008).12 The remaining article, from the
German Society for Nutrition Medicine (DGEM 2009),13 covered
HPN in a more general guideline.
Of the 27 candidate guidelines retrieved from the international
guideline database,9 only one guideline was included in our review.
It covered HPN in general and was developed by the National
Institute for Health and Clinical Excellence (NICE 2006).14
Manual searching the bibliographies of included guidelines
produced three additional documents. Two were from the Amer-
ican Society for Parenteral and Enteral Nutrition (ASPEN), which
penned a more general evidence-based guideline15 and standards
about home care services.16 The latter document is a standard and
presents a range of care interventions based on expert clinical
opinion. The third document, an evidence-based guideline con-
cerning central venous catheters, is an important addition to the

Table 1
Overview of included articles.

Reference Country Scope

ASPEN US General
15
(2002) Parenteral Enteral Nutrition (ASPEN) board of and enteral nutrition in adult and summarized primary literature and
and enteral
nutrition
ASPEN US General Home
16
2005 care patients Enteral Nutrition (ASPEN) board of support: home care patients.
General Oral, directors and Standards committee Nutrition support for adults: oral The GDG worked on informal
14
NICE England and parenteral Guideline Development Group (GDG) nutrition support, enteral tube consensus basis to formulate and
Wales nutrition and convened by National Collaborating feeding and parenteral nutrition. grade recommendations. In nal stages
enteral tube Centre for Acute Care (NCC-AC) with recommendations were further revised.
feeding guidance from National Institute for
Health and Clinical Excellence (NICE).

12
AuSPEN Australia and Specic Home Multidisciplinary working party of Clinical practice guideline for Draft guideline developed by GDG
New Zealand parenteral Australia and New Zealand health home parenteral nutrition patients consensus, peer-reviewed by both
nutrition professionals formalized into AuSPEN in Australia and New Zealand. countries and by internationally
HPN Guideline Development Group recognized home parenteral
(GDG). nutrition practitioners.
17
ESPEN Europe Central venous The European Society of Parenteral Guidelines on Parenteral nutrition: Working group approved guidelines
catheters and Enteral Nutrition (ESPEN) Clinical Central Venous catheters (access, that are reviewed by two independent
Practice guidelines (CPG) program diagnosis and therapy of externals reviewers. Thereafter, 3 further
complications). reviewers were selected by the editorial
31
board of Clinical nutrition.
11
ESPEN Europe Specic Home The European Society of Parenteral and Guidelines on Parenteral nutrition: Same method as for ESPEN guideline
parenteral Enteral Nutrition (ESPEN) Clinical Practice Home Parenteral Nutrition (HPN) in concerning central venous catheters.
31
nutrition guidelines (CPG) program. adult patients.
13
DGEM Germany General German Society for Nutritional Medicine in Guidelines on parenteral nutrition The working group carried out literature
Parenteral collaboration with specialist medical from the German Society for search and assessed scientic evidence.
nutrition associations
13
Nutrition Medicine (DGEM). To obtain ultimate guidelines consensus
conferences were used.
604 M. Dreesen et al. / Clinical Nutrition 31 (2012) 602e608
Discussed themes
Table 2
Content analysis of the included guidelines.
Indication benign patients
Indication malignant patients
Parenteral access
Nutritional requirements
Intravenous medication
Education
Monitoring of PN efcacy
Monitoring of nutritional status
Preventing and monitoring liver disease
Preventing and managing catheter-related
complications
Preventing, managing and monitoring bone metabolic disease

Nutrition support team

, Not discussed in the guideline; , devoted a specic part in the text to this topic for home parenteral nutrition (HPN) patients; , devoted a specic part in the text
to this topic but in general, not for HPN patients; , devoted no specic part to this topic but mentioned (briey) in the text.

ESPEN-specic HPN guideline.17 An overview of the articles
included in this review is provided in Table 1 and a content
analysis is provided in Table 2.
3.2. Quality of the guidelines
We evaluated the evidence-based guidelines using the vali-
dated AGREE instrument, which was also used by AuSPEN.12
Domain scores are presented in Table 3. All the guidelines
scored high on most of the domains. The mean score for the
applicability domain was low (30.2%), as were the scores evaluated
in a recent review on the quality of published guidelines (mean
score for applicability of 22%).18 Compared to other guidelines,
stakeholder involvement and editorial independence of the HPN
guidelines scored higher. All the evidence-based guidelines used
similar evidence-grading systems to assess their recommenda-
tions (Supplemental Table 1).
3.3. Comparison of steps in the guidance of patients receiving HPN
The main results of the comparison are listed in the
comparative table (Table 4). Additional topics that were not
included in the table because they did not meet inclusion criteria
(see Section 2) are discussed below.
3.3.1. Indication for starting HPN
NICE, AuSPEN, and DGEM advised that before initiating HPN
healthcare professionals must obtain a patients consent. DGEM
and ASPEN further advised against starting therapy if a minimal
expected duration could not be ensured (for DGEM, 4 weeks and
grade C; for ASPEN, 90 days).
3.3.1.1. Specic issues for patients with malignant disease. No graded
recommendations were available. DGEM, ASPEN, and ESPEN did
not recommend HPN for patients with a short life expectancy (at
least 40e60 days [ASPEN] or three months [DGEM, ESPEN, grade C]
required). Initiating HPN in patients with a short life expectancy
therefore remains difcult, as estimating life expectancy is very
subjective.
3.3.2. Parenteral access for HPN
For this topic, assigned grades differed greatly. Three recom-
mendations received both C and A grades (Table 4). This was also
the case for the recommendation that catheter insertion should be
based on ultrasound-guided venepuncture to reduce the risk of
complications (DGEM grade A; ESPEN grade C).
An example of a smaller difference in grading was the recom-
mendation to use infusion pumps (DGEM grade C vs. ESPEN grade
B). The other guidelines did not support the AuSPEN recommen-
dation that peripherally inserted central catheters (PICC) are
acceptable for short-duration use (12e18 months, level III-2).
DGEM and ESPEN did not recommend antibiotic prophylaxis for
catheter insertion (grade B), but both recommended routine
ushing with saline solution before and after applying PN.
3.3.3. Nutrition requirements
Table 5 summarizes the recommended nutrition
requirements according to the guidelines. For patients with
cancer, the ESPEN guidelines of PN oncology provided the most
information.19 Grading
differed substantially for non-protein energy provision. ESPEN
(grade
C) and DGEM (grade A) recommended delivering 100e150 kcal
and
130e170 kcal per gram nitrogen, respectively. ESPEN further
recom- mended daily supplements of essential fatty acids (7e10
g).

Table 3
Evaluation of the quality of the included evidence-based guidelines for HPN patients with the appraisal of guidelines research and evaluation (AGREE) instrument.

Quality domain Domain scores of included evidence-based guidelines with AGREE instrument

Scope and purpose

Stakeholder involvement
Rigour of development
Clarity and presentation
Applicability
Editorial independence

Overall assessment
Table 4
Comparative table of recommendations derived from the included guidelines for patients receiving home parenteral nutrition.

Topic

Indications in benign
patients

Indications in malignant
Verify patient has intestinal failure because of cancer / /
patients Veri
Ver
Con
Con

Parenteral access Con

Adm
ven
Pref
Dis
Con
Use
Use
If po
Use

Nutritional requirements Total calorie intake 20e35 kcal/kg/day; uid requirement

See text for more information
30e40 ml/kg/day; glucose administration 3 g/kg/day; protein intake
0.8e1.5 g/kg/day
Ensure that glucose-to-lipid ratio is 60e85% glucose to 15e40% lipid C B

Intravenous medication Review medication proles for potential interactions / / B

Avoid addition of medication in PN mixture if known to be B / / A
incompatible with PN

Education Assess home environment B

Takes place in an in-patient setting prior to discharge / C C
Includes pump use and care, catheter care, and problem recognition / C D *
Make a checklist of criteria for which competence is achieved /

Monitoring of PN efcacy Compare periodically the outcome goals of PN therapy D C

Monitor patients quality of life B

Monitoring of nutritional At each visit, monitor anthropometry, biochemistry, C D

status magnesium, iron status, and extrarenal losses
Every 6 to 12 months, monitor trace elements and vitamins C C D C

Preventing/monitoring Monitor periodically liver function tests A / D A

liver disease Administer PN cyclically or use shorter infusion times B /

Preventing / managing Diagnose catheter-related infection by obtaining culture samples A A / /

catheter-related from each catheter lumen and performing peripheral blood culture
complications Approach catheter sepsis with systematic antibiotic before C IV / /
removing catheter
Give urokinase or tPA in case of central venous thrombosis / /
Replace external part of damaged catheter using repair kit / /
to preserve catheter

Preventing/managing bone Ensure adequate intake of vitamin D for prevention C C /

metabolic disease Ensure intake of biphosphonates to maintain bone mineral density C B /
Perform bone densitometry upon initiation of HPN and periodically C / D C
thereafter

Nutrition support team Expertise of multidisciplinary team is recommended C D

(NST) The NST should:
e prepare management protocols to facilitate education D *
e make an individualized care plan with overall aims D *
e follow-up care of patients D C
e provide physiological and emotional support
e provide contact details of people with signicant role in their care D
*

AuSPEN, Australasian Society of Parenteral and Enteral Nutrition; DGEM, German Society for Nutrition Medicine; ESPEN, European Society of Parenteral and Enteral
Nutrition; HPN, home parenteral nutrition; NICE, National Institute for Health and Clinical Excellence; PN, parenteral nutrition; tPA, tissue plasminogen activator.
B or II/III, Well-performed, non-randomized studies (recommended); C or IV, reports and opinions of expert groups and/or clinical experience of recognized authorities
(recommended with reservations); D, good practice point, a recommendation for best practice based on the experience of the NICE guideline development group; /, subject
not discussed in the guideline text; D, mentioned in the text but no graded recommendation made; , not mentioned in the text but topic is briey discussed; *, mentioned
by the standards of ASPEN 2005 as an addition to the evidence-based guidelines of ASPEN 2002.
 Recommendation for nutritional requirements
Total calories per kilo bodyweight per day
Fluid requirements in ml/kg body weight/day
Glucose administration in g/kg body weight/day
Protein intake for unstressed adult patient
In g amino acids/kg body weight/day
In g nitrogen /kg body weight/day
Only DGEM and NICE graded the recommendation for trace
elements and vitamins, giving it a C and D Good Practice Point
[D(GPP)], respectively.
3.3.4. Intravenous medication
Little information was available concerning intravenous medi-
cation. ESPEN and NICE did not address this topic. AuSPEN and
ASPEN (grade A) as well as DGEM (grade B) advised not to add any
drug if it is known to be incompatible with the PN admixture.
3.3.5. Education for patients on HPN
Although educating patients on HPN is essential in order to
reduce the risk of complications,20 DGEM did not address this
important issue. Furthermore, ESPEN, AuSPEN and ASPEN (grade B)
recommended that the home environment should be assessed
before starting any training.
Our comparison of the guidelines education programs
revealed that training should include information on catheter
care, recognizing common problems, and pump use and care.
ESPEN and ASPEN 2005 also included in their recommendations
training on storage and handling of the PN bag, adding vitamins
and trace elements, and making arrangements for medication
supplies.
3.3.6. Complications and follow-up of patients
3.3.6.1. Monitoring of PN efcacy. To assess the efcacy of PN
therapy, the outcome of the therapy should be periodically re-
assessed according to NICE (grade D [GPP]) and ASPEN (grade C)
guidelines. Although all but NICE recommended the monitoring of
quality of life, only ASPEN gave this recommendation a grade B. For
patients with malignant disease, ESPEN recommended the moni-
toring of outcome variables, including pain relief and psychosocial
problems.
3.3.6.2. Monitoring of nutrition status. All guidelines agreed that
routine monitoring by a multidisciplinary nutrition support team is
important for preventing complications. The time intervals re-
ported for routine monitoring were broad. According to the
guidelines, the following items should be monitored: anthropom-
etry, magnesium, iron status, intestinal losses, and biochemistry,
including electrolytes, glucose, creatinine, and liver function tests.
3.3.6.3. Preventing and monitoring liver disease. All guidelines rec-
ommended the periodic monitoring of liver function (DGEM grade
A, ESPEN grade A, NICE grade D [GPP]). According to ESPEN (grade
B), the control of line sepsis helps prevent chronic cholestasis.
ESPEN (grade B), ASPEN, and AuSPEN (level IV) recommended
avoiding continuous administration of PN in order to prevent
overfeeding, and hence to reduce liver disease.11 ASPEN and ESPEN
(grade C) further recommended limiting the concentration of
intravenous lipids to less than 1 g per kilogram bodyweight per day
in order to prevent liver disease.
3.3.6.4. Preventing and managing, catheter-related complications. -
Grading the method for diagnosing catheter-related infections
differed for ESPEN (grade A) and DGEM (grade A) and for AuSPEN
(level III-2). There was no consensus about low-dose anticoagulant
therapy for thrombosis prevention. ASPEN recommended low-dose
anticoagulants in patients requiring long-term catheterization
(grade B), without specifying the mode of administration. On the
other hand, DGEM generally recommended the prophylactic use of
warfarin (grade B), but ESPEN and AuSPEN advised limiting the use
of warfarin to some patient groups. Furthermore, ESPEN advised
using subcutaneous low molecular weight heparins in patients at
high risk for thrombosis (grade C).
3.3.6.5. Preventing, managing and monitoring metabolic bone dis-
ease. Although AuSPEN did not specically address the manage-
ment of metabolic bone disease, it did agree with the other
guidelines that bone mineral density needs to be measured yearly
via dual-energy X-ray absorptiometry (DEXA) in order to detect
osteomalacia and/or osteoporosis7 (ESPEN and ASPEN both grade
C,
NICE grade D [GPP]). DGEM, ESPEN, and NICE also recommended
monitoring vitamin D serum concentrations.
ESPEN (grade B) and ASPEN indicated that aluminum contami-
nation should be prevented and limited to 25 mg per liter.21 DGEM
and ESPEN (grade B) stated that hypercalcuria should also be
reduced. Both guidelines also recommended vitamin D (200 IU/
day) supplementation in order to prevent and treat metabolic bone
disease (ESPEN and DGEM both grade C). To maintain bone mineral
density, ESPEN (grade B) and DGEM (grade C) suggested including
biophosphates into the PN regimen.
3.3.7. The nutrition support team
Even though all ve guidelines recommended the involvement
of a multidisciplinary nutrition support team, only ESPEN (grade C)
and NICE (grade D [GPP]) graded this recommendation. According
to ESPEN (grade C), AuSPEN, NICE (grade D [GPP]), and ASPEN, the
minimum core team should consist of a physician, a specialist
nurse, and a dietician.
All guidelines agreed on certain recommendations (Table 4). In
addition, ESPEN and NICE advised that the team should ensure
adherence to nutrition support protocols. Moreover, AuSPEN,
DGEM, and NICE supported coordination of care. Only DGEM,
however, stated that the nutrition support team should review
indications for HPN after an attending physician initiates therapy
(grade B).
4. Discussion
This paper is the rst to compare existing guidelines on the care
of adult HPN patients. Although critical care nutrition guidelines
have undergone critical analysis and comparison in the literature,22
to the best of our knowledge, specic guidelines for patients on
HPN have not.
4.1. Main ndings
Most of the recommendations analyzed were based on subjec-
tive assessments such as consensus, expert opinion, or weak levels
of evidence that correspond to a grade C. This is not surprising, as
it is very difcult to perform randomized controlled trials
with patients on HPN.
We found grading discrepancies across the various guidelines,
even though similar grading systems were used. For example, the
recommendation that TPN should be administered through
a catheter with its distal tip located in the superior vena cava
received a grade C from DGEM but a grade A from ESPEN (Table 4).
Some discrepancies may be related to differences in publication
dates, and hence in the available literature on the time of writing.
Discrepancies could be avoided if a proper procedure for updating
guidelines was available. Only DGEM and AuSPEN have such
a procedure. Most discrepancies were found between the DGEM
guideline and the other guidelines. DGEM and ESPEN were both
published in 2009 but we cannot directly relate discrepancies
between these guidelines to publication date or to different search
strategies because the ESPEN methodology is unclear. We noted
that these differences often were associated with the topic
parenteral access. For this specic topic, however, other
guidelines
are available for further guidance, namely the evidence-based
practice in infection control23 and those published by the center
for disease control and prevention.24
In addition, we observed a noticeable difference in the scope of
the different guidelines. Two guidelines were exclusively devoted
to HPN (ESPEN and AuSPEN), whereas three discussed HPN as a part
of a more general guideline on PN (DGEM, ASPEN, and NICE). In the
DGEM and NICE guidelines, and especially in the ASPEN 2002
guideline, recommendations specic to patients on HPN were
difcult to identify. To clarify ASPEN recommendations for patients
on HPN, we included ASPEN 2005 practice standards for patients in
need of HPN or PN.16 ASPEN is also working on a document
provisionally titled Clinical guidelines for the use of parenteral and
enteral nutrition in adult and pediatric patients.25 These guidelines
were not yet available at the time of writing this article.
Both the format of the guidelines and the issues covered showed
heterogeneity. Certain topics were consistently included in each
document, such as indications for patients with a benign under-
lying disease, parenteral access, monitoring of efcacy and nutri-
tional status, and nutrition support team (Table 2). Other topics,
such as intravenous medication, bone metabolic disease, and
indications in malignant patients, were not included in some
guidelines.
Implementing the guidelines in practice may be difcult, as the
advice was often very general and vague. For example, it is unclear
how home environments can be assessed and which elements
should be taken into account. Some recommendations such as
detection of aluminum contamination are difcult to follow in
practice, since the necessary technology has been established only
recently.26 Available resources may also differ between countries.
This is the case, for example, for reimbursement systems and the
use of infusion pumps.
Because resources vary across different countries, it seems
impossible to propose a universal guideline. However, all patients
should receive optimal evidence-based care. In addition, as avail-
able evidence is the same for every country, development of such
a guideline should be an aim. Of course, details for implementation
may differ slightly between countries depending on their available
resources. ESPEN has already tried to develop a more global
guideline. Guidelines accepted in Europe are indeed interesting,
but methods of development should be more detailed, as those
applied by AuSPEN.
and drafted the manuscript.
- Veerle Foulon conceived of the study, and participated in its
design and coordination and helped to draft the manuscript.
4.2. Strengths and limitations
The strength of this study is that it provides clarity in the midst
of a tangle of data by providing a comprehensive list of the most
important recommendations based on the level of evidence.
One limitation is that the content of the guidelines was not
examined and no expert panel was assembled to evaluate their
clinical contents. Moreover, evaluation was limited to the process
of development, as examined with the AGREE tool. Another limi-
tation is that the search string was restricted to home parenteral
nutrition and practice guideline; thus, other more general
guidelines or standards may have been missed. Standards or
guidelines may not be indexed correctly in databases. However,
we want to emphasize that, in terms of their approach to
management, a guideline is not superior than a standard and
vice versa. Both can provide healthcare workers with valuable
directions on HPN.
4.3. Implications for practice
Although guidelines exist for HPN, it is unclear which guide-
lines should really be followed in practice to ensure qualitative
care. Our comprehensive overview of the most important
recommendations (Table 4) may help multidisciplinary teams
launch evaluation and improvement projects. This paper should
facilitate the development of more comprehensive guidelines,
because it identies discrepancies in grading and omissions in
many of the guidelines. In the near future, consensus on which
recommendations should be followed in clinical practice should
be attained, possibly through a Delphi approach. Once this is
claried, the research priority is to identify barriers to imple-
mentation and to develop structured care methodologies such as
care pathways for improving the collaboration between the
members of the hospital and home care team.27,28 The most
important recommendations could be incorporated into medical
databases, where they would be available for constructing deci-
sion trees that ensure optimal transition from a hospital envi-
ronment to primary care. Since care pathways and other quality
improvement initiatives are complex interventions and since not
all changes lead to improvement,29,30 process, outcome, and
teamwork indicators will need to be followed up.
4.4. Conclusions
Our analysis and comparison of six evidence-based guidelines
and one standard for HPN revealed substantial differences between
the recommendations. The identication of discrepancies and
omissions should facilitate the development of more comprehen-
sive guidelines in the future. A critical discussion of the available
data should lead to better justication and to more uniform
grading of evidence.
Conict of interest statement
Mira Dreesen has an unconditional educational grant from the
company Baxter Belgium. However this company was not involved
in the study design, in the collection, analysis and interpretation of
the data, in writing the manuscript and in the decision to submit
the manuscript for publication.
Statement of authorship
All authors made substantial contributions and approved the
nal version of the conceptions, drafting and the nal version.
Specic contribution of each author to the paper:
- Kris Vanhaecht conceived of the study, and participated in its
design and coordination and helped to draft the manuscript.
 - Lutgart De Pourcq conceived of the study, and participated in
its design and coordination and helped to draft the
manuscript.
- Martin Hiele conceived of the study, and participated in its
design and coordination and helped to draft the manuscript.
- Ludo Willems conceived of the study, and participated in its
design and coordination and helped to draft the manuscript.
Appendix A. Supplementary material
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.clnu.2012.02.013.
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