Transcript International Nutrition QI Project 2007: Debriefing Session

International Critical Care
Nutrition Survey 2009:
Defining Gaps in Practice
Naomi E Cahill, RD MSc
Project Leader
Queen’s University and Clinical Evaluation Research Unit
Kingston, Ontario, Canada
Acknowledgments
• Participants of the International Nutrition Survey
2009
• Dr Daren Heyland and the Research Team at
the Clinical Evaluation Research Unit
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Lauren Murch, Project Assistant
Rupinder Dhaliwal, Project Leader
Andrew Day, Biostatistician
Miao Wang, Data Analyst
Fernando Ferrer, IT Support
Why Audit Nutrition Practice?
Benchmarking
Individual ICUs compared to:
•Canadian Clinical Practice Guidelines
•All ICUs
•ICUs from same geographic region
Benchmarking
Why Audit Nutrition Practice?
Objectives of International Survey
Quality Improvement
• To determine current nutrition practice in the adult critical
care setting (overall and subgroups)
• Illuminate gaps between best practice and current
practice
• To identify nutrition practices to target for quality
improvement initiatives
Generate New Knowledge
• To determine factors associated with optimal provision of
nutrition
• To determine what nutrition practices are associated with
best clinical outcomes
History of International Surveys
• 3 previous surveys in Canada
– 2001, 2003, 2004
– N > 50
• Extended to other countries in 2007 and 2008
– 167 ICUs each year
– >18 countries
– 65 ICUs from 10 countries participated in both years.
• Repeated in September 2009
– Focus on North America
– Preliminary results
Methods
Eligibility Criteria
• ICU Site
– >8 beds
– Availability of individual with knowledge of
clinical nutrition to collect data
• Patient
– Adult >18 years
– In ICU > 72 hours
– Mechanically ventilated within 48 hours
Methods
• Prospective observational cohort study
• Start date: 16th September 2009
• Aim 20 consecutive patients
– Min 8 pts
• Data included:
– Hospital and ICU demographics
– Patient baseline information (e.g. age, admission diagnosis,
APACHE II)
– Baseline Nutrition Assessment
– 12 days Daily Nutrition data (e.g. type of NS, amount NS
received)
– 60 day hospital outcomes (e.g. mortality, length of stay)
Web based Data Capture System
Who participated in 2009? :
152 ICUs
Canada: 32
Europe: 15
USA: 62
Mexico: 2
Brazil:1
Colombia:5
Peru:1
Venezuela:1
Latin
America: 10
Italy: 2
UK: 7
Ireland: 2
Norway: 1
Switzerland: 1
Czech Republic: 1
Asia: 12
China: 1
Taiwan: 1
India: 6
Iran : 1
Japan: 1
Singapore: 2
Australia &
New
Zealand: 22
ICU Characteristics
Characteristics
Total (n=152)
Hospital Type
Teaching
Non-teaching
Size of Hospital (beds)
Mean (Range)
ICU Structure
Open
Closed
Other
Size of ICU (beds)
Mean (Range)
Designated Medical Director
Presence of Dietitian(s)
FTE Dietitians (per 10 beds)
Mean (Range)
111 (73.0%)
41 (27.0%)
498 (50, 1500)
46 (30.3%)
102 (67.1%)
4 (2.6%)
19 (5,48)
150 (95.5%)
144 (94.7%)
0.4 (0.0, 1.7)
Patient Characteristics
Characteristics
Total
n=2948
Age (years)
Median [Q1,Q3]
62 [48, 73]
Sex
Female
Male
1197 (40.6%)
1751 (59.4%)
Medical
Surgical: Elective
Surgical: Emergency
1902 (64.5%)
357 (12.1%)
689 (23.4%)
Admission Category
BMI (kg|m2)
Median [Q1, Q3]
26.0 [22.8, 30.8]
Median [Q1, Q3]
22 [17, 28]
Apache II Score
Presence of ARDS
Yes
398 (13.5%)
Outcomes at 60 days
Characteristics
Length of Mechanical Ventilation (days)
Median [Q1, Q3]
Length of ICU Stay (days)
Median [Q1, Q3]
Length of Hospital Stay (days)
Median [Q1,Q3]
Patient Died (within 60 days)
Yes
Total
n=2948
7.2 [3.3, 15.3]
10.3 [5.9, 19.9]
19.0[10.5, 36.7]
721(24.7%)
We strongly recommend the use
of enteral nutrition over
parenteral nutrition
Type of Nutrition Support
PN Only
6%
EN+PN
13%
EN Only
71%
n=2948 patients
None
10%
Use of EN Only
100
73.7%
93.4%
90
80
% ICU days
70
55.6%
60
50
40
30
20
10
6.4%
0
Canada
Australia and New
Zealand
USA
Europe
Latin America
Asia
Total
66.5%
n=16983 patients days
Use of PN Only
100
90
80
% ICU days
70
60
50
40
12%
6.6%
30
20
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
8.9%
n=2279 patients days
Use of EN + PN
100
90
80
% ICU days
70
60
50
40
16.3%
30
20
2.7%
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
4.6%
n=292 patients days
No EN, PN or Oral intake received
100
90
80
% ICU days
70
60
50
26.9%
40
10.5%
30
20
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
20%
n=5117 patients days
We recommend early enteral
nutrition (within 24-48 hrs
following admission) in critically ill
patients
Timing of Initiation of EN
288
264
Time to Initiation of EN (hours)
240
216
192
168
144
50 hrs
120
96
30 hrs
72
48
24
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
41 hrs
An evidence based feeding
protocol should be considered
as a strategy to optimize delivery
of enteral nutrition
Feeding Protocol
Characteristics
Total
n=152
Feeding Protocol
Yes
Gastric Residual VolumeThreshold
Mean (range)
Algorithms included in Protocol
Motility agents
Small bowel feeding
Withholding for procedures
HOB Elevation
Other
128 (84.2%)
237 (100, 500)
85 (69.7%)
65 (53.3%)
62 (50.8%)
105 (86.1%)
21 (17.2%)
In critically ill patients who
experience feed intolerance (high
gastric residual volumes, emesis)
the use of a motility agent is
recommended
Strategies to Optimize EN Delivery:
Motility Agents
100
90
87%
% patients with HGRV
80
70
60
45%
50
40
30
20
10
0
Canada
Australia and New
Zealand
USA
Europe
Latin America
Asia
Total
60.7%
In units were achieving routine
small bowel access is not
feasible small bowel feeding
should be considered for patients
who repeatedly demonstrate high
gastric residual volumes and are
not tolerating EN
Location of Feeding Tube
8%
4% 1%
0%
2%
Gastric confirmed
Gastric presumed
19%
66%
Post-pyloric duodenal
confirmed
Post-pyloric duodenal
presumed
Post-pyloric jejunal
confirmed
Post-pyloric jejunal
presumed
No tube in place
Small Bowel Feeding
100
90
% patients with HGRV
80
70
60
43.8%
50
40
30
4.3%
20
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
12.2%
Composition of EN and
Pharmaconutrient Supplementation
recommendations
Arginine-supplemented formulas
Recommend NOT be used
Glutamine supplementation
Enteral should be considered in
burn and trauma
Parenteral strongly
recommended in PN pts
Fish oil enriched formula
Recommended in ARDS
Combined vitamins and trace
elements
Should be considered
Polymeric
Recommend
Use of EN Formula and
Pharmaconutrients
Arginine-supplemented formulas
8.0%(0.0%-94.7%)
Glutamine supplementation (All)
6.0%(0.0%-95%)
Fish oil enriched formula (ARDS)
19.5% (0.0%-100%)
Selenium Supplementation (All)
3.1% (0.0%-100%)
Polymeric
87.8% (0.0%-100.%)
In patients not tolerating
adequate amounts of EN, PN
should not be started until all
strategies to maximize EN
delivery (e.g. motility agents,
small bowel feeding) have been
attempted
EN in Combination with PN
% of patients received motility agents before PN started
% received motility agents before PN started
100
90
80
70
63%
60
50
40
30
21%
20
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
44.4%
We recommend that
hyperglycemia (blood sugars
>10mmol/l) be avoided
Blood Glucose >10 mmol/l
50
45
40
% patient-days
35
30
15.6%
25
20
8.8%
15
10
5
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
13.4%
Overall Performance
Adequacy of Nutrition Support =
Calories received from EN + appropriate PN+Propofol
Calories prescribed
Overall Performance: Kcals
93%
49.9%
8.3%
Overall Performance: Kcals
100
90
% receive/prescribed
80
70
60
55.47
56.91
53.92
47.40
43.67
50
50.84
49.86
40
30
20
10
0
Canada
Australia and
New Zealand
USA
Europe
Latin America
Asia
Total
Where can we do better?
• Inadequate EN delivery
– timing of initiation of EN
– feeding protocols
– small bowel feeding and motility agents
• Optimize Pharmaconutrition
– use of glutamine, antioxidants, omega-3 FFA.
• Tighten glycemic control
Nutritional Adequacy Over Time
How are you performing at your site?
Can you be the Best of the Best?
Further Information: www.criticalcarenutrition.com