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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

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international critical care nutrition survey 2009 defining gaps in practice

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
Acknowledgments
  • Participants of the International Nutrition Survey 2009
  • Dr Daren Heyland and the Research Team at the Clinical Evaluation Research Unit
    • Lauren Murch, Project Assistant
    • Rupinder Dhaliwal, Project Leader
    • Andrew Day, Biostatistician
    • Miao Wang, Data Analyst
    • Fernando Ferrer, IT Support
benchmarking
Benchmarking
  • Individual ICUs compared to:
  • Canadian Clinical Practice Guidelines
  • All ICUs
  • ICUs from same geographic region
objectives of international survey
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
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
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
methods10
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)
slide12

Who participated in 2009?:

152 ICUs

Canada: 32

Asia: 12

Europe: 15

USA: 62

China: 1

Taiwan: 1

India: 6

Iran : 1

Japan: 1

Singapore: 2

Italy: 2

UK: 7

Ireland: 2

Norway: 1

Switzerland: 1

Czech Republic: 1

Mexico: 2

Brazil:1

Colombia:5

Peru:1

Venezuela:1

Latin America: 10

Australia & New Zealand: 22

use of en only
Use of EN Only

73.7%

93.4%

55.6%

6.4%

66.5%

n=16983 patients days

use of pn only
Use of PN Only

12%

6.6%

8.9%

n=2279 patients days

use of en pn
Use of EN + PN

16.3%

2.7%

4.6%

n=292 patients days

no en pn or oral intake received
No EN, PN or Oral intake received

26.9%

10.5%

20%

n=5117 patients days

slide23

We recommend early enteral nutrition (within 24-48 hrs following admission) in critically ill patients

timing of initiation of en
Timing of Initiation of EN

50 hrs

30 hrs

41 hrs

slide25

An evidence based feeding protocol should be considered as a strategy to optimize delivery of enteral nutrition

slide27

In critically ill patients who experience feed intolerance (high gastric residual volumes, emesis) the use of a motility agent is recommended

slide29

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

small bowel feeding
Small Bowel Feeding

43.8%

4.3%

12.2%

slide34

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

slide35

EN in Combination with PN

% of patients received motility agents before PN started

63%

21%

44.4%

overall performance
Overall Performance

Adequacy of Nutrition Support =

Calories received from EN + appropriate PN+Propofol

Calories prescribed

where can we do better
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
slide43

How are you performing at your site?

Can you be the Best of the Best?

Next International Nutrition Survey

Coming Early in 2011

Further Information: www.criticalcarenutrition.com

The next international audit is May 14th, 2008

The next international audit is May 14th, 2008

The next international audit is May 14th, 2008