Harmonizing Nutrition Therapy Guidelines in Critical Care: Bridging the Gap

1. In Knowledge Translation: The Critical Care Experience 1

2. Outline of Session Guidelines for Nutrition Therapy in the ICU : How do they differ? Rupinder Dhaliwal, RD WHAT SHOULD BE DONE? Improving the practices of Nutrition Therapy in the Critically ill Naomi Cahill, RD WHAT IS BEING DONE? Bridging the Gap: Effective Dissemination Strategies for Improving Nutrition Practices in the ICU Daren Heyland, MD HOW TO NARROW THE GAP?

3. Questions to be held at the end of the session 1

4. Rupinder Dhaliwal, RD Team Leader/Project Leader Clinical Evaluation Research Unit Critical Care Nutrition Kingston ON, Canada Guidelines for Nutrition Therapy in the ICU: How do they differ? 1

5. Conflict of interest Co-author of Canadian Clinical Practice Guidelines

6. Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Best available evidence with integration of potential benefits, harm, feasibility, cost Reduce variability in care, improve quality, reduce costs and can improve outcomes Why bother with guidelines? 1

7. Proliferation of guidelines 1

8. The more guidelines they publish, the more confused I get!

9. Compare the content of recently published nutrition guidelines Differences between the recommendations Similarities in the recommendations Highlight the need for harmonization Objectives 1

10. North American guidelines www.criticalcarenutrition.com Available Online 1

11. Population Levels of Evidence Grading used Time frames, outcomes Level of transparency between evidence and recommendation What differences? 1

12. Differences

14. Rigor of development: Provide detailed information on the search strategy, the inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible). Transparent link between evidence, values, and resulting recommendation External review Procedure for updating the CPG Criteria High Quality CPGs 1 AGREE Qual Saf Health Care 2003;12:18

15. Integration of values evidence integrationof values + Validity Homogeneity Safety Feasibility Cost practice guidelines

16. Indirect calorimetry vs. predictive equations Differences: recommendations 1

17. Dose of enteral nutrition and target range Differences: recommendations 1

18. Gastric Residual Volumes & Motility agents Differences: recommendations 1

19. Arginine Differences: recommendations 1

20. Enteral Glutamine Differences: recommendations 1

21. Peptides Differences: recommendations 1

22. zzzz…….

23. Fibre Differences: recommendations 1

24. Probiotics Differences: recommendations 1

25. Intensive Insulin Therapy Differences: recommendations 1

26. Similarities?

27. ADOPT NOW!

28. Slight difference in strength Enteral Nutrition over Parenteral Nutrition Canadians and ADA: Strongest ASPEN/SCCM: second strongest Feeding Protocols Canadians and ASPEN/SCCM: weaker recommendation ADA: none for feeding protocol per se, but for GRV : expert opinion EN plus PN Canadian: recommend NOT be used ASPEN/SCCM: not be started for 7 -10 days (grade C) Blue Dye ASPEN/SCCM : not recommend ADA : do not recommend but highest level of evidence 1

29. Differences exist between the guidelines: Populations, levels of evidence, time frames, etc Recommendations: due to interpretation of the evidence, lack of transparency Similarities in many of the recommendations Highlight the need for harmonization across North American Societies Summary 1

30. Similarities should be adopted without hesitation Differences Harmonize between societies Define critically ill patient Transparency needed (websites) Practitioner: right recommendation for the right person Implications 1

31. Upcoming in JPEN Available online Knowledge Translation issue Fall 2010 1

32. Ahhh…..Harmonized Guidelines!