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International Critical Care Nutrition Survey 2008 Defining Gaps in Practice

International Critical Care Nutrition Survey 2008 Defining Gaps in Practice. Rupinder Dhaliwal , RD Project Leader Critical Care Nutrition, Clinical Evaluation Research Unit Kingston, Ontario, Canada. Critical Care Nutrition. Mission Statement

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International Critical Care Nutrition Survey 2008 Defining Gaps in Practice

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  1. International Critical Care Nutrition Survey 2008 Defining Gaps in Practice RupinderDhaliwal, RD Project Leader Critical Care Nutrition, Clinical Evaluation Research Unit Kingston, Ontario, Canada

  2. Critical Care Nutrition Mission Statement To improve practice of nutrition therapies in the critical care setting through knowledge generation, synthesis, and translation that ultimately leads to improved clinical outcomes for critically ill patients and improved efficiencies to our health care systems. Knowledge Generation Knowledge Synthesis Knowledge Translation www.criticalcarenutrition.com

  3. History of International Surveys • 3 previous surveys in Canada • 2001, 2003, 2004 • N > 50 ICUs each year • Extended to other countries in 2007 • Focus on North America • n=165 • Repeated in 2008 • Focus on Australasia

  4. Objectives of International Survey • To determine current nutrition practice in the adult critical care setting • Illuminate gaps between best practice and current practice • To identify interventions to target for quality improvement initiatives • To determine what nutrition practices are associated with best clinical outcomes • To determine factors associated with optimal provision of nutrition

  5. Methods • Prospective observational cohort study • Start date: 14 May 2008 • 20 consecutive critically ill patients • Data included: • Hospital and ICU demographics • Patient baseline information (e.g. age, admission diagnosis, APACHE II) • Baseline Nutrition Assessment • Daily Nutrition data (e.g. type of NS, amount NS received) • 60 day hospital outcomes (e.g. mortality, length of stay)

  6. Methods Eligibility Criteria • ICU Site • >8 beds • Availability of individual with knowledge of clinical nutrition to collect data • Patient • In ICU > 72 hours • Mechanically ventilated within 48 hours

  7. Web based Data Capture System

  8. Who participated?: 157 ICUs Canada: 34 Europe and Other: 17 USA: 44 Asia: 27 Italy: 3 UK: 7 Ireland: 3 Portugal: 1 South Africa: 3 China: 20 Taiwan: 1 India: 5 Mexico:1 Brazil:3 Colombia:3 Peru:1 Paraguay:1 Venezuela:1 Latin America: 10 Australia & New Zealand: 26

  9. Who participated?Patients • Number of finalized patients per site • 18.2 (8-26) • Total number of finalized patients • 2,850 • Days of observation per patient • 9.4 (3-12) • Total number of patient days in ICU • 23,811 days • <3% missing data for ALL variables

  10. ICU Characteristics

  11. Patient Characteristics

  12. Type of Nutrition Support “We strongly recommend the use of EN over PN” n=2850 patients

  13. Type of Nutrition: EN Only

  14. Type of Nutrition: PN Only

  15. Type of Nutrition: EN + PN

  16. Type of Nutrition: None

  17. Enteral Nutrition • 2368/2850 (84%) patients received EN (alone or combined with PN) • Median # days EN received: • 8 days [IQR 4-11 days] • 260/2368 patients (11.0%) received EN for all 12 days of observation.

  18. Early vs Delayed EN

  19. Strategies to Optimize EN Delivery:Feeding Protocol

  20. Location of Feeding Tube

  21. Feeding Intolerance • 638/2368 (26.9%) EVER had EN interrupted due to intolerance* • 1399/17,438 (8.0%) patients days had EN interrupted due to intolerance * Presence of high gastric residual volumes / emesis / aspiration

  22. Strategies to Optimize EN Delivery:Motility Agents

  23. Strategies to Optimize EN Delivery:Small Bowel Feeding

  24. EN in Combination with PN % of patients received small bowel feeding before PN started

  25. Strategies to Optimize EN Delivery:Head of Bed Elevation

  26. Use of Pharmaconutrients Total % Patients Ever on EN receiving formula

  27. Strategies to Optimize PN Delivery:Use of IV Glutamine Use of PN glutamine in Patients receiving PN

  28. Intensive Insulin Therapy In all critically ill patients, we recommend avoiding hyperglycemia (blood glucose > 10 mmol/l)

  29. Overall Performance Adequacy of Nutrition Support = Calories received from EN + appropriate PN+Propofol Calories prescribed

  30. Overall Performance: Kcals

  31. Adequacy of EN: Kcals

  32. Adequacy of EN: Protein

  33. Benchmarking Compared to Canadian Clinical Practice Guidelines* *Originally published 2003. Benchmarked against 2007 recommendations. New Revised Sections January 31st 2009 on www.criticalcarenutrition.com

  34. Ranking Performance Figure 1.5 Overall Performance of Your Site

  35. Future Directions Quality Improvement Initiatives • Inadequate EN delivery • early EN feeding protocols • small bowel feeding • Optimize Pharmaconutrition • use of glutamine, antioxidants, omega-3 FFA. • Tighten glycemic control • Withhold soy bean emulsion lipids • others?

  36. How are you performing at your site? Can you be the Best of the Best? Next International Nutrition Survey Coming Soon ..... Sept 2009 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

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