1 / 37

Bridging the Guideline-Practice Gap: The Critical Care Experience

Bridging the Guideline-Practice Gap: The Critical Care Experience. Rupinder Dhaliwal, RD Daren Heyland , MD. Guidelines for Nutrition Therapy in the ICU. Rupinder Dhaliwal, RD Operations Manager Clinical Evaluation Research Unit Kingston, Ontario. Disclosure. Rupinder Dhaliwal.

rico
Download Presentation

Bridging the Guideline-Practice Gap: The Critical Care Experience

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Bridging the Guideline-Practice Gap: The Critical Care Experience Rupinder Dhaliwal, RD Daren Heyland, MD

  2. Guidelines for Nutrition Therapy in the ICU Rupinder Dhaliwal, RD Operations Manager Clinical Evaluation Research Unit Kingston, Ontario

  3. Disclosure • Rupinder Dhaliwal Canadian Clinical Practice Guidelines for Nutrition Support for the Mechanically Ventilated Critically ill • Co-Author

  4. Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right outcome! www.criticalcarenutrition.com

  5. www.criticalcarenutrition.com

  6. A Continuous Quality Improvement Effort What ought to be done? RCTs, Systematic Reviews, and Evidence-based practice guidelines What is done? What is done? How to change? “KT strategies” www.criticalcarenutrition.com Survey results What do we need to do differently? “Gaps” - site reports

  7. Objectives • To identify the similarities and the differences between the recommendations of three North American Clinical Practice Guidelines • Understand why these differences occur • Need for harmonization across guidelines

  8. Why bother with guidelines? 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

  9. Proliferation of guidelines

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

  11. Review of guidelines needed What is needed Assesses the process of development A review of the content and the evidence used to formulate the recommendations

  12. Which Guidelines to compare? • Critically ill populations • Developed by North American professional/national organization • Published/online 1999-2009 • Addressed more than one single topic • Were not consensus statements (i.e. immunonutrition ) • Were original work vs. part of cluster RCTs

  13. North American Guidelines www.criticalcarenutrition.com

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

  15. Differences

  16. 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 AGREE QualSaf Health Care 2003;12:18

  17. Integration of values evidence integration of values + Validity Homogeneity Safety Feasibility Cost practice guidelines

  18. Indirect calorimetry vs. predictive equations Differences: recommendations

  19. Dose of EN/Achieving target range Differences: recommendations

  20. Gastric Residual Volumes & Motility agents Differences: recommendations

  21. Arginine Differences: recommendations

  22. Enteral Glutamine Differences: recommendations

  23. Peptides Differences: recommendations

  24. Fibre Differences: recommendations

  25. Probiotics Differences: recommendations

  26. Intensive Insulin Therapy Differences: recommendations

  27. Similarities?

  28. ADOPT NOW!

  29. 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 until strategies to maximize EN adopted 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

  30. Differences exist between the guidelines: Populations Levels of evidence: not enough RCTs so tendency to make a recommendation Time frames of literature searches and updates Recommendations: due to interpretation of the evidence, lack of transparency Similarities in many of the recommendations Conclusions

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

  32. JPEN Nov 2010:625-643

  33. Ahhh…..Harmonized Guidelines!

  34. Thank You!

More Related