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2008 International Nutrition Survey: Preliminary Results. ANZICS/ AuSPEN Conference Sydney, Australia November 1, 2008. Critical Care Nutrition. . Mission Statement
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2008 International Nutrition Survey: Preliminary Results ANZICS/ AuSPEN Conference Sydney, Australia November 1, 2008
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.
Andrew Day Biostatistician Siouxzy Morrison Project Leader AuSPEN/ANZICS Nutrition Research Fellow
Achieving Best Practice:Quality Improvement What ought to be done? RCTs, Systematic Reviews, and Evidence-based practice guidelines What is done? How to change? Survey results KT Strategies What do we need to do differently? Benchmarking; Best Achievable Practice
Objectives of International Audit • To determine current nutrition practice in the adult critical care setting (overall and subgroups) • Illuminate gaps between best practice and current practice • To identify interventions to target for quality improvement initiatives • To determine factors associated with optimal provision of nutrition • To determine what nutrition practices are associated with best clinical outcomes
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 outcomes (e.g. mortality, length of stay)
Methods Eligibility Criteria • ICU Site • >5 beds • Availability of individual with knowledge of clinical nutrition to collect data • Patient • In ICU > 72 hours • Mechanically ventilated within 48 hours
Who participated?: 159 ICUs Canada: 34 USA: 43 Europe and Other: 18 Asia: 27 Italy: 3 UK: 9* Ireland: 2 Portugal: 1 South Africa: 3 China: 20* Taiwan: 1 India: 6 Mexico:1 Brazil:3 Colombia:3 Peru:1 Paraguay:1 Venezuela:1 Latin America: 10 Australia & New Zealand: 27
Who participated?Health practitioners 164 Registered Practitioners
Who participated?Patients • Number of finalized patients per site • 18.0 (1-26) • Total number of finalized patients • 2486 • Days of observation per patient • 9.3 (3-12) • Total number of patient days in ICU • 23199 days • <3% missing data for ALL variables
Baseline Nutrition Assessment Methods Used to Calculate Energy Requirements
Type of Nutrition Support “We strongly recommend the use of EN over PN” n=2486 patients
Contraindication to EN(In Pts receiving PN) In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely
Use of Pharmaconutrients Total % Patients Ever on EN receiving formula
EN in Combination with PN % patients on EN where PN was started 72 hours after initiation of EN
Strategies to Optimize PN Delivery:Use of Lipids no pt days on PN=2895
Strategies to Optimize PN Delivery:Use of IV Glutamine Use of PN glutamine in Patients receiving PN
Intensive Insulin Therapy In all critically ill patients, we recommend avoiding hyperglycemia (blood glucose > 10 mmol/l)
Overall Performance Adequacy of Nutrition Support = Calories received from EN + appropriate PN+Propofol Calories prescribed
Ranking Performance Figure 1.5 Overall Performance of Your Site
Best of the Best Can you be the best in the International Nutrition Survey 2008 • Eligible sites: • Data on 20 critically ill patients • Complete baseline nutrition assessment • Presence of feeding protocol • No missing data or outstanding queries • Permit source verification by CCN • Awarded to ICU that demonstrate: • High nutritional adequacy • Adherence to the Canadian guidelines
Best of the Best Can you be the best in the International Nutrition Survey 2008 • Eligible sites: • Data on 20 critically ill patients • Complete baseline nutrition assessment • Presence of feeding protocol • No missing data or outstanding queries • Permit source verification by CCN • Awarded to ICU that demonstrate: • High nutritional adequacy • Adherence to the Canadian guidelines
Best of the Best • Rank all eligible ICUs by determinants • Multiply ranking by weighting • ICU with highest score is crowned ‘Best of the Best’