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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. Participants of the International Nutrition Survey 2009

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International Critical Care Nutrition Survey 2009: Defining Gaps in Practice

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  1. 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

  2. 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

  3. Why Audit Nutrition Practice?

  4. Benchmarking • Individual ICUs compared to: • Canadian Clinical Practice Guidelines • All ICUs • ICUs from same geographic region

  5. Benchmarking

  6. Why Audit Nutrition Practice?

  7. 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

  8. 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

  9. 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

  10. 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)

  11. Web based Data Capture System

  12. 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

  13. ICU Characteristics

  14. Patient Characteristics

  15. Outcomes at 60 days

  16. We strongly recommend the use of enteral nutrition over parenteral nutrition

  17. Type of Nutrition Support n=2948 patients

  18. Use of EN Only 73.7% 93.4% 55.6% 6.4% 66.5% n=16983 patients days

  19. Use of PN Only 12% 6.6% 8.9% n=2279 patients days

  20. Use of EN + PN 16.3% 2.7% 4.6% n=292 patients days

  21. No EN, PN or Oral intake received 26.9% 10.5% 20% n=5117 patients days

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

  23. Timing of Initiation of EN 50 hrs 30 hrs 41 hrs

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

  25. Feeding Protocol

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

  27. Strategies to Optimize EN Delivery:Motility Agents 87% 45% 60.7%

  28. 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

  29. Location of Feeding Tube

  30. Small Bowel Feeding 43.8% 4.3% 12.2%

  31. Composition of EN and Pharmaconutrient Supplementation recommendations

  32. Use of EN Formula and Pharmaconutrients

  33. 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

  34. EN in Combination with PN % of patients received motility agents before PN started 63% 21% 44.4%

  35. We recommend that hyperglycemia (blood sugars >10mmol/l) be avoided

  36. Blood Glucose >10 mmol/l 15.6% 8.8% 13.4%

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

  38. Overall Performance: Kcals 93% 49.9% 8.3%

  39. Overall Performance: Kcals

  40. 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

  41. Nutritional Adequacy Over Time

  42. 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

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