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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 RupinderDhaliwal, RD Project Leader Critical Care Nutrition, Clinical Evaluation Research Unit Kingston, Ontario, Canada
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
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
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
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)
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
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
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
Type of Nutrition Support “We strongly recommend the use of EN over PN” n=2850 patients
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.
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
EN in Combination with PN % of patients received small bowel feeding before PN started
Use of Pharmaconutrients Total % Patients Ever on EN receiving formula
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
Benchmarking Compared to Canadian Clinical Practice Guidelines* *Originally published 2003. Benchmarked against 2007 recommendations. New Revised Sections January 31st 2009 on www.criticalcarenutrition.com
Ranking Performance Figure 1.5 Overall Performance of Your Site
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?
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