Bridging the Gap: Effective Dissemination Strategies for Improving Nutrition Practice in the ICU

1. Bridging the Gap: Effective Dissemination Strategies for Improving Nutrition Practice in the ICU Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

2. More is Better! Our Field of Dream If you feed them (better!) They will leave (sooner!)

3. In patients with high gastric residual volumes: • use of motility agents 58.7% (site average range: 0-100%) • use of small bowel feeding 14.7% (range: 0-100%) Cahill N Crit Care Med 2010

4. “Minding the GAP”an Important Part of Patient Safety The time to ACT is NOW!

5. How to Change?CPGs to bedside Guidelines Bedside Dissemination and Implementation Strategies

6. Special JPEN Issue Dedicated to KT • Knowledge Translation (KT) • describes the process of moving evidence learned from clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making. • defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system.” • Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept. Available online now In press shortly

7. Lost in (Knowledge) Translation! Knowledge to Action Model by Graham Heyland DK, Cahill N, Dhaliwal R

8. Knowledge Generation Knowledge To Action Model Since 1980, >200 randomized trials of nutrition interventions studying >2000 critically ill patients

9. Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

10. Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

11. Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

12. Knowledge Synthesis Knowledge – To- Action Model Systematic reviews and meta-analyses of 34 nutrition related topics

13. Clinical Practice Guidelines Knowledge – To- Action Model Development of multiple Critical Care Nutrition Clinical Practice Guidelines

14. Guidelines, Guidelines, Guidelines. What Are We to do With all of These North American Guidelines? • Comparison of Canadian, American Dietetic Association, ASPEN/SCCM CPGs • Different methods, studies included, ratings of evidence and values • Similarities, minor and major differences in recommendations • Can we harmonize this process? Dhaliwal R, Madden S, Cahill N, Jeejeebhoy K, Kutsogiannis J, Muscedere J, McClave S, Heyland DK

15. How to Narrow the Gap?First Define the Gap International audits of nutrition practice

16. In patients with high gastric residual volumes: • use of motility agents 58.7% (site average range: 0-100%) • use of small bowel feeding 14.7% (range: 0-100%) Cahill N Crit Care Med 2010

17. Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within 24-48 hrs following resuscitation) in critically ill patients. Value of Bench-marked Site Reports Early vs Delayed Nutrition Intake

18. The Value of ‘Audit and Feedback Reports’ in Improving Nutritional Therapy in the ICU: A Multicenter Observational Study • 26 Canadian ICUs participating in 2007 and 2008 Surveys (45.1% to 51.9%, p<0.001 and 44.8% to 51.5%, p<0.001 for calories and protein respectively Sinuff T, Cahill N, Dhaliwal R, Wang M, Day A, Heyland DK

19. Need to Understand Local Barriers Assess Barriers

20. Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework ADHERENCE CPG Characteristics Patient Characteristics Provider Intent Implementation Process Institutional Factors • Provider Characteristics • - Profession • Critical care expertise • Educational background • Personality • Hospital • characteristics • Structure • Processes • Resources • Patient Case-mix Knowledge Attitudes • ICU • characteristics • Structure • Processes • Resources • Patient Case-mix • Culture Familiarity Agreement Outcome expectancy Motivation Self-efficacy Awareness Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

21. The Relationship Between Organizational Culture and Implementation of Clinical Practice Guidelines: A Narrative Review • “The way things are around here” • Major influence on CPG adherence • Defining, measuring, and changing Dodek P, Cahill N, Heyland DK

22. The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:Results of a multicenter observational study • International, prospective, observational, cohort studies conducted in 2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries • Included 5497 mechanically ventilated adult patients > 3 days in ICU • Sites recorded the presence or absence of a feeding protocol • Sites provided nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. 78% of sites reported use of Feeding Protocol P<0.05 Heyland DK, Cahill N, Dhaliwal R, Sun, Xiaoqun, Day A, McClave S

23. Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework ADHERENCE CPG Characteristics Patient Characteristics Provider Intent Implementation Process Institutional Factors • Provider Characteristics • - Profession • Critical care expertise • Educational background • Personality • Hospital • characteristics • Structure • Processes • Resources • Patient Case-mix Knowledge Attitudes • ICU • characteristics • Structure • Processes • Resources • Patient Case-mix • Culture Familiarity Agreement Outcome expectancy Motivation Self-efficacy Awareness Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

24. Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians • International web-based survey of 514 practitioners from 27 countries Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

25. Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians • Majority (91.4%) considered nutrition therapy to be very important • Strong endorsement for the following established practices: enteral nutrition (EN) used in preference to parenteral nutrition (PN), use of polymeric solutions and feeding protocols, and avoiding hyperglycemia. • Also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within 24-48 hours of admission, use of motility agents, head of the bed elevation, use of glutamine and antioxidants, and maximizing EN prior to starting PN. • There was diversity of opinion on the recommendations pertaining to arginine-supplemented diets, small bowel feeding, use of pharmaconutrients, intensive insulin therapy, and withholding soybean oil lipids in PN solutions and hypocaloric PN. Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

26. Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework ADHERENCE CPG Characteristics Patient Characteristics Provider Intent Implementation Process Institutional Factors • Provider Characteristics • - Profession • Critical care expertise • Educational background • Personality • Hospital • characteristics • Structure • Processes • Resources • Patient Case-mix Knowledge Attitudes • ICU • characteristics • Structure • Processes • Resources • Patient Case-mix • Culture Familiarity Agreement Outcome expectancy Motivation Self-efficacy Awareness Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

27. Nutrition Therapy for the Critically Ill Surgical Patient: We Need to do Better! • Combined 2007 and 2008 survey database • 5497 mechanically ven’t patients >3days • 37% surgical Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day A, Heyland DK

28. Need for a Tailored Approach Select Intervention(s)

29. Bridging the Guideline – Practice Gap In Critical Care Nutrition: A Review of Guideline Implementation Studies 3 Cluster RCTs Guidelines Bedside 14 ICUs in Canada 60 ICUs in Canada 27 ICUs in Australia Cahill N, Heyland DK

30. Practice Changing Interventions • Protocolize/automate care • Improve organizational culture • Develop Dietitian and other KOL as local opinion leaders • Audit and feedback with bench-marked site reports • Assess barriers and have interactive workshops with small group problem solving • Implement strategies with rapid cycle change (PDSA) • Educational reminders (manuals, posters, pocket cards) • One on one academic detailing

31. What works best at your site? (barriers and enablers will vary site to site) What is already working well at your site? (strengths and weakness are different across sites)

32. Vs. Tailored Intervention: Change strategies specifically chosen to address the barriers identified at a specific setting at a specific time

33. PERFormance Enhancement of the Canadian nutrition guidelines through a Tailored Implementation Strategy: The PERFECTIS Study Hypothesis Barriers are inversely related to nutrition performance and tailoring change strategies to overcome barriers to change will reduce the presence of these barriers and lead to improvements in nutrition practice.

34. And the Cycle continues...

35. Creating a Culture of Clinical Excellence in Critical Care Nutrition: The ‘Best of the Best’ Award Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

36. Recognition and Reward Recognition a powerful motivator of human performance

37. Recognition Produces Results! • The results of a 10-year, 200,000 employee study: • Organizations excelling at rewarding excellence had avg. ROE of 3x greater than the lowest rated organizations • Institutions that excel at recognizing employee contributions: • HIGHER in customer satisfaction • HIGHER in employee satisfaction/morale (94.4% agree their superior is effective at recognition, only 2.4% with low morale agree) • HIGHER in employee retention

38. Determining the Best of the Best • Rank all eligible ICUs by determinants • Multiply ranking by weighting • ICU with highest score is crowned ‘Best of the Best’

39. Best of the Best Award • 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: • Highest ranking nutritional performance

40. 2008 Best of the Best Top 3 ICUs1. Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand 2. Kingston General Hospital, Kingston, Canada 3. Regional Hospital A. Cardarelli, Italy

41. 2008Best of the Best Lyn Gillanders, Senior Clinical Dietitian and her ICU colleagues at the Department of Critical Care Medicine, Auckland City Hospital being presented with the Best of the Best Award by the Hospital Medical Director.

42. Determinants to Top Performance (Best Rank=1rst thus a negative number is associated with a better ranking) What site and hospital characteristics are associated with top BOB ranking? Heyland JPEN 2010

43. 2009 Best of the Best Of >200 ICUS competing Internationally TOP Performers 1. Instituto Neurologico de Antioquia, Medellin, Colombia 1. Royal Prince Alfred Hospital, Sydney, Australia 1. The Alfred, Melbourne, Australia

44. 2009 Best of the Best Of >200 ICUS competing Internationally Outstanding Performers Trillium Health Centre, Mississauga, Canada Regional Hospital A. Cardarell, Campobasso, Italy Royal Columbian Hospital, New Westminster, Canada Community Hospital of Monterey Peninsula, Monterey, USA Auckland City Hospital, Auckland, New Zealand Hamilton General Hospital, Hamilton, Canada University District Hospital Neuro-ICU, San Juan, USA

46. How to Change?CPGs to bedside Bedside Dissemination and Implementation Strategies