Bridging the Guideline-Practice Gap: The Critical Care Experience

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

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

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

5. 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

6. www.criticalcarenutrition.com

7. 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

8. 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

9. 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

10. Proliferation of guidelines

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

12. 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

13. 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

14. North American Guidelines www.criticalcarenutrition.com

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

16. Differences

18. 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

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

20. Indirect calorimetry vs. predictive equations Differences: recommendations

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

22. Gastric Residual Volumes & Motility agents Differences: recommendations

23. Arginine Differences: recommendations

24. Enteral Glutamine Differences: recommendations

25. Peptides Differences: recommendations

27. Fibre Differences: recommendations

28. Probiotics Differences: recommendations

29. Intensive Insulin Therapy Differences: recommendations

30. Similarities?

31. ADOPT NOW!

32. 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

33. 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

34. 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

35. JPEN Nov 2010:625-643

36. Ahhh…..Harmonized Guidelines!

37. Thank You!