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International Nutrition QI Project 2007: Debriefing Session

International Nutrition QI Project 2007: Debriefing Session. Friday June 15 th , 2007 Confederation 3, Fairmont Royal York, Toronto. Agenda. Brief Overview of Survey Results Review of Benchmarked Performance Reports Small Group Discussion Future Research Summary and Closing Comments.

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International Nutrition QI Project 2007: Debriefing Session

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  1. International Nutrition QI Project 2007: Debriefing Session Friday June 15th, 2007 Confederation 3, Fairmont Royal York, Toronto

  2. Agenda • Brief Overview of Survey Results • Review of Benchmarked Performance Reports • Small Group Discussion • Future Research • Summary and Closing Comments

  3. Purpose • To describe and compare nutrition practices • To compare nutrition practices to the Canadian Nutrition Support Clinical Practice Guidelines • To identify opportunities for improvement • Illuminate research opportunities

  4. Who participated?: 165 ICUs Malaysia: 2 China: 6 Saudi Arabia: 2 Indonesia: 1 Canada: 47 UK & Ireland:22 USA:41 Asia:11 EU (other): 14 Austria:2 Czech Republic: 3 Italy: 5 Slovenia:1 Spain:1 Sweden: 2 Brazil:1 Mexico:3 Uruguay:1 Venezuala:1 Latin America: 5 Australia & New Zealand: 23

  5. Who participated?:Health practitioners 206 Registered Practitioners

  6. Ethics Approval • 206 Registered ICUs • 41 ICUs excluded as no data entered Reason for attrition: ? Ethics approval • 120 ICUs (57.5%) required local ethics approval • 97 expedited review • 1 expedited review plus informed consent required • 21 full review • 1 full review plus informed consent required

  7. Who participated?Patients • Number of patients per site • 19.3 (1-40) • Total number of patients • 2896 • Days of observation per patient • 9.5 (1-12) • Total number of patient days in ICU • 27192 days • <3% missing data for ALL variables

  8. Preliminary Site Report Purpose of review: • Communicate how to interpret your site report • Review ‘preliminary’ results of the survey • Receive feedback on format of site reports

  9. Sister Sites

  10. Overall Performance Adequacy of Nutrition Support = Calories received from EN & appropriate PN X 100 Calories prescribed

  11. Overall Performance

  12. Adequacy of EN

  13. Overall Performance

  14. EN vs. PN We strongly recommend the use of EN over PN

  15. EN vs. Standard Care In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely

  16. Early vs. Delayed EN We recommend early EN (within 24-48 hours following admission)

  17. EN in combination with PN For critically ill patients starting on EN, we recommend that PN not be started at the same time as EN

  18. Composition of Nutrition Support

  19. Strategies to Optimize EN Delivery: Feeding Protocol

  20. Strategies to Optimize EN Delivery

  21. Strategies to Optimize PN Delivery: Dose of PN

  22. Strategies to Optimize PN Delivery: Use of Lipids

  23. Intensive Insulin Therapy

  24. Intensive Insulin Therapy

  25. Intensive Insulin Therapy

  26. Small Group Discussion What are the most effective strategies for changing behaviour around nutrition practices in the ICU? What are your thoughts on the data elements collected in the survey, the method of data collection, and how it is represented in the site reports?

  27. Small Group Discussion • 20 mins • Nominate ‘recorder’ and ‘spokesperson’ • Give freely of your experience • Keep confidences and assume others will • Feel free to ask us questions • Summarize key points

  28. Moving Forward:QI in the ICU • Changing nutrition practice is complex • Need to identify barriers and enablers to changing practice • Need to understand factors associated with guideline implementation and adherence

  29. Understanding Guideline Implementation • Secondary Analysis of Canadian Nutrition Survey 2004 dataset • Multiple case study • 4 case ICU sites • 28 Semi-structured key informant interviews

  30. Guidelines Information overload Weak evidence Impractical / Complex Institution Community Hospital setting Open ICU Slow administrative process Resource constraints Practitioner Lack of awareness Limited critical care experience Resistance to change Nursing workload Patient Poor clinical condition Surgical Identified Barriers

  31. Enablers • Agreement of the attending physician & ICU team • Part of routine practice • Dietitian / Opinion leader • Access / Visibility • Easy to follow and perform • Provision of education • Open discussion

  32. Successful Implementation Strategies • Informal one-on-one discussions • Academic detailing, ward rounds • Bed-side reminders • Check-list, algorithms, • Feedback and audit • Site reports

  33. Framework for Adherence to CPGs in the ICU OPTIMAL NUTRITION Canadian Nutrition Guidekines 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 Legend: Italics = New themes ICU = Intensive Care Unit Awareness

  34. Future Research • Survey of Attitudes towards the Canadian Nutrition Support Clinical Practice Guidelines • Tailored approach to guideline implementaton • Development of screening questionnaire and educational toolkit • ? Future Cluster Randomized Controlled Trial

  35. International QI Project 2008 !!

  36. Thank you

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