International Critical Care Nutrition Survey 2008 Defining Gaps in Practice

Rupinder Dhaliwal, RDProject Leader

Critical Care Nutrition, Clinical Evaluation Research Unit

Kingston, Ontario, Canada

Critical Care Nutrition

Mission StatementTo 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.

www.criticalcarenutrition.com

Knowledge Generation

Knowledge Synthesis

Knowledge Translation

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

Web based Data Capture System

Canada: 34

USA: 44

Australia & New Zealand: 26

Europe and Other: 17

Latin America: 10

Asia: 27

Mexico:1 Brazil:3Colombia:3Peru:1Paraguay:1Venezuela:1

Who participated?: 157 ICUs

Italy: 3UK: 7

Ireland: 3Portugal: 1

South Africa: 3

China: 20Taiwan: 1India: 5

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

ICU CharacteristicsCharacteristics Total

n=157

Hospital Type

Teaching 122 (78.5%)

Non-teaching 33 (21.3%)

Size of Hospital (beds)

Mean (Range) 617 (108, 3000)

Multiple ICUs in Hospital

Yes 84 (53.5%)

ICU Structure

Open 42 (26.8%)

Closed 113 (72.0%)

Other 2 (1.3%)

Size of ICU (beds)

Mean (Range) 17 (5,48)

Characteristics Total

n=157

Case Type

Medical 140 (89.2%)

Surgical 140 (89.2%)

Trauma 93 (59.2%)

Pediatrics 17 (10.8%)

Neurological 109 (69.4%)

Neurosurgical 89 (56.7%)

Cardiac Surgery 55 (35.0%)

Burns 29 (18.5%)

Others 17(10.8%)

Designated Medical Director

150 (95.5%)

FTE Dietitians

(per 10 beds)

Mean (Range) 0.4 (0.0, 2.2)

Patient Characteristics

Characteristics Total n=2850

Age (years)

Median [Q1,Q3] 62 [48, 73]

Sex

Female 1054 (37.0%)

Male 1796 (63.0%)

Admission Category

Medical 1756 (61.6%)

Surgical: Elective 405 (14.2%)

Surgical: Emergency 689 (24.2%)

Apache II Score

Median [Q1, Q3] 22 [17, 28]

Presence of ARDS

Yes 320 (11.2%)

Admission Diagnosis

Cardiovascular / Vascular

501 (17.6%)

Respiratory 747 (26.2%)

Pancreatitis 40 (1.4%)

Gastrointestinal 391 (13.7%)

Neurologic 339 (11.9%)

Sepsis 241 (8.5%)

Trauma 289 (10.1%)

Metabolic 72 (2.5%)

Hematologic 18 (0.6%)

Renal 46 (1.6%)

Gynecologic 5 (0.2%)

Orthopedic 15 (0.5%)

Bariatric Surgery 3 (0.1%)

Burns 30 (1.1%)

Other 113 (4.0%)

Type of Nutrition Support

“We strongly recommend the use of EN over PN”

n=2850 patients

Type of Nutrition: EN Only

Type of Nutrition: PN Only

Type of Nutrition: EN + PN

Type of Nutrition: None

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.

Early vs Delayed EN

Strategies to Optimize EN Delivery:Feeding Protocol

Characteristics Total

n=157

Feeding Protocol

Yes 125 (79.6%)

Gastric Residual Volume Tolerated in Protocol

Mean (range) 208 (100, 500)

Algorithms included in Protocol

Motility agents 83 (71.6%)

Small bowel feeding 61 (52.6%)

Withholding for procedures 57 (49.1%)

HOB Elevation 93 (80.2%)

Other 22 (19.0%)

Location of Feeding Tube

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

Strategies to Optimize EN Delivery:Motility Agents

Strategies to Optimize EN Delivery:Small Bowel Feeding

EN in Combination with PN% of patients received small bowel feeding before PN started

Strategies to Optimize EN Delivery:Head of Bed Elevation

Use of Pharmaconutrients

Total % Patients Ever on EN receiving formula

Arginine-supplemented formulas 6.0%(0.0%-93.8%)

Glutamine supplementation 7.6%(0.0%-88.9%)

Fish oil enriched formula (All) 3.1% (0.0%-83.3%)

Fish oil enriched (ARDS) 10.5% (0.0%-88.9%)

Polymeric 90.5% (0.0%-100.0%)

Strategies to Optimize PN Delivery:Use of IV Glutamine

Use of PN glutamine in Patients receiving PN

Intensive Insulin TherapyIn 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

Overall Performance: Kcals

Adequacy of EN: Kcals

Adequacy of EN: Protein

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 PerformanceFigure 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?

Further Information: www.criticalcarenutrition.com