International Critical Care Nutrition Survey 2009:

Defining Gaps in Practice

Naomi E Cahill, RD MScProject Leader

Queen’s University/Clinical Evaluation Research Unit

Kingston, Ontario, Canada

Acknowledgments

• Participants of the International Nutrition Survey 2009

• Dr Daren Heyland and the Research Team at the Clinical Evaluation Research Unit– Lauren Murch, Project Assistant– Rupinder Dhaliwal, Project Leader– Andrew Day, Biostatistician– Miao Wang, Data Analyst– Fernando Ferrer, IT Support

The provision of safe and adequate nutrition for all our

critically ill patients

5

What is an audit?

What is an audit?

Nutrition

Canadian CPGs

International Nutrition Survey

Benchmarking

Benchmarking

Individual ICUs compared to:

•Canadian Clinical Practice Guidelines

•All ICUs

•ICUs from same geographic region

Why Audit Nutrition Practice?

Objectives of International Survey

Quality Improvement• To observe current nutrition practice in the adult critical

care setting (overall and subgroups)• Define gaps between best practice and current practice • To identify opportunities for improvement

Generate New Knowledge• To identify factors associated with optimal provision of

nutrition • To determine what nutrition practices are associated with

best clinical outcomes

History of International Surveys

• 3 previous surveys in Canada– 2001, 2003, 2004– N > 50

• Extended to other countries in 2007 and 2008– 167 ICUs each year– >18 countries

– 65 ICUs from 10 countries participated in both years.

• Repeated in September 2009– Focus on North America

Methods

Eligibility Criteria• ICU Site

– >=8 beds– Availability of individual with knowledge of

clinical nutrition to collect data

• Patient– Adult >18 years– Mechanically ventilated within 48 hours– In ICU > 72 hours

Methods

• Start date: 16th September 2009

• Aim 20 consecutive patients– Min 8 pts

• Data included:– Hospital and ICU demographics– Patient baseline information (e.g. age, admission diagnosis,

APACHE II)– Baseline Nutrition Assessment– 12 days Daily Nutrition data (e.g. type of NS, amount NS

received)– 60 day hospital outcomes (e.g. mortality, length of stay)

Web based Data Capture System

Canada: 32

USA: 63

Australia & New Zealand: 22

Europe: 14

Latin America: 10

Asia: 16

Mexico: 2 Brazil:1Colombia:5Peru:1Venezuela:1

Italy: 2UK: 7

Ireland: 2Norway: 1

Switzerland: 1Czech Republic: 1

China: 1Taiwan: 1India: 10Iran : 1

Japan: 1Singapore: 2

Who participated in 2009? : 157 ICUs

ICU CharacteristicsCharacteristics Total (n=157)

Hospital Type

Teaching 116 (73.9%)

Non-teaching 41 (26.1%)

Size of Hospital (beds)

Mean (Range) 503 (50, 1500)

ICU Structure

Open 49 (31.2%)

Closed 104 (66.2%)

Other 4 (2.5%)

Size of ICU (beds)

Mean (Range) 19 (6, 64)

Designated Medical Director 149 (94.9%)

Presence of Dietitian(s) 145 (92.4%)

FTE Dietitians (per 10 beds)

Mean (Range) 0.4 (0.0, 1.7)

Patient CharacteristicsCharacteristics Total n=3032

Age (years)

Median [Q1,Q3] 61 [48, 73]

Sex

Female 1217 (40.1%)

Male 1815 (59.9%)

Admission Category

Medical 1954 (64.4%)

Surgical: Elective 366 (12.1%)

Surgical: Emergency 712 (23.5%)

BMI (kg|m2)

Median [Q1, Q3] 26.0 [22.8, 30.8]

Apache II Score

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

Presence of ARDS

Yes 413 (13.6%)

We strongly recommend the use of enteral nutrition over

parenteral nutrition

Type of Nutrition Support

n=3032 patients

EN Only72%

PN Only5%

EN+PN13%

None10%

Use of EN Only

n=17,574 patients days

73.6%

66.7%

93.9%

9.8%0

10

20

30

40

50

60

70

80

90

100

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% IC

U d

ays

Use of PN Only

n=2,295 patients days

6.6% 8.7%

38.6%

0.6%0

5

10

15

20

25

30

35

40

45

50

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% IC

U d

ays

Use of EN + PN

n=1,158 patients days

2.7%4.4%

72.2%

0.3%0

10

20

30

40

50

60

70

80

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% IC

U d

ays

No EN, PN or Oral intake received

n=5,320 patients days

20.2%

61.7

4.30

10

20

30

40

50

60

70

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% IC

U d

ays

17.2%

We recommend early enteral nutrition (within 24-48 hrs

following admission) in critically ill patients

Timing of Initiation of EN

41hrs

144hrs

9hrs0

24

48

72

96

120

144

168

Canada Australia and New Zealand

USA Europe Latin America Asia Total

Tim

e to

Init

iati

on

of

EN

(h

ou

rs)

35 hrs

An evidence based feeding protocol should be considered

as a strategy to optimize delivery of enteral nutrition

Feeding Protocol

Characteristics Total n=157

Feeding Protocol

Yes 129 (82.2%)

Gastric Residual VolumeThreshold

Mean (range) 240 (50, 500)

Algorithms included in Protocol

Motility agents 90 (72.6%)

Small bowel feeding 69 (55.6%)

Withholding for procedures 69 (55.6%)

HOB Elevation 117 (94.4%)

Other 19 (15.3%)

In critically ill patients who experience feed intolerance (high gastric residual volumes, emesis)

the use of a motility agent is recommended

Strategies to Optimize EN Delivery:Motility Agents

86%

66%

100.0

0.00

10

20

30

40

50

60

70

80

90

100

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% p

atie

nts

with

HG

RV

In units were achieving routine small bowel access is not

feasible small bowel feeding should be considered for patients who repeatedly demonstrate high gastric residual volumes and are

not tolerating EN

Location of Feeding Tube

61%20%

11%

2%4% 2% 0% Gastric confirmed

Gastric presumed

Post-pyloric duodenalconfirmed

Post-pyloric duodenalpresumed

Post-pyloric jejunalconfirmed

Post-pyloric jejunalpresumed

No tube in place

Small Bowel Feeding

12%

100.0

0.00

10

20

30

40

50

60

70

80

90

100

CanadaAustralia and New ZealandUSA Europe Latin America Asia Total

% p

atie

nts

with

HG

RV

15%

Composition of EN and Pharmaconutrient Supplementation recommendationsArginine-supplemented formulas Recommend NOT be used

Glutamine supplementation

Enteral should be considered in burn and trauma

Parenteral strongly recommended in PN pts

Fish oil enriched formula Recommended in ARDS

Combined vitamins and trace elements

Should be considered

Polymeric Recommend

Use of EN Formula and Pharmaconutrients

Arginine-supplemented formulas 8.2%(0.0%-94.7%)

Glutamine supplementation (All) 5.9%(0.0%-95%)

Fish oil enriched formula (ARDS) 18.9% (0.0%-100%)

Selenium Supplementation (All) 3.1% (0.0%-100%)

Polymeric 85.9% (0.0%-100.%)

We recommend that hyperglycemia (blood sugars

>10mmol/l) be avoided

Blood Glucose >10 mmol/l

13

0

5

10

15

20

25

30

35

40

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% p

atie

nt-

da

ys

13

Overall Performance

Adequacy of Nutrition Support =

Calories received from EN + appropriate PN+Propofol Calories prescribed

Overall Performance: Kcals

0

20

40

60

80

100

120

140

1 2 3 4 5 6 7 8 9 10 11 12

ICU Day

% r

ec

eiv

ed

/pre

sc

rib

ed

Mean of All Sites Best Performing Site Worst Performing Site

Overall Performance: Kcals

59 61

49

61

5155 55

0

10

20

30

40

50

60

70

80

90

100

Canada Australia and New Zealand

USA Europe Latin America Asia Total

% re

ceiv

e/p

resc

ribed

Where can we do better?

• Inadequate EN delivery– timing of initiation of EN– feeding protocols– small bowel feeding

• Optimize Pharmaconutrition– use of glutamine, antioxidants, omega-3 FFA.

• Tighten glycemic control

Nutritional Adequacy Over Time

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12

ICU Day

% r

ec

eiv

ed

/pre

sc

rib

ed

Year 2007 Year 2008 Year 2009

Why Audit Nutrition Practice?

How are you performing at your site?

Can you be the Best of the Best?

Further Information: www.criticalcarenutrition.com