2008 international nutrition survey: preliminary results anzics/ auspen conference sydney, australia...
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2008 International Nutrition Survey:
Preliminary Results
ANZICS/ AuSPEN Conference
Sydney, Australia
November 1, 2008
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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.
Knowledge Generation Knowledge Synthesis Knowledge Translation
•RCTs evaluating:
- Acidified EN
-Small bowel feedings
-Cisapride
- Immunonutrition
- Feeding Algorithms
•REDOXS
•Over 40 systematic reviews
•Internationally recognized clinical practice guidelines
•Cluster RCT of guideline implementation strategies
•Ongoing international practice audits
•International attitudes & beliefs survey
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Critical Care Nutrition Staff
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Andrew DayBiostatistician
Siouxzy Morrison Project Leader
AuSPEN/ANZICS Nutrition Research Fellow
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Achieving Best Practice:Quality Improvement
What is done?
What ought to be done?
What do we need to do differently?
How to change?Survey results
Benchmarking; Best Achievable Practice
RCTs, Systematic Reviews, and Evidence-based practice guidelines
KT Strategies
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Objectives of International Audit
• To determine current nutrition practice in the adult critical care setting (overall and subgroups)
• Illuminate gaps between best practice and current practice
• To identify interventions to target for quality improvement initiatives
• To determine factors associated with optimal provision of nutrition
• To determine what nutrition practices are associated with best clinical outcomes
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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 outcomes (e.g. mortality, length of stay)
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Methods
Eligibility Criteria• ICU Site
– >5 beds– Availability of individual with knowledge of clinical
nutrition to collect data• Patient
– In ICU > 72 hours– Mechanically ventilated within 48 hours
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Web based Data Capture System
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Canada: 34
USA: 43
Australia & New Zealand: 27
Europe and Other: 18
Latin America: 10
Asia: 27
Mexico:1 Brazil:3Colombia:3Peru:1Paraguay:1Venezuela:1
Who participated? : 159 ICUs
Italy: 3UK: 9*
Ireland: 2Portugal: 1
South Africa: 3
China: 20*Taiwan: 1India: 6
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Who participated?Health practitioners
164 Registered Practitioners
59%
2%
14%
21%
1%3%
Dietitian
Nurse
Research Co-ordinator
Physician
Pharmacist
Other
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Who participated?Patients
• Number of finalized patients per site– 18.0 (1-26)
• Total number of finalized patients– 2486
• Days of observation per patient– 9.3 (3-12)
• Total number of patient days in ICU– 23199 days
• <3% missing data for ALL variables
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ICU Characteristics
Characteristics Total n=138
Hospital Type
Teaching 104 (75.4%)
Non-teaching 34 (24.6%)
Size of Hospital (beds)
Mean (Range) 515 (108, 1500)
Multiple ICUs in Hospital
Yes 72 (52.2%)
No 66 (47.8%)
ICU Structure
Open 40 (29.0%)
Closed 96 (69.6%)
Other 2 (1.4%)
Size of ICU (beds)
Mean (Range) 18 (5,48)
Characteristics Total n=138
Case Type
Medical 123 (89.1%)
Surgical 124 (89.9%)
Trauma 81 (58.7%)
Pediatrics 15 (10.9%)
Neurological 91 (65.9%)
Neurosurgical 75 (54.3%)
Cardiac Surgery 47 (34.1%)
Burns 28 (20.3%)
Others 15 (10.9%)
Designated Medical Director
Yes 131 (94.9%)
No 7 (5.1%)
Full Time Equivalent Dietitians
Mean (Range) 0.4 (0.0, 2.5)
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Patient Characteristics
Characteristics Total n=2486
Age (years)
Median [Q1,Q3] 61 [48, 72]
Sex
Female 929 (37.4%)
Male 1557 (62.6%)
Admission Category
Medical 1517 (61.0%)
Surgical: Elective 339 (13.6%)
Surgical: Emergency 630 (25.3%)
Apache II Score
Median [Q1, Q3] 22 [17, 28]
Presence of ARDS
Yes 229 (9.2%)
Characteristics Total n=2486
Admission Diagnosis
Cardiovascular / Vascular 448 (18.0%)
Respiratory 608 (24.5%)
Pancreatitis 37 (1.5%)
Gastrointestinal 329 (13.2%)
Neurologic 284 (11.4%)
Sepsis 235 (9.5%)
Trauma 269 (10.8%)
Metabolic 67 (2.7%)
Hematologic 15 (0.6%)
Renal 37 (1.5%)
Gynecologic 4 (0.2%)
Orthopedic 14 (0.6%)
Bariatric Surgery 3 (0.1%)
Burns 30 (1.2%)
Other 106 (4.3%)
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Patient 60 day Outcomes
Characteristics Total
n=2486Length of Mechanical Ventilation (days)
Median [Q1, Q3] 6.5 [3.2, 12.9]
Length of ICU Stay (days)
Median [Q1, Q3] 10.0 [5.8, 17.3]
Length of Hospital Stay (days)
Median [Q1,Q3] 20.4 [12.9, 32.8]
Patient Died (within 60 days)
Yes 663 (26.8%)
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Baseline Nutrition Assessment
Characteristics Total n=2486
BMI (kgh|m2)
Median [Q1, Q3] 26.1 [22.9, 30.5]
Prescribed Energy Intake (Kcals)
Median (Q1, Q3] 1800.0 [1584.0, 2040.0]
Prescribed Protein Intake (g)
Median [Q1,Q3] 85.0 [71.5, 100.0]
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Baseline Nutrition Assessment
Methods Used to Calculate Energy Requirements 10%
1%
14%
1%
7%
4%
13%
32%
9%
1%
8% Harris Benedict Equation
Schofield Equation with noadjustment for stress andactivity Schofield Equation withadjustment for stress and/oractivity Mifflin-St. Jeor Equation
Ireton-Jones Equation
<20 Kcal/Kg
20-24 Kcals/Kg
25-29 Kcals/Kg
30-35 Kcals/Kg
Provide 1500-2000 Kcal asstandard
Other, please specify
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Type of Nutrition Support
“We strongly recommend the use of EN over PN”
n=2486 patients
73%
5%
12%
10%
EN Only
PN Only
EN+PN
None
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Type of Nutrition: EN Only
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Type of Nutrition: PN Only
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Type of Nutrition: EN + PN
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Contraindication to EN(In Pts receiving PN)
In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely
13.5%
4.5%
5.9%
8.6%
7.2%
10.4%
3.6%
7.4%
2.9%2.5%
2.7%7.7%
18.5%
52.8%
No clincal reasons
Mechanical bowel obstruction
Bowel ischemia
Small bowel ileus
Small bowl fistulae
Gastrointestinal perforation
Short Gut Syndrome
Hemodynamic instability
Proximal bowel anastomosis
No access to small bowel
Pancreatitis
Gastrointestinal bleed
Gastrointestinal surgery
Other, please specify
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Type of Nutrition: None
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Early vs Delayed EN
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Strategies to Optimize EN Delivery:Feeding Protocol
Characteristics Total n=138
Feeding Protocol
Yes 112 (81.2%)
Gastric Residual Volume Tolerated in Protocol
Mean (range) 214 (100, 500)
Algorithms included in Protocol
Motility agents 72 (70.6%)
Small bowel feeding 52 (51.0%)
Withholding for procedures 47 (46.1%)
HOB Elevation 79 (77.5%)
Other 21 (20.6%)
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Strategies to Optimize EN Delivery:Motility Agents
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Strategies to Optimize EN Delivery:Small Bowel Feeding
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Strategies to Optimize EN Delivery:Head of Bed Elevation
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Use of Pharmaconutrients
Total % Patients Ever on EN receiving formula
Arginine-supplemented formulas 19.8%(0.0%-93.8%)
Glutamine supplementation 7.4%(0.0%-88.9%)
Oxepa (All) 12.1% (0.0%-83.3%)
Oxepa (ARDS) 7.4% (0.0%-88.9%)
Polymeric 71.7% (0.0%-100.0%)
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Arginine-supplemented formulas
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Glutamine supplementation
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Oxepa (All)
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Oxepa (ARDS)
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EN in Combination with PN% patients on EN where PN was started 72 hours after initiation of EN
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Strategies to Optimize PN Delivery:Use of Lipids
no pt days on PN=2895
19%
52%
4%
8%
14%
2% 1%
Lipid Free
Soybean oil based (LCTs)
MCT/LCT physical mixture
MCT/LCT structured form
Olive oil based
Fish oil based
Mixture of soy oil
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% patients received Soybean oil based (LCTs)
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Strategies to Optimize PN Delivery:Use of IV Glutamine
Use of PN glutamine in Patients receiving PN
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Intensive Insulin TherapyCharacteristics Total
20713Glycemic Control Protocol
Yes 122 (88.4%)
Target of Blood Glucose: Lower (mmol|l)
Median [Q1,Q3] 4.4 [4.0, 5.0]
Target of Blood Glucose: Upper (mmol|l)
Median [Q1,Q3] 7.8 [6.7, 8.3]
Morning Blood Glucose (mmol|l)
Median [Q1,Q3] 7.1 [6.0, 8.5]
Total Hypoglycemic Events
Yes 676 (3.3%)
Hypoglycemic Blood Sugar (mmol/l)
Median [Q1,Q3] 3.1 [1.0, 3.1]
Insulin Received (units)
Median [Q1,Q3] 36.0 [14.0, 71.3]
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Intensive Insulin TherapyIn all critically ill patients, we recommend avoiding
hyperglycemia (blood glucose > 10 mmol/l)
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Overall Performance
Adequacy of Nutrition Support =
Calories received from EN + appropriate PN+Propofol Calories prescribed
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Overall Performance: Kcals
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Overall Performance: Kcals
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Overall Performance: Protein
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Adequacy of EN: Kcals
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Adequacy of EN: Protein
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Benchmarking
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Ranking PerformanceFigure 1.5 Overall Performance of Your Site
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Best of the Best
Can you be the best in the International Nutrition Survey 2008• 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: High nutritional adequacy Adherence to the Canadian guidelines
BEST OF THE BEST
KGH
2008
Last year, 156 ICUs participated in an international audit of nutrition practices in critically ill patients. This year we want to take part.
Please help us to improve our performance as it relates to nutrition in our ICU. Better nutrition therapy translates into reduced
morbidity and improved survival.
For more information, contact____________________
ADD HOSPLOGO
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Best of the Best
Can you be the best in the International Nutrition Survey 2008• 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: High nutritional adequacy Adherence to the Canadian guidelines
BEST OF THE BEST
KGH
2008
Last year, 156 ICUs participated in an international audit of nutrition practices in critically ill patients. This year we want to take part.
Please help us to improve our performance as it relates to nutrition in our ICU. Better nutrition therapy translates into reduced
morbidity and improved survival.
For more information, contact____________________
ADD HOSPLOGO
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Best of the Best
Determinant WeightingOverall Adequacy of EN plus appropriate PN 10% patients receiving EN 5% of patients with EN initiated within 48 hours 3% of patients with high gastric residual volumes (HGRV) receiving motility agents
1
% of patients with HGRV receiving small bowel tubes 1% of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best)
3
Rank all eligible ICUs by determinantsMultiply ranking by weightingICU with highest score is crowned ‘Best of the Best’
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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?
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Future Directions
Hypothesis–generating Observations– Protocolized vs Non protocolized– Academic vs Community– Presence of dietitian and how much? – Subgroups
• by BMI• by Case Mix (Trauma, Sepsis; Pancreatitis, etc.)
– others?
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Thank you