Final Site Report

International Nutrition Survey 2011

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www.criticalcarenutrition.com

Final Site Report

Improving the Practice of Nutrition Therapy in the Critically ill:An International Quality Improvement Project

Produced by:

Critical Care Nutrition,Clinical Evaluation Research Unit,Angada 4, Kingston General Hospital,Kingston, ON. Canada K7L 2V7e-mail: [email protected]


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Interpreting Your Site Report

The International Nutrition Survey is a prospective survey of nutrition practices in Intensive Care Units(ICUs) throughout the World. Since May 2011, your ICU has been involved in collecting data for thissurvey. This site report summarizes your site's performance and will allow you to compare your nutritionpractices to other ICUs within your own country or region ('Sister Sites') and all the ICUs in the database('All Sites'). You will also be able to compare your performance to the recommendations of the Canadian CriticalCare Nutrition Clinical Practice Guidelines (CPGs) (1).

The first few pages describe ICU and patient characteristics. This helps you to identify the similarities anddifferences in the structure and patient case-mix of your ICU compared to other ICUs and will help you tointerpret your site report in the context in which you work.

Pages 7-11 outline the adequacy of nutrition therapy and enteral nutrition at your site and provides an overallassessment or summary of your performance in providing nutrition.

Subsequent pages outline the recommendations of the Canadian Critical Care Nutrition CPGs. After eachrecommendation is stated, a figure or table illustrates how your site performed for every nutrition practicerelated to that specific recommendation. The language of summary recommendations should be interpreted asfollows:

"Strongly recommended" If there was no reservations about endorsing an intervention.

"Recommended" If evidence was supportive but there were minor uncertainties about the safety,

feasibility, or costs of the intervention.

"Should be considered" If the supportive evidence was weak and/or there were major uncertainties

about the safety, feasibility, or costs of an intervention.

Your site: this represents the mean or median of all the data from your site. This is often depicted in thefigures by a clear block and --- dissecting the sister and all sites range bar.

Sister sites: refers to the average of all the data from ICUs within your own country or region (see page 3).All sites: refers to the average of all the data from all the ICUs in the database.Range: refers to the highest and lowest site percentages or averages.Q1: refers to the first quartile point from either your / sister / all sites.Q3: refers to the third quartile point from either your / sister / all sites.N: number of ICU sites / patients / ICU days as indicated.NA: not applicable, no relevant data entered for this data point.PCT: percent.n/N: number of observations per total observations for your / sister / all sites.

(1) Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P and the Canadian Critical Care Clinical Practice Guidelines Committee (2003) "Canadian ClinicalPractice Guidelines for Nutrition Support in Mechanically Ventilated, Critically Ill Adult Patients". J Parenter Enteral Nutr 27;355-373. For current version of theGuidelines, see www.criticalcarenutrition.com


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Participating ICUs

‘Sister sites'refers to the average of all the data from hospitals within your country or region and areclassified as follows:

Sister Sites Countries Number of ICUs________________________________________________________________________________

Canada Canada 20

Australia and New Zealand Australia 35

New Zealand 3

USA United States 41

Europe Ireland 6

Italy 1

Norway 5

Spain 2

Switzerland 1

United Kingdom 8

Latin America Argentina 4

Brazil 4

Chile 3

Colombia 5

El Salvador 1

Mexico 1

Peru 1

Uruguay 1

Venezuela 2

Asia China 13

India 7

Iran 1

Japan 9

Philippines 1

Singapore 3

Taiwan 4

Thailand 1________________________________________________________________________________

‘All Sites'refers to the average of all the data from all the ICUs in the database (n=183).


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Table 1. Characteristics of Participating ICUsYour Site Sister Sites All Sites

Number of ICUs n=1 n=39 n=183_________________________________________________________________________________________________________

Type of HospitalNon-teaching Yes 9 (23.1%) 41 (22.4%)

Teaching - 30 (76.9%) 142 (77.6%)

Size of Hospital (beds)mean (range) 230 1122 (109-2600) 641 (100-2600)

Multiple ICUs in HospitalYes 34 (87.2%) 108 (59.0%)

ICU TypeOpen Yes 15 (38.5%) 47 (25.7%)

Closed - 24 (61.5%) 132 (72.1%)Other - 0 4 (2.2%)

Case TypesMedical Yes 31 (79.5%) 161 (88.0%)

Neurological Yes 22 (56.4%) 117 (63.9%)Surgical Yes 30 (76.9%) 162 (88.5%)

Neurosurgical Yes 25 (64.1%) 103 (56.3%)Trauma Yes 28 (71.8%) 112 (61.2%)

Cardiac surgery No 14 (35.9%) 61 (33.3%)Pediatrics No 8 (20.5%) 23 (12.6%)

Burns No 8 (20.5%) 30 (16.4%)

Medical DirectorNo 36 (92.3%) 172 (94.0%)

Size of ICU (beds)mean (range) 12 19 (6-65) 18 (5-65)

Presence of Dietitian(s)Yes 19 (48.7%) 145 (79.2%)

Full time equivalent dietitians(per 10 beds)

mean (range) 0.6 0.3 (0.0-1.5) 0.6 (0.0-27.8)_________________________________________________________________________________________________________

Legend

Type of Hospital: A teaching hospital is a hospital that provides training to medical students and residents. Hospitals that have onlyoccasional medical students/residents are considered non-teaching hospitals.ICU Structure: Open ICUs are sites where patients are under the care of an attending physician (e.g. internist, family physician,surgeon) with intensivists (i.e. physician with training in critical care) consulted as necessary. Closed ICUs are sites in whichpatients are under the care of an intensivist, or care is shared between the intensivist and another attending physician.Full Time Equivalent Dietitian: This is a measure of the amount of time the dietitian is dedicated to the ICU relative to a full-timeposition e.g. a FTE of 1.0 refers to a dietitian working in a 10 bedded ICU full-time or four dietitians working half-time ina 20 bedded ICU. A FTE of 0.5 means that the dietitian is in a 10 bedded ICU half-time, or two and a half days a week.


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Table 2. Patient CharacteristicsYour Site Sister Sites All Sites

Number of Patients n=20 n=807 n=3695_________________________________________________________________________________________________________

Personal InformationAge

median [Q1,Q3] 42 [34-57] 64.0 [52-75] 63.0 [50-74]

SexFemale 6 (30.0%) 273 (33.9%) 1495 (40.5%)Male 14 (70.0%) 533 (66.1%) 2197 (59.5%)

Admission InformationAdmission Category

Medical 15 (75.0%) 471 (58.4%) 2316 (62.7%)Surgical Elective 2 (10.0%) 153 (19.0%) 486 (13.2%)

Surgical Emergency 3 (15.0%) 183 (22.7%) 893 (24.2%)

Admission DiagnosisCardiovascular/vascular 0 76 (9.4%) 336 (9.1%)

Respiratory 3 (15.0%) 182 (22.6%) 883 (23.9%)Gastrointestinal 0 21 (2.6%) 122 (3.3%)

Neurologic 3 (15.0%) 69 (8.6%) 295 (8.0%)Sepsis 2 (10.0%) 49 (6.1%) 371 (10.1%)

Trauma 0 23 (2.9%) 129 (3.5%)Metabolic 1 (5.0%) 13 (1.6%) 68 (1.8%)

Hematologic 0 3 (0.4%) 10 (0.3%)Other non-operative conditions 6 (30.0%) 35 (4.3%) 101 (2.7%)

Vascular/cardiovascular -operative 0 87 (10.8%) 306 (8.3%)Respiratory -operative 0 9 (1.1%) 49 (1.3%)

Gastrointestinal - -operative 0 83 (10.3%) 429 (11.6%)Neurologic -operative 1 (5.0%) 68 (8.4%) 204 (5.5%)

Trauma -operative 3 (15.0%) 57 (7.1%) 252 (6.8%)Renal -operative 0 1 (0.1%) 15 (0.4%)

Gynecologic -operative 0 2 (0.2%) 5 (0.1%)Orthopedic -operative 0 4 (0.5%) 21 (0.6%)

Batriatric Surgery 0 0 4 (0.1%)Other operative conditions 1 (5.0%) 25 (3.1%) 91 (2.5%)

Apache II Scoremedian [Q1,Q3] 18 [14.5-20.5] 21.0 [15-27] 21.0 [16-27]

Presence of ARDSn/N (PCT) 0/20 105/806 (13.0%) 324/3694 (8.8%)

OutcomeDays on Mechanical Ventilation*

median [Q1,Q3] 4.5 [3.7-8.1] 7.2 [3.5-14.0] 6.8 [3.4-13.8]

Days in ICU*median [Q1,Q3] 10.3 [8.6-12.8] 10.0 [5.8-18.0] 9.9 [5.9-18.0]

Days in Hospital*median [Q1,Q3] 15.8 [11.4-26.2] 23.2 [12.1-49.2] 19.2 [10.8-37.0]

60 days mortalityn/N (PCT) 3/20 (15.0%) 201/807 (24.9%) 906/3695 (24.5%)

_________________________________________________________________________________________________________

Legend

*Censored at 60 days.


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Table 3. Patient Nutrition Assessment InformationYour Site Sister Sites All Sites

Number of Patients n=20 n=807 n=3695_________________________________________________________________________________________________________

Height(meters)median [Q1,Q3] 1.6 [1.6-1.7] 1.6 [1.6-1.7] 1.7 [1.6-1.8]

Weight(Kg)median [Q1,Q3] 70.0 [59.0-77.5] 61.0 [52.1-70.0] 71.5 [60.0-86.0]

BMI(kg|m2)median [Q1,Q3] 25.4 [23.3-27.8] 22.9 [20.8-25.4] 25.4 [22.2-29.8]

Weight Used in Calculate ofNutrition Prescription

Actual (ABW) 19 (100%) 303 (46.9%) 2025 (62.4%)Ideal (IBW) based on Hamwi

formula0 34 (5.3%) 197 (6.1%)

Ideal (IBW) based on BMI 20-25kg/m^2

0 156 (24.1%) 429 (13.2%)

Adjusted by 25% (ABW x0.25 + IBW)

0 25 (3.9%) 304 (9.4%)

Adjusted by 40% (ABW x0.4 + IBW)

0 1 (0.2%) 10 (0.3%)

Adjusted average ((ABW + IBW) x0.5)

0 33 (5.1%) 110 (3.4%)

No weight used in calculation 0 1 (0.2%) 35 (1.1%)Other, please specify 0 93 (14.4%) 136 (4.2%)

Method used to calculate EnergyRequirements

Harris Benedict Equation with noadjustment for stress and/or activity

0 10 (1.5%) 67 (2.1%)

Harris Benedict Equation withadjustment for stress and/or activity

0 111 (17.1%) 355 (10.9%)

Schofield Equations with noadjustment for stress and/or activity

0 1 (0.2%) 21 (0.6%)

Schofield Equation with adjustmentfor stress and/or activity

0 47 (7.3%) 475 (14.6%)

Mifflin-St. Jeor Equation) 0 0 71 (2.2%)Ireton-Jones Equation 19 (100%) 22 (3.4%) 230 (7.1%)Penn State Equation 0 0 267 (8.2%)

Weight based 0 403 (62.2%) 1955 (60.1%)Provide 1200-1499 kcal as standard 0 51 (7.9%) 83 (2.6%)Provide 1500-2000 kcal as standard 0 49 (7.6%) 84 (2.6%)

Indirect calorimetry 0 10 (1.5%) 39 (1.2%)Other, please specify 0 4 (0.6%) 149 (4.6%)

Prescribed Energey Intake(kcals)median [Q1,Q3] 2018 [1908.5-2335.5] 1500.0 [1360-1765] 1743.0 [1500-2000]

Prescribed Protein Intake(g)median [Q1,Q3] 85 [80-100] 67.2 [59.2-83.04] 83.0 [68-100]

Prescribed Energy Intake byWeight (Kcals|kg)

median [Q1,Q3] 30.0 [27.3-34.1] 25.0 [23.1-27.7] 25.0 [21.0-26.8]

Prescribed Protein Intake byWeight (Kcals|kg)

median [Q1,Q3] 1.2 [1.0-1.5] 1.0 [1.0-1.3] 1.1 [1.0-1.3]_________________________________________________________________________________________________________

Legend

BMI: Body Mass Index.Prescribed energy/protein intake: kilocalories / grams provided by the goal regimen (i.e. maximum rate/volume determined at theinitial assessment) for EN/PN according to the dietitians or physicians recommendation.


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Overall Performance at Your Site

Nutritional adequacy, defined as the amount of calories or protein received divided by the maximum amountprescribed at the initial assessment, expressed as a percentage, is a summary measure of your site's performance.As the recommendations of the Canadian Critical Care Nutrition CPGs focus on use of EN in preference to PNand on strategies to optimize delivery and minimize the risks of EN, adequacy of appropriate nutrition therapyand adequacy of EN are the primary measures of your success in following the Canadian Critical Care NutritionCPGs. (See legend for full definition of nutritional adequacy).

Figures 1.1-1.4 summarize your overall performance in providing nutrition (EN + Appropriate PN + Propofol)by day in the ICU compared to other ICUs. Figure 1.5 summarizes the mean adequacy over the first 12 days ofICU stay compared to other ICUs. For benchmarking purposes, the numbers above the bars in Figure 1.5 tellyou where you ranked or were placed out of your sister and all sites (i.e. 1/183 corresponds to the bestperforming site*). Appropriate PN is defined as PN received when a true contraindication to EN was specified(see page 23 for more information). Table 4 provides additional information about your practices by providingdata on adequacy of total nutrition (EN+PN+propofol) and adequacy of EN in patients who only received EN.*This ranking is not the same as the site ranking for the Best of the Best Award (See page 27).

Legend

Figure 1.1 Adequacy of Calories from Appropriate Nutrition:The amount of calories received by EN, appropriate PN (i.e presence of contraindication to EN), and propofol as a percentage ofthe maximum calories prescribed at baseline assessment in ALL patients.• Days without EN / appropriate PN are included and are counted as 0% adequacy, regardless of presence of prescription.• Only days that follow permanent progression to exclusive oral intake are excluded.

Figure 1.2 Adequacy of Protein from Appropriate NutritionThe amount of protein received by EN and appropriate PN (i.e presence of contraindication to EN) as a percentage of the maximumcalories prescribed at baseline assessment in ALL patients.• Days without EN / appropriate PN are included and are counted as 0% adequacy, regardless of presence of prescription• Only days that follow permanent progression to exclusive oral intake are excluded.

Figure 1.3 Adequacy of Calories from ENThe amount of calories received by EN as a percentage of the maximum calories prescribed at baseline assessment inALL patients.• Days without EN are included and are counted as 0% adequacy, regardless of presence of prescription• Only days that follow permanent progression to exclusive oral intake are excluded.

Figure 1.4 Adequacy of Protein from ENThe amount of protein received by EN as a percentage of the maximum calories prescribed at baseline assessment in ALL patients.• Days without EN are included and are counted as 0% adequacy, regardless of presence of prescription• Only days that follow permanent progression to exclusive oral intake are excluded.

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Table 4. Overall PerformanceYour Site Sister Sites All Sites

_________________________________________________________________________________________________________

Adequacy of Calories from TotalNutrition (EN+PN+propofol)

mean (range) 80.4% 72.2% (19.5%-152%) 64.4% (19.5%-152%)

Adequacy of Protein from TotalNutrition (EN+PN)

mean (range) 86.1% 65.5% (12.6%-97.2%) 59.8% (12.6%-97.2%)

Adequacy of Calories from EN inEN Only Patients

mean (range) 80.4% 59.4% (12.7%-102%) 53.6% (12.7%-102%)

Adequacy of Protein from EN inEN Only Patients

mean (range) 86.1% 56.3% (17.4%-92.4%) 53.0% (17.4%-92.4%)

Received Calories from TotalNutrition(EN+PN+propofol)

mean (range) 1885 1274 (733-2405) 1272 (489-2405)

Received Protein from TotalNutrition (EN+PN)

mean (range) 79 52 (25-80) 58 (22-100)

Received Calories from EN in ENonly Patients

mean (range) 1885 1138 (401-1885) 1152 (401-1885)

Received Protein from EN in ENonly Patients

mean (range) 79 47 (15-79) 53 (15-93)_________________________________________________________________________________________________________


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Composition of EN: Immune enhancing Diets: Arginine, Fish oils/borage oil,and Glutamine Containing DietsRecommendation:a) We recommend that diets supplemented with arginine and other selected nutrients NOT BE USED for critically ill patients.b) We recommend the use of an enteral formula with fish oils, borage oils, and antioxidants in patients with acute respiratorydistress syndrome (ARDS).c) When initiating enteral feeds, we recommend the use of whole protein formula (polymeric) in critically ill patients.

Table 7.1. Composition of Eneral FormulasEnteral Formulas Your Site Sister Sites All Sites_________________________________________________________________________________________________________

Arginine enriched formula 0 2.5% (0.0%-42.9%) 4.9% (0.0%-72.2%)Fish oil enriched formula (all

patients)0 2.9% (0.0%-38.5%) 3.2% (0.0%-50.0%)

Fish oil enriched formula (ARDSpatients)

NA 5.6% (0.0%-100%) 12.8% (0.0%-100%)

Glutamine enriched formula (allpatients)

0 1.9% (0.0%-42.9%) 0.8% (0.0%-43.8%)

Polymeric formulas 19/20 (95.0%) 60.6% (0.0%-100%) 83.0% (0.0%-100%)_________________________________________________________________________________________________________

LegendOf the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving these formulas• Arginine enriched formulas in all patients.• Fish oil and borage oil and antioxidant enriched formula in all patients• Fish oil and borage oil and antioxidant enriched formula in ARDS patients• Glutamine enriched formulas in all patients• Polymeric formulas in all patients


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Glutamine Supplementation

Recommendation:a) Enteral glutamine should be considered in burn and trauma patients. There are insufficient data to support the routine use ofenteral glutamine in other critically ill patients.b) When parenteral nutrition is prescribed to critically ill patients, parenteral supplementation with glutamine, where available, isstrongly recommended. There are insufficient data to generate recommendations for intravenous glutamine in critically ill patientswho are receiving enteral nutrition.

Table 7.2. Glutamine SupplementationGlutamine supplementation Your Site Sister Sites All Sites_________________________________________________________________________________________________________

All glutamine supplementation 0 21.9% (0.0%-100%) 8.6% (0.0%-100%)EN glutamine supplementation 0 8.3% (0.0%-100%) 3.3% (0.0%-100%)

IV/PN glutamine supplementation 0 15.6% (0.0%-80.8%) 5.8% (0.0%-80.8%)

EN PatientsAll glutamine supplementation 0 21.4% (0.0%-100%) 8.5% (0.0%-100%)EN glutamine supplementation 0 9.4% (0.0%-100%) 3.7% (0.0%-100%)

IV/PN glutamine supplementation 0 14.1% (0.0%-76.9%) 5.3% (0.0%-93.3%)

PN PatientsAll glutamine supplementation NA 45.7% (0.0%-100%) 25.7% (0.0%-100%)EN glutamine supplementation NA 10.1% (0.0%-100%) 3.6% (0.0%-100%)

IV/PN glutamine supplementation NA 40.4% (0.0%-100%) 23.8% (0.0%-100%)

Trauma PatientsAll glutamine supplementation 0 31.3% (0.0%-100%) 14.7% (0.0%-100%)

_________________________________________________________________________________________________________

Legend

Of ALL the patients, the average number (or %) of patients EVER receiving glutamine supplementation.Of ALL the patients, the average number (or %) of patients EVER receiving EN glutamine supplementation.Of ALL the patients, the average number (or %) of patients EVER receiving IV/PN glutamine supplementation.EN PATIENTSOf ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving glutamineOf ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving EN glutaminesupplementation.Of ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving IV/PN glutaminesupplementation.PN PATIENTSOf ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving glutamineOf ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving EN glutaminesupplementation.Of ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving IV/PN glutaminesupplementation.BURN PATIENTSOf ALL the BURNS patients the average number (or %) of patients EVER receiving glutamine supplementation.TRAUMA PATIENTSOf ALL the TRAUMA patients, the average number (or %) of patients EVER receiving glutamine supplementation.


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Selenium Supplementation

Recommendation:a) The use of supplemental combined vitamins and trace elements should be considered in critically ill patients.b) There are insufficient data to make a recommendation regarding IV/PN selenium supplementation alone or in combination withother antioxidants in critically ill patients.

Table 7.3. Selenium SupplementationSelenium supplementation Your Site Sister Sites All Sites_________________________________________________________________________________________________________

All selenium supplementation 0 5.2% (0.0%-100%) 2.1% (0.0%-100%)EN selenium supplementation 0 5.1% (0.0%-100%) 1.7% (0.0%-100%)

IV/PN selenium supplementation 0 1.7% (0.0%-65.0%) 0.8% (0.0%-65.0%)

EN PatientsAll selenium supplementation 0 6.1% (0.0%-100%) 2.3% (0.0%-100%)EN selenium supplementation 0 6.0% (0.0%-100%) 1.9% (0.0%-100%)

IV/PN selenium supplementation 0 2.0% (0.0%-65.0%) 0.8% (0.0%-65.0%)

PN PatientsAll selenium supplementation NA 7.9% (0.0%-100%) 4.7% (0.0%-100%)EN selenium supplementation NA 7.5% (0.0%-100%) 3.3% (0.0%-100%)

IV/PN selenium supplementation NA 5.2% (0.0%-65.0%) 3.2% (0.0%-100%)_________________________________________________________________________________________________________

Legend

Of ALL the patients, the average number (or %) of patients EVER receiving selenium supplementation.Of ALL the patients, the average number (or %) of patients EVER receiving EN selenium supplementation.Of ALL the patients, the average number (or %) of patients EVER receiving IV/PN selenium supplementation.EN PATIENTSOf ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving selenium supplementation.Of ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving EN seleniumsupplementation.Of ALL the patients EVER on EN (or EN+PN), the average number (or %) of patients EVER receiving IV/PN seleniumsupplementation.PN PATIENTSOf ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving selenium supplementation.Of ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving EN seleniumsupplementation.Of ALL the patients EVER on PN (or EN+PN), the average number (or %) of patients EVER receiving IV/PN seleniumsupplementation.


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Strategies to optimize delivery and minimize risks of EN

Recommendation:An evidence-based feeding protocol that incorporates prokinetics at initiation and a higher gastric residual volume (250mL) andthe use of post-pyloric feeding tubes should be considered as a strategy to optimize delivery of enteral nutrition in criticallyill adult patients.

Table 8. Feeding ProtocolsYour Site Sister Sites All Sites

Number of ICUs n=1 n=39 n=183_________________________________________________________________________________________________________

Feeding ProtocolYes 26 (66.7%) 148 (80.9%)

Gastric Residual VolumeTolerated in Protocol

mean (range) 200 197 (100-500) 264 (100-500)

Algorithms included in ProtocolMotility agents No 21 (53.8%) 116 (63.4%)

Small bowel feeding No 19 (48.7%) 90 (49.2%)Withholding for procedures Yes 23 (59.0%) 82 (44.8%)

Head of bed elevation Yes 23 (59.0%) 121 (66.1%)_________________________________________________________________________________________________________

Legend

HOB: Head of Bed.

Motility Agents

Recommendation:In critically ill patients who experience feed intolerance (high gastric residuals, emesis), the use of a motility agent isrecommended. Given the safety concerns associated with erythromycin, the recommendation is made for metoclopramide. Thereare insufficient data to make a recommendation about the combined use of metoclopramide and erythromycin.

Small Bowel Feeding

Recommendation:Small bowel feeding compared to gastric feeding may be associated with a reduction in pneumonia in critically ill patients. In unitswhere obtaining small bowel access is feasible, we recommend the routine use of small bowel feedings. In units where obtainingaccess involves more logistical difficulties, small bowel feedings should be considered for patients at high risk for intolerance toEN (on inotropes, continuous infusion of sedatives, or paralytic agents, or patients with high nasogastric drainage) or at high riskfor regurgitation and aspiration (nursed in supine position). Finally, in units where obtaining small bowel access is not feasible(no access to fluoroscopy or endoscopy and blind techniques not reliable), small bowel feedings should be considered for thoseselect patients who repeatedly demonstrate high gastric residual volumes and are not tolerating adequate amounts of EN deliveredinto the stomach.

Body Position

Recommendation:We recommend that critically ill patients receiving enteral nutrition have the head of the bed elevated to 45 degrees. Where this isnot possible, attempts to raise the head of the bed as much as possible should be considered.


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Table 9. EN Feeds InterruptedYour Site Sister Sites All Sites

Number of Patient-days on EN n=181 n=5308 n=23194_________________________________________________________________________________________________________

EN Feeds Interruptedn/N (PCT) 24/181 (13.3%) 893/5302 (16.8%) 6168/23169 (26.6%)

Total duration of feed interruption(hours)

median [Q1,Q3] 4.0 [2.0-4.5] 5.0 [3.0-11.0] 6.0 [3.0-11.6]

Reasons interruptionFasting for endotracheal extubation

or intubation21 (84.0%) 228 (23.5%) 1434 (22.8%)

Fasting for other bedside procedure 0 198 (20.4%) 794 (12.6%)Fasting for operating room

procedure1 (4.0%) 82 (8.4%) 642 (10.2%)

ReasFasting for radiology suiteprocedure

0 36 (3.7%) 643 (10.2%)

Fasting for administration ofmedications

0 61 (6.3%) 300 (4.8%)

Intolerance to enteral feeding - highgastric residuals

0 145 (14.9%) 749 (11.9%)

Intolerance to enteralfeeding - increased abdominal girth

or abdominal distension

0 36 (3.7%) 167 (2.7%)

Intolerance to enteralfeeding - vomiting/emesis

1 (4.0%) 27 (2.8%) 334 (5.3%)

Intolerance to enteralfeeding - diarrhea

0 20 (2.1%) 66 (1.0%)

Intolerance to enteralfeeding - subjective discomfort

0 15 (1.5%) 49 (0.8%)

No enteral access available/enteralaccess lost, displaced or

malfunctioning

0 17 (1.8%) 514 (8.2%)

Inotropes, vasopressor requirement 0 14 (1.4%) 70 (1.1%)Subject deemed too sick to continue

enteral feeding0 39 (4.0%) 185 (2.9%)

Enteral feeding formula notavailable

0 2 (0.2%) 31 (0.5%)

Other 2 (8.0%) 51 (5.3%) 323 (5.1%)_________________________________________________________________________________________________________


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PN vs. Standard Care

Recommendation:In critically ill patients with an intact gastrointestinal tract, we recommend that parenteral nutrition not be used routinely.

Table 10. Reason PN InitiatedYour Site Sister Sites All Sites

Number of Patients on PN n=1 n=283 n=842_________________________________________________________________________________________________________

Reason PN InitiatedMechanical bowel obstruction* 0 4 (1.4%) 35 (4.2%)

Bowel ischemia* 0 5 (1.8%) 36 (4.3%)Small bowel ileus* 0 8 (2.9%) 42 (5.0%)

Small bowel fistulae* 0 1 (0.4%) 6 (0.7%)Gastrointestinal perforation* 0 10 (3.6%) 105 (12.5%)

Short gut syndrome* 0 1 (0.4%) 8 (1.0%)Hemodynamic instability 0 41 (14.6%) 61 (7.3%)

Proximal bowel anastomosis 0 0 5 (0.6%)Not tolerating enteral feeding 0 54 (19.3%) 110 (13.1%)

No access to small bowel 0 5 (1.8%) 18 (2.1%)Pancreatitis 0 4 (1.4%) 18 (2.1%)

Gastrointestinal bleed 0 30 (10.7%) 62 (7.4%)Gastrointestinal surgery 0 58 (20.7%) 148 (17.6%)

No clinical reason 0 30 (10.7%) 69 (8.2%)Other (specify) 1 (100%) 29 (10.4%) 116 (13.8%)

_________________________________________________________________________________________________________

LegendOf all the patients that ever received PN (or EN+PN), the reason PN was initiated.*Considered as true contraindication to EN for assessment of appropriate PN in nutritional adequacy calculation (see page 8).


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Use of Lipids

Recommendation:In critically ill patients who are not malnourished, are tolerating some EN, or when parenteral nutrition is indicated for short-termuse (<10 days), withholding lipids high in soybean oil should be considered. There are insufficient data to make a recommendationabout withholding lipids high in soybean oil in critically ill patients who are malnourished or those requiring PN for long term(>10 days). Practitioners will have to weigh the safety and benefits of withholding lipids on an individual case-by-case basis inthese latter patient populations.

Table 11. Use of LipidsYour Site Sister Sites All Sites

Number of Patient-days on PN n=0 n=2625 n=8233_________________________________________________________________________________________________________

Lipids receivedLipid free 0 1681 (64.0%) 4279 (52.0%)

Other/Unknown 0 29 (1.1%) 102 (1.2%)Olive oil based 0 109 (4.2%) 1049 (12.7%)

Soybean oil based 0 517 (19.7%) 1797 (21.8%)MCT/LCT Physical mixture 0 198 (7.5%) 366 (4.4%)MCT/LCT Structured Form 0 75 (2.9%) 109 (1.3%)

Mixture of soy oil, MCTs, olive oil,and fish oil (SMOF)

0 8 (0.3%) 521 (6.3%)

Fish oil based 0 11 (0.4%) 15 (0.2%)_________________________________________________________________________________________________________

Legend

Type of PN: in those patients ever on PN (or EN+PN) the days on PN receiving specific type of lipids.


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Intensive insulin therapy

Recommendation:We recommend that hyperglycemia (blood sugars > 10 mmol/L) be avoided in all critically ill patients. We recommend a bloodglucose target of around 8.0mmol/L (or 7-9 mmol/L), rather than a more stringent target range (4.4 to 6.1 mmol/L) or a moreliberal target range (10 to 11.1 mmol/L).

Table 12. Glycemic Control ProtocolYour Site Sister Sites All Sites

Number of Patient-days n=190 n=6808 n=31211_________________________________________________________________________________________________________

Glycemic Control ProtocolYes 35 (89.7%) 152 (83.1%)

Target of BloodGlucose:Lower(mmol|l)

median [Q1,Q3] 6.1 6.0 [4.4-7.0] 5.1 [4.1-6.1]

Target of BloodGlucose:Upper(mmol|l)

median [Q1,Q3] 8.3 10.0 [10.0-10.0] 9.0 [8.0-10.0]

Morning Blood Glucose(mmol|l)median [Q1,Q3] 7.9 [6.9-11.0] 7.8 [6.6-9.9] 7.5 [6.4-9.2]

Insulin Received(units)median [Q1,Q3] 20.0 [14.0-36.0] 23.0 [11.0-42.9] 30.0 [12.0-63.0]

Total Hypoglycemic Daysn/N (PCT) 0/190 96/6799 (1.4%) 522/31192 (1.7%)

_________________________________________________________________________________________________________

Legend

Day 1 after admission to the ICU is excluded.Total days with Hypoglycemic events: Study day with at least one hypoglycemic event (i.e.blood glucose <3.5 mmol/l).


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Best of the Best 2011

Although the hard work and dedication of all ICUs who participate in the international nutrition survey isappreciated, in 2011, we wish to recognize the ICU that achieved the highest nutritional adequacy for theirsubmitted patients and adheres to the recommendations of the Canadian Critical Care Nutrition CPGs, throughthe Best of the Best Award.

To be eligible for this award, participating ICUs must meet the following criteria:1. Entered data on a total of 20 critically ill patients.2. Completion of a baseline nutrition assessment (i.e. nutrition prescription).3. Must have implemented a feeding protocol.4. No missing data or outstanding queries.5. Prepared to permit CCN to source verify the entered data.

The Best of the Best ICU is selected according to the following criteria:

Determinant Weighting*Overall 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 feeding 1% of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best) 3

In 2009, there were 98 eligible ICUs. For each of the above determinants, all eligible sites were ranked and thetop performing site awarded 97 points, the next top site 96 points, the third performing site, 95 points etc.For each determinant, the ranking points are multiplied by the weights and summed up to generate the totalpoints per site.

The 2011 Best of the Best Award recipients will be announced at ASPEN's Clinical Nutrition Week 2012 inOrlando, Florida.The top performing ICUs and recipients of the 2009 Best of the Best Award were:- Instituto Neurologico de Antioquia , Medellin, Colombia- Royal Prince Alfred Hospital, Sydney NSICU, Camperdown, Australia- The Alfred , Melbourne, Australia

Congratulations!

_______________________________________________________________________________________* The relative weightings reflect the importance of the overall findings (adequacy) and the strength of clinicalrecommendations: "strongly recommend"=5, "recommend"=3, "should consider"=1


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Disseminating the Results of Your Site Report

Your ICU has committed a significant amount of time to participate in the International Survey. We havecommitted a significant amount of time and resources to produce these site reports. We encourage you to useyour site report as a unique benchmarking opportunity to highlight your strengths and weaknesses, and informquality improvement initiatives.

The following are a few suggestions of useful forums from which to disseminate the site reports:• Print off and copy the site report and distribute to key stakeholders.• Meet with ICU management and/or Hospital administration.• Lead a small group interactive workshop with local doctors and nurses to strategize on ways to improve yourperformance.• Produce and post a poster outlining your main strengths and weaknesses and suggested changes.

Various resources designed to assist you in local dissemination of the site report (such as information onstrategies to improve practices, a variety of quality improvement tools in the "toolkit" and publications andpresentations) are available under 'Resource Centre' on the Critical Care Nutrition website

Thank you for your support with the International Nutrition Survey. The next opportunity to audit your nutritionpractice is scheduled for early 2013. We look forward to working with you again.

Final Site Report

Documents

Transcript of Final Site Report