Mr KT 76 perd diverticulum Septic shock, ARDS, MODS Day 1- high NG drainage, distended abdomen Day...

More is Better!

Our Field of Dream If you feed them (better!)They will leave (sooner!)

Cahill N Crit Care Med 2010

In patients with high gastric residual volumes:use of motility agents 58.7% (site average range: 0-100%)

use of small bowel feeding 14.7% (range: 0-100%)

“Minding the GAP” an Important Part of Patient Safety

The time to ACT is NOW!

How to Change?

CPGs to bedsideGuidelines

Bedside

Dissemination and Implementation Strategies

Special JPEN Issue Dedicated to KT

• Knowledge Translation (KT) – describes the process of moving evidence learned from

clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making.

– defined as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system.”

– Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept.

Available online nowIn press shortly

http://www.cihr-irsc.gc.ca/e/29418.html#Synthesis

http://www.cihr-irsc.gc.ca/e/29418.html#Dissemination

http://www.cihr-irsc.gc.ca/e/29418.html#Exchange

http://www.cihr-irsc.gc.ca/e/29418.html#Ethically-sound

Lost in (Knowledge) Translation!

Heyland DK, Cahill N, Dhaliwal R

Knowledge to Action Model by Graham

Knowledge Generation

Knowledge To Action Model

Since 1980, >200 randomized trials of nutrition interventions

studying >2000 critically ill patients

Randomized Trials in Critical Care Nutrition: Look How Far We’ve Come!

(and where do we go from here?)

Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

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Knowledge Synthesis

Knowledge – To- Action Model

Systematic reviews and meta-analyses

of 34 nutrition related topics

Clinical Practice Guidelines

Knowledge – To- Action Model

Development of multiple Critical Care Nutrition

Clinical Practice Guidelines

Guidelines, Guidelines, Guidelines. What Are We to do With all of These

North American Guidelines?

• Comparison of Canadian, American Dietetic Association, ASPEN/SCCM CPGs

• Different methods, studies included, ratings of evidence and values

• Similarities, minor and major differences in recommendations

• Can we harmonize this process?

Dhaliwal R, Madden S, Cahill N, Jeejeebhoy K, Kutsogiannis J, Muscedere J, McClave S, Heyland DK

How to Narrow the Gap?First Define the Gap

International audits of nutrition practice

Cahill N Crit Care Med 2010

In patients with high gastric residual volumes:use of motility agents 58.7% (site average range: 0-100%)

use of small bowel feeding 14.7% (range: 0-100%)

Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within 24-48 hrs following resuscitation) in critically ill patients.

Value of Bench-marked Site Reports

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Your site All sites Sister sites

Early vs Delayed Nutrition Intake

The Value of ‘Audit and Feedback Reports’ in Improving Nutritional

Therapy in the ICU: A Multicenter Observational Study

• 26 Canadian ICUs participating in 2007 and 2008 Surveys

Sinuff T, Cahill N, Dhaliwal R, Wang M, Day A, Heyland DK

(45.1% to 51.9%, p<0.001 and 44.8% to 51.5%, p<0.001 for calories and protein respectively

Adequacy of Calories from EN Only

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Need to Understand Local Barriers

Assess Barriers

Understanding Adherence to Guidelines in the ICU:

Development of a Comprehensive Framework

Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

CPGCharacteristics

ADHERENCE

Implementation Process Institutional Factors Provider Intent

Hospital characteristics

-Structure- Processes-Resources

-Patient Case-mix Knowledge Attitudes

Familiarity

AwarenessMotivation Self-efficacy

Outcomeexpectancy

Agreement

ICU characteristics


- Patient Case-mix-Culture

Provider Characteristics- Profession

-Critical care expertise-Educational background

-Personality

Patient Characteristics

The Relationship Between Organizational Culture and Implementation of Clinical

Practice Guidelines: A Narrative Review

• “The way things are around here”• Major influence on CPG adherence• Defining, measuring, and changing

Dodek P, Cahill N, Heyland DK

The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery:

Results of a multicenter observational study• International, prospective, observational, cohort studies conducted in

2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries

• Included 5497 mechanically ventilated adult patients > 3 days in ICU

• Sites recorded the presence or absence of a feeding protocol

• Sites provided nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days.

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No Protocol

P<0.05

78% of sites reported use of Feeding Protocol

Heyland DK, Cahill N, Dhaliwal R, Sun, Xiaoqun, Day A, McClave S




CPGCharacteristics

ADHERENCE





Familiarity


Outcomeexpectancy

Agreement

ICU characteristics





-Personality


Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice

Guidelines: An International Survey of Critical Care Physicians and

Dietitians

Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

• International web-based survey of 514 practitioners from 27 countries

Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice

Guidelines: An International Survey of Critical Care Physicians and

Dietitians• Majority (91.4%) considered nutrition therapy to be very important

• Strong endorsement for the following established practices: enteral nutrition (EN) used in preference to parenteral nutrition (PN), use of polymeric solutions and feeding protocols, and avoiding hyperglycemia.

• Also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within 24-48 hours of admission, use of motility agents, head of the bed elevation, use of glutamine and antioxidants, and maximizing EN prior to starting PN.

• There was diversity of opinion on the recommendations pertaining to arginine-supplemented diets, small bowel feeding, use of pharmaconutrients, intensive insulin therapy, and withholding soybean oil lipids in PN solutions and hypocaloric PN.

Cahill N, Narasimhan S, Dhaliwal R, Heyland DK




CPGCharacteristics

ADHERENCE





Familiarity


Outcomeexpectancy

Agreement

ICU characteristics





-Personality


Nutrition Therapy for the Critically Ill Surgical Patient: We Need to do Better!

• Combined 2007 and 2008 survey database

• 5497 mechanically ven’t patients >3days

• 37% surgical

Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day A, Heyland DK

Need for a Tailored Approach

Select Intervention(s)

Bridging the Guideline – Practice Gap In Critical Care Nutrition:

A Review of Guideline Implementation Studies

• 14 ICUs in Canada• 60 ICUs in Canada

• 27 ICUs in Australia

Cahill N, Heyland DK

GuidelinesBedside

3 Cluster RCTs

Protocolize/automate careImprove organizational cultureDevelop Dietitian and other KOL as local opinion

leaders Audit and feedback with bench-marked site reports Assess barriers and have interactive workshops with

small group problem solving Implement strategies with rapid cycle change (PDSA)Educational reminders (manuals, posters, pocket

cards) One on one academic detailing

Practice Changing Interventions

What works best at your site?

(barriers and enablers will vary site to site)

What is already working well at your site?

(strengths and weakness are different across sites)

Vs.

Tailored Intervention:Change strategies specifically chosen to address the

barriers identified at a specific setting at a specific time

Barriers are inversely related to nutrition performance and tailoring change strategies to overcome barriers to change will reduce the presence of these barriers

and lead to improvements in nutrition practice.

Hypothesis

PERFormance Enhancement of the Canadian nutrition guidelines through a Tailored Implementation Strategy:

The PERFECTIS Study

And the Cycle continues...

Creating a Culture of Clinical Excellence in Critical Care

Nutrition:

The ‘Best of the Best’ Award

Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

Recognition and Reward

Recognition a powerful

motivator of human

performance

Recognition Produces Results!

• The results of a 10-year, 200,000 employee study:• Organizations excelling at rewarding excellence had avg.

ROE of 3x greater than the lowest rated organizations

• Institutions that excel at recognizing employee contributions:

– HIGHER in customer satisfaction

– HIGHER in employee satisfaction/morale (94.4% agree their superior is effective at recognition, only 2.4% with low morale agree)

– HIGHER in employee retention

Determining the Best of the BestDeterminant 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’

Best of the Best Award

• 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: Highest ranking nutritional performance

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

2008 Best of the Best

Top 3 ICUs1. Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand

2. Kingston General Hospital, Kingston, Canada

3. Regional Hospital A. Cardarelli, Italy

Lyn Gillanders, Senior Clinical Dietitian and her ICU colleagues at the Department of Critical Care Medicine,

Auckland City Hospital being presented with the Best of the Best Award by the Hospital Medical Director.

2008Best of the Best

Determinants to Top PerformanceWhat site and hospital characteristics are associated with top BOB ranking?

Hospital/ICU characteristics** Ranking p values

Region

Australia and New Zealand vs. Canada -3.0 0.61

China vs. Canada +30.4 0.008

Europe and South Africa vs. Canada -7.9 0.22

India vs. Canada +32.7 0.08

Latin America vs. Canada 0.17 0.98

USA vs. Canada +30.4 <0.0001

Hospital size (per 100 beds) -0.24 0.78

ICU structure

Closed vs. open or other -0.89 0.89

Presence of Dietitian(s)

Yes vs. No -23.5 0.005

(Best Rank=1rst thus a negative number is associated with a better ranking)

Heyland JPEN 2010

2009 Best of the BestOf >200 ICUS competing Internationally

1. Instituto Neurologico de Antioquia, Medellin, Colombia

1. Royal Prince Alfred Hospital, Sydney, Australia

1. The Alfred, Melbourne, Australia

TOP Performers

2009 Best of the BestOf >200 ICUS competing Internationally

4) Trillium Health Centre, Mississauga, Canada5) Regional Hospital A. Cardarell, Campobasso, Italy6) Royal Columbian Hospital, New Westminster, Canada7) Community Hospital of Monterey Peninsula,

Monterey, USA8) Auckland City Hospital, Auckland, New Zealand9) Hamilton General Hospital, Hamilton, Canada10)University District Hospital Neuro-ICU, San Juan, USA

Outstanding Performers

How to Change?

CPGs to bedside

Bedside

Dissemination and Implementation Strategies

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