International Nutrition QI Project 2007: Debriefing Session Friday June 15 th, 2007 Confederation 3, Fairmont Royal York, Toronto

Brief Overview of Survey Results Review of Benchmarked Performance Reports Small Group Discussion Future Research Summary and Closing Comments Agenda

Purpose To describe and compare nutrition practices To compare nutrition practices to the Canadian Nutrition Support Clinical Practice Guidelines To identify opportunities for improvement Illuminate research opportunities

Canada: 47 USA:41 Australia & New Zealand: 23 UK & Ireland: 22 EU (other): 14 Latin America: 5 Asia:11 Brazil:1 Mexico:3 Uruguay:1 Venezuala:1 Who participated? : 165 ICUs Malaysia: 2 China: 6 Saudi Arabia: 2 Indonesia: 1 Austria:2 Czech Republic: 3 Italy: 5 Slovenia:1 Spain:1 Sweden: 2

Who participated?: Health practitioners 206 Registered Practitioners

Ethics Approval 206 Registered ICUs 41 ICUs excluded as no data entered Reason for attrition: ? Ethics approval 120 ICUs (57.5%) required local ethics approval –97 expedited review –1 expedited review plus informed consent required –21 full review –1 full review plus informed consent required

Who participated? Patients Number of patients per site –19.3 (1-40) Total number of patients –2896 Days of observation per patient –9.5 (1-12) Total number of patient days in ICU –27192 days <3% missing data for ALL variables

Preliminary Site Report Purpose of review: 1.Communicate how to interpret your site report 2.Review ‘preliminary’ results of the survey 3.Receive feedback on format of site reports

Sister Sites Sister Site GroupingsCountries Canada United States of AmericaUSA United Kingdom and Republic of Ireland England, Scotland, Ireland EuropeAustria, Czech Republic, Italy, Slovenia. Spain, Sweden Australia and New ZealandAustralia, New Zealand Latin AmericaBrazil, Mexico, Uruguay, Venezuela, AsiaMalaysia, China, Indonesia, Russia, Saudi Arabia

Overall Performance Adequacy of Nutrition Support = Calories received from EN & appropriate PN X 100 Calories prescribed

Overall Performance

Adequacy of EN

Overall Performance

EN vs. PN We strongly recommend the use of EN over PN

EN vs. Standard Care In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely

Early vs. Delayed EN We recommend early EN (within hours following admission)

EN in combination with PN For critically ill patients starting on EN, we recommend that PN not be started at the same time as EN

Composition of Nutrition Support

Strategies to Optimize EN Delivery: Feeding Protocol

Strategies to Optimize EN Delivery

Strategies to Optimize PN Delivery: Dose of PN

Strategies to Optimize PN Delivery: Use of Lipids

Intensive Insulin Therapy

Small Group Discussion What are your thoughts on the data elements collected in the survey, the method of data collection, and how it is represented in the site reports? What are the most effective strategies for changing behaviour around nutrition practices in the ICU?

Small Group Discussion 20 mins Nominate ‘recorder’ and ‘spokesperson’ Give freely of your experience Keep confidences and assume others will Feel free to ask us questions Summarize key points

Moving Forward: QI in the ICU Changing nutrition practice is complex Need to identify barriers and enablers to changing practice Need to understand factors associated with guideline implementation and adherence

Understanding Guideline Implementation Secondary Analysis of Canadian Nutrition Survey 2004 dataset Multiple case study  4 case ICU sites  28 Semi-structured key informant interviews

Identified Barriers Guidelines Information overload Weak evidence Impractical / Complex Institution Community Hospital setting Open ICU Slow administrative process Resource constraints Practitioner Lack of awareness Limited critical care experience Resistance to change Nursing workload Patient Poor clinical condition Surgical

Enablers Agreement of the attending physician & ICU team Part of routine practice Dietitian / Opinion leader Access / Visibility Easy to follow and perform Provision of education Open discussion

Successful Implementation Strategies Informal one-on-one discussions –Academic detailing, ward rounds Bed-side reminders –Check-list, algorithms, Feedback and audit –Site reports

Canadian Nutrition Guidekines OPTIMAL NUTRITION Implementation ProcessInstitutional Factors Provider Intent Hospital characteristics -Structure - Processes -Resources -Patient Case-mix KnowledgeAttitudes Familiarity Awareness MotivationSelf-efficacy Outcome expectancy Agreement ICU characteristics -Structure - Processes -Resources - Patient Case-mix -Culture Legend: Italics = New themes ICU = Intensive Care Unit Provider Characteristics - Profession -Critical care expertise -Educational background -Personality Patient Characteristics Framework for Adherence to CPGs in the ICU

Future Research Survey of Attitudes towards the Canadian Nutrition Support Clinical Practice Guidelines Tailored approach to guideline implementaton –Development of screening questionnaire and educational toolkit –? Future Cluster Randomized Controlled Trial

International QI Project 2008 !!

Thank you