1. 2008 International Nutrition Survey: Preliminary Results ANZICS/ AuSPEN Conference Sydney, Australia November 1, 2008

2. Critical Care Nutrition. Mission Statement To 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 GenerationKnowledge SynthesisKnowledge 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

3. Critical Care Nutrition Staff

4. Andrew Day Biostatistician Siouxzy Morrison Project Leader AuSPEN/ANZICS Nutrition Research Fellow

5. 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

6. 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

7. 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)

8. 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

9. Web based Data Capture System

10. Canada: 34 USA: 43 Australia & New Zealand: 27 Europe and Other: 18 Latin America: 10 Asia: 27 Mexico :1 Brazil:3 Colombia:3 Peru:1 Paraguay:1 Venezuela:1 Who participated? : 159 ICUs Italy: 3 UK: 9* Ireland: 2 Portugal: 1 South Africa: 3 China: 20* Taiwan: 1 India: 6

11. Ethics Approval 210 Registered ICUs 72 ICUs excluded as no complete data entered Reason for attrition: ? Ethics approval 99/210 ICUs (47%) required local ethics approval –87 expedited review –4 expedited review plus informed consent required –8 full review

12. Who participated? Health practitioners 164 Registered Practitioners

13. 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

14. ICU Characteristics CharacteristicsTotal n=138 Hospital Type Teaching104 (75.4%) Non-teaching34 (24.6%) Size of Hospital (beds) Mean (Range)515 (108, 1500) Multiple ICUs in Hospital Yes72 (52.2%) No66 (47.8%) ICU Structure Open40 (29.0%) Closed96 (69.6%) Other2 (1.4%) Size of ICU (beds) Mean (Range)18 (5,48) CharacteristicsTotal n=138 Case Type Medical123 (89.1%) Surgical124 (89.9%) Trauma81 (58.7%) Pediatrics15 (10.9%) Neurological91 (65.9%) Neurosurgical75 (54.3%) Cardiac Surgery47 (34.1%) Burns28 (20.3%) Others15 (10.9%) Designated Medical Director Yes131 (94.9%) No7 (5.1%) Full Time Equivalent Dietitians Mean (Range)0.4 (0.0, 2.5)

15. Patient Characteristics CharacteristicsTotal n=2486 Age (years) Median [Q1,Q3]61 [48, 72] Sex Female929 (37.4%) Male1557 (62.6%) Admission Category Medical1517 (61.0%) Surgical: Elective339 (13.6%) Surgical: Emergency630 (25.3%) Apache II Score Median [Q1, Q3]22 [17, 28] Presence of ARDS Yes229 (9.2%) CharacteristicsTotal n=2486 Admission Diagnosis Cardiovascular / Vascular448 (18.0%) Respiratory608 (24.5%) Pancreatitis37 (1.5%) Gastrointestinal329 (13.2%) Neurologic284 (11.4%) Sepsis235 (9.5%) Trauma269 (10.8%) Metabolic67 (2.7%) Hematologic15 (0.6%) Renal37 (1.5%) Gynecologic4 (0.2%) Orthopedic14 (0.6%) Bariatric Surgery3 (0.1%) Burns30 (1.2%) Other106 (4.3%)

16. Patient 60 day Outcomes CharacteristicsTotal n=2486 Length 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) Yes663 (26.8%)

17. Baseline Nutrition Assessment CharacteristicsTotal 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]

18. Baseline Nutrition Assessment Methods Used to Calculate Energy Requirements

19. Type of Nutrition Support We strongly recommend the use of EN over PN n=2486 patients

20. Type of Nutrition: EN Only

21. Type of Nutrition: PN Only

22. Type of Nutrition: EN + PN

23. Contraindication to EN (In Pts receiving PN) In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely

24. Type of Nutrition: None

25. Early vs Delayed EN

26. Strategies to Optimize EN Delivery: Feeding Protocol CharacteristicsTotal n=138 Feeding Protocol Yes112 (81.2%) Gastric Residual Volume Tolerated in Protocol Mean (range)214 (100, 500) Algorithms included in Protocol Motility agents72 (70.6%) Small bowel feeding52 (51.0%) Withholding for procedures47 (46.1%) HOB Elevation79 (77.5%) Other21 (20.6%)

27. Strategies to Optimize EN Delivery: Motility Agents

28. Strategies to Optimize EN Delivery: Small Bowel Feeding

29. Strategies to Optimize EN Delivery: Head of Bed Elevation

30. Use of Pharmaconutrients Total % Patients Ever on EN receiving formula Arginine-supplemented formulas19.8%(0.0%-93.8%) Glutamine supplementation7.4%(0.0%-88.9%) Oxepa (All)12.1% (0.0%-83.3%) Oxepa (ARDS)7.4% (0.0%-88.9%) Polymeric71.7% (0.0%-100.0%)

31. Arginine-supplemented formulas

32. Glutamine supplementation

33. Oxepa (All)

34. Oxepa (ARDS)

35. EN in Combination with PN % patients on EN where PN was started 72 hours after initiation of EN

36. Strategies to Optimize PN Delivery: Use of Lipids no pt days on PN=2895

37. % patients received Soybean oil based (LCTs)

38. Strategies to Optimize PN Delivery: Use of IV Glutamine Use of PN glutamine in Patients receiving PN

39. Intensive Insulin Therapy CharacteristicsTotal 20713 Glycemic Control Protocol Yes122 (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 Yes676 (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]

40. Intensive Insulin Therapy In all critically ill patients, we recommend avoiding hyperglycemia (blood glucose > 10 mmol/l)

41. Overall Performance Adequacy of Nutrition Support = Calories received from EN + appropriate PN+Propofol Calories prescribed

42. Overall Performance: Kcals

44. Overall Performance: Protein

45. Adequacy of EN: Kcals

46. Adequacy of EN: Protein

47. Benchmarking

48. Ranking Performance Figure 1.5 Overall Performance of Your Site

49. 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

50. 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

51. Best of the Best DeterminantWeighting Overall Adequacy of EN plus appropriate PN10 % patients receiving EN5 % of patients with EN initiated within 48 hours3 % of patients with high gastric residual volumes (HGRV) receiving motility agents 1 % of patients with HGRV receiving small bowel tubes1 % of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best) 3 Rank all eligible ICUs by determinants Multiply ranking by weighting ICU with highest score is crowned Best of the Best

52. 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?

53. 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?

54. Thank you