1. Building ICU – PNuT Intensive Care Unit – Pediatric Nutrition Team (ICU-PNuT) Sharon Y Irving, PhD, CRNP, FCCM Assistant Professor, Pediatric Nursing

2. Financial Disclosures  No Disclosures

3. Objectives  Discuss role of multi-disciplinary team for nutrition support in PICU  Present current clinical and research activities of the team

4. Background  Basis of the work  15 attending physicians, 12 ICU fellows = 27 approaches to nutrition support  7- 8 attending ‘opinions’ on any given day  No way to systematically assess nutrition  Patient safety  July 2011like-minded individuals organized to formally address the issues

5. What is / Who are ICU - PNuT? ICU - Pediatric Nutrition Team  Multidisciplinary Team  PICU RDs  RNs  Pharmacist  Research Coordinator  MDs

6. Why a “Formal” Group?  A desire to improve the prescription and delivery of macro/micro nutrients to the PICU patient population  CCM has several diagnosis-specific focus groups (they all need nutrition)  Have an interest in creating a quality improvement agenda related to nutrition support for PICU patients  Create a research agenda related to nutrition, nutrition prescription and delivery to PICU population, including securing funding for QI and research projects

7. ICU – PNuT Goals  Development of an overall plan for the safe and effective provision of nutrition for patients admitted to the PICU  Development of a program of nutrition research for pediatric critical care  Development of education initiatives regarding pediatric nutrition practice(s)

8. ICU – PNuTs Mission To improve nutritional assessment and the prescription, delivery and monitoring of nutritional needs to enhance patient outcomes and safety for infants, children and adolescents during and immediately following critical illness.

9. Activities / Projects  Clinical QI Projects  Raising awareness / education about the importance of anthropometry measurements in PICU patients Nursing staff education Critical Care Admission Orders  Feeding guidelines  Research Projects  International Pediatric ICU Nutrition Study  Internet Survey  Numerous poster presentations at professional meetings: SCCM, ASPEN, STTI, AND, CHOP  Upcoming collaborative projects: SuPPER; COBOII  Education  Nutrition lectures added to CCM fellows/NP curriculum

10. Research Projects - PICNIC  PICNIC Study  Improving the Practice of Nutrition Therapy in Critically Ill Children: Pediatric International Nutrition Intake Survey  An international period-prevalence survey of PICU nutrition practices  Goal: Compare nutrition practices with units of similar size and patient characteristics  Total of 59 PICUs; 20+ PICUs of > 24 beds

11. ItemCHOP (n=15) Sister Units (n=470; 24 units) Nutrition Assessment NoYes Energy Needs Schofield Talbot WHO IC Other 0 86.7% 0 13.3% 25.1% 1.5% 21.1% 1.1% 50.4% Stress Factor93.3%41.5% LOS Hosp PICU* Vent Days 35 (8-61) 27 (6-61) 11 (5-23) 16 (9-31) 9 (6-16) 6 (3-11) How Did CHOP Compare? *PIM scores -4.2 vs -1.9 in sister units

12. Research Projects - PICNIC  Other PICNIC findings for CHOP  No feeding protocol (30% sister units use protocol)  On average initiated EN on 2 nd PICU day (30.8% vs 27.2%) At 3 rd PICU day 61% of CHOP PICU were on EN compared to 74% in sister units  No algorithm for: motility agents, small bowel feedings, or withholding feedings for procedures  Slighter higher number of patients on PN compared to sister units

13. These data reflect frequent nutrition interruptions at CHOP

14. Research Projects  PICNIC Study Summary  Internationally, inadequate nutrition delivery in critically ill pediatric patients across all units with several barriers noted  PICUs that used feeding protocols had decrease prevalence of acquired infections  CHOP was below the international average Number of subjects entered Severity of illness of patients admitted to CHOP PICU

15. Research - PICNIC  Hamilton et al., 2014  Improved enteral nutrition delivery  Decreased reliance on parenteral delivery  Energy goals were achieved earlier in a larger proportion of patients  Meyer et al., 2009  Protocols improved nutritional practice  Nutritional support was started earlier in PICU stay  Increased enteral nutrition use  Increased attainment of energy goals earlier in PICU stay

16. Research Project – Anthropometric Measurements  Barriers to Obtaining Anthropometric Measurements in PICU Patients  Hypothesis: Barriers exist to obtaining anthropometry measurements and perceptions of these barriers differ between ordering clinicians and nurses  Participants*: physicians, nurse practitioners, physician assistants, nurses, RDs  Anthropometry measurements surveyed: weight, stature, head circumference in < 2 year olds

17. Research – Anthropometric Measurements  Methods  21-item survey using Survey Monkey  Locally tested for question clarity and construct validity  Internet distribution via listservs of professional organizations with membership known to care for critically ill children  Data collection x14 weeks, June – September 2012 w/ reminders

18.  Are growth parameters (weight, stature, head circumference) collected on each patient on admission to the ICU?  If an actual weight or length/height is not measured on admission, how do you obtain an estimate?  What do you consider to be barriers to obtaining anthropometrics on critically ill patients?  Do you routinely place orders for anthropometric measurements on PICU patients?  How is the anthropometric data shared with the care team? Research – Anthropometric Measurements Sample of survey items:

19. Total responses = 376  Responses with complete data for analysis = 318  Responses of nurses and ordering providers = 258  Most respondents were located in United States  92% ordering providers *  87% nurses Research – Anthropometric Measurements * Did not breakdown the ordering providers Chi-square and Fisher’s Exact STATA Data Analysis and Statisitical Software

20. Ordering Providers N = 119 Years Research – Anthropometric Measurements Nurses N = 139 p value 0.005 Note: values presented are % of respondents in each category Years Experience of Responders in Years

21. Research Project – Anthropometric Measurements p value 0.07 Type of PICU

22. Values are % of total respondents for each category Research – Anthropometric Measurements Sources of anthropometry when not obtained at PICU admission

23. Provider Specific Barriers Ordering provider (n=119) Nurses (n=139) p-value Nurses too busy, (%)* Weight Stature Head circumference 62 (52) 59 (50) 47 (34) 51 (37) 40 (29) 0.004 0.02 0.001 Patient does not want to be disturbed, (%)* Weight Stature Head circumference 52 (44) 43 (36) 41 (34) 60 (43) 52 (37) 46 (33) 1.00 0.90 Isolation, (%)* Weight Stature Head circumference 16 (13) 12 (10) 10 (8) 10 (7) 9 (7) 2 (1) 0.10 0.36 0.01 Not considered important, (%)* Weight Stature Head circumference 39 (33) 59 (50) 57 (48) 17 (12) 41 (30) 24 (17) 0.001 Lack of correct equipment, (%)* Weight Stature Head circumference 35 (29) 32 (27) 14 (12) 34 (25) 44 (32) 6 (4) 0.40 0.41 0.03 Unsure of correct technique, (%)* Weight Stature Head circumference 23 (19) 40 (34) 32 (27) 7 (5) 24 (17) 7 (5) 0.001 0.004 0.001

24. Research – Anthropometrc Measurements  Barriers to obtaining anthropometry measurements in critically ill children exist  Ordering clinicians perceived more barriers than nurses  Interdisciplinary education is necessary to overcome real and perceived barriers to obtaining anthropometry measurements in critically ill children  In Press: American Journal of Critical Care Conclusions from these data:

25. Quality Improvement – Anthropometry Measurements  Start at the Beginning  Standards around anthropometry measurements in PICU  Educate / re-educate PICU staff in safe technique to obtain anthropometry measurements  Consistent, accurate documentation of measurements  Compliance of EPIC orders with measurements obtained  Consistency, accuracy and frequency of anthropometry measurements have implications for patient safety  Medications, fluids, nutrition, ventilation and other therapies  Determination for emergencies and resuscitation needs

26. Quality Improvement  Methods  Survey of knowledge attitude and practice  Learning Link ppt with post test for nursing staff  PICU Skills fairs  CQI staff education  Team specific RD involvement  Equipment upgrade  Identified place to document in EPIC  “Forced behaviors” addition in PICU admission order set

27. Quality Improvement  Process assessment  Baseline audit from Dec 2011 – Feb 2012  Intervention April 2012 - ongoing  Repeat audit June – September 2013

28. Weight audit Increase in orders; weights not consistently obtained 20% to 33% do not have weight obtained

29. Stature audit Increase in orders, stature obtained more often NEEDS IMPROVEMENT

30. Head circumference audit Increase in orders, head circumference obtained more often NEEDS IMPROVEMENT

31. Recurring weight audit Increase in orders, improved compliance 33% to 45% do not have recurrent weight obtained NEEDS IMPROVEMENT

32. Follow-Up and Moving Forward  Identify and minimize hurdles to anthropometry measurements  Increase education to all clinical staff (FLOCs, RNs and CCM faculty) for orders and measurements  Collective ownership  Clinical team utilization of data  Monthly presentation at CQI  Education to SNAs to assist with obtaining anthropometry measurements in PICU patients

33. Quality Improvement  PICU Feeding Pathway Goal:  Consistent approach to nutrition initiation, delivery and goal energy and protein attainment in PICU population  Literature supports early nutrition initiation  Sustain organ function / prevent organ dysfunction  Feeding protocols facilitate early nutrition and improved delivery Meyer et al, 2009; Petrillo-Albarano et al, 2006; Khalid et al, 2010; Briassoulis et al, 2001  Early nutrition support – EN reduces total cost of care Doig et al, 2013

34. Quality Improvement – Feeding Pathway  Goals:  Reduce time from PICU admission to initiation of EN  Reduce time from EN initiation to attain goal nutrition (per RD recs)  Reduce unnecessary and prolonged interruptions to EN  Reduce unnecessary use of PN  Metrics  Expect decrease in time from admission to initiation of EN  Expect increase in patients that commence EN <48 hrs of PICU admission  Expect decrease in time to attain goal nutrition  Expect decrease in interruptions to EN

35. http://www.chop.edu/clinical-pathway/nutrition-picu-initiation-and-advancement-clinical-pathway-inpatient

36. Quality Improvement – Feeding Guidelines  Next Steps:  Comparison of pre / post pathway feeding initiation  Analysis of impact of initiation of feeding pathway on PICU and/or hospital stay (to date ~50 patients initiated on pathway )  Ongoing education efforts to raise awareness to PICU clinical staff and providers i.e. “Did your patient today receive nutrition today? If not why not?”

37. Quality Improvement to Research Question Intubated, no vasopressor support on EN only

38. Summary  ICU-PNuT is a multidisciplinary collaborative who goals is to improve nutrition prescription and delivery in PICU patients  Ultimately we plan to follow their short and potentially long-term outcomes is assess the “the fruit(s) of our labor