1. Critical Care Nutrition
A Case Study of Creating Knowledge and Moving it into Action!
Daren K. Heyland
Director of Clinical Evaluation Research Unit
Queen’s University, Kingston General Hospital
Kingston, ON Canada
HARD TO READ YOUR NAME

2. Learning Objectives
Understand key components of moving ‘knowledge’ into action
List main updates of Canadian Critical Care Nutrition Guidelines

3. Learning Objectives
Insert pic of me at home

4. Critical Care Nutrition
The right nutrient/nutritional strategy
The right timing
The right patient
The right intensity (dose/duration)
With the right outcome!

7. Lost in (Knowledge) Translation!
Knowledge to Action Model by Graham
Heyland DK, Cahill N, Dhaliwal R JPEN Nov 2010

8. Knowledge Creation

9. On behalf of the REDOXS Study Investigators
A RANDOMIZED TRIAL OF HIGH-DOSE GLUTAMINE AND ANTIOXIDANTS IN CRITICALLY ILL PATIENTS WITH MULTIORGAN FAILURE   The REDOXS study
On behalf of the REDOXS Study Investigators
N Engl J Med 2013;368:

10. R R R The REDOXS study antioxidants glutamine 1200 ICU patients
Factorial 2x2 design
Double blind treatment
glutamine R
1200 ICU patients R
Concealed
Stratified by site
Evidence of
placebo
Multi-organ failure
antioxidants
placebo R
placebo

11. The Research Protocol Inclusion Criteria Adults (>18)
With 2 or more organ failures related to their acute illness :
Requiring mechanically ventilation (P/F<300)
Clinical evidence of hypoperfusion defined by need for vasopressor agents for more than 2 hour
Renal dysfunction : Cr>171 or <500ml/24 hrs
platelet < 50

12. High dose associated with
Optimizing the Dose of Glutamine Dipeptides and Antioxidants In Critically Ill Patients: A Phase I dose finding study
Parenterally
Enterally
Glutamine/day
0.35 gms/kg
30 gms
Antioxidants
per day
500 mcg Selenium
Vit C 1500 mg
Vit E 500 mg
B carotene 10 mg
Zinc 20 mg
Se 300 ug
High dose appears safe
High dose associated with
no worsening of SOFA Scores
greater resolution of oxidative stress
greater preservation of glutathione
Improved mitochondrial function
Heyland JPEN Mar 2007

13. Mortality Outcomes Note: all P values pertain to GLN vs No GLN;
no significant differences between AOX vs. No AOX

14. Other Clinical Outcomes
No differences between groups
SOFA
Need for dialysis
Duration of mechanical ventilation
PODS
infections
ICU and Hospital LOS

15. Post-hoc Secondary Analyses

16. Adjusted Analysis
The 28-day mortality rates in the placebo, glutamine, antioxidant and combination groups were 25%, 32%, 29% and 33% respectively.
Compared to placebo, the unadjusted OR (95% CI) of mortality was Glutamine 1.4 ( , P =0.063),
Antioxidant 1.2 ( , P =0.31),
Both 1.4 ( , P=0.049).
After adjusting for all statistically significant baseline characteristics, the corresponding adjusted ORs remained virtually unchanged at:
Glutamine 1.4 ( , P =0.054)
Antioxidant 1.2( , P =0.34)
Both 1.4 ( , P =0.10)

17. Selected Subgroup Analyses
OR (95% CI) compared to placebo
P-values*
Subgroup
Deaths/n (%)
GLN alone
AOX alone
GLN+AOX
Overall
363/1218 (30%)
1.40 ( )
1.20 ( )
1.42 ( )
Study Setting
Region
0.37
Canada
303/1044 (29%)
1.41 ( )
1.14 ( )
1.29 ( )
USA
44/131 (34%)
1.56 ( )
1.43 ( )
3.43 ( )
Europe
16/43 (37%)
0.86 ( )
2.40 ( )
0.89 ( )
Baseline Patient Characteristics
Admission category
0.52
Surgical
59/255 (23%)
2.16 ( )
1.94 ( )
1.58 ( )
Medical
304/963 (32%)
1.28 ( )
1.08 ( )
1.43 ( )
Cancer patients
0.74 No
297/1048 (28%)
1.48 ( )
1.15 ( )
1.42 ( )
Yes
66/170 (39%)
1.05 ( )
1.43 ( )
1.38 ( )
Etiology of Shock
0.71
Cardiogenic
74/240 (31%)
1.24 ( )
1.62 ( )
2.19 ( )
Septic
256/826 (31%)
1.43 ( )
1.06 ( )
1.21 ( )
Other/Unkown/None
33/152 (22%)
1.45 ( )
1.45 ( )
1.83 ( )
Vasopressors
<15 mcg/min
162/595 (27%)
1.58 ( )
1.66 ( )
1.50 ( )
>=15 mcg/min
201/623 (32%)
1.32 ( )
0.92 ( )
1.39 ( )
Renal dysfunction
0.035
216/776 (28%)
0.93 ( )
0.90 ( )
1.14 ( )
147/442 (33%)
2.75 ( )
2.16 ( )
2.15 ( )
OR-odds ratio; CI-confidence interval; GLN-Glutamine; AOX-antioxidants

18. Conclusions
Glutamine and antioxidants at doses studied in this study do not improve clinical outcomes in critically ill patients with multi-organ failure
Glutamine may be harmful
For both glutamine and antioxidants, the greatest signal of harm was in patients with multi-organ failure that included renal dysfunction upon study enrollment.

19. A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury
Double blind treatment
EN glutamine
2700 Burn
Injury patients R
6 month mortality
Concealed
Stratified by site
placebo

20. SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX®-trial)
Double blind treatment
IV Selenium
Alive and free of POD
Or Time to freedom from life-sustain treatments
1400 high-risk
patients undergoing
cardiac surgery R
Concealed
Stratified by site
placebo

21. Knowledge To Action Model
Knowledge Synthesis
Knowledge To Action Model
Since 1980, 275 randomized trials
of nutrition interventions
studying >2000 critically ill patients
Rupinder, please update the number of RCTs: done n = 275 RCTs!

22. Knowledge – To- Action Model
Knowledge Synthesis
Knowledge – To- Action Model
Systematic reviews and
meta-analyses
of 45 nutrition related topics
Please update numbers..done! n = 45 topics

23. What does the evidence show about Alternative Lipid Emulsions
in the Critically Ill?

24. Therapeutic Options for PN Lipids
Soybean Oil (ω-6)
PN without Lipids
Olive Oil (ω-9)
MCT
Fish Oils (ω-3)
More
Pro-Inflammatory
Less
Pro-Inflammatory

25. Overall effect on Mortality of ω-6 Reducing Strategy (n= 12 RCT)
Ω-6 Sparing Strategies were associated with a reduction in Mortality (RR= 0.83, 95 % CI 0.62, 1.11, P= 0.20, heterogeneity I2 =0%)
Manzanares W, et al. Int Care Med 2013

26. Overall effect on Ventilation Days
(n= 5 RCT)
Ω-6 Sparing Strategies were associated with a trend towards a reduction in Ventilation Days
(WMD -2.57, 95% CI -5.51, 0.37, P=0.09)
Manzanares W, et al. Int Care Med 2013

27. Overall effect on ICU Length of Stay
(n= 8 RCT)
Ω-6 Reducing Strategies were associated with a trend towards a reduction in ICU LOS
(WMD -2.31, 95% CI -5.28, 0.66, P=0.13)
Manzanares W, et al. Int Care Med 2013

28. Canadian Clinical Practice Guidelines in 2013
February 10th 2012
PN Type of Lipids
2009 Recommendation
There are insufficient data to make a recommendation on the
type of lipids to be used in critically ill patients receiving
parenteral nutrition.
2013 Recommendation:
IV lipids that reduce the load of omega-6 fatty acids/soybean oil emulsions should be considered. There are insufficient data on type of soybean reducing lipids
Rupinder Dhaliwal

29. Which Alternative Lipid Emulsion to Use?
No head to head trials (and not likely to be)
We analyzed our International Nutrition Survey database to evaluate effect of Alternative Lipids on outcomes.
Analyzed adjusted for key confounding variables.
Edmunds CCM 2014 epub

30. Which Alternative Lipid Emulsion to Use?
Edmunds CCM 2014 epub

31. Which Alternative Lipid Emulsion to Use?
Fish Oil
Olive Oil
Lipid Free
MCT
Soybean
Edmunds CCM 2014 epub

32. Clinical Practice Guidelines
Knowledge – To- Action Model
Development of
Critical Care Nutrition
Clinical Practice Guidelines

33. Clinical Practice Guidelines for Nutrition
published initially in 2003
updated 2005, 2007, 2009 and 2013

35. How to Narrow the Gap? First Define the Gap
International audits of
nutrition practice

36. Objectives of International Survey
Quality Improvement
To determine current nutrition practice in the adult critical care setting (overall and subgroups)
Illuminate gaps between best practice and current practice
To identify nutrition practices to target for quality improvement initiatives
Generate New Knowledge
To determine factors associated with optimal provision of nutrition
To determine what nutrition practices are associated with best clinical outcomes

37. Australia & New Zealand: 36
Participation: INS 2013
202 ICUs
26 nations
4040 patients
37,872 days
Canada: 24
Europe & Africa: 35
Asia: 41
USA: 52
Japan: 21
India: 9
Singapore: 5
Philippines:2
China: 2
Iran : 1
Thailand: 1
Turkey: 11
UK: 8
Ireland: 4
Norway: 4
Switzerland: 3
Italy: 1
Sweden: 1
Spain: 1
South Africa: 2
Colombia:6
Uruguay:4
Venezuela:2
Peru:1
Mexico: 1
Added 2013 slide
Latin America: 14
Australia & New Zealand: 36 37

38. Australia & New Zealand: 40
Participation Across the 5 Years of the Survey : 355 Distinct ICUs
Canada: 69
Europe: 51
USA: 126
Asia: 52
Rupinder, please update this slide to be summative over all 5 years . Miao is combining the database now and can tell you these numbers.
Latin America: 17
Australia & New Zealand: 40 38

39. Value of Bench-marked Site Reports
Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within hrs following resuscitation) in critically ill patients.
Early vs Delayed Nutrition Intake

40. 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: %)
Cahill N Crit Care Med 2010

41. Need to Understand Local Barriers
Assess Barriers

42. Implementation Process Institutional Factors
Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework
ADHERENCE
CPG
Characteristics
Patient Characteristics
Provider Intent
Implementation Process
Institutional Factors
Provider Characteristics
- Profession
Critical care expertise
Educational background
Personality
System
characteristics
Hospital
characteristics
Structure
Processes
Resources
Knowledge
Attitudes
Familiarity
Agreement
Outcome
expectancy
ICU
characteristics
Structure
Processes
Resources
Culture
Motivation
Self-efficacy
Awareness
Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK JPEN Nov 2010

43. NO ONE COULD SEE THIS SLIDE AT CNW
NO ONE COULD SEE THIS SLIDE AT CNW..PERHAPS YOU COULD PICK SOME AND ENLARGE?

44. Can we do better with our current feeding protocols?
The same thinking that got you into this mess won’t get you out of it!

45. A major paradigm shift in how we feed enterally
The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol!
Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.
In select patients, we start the EN immediately at goal rate, not at 25 ml/hr.
We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume.
Start with a semi elemental solution, progress to polymeric.
Motility agents and protein supplements are started immediately, rather than started when there is a problem.
Tolerate higher GRV* threshold (300 ml or more).
A major paradigm shift in how we feed enterally
* GRV: gastric residual volume
Heyland DK. Crit Care. 2010;14(2):R78
Heyland DK CCM 2013.

46. Tools to Operationalize the PEP uP Protocol
Bedside Written Materials
Description
EN initiation orders
Physician standardized order sheet for starting EN.
Gastric feeding flow chart
Flow diagram illustrating the procedure for management of gastric residual volumes.
Volume-based feeding schedule
Table for determining goal rates of EN based on the 24 hour goal volume.
Daily monitoring checklist
Excel spreadsheet used to monitor the progress of EN.
Materials to Increase Knowledge and Awareness
Study information sheets
Information about the study rationale and guidelines for implementation of the PEP uP protocol. Three versions of the sheets were developed targeted at nurses, physicians, and patients’ family, respectively.
PowerPoint presentations
Information about the study rationale and how to implement the PEP uP protocol. A long (30-40 minute) and short (10-15 minute) version were available.
Self-learning module
Information about the PEP uP protocol and case example to work through independently.
Posters
A variety of posters were available to hang in the ICU during the study.
Frequently Asked Questions (FAQ) document
Document addresses common questions about the PEP uP Protocol.
Electronic reminder messages
Animated reminder messages about key elements of the PEP uP protocol to be displayed on a monitor in the ICU.
Monthly newsletters
Monthly circular with updates about the study.

48. % Protein Received/Prescribed
Change of Nutritional Intake from Baseline to Follow-up of All the Study Sites (All patients)
% Protein Received/Prescribed
p value=0.005
p value=0.81
Heyland DK CCM 2013.

49. Results of the Canadian PEP uP Collaborative
8 ICUs implemented PEP uP protocol through Fall of 2012-Spring 2013
Compared to 16 ICUs (concurrent control group)
All evaluated their nutrition performance in the context of INS 2013
Heyland JPEN 2014 (in submission)

50. Results of the Canadian PEP uP Collaborative

51. Results of the Canadian PEP uP Collaborative
Proportion of Prescribed Energy From EN According to Initial EN Delivery Strategy
Just say no
to NPO*

52. New Collaborative: PEP UP US?
Want to add a slide here re: this?
Do you want to do this ?

53. Need for a Tailored Approach
Select Intervention(s)

54. Bridging the Guideline – Practice Gap In Critical Care Nutrition: A Review of Guideline Implementation Studies
3 Cluster RCTs
14 ICUs in Canada
60 ICUs in Canada
27 ICUs in Australia
Guidelines
Bedside
Cahill N, Heyland DK

55. Practice Changing Interventions
Protocolize/automate care
Improve organizational culture
Develop 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 (checklists, manuals, posters, pocket cards)
One on one academic detailing

56. 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)

57. REPEATED SLIDE, CANNOT SEE THIS AT ALL

58. Tailored Intervention:
Vs.
Tailored Intervention:
Change strategies specifically chosen to address the barriers identified at a specific setting at a specific time

59. Systematic Review of Tailored Interventions
26 studies of tailored interventions
Pooled OR 1.52 (95% CI ), p=0.001
Variation in methodology
None in clinical nutrition
Baker et al Cochrane Database Syst Rev 2010

60. PERFormance Enhancement of the Canadian nutrition guidelines through a Tailored Implementation Strategy: The PERFECTIS Study
Hypothesis
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.

61. Study Schema: Pre-test Posttest

62. Example of Tailored Action Plan

63. Change in Prioritized Barriers Score
Site Range
-26.3% (SD 18.8%) To
-4.6% (SD 28.6%)
Overall Barriers Score
Before = 30.5%
After = 20.8%
Change = -9.7 %

64. Change in Adequacy of Total Nutrition
Before = 43%
After = 49%
Change = 6%
Site Range = -2 to 18%

65. OPTimal nutrition by Informing and Capacitating family members of best practices: The OPTICs feasibility study
Investigators
Andrea Marshall, RN, MN, PhD
Daren Heyland, MD, FRCPC, MSc
Naomi Cahill, RD, PhD candidate
Rupinder Dhaliwal, RD

66. Gap exists: best practice & current practice
Evidence-based nutrition guidelines are inconsistently implemented
Large scale, multi-faceted interventions have failed to improve nutrition practices & have not improved nutritional adequacy for the critically ill
Engaging family members to act as advocates for nutrition may be a promising strategy to narrow the gap between best practice & current practice both in the ICU and post ICU

67. Objectives: Definitive study
Hypothesis
Educating families about the importance of nutrition and having them advocate for better nutrition for their loved one in the ICU will result in better nutrition delivery during critical illness and in the recovery phase

68. Evidence for Family Advocacy
Literature supports family-centered care1,2,3,4
Families and ICU staff are very supportive of family involvement in patient care. Most patients are also favourable of family involvement in their care1
Garrouste-Orgeas M, Willems V, Timsit JF, Diaw F, Brochon S, Vesin A, et al. Opinions of families, staff, and patients about family participation in care in intensive care units. J Crit Care. 2010;25(4):
Cypress BS. The lived ICU experience of nurses, patients and family members: a phenomenological study with Merleau-Pontian perspective. Intensive Crit Care Nurs. 2011;27(5):273-80
Kinsala EL. The Very Important Partner program: integrating family and friends into the health care experience. Prog Cardiovasc Nurs. 1999;14(3):
Mitchell M, Chaboyer W, Burmeister E, Foster M. Positive effects of a nursing intervention on family-centered care in adult critical care. Am J Crit Care. 2009;18(6):543-52; quiz 53.

69. Objectives: Feasibility Study
Primary aim:
Evaluate the feasibility and acceptability of an intervention designed to educate family members about the importance of adequate nutrition in ICU and during recovery from critical illness

70. Intervention: Family education session & patient nutrition history
Education session and booklet
Information about nutrition therapy
Nutrition therapy risks, side effects
Initiating oral feeds following EN or PN
How family members can be advocates for
the best nutrition practices
Nutrition history (Family member)
Weight loss history
Past diets, food intolerances/allergies, GI problems
Chewing/swallowing difficulties
Eating patterns
Food preferences

71. Creating a Culture of Clinical Excellence in Critical Care Nutrition: The ‘Best of the Best’ Award
Heyland JPEN 2010: in press

72. Recognition and Reward
Recognition a powerful motivator of human performance

73. Determining the Best of the Best
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 tubes
% of patient glucose measurements greater than 10 mmol/L (excluding day 1; fewest is best)
Rank all eligible ICUs by determinants
Multiply ranking by weighting
ICU with highest score is crowned ‘Best of the Best’

74. 2008 Best of the Best
Top 3 ICUs 1. Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
2. Kingston General Hospital, Kingston, Canada
3. Regional Hospital A. Cardarelli, Italy  
ADDED A NEW PICTURE FOR THE BOB..other one needs to retore!
Top 3

75. The Team at the Alfred Hospital ICU, Melbourne, Australia
Best of the Best 2011
ADDED 2011 BOB IN CASE YOU WANT THIS?
The Team at the Alfred Hospital ICU, Melbourne, Australia

76. 2013 Best of the Best 1. Kingston General Hospital, Kidd2 ICU Canada
TOP 3 Sites
1. Kingston General Hospital, Kidd2 ICU Canada
2. Hospital General de Medellín, luz Castro de Gutiérrez Unidad de cuidados intensivos , Colombia
3. The Ministry of Health Ankara, Numune
Research and Training Hospital Turkey
Please fill this in and add some pics on the next slides…DONE!
Top 3

77. Kingston General Hospital

78. Hospital General de Medellín Colombia

79. The Ministry of Health Ankara Turkey

80. And the Cycle continues...

81. More (and Earlier) is Better!
If you feed them (better!)
They will leave (sooner!)