1. Objectives: To optimize the delivery of EN by implementing the PEP uP protocol in sites across North America. We provide practitioners the opportunity to improve current nutrition practices, and enable these practitioners to further their role as nutrition educators in the ICU while fostering a network of clinicians committed to the optimal delivery of EN in the ICU. Methods: This is a quality improvement project (in contrast to a research study). Participants are provided with practical tools and strategies to improve EN delivery, including a volume-based feeding protocol. All participating sites will receive: access to an educational presentation to train your multidisciplinary team, supporting tools such as visual aids and protocol templates, access to a member of the Critical Care Nutrition team who will support each site during the collaborative, access to an online discussion group around questions unique to PEP uP, a detailed site report showing nutrition performance following participation in the International Nutrition Survey and online access to the Bedside Nutrition Monitoring Tool. Bedside Nutrition Monitoring Tool Expectations of participants: To implement the PEP uP protocol and participate in group discussions with fellow PEP uP Collaborative participants. If you are interested in joining the collaborative or learning more, contact Margot Viola at violam@kgh.kari.net.learning more violam@kgh.kari.net The OPTICS feasibility study: OPTimal nutrition by Informing and Capacitating family members of best practices Background: In the critically ill, nutrition requirements are increased while nutritional intake may be suboptimal. To date, attempts to improve nutritional intake using multifaceted interventions have demonstrated modest improvements. Objectives: To determine the feasibility and acceptability of a novel intervention designed to educate families about the importance of nutrition during and following critical illness, and to encourage families to advocate for better nutrition on behalf of their family member. Methods: Family members will be provided with a short nutrition education session and accompanying booklet designed to educate them about the best nutrition practices in the intensive care unit and following discharge to the ward. Once on the ward, families will be provided with a nutrition diary to be completed daily once the patient resumes oral intake. Families will be encouraged to communicate with the health care team regarding the patient’s nutrition care. Expectations of participants: Ethics approval will be required at all sites. Sites are responsible for screening, implementing, collecting data and giving nutrition education sessions for the study. Funding: Currently being sought to support the research activities. Status: OPTICS is currently being conducted in 2 Australian and 1 Canadian site. We are interested in recruiting 2 Canadian and 2 American sites to the OPTICS feasibility study! If you are interested in receiving further information, contact Margot Viola at violam@kgh.kari.net.violam@kgh.kari.net Collaborative Visit us online at www.criticalcarenutrition.comwww.criticalcarenutrition.com We are conducting several critical care nutrition research studies at the Clinical Evaluation Research Unit! We are looking to recruit sites to participate in the following studies:

2. Attention Canadian and USA sites participating in the 2013 International Nutrition Survey (INS)! Background: Medications such as antibiotics, vasopressors and gastric acid suppressants all may have a major effect on changing the bacteria in our guts from a normal, helpful part of our physiology to an aggressive and pathologic make-up that may lead to infection, bacteremia, sepsis, and potentially death. Nutritional intake, use of enteral versus parenteral nutrition, and pharmaconutritional interventions all likely have a major role in the preservation or loss of our normal gut flora. Currently, the Human Microbiome Project has been defining what a normal, healthy individual’s gut bacteria looks like and American Gut is characterizing the diversity of the gut microbiome, but very little is known about the specific changes that occur in the microbiome of ICU patients and how this effects patient outcomes.Human Microbiome Project American Gut Objectives: To begin to define the changes that occur to the microbiome in the ICU, what effect they have on the patient outcomes and how the nutrition we give effects the bacterial make-up of critically ill patients. Methods: INS sites will collect the data normally collected for the survey, plus some antibiotic data. Utilizing easy to use pre-made collection kits, sites will collect a very small sample of stool and an oral swab form each survey patient. Sample collection will take approximately 10 minutes. Expectations of participants: Ethics approval with a waiver of informed consent is being sought at University of Colorado and Kingston General Hospital. Participants will be expected to obtain ethics approval and, in addition to INS data, collect antibiotic utilization and obtain an oral and stool swab at baseline and end of study on all INS patients. It is expected that sites that participate in this sub-study may need to delay the start up of INS until ethics approval has been obtained. Funding: None. Participating North American sites will receive $500 towards travel to an ASPEN meeting. Status: Recruiting a minimum of 10 sites. If you are interested in receiving further information, contact Paul.Wischmeyer@ucdenver.edu.Paul.Wischmeyer@ucdenver.edu Background: Providing optimal delivery of enteral nutrition early in the clinical course of critically ill patients is recognized as an integral component of high quality standard supportive care. Meanwhile, gastric emptying is well documented to be impeded in 40-60% of ICU patients resulting in an inability to deliver adequate enteral nutrition leading to increased gastric residual volumes, and potential for aspiration of gastric contents. Normalization of gastric emptying by the use of prokinetic agents is a recommended strategy for optimizing delivery and minimizing risks of EN. We are currently engaged in several randomized trials evaluating gastrointestinal prokinetic agents and are recruiting participating sites. Objectives: To assess the ability of new motility agents to enhance the delivery of enteral nutrition to critically ill patients at risk of feeding intolerance, enhance gastric emptying in this population and provide preliminary evidence on the drugs’ effects on patient outcomes. Methods: Randomized clinical trials of novel motility agents. Expectations of participants: Participating sites must have research personnel qualified to implement trials according to Good Clinical Practice standards. Funding: Industry sponsored, per patient remuneration varies depending on the trial. Status: Planning and recruiting sites. If you are interested in receiving further information, contact Margot Viola at violam@kgh.kari.net.violam@kgh.kari.net Visit us online at www.criticalcarenutrition.comwww.criticalcarenutrition.com Defining the Gut Microbiome in an International Critical Care Population The Evaluation of Motility Agents in Critically ill Patient on EN