1. International Critical Care Nutrition Survey 2009: Defining Gaps in Practice Naomi E Cahill, RD MSc Project Leader Queen’s University and Clinical Evaluation Research Unit Kingston, Ontario, Canada

2. Learning Objectives Be familiar with the recommendations of the Canadian Critical Care Nutrition Clinical Practice Guidelines Be aware of current nutrition practices in ICUs in your own geographic region and throughout the world Be able to identify gaps between guideline recommendations and current practices in ICUs

3. Acknowledgments Participants of the International Nutrition Survey 2009 Dr Daren Heyland and the Research Team at the Clinical Evaluation Research Unit –Lauren Murch, Project Assistant –Rupinder Dhaliwal, Project Leader –Andrew Day, Biostatistician –Miao Wang, Data Analyst –Fernando Ferrer, IT Support

4. Why Audit Nutrition Practice?

5. Benchmarking Individual ICUs compared to: Canadian Clinical Practice Guidelines All ICUs ICUs from same geographic region

6. Benchmarking

7. Why Audit Nutrition Practice?

8. 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

9. History of International Surveys 3 previous surveys in Canada –2001, 2003, 2004 –N > 50 Extended to other countries in 2007 and 2008 –167 ICUs each year –>18 countries –65 ICUs from 10 countries participated in both years. Repeated in September 2009 –Focus on North America –Preliminary results

10. Methods Eligibility Criteria ICU Site –>8 beds –Availability of individual with knowledge of clinical nutrition to collect data Patient –Adult >18 years –In ICU > 72 hours –Mechanically ventilated within 48 hours

11. Methods Prospective observational cohort study Start date: 16 th September 2009 Aim 20 consecutive patients –Min 8 pts Data included: –Hospital and ICU demographics –Patient baseline information (e.g. age, admission diagnosis, APACHE II) –Baseline Nutrition Assessment –12 days Daily Nutrition data (e.g. type of NS, amount NS received) –60 day hospital outcomes (e.g. mortality, length of stay)

12. Web based Data Capture System

13. Canada: 32 USA: 62 Australia & New Zealand: 22 Europe: 15 Latin America: 10 Asia: 12 Mexico: 2 Brazil:1 Colombia:5 Peru:1 Venezuela:1 Italy: 2 UK: 7 Ireland: 2 Norway: 1 Switzerland: 1 Czech Republic: 1 China: 1 Taiwan: 1 India: 6 Iran : 1 Japan: 1 Singapore: 2 Who participated in 2009? : 152 ICUs

14. Number of finalized patients per site –19.4 (9-41) Total number of finalized patients –2,948 Days of observation per patient –9.4 (3-12) Total number of patient days in ICU –27,615 days <3% missing data for ALL variables Who participated? Patients

15. ICU Characteristics CharacteristicsTotal (n=152) Hospital Type Teaching111 (73.0%) Non-teaching41 (27.0%) Size of Hospital (beds) Mean (Range)498 (50, 1500) ICU Structure Open46 (30.3%) Closed102 (67.1%) Other4 (2.6%) Size of ICU (beds) Mean (Range)19 (5,48) Designated Medical Director150 (95.5%) Presence of Dietitian(s)144 (94.7%) FTE Dietitians (per 10 beds) Mean (Range)0.4 (0.0, 1.7)

16. Patient Characteristics CharacteristicsTotal n=2948 Age (years) Median [Q1,Q3]62 [48, 73] Sex Female1197 (40.6%) Male1751 (59.4%) Admission Category Medical1902 (64.5%) Surgical: Elective357 (12.1%) Surgical: Emergency689 (23.4%) BMI (kg|m2) Median [Q1, Q3]26.0 [22.8, 30.8] Apache II Score Median [Q1, Q3]22 [17, 28] Presence of ARDS Yes398 (13.5%)

17. Outcomes at 60 days CharacteristicsTotal n=2948 Length of Mechanical Ventilation (days) Median [Q1, Q3]7.2 [3.3, 15.3] Length of ICU Stay (days) Median [Q1, Q3]10.3 [5.9, 19.9] Length of Hospital Stay (days) Median [Q1,Q3]19.0[10.5, 36.7] Patient Died (within 60 days) Yes721(24.7%)

18. Baseline Nutrition Assessment CharacteristicsTotal n=2850 BMI (kg|m2) Median [Q1, Q3]26.0 [22.8, 30.8] Prescribed Energy Intake (Kcals) Median (Q1, Q3]1800.0 [1540, 2020] Prescribed Protein Intake (g) Median [Q1,Q3]89 [74, 104] Received Energy Intake (Kcal) Median [Q1,Q3]1288 [657, 1895] Received Protein Intake (g) Median [Q1,Q3]63 [29,91]

20. We strongly recommend the use of enteral nutrition over parenteral nutrition

21. Type of Nutrition Support n=2948 patients

22. Use of EN Only n=16983 patients days 66.5% 73.7% 55.6% 6.4% 93.4%

23. Use of PN Only n=2279 patients days 8.9% 12% 6.6%

24. Use of EN + PN n=292 patients days 4.6% 2.7% 16.3%

25. No EN, PN or Oral intake received n=5117 patients days 20% 10.5% 26.9%

26. We recommend early enteral nutrition (within 24-48 hrs following admission) in critically ill patients

27. Timing of Initiation of EN 41 hrs 50 hrs 30 hrs

28. An evidence based feeding protocol should be considered as a strategy to optimize delivery of enteral nutrition

29. Feeding Protocol CharacteristicsTotal n=152 Feeding Protocol Yes128 (84.2%) Gastric Residual VolumeThreshold Mean (range)237 (100, 500) Algorithms included in Protocol Motility agents85 (69.7%) Small bowel feeding65 (53.3%) Withholding for procedures62 (50.8%) HOB Elevation105 (86.1%) Other21 (17.2%)

30. In critically ill patients who experience feed intolerance (high gastric residual volumes, emesis) the use of a motility agent is recommended

31. Strategies to Optimize EN Delivery: Motility Agents 60.7% 45% 87%

32. In units were achieving routine small bowel access is not feasible small bowel feeding should be considered for patients who repeatedly demonstrate high gastric residual volumes and are not tolerating EN

33. Location of Feeding Tube

34. Small Bowel Feeding 12.2% 43.8% 4.3%

35. Feeding Intolerance 425/2488 (17.1%) EVER had EN interrupted due to intolerance* 806/24,470 (3.3%) patients days had EN interrupted due to intolerance * Presence of high gastric residual volumes / emesis / aspiration

36. Strategies to Optimize EN Delivery: Head of Bed Elevation 32 0

37. We recommend that critically ill patients receiving EN should have the head of the bed elevated to 45 degrees

38. Composition of EN and Pharmaconutrient Supplementation recommendations Arginine-supplemented formulasRecommend NOT be used Glutamine supplementation Enteral should be considered in burn and trauma Parenteral strongly recommended in PN pts Fish oil enriched formulaRecommended in ARDS Combined vitamins and trace elements Should be considered PolymericRecommend

39. Use of EN Formula and Pharmaconutrients Arginine-supplemented formulas8.0%(0.0%-94.7%) Glutamine supplementation (All)6.0%(0.0%-95%) Fish oil enriched formula (ARDS)19.5% (0.0%-100%) Selenium Supplementation (All)3.1% (0.0%-100%) Polymeric87.8% (0.0%-100.%)

40. In patients not tolerating adequate amounts of EN, PN should not be started until all strategies to maximize EN delivery (e.g. motility agents, small bowel feeding) have been attempted

41. EN in Combination with PN % of patients received motility agents before PN started 44.4% 21% 63%

42. We recommend that hyperglycemia (blood sugars >10mmol/l) be avoided

43. Blood Glucose >10 mmol/l 13.4% 8.8% 15.6%

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

45. Overall Performance: Kcals 93% 49.9% 8.3%

46. Overall Performance: Kcals

47. Overall Performance: Protein

48. Where can we do better? Inadequate EN delivery –timing of initiation of EN –feeding protocols –small bowel feeding and motility agents Optimize Pharmaconutrition –use of glutamine, antioxidants, omega-3 FFA. Tighten glycemic control

49. Nutritional Adequacy Over Time

50. How are you performing at your site? Can you be the Best of the Best? Further Information: www.criticalcarenutrition.com