1. Barriers and Facilitators To making it Happen! Daren K. Heyland Professor of Medicine Queen’s University, Kingston General Hospital Kingston, ON Canada

2. Disclosures Research Contracts with the Following Companies Nestle Baxter Fresenius Kabi Abbott Nutrition

3. Results of 2007 International Nutrition Practice Audit Cahill N Crit Care Med 2010 (in press) Average time to start of EN : 46.5 hours (site average range: 8.2-149.1 hours) 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: 0-100%)

4. Adequacy of EN: Kcals

5. Relationship Between Increased Calories and 60 day Mortality BMI GroupOdds Ratio 95% Confidence Limits P-value Overall0.760.610.950.014 <200.520.290.950.033 20-<250.620.440.880.007 25-<301.050.751.490.768 30-<351.040.641.680.889 35-<400.360.160.800.012 >=400.630.321.240.180 Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition days, BMI, age, admission category, admission diagnosis and APACHE II score. Alberda Int Care Med 2009;35:1728

7. A Qualitative Assessment of “Barriers and Facilitators” to Implementing Nutrition CPGs in ICU  Multiple case study  4 case ICU sites  Purposeful sampling  Semi-structured key informant interviews (n=28)  Min. 5 years ICU experience  Employed at case ICU site May 2004  Document review Jones NCP 2007;22:449

8. Potential Barriers  Resistance to change  Patients clinical condition  Lack of awareness  Information overload  Weak evidence  Resource constraints  Slow administrative process  Impractical / Complex  Nursing workload  Limited critical care experience

9. Potential Facilitators  Agreement of the attending physician & ICU team  Part of routine practice  Dietitian / Opinion leader  Access / Visibility  Easy to follow and perform  Provision of education  Open discussion

10. Favored Implementation Strategies  Informal one-on-one discussions Academic detailing, ward rounds  Protocols Pre printed orders, Check-list, algorithms,  Bed-side reminders  Feedback and audit Site reports

11. The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results of a multicenter observational study  International, prospective, observational, cohort studies conducted in 2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries  Included 5497 mechanically ventilated adult patients > 3 days in ICU  Sites recorded the presence or absence of a feeding protocol  Sites provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. Heyland JPEN 2010 ( in press) P<0.05 78% of sites reported use of Feeding Protocol

15. Initial Efficacy and Tolerability of Early Enteral Nutrition with Immediate or Gradual Introduction in Intubated Patients Desachy ICM 2008;34:1054 This study randomized 100 mechanically ventilated patients (not in shock) to Immediate goal rate vs gradual ramp up (our usual standard). The immediate goal group rec’d more calories with no increase in complications

16.  Not all critically ill patients are the same; we have different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.  Use semi elemental solution  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.  Tolerate higher GRV threshold (250 ml or more)  Motility agents and protein supplements are started immediately, rather than started when there is a problem. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! A Major Paradigm Shift in How we Feed Enterally

17. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Heyland (in submission)

18. The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients: The PEP uP Protocol! Heyland (in submission)

19. Need for Constant Reminders

20. Poster

21. Reminder HOB sticker Reminder HOB sticker

22. Reminder screensavers Reminder screensavers

23. Early Enteral Nutrition in the ICU: The Clock Is Ticking! Daren K. Heyland, MD, FRCPC, MSc Professor of Medicine Queen’s University Kingston, Ontario Special DVD presentation

24. www.criticalcarenutrition.com

26. Overall Site Performance

28.  Protocolize/automate care  Improve organizational culture  Develop Dietitian and other KOL as 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 (manuals, posters, pocket cards)  One on one academic detailing Practice Changing Interventions

29. 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)

30. Conclusions  Long way to go to narrow the quality gap  Need to enrich our understanding on how best to achieve that; but in the mean time, act now!  With our emerging understanding of the problems, we need to develop more targeted or strategic solutions. Strengths & weaknesses; barriers & enablers vary across sites.  Stay tuned…