A Continuous Quality - DGEM...A Continuous Quality Improvement Effort What is done? What ought to be done? What do we need to do differently? “Gaps” - site reports How to change?

A Continuous QualityImprovement Effort

What is done?

What ought to be done?

What do we need to do differently?

“Gaps” - site reports

How to change?

“KT strategies”

RCTs, Systematic Reviews, and Evidence-based practice

guidelines

Survey results

Information Overload

Impractical for individual clinicians to assimilate massive amounts of

information to make unaided judgments about complex decisions

• Clinical practice guidelines can move us from

opinion based medicine to evidence based

medicine (McColl BMJ 1998:316)

• Need for Clinical Practice Guidelines– Decrease practice variation

– Improve clinical outcomes

– Significant cost savings

(Burns CCM 2003:31:2752; Martin C CMAJ 2004:197)

Need for Clinical Practice Guidelines ?

What Are Clinical Practice Guidelines?

• “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”

– U.S. Institute of Medicine

• applies to the average patient

Context of Guidelines

• Evidence-based Medicine

– “the conscientious, explicit, and judicious use

of current best evidence in making decisions

about the care of individual patients”

– Sackett DL et al. BMJ 1996;312:71-2

Levels of Evidence

�Systematic reviews

�RCT’s

�Cohort Studies

�Case Control

�Case Series

less bias/strong inferences

more bias/weaker inferences

RCT #1RCT #2

RCT #3 RCT #4

RCT #5

Meta-analysis vs RCTs

What is a GOOD guideline?

• Ideally, leads to improvement in patient

outcomes

• This information rarely available

• Alternative:

Have the producers of the CPG attempted to minimize bias in the complex process of creating the CPG?

Criteria for High Quality CPGs (1)

• Scope: – specific statement about the overall objectives, clinical questions and

describes the target population.

• Stakeholder involvement: – information on the composition, discipline, and relevant experience of the

development group.

• Rigor of development: – Provide detailed information on the search strategy, the

inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible).

– Transparent link between evidence, values, and resulting recommendation.

– External review

– Procedure for updating the CPG

AGREE Qual Saf Health Care 2003;12:18

Criteria for High Quality CPGs (2)

• Clarity and Presentation:

– Contains specific recommendations on appropriate patient care and

consider different possible options.

– Key recommendations are easily found

– A summary document and patient leaflet’s are provided.

• Applicability:

– Discuss the organizational changes and cost implications of applying the

recommendation and present criteria for monitoring the use of the CPG

• Editorial Independence:

– Include an explicit statement that the views or interests of the funding

body have not influenced the final recommendations.

– Members of the group have declared conflicts of interest.

AGREE Qual Saf Health Care 2003;12:18

www.criticalcarenutrition.com

� Updated January 2009

� Summarizes 191 trials studying >15000 patients

� 34 topics 18 recommendations

Will adoption of the Canadian CPGs

result in improved nutrition support

practice ?

Validation of the CPG’s: Results of a Prospective Observational Study

• Summary

– Patients and Sites that were more

consistent with CPG

recommendations tended to receive

more EN

Adoption of Canadian CPGs will likely lead to improved nutrition support practices in ICUs

Heyland CCM 2004;32:2260

Cahill N Crit Care Med 2010

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%)

Cahill NE CCM 2010

Average time to start of EN was 46.5 hours

(site average range: 8.2-149.1 hours)

More EN= Improved Outcomes

� Observational studies that better fed patients have fewer

infections, less time on ventilator, and lower survival

� RCTs of aggressive feeding protocols� Results in better protein-energy intake

� Associated with reduced complications and improved survival

� Meta-analysis of Early vs Delayed EN

� Reduced infections: RR 0.76 (.59,0.98),p=0.04

� Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06

Alberda ICM 2009, Heyland 2010, Taylor Crit Care Med 1999; Martin CMAJ 2004

How to change?

CPGs to bedsideGuidelines

Bedside

Dissemination and

Implementation Strategies

“Minding the GAP”

an Important Part of Patient Safety

The time to ACT is NOW!

Special JPEN Issue Dedicated to KT

• Knowledge Translation (KT)

– describes the process of moving evidence learned from

clinical research and summarized in CPGs to its

incorporation into clinical and policy decision-making.

– defined as “a dynamic and iterative process that includes

synthesis, dissemination, exchange and ethically-sound

application of knowledge to improve the health of patients,

provide more effective health services and products and

strengthen the health care system.”

– Knowledge transfer, knowledge exchange, research

utilization, implementation science, dissemination, and

diffusion are other terms that have been used

interchangeably to describe the same concept.

Available online nowIn press shortly

Lost in (Knowledge) Translation!

Heyland DK, Cahill N, Dhaliwal R

Knowledge to Action Model by Graham

Knowledge Generation

Knowledge To Action Model

Since 1980, >200 randomized trialsof nutrition interventions

studying >2000 critically ill patients

Randomized Trials in Critical Care Nutrition:

Look How Far We’ve Come!

(and where do we go from here?)

Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

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Since 1980, 207 RCTs of Critical Care Nutrition Therapies






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Knowledge Synthesis

Knowledge – To- Action Model

Systematic reviews and meta-analyses

of 34 nutrition related topics

Clinical Practice Guidelines

Knowledge – To- Action Model

Development of multiple

Critical Care Nutrition Clinical Practice Guidelines

Guidelines, Guidelines, Guidelines.

What Are We to do With all of These

North American Guidelines?

• Comparison of Canadian, American

Dietetic Association, ASPEN/SCCM CPGs

• Different methods, studies included, ratings

of evidence and values

• Similarities, minor and major differences in

recommendations

• Can we harmonize this process?

Dhaliwal R, Madden S, Cahill N, Jeejeebhoy K, Kutsogiannis J, Muscedere J, McClave S,

Heyland DK

How to Narrow the Gap?

First Define the Gap

International audits of

nutrition practice

Cahill N Crit Care Med 2010

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%)

Recommendations: Based on 8 level 2 studies, we recommend early enteral

nutrition (within 24-48 hrs following resuscitation) in critically ill patients.

Value of Bench-marked Site Reports

0

20

40

60

80

100

120

Tim

e t

o I

nit

iati

on

of

EN

(h

rs)

Site

Maximum

Minimum

Median

Your site All sites Sister sites

Early vs Delayed Nutrition Intake

The Value of ‘Audit and Feedback Reports’

in Improving Nutritional Therapy in the ICU:

A Multicenter Observational Study

• 26 Canadian ICUs participating in 2007 and 2008 Surveys

Sinuff T, Cahill N, Dhaliwal R, Wang M, Day A, Heyland DK

(45.1% to 51.9%, p<0.001 and 44.8% to 51.5%, p<0.001 for calories and protein respectively

Adequacy of Calories from EN Only

20

30

40

50

60

70

80

Year

2007 2008

Need to Understand Local Barriers

Assess Barriers

Understanding Adherence to Guidelines in the ICU:

Development of a Comprehensive Framework

Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

CPG

CharacteristicsADHERENCE

Implementation Process Institutional FactorsProvider Intent

Hospital

characteristics

-Structure

- Processes

-Resources

-Patient Case-mix Knowledge Attitudes

Familiarity

AwarenessMotivation Self-efficacy

Outcome

expectancyAgreement

ICU

characteristics

-Structure

- Processes

-Resources

- Patient Case-mix

-Culture

Provider Characteristics

- Profession

-Critical care expertise

-Educational background

-Personality

Patient Characteristics

The Relationship Between Organizational Culture

and Implementation of Clinical Practice Guidelines:

A Narrative Review

• “The way things are around here”

• Major influence on CPG adherence

• Defining, measuring, and changing

Dodek P, Cahill N, Heyland DK

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 nutritional data on enrolled patients from ICU

admission to ICU discharge for a maximum of 12 days.

0

20

40

60

80

Calories from EN Total Calories

Protocol

No Protocol

P<0.05

78% of sites reported use of Feeding Protocol

Heyland DK, Cahill N, Dhaliwal R, Sun, Xiaoqun, Day A, McClave S




CPG



Hospital

characteristics

-Structure

- Processes

-Resources


Familiarity


Outcome

expectancyAgreement

ICU

characteristics

-Structure

- Processes

-Resources

- Patient Case-mix

-Culture


- Profession



-Personality


Attitudes and Beliefs Related to the Canadian

Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians

Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

• International web-based survey of 514

practitioners from 27 countries

Attitudes and Beliefs Related to the Canadian

Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians

• Majority (91.4%) considered nutrition therapy to be very important

• Strong endorsement for the following established practices: enteral

nutrition (EN) used in preference to parenteral nutrition (PN), use of

polymeric solutions and feeding protocols, and avoiding

hyperglycemia.

• Also strong endorsement for the following practices that are not

routinely done in actual practice: EN initiated within 24-48 hours of

admission, use of motility agents, head of the bed elevation, use of

glutamine and antioxidants, and maximizing EN prior to starting PN.

• There was diversity of opinion on the recommendations pertaining to

arginine-supplemented diets, small bowel feeding, use of

pharmaconutrients, intensive insulin therapy, and withholding soybean

oil lipids in PN solutions and hypocaloric PN.

Cahill N, Narasimhan S, Dhaliwal R, Heyland DK




CPG



Hospital

characteristics

-Structure

- Processes

-Resources


Familiarity


Outcome

expectancyAgreement

ICU

characteristics

-Structure

- Processes

-Resources

- Patient Case-mix

-Culture


- Profession



-Personality


Nutrition Therapy for the Critically Ill Surgical

Patient: We Need to do Better!

• Combined 2007 and 2008 survey database

• 5497 mechanically ven’t patients >3days

• 37% surgical

Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day A, Heyland DK

Need for a Tailored Approach

Select Intervention(s)

Bridging the Guideline – Practice Gap

In Critical Care Nutrition:

A Review of Guideline Implementation Studies

• 14 ICUs in Canada

• 60 ICUs in Canada

• 27 ICUs in Australia

Cahill N, Heyland DK

GuidelinesBedside

3 Cluster RCTs

Implementation of CPGs

A Cluster randomized trial comparing 2 methods of dissemination of Canadian CPGs

Passive Active

meetings and Interactive Workshops

hard copy Web based tools and training

Jain, Heyland, et al. Crit Care Med 2006;34:2362

• Passive Strategies

- copy of published Canadian CPGs

- presented at national meetings

• Active Strategies

- as above plus

- dietitians positioned as local opinion leaders

- web-based tools including bench-marked site reports

- interactive workshops with small group problem solving

- training on rapid cycle change

- educational reminders (manuals, posters, pocket cards)

- academic detailing by phone

Cluster Randomized Control Trial

www.criticalcarenutrition.com

• Recommendations: Based on 8 level 2 studies, we recommend early

enteral nutrition (within 24-48 hrs following resuscitation) in critically ill

patients.

Early vs Delayed Nutrition Intake

0

20

40

60

80

100

120

Tim

e t

o I

nit

iati

on

of

EN

(h

rs)

Site

Maximum

Minimum

Median

Your site All sites Sister sites

Design

May 2003

Data collection

May 2004

Data Collection

Randomization

Before After

Active

Passive

EN Adequacy

Results of Cluster RCT

No difference between groups

Overall change from baseline =7.2%

(p<0.001)

B=Baseline, F=Follow-UpStudy Day

% P

rescri

bed C

alo

ries R

eceiv

ed b

y E

N

2 4 6 8 10 12

020

40

60

80

B

B

B

B

BB B B B

B BB

F

F

F

FF F

F FF F F

F

B

B

B

BB

BB B

B B B B

F

F

F

FF

FF

FF

F F

F

InterventionControl

No Differences Between Groups

�� Nutrition Support Practices:Nutrition Support Practices:

-- Type of nutrition support receivedType of nutrition support received

-- EN started within 48 hoursEN started within 48 hours

-- small bowel feeding, motility agentssmall bowel feeding, motility agents

-- feeding protocols, HOBfeeding protocols, HOB

-- use of glutamine, IV lipidsuse of glutamine, IV lipids

�� Clinical Outcomes:Clinical Outcomes:

-- ICU LOSICU LOS

-- MortalityMortality

Why Such Minimal Effect?

• Guideline implementation is complex

• Existing studies on adherence to CPGs:- Practitioner

- Intra-disciplinary

- Outside ICU

- Non-nutritional

• Need to identify barriers and enablers to nutrition guideline adherence in the ICU

�Protocolize/automate care

�Improve organizational culture

�Develop Dietitian and other KOL as local opinionleaders

�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 InterventionsPractice Changing InterventionsPractice Changing InterventionsPractice Changing Interventions

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)

Vs.

Tailored Intervention:

Change strategies specifically chosen to address the

barriers identified at a specific setting at a specific time

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.

Hypothesis

PERFormance Enhancement of the

Canadian nutrition guidelines

through a Tailored Implementation

Strategy: The PERFECTIS Study

And the Cycle continues...

Creating a Culture of Clinical

Excellence in Critical Care Nutrition:

The ‘Best of the Best’ Award

Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

Recognition and Reward

Recognition a powerful

motivator of

human performance

Recognition Produces Results!• The results of a 10-year, 200,000 employee study:

• Organizations excelling at rewarding excellence had

avg. ROE of 3x greater than the lowest rated

organizations

• Institutions that excel at recognizing employee

contributions:

– HIGHER in customer satisfaction

– HIGHER in employee satisfaction/morale (94.4% agree their

superior is effective at recognition, only 2.4% with low

morale agree)

– HIGHER in employee retention

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 1

% of patient glucose measurements greater than 10

mmol/L (excluding day 1; fewest is best)

3

�Rank all eligible ICUs by determinants

�Multiply ranking by weighting

�ICU with highest score is crowned ‘Best of the Best’

Best of the Best Award

• Eligible sites:� Data on 20 critically ill patients

� Complete baseline nutrition assessment

� Presence of feeding protocol

� No missing data or outstanding queries

� Permit source verification by CCN

• Awarded to ICU that demonstrate:� Highest ranking nutritional performance

BEST OF THE BEST

KGH

2008

Last year, 156 ICUs

participated in an

international audit of

nutrition practices in

critically ill patients. This

year we want to take part.

Please help us to improve our performance

as it relates to nutrition in our ICU. Better

nutrition therapy translates into reduced

morbidity and improved survival.

For more information, contact____________________

ADD HOSPLOGO

2008 Best of the Best

Top 3 ICUs1. Department of Critical Care Medicine, Auckland

City Hospital, Auckland, New Zealand

2. Kingston General Hospital, Kingston, Canada

3. Regional Hospital A. Cardarelli, Italy

Lyn Gillanders, Senior Clinical Dietitian and her ICU

colleagues at the Department of Critical Care Medicine,

Auckland City Hospital being presented with the Best of the

Best Award by the Hospital Medical Director.

2008Best of the Best

Determinants to Top PerformanceWhat site and hospital characteristics are associated with top BOB ranking?

Hospital/ICU characteristics** Ranking p values

Region

Australia and New Zealand vs. Canada -3.0 0.61

China vs. Canada +30.4 0.008

Europe and South Africa vs. Canada -7.9 0.22

India vs. Canada +32.7 0.08

Latin America vs. Canada 0.17 0.98

USA vs. Canada +30.4 <0.0001

Hospital size (per 100 beds) -0.24 0.78

ICU structure

Closed vs. open or other -0.89 0.89

Presence of Dietitian(s)

Yes vs. No -23.5 0.005

(Best Rank=1rst thus a negative number is associated with a better ranking)

Heyland JPEN 2010

2009 Best of the BestOf >200 ICUS competing Internationally

1. Instituto Neurologico de Antioquia, Medellin, Colombia

1. Royal Prince Alfred Hospital, Sydney, Australia

1. The Alfred, Melbourne, Australia

TOP Performers

2009 Best of the BestOf >200 ICUS competing Internationally

4) Trillium Health Centre, Mississauga, Canada5) Regional Hospital A. Cardarell, Campobasso, Italy

6) Royal Columbian Hospital, New Westminster, Canada

7) Community Hospital of Monterey Peninsula, Monterey, USA

8) Auckland City Hospital, Auckland, New Zealand9) Hamilton General Hospital, Hamilton, Canada

10)University District Hospital Neuro-ICU, San Juan, USA

Outstanding Performers

How to Change?

CPGs to bedside

Bedside

Dissemination and

Implementation Strategies

Documents

A Continuous Quality - DGEM...A Continuous Quality Improvement Effort What is done? What ought to be done? What do we need to do differently? “Gaps” - site reports How to change?