International Nutrition QI Project 2007:

Debriefing Session

Friday June 15th, 2007

Confederation 3, Fairmont Royal York, Toronto

• Brief Overview of Survey Results • Review of Benchmarked Performance Reports • Small Group Discussion • Future Research • Summary and Closing Comments

Agenda

Purpose

• To describe and compare nutrition practices • To compare nutrition practices to the Canadian

Nutrition Support Clinical Practice Guidelines• To identify opportunities

for improvement • Illuminate research opportunities

Canada:47

USA:41

Australia & New Zealand: 23

UK & Ireland:22

EU (other): 14

Latin America: 5

Asia:11

Brazil:1Mexico:3Uruguay:1Venezuala:1

Who participated? : 165 ICUs

Malaysia: 2China: 6

Saudi Arabia: 2Indonesia: 1

Austria:2Czech Republic: 3

Italy: 5Slovenia:1

Spain:1Sweden: 2

Who participated?:Health practitioners

206 Registered Practitioners

58%

4%

13%

20%

2%

3%

Dietitian

Nurse

Research Co-ordinator

Physician

Pharmacist

Other

Ethics Approval

• 206 Registered ICUs• 41 ICUs excluded as no data entered

Reason for attrition: ? Ethics approval• 120 ICUs (57.5%) required local ethics approval

– 97 expedited review – 1 expedited review plus informed consent required– 21 full review– 1 full review plus informed consent required

Who participated?Patients

• Number of patients per site– 19.3 (1-40)

• Total number of patients– 2896

• Days of observation per patient– 9.5 (1-12)

• Total number of patient days in ICU– 27192 days

• <3% missing data for ALL variables

Preliminary Site Report

Purpose of review:

1. Communicate how to interpret your site report2. Review ‘preliminary’ results of the survey3. Receive feedback on format of site reports

Sister Sites

Sister Site Groupings Countries

Canada Canada

United States of America USA

United Kingdom and Republic of Ireland

England, Scotland, Ireland

Europe Austria, Czech Republic, Italy, Slovenia. Spain, Sweden

Australia and New Zealand Australia, New Zealand

Latin America Brazil, Mexico, Uruguay, Venezuela,

Asia Malaysia, China, Indonesia, Russia, Saudi Arabia

Overall Performance

Adequacy of Nutrition Support =

Calories received from EN & appropriate PN X 100

Calories prescribed

Overall Performance

Adequacy of EN

Overall Performance

EN vs. PN

We strongly recommend the use of EN over PN

EN vs. Standard Care

In critically ill patients with an intact GIT, we strongly recommend that PN not be used routinely

Early vs. Delayed EN

We recommend early EN (within 24-48 hours following admission)

EN in combination with PN

For critically ill patients starting on EN, we recommend that PN not be started at the same time as EN

Composition of Nutrition Support

Strategies to Optimize EN Delivery: Feeding Protocol

Strategies to Optimize EN Delivery

Strategies to Optimize PN Delivery: Dose of PN

Strategies to Optimize PN Delivery: Use of Lipids

Intensive Insulin Therapy

Intensive Insulin Therapy

Intensive Insulin Therapy

Small Group Discussion

What are your thoughts on the data elements collected in the

survey, the method of data collection,

and how it is represented in the

site reports?

What are the most effective strategies

for changing behaviour around nutrition practices

in the ICU?

Small Group Discussion

• 20 mins• Nominate ‘recorder’ and ‘spokesperson’• Give freely of your experience• Keep confidences and assume others will• Feel free to ask us questions• Summarize key points

Moving Forward:QI in the ICU

• Changing nutrition practice is complex

• Need to identify barriers and enablers to changing practice

• Need to understand factors associated with guideline implementation and adherence

Understanding Guideline Implementation

• Secondary Analysis of Canadian Nutrition Survey 2004 dataset

• Multiple case study 4 case ICU sites 28 Semi-structured

key informant interviews

Identified Barriers

Guidelines• Information overload • Weak evidence• Impractical / ComplexInstitution• Community Hospital setting• Open ICU• Slow administrative process• Resource constraints

Practitioner• Lack of awareness• Limited critical care experience • Resistance to change• Nursing workloadPatient• Poor clinical condition• Surgical

Enablers

• 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

Successful Implementation Strategies

• Informal one-on-one discussions– Academic detailing, ward rounds

• Bed-side reminders– Check-list, algorithms,

• Feedback and audit– Site reports

Canadian NutritionGuidekines

OPTIMAL NUTRITION

Implementation Process Institutional Factors Provider Intent

Hospital characteristics

-Structure- Processes-Resources

-Patient Case-mix Knowledge Attitudes

Familiarity

AwarenessMotivation Self-efficacy

Outcomeexpectancy

Agreement

ICU characteristics

-Structure- Processes-Resources

- Patient Case-mix-Culture

Legend:Italics = New themesICU = Intensive Care Unit

Provider Characteristics- Profession

-Critical care expertise-Educational background

-Personality

Patient Characteristics

Framework for Adherence to CPGs in the ICU

Future Research

• Survey of Attitudes towards the Canadian Nutrition Support Clinical Practice Guidelines

• Tailored approach to guideline implementaton– Development of screening questionnaire and

educational toolkit– ? Future Cluster Randomized Controlled Trial

International QI Project 2008 !!

Thank you