2008 International Nutrition Survey:

Preliminary Results

ANZICS/ AuSPEN Conference

Sydney, Australia

November 1, 2008

Critical Care Nutrition .

Mission StatementTo improve practice of nutrition therapies in the critical care setting through

knowledge generation, synthesis, and translation that ultimately leads to improved clinical outcomes for critically ill patients

and improved efficiencies to our health care systems.

Knowledge Generation Knowledge Synthesis Knowledge Translation

•RCTs evaluating:

- Acidified EN

-Small bowel feedings

-Cisapride

- Immunonutrition

- Feeding Algorithms

•REDOXS

•Over 40 systematic reviews

•Internationally recognized clinical practice guidelines

•Cluster RCT of guideline implementation strategies

•Ongoing international practice audits

•International attitudes & beliefs survey

Critical Care Nutrition Staff

Andrew DayBiostatistician

Siouxzy Morrison Project Leader

AuSPEN/ANZICS Nutrition Research Fellow

Achieving Best Practice:Quality Improvement

What is done?

What ought to be done?

What do we need to do differently?

How to change?Survey results

Benchmarking; Best Achievable Practice

RCTs, Systematic Reviews, and Evidence-based practice guidelines

KT Strategies

Objectives of International Audit

• To determine current nutrition practice in the adult critical care setting (overall and subgroups)

• Illuminate gaps between best practice and current practice

• To identify interventions to target for quality improvement initiatives

• To determine factors associated with optimal provision of nutrition

• To determine what nutrition practices are associated with best clinical outcomes

Methods• Prospective observational cohort study

• Start date: 14 May 2008

• 20 consecutive critically ill patients

• Data included:– Hospital and ICU demographics– Patient baseline information (e.g. age, admission diagnosis, APACHE II)– Baseline Nutrition Assessment– Daily Nutrition data (e.g. type of NS, amount NS received)– 60 day outcomes (e.g. mortality, length of stay)

Methods

Eligibility Criteria• ICU Site

– >5 beds– Availability of individual with knowledge of clinical

nutrition to collect data• Patient

– In ICU > 72 hours– Mechanically ventilated within 48 hours

Web based Data Capture System

Canada: 34

USA: 43

Australia & New Zealand: 27

Europe and Other: 18

Latin America: 10

Asia: 27

Mexico:1 Brazil:3Colombia:3Peru:1Paraguay:1Venezuela:1

Who participated? : 159 ICUs

Italy: 3UK: 9*

Ireland: 2Portugal: 1

South Africa: 3

China: 20*Taiwan: 1India: 6

Who participated?Health practitioners

164 Registered Practitioners

59%

2%

14%

21%

1%3%

Dietitian

Nurse

Research Co-ordinator

Physician

Pharmacist

Other

Who participated?Patients

• Number of finalized patients per site– 18.0 (1-26)

• Total number of finalized patients– 2486

• Days of observation per patient– 9.3 (3-12)

• Total number of patient days in ICU– 23199 days

• <3% missing data for ALL variables

ICU Characteristics

Characteristics Total n=138

Hospital Type

Teaching 104 (75.4%)

Non-teaching 34 (24.6%)

Size of Hospital (beds)

Mean (Range) 515 (108, 1500)

Multiple ICUs in Hospital

Yes 72 (52.2%)

No 66 (47.8%)

ICU Structure

Open 40 (29.0%)

Closed 96 (69.6%)

Other 2 (1.4%)

Size of ICU (beds)

Mean (Range) 18 (5,48)

Characteristics Total n=138

Case Type

Medical 123 (89.1%)

Surgical 124 (89.9%)

Trauma 81 (58.7%)

Pediatrics 15 (10.9%)

Neurological 91 (65.9%)

Neurosurgical 75 (54.3%)

Cardiac Surgery 47 (34.1%)

Burns 28 (20.3%)

Others 15 (10.9%)

Designated Medical Director

Yes 131 (94.9%)

No 7 (5.1%)

Full Time Equivalent Dietitians

Mean (Range) 0.4 (0.0, 2.5)

Patient Characteristics

Characteristics Total n=2486

Age (years)

Median [Q1,Q3] 61 [48, 72]

Sex

Female 929 (37.4%)

Male 1557 (62.6%)

Admission Category

Medical 1517 (61.0%)

Surgical: Elective 339 (13.6%)

Surgical: Emergency 630 (25.3%)

Apache II Score

Median [Q1, Q3] 22 [17, 28]

Presence of ARDS

Yes 229 (9.2%)

Characteristics Total n=2486

Admission Diagnosis

Cardiovascular / Vascular 448 (18.0%)

Respiratory 608 (24.5%)

Pancreatitis 37 (1.5%)

Gastrointestinal 329 (13.2%)

Neurologic 284 (11.4%)

Sepsis 235 (9.5%)

Trauma 269 (10.8%)

Metabolic 67 (2.7%)

Hematologic 15 (0.6%)

Renal 37 (1.5%)

Gynecologic 4 (0.2%)

Orthopedic 14 (0.6%)

Bariatric Surgery 3 (0.1%)

Burns 30 (1.2%)

Other 106 (4.3%)

Patient 60 day Outcomes

Characteristics Total

n=2486Length of Mechanical Ventilation (days)

Median [Q1, Q3] 6.5 [3.2, 12.9]

Length of ICU Stay (days)

Median [Q1, Q3] 10.0 [5.8, 17.3]

Length of Hospital Stay (days)

Median [Q1,Q3] 20.4 [12.9, 32.8]

Patient Died (within 60 days)

Yes 663 (26.8%)

Baseline Nutrition Assessment

Characteristics Total n=2486

BMI (kgh|m2)

Median [Q1, Q3] 26.1 [22.9, 30.5]

Prescribed Energy Intake (Kcals)

Median (Q1, Q3] 1800.0 [1584.0, 2040.0]

Prescribed Protein Intake (g)

Median [Q1,Q3] 85.0 [71.5, 100.0]

Baseline Nutrition Assessment

Methods Used to Calculate Energy Requirements 10%

1%

14%

1%

7%

4%

13%

32%

9%

1%

8% Harris Benedict Equation

Schofield Equation with noadjustment for stress andactivity Schofield Equation withadjustment for stress and/oractivity Mifflin-St. Jeor Equation

Ireton-Jones Equation

<20 Kcal/Kg

20-24 Kcals/Kg

25-29 Kcals/Kg

30-35 Kcals/Kg

Provide 1500-2000 Kcal asstandard

Other, please specify

Type of Nutrition Support

“We strongly recommend the use of EN over PN”

n=2486 patients

73%

5%

12%

10%

EN Only

PN Only

EN+PN

None

Type of Nutrition: EN Only

Type of Nutrition: PN Only

Type of Nutrition: EN + PN

Contraindication to EN(In Pts receiving PN)

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

13.5%

4.5%

5.9%

8.6%

7.2%

10.4%

3.6%

7.4%

2.9%2.5%

2.7%7.7%

18.5%

52.8%

No clincal reasons

Mechanical bowel obstruction

Bowel ischemia

Small bowel ileus

Small bowl fistulae

Gastrointestinal perforation

Short Gut Syndrome

Hemodynamic instability

Proximal bowel anastomosis

No access to small bowel

Pancreatitis

Gastrointestinal bleed

Gastrointestinal surgery

Other, please specify

Type of Nutrition: None

Early vs Delayed EN

Strategies to Optimize EN Delivery:Feeding Protocol

Characteristics Total n=138

Feeding Protocol

Yes 112 (81.2%)

Gastric Residual Volume Tolerated in Protocol

Mean (range) 214 (100, 500)

Algorithms included in Protocol

Motility agents 72 (70.6%)

Small bowel feeding 52 (51.0%)

Withholding for procedures 47 (46.1%)

HOB Elevation 79 (77.5%)

Other 21 (20.6%)

Strategies to Optimize EN Delivery:Motility Agents

Strategies to Optimize EN Delivery:Small Bowel Feeding

Strategies to Optimize EN Delivery:Head of Bed Elevation

Use of Pharmaconutrients

Total % Patients Ever on EN receiving formula

Arginine-supplemented formulas 19.8%(0.0%-93.8%)

Glutamine supplementation 7.4%(0.0%-88.9%)

Oxepa (All) 12.1% (0.0%-83.3%)

Oxepa (ARDS) 7.4% (0.0%-88.9%)

Polymeric 71.7% (0.0%-100.0%)

Arginine-supplemented formulas

Glutamine supplementation

Oxepa (All)

Oxepa (ARDS)

EN in Combination with PN% patients on EN where PN was started 72 hours after initiation of EN

Strategies to Optimize PN Delivery:Use of Lipids

no pt days on PN=2895

19%

52%

4%

8%

14%

2% 1%

Lipid Free

Soybean oil based (LCTs)

MCT/LCT physical mixture

MCT/LCT structured form

Olive oil based

Fish oil based

Mixture of soy oil

% patients received Soybean oil based (LCTs)

Strategies to Optimize PN Delivery:Use of IV Glutamine

Use of PN glutamine in Patients receiving PN

Intensive Insulin TherapyCharacteristics Total

20713Glycemic Control Protocol

Yes 122 (88.4%)

Target of Blood Glucose: Lower (mmol|l)

Median [Q1,Q3] 4.4 [4.0, 5.0]

Target of Blood Glucose: Upper (mmol|l)

Median [Q1,Q3] 7.8 [6.7, 8.3]

Morning Blood Glucose (mmol|l)

Median [Q1,Q3] 7.1 [6.0, 8.5]

Total Hypoglycemic Events

Yes 676 (3.3%)

Hypoglycemic Blood Sugar (mmol/l)

Median [Q1,Q3] 3.1 [1.0, 3.1]

Insulin Received (units)

Median [Q1,Q3] 36.0 [14.0, 71.3]

Intensive Insulin TherapyIn all critically ill patients, we recommend avoiding

hyperglycemia (blood glucose > 10 mmol/l)

Overall Performance

Adequacy of Nutrition Support =

Calories received from EN + appropriate PN+Propofol Calories prescribed

Overall Performance: Kcals

Overall Performance: Kcals

Overall Performance: Protein

Adequacy of EN: Kcals

Adequacy of EN: Protein

Benchmarking

Ranking PerformanceFigure 1.5 Overall Performance of Your Site

Best of the Best

Can you be the best in the International Nutrition Survey 2008• 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: High nutritional adequacy Adherence to the Canadian guidelines

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

Best of the Best

Can you be the best in the International Nutrition Survey 2008• 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: High nutritional adequacy Adherence to the Canadian guidelines

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

Best of the Best

Determinant WeightingOverall 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 determinantsMultiply ranking by weightingICU with highest score is crowned ‘Best of the Best’

Future Directions

Quality Improvement Initiatives• Inadequate EN delivery

– early EN feeding protocols– small bowel feeding

• Optimize Pharmaconutrition– use of glutamine, antioxidants, omega-3 FFA.

• Tighten glycemic control• Withhold soy bean emulsion lipids• others?

Future Directions

Hypothesis–generating Observations– Protocolized vs Non protocolized– Academic vs Community– Presence of dietitian and how much? – Subgroups

• by BMI• by Case Mix (Trauma, Sepsis; Pancreatitis, etc.)

– others?

Thank you