International Critical Care Nutrition Survey 2008 Defining Gaps in Practice Rupinder Dhaliwal, RD Project Leader Critical Care Nutrition, Clinical Evaluation Research Unit Kingston, Ontario, Canada

Critical Care Nutrition Mission Statement To 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 www.criticalcarenutrition.com

History of International Surveys 3 previous surveys in Canada 2001, 2003, 2004 N > 50 ICUs each year Extended to other countries in 2007 Focus on North America n=165 Repeated in 2008 Focus on Australasia

Objectives of International Survey To determine current nutrition practice in the adult critical care setting Illuminate gaps between best practice and current practice To identify interventions to target for quality improvement initiatives To determine what nutrition practices are associated with best clinical outcomes To determine factors associated with optimal provision of nutrition

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 hospital outcomes (e.g. mortality, length of stay)

Methods Eligibility Criteria ICU Site Patient >8 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

Who participated?: 157 ICUs Canada: 34 Europe and Other: 17 USA: 44 Asia: 27 Italy: 3 UK: 7 Ireland: 3 Portugal: 1 South Africa: 3 China: 20 Taiwan: 1 India: 5 Mexico:1 Brazil:3 Colombia:3 Peru:1 Paraguay:1 Venezuela:1 Please verify these numbers are accurate Latin America: 10 Australia & New Zealand: 26

Who participated? Patients Number of finalized patients per site 18.2 (8-26) Total number of finalized patients 2,850 Days of observation per patient 9.4 (3-12) Total number of patient days in ICU 23,811 days <3% missing data for ALL variables Please verify these numbers are accuarate

ICU Characteristics Characteristics Total n=157 Hospital Type Teaching 122 (78.5%) Non-teaching 33 (21.3%) Size of Hospital (beds) Mean (Range) 617 (108, 3000) Multiple ICUs in Hospital Yes 84 (53.5%) ICU Structure Open 42 (26.8%) Closed 113 (72.0%) Other 2 (1.3%) Size of ICU (beds) 17 (5,48) Characteristics Total n=157 Case Type Medical 140 (89.2%) Surgical Trauma 93 (59.2%) Pediatrics 17 (10.8%) Neurological 109 (69.4%) Neurosurgical 89 (56.7%) Cardiac Surgery 55 (35.0%) Burns 29 (18.5%) Others 17(10.8%) Designated Medical Director 150 (95.5%) FTE Dietitians (per 10 beds) Mean (Range) 0.4 (0.0, 2.2) Yes, fill in table

Patient Characteristics Admission Diagnosis Cardiovascular / Vascular 501 (17.6%) Respiratory 747 (26.2%) Pancreatitis 40 (1.4%) Gastrointestinal 391 (13.7%) Neurologic 339 (11.9%) Sepsis 241 (8.5%) Trauma 289 (10.1%) Metabolic 72 (2.5%) Hematologic 18 (0.6%) Renal 46 (1.6%) Gynecologic 5 (0.2%) Orthopedic 15 (0.5%) Bariatric Surgery 3 (0.1%) Burns 30 (1.1%) Other 113 (4.0%) Characteristics Total n=2850 Age (years) Median [Q1,Q3] 62 [48, 73] Sex Female 1054 (37.0%) Male 1796 (63.0%) Admission Category Medical 1756 (61.6%) Surgical: Elective 405 (14.2%) Surgical: Emergency 689 (24.2%) Apache II Score Median [Q1, Q3] 22 [17, 28] Presence of ARDS Yes 320 (11.2%)

Type of Nutrition Support “We strongly recommend the use of EN over PN” n=2850 patients

Type of Nutrition: EN Only

Type of Nutrition: PN Only

Type of Nutrition: EN + PN

Type of Nutrition: None

2368/2850 (84%) patients received EN (alone or combined with PN) Enteral Nutrition 2368/2850 (84%) patients received EN (alone or combined with PN) Median # days EN received: 8 days [IQR 4-11 days] 260/2368 patients (11.0%) received EN for all 12 days of observation. fix

Early vs Delayed EN

Strategies to Optimize EN Delivery: Feeding Protocol Characteristics Total n=157 Feeding Protocol Yes 125 (79.6%) Gastric Residual Volume Tolerated in Protocol Mean (range) 208 (100, 500) Algorithms included in Protocol Motility agents 83 (71.6%) Small bowel feeding 61 (52.6%) Withholding for procedures 57 (49.1%) HOB Elevation 93 (80.2%) Other 22 (19.0%)

Location of Feeding Tube fix

638/2368 (26.9%) EVER had EN interrupted due to intolerance* Feeding Intolerance 638/2368 (26.9%) EVER had EN interrupted due to intolerance* 1399/17,438 (8.0%) patients days had EN interrupted due to intolerance This second number seems really low, please check * Presence of high gastric residual volumes / emesis / aspiration

Strategies to Optimize EN Delivery: Motility Agents

Strategies to Optimize EN Delivery: Small Bowel Feeding

% of patients received small bowel feeding before PN started EN in Combination with PN % of patients received small bowel feeding before PN started

Strategies to Optimize EN Delivery: Head of Bed Elevation

Use of Pharmaconutrients Total % Patients Ever on EN receiving formula Arginine-supplemented formulas 6.0%(0.0%-93.8%) Glutamine supplementation 7.6%(0.0%-88.9%) Fish oil enriched formula (All) 3.1% (0.0%-83.3%) Fish oil enriched (ARDS) 10.5% (0.0%-88.9%) Polymeric 90.5% (0.0%-100.0%) Please double check data

Strategies to Optimize PN Delivery: Use of IV Glutamine Use of PN glutamine in Patients receiving PN

Intensive Insulin Therapy In all critically ill patients, we recommend avoiding hyperglycemia (blood glucose > 10 mmol/l)

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

Overall Performance: Kcals

Adequacy of EN: Kcals

Adequacy of EN: Protein

Compared to Canadian Clinical Practice Guidelines* Benchmarking Compared to Canadian Clinical Practice Guidelines* *Originally published 2003. Benchmarked against 2007 recommendations. New Revised Sections January 31st 2009 on www.criticalcarenutrition.com

Ranking Performance Figure 1.5 Overall Performance of Your Site

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? Will revise these slides based on actual results

How are you performing at your site? Can you be the Best of the Best? Next International Nutrition Survey Coming Soon ..... Sept 2009 Further Information: www.criticalcarenutrition.com The next international audit is May 14th, 2008 The next international audit is May 14th, 2008 The next international audit is May 14th, 2008