Emerging Strategies in

Optimizing Nutrition Therapy

Delivery

Rupinder Dhaliwal, RD

Executive Director

Nutrition & Rehabilitation Investigators

Consortium

Clinical Evaluation Research Unit

Queen’s University, Kingston, Canada

Disclosures

I have received speaker honoraria and/or I have been

paid from grants from the following companies:

– Nestlé (including this session)

– Fresenius Kabi

– Baxter

– Abbott

Learning Objectives

Describe the incidence of underfeeding and calorie

deficit in the ICU

√ Strategies to minimize the calorie deficit • PEP UP Protocol

• PEP UP Collaborative

Knowledge Translation Efforts aimed at

Identifying gaps Audit and feedback Assessment of barriers to feeding Creating a culture of Excellence in critical care nutrition

0

20

40

60

80

100

120

1 2 3 4 5 6 7 8 9 10 11 12

% r

eceiv

ed

/pre

scri

bed

ICU Day

Mean of All Sites Best Performing Site Worst Performing Site

Current Practice in ICUs in 2011

n =211 ICUs, mean intake 56% prescribed calories

Heyland et al INS 2011 unpublished data

Optimal Amount of Calories for Critically Ill Patients: Depends on how you slice the cake!

Heyland DK, et al. Crit Care Med. 2011;39(12):2619-26.

Optimal

amount =

80-85%

Association Between 12-day Caloric Adequacy

and 60-day Hospital Mortality

Failure Rate

Heyland et al Unpublished observations

Results of 2011 International Nutrition Survey (INS)

% high risk patients who failed to meet minimal

quality targets (80% overall energy adequacy)

75.6 78.1

91.2

75.1

87.0

69.8

79.9

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%)

CCM 2010

A shift in the feeding paradigm is needed!

Can we do better?

PEP UP Protocol: components

• Early enteral nutrition

• Goal rate feeding in stable patients

• Trophic feeds

• Feeding unstable patients

• Motility agents

• Higher gastric residual volumes

• Protein supplements

• Semi-elemental formula

• Monitor nutritional adequacy

Early EN (within 24-48 Hours of Admission) Is Recommended!

Optimal amount of protein and calories

for critically ill patients?

Initial Efficacy and Tolerability of Early EN with Immediate or Gradual Introduction in Intubated Patients

Desachy A, et al. Intensive Care Med. 2008;34(6):1054-9.

N = 100 pts

mechanically ventilated pts

(not in shock) to immediate

goal rate vs gradual ramp up

“Trophic Feeds”

Progressive atrophy of villous height

and crypt depth in absence of EN

Leads to increased permeability

and decreased IgA** secretion

Can be preserved by a minimum

of 10-15% of goal calories

Observational study of 66 critically

ill patients suggests TPN† + trophic

feeds associated with reduced

infection and mortality compared

to TPN alone1

A = No EN; B = 100% EN

1Marik. Crit Care & Shock. 2002;5:1-10;

Ohta K, et al. Am J Surg. 2003;185(1):79-85.

Rice TW, et al. JAMA. 2012;307(8):795-803.

Initial Tropic vs. Full EN in Patients with Acute Lung Injury

The EDEN randomized trial

Trophic vs. Full EN in Critically Ill Patients with Acute Respiratory Failure

Despite no differences in

clinical outcomes……….

“Survivors who received initial

full-energy EN were more likely

to be discharged home with or

without help as compared to a

rehabilitation facility (68.3% for

the full-energy group vs. 51.3%

for the trophic group; p = .04).”

Rice TW, et al. Crit Care Med. 2011;39(5):967-74.

The EDEN randomized trial

What about feeding the hypotensive patient?

Resuscitation is the priority

No sense in feeding someone dying of

progressive circulatory failure

However, if resuscitated yet remaining

on vasopressors:

Safety and efficacy of EN??

Feeding the hypotensive patient?

Khalid I, et al. Am J Crit Care. 2010;19(3):261-8.

Prospectively collected multi-institutional ICU database of 1,174 patients who required mechanical

ventilation for more than two days and were on vasopressor agents to support blood pressure.

The beneficial

effect of early

feeding is more

evident in

the sickest

patients, i.e., those

on multiple

vasopressor

agents

Pro-motility Agents

“Based on 1 level 1 study and 5 level 2 studies,

in critically ill patients who experience feed

intolerance (high gastric residuals, emesis),

we recommend the use of a pro-motility agent”.

Conclusion:

1) Motility agents have no effect on mortality or

infectious complications in critically ill patients

2) Motility agents may be associated with an increase

in gastric emptying, a reduction in feeding intolerance

and a greater caloric intake in critically ill patients

2013 Canadian CPGs

www.criticalcarenutrition.com

It’s Not Just About Calories...

So in order to minimize this, we order: Protein supplement Beneprotein® 14 grams mixed

in 120 mls sterile water administered BID via NG

Loss of lean muscle mass

Inadequate protein intake

Immune dysfunction

Weak prolonged

mechanical ventilation

113 select ICU patients with sepsis

or burns

On average, receiving 1,900 kcal/day

and 84 grams of protein

No significant relationship with

energy intake but…

Allingstrup MJ, et al. Clin Nutr. 2012;31(4):462-8.

Begin 24 hour volume-based feeds. After initial tube placement confirmed, start Peptamen® 1.5.

Total volume to receive in 24 hours =<write in 24 target volume>. Determine initial rate as per

Volume Based Feeding Schedule. Monitor gastric residual volumes as per Adult Gastric Flow Chart

and Volume Based Feeding Schedule.

OR

Begin Peptamen® 1.5 at 10 ml/h after initial tube placement confirmed. Reassess ability to

transition to 24 hour volume-based feeds next day. {Intended for patient who is hemodynamically

unstable (on high dose or escalating doses of vasopressors, or inadequately resuscitated) or

not suitable for high volume EN (ruptured AAA, upper intestinal anastomosis, or impending

intubation)}

OR

NPO. Please write in reason: __________________ ______. (only if contraindication to EN

present: bowel perforation, bowel obstruction, proximal high output fistula. Recent operation and

high NG* output not a contraindication to EN.) Reassess ability to transition to 24 hour volume-

based feeds next day.

Stable patients should be

able to tolerate goal rate We use a concentrated

solution to maximize

calories per ml

Doctors need to justify

why they are keeping

patients NPO

If unstable or unsuitable,

just use trophic feeds

We want to minimize the use

of NPO but if selected, need

to reassess next day

The PEP uP Protocol

Note, there are only

a few absolute

contraindications to EN

Note indications

for trophic feeds

Single centre pilot study Heyland DK, et al. Crit Care 2010. 2010;14(2):R78

PEP UP Protocol: other components

Gastric residual volume threshold 300 mls or more (REGANE

Study 500 ml vs 250 mls safe Montejo et al 2010 Int Care Med)

Protein supplement Beneprotein® 14 grams mixed

in 120 mls sterile water administered BID via NG until full EN

Motility agents are started immediately, rather than started when

there is a problem

– Maxeran® 10 mg IV q 6h (halved in renal failure)

– Reassess need for motility agents daily

– If still develops high gastric residuals, add erythromycin 200 mg q 12h

– Can be used together for up to 7 days but should be discontinued when not

needed any more

– Reassess need for motility agents daily

24 Hour Volume-based goal vs Hourly rate •Make up for missed hours

over the remaining hours

•Max 150 ml/hr

•RN latitude to adjust

A Change to Nursing Report

Adequacy of nutrition support

=

24 hour volume of EN received

Volume prescribed to meet caloric

requirements in 24 hours

Please report

this % on

rounds as part

of the GI

systems report

Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in

Critically Ill Patients: The PEP uP Protocol

A multi-center cluster randomized trial

Heyland et al 2013 CCMed (in press)

Research Questions

What is the effect of the new innovative feeding protocol, (PEP

uP protocol), combined with a nursing educational intervention

on EN intake compared to usual care?

What is the safety, feasibility and acceptability of the new PEP

uP protocol?

Hypothesis: this aggressive feeding protocol combined

with a nurse-directed nutrition educational intervention will be

safe, acceptable, and effectively increase protein and energy

delivery to critically ill patients.

Design

Protocol utilized in all patient mechanically intubated within

the first 6 hours after ICU admission

Focus on those who remained mechanically ventilated > 72 hours

18 sites (low performing

from survey)

Control

Intervention

Baseline Follow-up 6-9 months later

Bedside Written Materials Description

EN initiation orders Physician standardized order sheet for starting EN.

Gastric feeding flow chart Flow diagram illustrating the procedure for management of gastric

residual volumes.

Volume-based feeding schedule Table for determining goal rates of EN based on the 24 hour goal

volume.

Daily monitoring checklist Excel spreadsheet used to monitor the progress of EN.

Materials to Increase Knowledge and Awareness

Study information sheets

Information about the study rationale and guidelines for implementation

of the PEP uP protocol. Three versions of the sheets were developed

targeted at nurses, physicians, and patients’ family, respectively.

PowerPoint presentations

Information about the study rationale and how to implement the PEP

uP protocol. A long (30-40 minute) and short (10-15 minute) version

were available.

Self-learning module Information about the PEP uP protocol and case example to work

through independently.

Posters A variety of posters were available to hang in the ICU during the study.

Frequently Asked Questions (FAQ) document Document addresses common questions about the PEP uP Protocol.

Electronic reminder messages Animated reminder messages about key elements of the PEP uP

protocol to be displayed on a monitor in the ICU.

Monthly newsletters Monthly circular with updates about the study.

Tools to Operationalize the PEP uP Protocol

Analysis

3 overall analyses:

– Intent To Treat involving all patients (n = 1,059)

– Efficacy analysis involving only those that

remain mechanically ventilated for > 72 hours

and receive the PEP uP protocol (n = 581)

– Those initiated on volume-based feeds (n = 57)

Flow of Clusters (ICUs) and Patients Through the Trial

45 ICUs with < 50% nutritional intake in 2009

International Nutrition Survey assessed for eligibility

18 Randomized

9 assigned to intervention group 9 assigned to control group

522 patients met eligibility

requirements and were enrolled

and included in ITT analysis.

537 patients met eligibility

requirements and were enrolled

and included in ITT analysis.

306 patients included in efficacy analysis

231 on MV ≤ 72 hours 197 on MV ≤ 72 hours

54 did not receive

the PEP uP protocol

271 patients included in efficacy analysis

57 patients initiated on 24 hour volume feeds

Participating Sites

Intervention (n = 9) Control (n = 9) p-values

Hospital type

Teaching

Non-teaching

4 (44.4%)

5 (55.6%)

4 (44.4%)

5 (55.6%)

1.00

Size of hospital (beds)

Mean (range)

396.9 (139.0, 720.0)

448.7 (99.0, 1000.0)

0.97

ICU structure

Open

Closed

3 (33.3%)

6 (66.7%)

4 (44.4%)

5 (55.6%)

1.00

Case type

Medical

Neurological

Surgical

Neurosurgical

Trauma

Cardiac surgery

Burns

Other

9 (40.9%)

3 (13.6%)

5 (22.7%)

2 (9.1%)

1 (4.5%)

0 (0.0%)

1 (4.5%)

1 (4.5%)

9 (36.0%)

2 (8.0%)

8 (32.0%)

2 (8.0%)

2 (8.0%)

1 (4.0%)

1 (4.0%)

0 (0.0%)

0.97

Size of ICU (beds)

Mean (range)

12.6 (7.0, 20.0)

16.3 (8.0,25.0)

0.12

Full time equivalent dietician (per 10 beds)

Mean (range)

0.5 (0.3, 0.9)

0.4 (0.0, 0.6)

0.76

Regions

Canada

USA

4 (44.4%)

5 (55.6%)

5 (55.6%)

4 (44.4%)

1.00

Intervention Control

Baseline Follow-up Baseline Follow-up p-value

n 270 252 270 267

Age Mean ± SD

65.1 ± 15.5

64.1 ± 16.7

63.4 ± 15.1

61.4 ± 16.2

0.45

Sex Male (%)

157 (58.1%)

137 (54.4%)

170 (63.0%)

173 (64.8%)

0.56

Admission category Medical

Elective surgery Emergent surgery

230 (85.2%)

14 (5.2%) 26 (9.6%)

222 (88.1%) 12 (4.8%) 18 (7.1%)

213 (78.9%) 23 (8.5%)

34 (12.6%)

212 (79.4%) 23 (8.6%) 30 (11.2%)

0.24

Admission diagnosis Cardiovascular/vascular

Respiratory Gastrointestinal

Neurologic Sepsis

Trauma Metabolic

Hematologic Other non-operative conditions

Renal-operative Gynecologic-operative

Orthopedic-operative Other operative conditions

40 (14.8%) 110 (40.7%) 35 (13.0%) 19 (7.0%)

37 (13.7%) 0 (0.0%) 11 (4.1%) 1 (0.4%) 7 (2.6%) 2 (0.7%) 1 (0.4%) 1 (0.4%) 6 (2.2%)

43 (17.1%) 112 (44.4%) 19 (7.5%) 19 (7.5%) 20 (7.9%) 2 (0.8%)

15 (6.0%) 0 (0.0%)

15 (6.0%) 0 (0.0%) 0 (0.0%) 1 (0.4%) 6 (2.4%)

31 (11.5%) 78 (28.9%) 29 (10.7%) 30 (11.1%) 57 (21.1%) 17 (6.3%) 13 (4.8%) 0 (0.0%) 5 (1.9%) 0 (0.0%) 0 (0.0%) 1 (0.4%) 9 (3.3%)

51 (19.1%) 81 (30.3%) 29 (10.9%) 28 (10.5%) 25 (9.4%) 18 (6.7%) 6 ( 2.2%) 1 (0.4%) 7 (2.6%) 3 (1.1%) 1 (0.4%) 3 (1.1%)

12 (4.5%)

un defined

APACHE II score Mean ± SD

23.0 ± 7.2

23.5 ± 7.1

21.1 ± 7.3

21.1 ± 7.3

0.53

Patient Characteristics (n = 1,059)

Patient Nutrition Assessment Information (All patients – n = 1,059)

Intervention Control

Baseline Follow-up Baseline Follow-up p-value

n 270 252 270 267

Height

Mean ± SD

1.7 ± 0.1

1.7 ± 0.1

1.7 ± 0.2

1.7 ± 0.1

0.55

Weight

Mean ± SD

81.0 ± 25.3

81.4 ± 26.3

83.5 ± 26.5

83.7 ± 22.6

0.77

Body mass index (kg|m2)

Mean ± SD

28.6 ± 8.2

28.6 ± 9.6

29.1 ± 8.1

28.6 ± 7.0

0.96

Prescribed energy intake (kcals)

Mean ± SD

1,776.6 ± 352.4

1,774.8 ± 339.3

1,768.6 ± 412.1

1,784.4 ± 387.9

0.82

Prescribed protein intake (g)

Mean ± SD

86.0±22.2

86.0 ± 19.8

99.9 ± 29.6

100.1 ± 27.8

0.09

Prescribed energy intake by

weight (kcals|kg)

Mean ± SD

23.3 ± 5.9

23.2 ± 5.9

22.1 ± 4.9

22.3 ± 5.5

0.79

Prescribed protein intake by

weight (g|kg)

Mean ± SD

1.1 ± 0.3

1.1 ± 0.3

1.2 ± 0.3

1.2 ± 0.3

0.26

Clinical Outcomes (All patients – n = 1,059)

Intervention Control p-value

Baseline Follow-up Baseline Follow-up

Length of ICU stay

(days)*

Median

(IQR†)

6.1

(3.4,11.1)

7.2

(3.4,11.1)

6.4

(3.3,12.6)

5.7

(2.8,11.8) 0.35

Length of hospital

stay (days)*

Median

(IQR)

14.2

(8.1,29.8)

13.5

(8.1,28.4)

16.7

(7.5,27.7)

13.8

(7.1,26.6) 0.73

Length of

mechanical

ventilation (days)*

Median

(IQR)

3.7

(1.6,9.1)

4.3

(1.3,9.9)

3.1

(1.4,8.4)

3

(1.4,7.3) 0.57

Patient died within

60 days of

ICU admission

Yes 70

(25.9%)

68

(27.0%)

65

(24.1%)

63

(23.6%) 0.53

* Based on 60-day survivors only. Time before ICU admission is not counted.

Change of Nutritional Intake from Baseline to Follow-up of All the Study Sites (All patients)

% Calories Received/Prescribed

% c

alor

ies

rece

ived

/pre

scrib

ed

326326

326326

331331

331331

360360

360360

371371

371371

372372

372372

373373373373

374374

374374

375375

375375

390390

390390

Baseline Follow-up

2030

4050

6070

80

p value <0.0001

Intervention sites

% c

alor

ies

rece

ived

/pre

scrib

ed

p value=0.65

327327 327327

p value=0.65p value=0.65

359359

359359

p value=0.65p value=0.65

362362

362362

p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65p value=0.65

376376

376376

p value=0.65

377377

377377

p value=0.65

378378378378

p value=0.65

379379

379379

p value=0.65

380380

380380

p value=0.65p value=0.65

404404

404404

p value=0.65p value=0.65

Baseline Follow-up

2030

4050

6070

80

Control sites

p value = 0.001 p value = 0.71

% p

rote

in re

ceiv

ed/p

resc

ribed

326326

326326

331331

331331

360360

360360

371371

371371

372372

372372

373373 373373

374374

374374

375375

375375390390

390390

Baseline Follow-up

2030

4050

6070

80

p value <0.0001

Intervention sites

% p

rote

in re

ceiv

ed/p

resc

ribed

p value=0.78

327327327327

p value=0.78p value=0.78

359359

359359

p value=0.78p value=0.78

362362362362

p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78p value=0.78

376376

376376

p value=0.78

377377

377377

p value=0.78

378378

378378

p value=0.78

379379

379379

p value=0.78

380380

380380

p value=0.78p value=0.78

404404

404404

p value=0.78p value=0.78

Baseline Follow-up

2030

4050

6070

80

Control sites

% Protein Received/Prescribed

Change of Nutritional Intake from Baseline to Follow-up of All the Study Sites (All patients)

p value = 0.005 p value = 0.81

ICU Day

% c

alor

ies

rece

ived

/pre

scrib

ed

1 2 3 4 5 6 7 8 9 10 12

010

2030

4050

6070

8090

100

n ITT

n Efficacy

n FVF

243

11357

219

11357

194

11357

171

10854

153

10552

138

9646

118

8340

107

7535

83

5926

76

5223

59

4017

52

3514

ITT

Efficacy

Full volume feeds

ICU Day

% p

rote

in re

ceiv

ed/p

resc

ribed

1 2 3 4 5 6 7 8 9 10 12

010

2030

4050

6070

8090

100

n ITT

n Efficacy

n FVF

243

11357

219

11357

194

11357

171

10854

153

10552

138

9646

118

8340

107

7535

83

5926

76

5223

59

4017

52

3514

ITT

Efficacy

Full volume feeds

Daily Proportion of Prescription Received by EN in ITT, Efficacy and Full Volume Feeds Subgroups

(Among Patients in the Intervention Follow-up Phase)

Compliance with PEP uP Protocol Components (All patients n = 1,059)

0

10

20

30

40

50

60

70

80

90

100

SupplementalProtein (ever)

SupplementalProtein

(first 48hrs)

Motility Agents(ever)

Motility Agents(first 48hrs)

Peptamen 1.5

Intervention - Baseline Intervention - Follow-up

Control - Baseline Control - Follow-up

Perc

en

t

Difference in Intervention baseline vs. follow up and vs. control all <0.05

-1

1

3

5

7

9

11

13

15

Vomiting Regurgitation Macro Aspiration Pneumonia

Intervention - Baseline Intervention - Follow-up

Control - Baseline Control - Follow-up

Complications (All patients – n = 1,059)

p > 0.05

Perc

en

t

Vomiting Regurgitation Macro Aspiration Pneumonia

Nurses’ Ratings of Acceptability

After Group

Mean (Range)

24 hour volume based target 8.0 (1-10)

Starting at a high hourly rate 6.0 (1-10)

Starting motility agents right away 8.0 (1-10)

Starting protein supplements right away 9.0 (1-10)

Acceptability of the overall protocol 8.0 (1-10)

1 = totally unacceptable and 10 = totally acceptable

Overall, how acceptable is this new PEP uP feeding protocol to you?

Need more instructions to include all staff members

Too much confusion over what protocol was

supposed to be

May need a few adjustments however I think its

overall acceptable

Good if everyone knows how to do it

Initial starting dose is too high

Maybe we needed more awareness by the MDs

Barriers to Implementation

Difficulties embed into Electronic record

Non-comprehensive dissemination

of educational tools

Involvement of nurse educator

(nurses owned it)

Ongoing bedside encouragement

and coaching by site dietitian

Facilitators to Implementation

PEP uP Trial Conclusion

Statistically significant improvements in

nutritional intake

– Suboptimal effect related to suboptimal implementation

Safe

Acceptable

Merits further use

Can successfully be implemented in a broad

range of ICUs in North America

Learning from the Trial : Next Steps Change PEP uP protocol first day

order to simplify (25 ml/hr for day 1)

Improve documentation of protein

supplements (add to MAR!)

Develop PEP uP collaborative

(community of practice) • PEP uP demonstration sites

• Revise and disseminate tools

Audit practice again in May 2015

Call to action – is there room and interest

to improve feeding practice in your ICU?

Identify nutrition champions – RNs, MDs, RDs

Feeding successfully requires a team approach

Education

– Comprehensive education of the entire ICU team is essential

– Tools and resources are available at criticalcarenutrition.com

Ongoing monitoring/feedback

Introduce PEP uP in YOUR ICU!

www.criticalcarenutrition.com

Education and Awareness Tools

PEP uP Pocket Guide PEP uP Poster

Protocol to Manage Interruptions to EN Due to Non-GI Reasons

Can be downloaded from www.criticalcarenutrition.com

PEP uP Monitoring Tool

Prompts for

high risk patients

improving calorie and protein intakes (≥ 80%

prescribed)

starting motility agents, small bowel feeding,

supplemental PN

Lost in (Knowledge) Translation!

Heyland DK, Cahill N, Dhaliwal R JPEN 2010

Knowledge to Action Model by Graham: a priori assessment of barriers

Canada: 24

USA: 47

Australia &

New

Zealand: 41

Europe and

Africa: 26

Latin

America:

31

Asia: 52

Argentina: 5 Chile: 3

El Salvador:1 Mexico: 2 Brazil:4 Colombia:9 Peru:1 Venezuela:2

Uruguay:4

Italy: 2 UK: 8

Ireland: 6 Norway: 5

Switzerland: 1 France: 1 Spain: 2

South Africa: 1

China: 19 Taiwan: 9 India: 9 Iran : 1

Japan: 9 Singapore: 3

Philippines:1 Thailand: 1

Participation: Nutrition Survey 2011

355 distinct ICUs over 3 years

12,000 patients

Adequacy of Calories from EN Only

20

30

40

50

60

70

80

Year

2007 2008

26 Canadian ICUs participating in both 2007 and 2008 Surveys

All sites collected nutrition data & received audit and feedback reports

EN adequacy over

12 days improved

energy:

45.1% to 51.9%,

p<0.001

protein:

44.8% to 51.5%,

p<0.001

Benchmarking Reports

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

Nutrition Practice

Audit

- 20 patients

Barriers

Assessment

- ICU staff

12 months

Baseline

Tailored

Action Plan

Identify strengths and weaknesses

Identify barriers to change

Small group problem solving

3 months

Evaluation

Nutrition Practice

Audit

Barriers

Assessment

Pre-test Post Test Feasibility Study in 7 ICUs in US and Canada

Top 5 Ranked Barriers

1. In resuscitated, hemodynamically stable patients, other aspects of

patient care still take priority over nutrition

2. No or not enough feeding pumps on the unit

3. Enteral formula not available on the unit

4. Delays and difficulties in obtaining small bowel access in patients

not tolerating enteral nutrition (i.e. high gastric residual volumes)

5. Delay in physicians ordering the initiation of EN

Assess Organizational Culture

• “The way things are around here”

• Defines how decisions regarding feeding are made

• Major influence on CPG adherence

• Define, measure and change

• Recognition: “Culture of Excellence”

Creating a Culture of Excellence

• 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

Adherence to the Canadian guidelines

Recognition Plaques for 2007, 2009 and 2001

Best of the Best 2011

The Team at the Alfred Hospital ICU, Melbourne, Australia

Determinants of Top Performance

What site and hospital characteristics are associated with top BOB ranking?

Hospital/ICU characteristics** p values

Region

Australia and New Zealand vs.

Canada 0.61

China vs. Canada 0.008

Europe and South Africa vs. Canada 0.22

India vs. Canada 0.08

Latin America vs. Canada 0.98

USA vs. Canada <0.0001

Hospital size (per 100 beds) 0.78

ICU structure

Closed vs. open or other 0.89

Presence of Dietitian(s)

Yes vs. No 0.005

Heyland JPEN 2010

Summary

Caloric and protein debt occurs in ICUs

Strategies aimed at minimizing this debt ought to be undertaken √ Pre-printed orders, RN involvement: PEP UP Protocol

√ PEP UP Collaborative

Knowledge to Action Model can be applied to optimize nutrition

therapy √ Identify gaps √ Provide audit and feedback √ Assess barriers to feeding

Creating a culture of Excellence in critical care nutrition helps √ Improve nutrition delivery √ Position the dietitian as a key opinion leader!