learning objectives understand key components of moving ‘knowledge’ into action list main...

Learning Objectives

• Understand key components of moving ‘knowledge’ into action

• List main updates of Canadian Critical Care Nutrition Guidelines

Learning Objectives

Critical Care NutritionThe right nutrient/nutritional strategy

The right timingThe right patient

The right intensity (dose/duration)With the right outcome!

www.criticalcarenutrition.com

Lost in (Knowledge) Translation!

Heyland DK, Cahill N, Dhaliwal R JPEN Nov 2010

Knowledge to Action Model by Graham

Knowledge Creation

A RANDOMIZED TRIAL OF HIGH-DOSE GLUTAMINE AND

ANTIOXIDANTS IN CRITICALLY ILL PATIENTS WITH MULTIORGAN

FAILURE

The REDOXS study

On behalf of the REDOXS Study Investigators

N Engl J Med 2013;368:1489-97.

1200 ICU patientsEvidence of

Multi-organ failureR

glutamine

placebo

ConcealedStratified by site

R

R

antioxidants

placebo

Factorial 2x2 designDouble blind treatment

placebo

antioxidants

The REDOXS study

The Research Protocol

• Adults (>18)• With 2 or more organ failures related to

their acute illness :– Requiring mechanically ventilation (P/F<300)– Clinical evidence of hypoperfusion defined by

need for vasopressor agents for more than 2 hour

– Renal dysfunction : Cr>171 or <500ml/24 hrs– platelet < 50

Inclusion Criteria

Optimizing the Dose of Glutamine Dipeptides and Antioxidants In Critically Ill Patients:

A Phase I dose finding study

• High dose appears safe • High dose associated with

– no worsening of SOFA Scores– greater resolution of oxidative stress– greater preservation of glutathione– Improved mitochondrial function

Heyland JPEN Mar 2007

Parenterally Enterally

Glutamine/day 0.35 gms/kg 30 gms

Antioxidantsper day

500 mcg Selenium

Vit C 1500 mgVit E 500 mg

B carotene 10 mgZinc 20 mgSe 300 ug

Mortality Outcomes

P=0.07

P=0.049

P=0.02

P=0.02

Note: all P values pertain to GLN vs No GLN; no significant differences between AOX vs. No AOX

Other Clinical Outcomes

• No differences between groups– SOFA– Need for dialysis– Duration of mechanical ventilation– PODS– infections– ICU and Hospital LOS

Post-hoc Secondary Analyses

Adjusted Analysis

• The 28-day mortality rates in the placebo, glutamine, antioxidant and combination groups were 25%, 32%, 29% and 33% respectively.

• Compared to placebo, the unadjusted OR (95% CI) of mortality was Glutamine 1.4 (1.0-2.0, P =0.063),

Antioxidant 1.2 (0.8-1.7, P =0.31),

Both 1.4 (1.0-2.0, P=0.049). • After adjusting for all statistically significant baseline characteristics,

the corresponding adjusted ORs remained virtually unchanged at:

Glutamine 1.4 (1.0-2.1, P =0.054)

Antioxidant 1.2(0.8-1.8, P =0.34)

Both 1.4 (0.9-2.0, P =0.10)

Selected Subgroup Analyses OR (95% CI) compared to placebo P-values*Subgroup Deaths/n (%) GLN alone AOX alone GLN+AOX Overall

363/1218 (30%) 1.40 (0.98-2.00) 1.20 (0.84-1.72) 1.42 (1.00-2.03)Study Setting Region 0.37

Canada 303/1044 (29%) 1.41 (0.96-2.07) 1.14 (0.77-1.67) 1.29 (0.88-1.89)

USA 44/131 (34%) 1.56 (0.51-4.81) 1.43 (0.47-4.38) 3.43 (1.17-10.07)

Europe 16/43 (37%) 0.86 (0.12-5.9) 2.40 (0.39-14.88) 0.89 (0.14-5.48)Baseline Patient Characteristics Admission category 0.52

Surgical 59/255 (23%) 2.16 (0.91-5.15) 1.94 (0.78-4.82) 1.58 (0.67-3.76)

Medical 304/963 (32%) 1.28 (0.87-1.89) 1.08 (0.73-1.60) 1.43 (0.97-2.12)Cancer patients 0.74

No 297/1048 (28%) 1.48 (1.01-2.18) 1.15 (0.77-1.71) 1.42 (0.97-2.10)

Yes 66/170 (39%) 1.05 (0.41-2.73) 1.43 (0.60-3.40) 1.38 (0.58-3.27)Etiology of Shock 0.71

Cardiogenic 74/240 (31%) 1.24 (0.56-2.79) 1.62 (0.75-3.51) 2.19 (1.03-4.67)

Septic 256/826 (31%) 1.43 (0.93-2.19) 1.06 (0.69-1.63) 1.21 (0.79-1.86)

Other/Unkown/None 33/152 (22%) 1.45 (0.46-4.57) 1.45 (0.43-4.86) 1.83 (0.60-5.78)Vasopressors 0.37

<15 mcg/min 162/595 (27%) 1.58 (0.92-2.70) 1.66 (0.97-2.84) 1.50 (0.87-2.58)

>=15 mcg/min 201/623 (32%) 1.32 (0.82-2.13) 0.92 (0.57-1.51) 1.39 (0.87-2.22)Renal dysfunction 0.035

No 216/776 (28%) 0.93 (0.59-1.46) 0.90 (0.58-1.40) 1.14 (0.74-1.77)

Yes 147/442 (33%) 2.75 (1.50-5.03) 2.16 (1.15-4.07) 2.15 (1.17-3.94)OR-odds ratio; CI-confidence interval; GLN-Glutamine; AOX-antioxidants

Conclusions• Glutamine and antioxidants at doses studied in

this study do not improve clinical outcomes in critically ill patients with multi-organ failure

• Glutamine may be harmful• For both glutamine and antioxidants, the

greatest signal of harm was in patients with multi-organ failure that included renal dysfunction upon study enrollment.

2700 Burn Injury patients R

EN glutamine

placebo


Double blind treatment

A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury

6 month mortality

1400 high-riskpatients undergoingcardiac surgery

R

IV Selenium

placebo


Double blind treatment

SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX®-trial)

Alive and free of POD

Or Time to freedom from life-sustain

treatments

Knowledge Synthesis

Knowledge To Action Model

Since 1980, 275 randomized trials of nutrition interventions

studying >2000 critically ill patients

Knowledge Synthesis

Knowledge – To- Action Model

Systematic reviews and meta-analyses

of 45 nutrition related topics

Study or Subgroup1.1.1 LCT + MCT vs LCT

Garnacho-MonteroIovinelliLindgrenNijveldtSubtotal (95% CI)

Total eventsHeterogeneity: Tau² = 0.00; Chi² = 0.94, df = 3 (P = 0.82); I² = 0%Test for overall effect: Z = 0.53 (P = 0.59)

1.1.2 Fish oil containing emulsions vs LCT or LCT + MCT

BarbosaFrieseckeGrecuWang 2009Subtotal (95% CI)


1.1.3 Olive oil containing emulsions vs LCT or LCT + MCT

Garcia de LorenzoHuschakPontes-Arruda 2012UmperrezSubtotal (95% CI)


Total (95% CI)

Total eventsHeterogeneity: Tau² = 0.00; Chi² = 4.19, df = 11 (P = 0.96); I² = 0%Test for overall effect: Z = 1.27 (P = 0.20)Test for subgroup differences: Chi² = 0.25, df = 2 (P = 0.88), I² = 0%

Events

8212

13

418

20

24

44

195

32

69

Total

3512151274

13832828

152

1118

10351

183

409

Events

11301

15

422

32

31

41

218

34

80

Total

371215

872

10822628

146

1115

10149

176

394

Weight

13.4%3.2%0.8%1.7%

19.1%

6.6%27.9%

2.8%0.9%

38.3%

6.7%1.9%

26.5%7.5%

42.7%

100.0%

M-H, Random, 95% CI

0.77 [0.35, 1.69]0.67 [0.13, 3.30]

3.00 [0.13, 68.26]1.33 [0.14, 12.37]0.84 [0.43, 1.61]

0.77 [0.25, 2.34]0.81 [0.47, 1.39]0.62 [0.11, 3.41]0.20 [0.01, 3.99]0.76 [0.48, 1.21]

1.00 [0.33, 3.02]3.33 [0.42, 26.72]

0.89 [0.51, 1.55]0.60 [0.21, 1.71]0.90 [0.58, 1.39]

0.83 [0.62, 1.11]

Omega-6 Reducing LCT or LCT+MCT Risk Ratio Risk RatioM-H, Random, 95% CI

0.01 0.1 1 10 100Favours omega-6 reducing Favours LCT or LCT+MCT

Manzanares W, et al. Int Care Med 2013

Ω-6 Sparing Strategies were associated with a reduction in Mortality (RR= 0.83,

95 % CI 0.62, 1.11, P= 0.20, heterogeneity I2 =0%)

Ω-6 Sparing Strategies were associated with a reduction in Mortality (RR= 0.83,

95 % CI 0.62, 1.11, P= 0.20, heterogeneity I2 =0%)

Study or Subgroup1.4.1 Fish oil containing emulsions vs LCT or LCT + MCT

GrecuFrieseckeBarbosaSubtotal (95% CI)

Heterogeneity: Tau² = 0.00; Chi² = 1.84, df = 2 (P = 0.40); I² = 0%Test for overall effect: Z = 1.63 (P = 0.10)


HuschakGarcia de LorenzoSubtotal (95% CI)


Total (95% CI)

Heterogeneity: Tau² = 3.00; Chi² = 5.36, df = 4 (P = 0.25); I² = 25%Test for overall effect: Z = 1.72 (P = 0.09)Test for subgroup differences: Chi² = 2.87, df = 1 (P = 0.09), I² = 65.2%

Mean

2.8322.8

10

1311

SD

1.6222.914.4

8.911.93

Total

88313

104

181129

133

Mean

5.2320.5

11

20.413

SD

2.819

12.64

716.25

Total

7821099

151126

125

Weight

50.5%16.4%

6.4%73.3%

21.1%5.6%

26.7%

100.0%

IV, Random, 95% CI

-2.40 [-4.76, -0.04]2.30 [-4.12, 8.72]

-1.00 [-12.07, 10.07]-1.81 [-3.98, 0.36]

-7.40 [-12.83, -1.97]-2.00 [-13.91, 9.91]

-6.47 [-11.41, -1.53]

-2.57 [-5.51, 0.37]

Year

200320082010

20052005

Omega-6 Reducing LCT or LCT+MCT Mean Difference Mean DifferenceIV, Random, 95% CI

-100 -50 0 50 100Favours omega-6 reducing Favours LCT or LCT+MCT

Ω-6 Sparing Strategies were associated with a trend towards a

reduction in Ventilation Days(WMD -2.57, 95% CI -5.51, 0.37, P=0.09)

Ω-6 Sparing Strategies were associated with a trend towards a

reduction in Ventilation Days(WMD -2.57, 95% CI -5.51, 0.37, P=0.09)

Manzanares W, et al. Int Care Med 2013

Study or Subgroup1.3.1 LCT + MCT vs LCT

NijveldtGarnacho-MonteroSubtotal (95% CI)


1.3.2 Fish oil containing emulsions vs LCT or LCT + MCT

GrecuFrieseckeBarbosaSubtotal (95% CI)



Garcia de LorenzoHuschakUmperrezSubtotal (95% CI)


Total (95% CI)

Heterogeneity: Tau² = 10.21; Chi² = 21.87, df = 7 (P = 0.003); I² = 68%Test for overall effect: Z = 1.53 (P = 0.13)Test for subgroup differences: Chi² = 0.46, df = 2 (P = 0.80), I² = 0%

Mean

13.816.6

3.322812

32.917.9

17

SD

2.96.1

1.4825

14.4

10.611.2

18

Total

123547

88313

104

11185180

231

Mean

17.415.8

9.282313

41.825.115.2

SD

37

3.0820

12.6

16.37

14

Total

83745

7821099

11154975

219

Weight

19.1%18.3%37.4%

19.4%10.2%

5.5%35.1%

5.2%11.2%11.2%27.6%

100.0%

IV, Random, 95% CI

-3.60 [-6.25, -0.95]0.80 [-2.23, 3.83]

-1.46 [-5.77, 2.85]

-5.96 [-8.46, -3.46]5.00 [-1.90, 11.90]

-1.00 [-12.06, 10.06]-1.13 [-8.96, 6.69]

-8.90 [-20.39, 2.59]-7.20 [-13.47, -0.93]

1.80 [-4.51, 8.11]-4.08 [-10.97, 2.81]

-2.31 [-5.28, 0.66]

Year

19982002

200320082010

200520052012

Omega-6 Reducing LCT or LCT+MCT Mean Difference Mean DifferenceIV, Random, 95% CI

-100 -50 0 50 100Favours omega-6 reducing Favours LCT or LCT+MCT

Ω-6 Reducing Strategies were associated with a trend towards a reduction in ICU

LOS (WMD -2.31, 95% CI -5.28, 0.66, P=0.13)

Ω-6 Reducing Strategies were associated with a trend towards a reduction in ICU

LOS (WMD -2.31, 95% CI -5.28, 0.66, P=0.13) Manzanares W, et al. Int Care Med 2013

PN Type of Lipids

2009 Recommendation

There are insufficient data to make a recommendation on the

type of lipids to be used in critically ill patients receiving

parenteral nutrition.

2013 Recommendation: IV lipids that reduce the load of omega-6 fatty acids/soybean

oil emulsions should be considered. There are

insufficient data on type of soybean reducing lipids

Which Alternative Lipid Emulsion to Use?

• No head to head trials (and not likely to be)

• We analyzed our International Nutrition Survey database to evaluate effect of Alternative Lipids on outcomes.

• Analyzed adjusted for key confounding variables.

Edmunds CCM 2014 epub


Soybean

Fish Oil

Olive Oil

Lipid FreeMCT


Clinical Practice Guidelines

Knowledge – To- Action Model

Development of Critical Care Nutrition

Clinical Practice Guidelines

Clinical Practice Guidelines for Nutrition

published initially in 2003 updated 2005, 2007, 2009 and 2013

How to Narrow the Gap?First Define the Gap

International audits of nutrition practice

Objectives of International Survey

Quality Improvement• To determine current nutrition practice in the adult critical

care setting (overall and subgroups)• Illuminate gaps between best practice and current practice • To identify nutrition practices to target for quality

improvement initiativesGenerate New Knowledge• To determine factors associated with optimal provision of

nutrition • To determine what nutrition practices are associated with

best clinical outcomes

Canada: 24

USA: 52

Australia & New

Zealand: 36

Europe & Africa: 35

Latin America:

14

Asia: 41

Colombia:6Uruguay:4

Venezuela:2Peru:1

Mexico: 1

Turkey: 11UK: 8

Ireland: 4Norway: 4

Switzerland: 3Italy: 1

Sweden: 1Spain: 1

South Africa: 2

Japan: 21India: 9

Singapore: 5Philippines:2

China: 2Iran : 1

Thailand: 1

Participation: INS 2013

202 ICUs 26 nations

4040 patients37,872 days

Canada: 69

USA: 126

Australia & New

Zealand: 40

Europe: 51

Latin America: 17

Asia: 52

Participation Across the 5 Years of the Survey : 355 Distinct ICUs

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 In

itia

tio

n o

f E

N (

hrs

)

Site

Maximum

Minimum

Median

Your site All sites Sister sites

Early vs Delayed Nutrition Intake

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%)

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 JPEN Nov 2010

CPGCharacteristics

ADHERENCE

Implementation Process Institutional Factors Provider Intent

Hospital characteristics

-Structure- Processes-Resources

Knowledge Attitudes

Familiarity

AwarenessMotivation Self-efficacy

Outcomeexpectancy

Agreement

ICU characteristics

-Structure- Processes-Resources

- Culture

Provider Characteristics- Profession

-Critical care expertise-Educational background

-Personality

Patient Characteristics

System characteristics

Can we do better with our current feeding protocols?

Different feeding options based on hemodynamic stability and suitability for high volume intragastric feeds.

In select patients, we start the EN immediately at goal rate, not at 25 ml/hr.

We target a 24 hour volume of EN rather than an hourly rate and provide the nurse with the latitude to increase the hourly rate to make up the 24 hour volume.

Start with a semi elemental solution, progress to polymeric.Motility agents and protein supplements are started

immediately, rather than started when there is a problem. Tolerate higher GRV* threshold (300 ml or more).

The Efficacy of Enhanced Protein-Energy Provision via the Enteral Route in Critically Ill Patients:

The PEP uP Protocol!

Heyland DK. Crit Care. 2010;14(2):R78Heyland DK CCM 2013.

* GRV: gastric residual volume

Bedside Written Materials Description

EN initiation orders Physician standardized order sheet for starting EN.

Gastric feeding flow chartFlow diagram illustrating the procedure for management of gastric residual volumes.

Volume-based feeding scheduleTable 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 sheetsInformation 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 presentationsInformation 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 moduleInformation 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 messagesAnimated 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

% p

rote

in r

ece

ive

d/p

rescri

be

d

326326

326326

331331

331331

360360

360360

371371

371371

372372

372372

373373 373373

374374

374374

375375

375375390390

390390

Baseline Follow-up

20

30

40

50

60

70

80

p value <0.0001

Intervention sites

% p

rote

in r

ece

ive

d/p

rescri

be

d

p value=0.78

327327 327327

p value=0.78p value=0.78

359359

359359


362362 362362

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


404404

404404


Baseline Follow-up

20

30

40

50

60

70

80

Control sites

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

p value=0.005 p value=0.81

Heyland DK CCM 2013.

Results of the Canadian PEP uP Collaborative

•8 ICUs implemented PEP uP protocol through Fall of 2012-Spring 2013

•Compared to 16 ICUs (concurrent control group)

•All evaluated their nutrition performance in the context of INS 2013

Heyland JPEN 2014 (in submission)

Results of the Canadian PEP uP Collaborative

Results of the Canadian PEP uP CollaborativeProportion of Prescribed Energy From EN According to Initial EN Delivery Strategy

New Collaborative: PEP UP US?

• Want to add a slide here re: this?

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

Protocolize/automate careImprove organizational cultureDevelop local opinion leaders 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 (checklists, manuals, posters,

pocket cards) One on one academic detailing

Practice 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

• 26 studies of tailored interventions

• Pooled OR 1.52 (95% CI 1.27-1.82), p=0.001

• Variation in methodology

• None in clinical nutrition

Systematic Review of Tailored Interventions

Baker et al Cochrane Database Syst Rev 2010

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

Study Schema: Pre-test Posttest

Example of Tailored Action Plan

Change in Prioritized Barriers Score

Site Range-26.3% (SD 18.8%)

To-4.6% (SD 28.6%)

Overall Barriers ScoreBefore = 30.5% After = 20.8%

Change = -9.7 %

Change in Adequacy of Total Nutrition

Before = 43%After = 49%

Change = 6% Site Range = -2 to 18%

OPTimal nutrition by Informing and Capacitating family members of best

practices:The OPTICs feasibility study

InvestigatorsAndrea Marshall, RN, MN, PhD

Daren Heyland, MD, FRCPC, MSc

Naomi Cahill, RD, PhD candidate

Rupinder Dhaliwal, RD

Gap exists: best practice & current practice

• Evidence-based nutrition guidelines are inconsistently implemented

• Large scale, multi-faceted interventions have failed to improve nutrition practices & have not improved nutritional adequacy for the critically ill

• Engaging family members to act as advocates for nutrition may be a promising strategy to narrow the gap between best practice & current practice both in the ICU and post ICU

Objectives: Definitive study

Hypothesis

Educating families about the importance of nutrition and having them advocate for better nutrition for their loved one in the ICU will result in better nutrition delivery during critical

illness and in the recovery phase

Evidence for Family Advocacy

• Literature supports family-centered care1,2,3,4

• Families and ICU staff are very supportive of family involvement in patient care. Most patients are also favourable of family involvement in their care1

1. Garrouste-Orgeas M, Willems V, Timsit JF, Diaw F, Brochon S, Vesin A, et al. Opinions of families, staff, and patients about family participation in care in intensive care units. J Crit Care. 2010;25(4):634-40.

2. Cypress BS. The lived ICU experience of nurses, patients and family members: a phenomenological study with Merleau-Pontian perspective. Intensive Crit Care Nurs. 2011;27(5):273-80

3. Kinsala EL. The Very Important Partner program: integrating family and friends into the health care experience. Prog Cardiovasc Nurs. 1999;14(3):103-10.

4. Mitchell M, Chaboyer W, Burmeister E, Foster M. Positive effects of a nursing intervention on family-centered care in adult critical care. Am J Crit Care. 2009;18(6):543-52; quiz 53.

Objectives: Feasibility Study

Primary aim: Evaluate the feasibility and acceptability of an intervention

designed to educate family members about the importance of adequate nutrition in ICU and during recovery from critical illness

Intervention: Family education session & patient nutrition history

Education session and booklet• Information about nutrition therapy• Nutrition therapy risks, side effects• Initiating oral feeds following EN or PN• How family members can be advocates for the best nutrition practices

Nutrition history (Family member)• Weight loss history• Past diets, food intolerances/allergies, GI problems• Chewing/swallowing difficulties• Eating patterns• Food preferences

Creating a Culture of Clinical Excellence in Critical Care

Nutrition:

The ‘Best of the Best’ Award

Heyland JPEN 2010: in press

Recognition and Reward

Recognition a powerful

motivator of human

performance

Determining the Best of the BestDeterminant 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 weighting

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

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

Top 3

Best of the Best 2011

The Team at the Alfred Hospital ICU, Melbourne, Australia

2013 Best of the Best

1. Kingston General Hospital, Kidd2 ICU Canada

2. Hospital General de Medellín, luz Castro de Gutiérrez Unidad de cuidados intensivos , Colombia

3. The Ministry of Health Ankara, Numune

Research and Training Hospital Turkey

TOP 3 Sites

Top 3

Kingston General Hospital

Hospital General de Medellín Colombia

The Ministry of Health Ankara Turkey

And the Cycle continues...

More (and Earlier) is Better!

If you feed them (better!)They will leave (sooner!)

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