ICU Nutrition Support : Development and Dissemination of Clinical Practice Guidelines

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ICU Nutrition Support Development and
Dissemination of Clinical Practice Guidelines

• Rupinder Dhaliwal, RD
• Nutrition Research Fellow
• Kingston General Hospital

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Overview

• current practice achieving best practice
• importance of evidence based medicine
• need for new clinical practice guidelines
• process of development
• dissemination strategies

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Achieving Best Practice Quality
Improvement
What ought to be done?
RCTs, Systematic Reviews, and Evidence-based
practice guidelines
What is done?
How to change?
Survey results
What do we need to do differently?
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Current Practice ?
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Nutrition Support in the Critical Care Setting
Current Practice in Canadian ICUs -Opportunities
for Improvement?

• Daren K Heyland MD, FRCPC, MSc
• Deborah Schroter-Noppe, RD
• John W Drover, MD, FACS, FRCSC
• Minto Jain MD, FACS, FRCSC
• Laurie Keefe, RD
• Rupinder Dhaliwal, RD
• Andrew Day, Msc

JPEN 2003 vol 27, 1, 74-83
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Survey Results

• Significant of patients did NOT receive
  nutrition support.
• EN is being used more frequently than PN limited
  use of PN.
• Early Enteral Feeding (within 24 hours) is not
  being achieved
• Actual nutrition received 50 to 60 of
  prescribed
• Only 50 sites use an Enteral Feeding Protocol
• EN via the small bowel is not occurring
  frequently
• provision of nutrition support needs to be
  improved
• educational initiatives geared towards community
  centres vs. academic centres likely to have
  greatest impact

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Need for Clinical Practice Guidelines ?

• McColl BMJ 1998 study of 362 GPs views on
  evidence based medicine
• Provision of evidence based medicine improves
  patient care (84 )

evidence based medicine

• opinion based
• medicine

Evidence based guidelines
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Existing Nutrition Support Practice Guidelines

• ASPEN Reviews (Klein JPEN 1997)
• ACCP Consensus Conference (Cerra Chest 1997)
• Systematic reviews, not guidelines
• Link between recommendations and level of
  supporting evidence not transparent
• Emphasis on expert opinion
• Outdated
• Not multidisciplinary
• No external validation
• Not detailed or practical

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CPGuidelines 2002 ASPEN

• Patients with critical illness are at nutrition
  risk and should undergo nutrition screening to
  identify those who require formal nutrition
  assessment with development of a nutrition care
  plan (B)
• SNS should be initiated when it is anticipated
  that critically ill patients will be unable to
  meet their nutrient needs orally for a period of
  5-10 days (B)
• EN is the preferred route of feeding in the
  critically ill requiring SNS (B)
• PN should be reserved for those patients
  requiring SNS in whom EN is not possible (C)

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Canadian ICU Nutrition Support Practice Guidelines

• Current
• Evidence-based
• Systematic reviews and RCTs
• Multidisciplinary
• MD, RN, RD, Pharmacist
• Broader in scope yet practical
• Recommendations to maximize benefits and minimize
  risks of nutrition (eg. Small bowel feeding)

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Canadian ICU Nutrition Support Practice
Guidelines
Nutrition support

• malnutrition
• nutrition assessment

EN gtgtTPN

• timing
• Dose
• composition
• small bowel feeds
• motility agents
• feeding protocols

• timing
• Dose
• Duration
• Lipids
• Low dose PN
• glutamine

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Clinical Practice Guidelines Committee

• Dr. Daren Heyland
• Dr. Leah Gramlich
• Rupinder Dhaliwal, RD
• Carmen Christman, RD
• Voula Christofilos, RD
• Dr. Deb Cook
• Dr. Peter Dodek
• Dr. John Drover
• Jan Greenwood, RD
• Darlene Harrietha, RD

• Dr. Minto Jain
• Brian Jureswitch, Pharmacist
• Dr. Jaime Pinilla
• Shannon Mackenzie, RD
• Sabrina Martin, RN
• Dominique Michaud, RN
• Deborah Schroter-Noppe, RD
• 9 external reviewers

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ICU Nutrition Support Guidelines

• Endorsed by
• Canadian Critical Care Society
• Canadian Critical Care Trials Group
• Canadian Society of Clinical Nutrition
• Dietitians of Canada
• Canadian Association of Critical Care Nurses
• Funded by
• Canadian Critical Care Society
• Institute of Nutrition, Metabolism, and Diabetes
  of CIHR
• Canadian Society of Clinical Nutrition

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CPG first steps

• Development of protocol December 2001
• Literature search and article procurement Dec
  2001 March 2002 and August 2002

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Study inclusion criteria

• Randomized controlled trial or
• Meta-analysis of RCTs
• EN, PN or combination
• Clinically important outcomes
• Critically ill adult patients

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Meta-analysis vs. RCTs
RCT 2
RCT 1
RCT 5
RCT 4
RCT 3
RR
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Outcomes
Mortality QOL Morbidity disease complications
LOS Nitrogen Balance GIT structure/function Immu
ne function Physiology Lab animals
Clinically Important
Surrogate
Not Clinically Important
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Literature review

• Period 1980-2002
• Broad search strategy
• MEDLINE, CINAHL COCHRANE 1440 citations
• EMBASE 3300 citations (duplication)
• Personal files

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Literature review results

• 180 possible articles
• 109 articles that met selection criteria

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Article Review Process

• Each panel member assigned to
• review relevant articles
• list details about population and study
  intervention
• abstract data on outcomes
• rate according to a methodological scale
• discuss results with partner
• content experts
• submit final results for synthesis into summaries

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Integration of values
evidence
integration of values

Validity Homogeneity Safety Feasibilty Cost
practice guidelines
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CPG the process

• Article review process Feb March 2002
• Synthesis of evidence April 2002
• Face to face discussion of evidence May 2002
• First draft for internal review June 2002
• External review Summer 2002
• Revisions and updated literature search Fall
  2002
• Final draft and publication submitted Jan 2003

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Guidelines Topics

• EN in combination with PN
• PN vs. standard care
• Composition of PN
• BCAA
• Type of lipids
• Zinc
• Glutamine
• Strategies to optimize PN and minimize risks
• Use of lipids
• Mode of lipid delivery
• Intensive insulin therapy
• Antioxidants combined
• Antioxidants selenium

• EN vs PN
• Early vs delayed EN
• Dose of EN
• Composition of EN
• Arginine,
• fish oils
• Glutamine
• CHO/fat, Pro, fibre
• pH
• Strategies to optimize EN
• Feeding protocols
• Motility agents
• Small bowel feeding
• Body position

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Dissemination of CPGs

• A Randomized Trial Of Web based Educational
  Interventions in Implementing Clinical Practice
  Guidelines For Nutrition Support In The
  Critically ill

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Educational Interventions

• Passive
• No intervention
• Hard copy of CPGs

• Multifaceted Strategies Vs.
• Interactive workshop
• Web based tools
• Audit and feedback
• Reminders (posters,pocket cards)
• Algorithms

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Design

• multicentre cluster randomization trial
• all sites collect baseline data (patient)
• data entered onto website
• sites randomized into two groups
• repeat data collection in 6 months to assess
  change

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Outcomes

• change in nutrition practices measured by patient
  data
• health care outcomes
• mortality
• ICU, hospital LOS

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Critical Care Nutrition Web Site

• www.criticalcarenutrition.com
• web based clinical practice guidelines
• online survey of current practice
• tools (protocols, etc)
• benchmarking (other sites and the clinical
  practice guidelines)
• research related news

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GASTRIC FEEDING GUIDELINE
Initiate feeds within 24-48 hours of
resuscitation as per MD order. Elevate head of
bed 45 (unless contraindicated). Begin feeds at
25 mL/hr and ? by 25 mLQ4H to goal rate as per
guideline below.
Q4H residual gt THRESHOLD MAXIMUM?
First Elevated Gastric Residual 1) Refeed
residual to maximum 400mL discard excess. 2)
Continue feeds at same rate. 3) Refer to
PROKINETIC GUIDE (blue box). 4) Continue in
white box. Second Elevated Gastric
Residual 1) Continue below (yellow box.)
1) Continue feeds at same rate if at goal
rate ? feeds by 25 mL if not at goal rate.
NO
YES
THRESHOLD MAXIMUM 250 mL
1) Refeed residual to maximum 400 mL discard
excess. 2) Hold feeds recheck residual in 1 hr.
PROKINETIC GUIDE Initiate metoclopramide 10 mg
IV Q6H (Q8H if renal failure). unless
contraindicated requires MD order
NO
Gastric residual gt THRESHOLD MAXIMUM?
YES
NASODUODENAL GUIDE (ND) 1) Place ND using a
manual, endoscopic, or fluoroscopic
technique. 2) Insert NG sump. Clamp NG. Discard
gastric residuals Q4H. 3) Following ND placement
resume feeds at final rate. 4) Reassess need for
prokinetic agent (s). unless contraindicated
requires MD order
1) Discard gastric residual. 2) ? feed rate by
multiple of 25 ml/hr (i.e. 100 ? 75 mL) to a
minimum of 25 mL/hr. 3) Do not stop feeds.
Continue with protocol. 4) Continue
metoclopramide. 5) If residuals gt THRESHOLD
MAXIMUM after 4 doses metoclopramide go to ND
GUIDE (green box).
Developed by J.Greenwood in collaboration with
the Vancouver General Hospital ICU medical and
nursing staff. Revised 28/1/03.
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Questions ?