Narrowing the Gap Quality Improvement in the ICU

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Narrowing the Gap Quality Improvement in the ICU

• Naomi Jones MSc RD
• Critical Care Nutrition,
• Queens University, Kingston ON Canada

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Outline

• Actual Nutrition Practices
• International Survey 2007
• Optimizing Nutrition Therapy
• Canadian Clinical Practice Guidelines
• Narrowing the Gap
• Identifying the barriers and enablers to
  guideline adherence

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Why does a gap exists?
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Clinical Practice Guidelines

• systematically developed statements to assist
  practitioner and patient decisions about
  appropriate health care for specific clinical
  circumstances
• U.S. Institute of Medicine
• Applies to the average patient
• Reduce variation, improve process of care and
  patient outcomes

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• Updated January 2007
• Summarizes 156 trials studying 15080 patients
• 34 topics 17 recommendations

www.crriticalcarenutrition.com
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Active Multifaceted
Before
After
Randomization
May 2004 Registered Dietitians collected data
May 2003 Registered Dietitians collected data
Passive
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Results of Cluster RCT
EN Adequacy
Overall change from baseline 7.2 (plt0.001)
No difference observed between groups
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Why such minimal effects?

• Variation in nutrition practices exist
• Changing nutrition practice is complex
• Need to identify barriers and enablers to
  guideline adherence

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Understanding Guideline Adherence Mixed Methods
Approach
Secondary analysis of Dissemination Guideline
Cluster RCT
Quantitative Phase
Document review
Qualitative Phase
Multiple case studies
Key Informant Interviews
Revision of Framework
Jones N et al Nutr Clin Prac 2007 Jones N et
al J Crit Care 2008
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Framework for Adherence to CPGs in the ICU
Figure 2 Framework for Adherence to Clinical
Practice Guidelines in the Intensive Care Unit
Legend Ovals Theme, Boxes Factors, Italics
New themes/factors, ICU Intensive Care Unit
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CPG Characteristics

• Up to date
• Evidence based
• Respected development team
• User friendly format

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Framework for Adherence to CPGs in the ICU
Figure 2 Framework for Adherence to Clinical
Practice Guidelines in the Intensive Care Unit
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Implementation

• Awareness
• Posters
• Education
• workshops, rounds, academic detailing
• Reminders
• pre-printed orders, protocol

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www.criticalcarenutrition.com
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Framework for Adherence to CPGs in the ICU
Figure 2 Framework for Adherence to Clinical
Practice Guidelines in the Intensive Care Unit
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Institutional Characteristics

• Hospital and ICU Characteristics
• Non-teaching
• Open structure
• Small size
• Rural location
• Hospital Processes
• Long / slow

• Resources
• Staff shortage
• Lack of equipment
• Lack of access to nutritional products formulas
• Lack of access to specialist services

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ICU Culture

• Shared beliefs, attitudes, values and norms of
  behaviour between colleagues
• Multi-disciplinary team
• Leadership Support
• Collaborative decision-making
• Respect for expertise of each ICU Team member
• Informal, open communication

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Framework for Adherence to CPGs in the ICU
Figure 2 Framework for Adherence to Clinical
Practice Guidelines in the Intensive Care Unit
Legend Ovals Theme, Boxes Factors, Italics
New themes/factors, ICU Intensive Care Unit
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Provider Characteristics

• Professional role
• Critical care experience
• Educational background
• Personality

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Attitudes to the Canadian CPGs Survey
515 critical care practitioners 27 countries
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Attitudes to the Canadian CPGs Survey

• 327 (64.2) used guidelines
• 138 (40) used the Canadian CPGs
• 281 (55.8) agreed that the Canadian CPGs
  represent best practice for nutrition therapy in
  the critically ill
• 229 (45.1) believed that adhering to the
  recommendations improves patient outcome

See our poster presentation
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Q. Enteral nutrition should be used in preference
to parenteral nutrition.
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Q. Supplementation with Glutamine in burn and
trauma patients
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Framework for Adherence to CPGs in the ICU
Figure 2 Framework for Adherence to Clinical
Practice Guidelines in the Intensive Care Unit
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Patient Characteristics

• Poor prognosis
• Other priorities of care
• Unstable clinical condition
• Surgical patients
• Reconciliation with family preferences

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Is Best Practice an Achievable Goal?
Yes!
ABC
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Automate

• Checklists
• Reminders
• Pre-printed orders
• Protocols

www.criticalcarenutrition.com
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Benchmarking

• Key QI strategy
• Can you be the best?
• Participate in the International Nutrition
• Survey 2008
• Data on 20 critically ill patients
• Complete baseline nutrition assessment
• No missing data or outstanding queries
• Permit source verification

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Communicate

• All staff educated and motivated
• Dietitian present on patient rounds
• Nurses reports on nutritional adequacy

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www.criticalcarenutrition.com
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Thank you

• Questions