cdp219-35

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Barriers and Facilitators To making it Happen!
Daren K. Heyland Professor of Medicine Queens
University, Kingston General Hospital Kingston,
ON Canada
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Disclosures

• Research Contracts with the Following Companies
• Nestle
• Baxter
• Fresenius Kabi
• Abbott Nutrition

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Results of 2007 International Nutrition Practice
Audit

• Average time to start of EN 46.5 hours (site
  average range 8.2-149.1 hours)
• 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)

Cahill N Crit Care Med 2010 (in press)
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Adequacy of EN Kcals
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Relationship Between Increased Calories and 60
day Mortality
BMI Group Odds Ratio 95 Confidence Limits 95 Confidence Limits P-value
Overall 0.76 0.61 0.95 0.014
lt20 0.52 0.29 0.95 0.033
20-lt25 0.62 0.44 0.88 0.007
25-lt30 1.05 0.75 1.49 0.768
30-lt35 1.04 0.64 1.68 0.889
35-lt40 0.36 0.16 0.80 0.012
gt40 0.63 0.32 1.24 0.180
Legend Odds of 60-day Mortality per 1000 kcals
received per day adjusting for nutrition days,
BMI, age, admission category, admission diagnosis
and APACHE II score.
Alberda Int Care Med 2009351728
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(No Transcript)
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A Qualitative Assessment of Barriers and
Facilitators to Implementing Nutrition CPGs in
ICU

• Multiple case study
• 4 case ICU sites
• Purposeful sampling
• Semi-structured key informant interviews (n28)
• Min. 5 years ICU experience
• Employed at case ICU site May 2004
• Document review

Jones NCP 200722449
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Potential Barriers

• Lack of awareness
• Information overload
• Weak evidence
• Resource constraints
• Slow administrative process
• Impractical / Complex
• Nursing workload
• Limited critical care experience

• Resistance to change
• Patients clinical condition

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Potential Facilitators

• Agreement of the attending physician ICU team
• Part of routine practice
• Dietitian / Opinion leader
• Access / Visibility
• Easy to follow and perform
• Provision of education
• Open discussion

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Favored Implementation Strategies

• Informal one-on-one discussions
• Academic detailing, ward rounds
• Protocols
• Pre printed orders, Check-list, algorithms,
• Bed-side reminders
• Feedback and audit
• Site reports

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The Impact of Enteral Feeding Protocols on
Enteral Nutrition DeliveryResults of a
multicenter observational study

• International, prospective, observational, cohort
  studies conducted in 2007 and 2008 from 269
  Intensive Care Units (ICUs) in 28 countries
• Included 5497 mechanically ventilated adult
  patients gt 3 days in ICU
• Sites recorded the presence or absence of a
  feeding protocol
• Sites provided selected nutritional data on
  enrolled patients from ICU admission to ICU
  discharge for a maximum of 12 days.

78 of sites reported use of Feeding Protocol
Plt0.05
Heyland JPEN 2010 ( in press)
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Initial Efficacy and Tolerability of Early
Enteral Nutrition with Immediate or Gradual
Introduction in Intubated Patients

• This study randomized 100 mechanically ventilated
  patients (not in shock) to Immediate goal
  rate vs gradual ramp up (our usual standard).
• The immediate goal group recd more calories with
  no increase in complications

Desachy ICM 2008341054
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The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!

• Not all critically ill patients are the same we
  have different feeding options based on
  hemodynamic stability and suitability for high
  volume intragastric feeds.
• Use semi elemental solution
• 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.
• Tolerate higher GRV threshold (250 ml or more)
• Motility agents and protein supplements are
  started immediately, rather than started when
  there is a problem.

A Major Paradigm Shift in How we Feed Enterally
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The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!
Heyland (in submission)
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The Efficacy of Enhanced Protein-Energy Provision
via the Enteral Route in Critically Ill Patients
The PEP uP Protocol!
Heyland (in submission)
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Need for Constant Reminders
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Poster
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Reminder HOB sticker
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Reminder screensavers
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Early Enteral Nutrition in the ICUThe Clock Is
Ticking!
Special DVD presentation
Daren K. Heyland, MD, FRCPC, MSc Professor of
Medicine Queens University Kingston, Ontario
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www.criticalcarenutrition.com
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(No Transcript)
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Overall Site Performance
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Practice Changing Interventions

• Protocolize/automate care
• Improve organizational culture
• Develop Dietitian and other KOL as 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 (manuals, posters, pocket
  cards)
• One on one academic detailing

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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)
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Conclusions

• Long way to go to narrow the quality gap
• Need to enrich our understanding on how best to
  achieve that but in the mean time, act now!
• With our emerging understanding of the problems,
  we need to develop more targeted or strategic
  solutions.
• Strengths weaknesses barriers enablers vary
  across sites.
• Stay tuned