Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study.

INTRODUCTION: Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. However, there is inadequate data to inform the optimal method or level of tailoring. Consequently, we conducted the PERFormance Enhancement of the Canadian nutrition guidelines by a Tailored Implementation Strategy (PERFECTIS) study to determine the feasibility of a multifaceted, interdisciplinary, tailored intervention aimed at improving adherence to critical care nutrition guidelines for the provision of enteral nutrition. METHODS: A before-after study was conducted in seven ICUs from five hospitals in North America. During a 3-month pre-implementation phase, each ICU completed a nutrition practice audit to identify guideline-practice gaps and a barriers assessment to identify obstacles to practice change. During a one day meeting, the results of the audit and barriers assessment were reviewed and used to develop a site-specific tailored action plan. The tailored action plan was then implemented over a 12-month period that included bi-monthly progress meetings. Compliance with the tailored action plan was determined by the proportion of items in the action plan that was completely implemented. We examined acceptability of the intervention through staff responses to an evaluation questionnaire. In addition, the nutrition practice audit and barriers survey were repeated at the end of the implementation phase to determine changes in barriers and nutrition practices. RESULTS: All five sites successfully completed all aspects of the study. However, their ability to fully implement all of their developed action plans varied from 14% to 75% compliance. Nurses, on average, rated the study-related activities and resources as 'somewhat useful' and a third of respondents 'agreed' or 'strongly agreed' that their nutrition practice had changed as a result of the intervention. We observed a statistically significant 10% (Site range -4.3% to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5% to 17.9%) and 4% (-8.3% to 18.2%) increase in the adequacy of total nutrition from calories and protein, respectively. CONCLUSIONS: The multifaceted tailored intervention appears to be feasible but further refinement is warranted prior to testing the effectiveness of the approach on a larger scale. TRIAL REGISTRATION: ClinicalTrials.gov NCT01168128. Registered 21 July 2010.

The validation of a questionnaire to assess barriers to enteral feeding in critically ill patients: a multicenter international survey.

BACKGROUND: A growing body of literature supports the need to identify and address barriers to knowledge use as a strategy to improve care delivery. To this end, we developed a questionnaire to assess barriers to enterally feeding critically ill adult patients, and sought to gain evidence to support the construct validity of this instrument by testing the hypothesis that barriers identified by the questionnaire are inversely associated with nutrition performance. METHODS: We conducted a multilevel multivariable regression analysis of data from an observational study in 55 Intensive Care Units (ICUs) from 5 geographic regions. Data on nutrition practices were abstracted from 1153 patient charts, and 1439 critical care nurses completed the 'Barriers to Enterally Feeding critically Ill Patients' questionnaire. Our primary outcome was adequacy of calories from enteral nutrition (proportion of prescribed calories received enterally) and our primary predictor of interest was a barrier score derived from ratings of importance of items in the questionnaire. RESULTS: The mean adequacy of calories from enteral nutrition was 48 (Standard Deviation (SD)17)%. Evaluation for confounding identified patient type, proportion of nurse respondents working in the ICU greater than 5 years, and geographic region as important covariates. In a regression model adjusting for these covariates plus evaluable nutrition days and APACHE II score, we observed that a 10 point increase in overall barrier score is associated with a 3.5 (Standard Error (SE)1.3)% decrease in enteral nutrition adequacy (p-values <0.01). CONCLUSION: Our results provide evidence to support our a priori hypothesis that barriers negatively impact the provision of nutrition in ICUs, suggesting that our recently developed questionnaire may be a promising tool to identify these important factors, and guide the selection of interventions to optimize nutrition practice. Further research is required to illuminate if and how the type of barrier, profession of the provider, and geographic location of the hospital may influence this association.

Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial.

OBJECTIVES: To determine the effect of the enhanced protein-energy provision via the enteral route feeding protocol, combined with a nursing educational intervention on nutritional intake, compared to usual care. DESIGN: Prospective, cluster randomized trial. SETTING: Eighteen ICUs from United States and Canada with low baseline nutritional adequacy. PATIENTS: One thousand fifty-nine mechanically ventilated, critically ill patients. INTERVENTIONS: A novel feeding protocol combined with a nursing educational intervention. MEASUREMENTS AND MAIN RESULTS: The two primary efficacy outcomes were the proportion of the protein and energy prescriptions received by study patients via the enteral route over the first 12 days in the ICU. Safety outcomes were the prevalence of vomiting, witnessed aspiration, and ICU-acquired pneumonia. The proportion of prescribed protein and energy delivered by enteral nutrition was greater in the intervention sites compared to the control sites. Adjusted absolute mean difference between groups in the protein and energy increases were 14% (95% CI, 5-23%; p = 0.005) and 12% (95% CI, 5-20%; p = 0.004), respectively. The intervention sites had a similar improvement in protein and calories when appropriate parenteral nutrition was added to enteral sources. Use of the enhanced protein-energy provision via the enteral route feeding protocol was associated with a decrease in the average time from ICU admission to start of enteral nutrition compared to the control group (40.7-29.7 hr vs 33.6-35.2 hr, p = 0.10). Complication rates were no different between the two groups. CONCLUSIONS: In ICUs with low baseline nutritional adequacy, use of the enhanced protein-energy provision via the enteral route feeding protocol is safe and results in modest but statistically significant increases in protein and calorie intake.

Daily consumption of a synbiotic yogurt decreases energy intake but does not improve gastrointestinal transit time: a double-blind, randomized, crossover study in healthy adults.

OBJECTIVE: Probiotic and synbiotic products are widely marketed to healthy individuals, although potential benefits for these individuals are rarely studied. This study investigated the effect of daily consumption of a synbiotic yogurt on gastrointestinal (GI) function in a sample of healthy adults. SUBJECTS/METHODS: In a randomized crossover double-blind study, 65 healthy adults consumed 200 g/day of yogurt with (synbiotic) or without (control) added probiotics (Bifidobacterium lactis Bb12, Lactobacillus acidophilus La5, Lactobacillus casei CRL431) and 4 g inulin for two 15-day treatment periods, each preceded by a 6-week washout period. GI transit time (GTT), duration of colour (DOC), GI symptoms and dietary intake were assessed and analyzed using repeated measures ANOVA, including PRE-treatment GTT as a covariate. Participants were grouped as short GTT (STT, n = 50, ≤32.7 h) or long GTT (LTT, n = 15, >32.7 h) based on their PRE-treatment GTT assessment. RESULTS: POST-treatment GTT and DOC were not different between synbiotic and control, and did not change from PRE-treatment, within the STT or LTT groups. There were no changes in GI symptom ratings, indicating that both yogurts were well tolerated. In STT, energy, fat and protein intakes were decreased from baseline with synbiotic (p = 0.055, p = 0.059 and p = 0.005, respectively) and dietary fibre intake was higher POST-treatment with synbiotic versus control (p = 0.0002). In LTT, decreases in energy and fat intakes with synbiotic were not significant (p = 0.14 and p = 0.18, respectively) and there were no differences in dietary fibre intake. CONCLUSION: Consuming 200 g/day of synbiotic yogurt did not significantly alter GTT in healthy adults, but was well tolerated and helped to reduce overall energy intake.

Antioxidant micronutrients in the critically ill: a systematic review and meta-analysis.

INTRODUCTION: Critical illness is characterized by oxidative stress, which is a major promoter of systemic inflammation and organ failure due to excessive free radical production, depletion of antioxidant defenses, or both. We hypothesized that exogenous supplementation of trace elements and vitamins could restore antioxidant status, improving clinical outcomes. METHODS: We searched computerized databases, reference lists of pertinent articles and personal files from 1980 to 2011. We included randomized controlled trials (RCTs) conducted in critically ill adult patients that evaluated relevant clinical outcomes with antioxidant micronutrients (vitamins and trace elements) supplementation versus placebo. RESULTS: A total of 21 RCTs met inclusion criteria. When the results of these studies were statistically aggregated (n = 20), combined antioxidants were associated with a significant reduction in mortality (risk ratio (RR) = 0.82, 95% confidence interval (CI) 0.72 to 0.93, P = 0.002); a significant reduction in duration of mechanical ventilation (weighed mean difference in days = -0.67, 95% CI -1.22 to -0.13, P = 0.02); a trend towards a reduction in infections (RR= 0.88, 95% CI 0.76 to 1.02, P = 0.08); and no overall effect on ICU or hospital length of stay (LOS). Furthermore, antioxidants were associated with a significant reduction in overall mortality among patients with higher risk of death (>10% mortality in control group) (RR 0.79, 95% CI 0.68 to 0.92, P = 0.003) whereas there was no significant effect observed for trials of patients with a lower mortality in the control group (RR = 1.14, 95% 0.72 to 1.82, P = 0.57). Trials using more than 500 µg per day of selenium showed a trend towards a lower mortality (RR = 0.80, 95% CI 0.63 to 1.02, P = 0.07) whereas trials using doses lower than 500 µg had no effect on mortality (RR 0.94, 95% CI 0.67 to 1.33, P = 0.75). CONCLUSIONS: Supplementation with high dose trace elements and vitamins may improve outcomes of critically ill patients, particularly those at high risk of death.

Improving the provision of enteral nutrition in the intensive care unit: a description of a multifaceted intervention tailored to overcome local barriers.

BACKGROUND: Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. The purpose of this article is to describe the development and implementation of a tailored intervention to overcome barriers to enterally feeding critically ill patients. METHODS: A before-after study was conducted in 5 hospitals in North America. We adopted a pragmatic stepwise approach to developing and implementing a tailored intervention-namely, (1) formation of a guideline implementation team, (2) identification of barriers to the provision of enteral nutrition (ie, guideline-practice gap analysis, staff survey, focus group with key stakeholders), (3) focus group to prioritize these barriers, (4) brainstorming to select interventions to overcome the prioritized barriers, (5) a 12-month implementation phase including bimonthly progress meetings, and (6) evaluation of the tailored intervention. RESULTS: All sites identified and prioritized barriers to target for change and developed a tailored action plan. Three of the 22 potential barriers were prioritized by all sites, resulting in common components to the action plans. However, barriers and interventions that were unique to specific sites were also identified. All sites were successful in implementing most of the selected strategies during the implementation phase, although the degree of implementation varied depending on the type of strategy and the site. CONCLUSION: This stepwise process to developing and implementing an intervention tailored to barriers is promising and could be considered by dietitians and other providers seeking to improve nutrition practice.

Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies.

Background: This study describes the results of an evaluation of educational strategies used to implement a novel enteral feeding protocol in 9 North American intensive care units (ICUs). Materials and Methods: Members of the protocol implementation teams at each ICU distributed a questionnaire to ICU nurses after the implementation of the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP) protocol. Eight different educational strategies were evaluated. Questionnaires were distributed in both paper and electronic format to all nursing staff and used both a visual analog Likert-type scale and open-ended questions. Results: The response rate to the questionnaire was 166 of 434 or 38.2%. More than 70% of respondents rated 5 of the educational strategies as very useful or somewhat useful, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 and group bedside teaching, and a self-learning module. The percentage of nurses who found the bedside protocol tools of the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either "very easy" or "somewhat easy" to use were 64.0%, 60.5%, and 59.1%, respectively. Conclusion: The use of multiple teaching formats, including the long and short PowerPoint presentations and self-teaching module, appeared to meet the learning needs of most of the group. The majority of the bedside tools developed to facilitate the implementation of the PEP uP protocol were considered easy to use.

Barriers to feeding critically ill patients: a multicenter survey of critical care nurses.

PURPOSE: The aims of this study were to describe the barriers to enterally feeding critically ill patients from a nursing perspective and to examine whether these barriers differ across centers. MATERIALS AND METHODS: A cross-sectional survey was conducted in 5 hospitals in North America. A 45-item questionnaire was administered to critical care nurses to evaluate the barriers to enterally feeding patients. RESULTS: A total of 138 of 340 critical care nurses completed the questionnaire (response rate of 41%). The 5 most important barriers to nurses were as follows: (1) other aspects of patient care taking priority over nutrition, (2) not enough feeding pumps available, (3) enteral formula not available on the unit, (4) difficulties in obtaining small bowel access in patients not tolerating enteral nutrition, and (5) no or not enough dietitian coverage during weekends and holidays. For 18 (81%) of 22 potential barriers, the rated magnitude of importance was similar across the 5 intensive care units. CONCLUSION: Nurses in our multicenter survey identified important barriers to providing adequate enteral nutrition to their critically ill patients. The importance of these barriers does not appear to differ significantly across different clinical settings. Future research is required to evaluate if tailoring interventions to overcome these identified barriers is an effective strategy of improving nutrition practice.

When early enteral feeding is not possible in critically ill patients: results of a multicenter observational study.

BACKGROUND: Early enteral nutrition (EN) is the preferred strategy for feeding the critically ill; however, it is not always possible to initiate EN within the recommended 24 to 48 hours. When these situations arise, controversy exists whether to start feeding early via the parenteral route or to delay feeding until EN can be provided. METHODS: A multicenter, international, observational study examined nutrition practices in intensive care units (ICUs). Eligible patients were critically ill patients with a medical diagnosis who remained in the ICU for >72 hours and received EN >48 hours after admission. Data were collected on site, including patient characteristics, daily nutrition practices, and outcomes at 60 days. Nutrition and clinical outcomes were compared between 3 groups of patients: (1) early parenteral nutrition (PN) (<48 hours after admission) and late EN (>48 hours after admission), (2) late PN and late EN, and (3) late EN and no PN. RESULTS: Of the 703 patients who met our inclusion criteria, 541 (77.0%) medical patients received late EN and no PN. In patients receiving late EN and PN, 83 (11.8%) received early PN and 79 (11.2%) received late PN. Adequacy of calories and protein from total nutrition was highest in the early PN group (74.1% ± 21.2% and 71.5% ± 24.9%, respectively) and lowest in the late EN group (42.9% ± 21.2% and 38.7% ± 21.6%) (P < .001). The proportion of patients dead or remaining in hospital was significantly higher for early PN compared with late EN and PN (unadjusted hazard ratio for early PN = 0.55; 95% confidence interval, 0.37-0.83, P = .015). However, this difference did not remain significant (P = .65) after adjustment for baseline characteristics. CONCLUSIONS: The results suggest that initiating PN early, when it is not possible to feed enterally early, may improve provision of calories and protein but is not associated with better clinical outcomes compared with late EN or PN.

Improving the Practice of Nutrition Therapy in the NRITLD Critically Ill Patients: An International Quality Improvement Project.

BACKGROUND: In previous decades several studies have been performed demonstrating that providing appropriate nutritional support to intensive care unit patients affects complications, time of mechanical ventilation, length of ICU stay, and risk of death. In this study we provided a report of nutrition statuses in Masih Daneshvari's ICU as compared to 156 ICUs from 20 countries that participated in an international nutrition survey. MATERIALS AND METHODS: All patients admitted to an intensive care unit during a specified one-month period who required artificial nutrition were included in this study. Characteristics of patients, performance of nutrition practices, and ICU outcomes were registered for all patients and compared with data from 156 other intensive care units from various countries around the world. RESULTS: Twenty patients, of which 11(55%) were males and 9(45%) were females, were included in this study. The median age was 50.5 yrs (IQR: 40.5-56.0). Seventeen (85%) of them had EN nutrition only, 2(10%) had PN nutrition only, and 1(5%) had both EN and PN nutrition during their stay in the ICU. The adequacy of calorie intake was 67.6% (vs. 61.1% in all 157 ICUs) and the adequacy of protein intake was 84.9% (vs. 56.7% in 157 ICUs). CONCLUSION: In our ICU, enteral feeding was superior to parenteral feeding. Also we considered early initiation of enteral feeding within 48 hours following ICU admission. We just used polymeric formula during this study. As a result of formula variation limits, we overestimated calories and protein needs. Glutamine and Selenium supplementations have not been used yet for patient in our ICU, regardless of their proven benefits in oxidative stress conditions like pulmonary diseases. Therefore, limited use of supplementations like selenium is inevitably among the disadvantages of Masih Daneshvari Hospital's ICU, which is a tertiary-care center for chronic pulmonary diseases.