Adult ICU Nutrition Perspectives in Asia Pacific and the Middle East:

Transcription

1 Adult ICU Nutrition Perspectives in Asia Pacific and the Middle East: An online survey conducted by PhilSPEN Maria Christina S. Reyes MD, MSCN, DPBCN

2 Acknowledgement Marianna Ramona Syquia-Sioson, MD

3 Objectives Understand variations in clinical nutrition practices of critical care units in different countries across the Asia-Pacific and Middle East regions Understand the perspectives of healthcare professionals in the regions as regards nutrition management Create an impetus for the formation of consensus statements on adult ICU nutrition practices that focus on the practices and needs of patients from these regions

4 Methodology Online questionnaire (survey monkey format) c/o MIMS developed by PhilSPEN, patterned after the PICU nutrition survey (Asia Pac J Clin Nutr 2016) Marianna Sioson Maria Christina Reyes Divina Cristy Redondo-Samin

5 ed to identified ICU specialists (Australia, India, Indonesia, Japan, Malaysia, Philippines, Saudi Arabia, Singapore, Sri Lanka, Taiwan, Thailand, UAE, Vietnam) ed to heads of PEN Societies (All of the above countries plus Korea, China, HongKong, Iran) Survey period: January to February 2016

6 Questionnaire content Consent Form If no consent, respondent will not have access to the questionnaire. Personal & Hospital Information profession, hospital type, ICU type, number of ICU beds ICU Staff/NST composition and services access to allied professionals, roles Nutrition support processes/steps nutrition screening and assessment, EN and PN practices/protocols, monitoring Barriers to nutrition practice implementation knowledge, training and education; financial coverage; beliefs and attitudes; manpower

7 Personal & Hospital Information

8 Countries Japan Sri Lanka Philippines Australia India Malaysia Indonesia Singapore Thailand UAE HK Saudi Arabia Taiwan Vietnam Respondents:176

9 Specialization Physician Nut-Diet Nurse Surgeon Others 78% - > 5 years of practice

10 Hospital Information Private 110 Public/ Government 10% % % Non-teaching 123 Teaching Type Academic ICU type Number of ICU Beds 42 Closed 51 Open 81 Semi-closed 16% % >20

11 Cases 100 Percentage of responses Surgical Medical Trauma Neurosurg Cardiac Burns Others

12 Staff/Nutrition Services

13 Support Staff Dietitian Services 88% had access to dietitian in ICU 43% had access to dietitian daily 53% of dietitians did regular nutrition assessments on all ICU patients Pharmacist Services 79% had access to pharmacist in ICU 59% had access to pharmacist daily

14 Nutrition Support Team only 36% had dedicated NST 55% of NSTs provided daily coverage 53% of NSTs did regular nutrition assessments in ICU Dietitian 92 Intensivist 60 Nurse 69 Surgeon 58 Pharmacist 68 IM 53 Others 13 CN MD Pedia 24 Percentage of respondents

15 What can we gather from the survey results? ICUs in the region have some access to dietitian and pharmacist assistance but staff limitations. Only a third of hospitals in the region have NSTs, and those that do have do not utilise their NSTs fully in their ICUs (only about 50% of the time).?expertise not fully utilised

16 Nutrition Screening & Assessment

17 Nutrition Screening Dietitian 37 Which tool is used? Physician 37 NRS 25 Nurse 34 MST 19 NST 21 MUST 7 Don t know Not done Who conducts nutrition screening? Don t know Others

18 Nutrition Assessment Dietitian 53 Which tool is used? Physician 43 SGA 55 Nurse 16 NUTRIC 7 NST 21 MNA 6 Don t know Not done Who conducts nutrition assessment? Don t know Others

19 Nutrition Assessment Parameters Clinical 89 Anthrop 80 Serum tests 70 Muscle fxn Body Comp 10 8 Don t know Others

20 Calculating Energy Needs

21 Indirect Calorimetry only 10% had access to IC Of those who did have access to IC 76% used it infrequently 18% used it daily 6% used it weekly

22 Predictive Equation used Wgt-based HBE DRI Ireton-Jones Don t know Others

23 What can we gather from the survey results? Although majority of ICUs do nutrition screening and assessment using standard validated tools, a third of respondents did not know exactly what these tools are. Almost all ICUs do not use IC and of those with access to IC, do not routinely use it in practice. Majority use weight-based equations to estimate nutrition needs.?need to improve understanding

24 Enteral Nutrition

25 EN Initiation/Progression no target 10% others 6% 1-3 days 3-5 days hr 3% 5-7 days days 3 48 hr 22% 24 hr 59% Don't know 6 don't know 1% Others

26 EN Formulas Kitchen feeds 38 Polymeric 80 Semi-elem 64 Elem 38 Disease-spec 57 Others

27 EN Access 98% use gastric route as first-line EN feeding route GI Intensivist Nurse Radio Others Who inserts access for small bowel feeding?

28 EN Delivery Continuous feeding Not at all 11% When indicated 32% Routinely 57%

29 EN Delivery Equipment (continuous) Equipment (bolus) Gravity set 23% Enteral pump 28% Gravity set 39% Enteral Pump 77% Bulb syringe 33%

30 What can we gather from the survey results? About 80% do early enteral nutrition (24-48 hours of ICU admission). Majority progress feeding within 1-5 days. Majority have access and use commercial EN but about 40% still turn to kitchen feeds for main nutrition source in ICU. Almost all (98%) use gastric route first More than half routinely deliver EN continuously (whether by pump or gravity set). About a third had limited access to EN equipment.?fairly good understanding of EN

31 Clinical Management while on EN

32 Motility Agents 80% use motility agents only when indicated high GRV GI intol Constip Others Indications 2 0 Metoclo Domper IV Eryth??? Others Agent used 6 Laxatives 89% use laxatives only when indicated

33 Steps in diarrhea management 1st step: Reassess medications being given 2nd step: Change formula dilution 3rd step: Change formula base 4th step: Start probiotics 5th step: Start anti-motility drugs

34 Probiotics 67% used probiotics only when indicated

35 What can we gather from the survey results? Most HCPs will use probiotics, laxatives and motility agents only when indicated. Commonly performed steps in diarrhea management were presented. Symptom-based and evidence-based practice

36 Bedside dysphagia screening GUSS 5% Don't know 9% EAT-10 4% Others 5% Water Swallow 35% None 41% Indications for dysphagia screening % respondents Before transitioning to oral diet from tube feeding 50% Not done at all 32% Immediately postextubation 25% After prolonged NPO 24% 70% had no ICU dysphagia protocol Others 15% All elderly patients 13%

37 Head-of-bed elevation Not at all 1% When indicated 8% Routinely 91%

38 What can we gather from the survey results? 70% had no ICU dysphagia protocol, with 35% using the simple water swallowing test. Half screen for dysphagia before transitioning to oral feeding. There are a small number (8%) of HCPs who do NOT routinely keep HOB elevated. Need to improve or develop protocols

39 Gastric Residual Volumes 30 With Threshold Cutoffs in ICU Don't know 3% No 13% Yes 84% up to % - depends on physician 1% - depends on nurse 1% - don t know 300 up

40 Clinical Management of feeding intolerance

41 Feeding intolerance Top 5 signs commonly seen as intolerance High GRV Abdominal distension Vomiting Diarrhea/Abdominal pain (tied) Abdominal pain Others GI bleed Gastric aspirate Constipation No bowel sounds

42 Feeding intolerance First 5 steps in addressing feeding intolerance Step 1: Stop feeding and recheck aspirates Step 2&3: Reduce the feed amount Step 4: Change the type of feed Step 5: Initiate supplemental PN Others Start continuous feeding Start motility agent Start small bowel feeding Start laxative Start acid suppressant Start motility agent Initiate aspiration precautions

43 What can we gather from the survey results? Most HCPs are highly dependent on GRVs. High GRV is considered as the most common sign of feeding intolerance and rechecking aspirates (while interrupting feeding is the first step in addressing intolerance. 25% use ml as automatic cutoff; but 21% have arbitrary cutoffs dependent on attending physician. Need to improve understanding

44 Parenteral Nutrition

45 Starting PN Indications PN time start when EN contraindicated or not fully tolerated EN intol 84 GI dysfxn no EN access high GRV others 13% don't know 4% 24 hr 19% aspiration risk patient pref no target 25% 48 hr 19% others hr 20%

46 PN monitoring Maximum PN hangtime Checks appropriate PN access (central vs peripheral) 66 Don't know 9% No 3% hr 36 hr 48 hr don't know Yes 88%

47 PN monitoring With catheter care bundles Don't know 13% trace water sol Incorporation of additives No 13% fat sol 44 Yes 74% none others

48 What can we gather from the survey results? No clarity as to when PN will be started, with an even distribution of responses (approximately 20% each for 24-, 48-, 72-hours, and no target) Indications are fairly clear that PN will be started only when EN feeding is not possible or limited. There is some monitoring of PN use. Need to improve understanding

49 Protocolised practice EN protocol PN protocol Yes No don't know 7

50 What can we gather from the survey results? About half of ICUs have EN and PN protocols in place (63% for EN, 48% for PN) Should we protocolize nutrition practice in the ICU?

51 Use of immunemodulation in the ICU

52 Immune-modulating nutrients Immune-modulating nutrients used Don't know 4% Glutamine 84 Arginine 59 No 48% Yes 48% EPA DHA GLA 31 others

53 Cases where immunemodulating nutrients are used Trauma 65 Cancer 55 Periop 49 Mech Vent 42 All ICU 24 Others

54 Challenges during feeding in the ICU

55 Common reasons for delaying EN Hemo instab Intest Obstrxn Radio evidence of ileus Radio evidence of ileus inc abdl girth no bowel sounds/flatus patient/family refusal lack of funds other care aspects priority

56 Common reasons for delaying PN Hemo instab 66 no stable IV access 32 Fluid/elect imbal 26 fear of inc sepsis risk 19 no stable IV access 15 sepsis diagnosis patient/family refusal lack of funds

57 Common reasons for inadequate EN GI intol 69 procedures/tests 46 high or increasing GRVs 51 high or increasing GRVs 26 AP forgetting to progress 35 hemo instab inc mech vent req can't get small bowel access

58 Common reasons for EN interruptions tests surgery tests intub/extub trache change GI intol Chest PT retaping of ET Chest tube placement Chest tube removal tests/surgery hours intub/extub - 4 hours

59 What can we gather from the survey results? Common reasons for delays in feeding: EN - hemodynamic instability PN - hemodynamic instability inadequate EN - GI intolerance (but with many still considering high GRVs) interrupted EN - tests/procedures Need to define things

60 Barriers to the implementation of nutrition practices in the ICU

61 In terms of knowledge, training and education (tick all applicable) % 80 45% 53% % 22% 29% 20 10% 10% 0 Lack of education and training of ICU staff and doctors/ trainees on proper feeding among critically ill patients Lack of expert or champion to lead, teach and drive the ICU nutrition practice ICU staff unfamiliar with international/ local guidelines regarding feeding in the ICU ICU staff unfamiliar with existing nutritional protocols of the hospital Existing nutrition protocol not updated, too vague or too complex No ICU nutrition protocol in existence No challenges identified Responses Others

62 In terms of manpower and team care (tick all applicable) % 42% 38% 36% % 29% % 10 6% 0 Lack of staff to manage nutrition needs of ICU patients Lack of access to specialist services Lack of individuals willing to take responsibility for feeding in the ICU Lack of coordination among ICU patient care team members Lack of agreement on nutritional processes among ICU team members No challenges identified Responses Others

63 In terms of supplies and materials (tick all applicable) % 48% 42% 50 28% % 0 Lack of certain equipment e.g. enteral pumps, gravity sets, IV pumps Inadequate access to certain formulas and nutrients No challenges identified Responses Others

64 In terms of financial coverage/issues (tick all applicable) % 42% 38% % % 10 0 Nutrition Support not covered by private insurance Nutrition support not covered by public/state insurance or not subsidized by the government Patient s lack of funds * No challenges identified Responses Others

65 In terms of beliefs and attitudes of HCPs (tick all applicable) % % 26% 12% 0 Hospital or ICU managers not supportive of implementing nutrition protocols ICU staff not supportive of implementing nutrition protocols No challenges identified Responses Others

66 Relevant educational/training tools available in local context to encourage better delivery of nutrition support (tick all applicable) Bedside teaching 81 Lectures 71 Invited expert speakers 60 Journal club 39 none 9 others

67 Degree of agreement to the ff statements: Nutrition in your ICU is important. Nutrition provided in your ICU is adequate. Nutrition in your ICU can improve clinical outcomes. Use of nutrition protocols can improve nutrient delivery. A. B. C. D Percent of respondents A B C D Strongly disagree Diasgree Neutral Agree Strongly agree

68 Challenges to improving nutrition practice in the ICU lack of training and education lack of staff limitations to access to formulas and equipment funding But about 55% do not see any problem in terms of attitudes of HCPs as regards ICU nutrition practices Need to help HCPs in the region overcome these challenges

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70 Limitations Response rate for this survey were low Survey was only available in English which is not the first language in many countries in the region. Different health systems determine the clinical practice

71 What s next? More Surveys? Consensus Statements! Address the gaps. Offer specific solutions to improve practice. Simplify the statements to make them workable and usable.

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73 Come together Philspen.. Leave a legacy for everyone

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