E S T A B L I S H I N G N U T R I T I O N I N Y O U R I C U The Need for a Protocol Arthur RH van Zanten, MD PhD Gelderse Vallei Hospital, Ede, The Netherlands
Learning objectives Develop an evidence based feeding protocol for the ICU (e.g. GRV, when to introduce prokinetics, the EN versus PN and supplemental PN debate and implement using a MDT approach) Describe the advantages of using a feeding protocol and also its limitations Audit the implementation of the feeding protocol as part of a regular cycle of clinical audit and clinical practice update
I have objections your honour Quality improvement is not EBM Cookbook medicine Expensive We have the best physicians Does not work Do not believe the underlying evidence Have to record more data..
Cookbook medicine? We hear that doctors do not like protocol medicine They do not want to follow a cookbook when every patient is different However, this is an incorrect understanding of the effect and importance of protocols
Improving system quality System approach versus individual approach System quality is depend of individuals, their skills, competencies and communication Teamwork is essential Team performance and quality is confounded by the weakest performer (weakest link)
Science i n c l i n i c a l p r a c t i c e? Percentage of patients receiving recommended care 60 50 53 56 55 54.9 40 30 20 10 0 Acute Chronic Preventive All In total 6712 patients studied in 2003 in USA 439 quality indicators available and tested 30 acute and chronic diseases, and preventive measures McGlynn EA, et al. N Engl J Med 2003;348:2635 2645.
Improving system quality Every 10 years total medical knowledge doubles Implementation of knowledge is slow It is impossible to keep up with all relevant research Practice guidelines and protocols may help to implement scientific evidence
Have we achieved optimal performance yet?
Perception versus daily practice 366 ICU patients with severe sepsis in 214 ICU departments in Germany 100 90 80 70 79,9 65,9 60 50 40 30 20 10 0 17,1 2,6 low tidal volume 33,8 6,2 Tight glucose Perception Borderline Norm Marked difference between perceived performance and actual performance in sepsis management Brunkhorst FM, et al. Crit Care Med 2008;36:2719 2725.
Nutritional adequacy over time 100 90 X. X % received/prescribed 80 70 60 50 40 30 20 10 We can do better! 0 1 2 3 4 5 6 7 8 9 10 11 12 ICU Day Year 2007 Year 2008 Year 2009 www.criticalcarenutrition.com
Evidence-based feeding guidelines and outcome in critically ill adults X. X ICUs of 27 community and tertiary hospitals in Australia and New Zealand Guideline ICU Control ICU P value Patients 561 557 Start enteral nutrition, days 0.75 1.32 < 0.001 Start parenteral nutrition, days 1.04 1.40 0.04 Caloric goals reached, days per 10 days 6.10 5.02 0.03 Hospital mortality, % 28.9 27.4 0.75 HLOS, days 24.2 24.3 0.97 ICU LOS, days 9.1 9.9 0.42 Protocol implementation promotes early enteral nutrition and achieving nutritional targets Doig GS, et al. JAMA 2008;300:2731 2341.
Adherence to practice guidelines? Poor adherence to immunonutrition and glutamine supplementation, timing of TPN and avoiding soybean in TPN Mean Range Start enteral nutrition 46.5 h 8.2 149.1 h Prokinetics in gastric residual retention 58.7% 0 100% Postpyloric feeding in gastric residual retention 14.7% 0 100% Mean adequate feeding energy 59% 20.5 94.4% Protein 60.3% 18.6 152.5% 20 countries; 158 ICUs 2946 consecutive MV patients > 72 h in IC Maximum 12 days Cahill NE, et al. Crit Care Med 2010;38:395 401.
Why use a protocol? It is impossible for all healthcare professionals to know everything at all times Nutrition specialists are not always available (7x24 hours) Performance is always overestimated Nutrition adequacy is low (all over the world) A protocol may help to improve adherence to the scientific evidence and EBM therapy Protocol/guideline ICUs have a better performance It is more simple to test adherence to a protocol than to replicate a randomised trial
Using a protocol as a cookbook is as dangerous as a monkey with a machine gun
Limitations of a protocol Protocols address common situations They are aiming for the best general strategy In specific conditions healthcare professionals should not follow the protocol if this is in the interest of the patient Always document the reasons for not adhering to the protocol This may help to optimize the protocol and avoids legal consequences (as in some countries protocols may have legal status)
Guidelines for provision and assessment of nutrition support in adult ICU patients X. X Proteins BMI < 30 BMI 30 40 BMI > 40 1.2 2.0 g/kg actual body weight/day 2.0 g/kg ideal body weight/day 2.5 g/kg ideal body weight/day Calories 25 kcal/kg/day or formula 60 70% target 11 14 kcal/kg actual weight 22 25 kcal/kg ideal body weight/day Advice Proteins higher in burn and trauma Permissive underfeeding, high protein Permissive underfeeding, high protein The ASPEN guidelines: can be used to set the goals Martindale RG, et al. Crit Care Med 2009;37:1757 1761.
How to develop a protocol? Select a multidisciplinary group to develop the protocol This can be the Nutrition MDT Appoint a leader, and discuss team roles and responsibilities Search for relevant literature (available national or international practice guidelines)
How to develop a protocol? Make a project framework (set goals and deadlines) Develop the protocol manuscript Make a flow chart Develop quality indicators and arrange audits and feedback information
Practical ICU nutrition protocol Example of ICU Nutrition Protocol Flow Chart Gelderse Vallei Hospital, Ede, The Netherlands Assess nutritional status and indication Contraindications? Hemodynamic stability? Select feed: protein & energy set targets Up to 100% GRV < 500 ml Increase 25% per 6 hours Within 24 hours Start at 50% of target rate 1: GRV > 500 ml prokinetics and continue feeding rate Retry Checklist jejunal feeding 2: GRV > 500 ml Discard surplus and continue feeding rate 4: GRV > 500 ml Discard surplus and introduce jejunal feeding tube Failure If not malnourished wait 7 days 3: GRV > 500 ml Discard surplus and decrease feeding rate 25% Start parenteral nutrition
Nutritional assessment BMI, Must-score, Weight loss >10% 3 months LOS estimation Contraindications EN Proven ischemia, Enteral fistula (no bypass option) unstable HD (start when stable vasopressors) Targets Formula or REE Protein target (step 1) (CVVH, IHD, encephalopathy) Energy target (step 2) (MV increases spontaneous/controlled) Select feeds Indications special feeds Fibers Fish oil Hydrolyzed Low-fat Concentrated Build-up Early Enhanced (A) Slow (Refeeding score>8) (B) Start Within 24 hours EN protocol A/B Enteral Nutrition A.Start at 50% of target B.Start at 12,5% of target Gastric Residual Volume (6 hours) < 500 ml Yes Enteral Nutrition A. Increase with 25% B. Increase with 12,5% Gastric Residual Volume (6 hours) < 500 ml Yes No, GRV steps Enteral Nutrition A. Increase with 25% B. Increase with 12,5% Gastric Residual Volume (6 hours) < 500 ml Yes No, GRV steps No, GRV steps Enteral Nutrition A. On target 100% B. On target after 48 hours Adjust with REE GRV steps 1x Gastric Residual Volume (6 hours) > 500 ml Prokinetics start Metoclopramide 4x20 mg IV Erythromycin 2x200 mg IV (4dys) 2x Gastric Residual Volume (6 hours) > 500 ml Prokinetics cont d Discard surplus Continue infusion rate 3x Gastric Residual Volume (6 hours) > 500 ml Prokinetics cont d Discard surplus Decrease infusion rate 25% 4x Gastric Residual Volume (6 hours) > 500 ml Postpyloric tube Endoscopic duodenal/ jejunal feeding tube Postpyloric EN protocol 1. Per 6 hours increase with 20 ml/hr or 25% of target until 100% independent of GRV (2 nd tube); no bolus feeding Monitoring post-pyloric-en intolerance 1. Major gastric enteral feed admixture 2. Important abdominal distention 3. Intra-abdominal pressure > 20 cm H 2 O 4. Severe diahrrea Parenteral nutrition (TPN+SPN) 1. Patients contraindicated for oral or EN intake, >7 days no intake after ICU admission (TPN). 2. Patients on oral/en intake >7 days after ICU admission with enteral intake <60% (SPN) 3. Patients with BMI<18.5: start TPN on day 1; start EN; stop PN at EN-intake of 80% of target. 4. Patients with >10% weight loss in 3-6 months before ICU admission: start TPN on day 1; start EN; stop PN at EN-intake of 80% of target. Monitoring (TPN+SPN) 1. Total bilirubine (>20 μmol/l) and/or doubling of bilirubine level or TG-level (> 3,0 mmol/l): stop fat emulsion completely in PN. 2. NB: 2x per week (Monday / Thursday) total bilirubine&tg testing. 3. In contrast to lab instructions do not interrupt nutritional interventions. Cernevit (multivitamin) & Nutritrace (trace elements) supplementation 1. No Nutrition: 1 ampoule daily of both. 2. Full TPN: 1 ampoule daily of both. 3. EN < 750 ml per 24 hours: 1 ampoule daily of both. 4. EN 750-1500 ml per 24 hours =/- SPN: every other day 1 ampoule of both 5. Full TPN only: 10 mg Konakion per week. NB: not necessary incase of EN. 6. In case of CVVH double dosages
How to audit a protocol? Try to develop quality indicators for the protocol Some examples: Ratio of numbers of patients screened within 24 hours after admission to the total number of admitted patients Number of episodes of high GRV and the prescriptions of prokinetics Episodes of early PN application in patients without indication according to the protocol Number of days that patients do not receive vitamin and trace element supplementation with an intake < 1500 ml EN per day
Quality indicators Keep it simple Only feasible and measurable Qis Make scoring and registration simple (automatic?) Make audit reports (e.g. 3 monthly) Discuss the results in the MDTs Provide feedback to the entire team
Updating the protocol Every 2 5 years the protocol should be updated Update immediately in case of safety issues In fact, it is a living document State the authors, and the launch and revision dates
Conclusions An ICU nutrition protocol is essential and improves adherence to practice guidelines A protocol is no cookbook and should be implemented and adhered to with expertise Performance without a protocol is overestimated Nutrition performance is low internationally Develop the protocol with the Nutrition MDT Start auditing using simple quality indicators to address aspects of the protocol
Questions?