Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients

doi:10.1016/j.jcrc.2007.08.004

Journal of Critical Care

Volume 23, Issue 3, September 2008, Pages 301-307

https://doi.org/10.1016/j.jcrc.2007.08.004 Get rights and content

Abstract

Purpose

The aim of this study was to determine factors that are associated with adherence to the Canadian nutrition support clinical practice guidelines (CPGs).

Materials and Methods

We conducted a secondary analysis of data from a prospective observational cohort study of nutrition support practices in 58 intensive care units (ICUs) across Canada, grouped into 50 clusters. Adequacy of enteral nutrition (EN) (energy received from EN ÷ energy prescribed by the dietitian × 100), was used as a marker of adherence to the guidelines. We applied hierarchical modeling techniques to examine the impact of various hospital, ICU, and patient factors on EN adequacy.

Results

The overall average EN adequacy was 51.3% (SE, 1.8%). In a multiple regression analysis, after adjusting for varying days of observation, hospital type (academic 54.3% vs community 45.2%, P < .001), admission category of the patient (medical 60.2% vs surgical 39.2%, P < .001), and sex of the patient (male 46.5% vs female 52.8%, P < .001) were found to be significant predictors of EN adequacy and adherence to the Canadian nutrition support CPGs.

Conclusions

Specific hospital, ICU, and patient characteristics influence adherence to the Canadian nutrition support CPGs. Further research is required to illuminate the mechanisms by which female and surgical patients and community hospitals lead to lower guideline adherence.

Introduction

Malnutrition is common among critically ill patients and has a negative effect on clinical outcomes, being strongly associated with increased morbidity and mortality in the intensive care unit (ICU) [1], [2]. Artificial nutrition support in the form of enteral nutrition (EN) or parenteral nutrition (PN) is therefore considered an integral part of the standard care received by the critically ill. Recent studies have generated evidence to support its use by demonstrating that various nutrition support practices influence clinically important outcomes such as length of stay, morbidity, and mortality [3], [4], [5], [6], [7]. Despite these benefits, enteral or parenteral feeding should be adopted with caution because nutrition practices themselves are not without adverse effects or risks [8], [9]. Consequently, making decisions regarding the most effective and safe means of feeding patients in the ICU can be challenging.

The Canadian Clinical Practice Guidelines (CPGs) for nutrition support in mechanically ventilated, critically ill adult patients sought to improve nutrition support practices in ICUs across Canada by providing guidance to assist health practitioners in decisions regarding feeding their patients [10]. Previous nutrition support guidelines relied heavily on expert opinion rather than on evidence and failed to meet the criteria for high-quality CPGs [11], [12], [13], [14].

A validation study before the widespread dissemination of the Canadian nutrition support CPGs tested the hypothesis that ICUs who were more adherent to the guidelines would have greater success in providing EN [15]. This observational study examined the association between EN adequacy and 5 key recommendations of the Canadian nutrition support CPGs that were most directly related to optimal provision of nutrition support (ie, EN over PN, feeding protocol, early EN, small bowel feedings, and motility agents). Enteral nutrition adequacy was calculated as the amount of energy received by EN divided by the amount that should have been received as per the dietitians' assessment. This study found that ICUs that were more adherent to the guidelines had greater success at providing EN. Enteral nutrition adequacy was greater for patients receiving EN alone, compared with patients who received both EN and PN. For ICUs that used more than the median of PN, EN adequacy was significantly less than ICUs who used less PN. The ICUs that used a feeding protocol had a higher EN adequacy than ICUs that did not use a feeding protocol. Overall EN adequacy was greater in patients who had EN initiated early, within 48 hours, compared with patients who had their EN initiated after 48 hours. In addition, ICUs who used motility agents and small bowel feeding in patients with high gastric residuals also tended to have higher EN adequacy than sites that did not. The validation study concluded that adherence to these guidelines should lead to improved nutrition practices and better outcomes for critically ill patients [15]. Subsequent studies in the critically ill population have supported this conclusion by demonstrating that failing to achieve goal energy is associated with worse clinical outcomes [16].

To compare the effectiveness of active to passive dissemination of the Canadian nutrition support CPGs, we conducted a cluster randomized control trial (RCT). The data from this trial were used in this study [17]. In May 2003, after a baseline survey of current nutrition support practices, 58 ICUs across Canada, grouped into 50 clusters, were randomized to either active or passive dissemination strategies. The active arm consisted of multifaceted educational intervention where the ICU dietitian received tools and training in conducting interactive workshops and quality improvement. The passive group only received a copy of the CPGs. A follow-up survey was repeated 12 months later to determine changes in practice. The study found no significant differences in the primary end point, change in EN adequacy, between the 2 arms from baseline to follow-up (8.0% vs 6.2%, P = .54). However, significant improvements in glycemic control were observed in the active arm compared to the passive arm and in a subgroup of medical patients. No other significant differences in nutrition support practices or clinical outcomes were noted between groups.

Despite the rigorous development process used in their production, together with concerted dissemination efforts, the impact of the Canadian nutrition support CPGs has been modest. The process of changing clinical practice through adopting the recommendations of guidelines is complex and often difficult to achieve. Although this problem is not unique to critical care, it is particularly pronounced in this setting due to the challenges created by the heterogeneity of ICU sites and patient population, the rapid pace of decision making, and multidisciplinary team involvement.

It is recognized that understanding barriers and enablers to guidelines adherence is necessary to enhance our knowledge of clinical decision making. This will, in turn, inform development of appropriate and more effective implementation interventions, helping to narrow the gap between best and actual practice. The objective of this study was to determine the specific hospital, ICU, and patient characteristics that are associated with adherence to the Canadian nutrition support CPGs. On the basis of information from a previous survey in Canada, which concluded that optimal provision of nutrition support may be more likely in academic centers compared with community settings [18], we hypothesized that adherence to the Canadian nutrition support CPGs and, thus, adequacy of EN, would be higher in academic hospitals compared to their community counterparts.

Section snippets

Study population

This study involved secondary analysis of data collected during the follow-up phase of the guideline dissemination cluster RCT [17]. To be eligible, ICUs had to have at least 8 beds and be affiliated with a registered dietitian. Of the 78 eligible ICUs, a total of 58 ICUs agreed to participate (74% response rate). Twelve of these sites shared staff and procedures with other participating ICUs. To prevent contamination across sites, these ICUs were combined into 4 distinct clusters resulting in

Results

Of the 50 ICU sites included in the analysis, 25 were from academic and 25 were from community hospitals. The ICUs contributed an average of 12.2 (range, 3-44) evaluable patients. The 612 evaluable patients were observed for an average of 10.4 days (range, 3-12 days). Site characteristics are described in Table 1. Academic hospitals are larger institutions with more ICU beds and are of a closed type, compared with community hospitals. Academic hospitals perform more specialist surgeries

Discussion

The process of translating evidence into clinical practice through CPGs is complex. Gaining a greater understanding of the factors that influence adherence to CPGs in this unique critical care setting will help to maximize the benefits and narrow the gap between best and actual practice. This study capitalized on existing data to address an important research question which, to our knowledge, has not been explored to date. The results support our a priori hypothesis that adherence to the

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Barriers to feeding critically ill patients: A multicenter survey of critical care nurses
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To this end, we conducted a cross-sectional survey to describe the barriers that nurses face when providing EN to critically ill adult patients. In addition, we hypothesized that although some barriers may be common across settings, the frequency and magnitude of some barriers will differ across ICUs because of unique elements of the local context [7,10]. If barriers differ across ICUs, tailoring interventions to overcome these local barriers may be a strategy to improve nutrition practice [11].
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.
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.
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.
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.
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Although the traditional emphasis of nutritional support has been on caloric intake, this has evolved to nutrition as a therapy in which the metabolic response to stress may be attenuated, cellular injury may be prevented, and the immune response may be favorably modulated (219). Extensive guidelines provide recommendations for nutrition therapy for the critically ill (217, 220–222) and have been shown to improve the provision of enteral nutrition (223). Consequently, incorporating such guidelines into the care of patients with severe sepsis is recommended.
To provide a series of recommendations based on the best available evidence to guide clinicians providing nursing care to patients with severe sepsis.
Modified Delphi method involving international experts and key individuals in subgroup work and electronic-based discussion among the entire group to achieve consensus.
We used the Surviving Sepsis Campaign guidelines as a framework to inform the structure and content of these guidelines. We used the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) system to rate the quality of evidence from high (A) to very low (D) and to determine the strength of recommendations, with grade 1 indicating clear benefit in the septic population and grade 2 indicating less confidence in the benefits in the septic population. In areas without complete agreement between all authors, a process of electronic discussion of all evidence was undertaken until consensus was reached. This process was conducted independently of any funding.
Sixty-three recommendations relating to the nursing care of severe sepsis patients are made. Prevention recommendations relate to education, accountability, surveillance of nosocomial infections, hand hygiene, and prevention of respiratory, central line-related, surgical site, and urinary tract infections, whereas infection management recommendations related to both control of the infection source and transmission-based precautions. Recommendations related to initial resuscitation include improved recognition of the deteriorating patient, diagnosis of severe sepsis, seeking further assistance, and initiating early resuscitation measures. Important elements of hemodynamic support relate to improving both tissue oxygenation and macrocirculation. Recommendations related to supportive nursing care incorporate aspects of nutrition, mouth and eye care, and pressure ulcer prevention and management. Pediatric recommendations relate to the use of antibiotics, steroids, vasopressors and inotropes, fluid resuscitation, sedation and analgesia, and the role of therapeutic end points.
Consensus was reached regarding many aspects of nursing care of the severe sepsis patient. Despite this, there is an urgent need for further evidence to better inform this area of critical care.
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It is also considered essential that changes suggested fit within the resources available and a combination of dissemination methods are used (21). A recent analysis of nutritional adequacy in centers where best practice guidelines had been disseminated found that adherence was better in academic teaching hospitals than in smaller centers (22). It has also been demonstrated that ICUs have different barriers to overcome when implementing guidelines (21).
To determine nutritional therapy practices of patients with severe acute pancreatitis (defined as those receiving critical care management in an intensive care unit or high-dependency unit) in Australia and New Zealand with focus on the choice of enteral nutrition or parenteral nutrition.
Prospective observational multicentered study performed at 40 sites in Australia and New Zealand over 6 months.
Intensive care units or high-dependency units within Australia and New Zealand.
Those with severe acute pancreatitis diagnosed by elevated lipase and/or amylase. Patients with chronic pancreatitis were excluded.
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View all citing articles on Scopus

^☆: This study received support from the Canadian Institutes for Health Research Training Program in Digestive Diseases (to Naomi E. Jones).

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Systems-Based Practice/InvestigationFactors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients☆

Abstract

Purpose

Materials and Methods

Results

Conclusions

Introduction

Section snippets

Study population

Results

Discussion

Nutrition

Nutrition

Crit Care Clin

Chest

Clin Nutr

Surgeon

Nutrition and nutrition support in critically ill patients

J Intensive Care Med

Should immunonutrition become routine in critically-ill patients: a systematic review of the evidence

JAMA

Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding

JPEN J Parenter Enteral Nutr

Glutamine supplementation in serious illness: a systematic review of the evidence

Crit Care Med

Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications

Crit Care Med

Total parenteral nutrition in the critically ill patient: a meta-analysis

JAMA

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients

JPEN J Parenter Enteral Nutr

Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients

JPEN J Parenter Enteral Nutr

Systems-Based Practice/Investigation
Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients☆