A Continuous Quality Improvement Effort

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2 A Continuous Quality Improvement Effort What ought to be done? RCTs, Systematic Reviews, and Evidence-based practice guidelines How to change? KT strategies What is done? Survey results What do we need to do differently? Gaps - site reports

3 Information Overload

4 Impractical for individual clinicians to assimilate massive amounts of information to make unaided judgments about complex decisions

5 Need for Clinical Practice Guidelines? Clinical practice guidelines can move us from opinion based medicine to evidence based medicine (McColl BMJ 1998:316) Need for Clinical Practice Guidelines Decrease practice variation Improve clinical outcomes Significant cost savings (Burns CCM 2003:31:2752; Martin C CMAJ 2004:197)

6 What Are Clinical Practice Guidelines? systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances U.S. Institute of Medicine applies to the average patient

7 Context of Guidelines Evidence-based Medicine the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients Sackett DL et al. BMJ 1996;312:71-2

8 Levels of Evidence Systematic reviews RCT s Cohort Studies Case Control Case Series less bias/strong inferences more bias/weaker inferences

9 Meta-analysis vs RCTs RCT #1 RCT #2 RCT #5 RCT #3 RCT #4

10 What is a GOOD guideline? Ideally, leads to improvement in patient outcomes This information rarely available Alternative: Have the producers of the CPG attempted to minimize bias in the complex process of creating the CPG?

11 Criteria for High Quality CPGs (1) Scope: specific statement about the overall objectives, clinical questions and describes the target population. Stakeholder involvement: information on the composition, discipline, and relevant experience of the development group. Rigor of development: Provide detailed information on the search strategy, the inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible). Transparent link between evidence, values, and resulting recommendation. External review Procedure for updating the CPG AGREE Qual Saf Health Care 2003;12:18

12 Criteria for High Quality CPGs (2) Clarity and Presentation: Contains specific recommendations on appropriate patient care and consider different possible options. Key recommendations are easily found A summary document and patient leaflet s are provided. Applicability: Discuss the organizational changes and cost implications of applying the recommendation and present criteria for monitoring the use of the CPG Editorial Independence: Include an explicit statement that the views or interests of the funding body have not influenced the final recommendations. Members of the group have declared conflicts of interest. AGREE Qual Saf Health Care 2003;12:18

13 Updated January 2009 Summarizes 191 trials studying >15000 patients 34 topics 18 recommendations

14 Will adoption of the Canadian CPGs result in improved nutrition support practice?

15 Validation of the CPG s: Results of a Prospective Observational Study Summary Patients and Sites that were more consistent with CPG recommendations tended to receive more EN Adoption of Canadian CPGs will likely lead to improved nutrition support practices in ICUs Heyland CCM 2004;32:2260

16 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

17 Average time to start of EN was 46.5 hours (site average range: hours) Cahill NE CCM 2010

18 More EN= Improved Outcomes Observational studies that better fed patients have fewer infections, less time on ventilator, and lower survival RCTs of aggressive feeding protocols Results in better protein-energy intake Associated with reduced complications and improved survival Meta-analysis of Early vs Delayed EN Reduced infections: RR 0.76 (.59,0.98),p=0.04 Reduced Mortality: RR 0.68 (0.46, 1.01) p=0.06 Alberda ICM 2009, Heyland 2010, Taylor Crit Care Med 1999; Martin CMAJ 2004

19 Guidelines How to change? CPGs to bedside Dissemination and Implementation Strategies Bedside

20 Minding the GAP an Important Part of Patient Safety The time to ACT is NOW!

21 Special JPEN Issue Dedicated to KT Knowledge Translation (KT) describes the process of moving evidence learned from clinical research and summarized in CPGs to its incorporation into clinical and policy decision-making. defined as a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically-sound application of knowledge to improve the health of patients, provide more effective health services and products and strengthen the health care system. Knowledge transfer, knowledge exchange, research utilization, implementation science, dissemination, and diffusion are other terms that have been used interchangeably to describe the same concept. Available online now In press shortly

22 Lost in (Knowledge) Translation! Knowledge to Action Model by Graham Heyland DK, Cahill N, Dhaliwal R

23 Knowledge Generation Knowledge To Action Model Since 1980, >200 randomized trials of nutrition interventions studying >2000 critically ill patients

24 Randomized Trials in Critical Care Nutrition: Look How Far We ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies Number of Trials Single Multicentre All Year Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

25 Randomized Trials in Critical Care Nutrition: Look How Far We ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies 500 Average Number of Patients/Trial Single Multicentre All Year Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

26 Randomized Trials in Critical Care Nutrition: Look How Far We ve Come! (and where do we go from here?) Since 1980, 207 RCTs of Critical Care Nutrition Therapies Single Multicentre All Average Methodological Score Year Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D

27 Knowledge Synthesis Knowledge To- Action Model Systematic reviews and meta-analyses of 34 nutrition related topics

28 Clinical Practice Guidelines Knowledge To- Action Model Development of multiple Critical Care Nutrition Clinical Practice Guidelines

29 Guidelines, Guidelines, Guidelines. What Are We to do With all of These North American Guidelines? Comparison of Canadian, American Dietetic Association, ASPEN/SCCM CPGs Different methods, studies included, ratings of evidence and values Similarities, minor and major differences in recommendations Can we harmonize this process? Dhaliwal R, Madden S, Cahill N, Jeejeebhoy K, Kutsogiannis J, Muscedere J, McClave S, Heyland DK

30 How to Narrow the Gap? First Define the Gap International audits of nutrition practice

31 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

32 Value of Bench-marked Site Reports Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within hrs following resuscitation) in critically ill patients. 120 Time to Initiation of EN (hrs) Site Maximum Minimum Median 0 Your site All sites Sister sites Early vs Delayed Nutrition Intake

33 The Value of Audit and Feedback Reports in Improving Nutritional Therapy in the ICU: A Multicenter Observational Study 26 Canadian ICUs participating in 2007 and 2008 Surveys 80 Adequacy of Calories from EN Only (45.1% to 51.9%, p<0.001 and 44.8% to 51.5%, p<0.001 for calories and protein respectively Year Sinuff T, Cahill N, Dhaliwal R, Wang M, Day A, Heyland DK

34 Need to Understand Local Barriers Assess Barriers

35 Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework CPG Characteristics ADHERENCE Patient Characteristics Implementation Process Institutional Factors Provider Intent Hospital characteristics Provider Characteristics - Profession -Critical care expertise -Educational background -Personality -Structure - Processes -Resources -Patient Case-mix Knowledge Attitudes ICU characteristics -Structure - Processes -Resources - Patient Case-mix -Culture Familiarity Awareness Agreement Motivation Outcome expectancy Self-efficacy Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

36 The Relationship Between Organizational Culture and Implementation of Clinical Practice Guidelines: A Narrative Review The way things are around here Major influence on CPG adherence Defining, measuring, and changing Dodek P, Cahill N, Heyland DK

37 The Impact of Enteral Feeding Protocols on Enteral Nutrition Delivery: Results 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 > 3 days in ICU Sites recorded the presence or absence of a feeding protocol Sites provided nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days Protocol No Protocol 78% of sites reported use of Feeding Protocol Calories from EN Total Calories P<0.05 Heyland DK, Cahill N, Dhaliwal R, Sun, Xiaoqun, Day A, McClave S

38 Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework CPG Characteristics ADHERENCE Patient Characteristics Implementation Process Institutional Factors Provider Intent Hospital characteristics Provider Characteristics - Profession -Critical care expertise -Educational background -Personality -Structure - Processes -Resources -Patient Case-mix Knowledge Attitudes ICU characteristics -Structure - Processes -Resources - Patient Case-mix -Culture Familiarity Awareness Agreement Motivation Outcome expectancy Self-efficacy Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

39 Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians International web-based survey of 514 practitioners from 27 countries Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

40 Attitudes and Beliefs Related to the Canadian Critical Care Nutrition Practice Guidelines: An International Survey of Critical Care Physicians and Dietitians Majority (91.4%) considered nutrition therapy to be very important Strong endorsement for the following established practices: enteral nutrition (EN) used in preference to parenteral nutrition (PN), use of polymeric solutions and feeding protocols, and avoiding hyperglycemia. Also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within hours of admission, use of motility agents, head of the bed elevation, use of glutamine and antioxidants, and maximizing EN prior to starting PN. There was diversity of opinion on the recommendations pertaining to arginine-supplemented diets, small bowel feeding, use of pharmaconutrients, intensive insulin therapy, and withholding soybean oil lipids in PN solutions and hypocaloric PN. Cahill N, Narasimhan S, Dhaliwal R, Heyland DK

41 Understanding Adherence to Guidelines in the ICU: Development of a Comprehensive Framework CPG Characteristics ADHERENCE Patient Characteristics Implementation Process Institutional Factors Provider Intent Hospital characteristics Provider Characteristics - Profession -Critical care expertise -Educational background -Personality -Structure - Processes -Resources -Patient Case-mix Knowledge Attitudes ICU characteristics -Structure - Processes -Resources - Patient Case-mix -Culture Familiarity Awareness Agreement Motivation Outcome expectancy Self-efficacy Jones N, Suurdt J, Ouellette-Kuntz H, Heyland DK

42 Nutrition Therapy for the Critically Ill Surgical Patient: We Need to do Better! Combined 2007 and 2008 survey database 5497 mechanically ven t patients >3days 37% surgical Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, Day A, Heyland DK

43 Need for a Tailored Approach Select Intervention(s)

44 Bridging the Guideline Practice Gap In Critical Care Nutrition: A Review of Guideline Implementation Studies 3 Cluster RCTs 14 ICUs in Canada 60 ICUs in Canada 27 ICUs in Australia Guidelines Cahill N, Heyland DK Bedside

45 Implementation of CPGs A Cluster randomized trial comparing 2 methods of dissemination of Canadian CPGs Passive meetings and hard copy Active Interactive Workshops Web based tools and training Jain, Heyland, et al. Crit Care Med 2006;34:2362

46 Cluster Randomized Control Trial Passive Strategies - copy of published Canadian CPGs - presented at national meetings Active Strategies - as above plus - dietitians positioned as local opinion leaders - web-based tools including bench-marked site reports - interactive workshops with small group problem solving - training on rapid cycle change - educational reminders (manuals, posters, pocket cards) - academic detailing by phone

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50 Early vs Delayed Nutrition Intake Recommendations: Based on 8 level 2 studies, we recommend early enteral nutrition (within hrs following resuscitation) in critically ill patients. 120 Time to Initiation of EN (hrs) Site Maximum Minimum Median 0 Your site All sites Sister sites

51 Design Active Before After Randomization May 2003 Data collection Passive May 2004 Data Collection

52 Results of Cluster RCT EN Adequacy % Prescribed Calories Received by EN B F F B F B B F B B F B B F F F F B B B B B B B B F F F F B B B B B B Intervention Control No difference between groups Overall change from baseline =7.2% (p<0.001) Study Day B=Baseline, F=Follow-Up

53 No Differences Between Groups Nutrition Support Practices: - Type of nutrition support received - EN started within 48 hours - small bowel feeding, motility agents - feeding protocols, HOB - use of glutamine, IV lipids Clinical Outcomes: - ICU LOS - Mortality

54 Why Such Minimal Effect? Guideline implementation is complex Existing studies on adherence to CPGs: - Practitioner - Intra-disciplinary - Outside ICU - Non-nutritional Need to identify barriers and enablers to nutrition guideline adherence in the ICU

55 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

56 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)

57 Vs. Tailored Intervention: Change strategies specifically chosen to address the barriers identified at a specific setting at a specific time

58 PERFormance Enhancement of the Canadian nutrition guidelines through a Tailored Implementation Strategy: The PERFECTIS Study Hypothesis Barriers are inversely related to nutrition performance and tailoring change strategies to overcome barriers to change will reduce the presence of these barriers and lead to improvements in nutrition practice.

59 And the Cycle continues...

60 Creating a Culture of Clinical Excellence in Critical Care Nutrition: The Best of the Best Award Heyland DK, Heyland R, Jones N, Dhaliwal R, Day A

61 Recognition and Reward Recognition a powerful motivator of human performance

62 Recognition Produces Results! The results of a 10-year, 200,000 employee study: Organizations excelling at rewarding excellence had avg. ROE of 3x greater than the lowest rated organizations Institutions that excel at recognizing employee contributions: HIGHER in customer satisfaction HIGHER in employee satisfaction/morale (94.4% agree their superior is effective at recognition, only 2.4% with low morale agree) HIGHER in employee retention

63 Determining the Best of the Best Determinant Weighting Overall Adequacy of EN plus appropriate PN 10 % patients receiving EN 5 % of patients with EN initiated within 48 hours 3 % of patients with high gastric residual volumes 1 (HGRV) receiving motility agents % of patients with HGRV receiving small bowel tubes 1 % of patient glucose measurements greater than 10 3 mmol/l (excluding day 1; fewest is best) Rank all eligible ICUs by determinants Multiply ranking by weighting ICU with highest score is crowned Best of the Best

64 Best of the Best Award Eligible sites: Data on 20 critically ill patients Complete baseline nutrition assessment Presence of feeding protocol No missing data or outstanding queries Permit source verification by CCN Awarded to ICU that demonstrate: Highest ranking nutritional performance Last year, 156 ICUs participated in an international audit of nutrition practices in critically ill patients. This year we want to take part. BEST OF THE BEST ADD HOSP KGH LOGO 2008 Please help us to improve our performance as it relates to nutrition in our ICU. Better nutrition therapy translates into reduced morbidity and improved survival. For more information, contact

65 2008 Best of the Best Top 3 ICUs 1. Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand 2. Kingston General Hospital, Kingston, Canada 3. Regional Hospital A. Cardarelli, Italy

66 2008Best of the Best Lyn Gillanders, Senior Clinical Dietitian and her ICU colleagues at the Department of Critical Care Medicine, Auckland City Hospital being presented with the Best of the Best Award by the Hospital Medical Director.

67 Determinants to Top Performance What site and hospital characteristics are associated with top BOB ranking? (Best Rank=1rst thus a negative number is associated with a better ranking) Hospital/ICU characteristics** Ranking p values Region Australia and New Zealand vs. Canada China vs. Canada Europe and South Africa vs. Canada India vs. Canada Latin America vs. Canada USA vs. Canada < Hospital size (per 100 beds) ICU structure Closed vs. open or other Presence of Dietitian(s) Yes vs. No Heyland JPEN 2010

68 2009 Best of the Best Of >200 ICUS competing Internationally TOP Performers 1. Instituto Neurologico de Antioquia, Medellin, Colombia 1. Royal Prince Alfred Hospital, Sydney, Australia 1. The Alfred, Melbourne, Australia

69 2009 Best of the Best Of >200 ICUS competing Internationally Outstanding Performers 4) Trillium Health Centre, Mississauga, Canada 5) Regional Hospital A. Cardarell, Campobasso, Italy 6) Royal Columbian Hospital, New Westminster, Canada 7) Community Hospital of Monterey Peninsula, Monterey, USA 8) Auckland City Hospital, Auckland, New Zealand 9) Hamilton General Hospital, Hamilton, Canada 10)University District Hospital Neuro-ICU, San Juan, USA

70 How to Change? CPGs to bedside Dissemination and Implementation Strategies Bedside