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Zaher S. Barriers to Delivery of Enteral Nutrition in Intensive Care Settings in Saudi Arabia: A Comparative Study of the Perceptions of Health Care Providers Working in Adult and Paediatric ICUs. Risk Manag Healthc Policy 2022; 15:2357-2370. [PMID: 36544506 PMCID: PMC9762403 DOI: 10.2147/rmhp.s394035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Achieving optimal nutrition prescription is challenging in critically ill patients. Many factors can hinder the adequate delivery of enteral nutrition (EN) in intensive care units (ICUs). In this study, we aim to describe EN barriers and compare the perceptions of health care practitioners working in adult and paediatric ICUs regarding these barriers. Methods In this cross-sectional study, data were collected via online survey. All physicians, dietitians, and nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The survey contained 24 potential EN barriers and participants were asked to rate their importance on a scale from 1 to 5. A total Likert rating score of the 24 items was later calculated. Results We recruited 244 health care providers working in adult and paediatric ICUs. The most important perceived barriers were "Delay in physician ordering EN initiation" (3.33 ±1.32), and 'Waiting for dietitians to assess patients' (3.22 ±1.20). There was a statistical difference between the responses of health care providers based on their work settings for the following items; "Nurses failing to progress feeds according to feeding protocol" (p=0.006) and 'Feeding being held too far prior procedures or operating-room visits' (p=0.021). Profession significantly influenced the total Likert rating score of the 24 items (r=-0.234, p=0.001). Conclusion This study identified some barriers of EN delivery in ICUs and showed that participants' perceptions regarding these barriers were influenced by their roles. These findings shed light on the nutritional practices in Saudi hospitals and identify areas of improvement in EN practice and advancements in the field of critical care nutrition in the region.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Kingdom of Saudi Arabia,National Nutrition Committee (NNC), Saudi Food and Drug Authority (Saudi FDA), Riyadh, Saudi Arabia,Correspondence: Sara Zaher, Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia, Email ;
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Consent models in Canadian critical care randomized controlled trials: a scoping review. Can J Anaesth 2021; 69:513-526. [PMID: 34907503 DOI: 10.1007/s12630-021-02176-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/06/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022] Open
Abstract
PURPOSE Our primary objective was to describe consent models used in Canadian-led adult and pediatric intensive care unit (ICU/PICU) randomized controlled trials (RCTs). Our secondary objectives were to determine the consent rate of ICU/PICU RCTs that did and did not use an alternate consent model to describe consent procedures. SOURCE Using scoping review methodology, we searched MEDLINE, Embase, and CENTRAL databases (from 1998 to June 2019) for trials published in English or French. We included Canadian-led RCTs that reported on the effects of an intervention on ICU/PICU patients or their families. Two independent reviewers assessed eligibility, abstracted data, and achieved consensus. PRINCIPAL FINDINGS We identified 48 RCTs of 17,558 patients. Included RCTs had ethics approval to use prior informed consent (43/48; 90%), deferred consent (13/48; 27%), waived consent (5/48; 10%), and verbal consent (1/48; 2%) models. Fifteen RCTs (15/48; 31%) had ethics approval to use more than one consent model. Twice as many trials used alternate consent between 2010 and 2019 (13/19) than between 2000 and 2009 (6/19). The consent rate for RCTs using only prior informed consent ranged from 54 to 91% (ICU) and 43 to 94% (PICU) and from 78 to 100% (ICU) and 74 to 87% (PICU) in trials using an alternate/hybrid consent model. CONCLUSION Alternate consent models were used in the minority of Canadian-led ICU/PICU RCTs but have been used more frequently over the last decade. This suggests that Canadian ethics boards and research communities are becoming more accepting of alternate consent models in ICU/PICU trials.
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Rationale, Methodological Quality, and Reporting of Cluster-Randomized Controlled Trials in Critical Care Medicine: A Systematic Review. Crit Care Med 2021; 49:977-987. [PMID: 33591020 DOI: 10.1097/ccm.0000000000004885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Compared with individual-patient randomized controlled trials, cluster randomized controlled trials have unique methodological and ethical considerations. We evaluated the rationale, methodological quality, and reporting of cluster randomized controlled trials in critical care studies. DATA SOURCES Systematic searches of Medline, Embase, and Cochrane Central Register were performed. STUDY SELECTION We included all cluster randomized controlled trials conducted in adult, pediatric, or neonatal critical care units from January 2005 to September 2019. DATA EXTRACTION Two reviewers independently screened citations, reviewed full texts, protocols, and supplements of potentially eligible studies, abstracted data, and assessed methodology of included studies. DATA SYNTHESIS From 1,902 citations, 59 cluster randomized controlled trials met criteria. Most focused on quality improvement (24, 41%), antimicrobial therapy (9, 15%), or infection control (9, 15%) interventions. Designs included parallel-group (25, 42%), crossover (21, 36%), and stepped-wedge (13, 22%). Concealment of allocation was reported in 21 studies (36%). Thirteen studies (22%) reported at least one method of blinding. The median total sample size was 1,660 patients (interquartile range, 813-4,295); the median number of clusters was 12 (interquartile range, 5-24); and the median patients per cluster was 141 (interquartile range, 54-452). Sample size calculations were reported in 90% of trials, but only 54% met Consolidated Standards of Reporting Trials guidance for sample size reporting. Twenty-seven of the studies (46%) identified a fixed number of available clusters prior to trial commencement, and only nine (15%) prespecified both the number of clusters and patients required to detect the expected effect size. Overall, 36 trials (68%) achieved the total prespecified sample size. When analyzing data, 44 studies (75%) appropriately adjusted for clustering when analyzing the primary outcome. Only 12 (20%) reported an intracluster coefficient (median 0.047 [interquartile range, 0.01-0.13]). CONCLUSIONS Cluster randomized controlled trials in critical care typically involve a small and fixed number of relatively large clusters. The reporting of key methodological aspects of these trials is often inadequate.
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Knight DE, Larmour K, Wellman P, Mulvey N, Hopkins J, Tibby SM. Prospective evaluation of a novel enteral feeding guideline based on individual gastric emptying times: an improvement project in a pediatric intensive care unit. JPEN J Parenter Enteral Nutr 2021; 45:1720-1728. [PMID: 33475176 DOI: 10.1002/jpen.2077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND On a 20-bed, mixed cardiac and general, UK pediatric intensive care unit (PICU), we aimed to determine if a physiologically based enteral feeding guideline for critically ill children, using feed frequency tailored to individual gastric emptying times, resulted in earlier establishment of full feeds (when 100% of fluid allowance (FA) available to be given as intravenous maintenance fluid or feed, defined as free FA [FFA], is given as enteral nutrition [EN]) and an increase in FFA given as EN. METHODS Four prospective audits (totaling 331 patients and 19,771 hours) were conducted at 1 year before guideline introduction and 1, 5, and 10 years after. Patient feeding data were collected from admission until day 4 or discharge, including reasons why feed was withheld. RESULTS The median time from admission to establishing full feeds decreased from 18 to 10 hours preguideline and postguideline and was sustained over 10 years. After adjustment for 5 confounders, this represented a reduction in the geometric mean time to full feeds of 30% (2009), 29% (2013), and 48% (2019) compared with 2007 (all P < .01). Nil-per-oral (NPO) hours were categorized as due to modifiable and nonmodifiable factors. Preguideline and postguideline NPO hours from modifiable factors decreased from 21 (2007) to 10 (2009) per 100 audit hours, which was sustained across 10 years (all P < .01). Conversely, NPO hours from nonmodifiable factors ranged from 27 to 36 per 100 audit hours throughout the audits, with no consistent trend over time. Similar inconsistency was shown in the proportion of FFA given as EN: 48% (2007), 71% (2009), 51% (2013), and 64% (2019). Continuous nasogastric and hourly bolus feeds decreased over time; they comprised 66% of feeds in 2007 but only 4%-11% in subsequent periods, being replaced with more 2-6 hour bolus, on-demand, or continuous nasojejunal feeds. CONCLUSION The guideline was associated with sustained reduction in the time to establishing full feeds and NPO hours due to modifiable factors and more or no less FFA being given as EN.
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Affiliation(s)
- Dawn E Knight
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Kelly Larmour
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Paul Wellman
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Nicki Mulvey
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Julia Hopkins
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - Shane M Tibby
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
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Alsohime F, Assiry G, AlSalman M, Alabdulkareem W, Almuzini H, Alyahya M, Allhidan R, Al-Eyadhy A, Temsah MH, Al Sarkhy AA. Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey. Int J Pediatr Adolesc Med 2020; 8:186-190. [PMID: 34350333 PMCID: PMC8319679 DOI: 10.1016/j.ijpam.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
Background and Aim According to previously reported studies in the literature, a significant number of patients do not receive enteral nutrition in pediatric intensive care unit (PICU) because of avoidable barriers. Optimal nutrition is a fundamental goal in PICU. This study aims to identify the barriers of enteral nutrition in PICU. Setting and Design A cross-sectional study of the results of a 25-item questionnaire-based survey distributed during the Annual International Critical Care Conference by the Saudi Critical Care Society. Methods and material A 7-point Likert-type scale was used to rank the participants’ responses, and the relative importance index (RII) approach was used to analyze the relative contribution of each indicator to its main theme. The factor and parallel analysis methods were used to assess the factorial and unidimensionality of the enteral feeding barriers scale. Results A total of 223 PICU healthcare workers from various intensive care settings responded to the survey. The top-three perceived barriers for commencing enteral feeding were due to the patient being hemodynamically unstable (M = 3.6 and SD = 1.70), delays and difficulties in obtaining small bowel access in patients not tolerating other types of enteral nutrition (M = 3.4 and SD = 1.52), or severe fluid restriction, particularly in postoperative cardiac surgery (M = 3.3 and SD = 1.59). The top perceived overall barriers to enteral feeding were the dietician-related issues (M = 3.3, SD = 1.32), barriers related to enteral feeding delivery (M = 3.16 and SD = 1.13), and medical practice-related (M = 3 and SD = 1.10) issues. The lowest reported overall barriers were the resource-related obstacles (M = 2.7 and SD = 1.26). Conclusion Being hemodynamically unstable and other dietician-related reasons were the top overall barriers in commencing enteral feeding.
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Affiliation(s)
- Fahad Alsohime
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ghadeer Assiry
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Wejdan Alabdulkareem
- Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hissah Almuzini
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak Alyahya
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reema Allhidan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Al Sarkhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Gastroenterology Unit, Pediatric Department, King Khalid University Medical City, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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McNett M, O'Mathúna D, Tucker S, Roberts H, Mion LC, Balas MC. A Scoping Review of Implementation Science in Adult Critical Care Settings. Crit Care Explor 2020; 2:e0301. [PMID: 33354675 PMCID: PMC7746210 DOI: 10.1097/cce.0000000000000301] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this scoping review is to provide a synthesis of the available literature on implementation science in critical care settings. Specifically, we aimed to identify the evidence-based practices selected for implementation, the frequency and type of implementation strategies used to foster change, and the process and clinical outcomes associated with implementation. DATA SOURCES A librarian-assisted search was performed using three electronic databases. STUDY SELECTION Articles that reported outcomes aimed at disseminating, implementing, or sustaining an evidence-based intervention or practice, used established implementation strategies, and were conducted in a critical care unit were included. DATA EXTRACTION Two reviewers independently screened titles, abstracts, and full text of articles to determine eligibility. Data extraction was performed using customized fields established a priori within a systematic review software system. DATA SYNTHESIS Of 1,707 citations, 82 met eligibility criteria. Studies included prospective research investigations, quality improvement projects, and implementation science trials. The most common practices investigated were use of a ventilator-associated pneumonia bundle, nutritional support protocols, and the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility bundle. A variety of implementation strategies were used to facilitate evidence adoption, most commonly educational meetings, auditing and feedback, developing tools, and use of local opinion leaders. The majority of studies (76/82, 93%) reported using more than one implementation strategy. Few studies specifically used implementation science designs and frameworks to systematically evaluate both implementation and clinical outcomes. CONCLUSIONS The field of critical care has experienced slow but steady gains in the number of investigations specifically guided by implementation science. However, given the exponential growth of evidence-based practices and guidelines in this same period, much work remains to critically evaluate the most effective mechanisms to integrate and sustain these practices across diverse critical care settings and teams.
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Affiliation(s)
- Molly McNett
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Dónal O'Mathúna
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Sharon Tucker
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
- College of Nursing, The Ohio State University, Columbus, OH
| | - Haley Roberts
- Helene Fuld Health Trust National Institute for Evidence-based Practice in Nursing and Healthcare, The Ohio State University, Columbus, OH
| | - Lorraine C Mion
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
| | - Michele C Balas
- College of Nursing, The Ohio State University, Columbus, OH
- Center for Healthy Aging, Self Management, and Complex Care, The Ohio State University, Columbus, OH
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Giguère A, Zomahoun HTV, Carmichael PH, Uwizeye CB, Légaré F, Grimshaw JM, Gagnon MP, Auguste DU, Massougbodji J. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2020; 8:CD004398. [PMID: 32748975 PMCID: PMC8475791 DOI: 10.1002/14651858.cd004398.pub4] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Printed educational materials are widely used dissemination strategies to improve the quality of healthcare professionals' practice and patient health outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. This is the fourth update of the review. OBJECTIVES To assess the effect of printed educational materials (PEMs) on the practice of healthcare professionals and patient health outcomes. To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on healthcare professionals' practice and patient health outcomes. SEARCH METHODS We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and EPOC Register from their inception to 6 February 2019. We checked the reference lists of all included studies and relevant systematic reviews. SELECTION CRITERIA We included randomised trials (RTs), controlled before-after studies (CBAs) and interrupted time series studies (ITSs) that evaluated the impact of PEMs on healthcare professionals' practice or patient health outcomes. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. Any objective measure of professional practice (e.g. prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS Two reviewers undertook data extraction independently. Disagreements were resolved by discussion. For analyses, we grouped the included studies according to study design, type of outcome and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where data were available, we re-analysed the ITS studies by converting all data to a monthly basis and estimating the effect size from the change in the slope of the regression line between before and after implementation of the PEM. We reported median changes in slope for each outcome, for each study, and then across studies. We standardised all changes in slopes by their standard error, allowing comparisons and combination of different outcomes. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. We assessed the risks of bias of all the included studies. MAIN RESULTS We included 84 studies: 32 RTs, two CBAs and 50 ITS studies. Of the 32 RTs, 19 were cluster RTs that used various units of randomisation, such as practices, health centres, towns, or areas. The majority of the included studies (82/84) compared the effectiveness of PEMs to no intervention. Based on the RTs that provided moderate-certainty evidence, we found that PEMs distributed to healthcare professionals probably improve their practice, as measured with dichotomous variables, compared to no intervention (median absolute risk difference (ARD): 0.04; interquartile range (IQR): 0.01 to 0.09; 3,963 healthcare professionals randomised within 3073 units). We could not confirm this finding using the evidence gathered from continuous variables (standardised mean difference (SMD): 0.11; IQR: -0.16 to 0.52; 1631 healthcare professionals randomised within 1373 units ), from the ITS studies (standardised median change in slope = 0.69; 35 studies), or from the CBA study because the certainty of this evidence was very low. We also found, based on RTs that provided moderate-certainty evidence, that PEMs distributed to healthcare professionals probably make little or no difference to patient health as measured using dichotomous variables, compared to no intervention (ARD: 0.02; IQR: -0.005 to 0.09; 935,015 patients randomised within 959 units). The evidence gathered from continuous variables (SMD: 0.05; IQR: -0.12 to 0.09; 6,737 patients randomised within 594 units) or from ITS study results (standardised median change in slope = 1.12; 8 studies) do not strengthen these findings because the certainty of this evidence was very low. Two studies (a randomised trial and a CBA) compared a paper-based version to a computerised version of the same PEM. From the RT that provided evidence of low certainty, we found that PEM in computerised versions may make little or no difference to professionals' practice compared to PEM in printed versions (ARD: -0.02; IQR: -0.03 to 0.00; 139 healthcare professionals randomised individually). This finding was not strengthened by the CBA study that provided very low certainty evidence (SMD: 0.44; 32 healthcare professionals). The data gathered did not allow us to conclude which PEM characteristics influenced their effectiveness. The methodological quality of the included studies was variable. Half of the included RTs were at risk of selection bias. Most of the ITS studies were conducted retrospectively, without prespecifying the expected effect of the intervention, or acknowledging the presence of a secular trend. AUTHORS' CONCLUSIONS The results of this review suggest that, when used alone and compared to no intervention, PEMs may slightly improve healthcare professionals' practice outcomes and patient health outcomes. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
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Affiliation(s)
- Anik Giguère
- Department of Family Medicine and Emergency Medicine, Laval University, Québec, Canada
- VITAM Research center on Sustainable Health, Quebec, Canada
| | - Hervé Tchala Vignon Zomahoun
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Centre de recherche sur les soins et les services de première ligne - Université Laval, Quebec, Canada
| | | | - Claude Bernard Uwizeye
- Laval University Research Center on Primary Health Care and Services (CERSSPL-UL), Québec, Canada
| | - France Légaré
- Centre de recherche sur les soins et les services de première ligne de l'Université Laval (CERSSPL-UL), Université Laval, Quebec, Canada
| | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marie-Pierre Gagnon
- Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Centre, Québec City, Canada
| | - David U Auguste
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - José Massougbodji
- Health and Social Services Systems, Knowledge Translation and Implementation Component of the SPOR-SUPPORT Unit of Québec, Quebec SPOR-SUPPORT Unit, Québec, Canada
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Prognostic Analysis of Elderly Patients with Multiple Organ Dysfunction Syndrome Undergoing Invasive Mechanical Ventilation. JOURNAL OF HEALTHCARE ENGINEERING 2020; 2020:6432048. [PMID: 32257085 PMCID: PMC7106932 DOI: 10.1155/2020/6432048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Accepted: 02/17/2020] [Indexed: 12/16/2022]
Abstract
Objective To prospectively investigate early prognostic assessments of patients with Multiple Organ Dysfunction Syndrome in the Elderly (MODSE) who were receiving invasive mechanical ventilation (IMV). Methods The clinical data of 351 patients were enrolled prospectively between January 2013 and January 2018. The Acute Physiology and Chronic Health Evaluation II (APACHE II), APACHE III, Simplified Acute Physiology Score (SAPS II), and Multiple Organ Dysfunction Score (MODS) were calculated. According to the outcome of 28-day, the patients were divided into survivors and nonsurvivors. Additionally, based on whether weaning could be implemented, all patients were divided into a successful-weaning group and a failure-to-wean group. Results According to the prognosis, the areas under the receiver operating characteristic curve of the APACHE II, APACHE III, SAPS II, and MODS scoring systems were 0.837, 0.833, 0.784, and 0.860, respectively. MODS exhibited the highest sensitivity, whereas APACHE II showed the highest specificity, and successful weaning was conducive to ameliorating patients' prognosis. Multivariate logistic regression analyses revealed that underlying lung disease, plasma albumin, serum creatinine level, number of failing organs, and IMV duration were related to prognosis of weaning, with odds ratios (ORs) of 1.447, 0.820, 1.603, 2.374, and 3.105, respectively. Conclusions The APACHE II, APACHE III, SAPS II, and MODS systems could perform excellent prognostic assessment for patients with Multiple Organ Dysfunction Syndrome in the elderly. Underlying lung disease, plasma albumin, serum creatinine, number of failing organs, and IMV duration were independent prognostic factors of weaning in MODSE patients with invasive mechanical ventilation.
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Flodgren G, O'Brien MA, Parmelli E, Grimshaw JM. Local opinion leaders: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2019; 6:CD000125. [PMID: 31232458 PMCID: PMC6589938 DOI: 10.1002/14651858.cd000125.pub5] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Local opinion leaders (OLs) are individuals perceived as credible and trustworthy, who disseminate and implement best evidence, for instance through informal one-to-one teaching or community outreach education visits. The use of OLs is a promising strategy to bridge evidence-practice gaps. This is an update of a Cochrane review published in 2011. OBJECTIVES To assess the effectiveness of local opinion leaders to improve healthcare professionals' compliance with evidence-based practice and patient outcomes. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, three other databases and two trials registers on 3 July 2018, together with searching reference lists of included studies and contacting experts in the field. SELECTION CRITERIA We considered randomised studies comparing the effects of local opinion leaders, either alone or with a single or more intervention(s) to disseminate evidence-based practice, with no intervention, a single intervention, or the same single or more intervention(s). Eligible studies were those reporting objective measures of professional performance, for example, the percentage of patients being prescribed a specific drug or health outcomes, or both. We included all studies independently of the method used to identify OLs. DATA COLLECTION AND ANALYSIS We used standard Cochrane procedures in this review. The main comparison was (i) between any intervention involving OLs (OLs alone, OLs with a single or more intervention(s)) versus any comparison intervention (no intervention, a single intervention, or the same single or more intervention(s)). We also made four secondary comparisons: ii) OLs alone versus no intervention, iii) OLs alone versus a single intervention, iv) OLs, with a single or more intervention(s) versus the same single or more intervention(s), and v) OLs with a single or more intervention(s) versus no intervention. MAIN RESULTS We included 24 studies, involving more than 337 hospitals, 350 primary care practices, 3005 healthcare professionals, and 29,167 patients (not all studies reported this information). A majority of studies were from North America, and all were conducted in high-income countries. Eighteen of these studies (21 comparisons, 71 compliance outcomes) contributed to the median adjusted risk difference (RD) for the main comparison. The median duration of follow-up was 12 months (range 2 to 30 months). The results suggested that the OL interventions probably improve healthcare professionals' compliance with evidence-based practice (10.8% absolute improvement in compliance, interquartile range (IQR): 3.5% to 14.6%; moderate-certainty evidence).Results for the secondary comparisons also suggested that OLs probably improve compliance with evidence-based practice (moderate-certainty evidence): i) OLs alone versus no intervention: RD (IQR): 9.15% (-0.3% to 15%); ii) OLs alone versus a single intervention: RD (range): 13.8% (12% to 15.5%); iii) OLs, with a single or more intervention(s) versus the same single or more intervention(s): RD (IQR): 7.1% (-1.4% to 19%); iv) OLs with a single or more intervention(s) versus no intervention: RD (IQR):10.25% (0.6% to 15.75%).It is uncertain if OLs alone, or in combination with other intervention(s), may lead to improved patient outcomes (3 studies; 5 dichotomous outcomes) since the certainty of evidence was very low. For two of the secondary comparisons, the IQR included the possibility of a small negative effect of the OL intervention. Possible explanations for the occasional negative effects are, for example, the possibility that the OLs may have prioritised some outcomes, at the expense of others, or that an unaccounted outcome difference at baseline, may have given a faulty impression of a negative effect of the intervention at follow-up. No study reported on costs or cost-effectiveness.We were unable to determine the comparative effectiveness of different approaches to identifying OLs, as most studies used the sociometric method. Nor could we determine which methods used by OLs to educate their peers were most effective, as the methods were poorly described in most studies. In addition, we could not determine whether OL teams were more effective than single OLs. AUTHORS' CONCLUSIONS Local opinion leaders alone, or in combination with other interventions, can be effective in promoting evidence-based practice, but the effectiveness varies both within and between studies.The effect on patient outcomes is uncertain. The costs and the cost-effectiveness of the intervention(s) is unknown. These results are based on heterogeneous studies differing in types of intervention, setting, and outcomes. In most studies, the role and actions of the OL were not clearly described, and we cannot, therefore, comment on strategies to enhance their effectiveness. It is also not clear whether the methods used to identify OLs are important for their effectiveness, or whether the effect differs if education is delivered by single OLs or by multidisciplinary OL teams. Further research may help us to understand how these factors affect the effectiveness of OLs.
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Affiliation(s)
- Gerd Flodgren
- Norwegian Institute of Public HealthDivision of Health ServicesMarcus Thranes gate 6OsloNorway0403
| | - Mary Ann O'Brien
- University of TorontoDepartment of Family and Community Medicine500 University AvenueFifth FloorTorontoONCanadaM5G 1V7
| | - Elena Parmelli
- Lazio Regional Health Service ‐ ASL Roma1Department of EpidemiologyRomeItaly
| | - Jeremy M Grimshaw
- Ottawa Hospital Research InstituteClinical Epidemiology ProgramThe Ottawa Hospital ‐ General Campus501 Smyth Road, Box 711OttawaONCanadaK1H 8L6
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10
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Rattray M, Roberts S, Desbrow B, Marshall AP. Hospital Staffs' Perceptions of Postoperative Nutrition Among Colorectal Patients: A Qualitative Study. Nutr Clin Pract 2019; 35:306-314. [PMID: 31144380 DOI: 10.1002/ncp.10315] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND After lower gastrointestinal surgery, few patients start eating within timeframes outlined by evidence-based guidelines or meet their nutrition requirements in hospital. The present study explored hospital staffs' perceptions of factors influencing timely and adequate feeding after colorectal surgery to inform future interventions for improving postoperative nutrition practices and intakes. METHODS This qualitative exploratory study was conducted at an Australian hospital where Enhanced Recovery After Surgery guidelines had not been formally implemented. One-on-one semistructured interviews were conducted with hospital staff who provided care to patients undergoing colorectal surgery. Interviews lasted from 21 to 47 minutes and were audio recorded and transcribed verbatim. Data were analyzed using inductive thematic analysis. Emergent themes and subthemes were discussed by all investigators to ensure consensus of interpretation. RESULTS Eighteen staff participated in interviews, including 9 doctors, 5 nurses, 2 dietitians, and 2 foodservice staff. Staffs' responses formed 3 themes: (1) variability in perceived acceptability of postoperative feeding; (2) improving dynamics and communication within the treating team; and (3) optimizing dietary intakes with available resources. CONCLUSION Staff and organizational factors need to be considered when attempting to improve postoperative nutrition among patients who undergo colorectal surgery. Introducing a feeding protocol, enhancing intraprofessional and interdisciplinary communication, and ensuring the availability of appropriate, nutrient-dense foods are pivotal to improve nutrition practices and intakes.
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Affiliation(s)
- Megan Rattray
- School of Allied Health Sciences, Griffith University, Gold Coast Campus, Gold Coast, QLD, Australia
| | - Shelley Roberts
- School of Allied Health Sciences, Griffith University, Gold Coast Campus, Gold Coast, QLD, Australia.,Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia
| | - Ben Desbrow
- School of Allied Health Sciences, Griffith University, Gold Coast Campus, Gold Coast, QLD, Australia
| | - Andrea P Marshall
- Gold Coast Hospital and Health Service, Gold Coast, QLD, Australia.,Menzies Health Institute Queensland, Griffith University and Gold Coast Health, Gold Coast, Australia
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11
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Babajafari S, Hojhabrimanesh A, Sohrabi Z, Ayaz M, Noorafshan A, Akrami A. Comparing isolated soy protein with flaxseed oil vs isolated soy protein with corn oil and wheat flour with corn oil consumption on muscle catabolism, liver function, blood lipid, and sugar in burn patients: a randomized clinical trial. Trials 2018; 19:308. [PMID: 29866187 PMCID: PMC5987465 DOI: 10.1186/s13063-018-2693-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/17/2018] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND There is controversy regarding whether increasing isolated soy protein (ISP) with or without flaxseed oil (FO), as functional foods, would lead to reduce muscle catabolism and cachexia in burn patients. METHODS One hundred and eighty-eight patients were assessed for eligibility in this randomized controlled trial. Of these, seventy-three eligible patients (total burn surface area 20-50%) were randomly assigned to three groups, labeled as Control (wheat flour [WF] + corn oil [CO]), ISP + FO, and ISP + CO, to receive these nutrients for three weeks. Weight, body mass index (BMI), serum hepatic enzymes (alanine transaminase [ALT], aspartate transaminase [AST], alkaline phosphatase [ALP]), systemic inflammatory response syndrome (SIRS), 24-h urinary urea nitrogen excretion (UUN), serum creatinine, 24-h urinary creatinine (UUC) excretion, fasting blood sugar (FBS), triglyceride (TG), and cholesterol were measured. RESULTS Using analysis of covariance models in the intention-to-treat population (n = 73), we found that at three weeks, patients in the ISP groups had lost significantly less in weight and BMI compared to those in the control group (all P < 0.01). Nitrogen retention and serum creatinine (primary outcomes) increased significantly in the ISP groups compared with the control group. Even after controlling for potential covariates in ANCOVA models, changes in these indices were still statistically significant (P = 0.008 and P = 0.005 for nitrogen balance and serum creatinine, respectively). However, no such significant differences were found between the ISP groups. On the other hand, 24-h UUN, and UUC excretion, serum hepatic enzymes, FBS, TG, and cholesterol were not significant between the groups (P > 0.05). CONCLUSION ISP and FO compared to WF and CO reduced muscle catabolism and increased body weight in burn patients. TRIAL REGISTRATION Iranian Registry of Clinical Trials, IRCT2014051817740N1 . Registered on 27 June 2014.
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Affiliation(s)
- Siavash Babajafari
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Abdollah Hojhabrimanesh
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Sohrabi
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mehdi Ayaz
- Burn Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Noorafshan
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Atefeh Akrami
- Nutrition Research Center, School of Nutrition and Food Sciences, Shiraz University of Medical Sciences, Shiraz, Iran
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12
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Pellegrini JAS, Cordioli RL, Grumann ACB, Ziegelmann PK, Taniguchi LU. Point-of-care ultrasonography in Brazilian intensive care units: a national survey. Ann Intensive Care 2018; 8:50. [PMID: 29808412 PMCID: PMC5972134 DOI: 10.1186/s13613-018-0397-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Point-of-care ultrasonography (POCUS) has recently become a useful tool that intensivists are incorporating into clinical practice. However, the incorporation of ultrasonography in critical care in developing countries is not straightforward. METHODS Our objective was to investigate current practice and education regarding POCUS among Brazilian intensivists. A national survey was administered to Brazilian intensivists using an electronic questionnaire. Questions were selected by the Delphi method and assessed topics included organizational issues, POCUS technique and training patterns, machine availability, and main applications of POCUS in daily practice. RESULTS Of 1533 intensivists who received the questionnaire, 322 responded from all of Brazil's regions. Two hundred and five (63.8%) reported having access to an ultrasound machine dedicated to the intensive care unit (ICU); however, this was more likely in university hospitals than in non-university hospitals (80.6 vs. 59.6%; risk ratio [RR] = 1.35 [1.16-1.58], p = 0.002). The main applications of POCUS were ultrasound-guided central vein catheterization (49.4%) and bedside echocardiographic assessment (33.9%). Two hundred and fifty-eight (80.0%) reported having at least one POCUS-trained intensivist in their staff (trained units). Trained units were more likely to perform routine ultrasound-guided jugular vein catheterization than non-trained units (38.6 vs. 16.4%; RR = 2.35 [1.31-4.23], p = 0.001). The proportion of POCUS-trained intensivists and availability of a dedicated ultrasound machine were both independently associated with performing ultrasound-guided jugular vein catheterization (RR = 1.91 [1.32-2.77], p = 0.001) and (RR = 2.20 [1.26-3.29], p = 0.005), respectively. CONCLUSIONS A significant proportion of Brazilian ICUs had at least one intensivist with POCUS capability in their staff. Although ultrasound-guided central vein catheterization constitutes the main application of POCUS, adherence to guideline recommendations is still suboptimal.
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Affiliation(s)
- José Augusto Santos Pellegrini
- Department of Critical Care Medicine, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Ricardo Luiz Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. .,Department of Critical Care Medicine, Alemão Oswaldo Cruz Hospital, São Paulo, Brazil. .,Department of Intensive Care Unit, Hospital Israelita Albert Einstein, 627, Albert Einstein St., São Paulo, 05652-900, Brazil.
| | | | - Patrícia Klarmann Ziegelmann
- Statistics Department and Post-Graduation Program in Epidemiology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Leandro Utino Taniguchi
- Department of Critical Care Medicine, Hospital das Clínicas de São Paulo, FMUSP, São Paulo, Brazil
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13
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Jordan P, Mpasa F, Ten Ham-Baloyi W, Bowers C. Implementation strategies for guidelines at ICUs: a systematic review. Int J Health Care Qual Assur 2018; 30:358-372. [PMID: 28470131 DOI: 10.1108/ijhcqa-08-2016-0119] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The purpose of this paper is to critically analyze empirical studies related to the implementation strategies for clinical practice guidelines (CPGs) in intensive care units (ICUs). Design/methodology/approach A systematic review with a narrative synthesis adapted from Popay et al.'s method for a narrative synthesis was conducted. A search using CINAHL, Google Scholar, Academic search complete, Cochrane Register for Randomized Controlled Trials, MEDLINE via PUBMED and grey literature was conducted in 2014 and updated in 2016 (August). After reading the abstracts, titles and full-text articles, 11 ( n=11) research studies met the inclusion criteria. Findings After critical appraisal, using the Joanna Briggs Critical Appraisal Tools, eight randomized controlled trials conducted in adult and neonatal ICUs using implementation strategies remained. Popay et al.'s method for narrative synthesis was adapted and used to analyze and synthesize the data and formulate concluding statements. Included studies found that multi-faceted strategies appear to be more effective than single strategies. Strategies mostly used were printed educational materials, information/ sessions, audit, feedback, use of champion leaders, educational outreach visits, and computer or internet usage. Practical training, monitoring visits and grand rounds were less used. Practical implications Findings can be used by clinicians to implement the best combination of multi-faceted implementation strategies in the ICUs in order to enhance the optimal use of CPGs. Originality/value No systematic review was previously done on the implementation strategies that should be used best for optimal CPG implementation in the ICU.
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Affiliation(s)
- Portia Jordan
- Department of Nursing Science, Nelson Mandela Metropolitan University , Port Elizabeth, South Africa
| | - Ferestas Mpasa
- Department of Nursing Science, Nelson Mandela Metropolitan University , Port Elizabeth, South Africa
| | - Wilma Ten Ham-Baloyi
- Faculty of Health Sciences, Nelson Mandela Metropolitan University , Port Elizabeth, South Africa
| | - Candice Bowers
- Department of Nursing Science, Nelson Mandela Metropolitan University , Port Elizabeth, South Africa
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Vest MT, Kolm P, Bowen J, Trabulsi J, Lennon SL, Shapero M, McGraw P, Halbert J, Jurkovitz C. Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit. Am J Crit Care 2018; 27:136-143. [PMID: 29496770 DOI: 10.4037/ajcc2018598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting. OBJECTIVES To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship. METHODS A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index. RESULTS Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission. CONCLUSION The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.
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Affiliation(s)
- Michael T Vest
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute.
| | - Paul Kolm
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - James Bowen
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - Jillian Trabulsi
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - Shannon L Lennon
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - Mary Shapero
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - Patty McGraw
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - James Halbert
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
| | - Claudine Jurkovitz
- Michael T. Vest is an attending physician in the Pulmonary and Critical Care Section of the Department of Internal Medicine, a Value Institute Scholar at Christiana Care Value Institute, Newark, Delaware; and an assistant professor of medicine at the Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. Paul Kolm is director of biostatistics and James Bowen was a senior system engineer at Christiana Care Value Institute. Jillian Trabulsi is an associate professor, Department of Behavioral Health and Nutrition, and Shannon L. Lennon is an associate professor, Department of Kinesiology and Applied Physiology, University of Delaware, Newark, Delaware. Mary Shapero is a clinical nutrition manager in the Department of Nutrition, Patty McGraw is a research nurse supervisor in the Department of Internal Medicine Research, and James Halpert is the physical therapy program manager in the Department of Physical Therapy, Christiana Care Healthcare System, Newark, Delaware. Claudine Jurkovitz is a senior physician scientist at Christiana Care Value Institute
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15
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Babajafari S, Akhlaghi M, Mazloomi SM, Ayaz M, Noorafshan A, Jafari P, Hojhabrimanesh A. The effect of isolated soy protein adjunctive with flaxseed oil on markers of inflammation, oxidative stress, acute phase proteins, and wound healing of burn patients; a randomized clinical trial. Burns 2018; 44:140-149. [DOI: 10.1016/j.burns.2017.05.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 05/12/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
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Marshall AP, Lemieux M, Dhaliwal R, Seyler H, MacEachern KN, Heyland DK. Novel, Family-Centered Intervention to Improve Nutrition in Patients Recovering From Critical Illness: A Feasibility Study. Nutr Clin Pract 2017; 32:392-399. [PMID: 28537514 DOI: 10.1177/0884533617695241] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Critically ill patients are at increased risk of developing malnutrition-related complications because of physiological changes, suboptimal delivery, and reduced intake. Strategies to improve nutrition during critical illness recovery are required to prevent iatrogenic underfeeding and risk of malnutrition. The purpose of this study was to assess the feasibility and acceptability of a novel family-centered intervention to improve nutrition in critically ill patients. MATERIALS AND METHODS A 3-phase, prospective cohort feasibility study was conducted in 4 intensive care units (ICUs) across 2 countries. Intervention feasibility was determined by patient eligibility, recruitment, and retention rates. The acceptability of the intervention was assessed by participant perspectives collected through surveys. Participants included family members of the critically ill patients and ICU and ward healthcare professionals (HCPs). RESULTS A total of 75 patients and family members, as well as 56 HCPs, were enrolled. The consent rate was 66.4%, and 63 of 75 (84%) of family participants completed the study. Most family members (53/55; 98.1%) would recommend the nutrition education program to others and reported improved ability to ask questions about nutrition (16/20; 80.0%). Family members viewed nutrition care more positively in the ICU. HCPs agreed that families should partner with HCPs to achieve optimal nutrition in the ICU and the wards. Health literacy was identified as a potential barrier to family participation. CONCLUSION The intervention was feasible and acceptable to families of critically ill patients and HCPs. Further research to evaluate intervention impact on nutrition intake and patient-centered outcomes is required.
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Affiliation(s)
- Andrea P Marshall
- 1 National Health and Medical Research Council Centre for Research Excellence in Nursing Interventions for Hospitalised Patients, School of Nursing and Midwifery, Menzies Health Institute, Griffith University and Gold Coast Health, Southport, Queensland, Australia
| | - Margot Lemieux
- 2 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Rupinder Dhaliwal
- 2 Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.,3 Metabolic Syndrome Canada, Kingston, Ontario, Canada
| | - Hilda Seyler
- 4 Clinical Nutrition and Food Services, Halton Healthcare, Oakville Trafalgar Memorial Hospital, Oakville, Ontario, Canada
| | - Kristen N MacEachern
- 5 Clinical Nutrition and Critical Care, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Daren K Heyland
- 6 Department of Critical Care Medicine, Queen's University and Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
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17
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Jones K, Maxwell PJ, McClave S, Allen K. Optimizing Enteral Nutrition in Medical Intensive Care Patients. CURRENT PULMONOLOGY REPORTS 2017. [DOI: 10.1007/s13665-017-0169-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Jones NE, Suurdt J, Ouelette-Kuntz H, Heyland DK. Implementation of the Canadian Clinical Practice Guidelines for Nutrition Support: A Multiple Case Study of Barriers and Enablers. Nutr Clin Pract 2017; 22:449-57. [PMID: 17644700 DOI: 10.1177/0115426507022004449] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The Canadian Nutrition Support Clinical Practice Guidelines (CPGs), published in 2003, were designed to improve nutrition support practices in intensive care units (ICUs). However, their impact to date has been modest. This study aimed to identify important barriers and enablers to implementation of these guidelines. METHODS Case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each site. During the interviews, the key informants were asked about their perceptions of the barriers and enablers to implementation of the Canadian Nutrition Support CPGs. Interview transcripts were analyzed qualitatively, using a framework approach. RESULTS Resistance to change, lack of awareness, lack of critical care experience, clinical condition of the patient, resource constraints, a slow administrative process, workload, numerous guidelines, complex recommendations, paucity of evidence, and outdated guidelines were cited as the main barriers to guideline implementation. Agreement of the ICU team, easy access to the guidelines, ease of application, incorporation into daily routine, education and training, the dietitian as an opinion leader, and open discussion were identified as the primary enabling factors. Although consistent across all sites, the influence of these factors seemed to differ by site and profession. CONCLUSIONS Our findings suggest that implementation of the Canadian Nutrition Support CPGs is profoundly complex and is determined by practitioner, patient, institutional, and guideline factors. Further research is required to quantify the impact of each barrier and enabler and the mechanism by which they influence guideline adherence.
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Affiliation(s)
- Naomi E Jones
- Department of Community Health and Epidemiology, Queen's University, 76 Stuart Street, Kingston, ON, Canada, K7L 2V7
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Affiliation(s)
- David A. August
- Department of Surgery, Division of Surgical Oncology, UMDNJ/Robert Wood Johnson Medical School; and The Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Denise Serrano
- Department of Surgery, Division of Surgical Oncology, UMDNJ/Robert Wood Johnson Medical School; and The Cancer Institute of New Jersey, New Brunswick, New Jersey
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Safdar N, Musuuza JS, Xie A, Hundt AS, Hall M, Wood K, Carayon P. Management of ventilator-associated pneumonia in intensive care units: a mixed methods study assessing barriers and facilitators to guideline adherence. BMC Infect Dis 2016; 16:349. [PMID: 27448800 PMCID: PMC4957386 DOI: 10.1186/s12879-016-1665-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 06/24/2016] [Indexed: 01/28/2023] Open
Abstract
Background Guidelines from the Infectious Diseases Society of America/The American Thoracic Society (IDSA/ATS) provide recommendations for diagnosis and treatment of ventilator-associated pneumonia (VAP). However, the mere presence of guidelines is rarely sufficient to promote widespread adoption and uptake. Using the Systems Engineering Initiative for Patient Safety (SEIPS) model framework, we undertook a study to understand barriers and facilitators to the adoption of the IDSA/ATS guidelines. Methods We conducted surveys and focus group discussions of different health care providers involved in the management of VAP. The setting was medical-surgical ICUs at a tertiary academic hospital and a large multispecialty rural hospital in Wisconsin, USA. Results Overall, we found that 55 % of participants indicated that they were aware of the IDSA/ATS guideline. The top ranked barriers to VAP management included: 1) having multiple physician groups managing VAP, 2) variation in VAP management by differing ICU services, 3) physicians and level of training, and 4) renal failure complicating doses of antibiotics. Facilitators to VAP management included presence of multidisciplinary rounds that include nurses, pharmacist and respiratory therapists, and awareness of the IDSA/ATS guideline. This awareness was associated with receiving effective training on management of VAP, keeping up to date on nosocomial infection literature, and belief that performing a bronchoscopy to diagnose VAP would help with expeditious diagnosis of VAP. Conclusions Findings from our study complement existing studies by identifying perceptions of the many different types of healthcare workers in ICU settings. These findings have implications for antibiotic stewardship teams, clinicians, and organizational leaders.
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Affiliation(s)
- Nasia Safdar
- William S. Middleton Memorial Veterans Hospital, Madison, WI, USA. .,Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA. .,Department of Infectious Disease, University of Wisconsin Hospital and Clinics, Madison, WI, USA.
| | - Jackson S Musuuza
- Institute for Clinical and Translational Research, University of Wisconsin, Madison, WI, USA
| | - Anping Xie
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ann Schoofs Hundt
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA
| | - Matthew Hall
- Department of Infectious Medicine, Marshfield Clinic, Marshfield, WI, USA
| | - Kenneth Wood
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Pascale Carayon
- Center for Quality and Productivity Improvement, University of Wisconsin-Madison, Madison, WI, USA
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Marshall AP, Wake E, Weisbrodt L, Dhaliwal R, Spencer A, Heyland DK. A multi-faceted, family-centred nutrition intervention to optimise nutrition intake of critically ill patients: The OPTICS feasibility study. Aust Crit Care 2015; 29:68-76. [PMID: 26603213 DOI: 10.1016/j.aucc.2015.10.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 10/21/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Critically ill patients are at risk of developing malnutrition which contributes to functional decline and hospital re-admission. Strategies to promote nutritional intake have had a modest effect on protein-calorie intake. None have addressed the recovery trajectory of critical illness or incorporated family as advocates. OBJECTIVES We evaluated the feasibility and acceptability of a family-centred intervention designed to optimise nutrition during and following recovery from critical illness. DESIGN A prospective cohort study. SETTING Two Australian adult intensive care units. PARTICIPANTS A convenience sample of 49 patients and their families was recruited. Patients ≥18 years of age anticipated to require mechanical ventilation for at least 2 days were eligible, provided their family visited regularly and were able to communicate in English. Health care professionals including doctors (n=4), nurses (n=20) and dietitians (n=2) also participated. METHODS Demographic data were obtained from participants. Recruitment and retention informed study feasibility. Individual and group interviews informed participant views on the acceptability, perception of and experience with the intervention. Inductive analysis was used to analyse qualitative data. RESULTS 187 (15.8%) patients met the eligibility criteria; 49 patients and 51 family members consented to participate for a 20.3% consent failure rate. We interviewed 33 (67.3%) family members and 13 (43.4%) patients, all of whom considered the intervention acceptable and who would participate in a similar intervention again, given the opportunity. Inductive analysis of qualitative data from all participants identified three themes: variability in in-hospital nutrition support, families as advocates for optimal nutrition, and partnering with health care providers. CONCLUSION We described a feasible and acceptable family centred intervention that may be effective in promoting nutrition intake in critically ill patients. Further research is required to examine contextual factors impacting implementation of family-centred interventions, particularly those that involve active family participation and advocacy.
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Affiliation(s)
- Andrea P Marshall
- NHMRC Centre for Research Excellence in Nursing, Menzies Health Institute Queensland, Griffith University and Gold Coast Health, Australia; Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Elizabeth Wake
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | | | | | - Alan Spencer
- Gold Coast Health, 1 Hospital Dr., Southport, QLD 4215, Australia.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, 76 Stuart Street, Suite 5-416, Kingston, Ontario, Canada K7L 2V7; Queen's University, 99 University Avenue, Kingston, Ontario, Canada K7L 3N6.
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Garcia NM, McClave SA, Bozeman MC, Miller KR, Harbrecht BG, Franklin GA. Emerging Concepts in Critical Care Nutrition and the Provision of Enteral Nutrition Support. CURRENT SURGERY REPORTS 2015. [DOI: 10.1007/s40137-015-0117-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Francis DK, Smith J, Saljuqi T, Watling RM. Oral protein calorie supplementation for children with chronic disease. Cochrane Database Syst Rev 2015; 2015:CD001914. [PMID: 26014160 PMCID: PMC4460719 DOI: 10.1002/14651858.cd001914.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Poor growth and nutritional status are common in children with chronic diseases. Oral protein calorie supplements are used to improve nutritional status in these children. These expensive products may be associated with some adverse effects, e.g. the development of inappropriate eating behaviour patterns. This is a new update of a Cochrane review last updated in 2009. OBJECTIVES To examine evidence that in children with chronic disease, oral protein calorie supplements alter daily nutrient intake, nutritional indices, survival and quality of life and are associated with adverse effects, e.g. diarrhoea, vomiting, reduced appetite, glucose intolerance, bloating and eating behaviour problems. SEARCH METHODS Trials of oral protein calorie supplements in children with chronic diseases were identified through comprehensive electronic database searches, handsearching relevant journals and abstract books of conference proceedings. Companies marketing these products were also contacted.Most recent search of the Group's Trials Register: 24 February 2015. SELECTION CRITERIA Randomised or quasi-randomised controlled trials comparing oral protein calorie supplements for at least one month to increase calorie intake with existing conventional therapy (including advice on improving nutritional intake from food or no specific intervention) in children with chronic disease. DATA COLLECTION AND ANALYSIS We independently assessed the outcomes: indices of nutrition and growth; anthropometric measures of body composition; calorie and nutrient intake (total from oral protein calorie supplements and food); eating behaviour; compliance; quality of life; specific adverse effects; disease severity scores; and mortality; we also assessed the risk of bias in the included trials. MAIN RESULTS Four studies (187 children) met the inclusion criteria. Three studies were carried out in children with cystic fibrosis and one study included children with paediatric malignant disease. Overall there was a low risk of bias for blinding and incomplete outcome data.Two studies had a high risk of bias for allocation concealment. Few statistical differences were found in the outcomes we assessed between treatment and control groups, except change in total energy intake at six and 12 months, mean difference 304.86 kcal per day (95% confidence interval 5.62 to 604.10) and mean difference 265.70 kcal per day (95% confidence interval 42.94 to 485.46), respectively. However, these were based on the analysis of just 58 children in only one study. Only two chronic diseases were included in these analyses, cystic fibrosis and paediatric malignant disease. No other studies were identified which assessed the effectiveness of oral protein calorie supplements in children with other chronic diseases. AUTHORS' CONCLUSIONS Oral protein calorie supplements are widely used to improve the nutritional status of children with a number of chronic diseases. We identified a small number of studies assessing these products in children with cystic fibrosis and paediatric malignant disease, but were unable to draw any conclusions based on the limited data extracted. We recommend a series of large, randomised controlled trials be undertaken investigating the use of these products in children with different chronic diseases. Until further data are available, we suggest these products are used with caution.
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Affiliation(s)
- Damian K Francis
- Caribbean Institute for Health Research, The University of the West Indies, MonaEpidemiology Research UnitKingstonJamaica
| | | | | | - Ruth M Watling
- Alder Hey Children's NHS Foundation TrustDepartment of Nutrition and DieteticsEaton RoadLiverpoolMerseysideUKL12 2AP
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Sinuff T, Muscedere J, Rozmovits L, Dale CM, Scales DC. A qualitative study of the variable effects of audit and feedback in the ICU. BMJ Qual Saf 2015; 24:393-9. [PMID: 25918432 DOI: 10.1136/bmjqs-2015-003978] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 04/08/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Audit and feedback is integral to performance improvement and behaviour change in the intensive care unit (ICU). However, there remain large gaps in our understanding of the social experience of audit and feedback and the mechanisms whereby it can be optimised as a quality improvement strategy in the ICU setting. METHODS We conducted a modified grounded theory qualitative study. Seventy-two clinicians from five academic and five community ICUs in Ontario, Canada, were interviewed. Team members reviewed interview transcripts independently. Data analysis used constant comparative methods. RESULTS Clinicians interviewed experienced audit and feedback as fragmented and variable in its effectiveness. Moreover, clinicians felt disconnected from the process. The audit process was perceived as being insufficiently transparent. Feedback was often untimely, incomplete and not actionable. Specific groups such as respiratory therapists and night-shift clinicians felt marginalised. Suggestions for improvement included improving information sharing about the rationale for change and the audit process, tools and metrics; implementing peer-to-peer quality discussions to avoid a top-down approach (eg, incorporating feedback into discussions at daily rounds); providing effective feedback which contains specific, transparent and actionable information; delivering timely feedback (ie, balancing feedback proximate to events with trends over time) and increasing engagement by senior management. CONCLUSIONS ICU clinicians experience audit and feedback as fragmented communication with feedback being especially problematic. Attention to improving communication, integration of the process into daily clinical activities and making feedback timely, specific and actionable may increase the effectiveness of audit and feedback to affect desired change.
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Affiliation(s)
- Tasnim Sinuff
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Muscedere
- Department of Medicine and Critical Care Program, Queens University, Kingston General Hospital, Kingston, Ontario, Canada
| | - Linda Rozmovits
- Independent Qualitative Researcher, Toronto, Ontario, Canada
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
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Cahill NE, Murch L, Cook D, Heyland DK. Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R96. [PMID: 24887445 PMCID: PMC4229943 DOI: 10.1186/cc13867] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 04/30/2014] [Indexed: 11/23/2022]
Abstract
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.
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Mandell SP, Gibran NS. Early Enteral Nutrition for Burn Injury. Adv Wound Care (New Rochelle) 2014; 3:64-70. [PMID: 24761346 DOI: 10.1089/wound.2012.0382] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 12/12/2012] [Indexed: 11/13/2022] Open
Abstract
Significance: Nutrition has been recognized as a critical component of acute burn care and ultimate wound healing. Debate remains over the appropriate timing of enteral nutrition and the benefit of supplemental trace elements, antioxidants, and immunonutrition for critically ill burn patients. Pharmacotherapy to blunt the metabolic response to burn injury plays a critical role in effective nutritional support. Recent Advances: Further evidence is demonstrating long-term benefits from pharmacologic immunomodulation given the prolonged metabolic response to injury that may last for over a year following the initial insult. Critical Issues: The majority of evidence regarding early enteral feeding comes from mixed populations and smaller studies. However, on balance, available evidence favors early feeding. Data regarding immunonutrition does not support the routine use of these products. Limited data regarding use of antioxidants and trace elements support their use. Future Directions: Further evaluation of anti-inflammatory mediators of the immune response, such as statins, will likely play a role in the future. Further data are needed on the dosing and route of micronutrients as well as the utility of immunonutrition. Finally, little is known about nutrition in the obese burn patient making this an important area for investigation.
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Affiliation(s)
- Samuel P. Mandell
- Department of Surgery, University of Washington Burn Center, Harborview Medical Center, Seattle, Washington
| | - Nicole S. Gibran
- Department of Surgery, University of Washington Burn Center, Harborview Medical Center, Seattle, Washington
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Abstract
OBJECTIVE We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care. DATA SOURCES We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews. STUDY SELECTION Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies. DATA EXTRACTION Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care. DATA SYNTHESIS From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes. CONCLUSIONS Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.
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Cahill NE, Murch L, Cook D, Heyland DK. Improving the Provision of Enteral Nutrition in the Intensive Care Unit. Nutr Clin Pract 2013; 29:110-7. [DOI: 10.1177/0884533613516512] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Naomi E. Cahill
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Lauren Murch
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
| | - Deborah Cook
- Department of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, Ontario, Canada
| | - Daren K. Heyland
- Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada
- Department of Medicine, Queen’s University, Kingston, Ontario, Canada
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Cahill NE, Day AG, Cook D, Heyland DK. Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients. Implement Sci 2013; 8:140. [PMID: 24305039 PMCID: PMC4235036 DOI: 10.1186/1748-5908-8-140] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 11/26/2013] [Indexed: 12/20/2022] Open
Abstract
Background To successfully implement the recommendations of critical care nutrition guidelines, one potential approach is to identify barriers to providing optimal enteral nutrition (EN) in the intensive care unit (ICU), and then address these barriers systematically. Therefore, the purpose of this study was to develop a questionnaire to assess barriers to enterally feeding critically ill patients and to conduct preliminary validity testing of the new instrument. Methods The content of the questionnaire was guided by a published conceptual framework, literature review, and consultation with experts. The questionnaire was pre-tested on a convenience sample of 32 critical care practitioners, and then field tested with 186 critical care providers working at 5 hospitals in North America. The revised questionnaire was pilot tested at another ICU (n = 43). Finally, the questionnaire was distributed to a random sample of ICU nurses twice, two weeks apart, to determine test retest reliability (n = 17). Descriptive statistics, exploratory factor analysis, Cronbach alpha, intraclass correlations (ICC), and kappa coefficients were conducted to assess validity and reliability. Results We developed a questionnaire with 26 potential barriers to delivery of EN asking respondents to rate their importance as barriers in their ICU. Face and content validity of the questionnaire was established through literature review and expert input. The factor analysis indicated a five-factor solution and accounted for 72% of the variance in barriers: guideline recommendations and implementation strategies, delivery of EN to the patient, critical care provider attitudes and behavior, dietitian support, and ICU resources. Overall, the indices of internal reliability for the derived factor subscales and the overall instrument were acceptable (subscale Cronbach alphas range 0.84 – 0.89). However, the test retest reliability was variable and below acceptable thresholds for the majority of items (ICC’s range −0.13 to 0.70). The within group agreement, an indices reflecting the reliability of aggregating individual responses to the ICU level was also variable (ICC’s range 0.0 to 0.82). Conclusions We developed a questionnaire to identify barriers to enteral feeding in critically ill patients. Additional studies are planned to further revise and evaluate the reliability and validity of the instrument.
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Affiliation(s)
- Naomi E Cahill
- Department of Public Health Sciences, Queen's University, Carruthers Hall, Kingston, Ontario, Canada.
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Kiss CM, Byham-Gray L, Denmark R, Loetscher R, Brody RA. The impact of implementation of a nutrition support algorithm on nutrition care outcomes in an intensive care unit. Nutr Clin Pract 2013; 27:793-801. [PMID: 23135707 DOI: 10.1177/0884533612457178] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A nutrition support algorithm is an operational version of a guideline that is adapted to local requirements and easy to apply in clinical practice. The purpose of this study was to determine the impact of implementing a nutrition support algorithm on nutrition care outcomes in an intensive care unit (ICU) in Switzerland without a designated dietitian. METHODS The retrospective study included data collection on 2 cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of a nutrition support algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines. RESULTS There were significant differences between groups for the mean delivery of total energy in the pre- vs postimplementation group (909 ± 444 vs 1097 ± 420 kcal/d; P = .023) and mean delivery of protein per day (35 ± 17.9 vs 59.1 ± 27.3 g; P < .001). For patients staying at least 7 days in the ICU, the cumulative energy deficit decreased from -5664 ± 3613 kcal in the preimplementation group to -2972 ± 2420 kcal (P = .011) in the postimplementation group. No significant differences in the route of feeding and timing of enteral nutrition initiation were found. CONCLUSIONS Implementation of a nutrition support algorithm resulted in improved provision of energy and protein delivery. This may be further improved with routine nutrition assessment by a dietitian or a designated nutrition support team.
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Affiliation(s)
- Caroline M Kiss
- University Hospital Basel, Ernährungsberatung, Basel, 4031, Switzerland.
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Williams TA, Leslie GD, Leen T, Mills L, Dobb GJ. Reducing interruptions to continuous enteral nutrition in the intensive care unit: a comparative study. J Clin Nurs 2013; 22:2838-48. [DOI: 10.1111/jocn.12068] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2012] [Indexed: 12/26/2022]
Affiliation(s)
- Teresa A Williams
- Discipline of Emergency Medicine (M516); School of Primary; Aboriginal and Rural Health Care (SPARHC); The University of Western Australia and Research Fellow; ICU Royal Perth Hospital; Perth WA Australia
| | - Gavin D Leslie
- School of Nursing & Midwifery; Curtin Health Innovation Research Institute; Faculty Health Science; Curtin University; Perth WA Australia
| | - Tim Leen
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Lauren Mills
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
| | - Geoff J Dobb
- Intensive Care Unit; Royal Perth Hospital; Perth WA Australia
- School of Medicine and Pharmacology ; The University of Western Australia; Perth WA Australia
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Castro MG, Pompilio CE, Horie LM, Verotti CCG, Waitzberg DL. Education program on medical nutrition and length of stay of critically ill patients. Clin Nutr 2012; 32:1061-6. [PMID: 23260748 DOI: 10.1016/j.clnu.2012.11.023] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 11/21/2012] [Accepted: 11/21/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND & AIMS To evaluate the impact of a multifaceted nutritional educational intervention on the quality of nutritional therapy and clinical outcomes in critically ill patients. METHODS We conducted a prospective, non-blinded study with a non-contemporaneous control group at a 16-bed intensive care unit (ICU) at the Hospital das Clinicas, Department of Gastroenterology, University of Sao Paulo Medical School in Sao Paulo, Brazil. There were three phases. Phase 1: the quality of NT was evaluated in 50 newly admitted intensive care unit patients in a pre-educational program (Pre-EP). Phase 2: nutritional protocols were created and an education program was implemented. Phase 3: another 50 patients were enrolled and observed in a post-educational program (Post-EP) using phase 1 methodology. Nutritional Therapy practice was evaluated through nutritional assessments, adequacy of energy requirements, duration of fasting, and use of early enteral nutrition. Intensive care unit length of stay and hospital length of stay were measured as primary end-points. RESULTS The pre-educational program and post-educational program groups did not differ in age, APACHE II score, gender, or nutritional assessment. The mean ± SD duration of fasting decreased (Pre-EP 3.8 ± 3.1 days vs. Post-EP: 2.2 ± 2.6 days; p = 0.002), the adequacy of nutritional therapy improved (Pre-EP 74.2% ± 33.3% vs. Post-EP 96.2% ± 23.8%; p < 0.001), and enteral nutrition was initiated earlier than 48 h more commonly (Pre-EP 24% vs. Post-E 60%; p = 0.001). Median intensive care unit length of stay decreased (Pre-EP: 18.5 days vs. Post-EP: 9.5 days; p < 0.001) although hospital length of stay did not. CONCLUSION Implementing a multifaceted nutritional educational intervention could improve the quality of nutritional therapy and may decrease intensive care unit length of stay in critically ill patients.
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Affiliation(s)
- Melina Gouveia Castro
- Department of Gastroenterology, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil.
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Barriers to feeding critically ill patients: A multicenter survey of critical care nurses. J Crit Care 2012; 27:727-34. [DOI: 10.1016/j.jcrc.2012.07.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2012] [Revised: 07/03/2012] [Accepted: 07/04/2012] [Indexed: 11/17/2022]
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Giguère A, Légaré F, Grimshaw J, Turcotte S, Fiander M, Grudniewicz A, Makosso-Kallyth S, Wolf FM, Farmer AP, Gagnon MP. Printed educational materials: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 10:CD004398. [PMID: 23076904 PMCID: PMC7197046 DOI: 10.1002/14651858.cd004398.pub3] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Printed educational materials are widely used passive dissemination strategies to improve the quality of clinical practice and patient outcomes. Traditionally they are presented in paper formats such as monographs, publication in peer-reviewed journals and clinical guidelines. OBJECTIVES To assess the effect of printed educational materials on the practice of healthcare professionals and patient health outcomes.To explore the influence of some of the characteristics of the printed educational materials (e.g. source, content, format) on their effect on professional practice and patient outcomes. SEARCH METHODS For this update, search strategies were rewritten and substantially changed from those published in the original review in order to refocus the search from published material to printed material and to expand terminology describing printed materials. Given the significant changes, all databases were searched from start date to June 2011. We searched: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), HealthStar, CINAHL, ERIC, CAB Abstracts, Global Health, and the EPOC Register. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-randomised trials, controlled before and after studies (CBAs) and interrupted time series (ITS) analyses that evaluated the impact of printed educational materials (PEMs) on healthcare professionals' practice or patient outcomes, or both. We included three types of comparisons: (1) PEM versus no intervention, (2) PEM versus single intervention, (3) multifaceted intervention where PEM is included versus multifaceted intervention without PEM. There was no language restriction. Any objective measure of professional practice (e.g. number of tests ordered, prescriptions for a particular drug), or patient health outcomes (e.g. blood pressure) were included. DATA COLLECTION AND ANALYSIS Two review authors undertook data extraction independently, and any disagreement was resolved by discussion among the review authors. For analyses, the included studies were grouped according to study design, type of outcome (professional practice or patient outcome, continuous or dichotomous) and type of comparison. For controlled trials, we reported the median effect size for each outcome within each study, the median effect size across outcomes for each study and the median of these effect sizes across studies. Where the data were available, we re-analysed the ITS studies and reported median differences in slope and in level for each outcome, across outcomes for each study, and then across studies. We categorised each PEM according to potential effects modifiers related to the source of the PEMs, the channel used for their delivery, their content, and their format. MAIN RESULTS The review includes 45 studies: 14 RCTs and 31 ITS studies. Almost all the included studies (44/45) compared the effectiveness of PEM to no intervention. One single study compared paper-based PEM to the same document delivered on CD-ROM. Based on seven RCTs and 54 outcomes, the median absolute risk difference in categorical practice outcomes was 0.02 when PEMs were compared to no intervention (range from 0 to +0.11). Based on three RCTs and eight outcomes, the median improvement in standardised mean difference for continuous profession practice outcomes was 0.13 when PEMs were compared to no intervention (range from -0.16 to +0.36). Only two RCTs and two ITS studies reported patient outcomes. In addition, we re-analysed 54 outcomes from 25 ITS studies, using time series regression and observed statistically significant improvement in level or in slope in 27 outcomes. From the ITS studies, we calculated improvements in professional practice outcomes across studies after PEM dissemination (standardised median change in level = 1.69). From the data gathered, we could not comment on which PEM characteristic influenced their effectiveness. AUTHORS' CONCLUSIONS The results of this review suggest that when used alone and compared to no intervention, PEMs may have a small beneficial effect on professional practice outcomes. There is insufficient information to reliably estimate the effect of PEMs on patient outcomes, and clinical significance of the observed effect sizes is not known. The effectiveness of PEMs compared to other interventions, or of PEMs as part of a multifaceted intervention, is uncertain.
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Affiliation(s)
- Anik Giguère
- Health Information Research Unit (HIRU), Department of Clinical Epidemiology, McMaster University, Hamilton, Canada.
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Massanet P, Morquin D, Richard C, Jonquet O, Corne P. Stratégie d’optimisation multimodale et pluridisciplinaire de la nutrition en réanimation. MEDECINE INTENSIVE REANIMATION 2012. [DOI: 10.1007/s13546-012-0492-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Abstract
BACKGROUND Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial. QUESTIONS/PURPOSES The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries. METHODS We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size. RESULTS Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results. CONCLUSION Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.
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Affiliation(s)
| | - James G. Wright
- Division of Orthopaedic Surgery, Child Health Evaluative Sciences, Toronto, ON
Canada
- The Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON M5G 1X8 Canada
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Flodgren G, Parmelli E, Doumit G, Gattellari M, O’Brien MA, Grimshaw J, Eccles MP. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2011:CD000125. [PMID: 21833939 PMCID: PMC4172331 DOI: 10.1002/14651858.cd000125.pub4] [Citation(s) in RCA: 294] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Clinical practice is not always evidence-based and, therefore, may not optimise patient outcomes. Opinion leaders disseminating and implementing 'best evidence' is one method that holds promise as a strategy to bridge evidence-practice gaps. OBJECTIVES To assess the effectiveness of the use of local opinion leaders in improving professional practice and patient outcomes. SEARCH STRATEGY We searched Cochrane EPOC Group Trials Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, HMIC, Science Citation Index, Social Science Citation Index, ISI Conference Proceedings and World Cat Dissertations up to 5 May 2009. In addition, we searched reference lists of included articles. SELECTION CRITERIA Studies eligible for inclusion were randomised controlled trials investigating the effectiveness of using opinion leaders to disseminate evidence-based practice and reporting objective measures of professional performance and/or health outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from each study and assessed its risk of bias. For each trial, we calculated the median risk difference (RD) for compliance with desired practice, adjusting for baseline where data were available. We reported the median adjusted RD for each of the main comparisons. MAIN RESULTS We included 18 studies involving more than 296 hospitals and 318 PCPs. Fifteen studies (18 comparisons) contributed to the calculations of the median adjusted RD for the main comparisons. The effects of interventions varied across the 63 outcomes from 15% decrease in compliance to 72% increase in compliance with desired practice. The median adjusted RD for the main comparisons were: i) Opinion leaders compared to no intervention, +0.09; ii) Opinion leaders alone compared to a single intervention, +0.14; iii) Opinion leaders with one or more additional intervention(s) compared to the one or more additional intervention(s), +0.10; iv) Opinion leaders as part of multiple interventions compared to no intervention, +0.10. Overall, across all 18 studies the median adjusted RD was +0.12 representing a 12% absolute increase in compliance in the intervention group. AUTHORS' CONCLUSIONS Opinion leaders alone or in combination with other interventions may successfully promote evidence-based practice, but effectiveness varies both within and between studies. These results are based on heterogeneous studies differing in terms of type of intervention, setting, and outcomes measured. In most of the studies the role of the opinion leader was not clearly described, and it is therefore not possible to say what the best way is to optimise the effectiveness of opinion leaders.
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Affiliation(s)
- Gerd Flodgren
- Department of Public Health, University of Oxford, Headington, UK
| | - Elena Parmelli
- Department of Oncology, Hematology and Respiratory Diseases, University of Modena and Reggio Emilia, Modena, Italy
| | - Gaby Doumit
- Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Melina Gattellari
- School of Public Health and Community Medicine, The University of New South Wales, Sydney, Australia
| | - Mary Ann O’Brien
- School of Rehabilitation Science, Institute for Applied Health Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Canada
| | - Martin P Eccles
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study. J Burn Care Res 2011; 32:104-9. [PMID: 21116188 DOI: 10.1097/bcr.0b013e318204b3be] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Early nutritional support is an essential component of burn care to prevent ileus, stress ulceration, and the effects of hypermetabolism. The American Burn Association practice guidelines state that enteral feedings should be initiated as soon as practical. The authors sought to evaluate compliance with early enteral nutrition (EN) guidelines, associated complications, and hospitalization outcomes in a prospective multicenter observational study. They conducted a retrospective review of mechanically ventilated burn patients enrolled in the prospective observational multicenter study "Inflammation and the Host Response to Injury." Timing of initiation of tube feedings was recorded, with early EN defined as being started within 24 hours of admission. Univariate and multivariate analyses were performed to distinguish barriers to initiation of EN and the impact of early feeding on development of multiple organ dysfunction syndrome, infectious complications, days on mechanical ventilation, intensive care unit (ICU) length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort comprised 73% men, with a mean age of 41 ± 15 years and a mean %TBSA burn of 46 ± 18%. One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48 hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health Evaluation II scores (26 vs 23, P = .03) and smaller total burn size (44 vs 54% TBSA burn, P = .01) in those fed early. There was no significant difference in rates of hyperglycemia, abdominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed early had shorter ICU length of stay (adjusted hazard ratio 0.57, P = 0.03, 95% confidence interval 0.35-0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P = 0.01, 95% confidence interval 0.10-0.76). The investigators have found early EN to be safe, with no increase in complications and a lower rate of wound infections and shorter ICU length of stay. Across institutions, there has been high compliance with early EN as part of the standard operating procedure in this prospective multicenter observational trial. The investigators advocate that initiation of EN by 24 hours be used as a formal recommendation in nutrition guidelines for severe burns, and that nutrition guidelines be actively disseminated to individual burn centers to permit a change in practice.
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Heyland DK, Heyland RD, Cahill NE, Dhaliwal R, Day AG, Jiang X, Morrison S, Davies AR. Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award. JPEN J Parenter Enteral Nutr 2011; 34:707-15. [PMID: 21097771 DOI: 10.1177/0148607110361901] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs). DESIGN An international, prospective, observational, cohort study conducted in May 2008. SETTING 179 ICUs from 18 countries. PATIENTS 2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours. INTERVENTIONS To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients. MEASUREMENTS AND MAIN RESULTS Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance. CONCLUSIONS There is variable performance with respect to critical care nutrition practices across the world.
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Affiliation(s)
- Daren K Heyland
- Department of Medicine, Queen's University, Kingston, ON, Canada.
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Cahill NE, Heyland DK. Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies. JPEN J Parenter Enteral Nutr 2011; 34:653-9. [PMID: 21097765 DOI: 10.1177/0148607110361907] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Several clinical practice guidelines focusing on nutrition therapy in mechanically ventilated, critically ill patients are available to assist busy critical care practitioners in making decisions regarding feeding their patients. However, large gaps have been observed between guideline recommendations and actual practice. To be effective in optimizing nutrition practice, guideline development must be followed by systematic guideline implementation strategies. Systematic reviews of studies evaluating guideline implementation interventions outside the critical care setting found that these strategies, such as reminders, educational outreach, and audit and feedback, produce modest to moderate improvements in processes of care, with considerable variation observed both within and across studies. Unfortunately, the optimal strategies to implement guidelines in the intensive care unit are poorly understood, with scarce data available to guide our decisions on which strategies to use. The authors identified 3 cluster randomized trials evaluating the implementation of nutrition guidelines in the critical care setting. These studies demonstrated small improvements in nutrition practice, but no significant effect on patient outcomes. There are some data to suggest that tailoring guideline implementation strategies to overcome identified barriers to change might be a more effective approach than the multifaceted "one size fits all" strategy used in previous studies. Adopting this tailored approach to guideline implementation in future studies may help bridge the current guideline-practice gap and lead to significant improvements in nutrition practices and patient outcomes.
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Dodek P, Cahill NE, Heyland DK. The relationship between organizational culture and implementation of clinical practice guidelines: a narrative review. JPEN J Parenter Enteral Nutr 2011; 34:669-74. [PMID: 21097767 DOI: 10.1177/0148607110361905] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The context in which critical care providers work has been shown to be associated with adherence to recommendations of clinical practice guidelines (CPGs). Consideration of contextual factors such as organizational culture may therefore be important when implementing guidelines. Organizational culture has been defined simply as "how things are around here" and encompasses leadership, communication, teamwork, conflict resolution, and other domains. This narrative review highlights the results of recent quantitative and qualitative studies, including studies on adherence to nutrition guidelines in the critical care setting, which demonstrate that elements of organizational culture, such as leadership support, interprofessional collaboration, and shared beliefs about the utility of guidelines, influence adherence to guideline recommendations. Outside nutrition therapy, there is emerging evidence that strategies focusing on organizational change (eg, revision of professional roles, interdisciplinary teams, integrated care delivery, computer systems, and continuous quality improvement) can favorably influence professional performance and patient outcomes. Consequently, future interventions aimed at implementing nutrition guidelines should aim to measure and take into account organizational culture, in addition to considering the characteristics of the patient, provider, and guideline. Further high quality, multimethod studies are required to improve our understanding of how culture influences guideline implementation, and which organizational change strategies might be most effective in optimizing nutrition therapy.
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Affiliation(s)
- Peter Dodek
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Cahill NE, Narasimhan S, Dhaliwal R, Heyland DK. Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr 2011; 34:685-96. [PMID: 21097769 DOI: 10.1177/0148607110361908] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the attitudes of critical care practitioners toward the Canadian Critical Care Nutrition Clinical Practice Guidelines (CPGs) and compare them with actual practice. METHODS An international Web-based survey was conducted. Respondents were asked to rate their strength of recommendation for 26 nutrition practices included in the Canadian CPGs. Attitudinal results were compared with actual practice on each recommendation. RESULTS 514 practitioners from 27 countries completed the survey. The majority (91.4%) considered nutrition therapy to be very important for critically ill patients. There was 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. There was also strong endorsement for the following practices that are not routinely done in actual practice: EN initiated within 24 to 48 hours of admission, use of motility agents, head-of-bed elevation, use of glutamine and antioxidants, and maximizing EN before 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. CONCLUSIONS Overall, attitudes toward the Canadian CPGs were positive. However, we identified some areas where there was diversity of opinion, highlighting a need for further research and education. System tools may be a useful strategy to integrate guideline recommendations into practice where there is strong endorsement but the recommendation is not happening in actual practice.
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Cahill NE, Suurdt J, Ouellette-Kuntz H, Heyland DK. Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework. JPEN J Parenter Enteral Nutr 2011; 34:616-24. [PMID: 21097762 DOI: 10.1177/0148607110361904] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Clinical practice guidelines (CPGs) have been hailed as a useful method of translating evidence into practice. Several CPGs have been published that provide recommendations for feeding patients in the intensive care unit (ICU). Despite a rigorous development process and active dissemination of these guidelines, their impact on nutrition practice has been modest. The purpose of this study was to develop a comprehensive framework for understanding adherence to nutrition CPGs in the critical care setting. METHODS Multiple case studies were completed at 4 Canadian ICUs. Semistructured interviews were conducted with 7 key informants at each ICU site who were asked about their perceptions and attitudes toward guidelines in general and the Canadian Critical Care Nutrition CPGs specifically. Interview transcripts and related documents were analyzed qualitatively using a framework approach. RESULTS The 5 key components of the developed framework were characteristics of the CPGs, the implementation process, institutional factors, provider intent, and the clinical condition of the patient. These key themes encapsulate numerous itemized factors that contribute to guideline adherence either as barriers or enablers. CONCLUSIONS Adherence to nutrition CPGs is determined by a complex interaction of multiple factors that act as barriers or enablers. The comprehensive framework for adherence to CPGs in the ICU attempts to elucidate this process and provides a useful template for future research. Future quality improvement initiatives should assess local barriers to change and design interventions to overcome these barriers.
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Affiliation(s)
- Naomi E Cahill
- Department of Community Health and Epidemiology, Queen's University, Kingston, Ontario, Canada
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Sinuff T, Cahill NE, Dhaliwal R, Wang M, Day AG, Heyland DK. The value of audit and feedback reports in improving nutrition therapy in the intensive care unit: a multicenter observational study. JPEN J Parenter Enteral Nutr 2011; 34:660-8. [PMID: 21097766 DOI: 10.1177/0148607110373484] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The objective of this study was to determine whether auditing practice and providing feedback in the form of benchmarked site reports is an effective strategy to improve adherence to nutrition guidelines. METHODS The authors conducted a multicenter observational study in Canadian intensive care units (ICUs). In January 2007, an audit of daily nutrition information was collected (type and amount of nutrition received and strategies to improve nutrition delivery). Each ICU was e-mailed individualized benchmarked performance reports documenting their performance compared with the Canadian Critical Care Nutrition guidelines and in relation to the other ICUs. Nutrition practice was reaudited in May 2008 to evaluate changes in practice. RESULTS Twenty-six ICUs in Canada participated, with 473 and 486 patients accrued in 2007 and 2008, respectively. The authors observed a significant increase in enteral nutrition (EN) adequacy (from 45.1% to 51.9% for calories, and from 44.8% to 51.5% for protein) and an increase in the percentage of patients receiving EN without parenteral nutrition (from 71.9% to 81.3%). They also observed trends toward improvements in the percentage of patients who had EN started within 48 hours (from 60.3% to 66.8%). There were no significant differences in the use of motility agents or small bowel feeding in patients who had high gastric residual volumes. CONCLUSION Audit and feedback reports are associated with improvement in some nutrition practices in many ICUs; however, the magnitude of these effects is quite modest. More research is needed to determine the optimal methods of using audit and feedback to improve quality of nutrition care.
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Affiliation(s)
- Tasnim Sinuff
- Department of Critical Care Medicine, University of Toronto, Ontario, Canada
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Heyland DK, Cahill NE, Dhaliwal R, Sun X, Day AG, McClave SA. Impact of enteral feeding protocols on enteral nutrition delivery: results of a multicenter observational study. JPEN J Parenter Enteral Nutr 2011; 34:675-84. [PMID: 21097768 DOI: 10.1177/0148607110364843] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND To evaluate the effect of enteral feeding protocols on key indicators of enteral nutrition in the critical care setting. METHODS International, prospective, observational, cohort studies conducted in 2007 and 2008 in 269 intensive care units (ICUs) in 28 countries were combined for the purposes of this analysis. The study included 5497 consecutively enrolled, mechanically ventilated, adult patients who stayed in the ICU for at least 3 days. Sites recorded the presence or absence of a feeding protocol operational in their ICU. They provided selected nutritional data on enrolled patients from ICU admission to ICU discharge for a maximum of 12 days. Sites that used a feeding protocol were compared with those that did not. RESULTS On average, protocolized sites used more enteral nutrition (EN) alone (70.4% of patients vs 63.6%, P = .0036), started EN earlier (41.2 hours from admission to ICU vs 57.1, P = .0003), and used more motility agents in patients with high gastric residual volumes (64.3% of patients vs 49.0%, P = .0028) compared with sites that did not use a feeding protocol. Overall nutritional adequacy (61.2% of patients' caloric requirements vs 51.7%, P = .0003) and adequacy from EN were higher in protocolized sites compared with nonprotocolized sites (45.4% of requirements vs 34.7%, P < .0001). EN adequacy remained significantly higher after adjustment for pertinent patient and ICU level baseline characteristics. CONCLUSIONS The presence of an enteral feeding protocol is associated with significant improvements in nutrition practice compared with sites that do not use such a protocol.
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Affiliation(s)
- Daren K Heyland
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
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Tsai JR, Chang WT, Sheu CC, Wu YJ, Sheu YH, Liu PL, Ker CG, Huang MC. Inadequate energy delivery during early critical illness correlates with increased risk of mortality in patients who survive at least seven days: A retrospective study. Clin Nutr 2011; 30:209-14. [PMID: 20943293 DOI: 10.1016/j.clnu.2010.09.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2010] [Revised: 08/03/2010] [Accepted: 09/15/2010] [Indexed: 02/08/2023]
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Abstract
PURPOSE OF REVIEW To review the domains in which computerized information systems have proven beneficial in facilitating the metabolic and nutritional management RECENT FINDINGS In glucose control, computerized insulin algorithms have proven safer and more efficient than manual systems, reducing workload, time to target glycemia and numbers of hypoglycemic and hyperglycemic events. By rendering the nutritional variables visible through specific customization, computers do improve daily monitoring of energy balance and adherence to guidelines, particularly for substrate delivery. Nurse-centered systems have shown to be the most successful to enable routine workflow based on protocol-based care. SUMMARY Computers are needed to analyze the increasing amount of data collected from critically ill patients from monitoring systems, laboratories and other sources. Studies have shown that computerized information systems do facilitate glucose control, helping reducing hypoglycemic events. They also improve nutritional monitoring (energy delivery and balance, protein and fat delivery), and quality of nutrition. They reduce nurse workload associated with the multiple balance calculations and ease visualization of events out of planned targets. Though integrated systems are expensive, they improve work efficiency.
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Affiliation(s)
- Mette M Berger
- Service de Médecine Intensive Adulte et Centre des Brûlés, University Hospital, Rue du Bugnon 46, Lausanne, Switzerland.
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Jefferies A, Shah V. Clinicians prefer simple educational tools for implementing practice change. MEDICAL TEACHER 2011; 33:e602-e606. [PMID: 22022913 DOI: 10.3109/0142159x.2011.610838] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Successful implementation of practice change requires educational tools that engage and motivate clinicians. AIM To examine clinician usage and preference for different educational tools when a multifaceted strategy was used for implementation of new recommendations for managing newborns at risk of sepsis. METHODS Seminars, web-based tutorial, handouts, pocket cards and web-based management algorithm were used to educate health professionals. Ninety-two clinicians attended seminars and completed feedback questionnaires that included three questions assessing knowledge of the recommendations. After 3 months, an electronic survey containing the same questions was sent to 41 key stakeholders (staff neonatologists, trainee physicians, nurse practitioners and respiratory therapists) who provided patient care during the implementation period. Compliance with recommendations was assessed by chart audit. RESULTS Seminar content was helpful to 97% of participants and 88% were comfortable using the recommendations. Response rate for the 3-month survey was 80%. The most frequently used and useful tools were pocket cards (76%) and seminars (76%); 79% continued to use the card. Only one respondent used the web tutorial and four used the algorithm. There was no significant difference in percent correct responses to the questions between the two timepoints (p > 0.05). Compliance with the recommendations was 83%. CONCLUSIONS When provided with different educational tools, clinicians prefer pocket cards and seminars - tools that are simple and readily accessed.
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McClave SA, Hurt RT. Clinical guidelines and nutrition therapy: better understanding and greater application to patient care. Crit Care Clin 2010; 26:451-66, viii. [PMID: 20643299 DOI: 10.1016/j.ccc.2010.04.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The volume of clinical guidelines produced by national and international societies has virtually exploded in the literature over the past decade. The most important aspect of guidelines is transparency, that is, the connection between the recommendation or guideline statement and the underlying supportive studies from the literature should be transparent. Clinical guidelines should help organize the literature, identify key areas of patient management, and provide a framework with which the clinician may operate. The reader of a guideline should embrace controversy, trace back and review the underlying literature, and then determine whether practice should be altered as a result of the guideline recommendations. The purpose of this article is to understand the derivation of clinical guidelines, to learn how to resolve controversy or differences between guidelines and clinical practice, and to learn steps to apply the guidelines to an individual institution or clinical practice.
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Affiliation(s)
- Stephen A McClave
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Louisville School of Medicine, 550 South Jackson Street, Louisville, KY 40202, USA.
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