Barriers and Facilitators
To making it Happen!
Daren K. Heyland
Professor of Medicine
Queen’s University, Kingston General Hospital
Kingston, ON Canada
Disclosures
Research Contracts with the Following Companies
• Nestle
• Baxter
• Fresenius Kabi
• Abbott Nutrition
Results of 2007 International
Nutrition Practice Audit
Average time to start of EN : 46.5 hours (site average range: 8.2-149.1 hours)
In patients with high gastric residual volumes:
use of motility agents 58.7% (site average range: 0-100%)
use of small bowel feeding 14.7% (range: 0-100%)
Cahill N Crit Care Med 2010 (in press)
Adequacy of EN: Kcals
Relationship Between Increased Calories
and 60 day Mortality
BMI Group
Odds
Ratio
Overall
0.76
0.61
0.95
0.014
<20
0.52
0.29
0.95
0.033
20-<25
0.62
0.44
0.88
0.007
25-<30
1.05
0.75
1.49
0.768
30-<35
1.04
0.64
1.68
0.889
35-<40
0.36
0.16
0.80
0.012
>=40
0.63
0.32
1.24
0.180
95%
Confidence
Limits
P-value
Legend: Odds of 60-day Mortality per 1000 kcals received per day adjusting for nutrition
days, BMI, age, admission category, admission diagnosis and APACHE II score.
Alberda Int Care Med 2009;35:1728
Relationship of Caloric Intake, 60 day Mortality and BMI
60
BMI
All Patients
< 20
20-25
25-30
30-35
35-40
>40
Mortality (%)
50
40
30
20
10
0
0
500
1000
1500
Calories Delivered
2000
A Qualitative Assessment of
“Barriers and Facilitators”
to Implementing Nutrition CPGs in ICU
Multiple case study
 4 case ICU sites
 Purposeful sampling
Semi-structured key informant interviews
(n=28)
 Min. 5 years ICU experience
 Employed at case ICU site May 2004
Document review
Jones NCP 2007;22:449
Potential Barriers
Resistance to change
Patients clinical
condition
Lack of awareness
Information overload
Weak evidence
Resource constraints
Slow administrative
process
Impractical / Complex
Nursing workload
Limited critical care
experience
Potential Facilitators
Agreement of the attending physician & ICU team
Part of routine practice
Dietitian / Opinion leader
Access / Visibility
Easy to follow and perform
Provision of education
Open discussion
Favored Implementation Strategies
Informal one-on-one discussions
 Academic detailing, ward rounds
Protocols
 Pre printed orders, Check-list, algorithms,
Bed-side reminders
Feedback and audit
 Site reports
The Impact of Enteral Feeding Protocols
on Enteral Nutrition Delivery:
Results of a multicenter observational study
 International, prospective, observational, cohort studies conducted in
2007 and 2008 from 269 Intensive Care Units (ICUs) in 28 countries
 Included 5497 mechanically ventilated adult patients > 3 days in ICU
 Sites recorded the presence or absence of a feeding protocol
 Sites provided selected nutritional data on enrolled patients from ICU
admission to ICU discharge for a maximum of 12 days.
78% of sites reported
use of Feeding Protocol
P<0.05
Heyland JPEN 2010 ( in press)
Initial Efficacy and Tolerability of Early Enteral
Nutrition with Immediate or Gradual
Introduction in Intubated Patients
• This study randomized 100
mechanically ventilated patients
(not in shock) to Immediate
goal rate vs gradual ramp up
(our usual standard).
• The immediate goal group rec’d
more calories with no increase
in complications
Desachy ICM 2008;34:1054
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
 Not all critically ill patients are the same; we have different
feeding options based on hemodynamic stability and
suitability for high volume intragastric feeds.
 Use semi elemental solution
 In select patients, we start the EN immediately at goal rate,
not at 25 ml/hr.
 We target a 24 hour volume of EN rather than an hourly rate
and provide the nurse with the latitude to increase the
hourly rate to make up the 24 hour volume.
 Tolerate higher GRV threshold (250 ml or more)
 Motility agents and protein supplements are started
immediately, rather than started when there is a problem.
A Major Paradigm Shift in How we Feed Enterally
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
Figure 2.1 Adequacy of Calories from EN (Before Group vs. After Group on Full Volume
Feeds)
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
ICU Day
PLOT
P-value
Day 1
0.049
Before Group
Day 2
0.0005
Day 3
0.17
Day 4
0.31
After Group
Day 5
0.60
Day 6
0.34
Day 7
0.20
Total
0.015
Heyland (in submission)
% protein received/prescribed
The Efficacy of Enhanced Protein-Energy Provision via the
Enteral Route in Critically Ill Patients:
The PEP uP Protocol!
Figure 2.2 Adequacy of Protein from EN (Before Group vs. After Group on Full Volume
Feeds)
120
110
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
ICU Day
PLOT
P-value
Day 1
0.014
Before Group
Day 2
<0.0001
Day 3
0.0015
Day 4
0.13
After Group
Day 5
0.57
Day 6
0.62
Day 7
0.34
Total
0.002
Heyland (in submission)
Need for Constant Reminders
Poster
Reminder
HOB
sticker
Reminder
screensavers
Special DVD presentation
Early Enteral Nutrition in the ICU:
The Clock Is Ticking!
Daren K. Heyland, MD, FRCPC, MSc
Professor of Medicine
Queen’s University
Kingston, Ontario
www.criticalcarenutrition.com
Overall Site Performance
Practice Changing Interventions
 Protocolize/automate care
 Improve organizational culture
 Develop Dietitian and other KOL as local opinion
leaders
 Audit and feedback with bench-marked site reports
 Assess barriers and have interactive workshops with
small group problem solving
 Implement strategies with rapid cycle change
(PDSA)
 Educational reminders (manuals, posters, pocket
cards)
 One on one academic detailing
What works best at your site?
(barriers and enablers will vary site to site)
What is already working well at your site?
(strengths and weakness are different across sites)
Conclusions
Long way to go to narrow the quality gap
Need to enrich our understanding on how best to
achieve that; but in the mean time, act now!
With our emerging understanding of the
problems, we need to develop more targeted or
strategic solutions.
 Strengths & weaknesses; barriers & enablers vary
across sites.
Stay tuned…