Instruction Manual
International Nutrition Survey 2008
Instructions: INS08
Date: 1 April 08
1
Table of Contents
Introduction .........................................................................................................................................……….3
Study Contacts .............................................................................................................................................. 5
Acronyms....................................................................................................................................................... 6
General Guidelines for Electronic Data Capture ............................................................................................ 7
Critical Care Nutrition Website ....................................................................................................................... 9
Survey Log In and Registration Page .......................................................................................................... 10
Welcome Home Page .................................................................................................................................. 13
Patient Status Page .................................................................................................................................... 15
Screening ................................................................................................................................................... 16
Patient Baseline ........................................................................................................................................... 18
APACHE II ................................................................................................................................................... 21
Baseline Nutrition ........................................................................................................................................ 24
Daily Nutrition Data .................................................................................................................................... 26
Enteral Nutrition Data .................................................................................................................................. 28
Parenteral Nutrition Data ............................................................................................................................. 30
Outcomes .................................................................................................................................................... 32
Finalizing Data Collection ............................................................................................................................ 34
Appendices
Appendix 1
Height Conversion Table ..................................................................................... 35
Appendix 2
Enteral Nutrition Formulas……………………………...…………………………..… 36
Instructions: INS08
Date: 1 April 08
2
Introduction
International Nutrition Survey
This project involves a point-prevalence survey of nutrition therapies in critically ill patients in
intensive care units (ICUs) across the world. This survey is to be conducted on 14 May 2008 or
the nearest date practically possible.
Dietitians (or other healthcare practitioner) at the respective ICUs will collect data such as site
characteristics, patient demographics, direct observational data (i.e. head of the bed elevation),
baseline APACHE II variables, length of stay, duration of ventilation and mortality. In addition,
nutrition practices such as route of nutrition, kilocalories and protein levels prescribed and
received, interruptions, supplementation, blood sugars, insulin, etc will also be collected on a
daily basis from ICU admission to ICU discharge or for a maximum of 12 days.
It is projected that the results of this survey will identify differences, highlight strengths and
weaknesses, and hopefully illuminate opportunities to improve nutrition practices in Canada and
throughout the world
Benchmarked Site Report
There is no remuneration for participating in this project. Rather, you will be provided with a
benchmarked site report. This site report summarizes your sites performance and will allow
you to compare your nutrition practices to other ICUs within your own country or region (‘Sister
Sites’) and all the ICUs in the database (‘All Sites’). You will also be able to compare your
performance to the recommendations of the Canadian Nutrition Support Clinical Practice
Guidelines (CPGs).
Best of the Best 2008
Although the hard work and dedication of all ICUs who participate in the international nutrition
survey is recognized, in 2008, the top performing site in the World will receive an award for
being the ‘Best of the Best’. The top ranked ICU will personally be presented with a ‘Best of the
Best’ plaque by Dr Heyland in a ceremony to be held at their hospital. To be considered for this
award, participating ICUs must meet the following criteria:
1. Entered data on a total of 20 critically ill patients.
2. Completion of a baseline nutrition assessment (i.e. nutrition prescription).
3. No missing data or outstanding queries.
4. Prepared to permit CCN to source verify the entered data.
Instruction Manual
The Instruction Manual functions as a resource for successful completion of electronic case
report forms (eCRFs) for the International Nutrition Survey.
The manual is formatted to provide written instruction for each electronic CRF. A webshot of
the actual web page will follow written instructions.
ECRFs are the primary mode of data capture used in the International Nutrition Survey. The
dietitian (or other healthcare practitioner) is expected to enter data online as soon as it becomes
Instructions: INS08
Date: 1 April 08
3
available. Paper CRFs and worksheet templates are available as tools to assist in capturing the
required data elements prior to online data entry. Copies of these paper CRFs/worksheets can
be downloaded from our website www.criticalcarenutrition.com.
Please keep ALL worksheets/documents that you use until you receive your benchmarked performance
report. This will provide you with an opportunity to check your site report with the raw data and ensure
that it is accurate.
Please check with your hospital for local requirements regarding storage of data collection forms as this
may differ by hospital site.
In the event that additional clarification is required; please contact the Project Leader (PL).
Instructions: INS08
Date: 1 April 08
4
Study Contacts

Principal Investigator
Dr Daren Heyland
Clinical Evaluation Research Unit
Kingston General Hospital
Angada 4, 76 Stuart Street
Kingston
ON Canada
K7L 2V7
Tel: 613 549 6666 ext. 3339
Fax: 613 548 2428
Email: dkh2@queensu.ca

Project Leader
Siouxzy Morrison
AuSPEN/ANZIC-RC Nutrition Research Fellow
ANZIC Research Centre
Department of Epidemiology & Preventative Medicine
Monash University
Postal Address:
Department of Epidemiology & Preventative Medicine, Monash University,
The Alfred Hospital, Melbourne VIC 3004 Australia
Delivery Address:
Level 3, Burnet Building, 89 Commercial Road, Melbourne, VIC 3004
Tel: +61 3 9903 0280
Mobile: +61 4 3707 7795
Fax: +61 3 9903 0071
E-mail: Siouxzy.Morrison@med.monash.edu.au

Technical Support
Fernando Ferrer
Kingston General Hospital
Angada 4, 76 Stuart Street
Kingston
ON Canada
K7L 2V7
Tel: 613 549 6666 ext.
Fax: 613 548 2428
Email: FFerrer@ctg.queensu.ca
Instructions: INS08
Date: 1 April 08
5
Acronyms
CERU
Clinical Evaluation Research Unit
CRF
Case Report Form
eCRF
Electronic Case Report Form
EN
Enteral Nutrition
FTE
Full time equivalent
ICU
Intensive Care Unit
PL
Project Leader
PN
Parenteral Nutrition
QI
Quality Improvement
RD
Registered Dietitian
RT
Respiratory Technician
Instructions: INS08
Date: 1 April 08
6
General Guidelines
Ethics
As this is a quality improvement (QI) project, ethical committee approval is not usually required.
We have received ethics approval from Queen’s University, Kingston, Ontario, Canada to
conduct this survey and publish the results. However, you may still want to contact your local
ethics committee to check if additional approval is needed. For more information please refer to
the document ‘Preparing for Ethics Submission’ available on our website.
Accessing the Website
 The Clinical Evaluation Research Unit (CERU) will provide a username and password only
to individuals who have registered to participate in the International Nutrition Survey 2008,
and to those that have been granted access by these registrants.
 The Web Based Data Capturing System for the International Nutrition Survey can be
accessed by following the International Survey login link on the
www.criticalcarenutrition.com website, or directly at https://ceru.hpcvl.queensu.ca/CCN/.
 All users must log onto the website using their own username and password prior to data
entry.
 Prior to accessing the website, first ensure that your browser is configured appropriately.
For more information please refer to the help document on our website and on the login
page.
 When you log in, you will be taken to the appropriate page based on the ICUs that you have
access to. If you are registered for more than one ICU, you will be taken to the ‘My ICUs’
page. If you are registered for a single ICU, you will be taken to the appropriate ICU status
page.
 Your user profile and password can be changed at any time by clicking the appropriate links
on the International Nutrition Survey home page.
Completions of Electronic Case Report Forms
 All data collection activities will be completed on the web.
 Only patients meeting inclusion criteria should be entered on the web. See page 14.
 Dates are entered using YYYY/MM/DD format i.e. 2008/03/14. To ensure that proper date
format is obtained, click on the calendar icon and select the appropriate date. The date field
will automatically be completed for you.
 Enter all times using the 24-hour period format i.e. 22:37. To ensure a proper time format
the web system will automatically enter a colon for you or you can manually enter a colon or
semi-colon.
o Midnight (24:00 hours) should be entered as 00:00
 To access eCRFs single click the appropriate link using the left side of your mouse.
 The data field only supports numerical data and will not recognize a unit suffix (e.g. Kg,
Kcal, mmol). Enter all data without units. All units are displayed next to the appropriate
data field.
 To expand a menu or taxonomy click on ‘+’ next to the title of the menu/taxonomy. To
collapse the menu or taxonomy click on ‘-‘.
 The RESET form button will take you back to the last saved version.
 The EXIT form button will take you back to the ICU or Patient Status page.
Instructions: INS08
Date: 1 April 08
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Duration of Data Collection
 All daily nutrition data needs to be collected from Study day 1 and each day following
until day 12 unless ICU discharge (actual) or death occurs before day 12
Study Day 1 is from ICU admission to the end of your 24 hr flowsheet.
Study Day 2 and subsequent days starts at the time the ICU chart starts until it ends 24 hours later (eg from
08:00 on the 15 May 08 until 08:00 on the16 May 08).

If a patient is re-admitted to your ICU within 48 hrs of discharge, consider this to be a
continuation of the previous stay. If a patient is re-admitted to your ICU after 48 hours of
discharge, this is not considered to be a continuation of previous stay and patient cannot be
included in the survey again.
Time frames for completion of data entry
 The web pages are to be completed retrospectively but it is encouraged that data is entered
online as soon as possible after it is collected.
 Deadline for completion of data entry:
o 1st August 2008
o If you have concerns regarding this deadline date, please contact the Project Leader.
The web based data entry system has been programmed with various checks to simplify the query process.
When proceeding with the data entry, please follow the order in which the forms appear. This will reduce the
‘outstanding issues’ that you will encounter.
Finalizing Patients
The web based data entry system has been programmed to recognize when the patient is
eligible for finalization (i.e. no outstanding queries and a minimum of three days data entered).
At this point, you can access and complete the Outcomes page for this patient and the patients’
status will change to ‘Finalized’. When all 20 patients have been finalized, navigate back to the
ICU Status page and tick the box that asks ‘Is data entry finalized at your ICU?’.
Instructions: INS08
Date: 1 April 08
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Critical Care Nutrition Website
The Critical Care Nutrition website will be the gateway for accessing the web application’s login
page. Go to the website www.criticalcarenutrition.com and click on ‘International Survey 2008’ or
access the login site directly at https://ceru.hpcvl.queensu.ca/CCN.
Regular updates and useful information regarding the International Nutrition Survey will also be
posted on this website so please check it regularly.
Webshot of www.criticalcarenutrition.com
Instructions: INS08
Date: 1 April 08
9
Survey Login Page and Registration
User and ICU Site Registration can be completed on or before 14 May 2008.
Prior to entering data for your ICU, you will first need to create a user account for your ICU.
This only needs to be completed once. Although several individuals can have access and enter
data for your ICU site, we ask that the individual coordinating the survey at your ICU site take
responsibility for this initial registration process.
User Registration
 Go to survey login page and click on ‘Create a new login account’.
 Complete the questions about yourself (Form A, Part A).
 Complete your login information (i.e. select and confirm a password and complete
human user verification).
 Click on ‘Save User’.
 You will be sent an e-mail confirming that you have successfully registered your ICU site
and you will be provided with your username. All usernames start with the prefix ccn
followed by four digits.
ICU Registration
 Go to the survey login page and enter your username and password.
 You will be asked to complete questions about your hospital and ICU (Form A, Part B).
 Click on ‘Save ICU’.
 You will be directed to the ICU status page and can begin to enter patient data.
 If you wish to register more than one ICU, on the ICU status page, click on ‘Register
New ICU’.
 You can edit your user profile and hospital / ICU details or change your password at any
time by following the appropriate links.
Grant Permission to Other Users
 If you wish to grant permission for other users, on the ICU status page, click on ‘grant
permissions for this ICU to other users’, enter their e-mail addresses and click on ‘grant
permissions’. This will generate an e-mail to new users with a username and temporary
password to access the survey.
Instructions: INS08
Date: 1 April 08
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o
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o
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Consent to participate: Checking this box tells us that you have read the information about the study and
understand its purpose. It will allow us to compute benchmarked site reports comparing your performance
with other ICUs in the dataset. All data will be aggregated, so that individual patients will not be identifiable
and other sites will not be able to identify your ICU. Consenting to participate also allows us to correctly
acknowledge your participation on the website and other publications.
Password: Select a password for your personal account. The password is case sensitive (i.e. it must be
typed with the required capitalization) and must be at least 6 characters long. Do not type spaces between
characters and do not use repeating characters (i.e. aaaaaa). To secure your password please select a
combination of characters that will not be easily guessed by others, and don’t write down your password or
share it with anyone else.
Forget your Password? : If you forget your password, click on the ‘forget your password?’ tab on the login
page. Enter your e-mail address and complete the human user verification. You will be sent an e-mail with
your username and a temporary password. Please change your password when you next login to the
survey.
Human User Verification: You must type the letters or numbers you see in the box to confirm that a
person is trying to access the survey and not an automated program. This helps to prevent automated
programs from misusing the survey.
Registration e-mail: Please be aware that your username will be sent to you by e-mail shortly after you
register (or after you are granted permissions), as the source of the e-mail may not be recognized by your
provider please remember to also check your junk mail in the event that the survey e-mail is diverted to this
folder.
ICU Registration: Although you may be aware of the answers to these questions about your hospital and
ICU, we request that you ask the medical or nursing director of your ICU to answer questions related to the
type of ICU and case mix.
Multiple ICUs: If your hospital has multiple ICUs, please enter YES when prompted, enter your ICU name.
Make sure that you select a name for your ICU that is distinct from the other ICUs in your hospital (e.g.
medical, surgical, trauma, neuro)
Type of Hospital: A teaching hospital is a hospital that provides training to medical student and residents.
If your hospital only has occasional medical students/residents, record your hospital as a non-teaching
hospital.
ICU Structure: Open ICUs are sites where patients are under the care of an attending physician (e.g.
internist, family physician, surgeon) with intensivists (i.e. physician with training in critical care) consulted as
necessary. Closed ICUs are sites in which patients are under the care of an intensivist, or care is shared
between the intensivist and another attending physician.
Full Time Equivalent Dietitian: This is a measure of the amount of time the dietitian is dedicated to the
ICU relative to a full-time position e.g. a FTE of 1.0 means that the dietitian works in the ICU full-time and a
FTE of 0.5 means that the dietitian is in the ICU half-time, or two and a half days a week.
Grant permissions: If more than one person is entering data for your ICU, the primary user will be provided
with an option to authorize other users to access your ICU site account. The new users will be sent an email with their own username and password.
Instructions: INS08
Date: 1 April 08
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Webshot of Login Page
Instructions: INS08
Date: 1 April 08
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Welcome ‘Home’ Page
My ICUs
 This will be your ‘home’ page if you are registered for more than one ICU.
 This page will display a list of ICUs for which you have been granted permission to enter
data. The list will include the name of the ICU, the number of patients registered and the
number of patients finalized.
 Clicking on a specific ICU will take you to the ‘ICU Status’ page for that ICU.
 You can enter the ‘My ICUs’ page at any time by clicking on the appropriate links on the
menu.
ICU Status Page
 This will be your ‘home’ page if you are registered for a single ICU.
 This page displays a list of all the patients registered at your ICU. The list includes the
patient number, basic demographic data, and the patient’s status. The statuses are:
o Invalid: There are outstanding queries for this patient.
o Valid: The patient has no outstanding queries but has less than three days of
data, and is therefore not eligible for finalization.
o Eligible for finalization: The patient has no outstanding queries and has a
minimum of three days of data entered, and is therefore eligible for finalization.
o Finalized: Data entry, including outcomes, is complete, with no outstanding
queries.
 Click on the line containing details about a specific patient to navigate to the Patient
Status page for that patient.
Menu
 My ICUs. To view a summary of all registered ICUs and the number of patients
registered and finalized click on the ‘My ICUs’ left hand menu.

ICU Status. To view a summary of the number of patients registered at a single ICU
and the number of patients finalized click on the ‘ICU Status’ left hand menu.

Register New Patient. To register a new patient, click on ‘register new patient’ on the
left hand side menu.

Edit User Profile. To change your personal information click on ‘edit user profile’ on the
left hand side menu

Change password. To change password, click on ‘change password’ on the left hand
side menu. You will be asked to enter your old password, select and confirm a new
password.

Contact Us. On the left hand side of the menu click on ‘contact us’ to view the contact
details of the Project Leader and Technical Support.
Instructions: INS08
Date: 1 April 08
13

Help. To access documents related to the study and how to navigate the web-based
data collection tool click on ‘help’ on the left hand side menu.

Log Out. To log out of the web system and return to the login page click on “Log out’ on
the left hand side menu.
Webshot of ‘My ICUs’ Page
Webshot of ‘ICU Status’ Page
Instructions: INS08
Date: 1 April 08
14
Patient Status Page

After clicking on a specific patient on the ICU Status Page you will be directed to the
Patient Status page.

From this page you can view, enter data, or edit information for all International Nutrition
Survey related eCRFs.

If you ‘save’ any eCRF, you will be directed back to this page.

To review or edit daily nutrition data, click on row corresponding to the study day.

To review or edit EN or PN data, click on ‘Yes’ in the appropriate column.
Webshot of Patient Status Page
Instructions: INS08
Date: 1 April 08
15
Screening
You must begin to identify study patients on 14 May 2008 (or nearest possible date
thereafter).
The Screening Log is not part of the data collection process but has been developed as a tool to
help you to identify which patients in the ICU meet the inclusion criteria. As the Screening Log
is for your own personal use we will not be asking you to enter any of the data on this form
online.
Eligibility Criteria
Inclusion:
 Critically ill patients that are mechanically ventilated within the first 48 hours of admission
to ICU.
 Are in the ICU  3 days.
 Adult patients (i.e.  18 years).
Exclusion:
 Patients on mask ventilation.
 Patients who were not ventilated within the first 48 hours of admission to ICU but
became ventilated after.
Duration of Ventilation does not matter. Patients that were ventilated within the first 48 hours of admission
to the ICU, then came off the ventilator and stay in the ICU > 3 days, still meet the eligibility criteria. If the
patient is ventilated prior to admission to the ICU they meet the eligibility criteria.
To identify the 20 eligible study patients, complete the following steps:








Go to your ICU and record the initials of ALL patients that are currently in your unit on this
day in Column 1 of the Screening Log.
In Column 2, record only those patients from Column 1 that were intubated and ventilated
within the first 48 hrs of admission to ICU or prior to ICU admission.
In Column 3, list only those patients from Column 2 that were in ICU  3 days.
In Column 4, number the patients from Column 3 consecutively and these are your eligible
study patients.
In Column 5, enter the number the patient was allocated by the web-based data capture
system (if different from Column 4).
If you have less than 20 patients in your cohort of study patients on 14 May 2008, continue
to screen daily until you get a minimum of 20 consecutive patients.
For patients that are just admitted and are ventilated, please follow them up for 72 hours to
see if they stay in the ICU  3 days, as they will also be included.
Please keep the Screening Log to help track down which patient corresponds to which
patient number in case we have data queries at a later date.
Instructions: INS08
Date: 1 April 08
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Consecutive Patient: the very next patient that was admitted that meets the criteria. Please do not ‘pick
and choose’ patients randomly.
Inclusion Criteria:
o Include the patient if he/she is physically in the ICU at time of screening and meets the criteria even if
they are ready for discharge from the ICU and are waiting for a bed on the ward.
o If the patient has had several admissions to the ICU, use the most recent admission.
o If a patient is discharged from the ICU but re-admitted within 48 hours consider that this patient never
left the ICU.
o If there is a patient in the ICU on 14 May 2008, is ventilated and was admitted less than 72 hours ago,
say 12 May 2008, please follow the patient up and see if he/she stays in the ICU > 72 hours. If so, you
will need to collect daily data from date of admission onwards to a maximum of 12 days (or discharge
from the ICU). This can be done retrospectively at the end of the 12 days if you prefer.
o If the patient is in the ICU on 14 May 2008 and was admitted 01 April 2008, you need to collect daily
from 01 April 2008 onwards until 12 April 2008. However, if charts are missing and you are unable to
collect the relevant data for this patient, please exclude and include the next eligible consecutive patient
Instructions: INS08
Date: 1 April 08
17
Patient Baseline Form
This page is to be filled out once for each patient.
ICU Admission: If a patient was admitted to the ICU, then discharged or transferred and then
readmitted to the ICU, enter the date of the most recent admission to the ICU. If a patient is
transferred from another ICU enter the date of admission to your ICU.
Date and time of mechanical ventilation in ICU): This refers to invasive mechanical
ventilation i.e. intubation with mechanical ventilation or tracheostomy with mechanical
ventilation. This includes any positive pressure delivered via an endotracheal tube or a
tracheostomy. This does not refer to non-invasive methods of ventilation such as BI-PAP or
mask-CPAP. For the patient that is mechanically ventilated prior to admission to your hospital,
this is the same as the admission date and time to your hospital, including patients undergoing
outpatient surgery. Simply, click on ‘ventilation initiated prior to ICU admission’.
Admission Category): Choose the most suitable from Medical or Surgical. If surgical
indicate if this is elective or emergency surgery.
Admission Diagnosis): View the ICU Admission Taxonomy provided (see Appendix). This is
the diagnosis that resulted in the patient’s admission to ICU. If the patient’s admission
category is Medical, choose the most suitable diagnosis from the Non-Operative list of the
Taxonomy (i.e. 1 to 49). If the patient’s admission category is Surgical, choose the most
suitable diagnosis from the Post-Operative list of the Taxonomy (i.e. from 50-86). If the
Admission Diagnosis is not present in the taxonomy, look for the appropriate condition (based
on admission category) and choose “Other” and type in the diagnosis. For example, if
Admission Category is Non-Operative and Admission Diagnosis is Acute Renal Failure, choose
“Other Metabolic disease (#44)” and type in “Acute renal failure”). We are specifically interested
in reporting on patients with sepsis, pancreatitis, bariatric surgery, ARDS, and burns, therefore if
a suitable diagnosis for a patient includes one of these conditions please select in preference to
other diagnoses (e.g. if a patient is admitted with pneumonia or sepsis, select sepsis).
Presence of Acute Respiratory Distress Syndrome (ARDS)): ARDS is an acute lung
condition characterized by PaO2:FiO2 < 200 mmHg in the presence of bilateral alveolar
infiltrates on chest x-ray. You are not expected to diagnose ARDS. You only need to review
the chart for the first 72 hrs from admission to the ICU for either a confirmed or suspected
diagnosis of ARDS. If the chart says “? ARDS”, this is suspected ARDS, enter Yes.
Head of Bed Elevation: Head of the bed should be observed at screening (i.e. when the
patient is first included in the survey. For determining head of the bed elevation, use the device
that the ICU bed is equipped with. If no such device is available, you will need to estimate the
angle and we suggest that you do this with another team member i.e. RN, RT, etc. When you
are estimating, please note if the patient has pillows under his/her head. If there are pillows,
make sure that you record the angle at which the patient’s trunk meets the bed instead of the
angle between the head and the pillow.
Instructions: INS08
Date: 1 April 08
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See figure below:
Incorrect angle
Correct angles
Head of Bed Elevation is the only data element to be completed prospectively, consequently it is
an OPTIONAL field.
APACHE II Score: If routinely calculated directly enter score, if unavailable, leave field blank
and you will be directed to the Apache II Online Worksheet.
Logic Alert
Instructions: INS08
Date: 1 April 08


Dates must be in a logical sequence.

If mechanical ventilation initiated prior to ICU admission (e.g. patient
transferred from another ICU), tick the box that says ‘ventilation initiated prior
to ICU admission’. Date and time will be set the same as ICU admission.
Start of Mechanical Ventilation cannot be more than 1 day before ICU admission
and cannot be more than 2 days after ICU admission.
19
Webshot of Patient Baseline Form
Instructions: INS08
Date: 1 April 08
20
APACHE II
Note: Use values from the first 24 hours from admission to ICU.

















You will only need to complete this page if the patient does not have an Apache II score
entered in the patient registration page.
Enter the lowest and highest value recorded in the source documentation within the first
24 hours from admission to ICU. The worst value that generates the highest severity score
will be selected by the web application.
When you enter the values in the right-hand columns, the severity score will be
automatically calculated.
Note: If variables are not available from the first 24 hrs, go outside the 24-hour window and
use the data closest to ICU admission. Use the Comment Box to indicate that you used data
outside the 24-hour window.
Age will be automatically transferred from previous web page.
Temperature: Enter the value and indicate, core, oral, axilla or tympanic listed in the second
drop box.
o The program will re-calculate to the appropriate core temperature.
o Rectal, tympanic, temporal, and bladder temperatures are considered as core
temperature.
o For manual calculations of APACHE: To obtain the core temperature: if oral
temperature is reported, add 0.5 C to oral temperature; if axilla temperature is
reported, add 1.0C.
Enter the systolic and diastolic blood pressures in the appropriate box. Once these values
have been entered the Mean Arterial Pressure (MAP) value will automatically be calculated
and entered in the right-hand column.
Heart Rate: enter the highest and lowest value.
Respiratory rate: (either ventilated, or non-ventilated)
Oxygenation:
o If the FiO2 is > 0.5, the PaCO2, and the PaO2 boxes appear. Enter the values
into the appropriate boxes. Again, the program will calculate the A-aD02 and
enter the value in the right-hand column. For the purposes of this trial the
barometric pressure value will be standardized at 713.
o If the FiO2 is < 0.5, only the PaO2 box will appear. Enter the value.
o If no ABGs available, tick the appropriate box and enter the HCO3 in place of
arterial pH. Serum HCO3 should only be used if there are no ABGs available in
the previous 24 hours.
Arterial pH.
Serum Sodium: the unit of measure is mmol/L.
Serum Potassium: the unit of measure is mmol/L.
Serum Creatinine: the unit of measure is umol/L. If you require a definition of Acute Renal
Failure, click on “Explain” and definitions will be provided.
Hematocrit: enter this value as a percentage.
White Blood Cells (total/mm3)(in 1000’s).
Glasgow Coma Score (GCS): If this patient has a GCS documented in their chart for the first
24 hours after ICU admission, directly enter the score. Otherwise, to determine the GCS
choose the best response from each of the 3 categories for the first 24 hours after ICU
admission. If the patient is sedated, then go back to the period when the patient was not
Instructions: INS08
Date: 1 April 08
21
receiving sedation or approximate what the score would be if the sedation where to be
removed. See worksheet or CCN website for GCS flow sheet. If you are unable to calculate
a pre-sedation GCS, assume that the GCS is normal and enter a score of 15. Enter the
values in the 3 separate categories and the GCS will automatically be calculated.
Eye Opening:
1- None
2- To Pain
3- To speech
4-Spontanous
Verbal Response:
1- None
2- Incomprehensible words
3- Inappropriate words
4- Confused
5- Oriented
Best Motor Response: 1- None
2- Extension
3- Abnormal flexion
4- Withdraws from pain
5- Localizes to pain
6- Obeys commands


Chronic Health Points: Choose one of the 3 categories for patients with a history of severe
organ system insufficiency or immunocompromised – Click “Explain” box on the left hand
side of the screen for definitions.
When all the categories are completed, click on the box labeled “Save Apache II Form”
and the system will automatically save and calculate your Apache Score.
Instructions: INS08
Date: 1 April 08
22
Apache II Form
Instructions: INS08
Date: 1 April 08
23
Baseline Nutrition Assessment
This form is to be filled out once for each patient.

Record height in metres and weight in kilograms. If unable to obtain “actual” height or
weight, use estimated height and weight or that obtained from family members and tick the
appropriate box to indicate that data was estimated.

For weight used to determine prescribed energy requirements, choose from the list.
Code
1
2
3
4
5
6
7
8
9

For determination of energy requirements choose from the list.
Code
1
2
3
4
5
6
7
8
9
10
11
12
13
Weight
Actual (ABW)
Ideal (IBW) based on Hamwi formula
Ideal (IBW) based on BMI 20-25 Kg/m2
Adjusted by 25% (ABW x 0.25 + IBW)
Adjusted by 40% (ABW x 0.4 + IBW)
Adjusted average ((ABW + IBW) x 0.5)
No weight used in calculation
No assessment completed
Other, please specify
Predictive Equation
Harris Benedict Equation
Schofield Equation with no adjustment for stress and
activity
Schofield Equation with adjustment for stress and/or
activity
Mifflin-St. Jeor Equation
Ireton-Jones Equation
Weight based <20 Kcal/Kg
Weight based: 20-24 Kcal/Kg
Weight based: 25-29 Kcals/Kg
Weight based: 30-35 Kcal/Kg
Provide 1200 – 1499 Kcal as standard
Provide 1500-2000 Kcal as standard
Indirect calorimetry
Other, please specify

For prescribed energy intake enter the kilocalories provided by the goal regimen (i.e.
maximum rate/volume determined at the initial assessment) for EN/PN according to the
dietitians or physicians recommendation.
o e.g. If the dietitian recommends a starting rate of 25 ml/hr on day 1 with a final
rate of 75 ml/hr by day 3, calculate the calories and protein that the final rate =
75ml/hr X 24 would provide

For prescribed protein intake enter the grams provided by the goal regimen (i.e. maximum
rate/volume determined at the initial assessment) for EN/PN according to the dietitians or
physicians recommendation.
Instructions: INS08
Date: 1 April 08
24

For those on EN and PN, please record the kilocalories and protein from the combined
prescription of EN and PN.
o
Weight: Enter the patient’s actual weight in kilograms. Do not enter the weight used to estimate the patients
nutritional requirements if it differs from the patients actual weight. Enter “actual” if the patient has been weighed
during the current admission or if there is a recent recorded weight in the chart. Enter “estimated” if the weight
was obtained by enquiring of relatives or estimated by a clinician. Use “dry weight” (i.e. weight in the absence of
fluid overload) if fluid retention is present. See Appendix or CCN website for height and weight conversion
charts.
Height: Enter height in meters. See Appendix or CCN website for height and weight conversion charts.
Weight used to determine requirements: If an unadjusted estimated weight is used to calculate nutritional
requirements, select ‘actual’body weight.
Prescription: Record total kilocalories i.e. include the kilocalories from protein. If the prescription changes over
the days of observation, calculate the average prescribed calories and protein.
If a nutritional assessment was not completed, calculate prescription as 25 kcals/kg for energy and
1g/kg protein. (e.g. a 80Kg make patient would have a prescription of 2000kcals and 80g protein).
o
o
o
o
Webshot of Baseline Nutrition
Instructions: INS08
Date: 1 April 08
25
Daily Nutrition Data
This form is to be filled out for each patient daily. The study day will automatically appear on
the screen.
Study Day 1 is from ICU admission to the end of your 24 hr flowsheet.
Study Day 2 and subsequent days starts at the time the ICU chart starts until it ends 24 hours later. (eg from
08:00 on the 15 May 08 until 08:00 on the16 May 08)"





o
o
o
o
o
o
For each study day, indicate “Yes” or “No” to indicate if patient received nutrition.
If patient is on both enteral and parenteral nutrition on the same day, click the ‘yes’
response in both places “Enteral nutrition” and “Parenteral nutrition”.
If patient received EN (either EN only, or EN and PN), you will automatically be
directed to the Enteral Nutrition page after saving this page.
If patient received PN (either PN only, or PN with EN), you will automatically be
directed to the Parenteral Nutrition page after saving this page.
Click on ‘save’ to save the form and return to the patient status page or proceed to
EN or PN page as applicable.
Blood sugars: record first blood sugar reading closest to 08:00 hrs. This can be either serum or capillary. If
no blood sugars were recorded for that day, click on ‘none recorded’.
Hypoglycemic episodes: Record any blood sugar reading <3.5mmol/l (63 mg/dL)(up to 3 episodes per day). If
reading is in mg/dL multiply by 0.0555 to convert to mmol/L.
Insulin: Add up the total number of units of insulin over the 24 hr period regardless of route or type. If the
patient is receiving 2 different types of insulin add together to provide total units of insulin. If the patient did no
receive insulin click on ‘no insulin received’.
Supplemental Glutamine: This refers to glutamine given as a supplement over and above what would normally
be present in the standard enteral or parenteral formula.
Supplemental Selenium: This refers to selenium given as a supplement over and above what would normally
be present in the standard enteral or parenteral formula.
Propofol: Indicate Yes if continuous infusion ≥ 6 hrs and No if no propofol given or if continuous < 6hrs or
provided intermittently. If Yes, indicate kilocalories received from propofol (provides 1.1Kcal/ml). Do not count
propofol in kilocalories from EN/PN.
If you do not have three days of daily data entered, you will not be able to proceed
to complete the Outcomes page and finalize the patient.
Logic Alert
Instructions: INS08
Date: 1 April 08
Proceed with entering data for the missing days.
26
Webshot of Daily Nutrition Data Page
If you have accidentally entered an extra day, contact Technical Support stating your username, the patient
number and patient day that you wish to delete.
Instructions: INS08
Date: 1 April 08
27
Enteral Nutrition Data

This form is to be filled out for each patient daily. The study day will automatically
appear on the screen.

EN Formula: Using taxonomy provided on the web, please record enteral formula(s)
received. See appendix for list of formulas.
o You may select up to 3 formulas per day. In the event that the patient receives
more than 3 formulas, select the 3 that provided the largest volumes.

Kilocalories Received: The total calories will need to be calculated by the dietitian
daily as follows:
o Include calories from protein
o Include calories from other supplements.
o Include calories from propofol if continuous infusion ≥ 6 hrs. Do NOT include
intermittent doses of propofol.
o Do NOT include calories from IV solutions.

Protein Received: The total protein will need to be calculated by the dietitian daily as
follows:
o Include protein from glutamine and supplements, if applicable.

If patient is on a combination of Enteral Nutrition and Parenteral Nutrition, please
calculate the calories received from each separately.

Location of feeding tube: Pick one of the options from the drop down box to indicate
the location of feeding tube (refers to any oro/naso-gastric or feeding tube). Choose one
of the following options:
1. “Gastric confirmed” if placement was confirmed by an X ray on that day
2. “Gastric presumed” if placement was confirmed by an X-ray earlier but not on
that day
3. “Post-pyloric duodenal confirmed” if placement was confirmed by an X-ray on
that day
4. “Post-pyloric duodenal presumed” if placement was confirmed by an X-ray earlier
but not on that day
5. “Post-pyloric jejunal confirmed” if placement was confirmed by an X-Ray on that
day
6. “Post-pyloric jejunal presumed” if placement was confirmed by an X-ray earlier
but not on that day
7. No tube in place on that day
If the location of the feeding tube changes within the day, please choose the location that was used for the
majority of the day. If gastric was used for half the day and post-pyloric for the other half, choose postpyloric.
Instructions: INS08
Date: 1 April 08
28

Feeding Intolerance: Indicate Yes or No if enteral nutrition was ever interrupted due to
feeding intolerance. An interruption in enteral feeding is defined as a reduction in the
rate of delivering the feed or stopping the feed. Feeding intolerance is defined as the
presence of any one of the following:
o High gastric residual volumes
o Emesis (i.e. vomiting)
o Aspiration of enteral nutrition

Motility Agents: Choose from the options below. We are not asking you to record the
route of administration or dose. If patient has been prescribed combination therapy,
please select all motility agents prescribed (hold control and click to select multiple
options).
Motility agents
1. Metoclopramide
2. Motilium
3. Erythromycin
4. Other: Specify______
5. None
d. Erythromycin
Webshot
of Enteral Nutrition Page
e. Other or NONE
Instructions: INS08
Date: 1 April 08
29
Parenteral Nutrition Data
This form is to be filled out for each patient daily. The study day will automatically appear on
the screen.

Reason EN not provided: Choose from taxonomy, if reason for PN not listed, select
‘other’ and specify.
Reason Enteral Nutrition Not Provided
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
No clinical reason
Mechanical bowel obstruction
Bowel ischemia
Small bowel ileus
Small bowel fistulae
Gastrointestinal perforation
Short Gut Syndrome
Hemodynamic instability
Proximal bowel anastomosis
Not tolerating enteral feeding
No access to small bowel
Pancreatitis
Gastrointestinal bleed
Gastrointestinal surgery
Other, specify ________

Kilocalories Received: The total calories will need to be calculated by the dietitian
daily as follows:
o Include calories from protein
o Include calories from other supplements.
o Include calories from propofol if continuous infusion ≥ 6 hrs. Do NOT include
intermittent doses of propofol.
o Do NOT include calories from other IV solutions.

Protein Received: The total protein will need to be calculated by the dietitian daily as
follows:
o Include protein from glutamine and supplements, if applicable.

If patient is on a combination of Enteral Nutrition and Parenteral Nutrition, please
calculate the calories received from each separately.

Lipids Received: Use the taxonomy provided to select the type of lipid (see below).
Instructions: INS08
Date: 1 April 08
Type of lipids
None
1. Soybean oil based (LCTs)
2. MCT/LCT physical mixture
3. MCT/LCT structured form
4. Olive Oil based
5. Fish Oil based (10-20% of total lipid emulsion)
6. Mixture of soy oil, MCTs, and fish oil
7. Mixture of soy oil, MCTs, olive oil, and fish oil (SMOF)
8. Other, specify ____________
30

Click on ‘save’ to save the form and return to the patient status page.
Webshot of Daily Parenteral Nutrition Page
Instructions: INS08
Date: 1 April 08
31
Outcomes
All outstanding issues must be addressed before you can access this page. The outstanding issues will
appear at the top of the Patient Status Page
This form is to be completed upon discharge from ICU/hospital or if the patient dies. This form
is to be completed once for each patient. You may need to wait until day 60 (from admission to
ICU) to complete some of the questions.

On the Patient Status Page under Outcomes and Follow-up select ‘Finalize Patient’.
You will be directed to the Outcome page.

Enteral/Parenteral Nutrition First Initiated: Indicate when EN/PN was initiated.
o If started prior to ICU admission and continued in ICU, date and time of enteral
nutrition started will become ICU admission date/time.
o If initiated in ICU, record the date and time enteral nutrition was started in ICU.

“Did patient die in hospital/ICU?” “Yes” or “No”
o If “Yes”:
o You will be prompted to provide date and time of actual death. Note: Death date
& time will be same as Hospital & ICU discharge date and time, therefore you do
not complete the date fields, simply indicate that hospital/ICU discharge date
same as date of death.
o If “No”
o You will be prompted to indicate if the patient is still in ICU or hospital at day 60
(from admission to ICU). If the patient was discharged, you will be prompted to
enter hospital/ICU date and time.
When was mechanical ventilation discontinued in the ICU? Indicate when mechanical
ventilation discontinued.

If patient is discharged from ICU while still ventilated (for example, transfer to step-down unit or transfer to
another hospital), discontinuation date and time of ventilation is same as ICU discharge date and time. In
addition, please make a comment in the Comment Box describing the situation.
Death or ICU/hospital discharge marks the end of data collection. We are not asking you to follow-up for 60
days after discharge home or transfer to another healthcare facility.
:

Logic Alert
Click ‘Finalize Patient’ to save the form and be directed back to the patient status page.
If ICU discharge date is not consistent with the duration of the daily data that you
have entered, an input warning will be generated, as follows
“Date EN initiated does not match observation data”
You may either correct the ICU discharge date or enter additional daily data to the
end of the study period
Instructions: INS08
Date: 1 April 08
32
Webshot of Outcomes
Instructions: INS08
Date: 1 April 08
33
Finalizing Data Entry
To determine when the data entry has been completed, a data finalization process has been
incorporated into the web based data entry system.
When you have completed data entry for all 20 patients go to the ICU Status Page and Data
Entry Status, tick the box that asks ‘Is data entry finalized at your ICU?’
Make sure that the data you have entered is accurate to the best of your knowledge before you
finalize the data.
Instructions: INS08
Date: 1 April 08
34
Appendices
Appendix 1
Height Conversion Table
One foot = 12 inches
One inch = 2.54 cms
Feet/Inches
Inches
Centimeters
Feet/Inches
Inches
Centimeters
4ft 6 inch
54
137
5ft 10 inch
70
178
4ft 7 inch
55
140
5ft 11 inch
71
180
4ft 8 inch
56
142
6 ft
72
183
4ft 9 inch
57
145
6ft 1 inch
73
185
4ft 10 inch
58
147
6ft 2 inch
74
188
4ft 11 inch
59
150
6ft 3 inch
75
191
4ft 12 inch
60
152
6ft 4 inch
76
193
5ft 1 inch
61
155
6ft 5 inch
77
196
5ft 2 inch
62
157
6ft 6 inch
78
198
5ft 3 inch
63
160
6ft 7 inch
79
201
5ft 4 inch
64
163
6ft 8 inch
80
203
5ft 5 inch
65
165
6ft 9 inch
81
206
5ft 6 inch
66
168
6ft 10 inch
82
208
5ft 7 inch
67
170
6ft 11 inch
83
211
5ft 8inch
68
173
7ft
84
213
5ft 9inch
69
175
7ft 1 inch
85
216
Instructions: INS08
Date: 1 April 08
35
Appendix 2
Enteral Nutrition Formula Taxonomy
A. Abbott International
Code
A1
A2
A3
A4
A5
A6
A7
A8
A9
A10
A11
A12
A13
A14
A15
A16
A17
A18
A19
A20
A21
A22
A23
Formula Name
AlitraQ
Edanec
Edanec HN
Ensure
Ensure HP
Ensure Plus
Glucerna
Glucerna Select
Jevity
Jevity 1 Cal
Jevity 1.2 Cal
Jevity 1.5 Cal
Jevity Plus 1.5 k/cal
Jevity 2 with FOS
Jevity with FOS
Jevity HiCal
Jevity Plus
Jevity Promote
Nepro
Osmolite
Osmolite 1 Cal
Osmolite 1.2 Cal
Osmolite 1.5 Cal
Code
A24
A25
A26
A27
A28
A29
A30
A31
A32
A33
A34
A35
A36
A37
A38
A39
A40
A41
A42
A43
A44
A45
A46
Formula Name
Osmolite with Fiber
Osmolite HN
Osmolite HN Plus
Osmolite High Protein
Oxepa
Optimental
Optimental 1.0
Perative
Pivot 1.5 Cal
Promote
Promote with Fiber
Pulmocare
Pulmocare II
Suplena
Two Cal HN
Vital
Vital HN
Supplement: Juven
Supplement: Polycose powder
Supplement: Polycose Liquid
Supplement: Promod
Supplement: Prosure
Other Abbott Product (please specify)
B. Fresenius Kabi
Code
B1
B2
B3
B4
B5
B6
B7
B8
B9
B10
B11
B12
B13
Formula Name
1000 complete
1200 complete
1800 complete
Diben
Fresubin Original
Fresubin Original Fibre
Fresubin Energy
Fresubin Energy Fibre
Fresubin HP Energy
Fresubin Soya Fibre
Fresubin HEPA
Fresubin Diabetes
Fresubin
B14
B15
B16
B17
B18
B19
Intestamin
Reconvan
Supportan
Survimed Renal
Survimed OPD
Other Fresenius Kabi Product
Instructions: INS08
Date: 1 April 08
36
C. Nestle
Code
C1
C2
C3
C4
C5
Formula Name
Crucial
Peptamen with Prebio 1
Peptamen
Peptamen 1.5
Peptamen VHP
C6
C7
C8
C9
C10
C11
C12
C13
C14
C15
Peptamen AF
Nutren 1.0
Nutren 1.0 Fiber
Nutren 1.5
Nutren 1.5 Fiber
Nutren 2.0
Nutren Glytrol
Nutren Probalance
Nutren Pulmonary
Nutren Renal
Code
Formula Name
C16
C17
C18
C19
C20
C21
Nutren Replete
Nutren Replete Fiber
Nutren VHP
Nutren VHP Fiber
Nutren Fibre with Prebio 1
Nutren Fibre 1.5 with Prebio 1
C22
C23
C24
Nutrihep
Supplements: Caloreen
Other Nestle Product
D Novartis
Code
D1
D2
D3
D4
D5
D6
D7
D8
D9
D10
D11
D12
D13
D14
D15
D16
D17
D18
D19
D20
D21
D22
Formula Name
Compleat
Diabetisource AC
Fibersource
Fibersource HN
Impact
Impact Glutamine
Impact with Fiber
Impact 1.5
Isocal
Isocal HN
Isosource
Isosource HN
Isosource HN with fibre
Isosource VHN
Isosource 1.5
Novasource Renal
Novasource Pulmonary
Novasource GI Control
Novasource 2.0
Novasource Diabetes
Peptinex
Peptinex AF 1.2
Code
D23
D24
D25
D26
D27
D28
D29
D30
D31
D32
D33
D34
D35
D36
D37
D38
D39
D40
D41
D42
D43
D44
Formula Name
Peptinex HN
Peptinex DT
Peptinex DT with Prebiotics
Resource 2.0
Resource Plus
Resource Standard
Resource Diabetic
Subdue Plus
Tolerex
Trauma-cal
Ultracal
Vivonex TEN
Vivonex Plus
Vivonex RTF
Supplements- Beneprotein Instant Protein Powder
Supplements - Microlipid
Supplements –Benecalorie
Supplements - MCT oil
Supplements-Resource Glutasolve
Supplements: Resource Arginaid
Supplements- Benefiber
Other Novartis Product
Instructions: INS08
Date: 1 April 08
37
E Nutricia
Code
E1
E2
E3
E4
E5
E6
E7
E8
E9
E10
E11
E12
E13
Formula Name
Cubison
Diason
Nutrison Standard
Nutrison Multi Fibre
Nutrison Protein Plus Multi Fibre
Nutrison Protein Plus
Nutrison1000 Complete Multi Fibre
Nutrison 1200 Complete Multi Fibre
Nutrison Energy Multi Fibre
Nutrison Energy
Nutrison Soya
Nutrison MCT
Nutrison Low Sodium
Code
E14
E15
E16
E17
E18
E19
E20
E21
E22
E23
E24
E25
E26
Formula Name
Nutrison Concentrated
Nutrison Pre
Nutrison Low Energy Multi Fibre
Nutrisorb Low Energy
Nutrisorb Low Energy Soy Multi Fibre
Peptisorb
Supplement: Calogen
Supplement: Protifar
Supplement: Polycal Powder / Fantomalt
Supplement: Polycal Liquid
Supplement: DuoCal
Supplement: Fortimel
Other Nutricia Product
G. Miscellaneous Companies
F. B.Braun
Code
F1
F2
F3
F4
F5
F6
F7
F8
F9
F10
F11
F12
F13
Formula Name
Nutricomp Standard
Nutricomp Standard with Fibre
Nutricomp Standard with Fibre D
Nutricomp
Nutricomp Diabetes
Nutricomp Hepa
Nutricomp Intensive
Nutricomp Immun
Nutricomp MCT
Nutricomp Peptid
Nutricomp Energy
Nutricomp Energy Fibre
Other B.Braun Product
Code
G1
G2
G3
G4
G5
G6
G7
Formula Name
Baxter: Restore-X
MEAD JOHNSON: Portagen
Hormel Health: Immun-Aid
Hormel Health: Hepatic-Aid
Hormel Health: Glutasorb
Hormel Health: Propass
National Nutrition: Argiment
G8
G9
G10
G11
G12
G13
G14
G15
G16
National Nutrition: Argitein
National Nutrition: Prosource liquid
National Nutrition: Prosource powder
Global Health: Procel
Medical Nutrition: Pro-stat
Victus Inc: Immunex Plus
Wyeth: Enercal
Wyeth: Enercal Plus
Other
Instructions: INS08
Date: 1 April 08
38