Building ICU – PNuT
Intensive Care Unit –
Pediatric Nutrition Team (ICU-PNuT)
Sharon Y Irving, PhD, CRNP, FCCM
Assistant Professor, Pediatric Nursing
Financial Disclosures
 No Disclosures
Objectives
 Discuss role of multi-disciplinary team for nutrition
support in PICU
 Present current clinical and research activities of the
team
Background
 Basis of the work
 15 attending physicians, 12 ICU fellows = 27
approaches to nutrition support
 7- 8 attending ‘opinions’ on any given day
 No way to systematically assess nutrition
 Patient safety
 July 2011like-minded individuals organized to
formally address the issues
What is / Who are ICU - PNuT?
ICU - Pediatric Nutrition Team
Multidisciplinary Team
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PICU RDs
RNs
Pharmacist
Research Coordinator
MDs
Why a “Formal” Group?
 A desire to improve the prescription and delivery of
macro/micro nutrients to the PICU patient population
 CCM has several diagnosis-specific focus groups
(they all need nutrition)
 Have an interest in creating a quality improvement
agenda related to nutrition support for PICU patients
 Create a research agenda related to nutrition, nutrition
prescription and delivery to PICU population, including
securing funding for QI and research projects
ICU – PNuT Goals
 Development of an overall plan for the safe and
effective provision of nutrition for patients admitted
to the PICU
 Development of a program of nutrition research for
pediatric critical care
 Development of education initiatives regarding
pediatric nutrition practice(s)
ICU – PNuTs Mission
To improve nutritional assessment and the
prescription, delivery and monitoring of nutritional
needs to enhance patient outcomes and safety for
infants, children and adolescents during and
immediately following critical illness.
Activities / Projects
 Clinical QI Projects
 Raising awareness / education about the importance of
anthropometry measurements in PICU patients
• Nursing staff education
• Critical Care Admission Orders
 Feeding guidelines
 Research Projects
 International Pediatric ICU Nutrition Study
 Internet Survey
 Numerous poster presentations at professional meetings:
SCCM, ASPEN, STTI, AND, CHOP
 Upcoming collaborative projects: SuPPER; COBOII
 Education
 Nutrition lectures added to CCM fellows/NP curriculum
Research Projects - PICNIC
PICNIC Study
 Improving the Practice of Nutrition Therapy in Critically Ill
Children: Pediatric International Nutrition Intake Survey
 An international period-prevalence survey of PICU nutrition
practices
 Goal: Compare nutrition practices with units of similar size
and patient characteristics
 Total of 59 PICUs; 20+ PICUs of > 24 beds
How Did CHOP Compare?
Item
CHOP
(n=15)
Sister Units
(n=470; 24 units)
Nutrition
Assessment
No
Yes
Energy Needs
Schofield
Talbot
WHO
IC
Other
0
0
86.7%
0
13.3%
25.1%
1.5%
21.1%
1.1%
50.4%
Stress Factor
93.3%
41.5%
35 (8-61)
27 (6-61)
11 (5-23)
16 (9-31)
9 (6-16)
6 (3-11)
LOS
Hosp
PICU*
Vent Days
*PIM scores -4.2 vs -1.9 in sister units
Research Projects - PICNIC
 Other PICNIC findings for CHOP
 No feeding protocol (30% sister units use protocol)
 On average initiated EN on 2nd PICU day (30.8% vs
27.2%)
•
At 3rd PICU day 61% of CHOP PICU were on EN compared
to 74% in sister units
 No algorithm for: motility agents, small bowel feedings, or
withholding feedings for procedures
 Slighter higher number of patients on PN compared to
sister units
These data reflect frequent nutrition interruptions at CHOP
Research Projects
 PICNIC Study Summary
 Internationally, inadequate nutrition delivery in
critically ill pediatric patients across all units with
several barriers noted
 PICUs that used feeding protocols had decrease
prevalence of acquired infections
 CHOP was below the international average
• Number of subjects entered
• Severity of illness of patients admitted to
CHOP PICU
Research - PICNIC
 Hamilton et al., 2014
 Improved enteral nutrition delivery
 Decreased reliance on parenteral delivery
 Energy goals were achieved earlier in a larger
proportion of patients
 Meyer et al., 2009
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Protocols improved nutritional practice
Nutritional support was started earlier in PICU stay
Increased enteral nutrition use
Increased attainment of energy goals earlier in PICU
stay
Research Project –
Anthropometric Measurements
Barriers to Obtaining Anthropometric
Measurements in PICU Patients
 Hypothesis:
Barriers exist to obtaining anthropometry measurements
and perceptions of these barriers differ between ordering
clinicians and nurses
 Participants*: physicians, nurse practitioners, physician
assistants, nurses, RDs
 Anthropometry measurements surveyed: weight, stature,
head circumference in < 2 year olds
Research –
Anthropometric Measurements
 Methods
 21-item survey using Survey Monkey
 Locally tested for question clarity and construct validity
 Internet distribution via listservs of professional
organizations with membership known to care for
critically ill children
 Data collection x14 weeks, June – September 2012 w/
reminders
Research –
Anthropometric Measurements
Sample of survey items:
 Are growth parameters (weight, stature, head circumference)
collected on each patient on admission to the ICU?
 If an actual weight or length/height is not measured on
admission, how do you obtain an estimate?
 What do you consider to be barriers to obtaining
anthropometrics on critically ill patients?
 Do you routinely place orders for anthropometric
measurements on PICU patients?
 How is the anthropometric data shared with the care team?
Research –
Anthropometric Measurements
Total responses = 376
 Responses with complete data for analysis = 318
 Responses of nurses and ordering providers = 258
 Most respondents were located in United States
 92% ordering providers*
 87% nurses
Chi-square and Fisher’s Exact
STATA Data Analysis and Statisitical Software
* Did
not breakdown the ordering providers
Research –
Anthropometric Measurements
Experience of Responders in Years
Ordering Providers
Nurses
N = 119
N = 139
Years
Years
Years
p value 0.005
Note: values presented are % of respondents in each category
Research Project –
Anthropometric Measurements
Type of PICU
70
% of Respondents
60
50
40
Ordering Provider
30
Nurses
20
10
0
Med-Surg
Cardiac
Mixed
Other
p value 0.07
Research –
Anthropometric Measurements
Sources of anthropometry when not obtained at PICU admission
Values are % of total respondents for each category
Ordering provider
Nurses
(n=119)
(n=139)
Nurses too busy, (%)*
Weight
Stature
Head circumference
62 (52)
62 (52)
59 (50)
47 (34)
51 (37)
40 (29)
0.004
0.02
0.001
Patient does not want to be disturbed, (%)*
Weight
Stature
Head circumference
52 (44)
43 (36)
41 (34)
60 (43)
52 (37)
46 (33)
1.00
0.90
0.90
Isolation, (%)*
Weight
Stature
Head circumference
16 (13)
12 (10)
10 (8)
10 (7)
9 (7)
2 (1)
0.10
0.36
0.01
Not considered important, (%)*
Weight
Stature
Head circumference
39 (33)
59 (50)
57 (48)
17 (12)
41 (30)
24 (17)
0.001
0.001
0.001
Lack of correct equipment, (%)*
Weight
Stature
Head circumference
35 (29)
32 (27)
14 (12)
34 (25)
44 (32)
6 (4)
0.40
0.41
0.03
Unsure of correct technique, (%)*
Weight
Stature
Head circumference
23 (19)
40 (34)
32 (27)
7 (5)
24 (17)
7 (5)
0.001
0.004
0.001
Provider Specific Barriers
p-value
Research –
Anthropometrc Measurements
Conclusions from these data:
 Barriers to obtaining anthropometry measurements in
critically ill children exist
 Ordering clinicians perceived more barriers than nurses
 Interdisciplinary education is necessary to overcome real
and perceived barriers to obtaining anthropometry
measurements in critically ill children
 In Press: American Journal of Critical Care
Quality Improvement –
Anthropometry Measurements
 Start at the Beginning
 Standards around anthropometry measurements in PICU
 Educate / re-educate PICU staff in safe technique to obtain
anthropometry measurements
 Consistent, accurate documentation of measurements
 Compliance of EPIC orders with measurements obtained
 Consistency, accuracy and frequency of anthropometry
measurements have implications for patient safety
 Medications, fluids, nutrition, ventilation and other therapies
 Determination for emergencies and resuscitation needs
Quality Improvement
Methods
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Survey of knowledge attitude and practice
Learning Link ppt with post test for nursing staff
PICU Skills fairs
CQI staff education
Team specific RD involvement
Equipment upgrade
Identified place to document in EPIC
“Forced behaviors” addition in PICU admission order set
Quality Improvement
 Process assessment
 Baseline audit from Dec 2011 – Feb 2012
 Intervention April 2012 - ongoing
 Repeat audit June – September 2013
Weight audit
90
85
79
80
69
70
56
60
50
49
45
PRE
40
POST
30
20
10
0
Census
Weight ordered
Weight measured
Increase in orders; weights not consistently obtained
20% to 33% do not have weight obtained
Stature audit
90
81
80
70
60
50
49
45
PRE
36
40
26
30
20
10
5
0
Census
Stature ordered
Stature measured
Increase in orders, stature obtained more often
NEEDS IMPROVEMENT
POST
Head circumference audit
40
37
35
30
25
20
20
19
16
PRE
POST
15
11
8
10
5
0
Census
Head circ ordered
Head circ measured
Increase in orders, head circumference obtained more often
NEEDS IMPROVEMENT
Recurring weight audit
80
72
68
70
60
50
54
49
55
45
40
40
PRE
30
23
20
10
0
Census
Recurring weight
ordered
Recurring weight
measured
Compliance
Increase in orders, improved compliance
33% to 45% do not have recurrent weight obtained
NEEDS IMPROVEMENT
POST
Follow-Up and Moving Forward
 Identify and minimize hurdles to anthropometry
measurements
 Increase education to all clinical staff (FLOCs , RNs
and CCM faculty) for orders and measurements
 Collective ownership
 Clinical team utilization of data
 Monthly presentation at CQI
 Education to SNAs to assist with obtaining
anthropometry measurements in PICU patients
Quality Improvement
PICU Feeding Pathway
Goal:
 Consistent approach to nutrition initiation, delivery and goal
energy and protein attainment in PICU population
 Literature supports early nutrition initiation
 Sustain organ function / prevent organ dysfunction
 Feeding protocols facilitate early nutrition and improved
delivery
Meyer et al, 2009; Petrillo-Albarano et al, 2006; Khalid et al, 2010; Briassoulis et al, 2001
 Early nutrition support – EN reduces total cost of care
Doig et al, 2013
Quality Improvement –
Feeding Pathway
 Goals:
 Reduce time from PICU admission to initiation of EN
 Reduce time from EN initiation to attain goal nutrition (per RD
recs)
 Reduce unnecessary and prolonged interruptions to EN
 Reduce unnecessary use of PN
 Metrics
 Expect decrease in time from admission to initiation of EN
 Expect increase in patients that commence EN <48 hrs of
PICU admission
 Expect decrease in time to attain goal nutrition
 Expect decrease in interruptions to EN
http://www.chop.edu/clinical-pathway/nutrition-picu-initiation-and-advancement-clinical-pathway-inpatient
Quality Improvement –
Feeding Guidelines
Next Steps:
 Comparison of pre / post pathway feeding initiation
 Analysis of impact of initiation of feeding pathway on
PICU and/or hospital stay
(to date ~50 patients initiated on pathway )
 Ongoing education efforts to raise awareness to PICU
clinical staff and providers
i.e. “Did your patient today receive nutrition today? If
not why not?”
Quality Improvement to
Research Question
Intubated, no vasopressor support on EN only
Summary
 ICU-PNuT is a multidisciplinary collaborative who
goals is to improve nutrition prescription and
delivery in PICU patients
 Ultimately we plan to follow their short and
potentially long-term outcomes is assess the “the
fruit(s) of our labor