Table 3 Description of intervention

Audit and feedback

Summary of nutrition performance data collected by abstracting data from the charts of 20 consecutive mechanically ventilated critically ill patients

Demonstrating the gap between actual and desired performance motivates providers to change practice to reduce the gap

Benchmarked performance report comparing current nutrition practice with guideline recommendations and with other ICUs

Review of performance with small group, discussion of reasons for poor performance, and identification of opportunities for improvement

Educational outreach visit

Personal visit by an external nutrition expert to critical care providers in their own setting, including:

Current evidence-based information is communicated to providers, increasing their knowledge of nutrition, awareness of guideline–practice gaps, and leading to practice change

Grand rounds with ICU providers

Face-to-face discussions with physicians

1. a 1-hour interactive presentation with the following content:

 • evidence supporting nutrition guideline recommendations

 • strategies to optimize EN

 • rationale for tailored intervention

2. feedback on nutrition performance

3. opportunity for discussion

Tailored action plan to overcome identified barriers

Site-specific bundle of interventions selected to overcome local barriers to the provision of EN. Developed at 1-day meeting attended by the local guideline implementation team and key stakeholders and facilitated by the external research team; involving identification of and prioritization of barriers to target for change, brainstorming of feasible and impactful solutions, and development of a step-by-step action plan for implementation. Action plan included interventions targeting at both individual provider and system supports

Strategies selected to address identified barriers, reduce the influence of these barriers leading to practice improvements

System/organizational:

• addition of EN initiation to ICU admission order set

• stock of enteral formula in the ICU

Individual provider:

• education through noon hour workshops (that is, ‘lunch and learns’)/bedside huddles (that is, brief small group meetings held on the unit)

• information sheets summarizing current evidence/guideline recommendations

Reminders:

• posters

• checklist

Performance coaching

External research team provide support to the local guideline implementation team while they implement their action plan

By receiving advice and guidance while going through the action plan implementation process, local teams are more likely to achieve their goals

Facilitation of bimonthly teleconference calls monitoring the progress of the implementation of the tailored action plans

Local opinion leaders

Physician, dietician, and nurse who work in the ICU and are knowledgeable about nutrition therapy

Opinion leaders change practice by influencing the attitudes and behavior of their peers through informal guidance

Informal discussions at the bedside regarding provision of EN to the patients

Networking meeting

Half-day meeting with all participating sites, where each site present the successes and challenges experienced implementing their action plans

Engaging with others with similar experiences leads to sharing of knowledge and motivates change

Informal discussions