Nutrition therapy in the critical care setting: what is best achievable practice? An international quality improvement project

Introduction

The purpose of this study was to describe current nutrition practices in ICUs and to determine the best achievable practice relative to the Critical Care Nutrition Clinical Practice Guidelines (CPGs).

Methods

We conducted an international, prospective, observational, cohort study. In January 2007, each ICU recorded data on nutrition practices on a consecutive cohort of 20 mechanically ventilated adult patients that stayed in the ICU for at least 72 hours. Data were collected from the time of admission to the ICU to ICU discharge, or for a maximum of 12 days. Relative to the CPGs, we report average, best, and worst site performance on key nutrition practices.

Results

A total of 158 ICUs from 20 countries participated, and each enrolled an average of 18.6 patients for a total of 2,946 patients. Adherence to CPG recommendations was high for some recommendations; namely, use of enteral nutrition (EN) in preference to parenteral nutrition (PN) (site average 61.7% (range 1 to 97.3%) of patients received EN alone), glycemic control (site average 7.5 (range 3.5 to 10.4) mmol/l), lack of utilization of arginine-enriched enteral formulas (site average 3.5% (range 0 to 92.3%) of patients on EN), delivery of hypocaloric PN (site average 16.8 (range 2.7 to 35.5) kcal/kg), and the presence of a feeding protocol (79.7% of ICUs). However, significant practice gaps were identified for other recommendations. The average time to start of EN was 46.5 hours (range 8.2 to 149.1 hours). The average use of motility agents and small bowel feeding in patients with high gastric residual volumes was 58.7% (range 0 to 100%) and 14.7% (range 0 to 100%), respectively. There was poor compliance with recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental PN, and avoidance of soy-bean-oil-based parenteral lipids. Average nutritional adequacy was 59% (range 20.5 to 94.7%) for energy and 60.3% (range 18.6 to 153.5%) for protein.

Conclusion

Large gaps exist between the evidence-based recommendations and actual practice in ICUs, and consequently nutrition therapy is suboptimal. We have identified best achievable practice that can serve as targets for future quality improvement initiatives.