Multi-faceted strategy improves nutritional support for ICU patients, but not outcomes

Dec 16 2008

A strategy to change practice in intensive care units was effective in implementing earlier nutritional support for critically ill patients, but the change did not result in a reduced risk of death or reduced length of stay in the ICU, according to a study in the December 17 issue of JAMA, the Journal of the American Medical Association.

Previous studies have found that early nutritional support, provided within 24 hours of injury or intensive care unit (ICU) admission, is a key component in the treatment of critically ill patients and may reduce the risk of death. But early nutritional support varies widely between ICUs, and up to 40 percent of eligible patients may remain unfed after 48 hours in the ICU, according to background information in the article.

"Evidence-practice gaps are common in clinical practice, with 30 percent of hospitalized patients receiving care inconsistent with current best evidence. Evidence-based guidelines (EBGs) help reduce evidence-practice gaps by promoting awareness of interventions of proven benefit and discouraging ineffective care. However, the ICU is a complex multidisciplinary environment, and reducing evidence-practice gaps through the successful implementation of an EBG in such an environment is difficult," the authors write. They add that evidence supporting whether guidelines can improve ICU feeding practices and patient outcomes is contradictory.

Gordon S. Doig, Ph.D., of the University of Sydney, Australia, and colleagues conducted a study to examine the effect on death and measures of practice change of implementing EBGs for nutritional support in ICUs. The trial included 27 hospitals in Australia and New Zealand and 1,118 critically ill adult ICU patients. Intensive care units were randomly assigned as either guideline or control groups. An evidence-based guideline was developed and a practice-change strategy, consisting of 18 specific interventions, supported by educational outreach visits, was implemented in guideline ICUs. Guideline and control ICUs enrolled 561 and 557 patients, respectively.

The researchers found that no guideline hospitals failed to implement the evidence-based guideline. Significantly more patients in guideline ICUs received nutritional support during their ICU stay (94.3 percent vs. 72.7 percent) and were fed within 24 hours of ICU admission (60.8 percent vs. 37.3 percent). Patients in guideline ICUs were fed significantly earlier (0.75 vs. 1.37 average days to start of enteral nutrition [food provided through a feeding tube placed through the nose and into the stomach or small intestine]; and 1.04 vs. 1.40 average days to start of parenteral nutrition [intravenous feeding]), achieved caloric goals more often, and were fed on a greater proportion of ICU days (8.08 vs. 6.90 fed days per 10 patient-days) than patients in control ICUs.

There were no significant differences between guideline and control ICUs with regard to the rate of death in the hospital or ICU, or average length of stay in the ICU or hospital. The incidence of clinically significant kidney dysfunction was significantly lower in the guideline ICUs compared with controls; however, there was no difference in the use of renal replacement therapy (such as dialysis).

"We achieved significant practice change in the complex environment of the ICU through the use of a multifaceted, multilevel practice-change strategy, leveraged by educational outreach visits. Although the successful implementation of the guideline resulted in significant practice change, it did not result in reduced hospital mortality in critically ill patients," the authors conclude.

(JAMA. 2008;300[23]:2731-2741.

Editorial: Implementing Nutrition Guidelines in the Critical Care Setting - A Worthwhile and Achievable Goal?

In an accompanying editorial, Naomi E. Jones, R.D., M.Sc., and Daren K. Heyland, M.D., F.R.C.P.C., of Queen's University and Kingston General Hospital, Kingston, Ontario, Canada, comment on the findings of Doig and colleagues.

"These results are somewhat disappointing and prompt reflection on possible explanations. Existing guidelines recommend starting enteral nutrition within 24 to 48 hours, so shifting the average time to initiation of enteral nutrition from 1.37 days (32.9 hours) to 0.75 days (18 hours) may not be a large enough effect to influence clinical outcomes. Moreover, practices in both treatment groups were within recommended limits, with 95 percent of patients in both groups fed by 1.6 days after admission."

"While Doig et al have made significant efforts to improve nutrition practice in the critical care setting, it is only through tailoring interventions to address identified barriers that change ultimately will occur and optimal nutrition will have positive effects on the morbidity and mortality of critically ill patients. The design of future studies will be strengthened by including barrier assessment and aligning the intervention with the complexity of the critical care environment."

(JAMA. 2008;300[23]:2798-2799.