Bridging the Guideline-Practice Gap: The Critical Care Experience Rupinder Dhaliwal, RD Daren Heyland, MD Guidelines for Nutrition Therapy in the ICU Rupinder Dhaliwal, RD Operations Manager Clinical Evaluation Research Unit Kingston, Ontario Disclosure Rupinder Dhaliwal Canadian Clinical Practice Guidelines for Nutrition Support for the Mechanically Ventilated Critically ill • Co-Author Critical Care Nutrition The right nutrient/nutritional strategy The right timing The right patient The right intensity (dose/duration) With the right outcome! www.criticalcarenutrition.com www.criticalcarenutrition.com A Continuous Quality Improvement Effort What ought to be done? RCTs, Systematic Reviews, and Evidence-based practice guidelines How to change? What done? What isis done? www.criticalcarenutrition.com “KT strategies” Survey results What do we need to do differently? “Gaps” - site reports Objectives To identify the similarities and the differences between the recommendations of three North American Clinical Practice Guidelines Understand why these differences occur Need for harmonization across guidelines Why bother with guidelines? Clinical practice guidelines are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Best available evidence with integration of potential benefits, harm, feasibility, cost Reduce variability in care, improve quality, reduce costs and can improve outcomes Proliferation of guidelines The more guidelines they publish, the more confused I get! Review of guidelines needed Assesses the process of development A review of the content and the evidence used to formulate the recommendations Which Guidelines to compare? Critically ill populations Developed by North American professional/national organization Published/online 1999-2009 Addressed more than one single topic Were not consensus statements (i.e. immunonutrition ) Were original work vs. part of cluster RCTs North American Guidelines www.criticalcarenutrition.com What differences? • Population • Levels of Evidence • Grading used • Time frames, outcomes • Level of transparency between evidence and recommendation Differences Area Canadian ADA ASPEN/SCCM Population Mechanically ventilated critically ill patients Critically ill patients eligible for EN Medical and surgical critically ill patients no elective surgery no burns expected to stay in the ICU > 2-3 days RCTs, meta analyses All levels of evidence All levels of evidence Level 1 or 2 based on validity of evidence Grade 1-5 based on validity of evidence Minimum n>20 Level 1-5 based on validity of evidence Level of evidence Time Frame 1980-2009 1993-2003 1993-2009 1996-2006 (2009) unclear Outcomes clinical outcomes clinical and non clinical outcomes clinical and non clinical outcomes Grading Canadian ADA ASPEN/SCCM (5%) “Strong” benefits exceed harm high quality evidence anticipated benefits (41%) “A” supported by at least 2 Level 1 (RCT n > 100) (3%) “Recommend” supportive evidence but minor uncertainties re: safety/feasibility or costs “Fair” Same as above but quality of evidence is not as strong “B” supported by 1 level 1 “Should be considered” Evidence was weak or major uncertainties re: safety/cost/feasibility “Weak” Suspect quality of evidence little clear benefit “C” Level 2 (RCTs <100) “Insufficient data” Inadequate data or conflicting evidence (51%) “Consensus” Expert opinion “D” At least 2 Level 3 (non RCT, contemporaneous controls) “Insufficient evidence” No pertinent evidence and harm/risk is ? (37%) “E” Level 4 (non RCT, historical controls) Level 5 (case series), expert opinion (39%) Strongest “Strongly recommend” no reservations re: endorsement Weakest Criteria High Quality CPGs Rigor of development: – Provide detailed information on the search strategy, the inclusion/exclusion criteria, and methods used to formulate the recommendation (reproducible). Transparent link between evidence, values, and resulting recommendation – External review – Procedure for updating the CPG AGREE Qual Saf Health Care 2003;12:18 Integration of values evidence + practice guidelines integration of values Validity Homogeneity Safety Feasibility Cost Differences: recommendations Indirect calorimetry vs. predictive equations Canadian ADA ASPEN/SCCM Insufficient data Strong Grade E Use indirect calorimetry Use either, caution with equations Non RCTs, no clinical outcomes Narrative review article 1 small RCT burn patients Differences: recommendations Dose of EN/Achieving target range Canadian ADA ASPEN/SCCM Should be considered Fair Grade C Use strategies to optimize EN i.e. goal rate start, 250 mls GRVs, m. agents, small bowel feeding Give at least 60-70% energy within first week Provide >50-65% goal calories in first week Specifics for Obese (Grade E and D) No threshold 1 RCT and 2 Cluster RCTs 2 RCTs and 2 non RCTs 1 RCT and 1 non RCT Differences: recommendations Gastric Residual Volumes & Motility agents GRVs Canadian ADA ASPEN/SCCM Should be considered 250 mls Consensus Grade B 250 mls 500 mls 1 RCT and 2 Cluster RCTs Motility agents Recommend metoclopromide 4 RCTs Strong metoclopromide Grade C Metoclopromide Erythromycin Opiod antagonists Differences: recommendations Arginine Canadian ADA ASPEN/SCCM Recommend NOT be used Fair Not be used Grade A Surgical Grade B Medical Cautious in severe sepsis Volume use 50-65% goal Meta-analyses of 22 RCTs 3 RCTs harm (Bower. Bertolini, Dent) 11 RCTs 2 RCTS harm (Bower, Bertolini) earlier meta-analyses showing no benefit RCT showing benefit (Galban) Grade A: based on elective surgery patients Differences: recommendations Enteral Glutamine Canadian Burns & Trauma: ADA ASPEN/SCCM -------- Grade B Should be considered Other ICU: Insufficient data 9 RCTS Burns, Trauma and mixed ICU patients 1 RCT (Jones mixed ICU pts) Differences: recommendations Peptides Canadian Recommend polymeric (since no benefit for peptides) 4 RCTs ADA ASPEN/SCCM --------- Grade E Use small peptides in diarrhea 1 non RCT Differences: recommendations Fibre Canadian ADA ASPEN/SCCM Insufficient data --------- Grade E Use soluble fibre 3 RCTs 6 RCTs Grade C Avoid soluble and insoluble fibre for bowel ischemia/severe dysmotility 2 non RCTs (review, case study) Differences: recommendations Probiotics Canadian ADA ASPEN/SCCM Insufficient data --------No benefit in outcomes, potential for harm Grade C Use in transplant, major abd surgery, severe trauma Not in necrotizing pancreatitis 12 RCTs 5 RCTs (elective sx) Differences: recommendations Intensive Insulin Therapy Canadian ADA ASPEN/SCCM Recommend Target around 144 mg/dl (8.0 mmol/L) Strong Medical: 80-110 mg/dL (4.4-6.1 mmol/L) Grade B Moderate strict control Range 120-160 mg/dL (7-9 mmol/L) Grade E BEING UPDATED 2009 110-150 mg/dL (6.1-8.3 mmol/L) Keep < 180 mg/dL (10 mmol/L) in all Most recent metaanalyses includes NICE SUGAR Similarities? Topic Canadian ADA ASPEN/SCCM Use of EN over PN Start EN within 24-48 hr EN Fish Oils ----- Insufficient ----- Insufficient (45) (45) CHO/Fat Body position Small bowel vs. gastric ADOPT NOW! Continuous vs. other insufficient ---- High risk (D) PN vs std care Not be used ---- Not for 7 days No soy based ---- No soy based PN Glutamine ---- Low dose of PN ---- AOX/vits/minerals ---- Type of IV lipids Slight difference in strength Enteral Nutrition over Parenteral Nutrition Canadians and ADA: Strongest ASPEN/SCCM: second strongest Feeding Protocols Canadians and ASPEN/SCCM: weaker recommendation ADA: none for feeding protocol per se, but for GRV : expert opinion EN plus PN Canadian: recommend NOT be used until strategies to maximize EN adopted ASPEN/SCCM: not be started for 7 -10 days (grade C) Blue Dye ASPEN/SCCM : not recommend ADA : do not recommend but highest level of evidence Conclusions Differences exist between the guidelines: – Populations – Levels of evidence: not enough RCTs so tendency to make a recommendation – Time frames of literature searches and updates – Recommendations: due to interpretation of the evidence, lack of transparency Similarities in many of the recommendations Implications Similarities should be adopted without hesitation Differences Define critically ill patient Transparency needed (websites) Harmonize between societies Practitioner: right recommendation for the right person JPEN Nov 2010:625-643 Ahhh…..Harmonized Guidelines! Thank You!