Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multicenter observational study.
OBJECTIVE
To describe current nutrition practices in intensive care units and determine "best achievable" practice relative to evidence-based Critical Care Nutrition Clinical Practice Guidelines.


METHODS
An international, prospective, observational, cohort study conducted January to June 2007.


METHODS
One hundred fifty-eight adult intensive care units from 20 countries.


METHODS
Two-thousand nine-hundred forty-six consecutively enrolled mechanically ventilated adult patients (mean, 18.6 per site) who stayed in the intensive care unit for at least 72 hrs.


METHODS
Data on nutrition practices were collected from intensive care unit admission to intensive care unit discharge or a maximum of 12 days.


RESULTS
Relative to recommendations of the Clinical Practice Guidelines, we report average, best, and worst site performance on key nutrition practices. Adherence to Clinical Practice Guideline recommendations was high for some recommendations: use of enteral nutrition in preference to parenteral nutrition, glycemic control, lack of utilization of arginine-enriched enteral formulas, delivery of hypocaloric parenteral nutrition, and the presence of a feeding protocol. However, significant practice gaps were identified for other recommendations. Average time to start of enteral nutrition was 46.5 hrs (site average range, 8.2-149.1 hrs). The average use of motility agents and small bowel feeding in patients who had high gastric residual volumes was 58.7% (site average range, 0%-100%) and 14.7% (site average range, 0%-100%), respectively. There was poor adherence to recommendations for the use of enteral formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition, and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5%-94.4%) for energy and 60.3% (site average range, 18.6%-152.5%) for protein.


CONCLUSIONS
Despite high adherence to some recommendations, large gaps exist between many recommendations and actual practice in intensive care units, and consequently nutrition therapy is suboptimal. We have identified "best achievable" practice that can serve as targets for future quality improvement initiatives.
Cahill
Naomi E
NE
Department of Community Health and Epidemiology, Queen's University, and Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada.
Dhaliwal
Rupinder
R
Day
Andrew G
AG
Jiang
Xuran
X
Heyland
Daren K
DK
D003422:Critical Care / Q000379:methods / Q000592:standards*; D004750:Enteral Nutrition / Q000592:standards; D005217:Fat Emulsions, Intravenous / Q000592:standards; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D018529:Nutritional Support / Q000592:standards*; D010288:Parenteral Nutrition / Q000592:standards; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D013997:Time Factors
D005217:Fat Emulsions, Intravenous