title: Implementing the PEP uP Protocol in Critical Care Units in Canada: Results of a Multicenter, Quality Improvement Study.
abstract: BACKGROUND
  Previous studies have documented widespread iatrogenic underfeeding in intensive care unit (ICU) patients. In an experimental setting, we demonstrated the safety and efficacy of a novel enteral feeding protocol designed to overcome the main barriers to adequate delivery of enteral nutrition (EN), the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol (PEP uP protocol). The purpose of this article is to describe our experience with implementing this feeding protocol under "real-world" settings in Canada.
  
  
  METHODS
  This study is a multicenter quality improvement initiative with a concurrent control group. Selected ICUs implemented the PEP uP protocol, and nutrition practices and outcomes were compared with a concurrent control group of ICUs.
  
  
  RESULTS
  In 2013, of the 24 ICUs from Canada that participated in the International Nutrition Survey, 8 implemented the PEP uP protocol and the remaining 16 served as concurrent control sites. Patients at PEP uP sites received 60.1% of their prescribed energy requirements from EN compared with 49.9% in patients from control hospitals (P = .02). In addition, patients in PEP uP protocol sites received more protein from EN (61.0% vs 49.7% of prescribed amounts; P = .01), were more likely to receive protein supplements (71.8% vs 47.7%; P = .01), and were more likely to receive >80% of their protein requirements by day 3 (46.1% vs 29.3%; P = .05) compared with patients in control hospitals.
  
  
  CONCLUSIONS
  In the real-life setting, the PEP uP protocol can improve the delivery of EN to critically ill patients.
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada Department of Medicine, Queen's University, Kingston, Ontario, Canada dkh2@queensu.ca.
authors.forename: Daren K
authors.initials: DK
authors.lastname: Heyland
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
authors.forename: Rupinder
authors.initials: R
authors.lastname: Dhaliwal
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
authors.forename: Margot
authors.initials: M
authors.lastname: Lemieux
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
authors.forename: Miao
authors.initials: M
authors.lastname: Wang
authors.affiliation: Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada.
authors.forename: Andrew G
authors.initials: AG
authors.lastname: Day
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002170:Canada; D002985:Clinical Protocols; D003422:Critical Care / Q000379:methods*; D016638:Critical Illness / Q000628:therapy*; D004044:Dietary Proteins / Q000008:administration & dosage; D002149:Energy Intake; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D009751:Nutritional Requirements; D058996:Quality Improvement
chemical_list: D004044:Dietary Proteins
keywords: caloric intake; critical care; energy balance; feeding protocols; nutrition status; nutrition therapy; quality improvement; underfeeding