Building ICU – PNuTIntensive Care Unit – Pediatric Nutrition Team (ICU-PNuT)

Sharon Y Irving, PhD, CRNP, FCCMAssistant Professor, Pediatric Nursing

Financial Disclosures

No Disclosures

Objectives

Discuss role of multi-disciplinary team for nutrition support in PICU

Present current clinical and research activities of the team

Background

Basis of the work 15 attending physicians, 12 ICU fellows = 27

approaches to nutrition support 7- 8 attending ‘opinions’ on any given day No way to systematically assess nutrition Patient safety July 2011like-minded individuals organized to

formally address the issues

What is / Who are ICU - PNuT?

ICU - Pediatric Nutrition TeamMultidisciplinary Team

PICU RDs RNs Pharmacist Research Coordinator MDs

Why a “Formal” Group? A desire to improve the prescription and delivery of

macro/micro nutrients to the PICU patient population

CCM has several diagnosis-specific focus groups (they all need nutrition)

Have an interest in creating a quality improvement agenda related to nutrition support for PICU patients

Create a research agenda related to nutrition, nutrition prescription and delivery to PICU population, including securing funding for QI and research projects

ICU – PNuT Goals

Development of an overall plan for the safe and effective provision of nutrition for patients admitted to the PICU

Development of a program of nutrition research for pediatric critical care

Development of education initiatives regarding pediatric nutrition practice(s)

ICU – PNuTs Mission

To improve nutritional assessment and the prescription, delivery and monitoring of nutritional needs to enhance patient outcomes and safety for infants, children and adolescents during and immediately following critical illness.

Activities / Projects Clinical QI Projects

Raising awareness / education about the importance of anthropometry measurements in PICU patients• Nursing staff education• Critical Care Admission Orders

Feeding guidelines

Research Projects International Pediatric ICU Nutrition Study Internet Survey Numerous poster presentations at professional meetings:

SCCM, ASPEN, STTI, AND, CHOP Upcoming collaborative projects: SuPPER; COBOII

Education Nutrition lectures added to CCM fellows/NP curriculum

Research Projects - PICNIC

PICNIC Study Improving the Practice of Nutrition Therapy in Critically Ill

Children: Pediatric International Nutrition Intake Survey An international period-prevalence survey of PICU nutrition

practices Goal: Compare nutrition practices with units of similar size

and patient characteristics Total of 59 PICUs; 20+ PICUs of > 24 beds

Item CHOP (n=15)

Sister Units(n=470; 24 units)

Nutrition Assessment

No Yes

Energy Needs Schofield Talbot WHO IC Other

0086.7%013.3%

25.1% 1.5%21.1% 1.1%50.4%

Stress Factor 93.3% 41.5%

LOS Hosp PICU* Vent Days

35 (8-61)27 (6-61)11 (5-23)

16 (9-31) 9 (6-16) 6 (3-11)

How Did CHOP Compare?

*PIM scores -4.2 vs -1.9 in sister units

Research Projects - PICNIC

Other PICNIC findings for CHOP No feeding protocol (30% sister units use protocol)

On average initiated EN on 2nd PICU day (30.8% vs 27.2%)• At 3rd PICU day 61% of CHOP PICU were on EN compared

to 74% in sister units No algorithm for: motility agents, small bowel feedings, or

withholding feedings for procedures Slighter higher number of patients on PN compared to

sister units

These data reflect frequent nutrition interruptions at CHOP

Research Projects

PICNIC Study Summary Internationally, inadequate nutrition delivery in

critically ill pediatric patients across all units with several barriers noted

PICUs that used feeding protocols had decrease prevalence of acquired infections

CHOP was below the international average

• Number of subjects entered

• Severity of illness of patients admitted to CHOP PICU

Research - PICNIC

Hamilton et al., 2014 Improved enteral nutrition delivery Decreased reliance on parenteral delivery Energy goals were achieved earlier in a larger

proportion of patients

Meyer et al., 2009 Protocols improved nutritional practice Nutritional support was started earlier in PICU stay Increased enteral nutrition use Increased attainment of energy goals earlier in PICU

stay

Research Project – Anthropometric Measurements

Barriers to Obtaining Anthropometric Measurements in PICU Patients Hypothesis: Barriers exist to obtaining anthropometry measurements and perceptions of these barriers differ between ordering clinicians and nurses Participants*: physicians, nurse practitioners, physician

assistants, nurses, RDs Anthropometry measurements surveyed: weight, stature,

head circumference in < 2 year olds

Research – Anthropometric Measurements

Methods 21-item survey using Survey Monkey Locally tested for question clarity and construct validity Internet distribution via listservs of professional

organizations with membership known to care for critically ill children

Data collection x14 weeks, June – September 2012 w/ reminders

Are growth parameters (weight, stature, head circumference) collected on each patient on admission to the ICU?

If an actual weight or length/height is not measured on admission, how do you obtain an estimate?

What do you consider to be barriers to obtaining anthropometrics on critically ill patients?

Do you routinely place orders for anthropometric measurements on PICU patients?

How is the anthropometric data shared with the care team?

Research – Anthropometric Measurements

Sample of survey items:

Total responses = 376

Responses with complete data for analysis = 318

Responses of nurses and ordering providers = 258

Most respondents were located in United States 92% ordering providers*

87% nurses

Research –Anthropometric Measurements

* Did not breakdown the ordering providers

Chi-square and Fisher’s ExactSTATA Data Analysis and Statisitical Software

Ordering ProvidersN = 119

Years

Research – Anthropometric Measurements

NursesN = 139

p value 0.005Note: values presented are % of respondents in each category

YearsYears

Experience of Responders in Years

Research Project – Anthropometric Measurements

p value 0.07

Med-Surg Cardiac Mixed Other0

10

20

30

40

50

60

70

Ordering ProviderNurses

% o

f R

espo

nden

ts

Type of PICU

Values are % of total respondents for each category

Research – Anthropometric Measurements

Sources of anthropometry when not obtained at PICU admission

 Provider Specific Barriers Ordering provider

(n=119)

Nurses(n=139)

p-value

Nurses too busy, (%)* Weight Stature Head circumference

 62 (52)62 (52)59 (50)

 47 (34)51 (37)40 (29)

 0.0040.02

0.001

Patient does not want to be disturbed, (%)* Weight Stature Head circumference

 52 (44)43 (36)41 (34)

 60 (43)52 (37)46 (33)

 1.000.900.90

Isolation, (%)* Weight Stature Head circumference

 16 (13)12 (10)10 (8)

 10 (7)9 (7)2 (1)

 0.100.360.01

Not considered important, (%)* Weight Stature Head circumference

 39 (33)59 (50)57 (48)

 17 (12)41 (30)24 (17)

 0.0010.0010.001

Lack of correct equipment, (%)* Weight Stature Head circumference

 35 (29)32 (27)14 (12)

 34 (25)44 (32)

6 (4)

 0.400.410.03

Unsure of correct technique, (%)* Weight Stature Head circumference

 23 (19)40 (34)32 (27)

 7 (5)

24 (17)7 (5)

 0.0010.0040.001

Research – Anthropometrc Measurements

Barriers to obtaining anthropometry measurements in critically ill children exist

Ordering clinicians perceived more barriers than nurses

Interdisciplinary education is necessary to overcome real and perceived barriers to obtaining anthropometry measurements in critically ill children

In Press: American Journal of Critical Care

Conclusions from these data:

Quality Improvement – Anthropometry Measurements

Start at the Beginning Standards around anthropometry measurements in PICU Educate / re-educate PICU staff in safe technique to obtain

anthropometry measurements Consistent, accurate documentation of measurements Compliance of EPIC orders with measurements obtained

Consistency, accuracy and frequency of anthropometry measurements have implications for patient safety

Medications, fluids, nutrition, ventilation and other therapies Determination for emergencies and resuscitation needs

Quality Improvement

Methods Survey of knowledge attitude and practice Learning Link ppt with post test for nursing staff PICU Skills fairs CQI staff education Team specific RD involvement Equipment upgrade Identified place to document in EPIC “Forced behaviors” addition in PICU admission order set

Quality Improvement

Process assessment Baseline audit from Dec 2011 – Feb 2012 Intervention April 2012 - ongoing Repeat audit June – September 2013

Weight audit

Census Weight ordered Weight measured0

10

20

30

40

50

60

70

80

90

49

56

79

45

85

69

PREPOST

Increase in orders; weights not consistently obtained

20% to 33% do not have weight obtained

Stature audit

Increase in orders, stature obtained more oftenNEEDS IMPROVEMENT

Census Stature ordered Stature measured0

10

20

30

40

50

60

70

80

90

49

5

26

45

81

36PREPOST

Head circumference audit

Increase in orders, head circumference obtained more oftenNEEDS IMPROVEMENT

Census Head circ ordered Head circ measured0

5

10

15

20

25

30

35

40

20

8

11

16

37

19 PREPOST

Recurring weight audit

Census Recurring weight ordered

Recurring weight

measured

Compliance0

10

20

30

40

50

60

70

80

4954 55

23

45

7268

40

PREPOST

Increase in orders, improved compliance33% to 45% do not have recurrent weight obtained

NEEDS IMPROVEMENT

Follow-Up and Moving Forward

Identify and minimize hurdles to anthropometry measurements

Increase education to all clinical staff (FLOCs , RNs and CCM faculty) for orders and measurements

Collective ownership Clinical team utilization of data Monthly presentation at CQI

Education to SNAs to assist with obtaining anthropometry measurements in PICU patients

Quality Improvement

PICU Feeding Pathway

Goal: Consistent approach to nutrition initiation, delivery and goal

energy and protein attainment in PICU population

Literature supports early nutrition initiation Sustain organ function / prevent organ dysfunction Feeding protocols facilitate early nutrition and improved

deliveryMeyer et al, 2009; Petrillo-Albarano et al, 2006; Khalid et al, 2010; Briassoulis et al, 2001

Early nutrition support – EN reduces total cost of careDoig et al, 2013

Quality Improvement – Feeding Pathway

Goals: Reduce time from PICU admission to initiation of EN Reduce time from EN initiation to attain goal nutrition (per RD

recs) Reduce unnecessary and prolonged interruptions to EN Reduce unnecessary use of PN

Metrics Expect decrease in time from admission to initiation of EN Expect increase in patients that commence EN <48 hrs of

PICU admission Expect decrease in time to attain goal nutrition Expect decrease in interruptions to EN

http://www.chop.edu/clinical-pathway/nutrition-picu-initiation-and-advancement-clinical-pathway-inpatient

Quality Improvement – Feeding GuidelinesNext Steps:

Comparison of pre / post pathway feeding initiation Analysis of impact of initiation of feeding pathway on

PICU and/or hospital stay

(to date ~50 patients initiated on pathway ) Ongoing education efforts to raise awareness to PICU

clinical staff and providers

i.e. “Did your patient today receive nutrition today? If not why not?”

Quality Improvement to Research Question

Intubated, no vasopressor support on EN only

Summary

ICU-PNuT is a multidisciplinary collaborative who goals is to improve nutrition prescription and delivery in PICU patients

Ultimately we plan to follow their short and potentially long-term outcomes is assess the “the fruit(s) of our labor