building icu – pnut intensive care unit – pediatric nutrition team (icu-pnut) sharon y irving,...
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Building ICU – PNuTIntensive Care Unit – Pediatric Nutrition Team (ICU-PNuT)
Sharon Y Irving, PhD, CRNP, FCCMAssistant Professor, Pediatric Nursing
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
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?”