Clinical trial NCT01168128: PERFormance Enhancement of the Canadian Nutrition Guidelines by a Tailored Implementation Strategy: The PERFECTIS Study
Official title: PERFormance Enhancement of the Canadian Nutrition Guidelines by a Tailored Implementation Strategy: The PERFECTIS Study
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Critically Ill
Intensive Care Unit
Keywords: Enteral Nutrition
Parenteral Nutrition
Critically ill
Nutrition Therapy
Nutrition Support
Practice Guidelines as Topic
Guideline Adherence
Quality Assurance, Health Care
Nutrition Surveys
Questionnaires
Lead sponsor: Clinical Evaluation Research Unit at Kingston General Hospital
Sponsor class: OTHER
Collaborators: name: Ministry of Research, Innovation and Science, Ontario
name: Canadian Foundation for Dietetic Research (CFDR)
First posted: 2010-07-23
Enrollment: 278
Sex: ALL
Minimum age (years): 18
Standard ages: ADULT
OLDER_ADULT
Accepts healthy volunteers: no
Allocation: NA
Intervention model: SINGLE_GROUP
Primary purpose: HEALTH_SERVICES_RESEARCH

Brief summary: Canadian Critical Care Nutrition Guidelines assist health practitioners in identifying best practices for feeding critically ill patients. However, guidelines have resulted in little change in Intensive Care Unit (ICU) practices, possibly because barriers to change differ between ICUs. Change may be facilitated if strategies specifically address identified barriers. The investigators hypothesize that barriers are inversely related to nutrition performance. Tailoring change strategies to overcome barriers to change will reduce the presence of these barriers and lead to improvements in nutrition practice.

Detailed description: A before-after study will be conducted in 7 Canadian and US ICUs. Each participating ICU will implement a tailored guideline implementation intervention aimed at narrowing the guideline-practice gap. The tailored implementation will consist of 4 phases:

1. Audit of Nutrition Practices: The nutrition practice audit will be conducted as part of the data collection for our ongoing international nutrition quality improvement project. This involves collecting data on personal characteristics and nutrition therapy in a consecutive cohort of 20 mechanically-ventilated critically ill adult patients. Performance at each ICU will be assessed by a benchmarked report comparing the nutrition practices to individual recommendations of the Canadian Critical Care Nutrition CPGs, thus enabling identification of the ICUs strengths and weaknesses, and highlighting areas to target for improvement.
2. Barriers Questionnaire: The barriers and enablers questionnaire will be completed by all physicians, all ICU leadership, the dietitian(s), and a random sample of 30 full- and part-time nurses. This questionnaire asks questions about barriers associated with guideline implementation, such as the characteristics of the guidelines, the care provider, the patient, and the context.
3. Tailored Action Plan: Results of the audit of nutrition practices and barriers questionnaire will be evaluated by the investigators and representatives from the Canadian Critical Care Nutrition CPGs Committee. Committee members include research personnel, intensivists, ICU nurse educators, dietitians, and experts in knowledge translation and health services research. They will be responsible for reviewing the benchmarked reports for each participating ICU, identifying the gaps between the key guideline recommendations and what is actually happening in practice, and reviewing the results of the barriers questionnaire to identify the barriers associated with adhering to these specific recommendations at each site. In collaboration with the local opinion leaders, a tailored 12 month action plan will be developed for each individual ICU.

   The specific behavioral change strategies to be implemented as part of the tailored action plan will likely include powerpoint presentations and handouts, packages of key journal articles, reminders (e.g. posters, checklists), system tools (e.g. pre-printed orders, bedside algorithms), interactive web-based tutorials, guidelines on establishing local implementation teams and creating a culture of team work. Prior to the implementation of these behavioral change strategies in the context of the before-after study, focus groups will be conducted to elicit feedback, and revisions made accordingly.
4. Audit of Nutrition Practices: The audit of nutrition practices will be repeated following the 12 month implementation period in order to evaluate changes in nutrition practices.

Eligibility criteria: Inclusion Criteria:

* ICUs must be affiliated with a registered dietitian.
* ICUs must have a minimum of 8 beds.
* ICUs must be located in Canada, Australia, or US.
* ICUs have previously participated in the International Nutrition Survey.

Exclusion Criteria:

* ICUs with less than 8 beds.
* ICUs with high nutrition performance, as demonstrated previously in the International Nutrition Survey (i.e. average nutritional adequacy \>60% and/or above 50th percentile when ranked against all participating ICUs according to nutrition practice performance score)

Primary outcomes:
measure: Feasibility of the study design and intervention
timeFrame: 12 months post implementation of intervention
Secondary outcomes:
measure: Change in nutrition performance score
timeFrame: 20-24 months
measure: Change in barriers to implementation of critical care nutrition clinical practice guidelines
timeFrame: 12 months post implementation of intervention
Other outcomes:
Locations:
city: Annapolis
country: United States
facility: Anne Arundel Medical Center
state: Maryland
city: Spartanburg
country: United States
facility: Spartanburg Regional Medical Center
state: South Carolina
city: Calgary
country: Canada
facility: Peter Lougheed
state: Alberta
city: Edmonton
country: Canada
facility: Capital Health - University of Alberta Hospital (hospital general systems)
state: Alberta
city: Newmarket
country: Canada
facility: Southlake Regional Health Centre
state: Ontario
Study officials:
affiliation: Clinical Evaluation Research Unit
name: Daren K Heyland, MD
role: PRINCIPAL_INVESTIGATOR
affiliation: Queen's University
name: Heather Stuart, PhD
role: PRINCIPAL_INVESTIGATOR
affiliation: Queen's University, Clinical Evaluation Research Unit
name: Naomi E Cahill, RD, MSc
role: PRINCIPAL_INVESTIGATOR
References:
citation: Jones NE, Dhaliwal R, Day AG, Ouellette-Kuntz H, Heyland DK. Factors predicting adherence to the Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Crit Care. 2008 Sep;23(3):301-7. doi: 10.1016/j.jcrc.2007.08.004. Epub 2007 Dec 11.
citation: Jones NE, Suurdt J, Ouelette-Kuntz H, Heyland DK. Implementation of the Canadian Clinical Practice Guidelines for Nutrition Support: a multiple case study of barriers and enablers. Nutr Clin Pract. 2007 Aug;22(4):449-57. doi: 10.1177/0115426507022004449.
citation: Cahill NE, Heyland DK. Bridging the guideline-practice gap in critical care nutrition: a review of guideline implementation studies. JPEN J Parenter Enteral Nutr. 2010 Nov-Dec;34(6):653-9. doi: 10.1177/0148607110361907.
citation: Cahill NE, Suurdt J, Ouellette-Kuntz H, Heyland DK. Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework. JPEN J Parenter Enteral Nutr. 2010 Nov-Dec;34(6):616-24. doi: 10.1177/0148607110361904.
citation: Cahill NE, Murch L, Cook D, Heyland DK; Canadian Critical Care Trials Group. Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study. Crit Care. 2014 May 11;18(3):R96. doi: 10.1186/cc13867.
citation: Cahill NE, Murch L, Cook D, Heyland DK; Canadian Critical Care Trials Group. Barriers to feeding critically ill patients: a multicenter survey of critical care nurses. J Crit Care. 2012 Dec;27(6):727-34. doi: 10.1016/j.jcrc.2012.07.006. Epub 2012 Sep 13.