Implementation of an evidence-based feeding guideline did not reduce mortality in intensive care units

摘要

QuestionnnDoes implementation of an evidence-based nutritional support guideline improve feeding practices and reduce mortality in patients in intensive care units (ICUs)? nnMethodsnnDesign: Cluster-randomized controlled trial. Australian New Zealand Trials Registry. ACTRN12608000407392.nnAllocation: Concealed.*nnBlinding: Unblinded.*nnFollow-up period: 20 weeks (individual patients were followed until death or hospital discharge).nnSetting: 27 level II or III ICUs in Australia and New Zealand.nnPatients: 1118 adults (mean age 59 y, 61% men) who were recently admitted to the ICU and expected to stay > 2 days and were not tolerating an oral diet. Palliative care, moribund, or brain-dead patients and those admitted from another ICU were excluded.nnIntervention: Development and implementation of a nutrition guideline (14 ICUs, 561 patients) or maintenance of usual feeding protocols (13 ICUs, 557 patients). The intensive care specialist and dietitian coinvestigators from each intervention ICU participated in a 2-day conference to develop the evidence-based feeding guideline. Physicians and staff at intervention ICUs were exposed to a multifaceted practice change strategy, including lectures, individual encouragement, active and passive reminders, and feedback.nnOutcomes: ICU and hospital mortality and length of stay, and process measures.nnPatient follow-up: 100% (intention-to-treat analysis).nnnMain resultsnnThe guideline intervention increased the proportion of ICU patients receiving nutritional support (95% vs 73%, P < 0.001) and fed within 24 hours of admission (61% vs 37%, P < 0.001), reduced mean time to first parenteral feeding (1.0 vs 1.4 d, P = 0.04) and first enteral feeding (0.8 vs 1.4 d, P < 0.001), and increased mean proportion of days in the ICU that patients were fed (81% vs 69%, P = 0.002). Groups did not differ for mortality or length of stay (Table). nnConclusionnnA multifaceted practice change strategy to implement an evidence-based nutritional support guideline improved feeding practices in intensive care units but did not reduce mortality.