Evaluation of quality indicators for nutrition and metabolism in critically ill patients: role of the pharmacist

Pelayo Nieto-Gómez; Rocío Morón Romero; Elena Planells del Pozo; Jose Cabeza-Barrera; Manuel Colmenero Ruiz

doi:10.1136/ejhpharm-2019-002195

. 2020 Jun 23;28(e1):e62–e65. doi: 10.1136/ejhpharm-2019-002195

Evaluation of quality indicators for nutrition and metabolism in critically ill patients: role of the pharmacist

Pelayo Nieto-Gómez ¹, Rocío Morón Romero ^1,^2,^✉, Elena Planells del Pozo ^2,³, Jose Cabeza-Barrera ^1,², Manuel Colmenero Ruiz ^2,⁴

PMCID: PMC8640402 PMID: 32576571

Abstract

Objective

To assess compliance in a Spanish intensive care unit (ICU) with 8 of the 13 quality indicators of the Spanish Society of Intensive Medicine and Coronary Units (Sociedad Española de Medicina Intensiva y Unidades Coronarias, SEMICyUC) related to nutrition and metabolism in critically ill patients.

Patients and methods

The study included all patients over 18 years of age with an ICU stay of >48 hours between January and May 2019. The pharmacist was integrated into the daily activity of the multidisciplinary team of a 20-bed ICU to monitor and carry out the control of the quality indicators of the SEMICyUC. Studied indicators refer to: nutritional risk assessment and nutritional status (three indicators), glycaemic control, calculation of calorie–protein requirements, and use of early enteral nutrition or adequate parenteral nutrition. Compliance with each indicator was measured as the percentage of patients.

Results

110 patients were included and 73 (66.4%) were male. Compliance results were: blood glucose range (90.7%), severe hypoglycaemia (0%), identification of patients at nutritional risk (58.2%) or with possible refeeding syndrome (8.9%), assessment of nutritional status at admission (58.2%), calculation of calorie–protein requirements (77.8%), early enteral nutrition (96.4%), and adequate use of parenteral nutrition (37.8%)

Conclusion

Compliance with indicators related to glycaemic control and artificial nutrition (enteral and parenteral nutrition) was higher than reference standards, but there is a need to improve compliance with indicators related to nutritional risk and status at ICU admission. The hospital pharmacist integrated into the ICU multidisciplinary team can add value to the nutrition monitoring and quality indicators of the nutritional process of the critical patient, providing safe and effective nutritional therapy to patients.

Keywords: clinical pharmacy, intensive & critical care, nutrition & dietetics, quality in health care, quality control

Introduction

Patients are admitted to the intensive care unit (ICU) due to polytrauma, high-risk/urgent surgery, acute respiratory failure, sepsis/septic shock, acute coronary syndrome, stroke, intoxication, decompensation of chronic disease, or the acute phase of autoimmune disease (eg, pancreatitis), among others. The approach to nutrition, a vital part of the medical care required by these patients, varies widely according to the reason for ICU admission, with some patients able to eat in the normal manner and others requiring artificial nutritional support. When this support is needed, clinicians must select enteral (EN) or parenteral (PN) nutrition and determine its timing according to the best available scientific evidence. Adequate and timely nutrition is essential to achieve the maximum recovery of critical patients with minimal sequelae. Malnutrition has been associated with increased mortality and complication rates and a longer ICU stay^{1 2} and its prevalence is higher among the critically ill than among other hospitalised patients.³ The prevention, detection and treatment of malnutrition are therefore especially important in these patients.

Clinical practice guidelines on the nutrition of critical patients have been produced by the American (ASPEN)⁴ and European (ESPEN)⁵ Societies of Parenteral and Enteral Nutrition and the Canadian Society of Critical Care Nutrition,⁶ among others, and various critical care societies have published consensus documents on quality criteria in critical patients, including the approach to nutrition.^{7 8} The latest update published by the Spanish Society of Intensive Medicine and Coronary Units (Sociedad Española de Medicina Intensiva y Unidades Coronarias, SEMICyUC) in 2017⁸ contains a section on metabolism and nutrition, with indicators to assess the quality of nutritional practice in Spanish ICUs. Studies on compliance with nutrition-related indicators in Spain and elsewhere^9–14 have revealed discrepancies between recommendations and real-life clinical practice that warrant further investigation.

The clinical roles of pharmacists in supporting direct patient care that need nutritional therapy are well established and documented in developed countries.^15–19

Pharmacists have diverse roles in relation to nutritional therapy, including the assessment of patients’ nutritional needs; the design, compounding, dispensing, and quality management of PN formulations; and the monitoring of patients’ responses to nutritional therapy. Each of these practice domains helps to support the delivery of safe and effective nutritional therapy to patients.²⁰

With this background, the main objective of this study was to evaluate the compliance in our ICU with quality indicators related to metabolism and nutrition in the latest SEMICyUC recommendations performed by the clinical pharmacist integrated into an ICU.

Methods

The study was conducted in the ICU of San Cecilio University Hospital of Granada (Southern Spain) and approved by the Clinical Research Ethics Committee of Granada (CEIC) (ID of the approval 0151 N-19). The pharmacist is integrated into the daily activity of the multidisciplinary team of a 20-bed ICU to monitor and carry out the control of the quality indicators of the SEMICyUC. The study included all patients aged ≥18 years with an ICU stay >48 hours between January and May 2019. In accordance with ESPEN criteria, an ICU stay of >48 hours poses a malnutrition risk. Readmissions were not considered.

Indicators of interest for this study were identified by reviewing the webpages of the SEMICyUC, ESPEN, ASPEN, the European Society of Intensive Medicine (ESCIM), the UK National Institute for Health and Care Excellence (NICE) and the US Society of Critical Care Medicine (SCCM). In addition, a search of the MEDLINE database was conducted through PubMed using the terms “intensive care”, “quality indicator”, and “nutrition” linked with the Boolean operator “AND”, repeating the search using the terms “critically ill”, “quality indicator”, and “nutrition”. These searches retrieved 72 articles, but only one contained a list of quality indicators. It was finally decided to use the recent SEMICyUC quality indicators, consensually agreed by clinicians and other experts and based on a thorough review of updated scientific evidence. Of the 13 quality indicators related to metabolism and nutrition in the 2017 publication, eight were selected on the basis of their relevance and the feasibility of gathering the corresponding data (see table 1).

Table 1.

Results for SEMICyUC quality indicators related to metabolism and nutrition

N° 55: Maintenance of appropriate glycaemic levels	$\frac{n ° p a t i e n t s w i t h g l y c e m i a §amp;gt; 150 m g / d L a n d u n d e r i n s u l i n t r e a t m e n t}{n ° p a t i e n t s w i t h g l y c e m i a §amp;gt; 150 m g / d l} X 100$
N° 56: Severe hypoglycaemia	$\frac{t o t a l n ° g l y c e m i a d e t e r m i n a t i o n s §amp;lt; 40 m g / d L}{t o t a l n ° g l y c e m i a d e t e r m i n a t i o n s} X 100$
N° 57: Identification of patients at nutritional risk	$\frac{n ° p a t i e n t s w i t h n u t r i t i o n a l r i s k a s s e s s m e n t a t a d m i s s i o n}{n ° p a t i e n t s d i s c h a r g e d f r o m t h e I C U} X 100$
N° 58: Nutritional status assessment (EN)	$\frac{n ° p a t i e n t s w i t h n u t r i t i o n a l r i s k a n d n u t r i t i o n a l s t a t u s a s s e s s m e n t}{n ° o f p a t i e n t s a d m i t t e d w i t h n u t r i t i o n a l r i s k} X 100$
N° 59: Calorie-protein requirements in critical patients	$\frac{n ° p a t i e n t s w i t h a r t i f i c a l n u t r i t i o n a n d c o r r e c t r e q u i r e m e n t c a l c u l a t i o n}{t o t a l n ° p a t i e n t s w i t h a r t i f i c a l n u t r i t i o n} X 100$
N° 60: Early enteral nutrition	$\frac{n ° p a t i e n t s w i t h e a r l y e n t e r a l n u t r i t i o n}{n ° p a t i e n t s w i t h e n t e r a l n u t r i t i o n} X 100$
N° 63: Adequate use of parenteral nutrition	$\frac{n ° p a t i e n t s w i t h p a r e n t e r a l n u t r i t i o n i n d i c a t i o n}{t o t a l n ° p a t i e n t s n e e d i n g a r t i f i c a l n u t r i t i o n} X 100$
N° 64: Refeeding syndrome	$\frac{n ° p a t i e n t s w i t h a r t i f i c a l n u t r i t i o n a s s e s s e d f o r r e f e e d i n g y n d r o m e r i s k}{n ° p a t i e n t s w i t h a r t i f i c a l n u t r i t i o n} X 100$

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EN, enteral nutrition; SEMICyUC, Sociedad Española de Medicina Intensiva y Unidades Coronarias (Spanish Society of Intensive Medicine and Coronary Units).

Furthermore, these indicators are in line with the ESPEN guideline, even considering these recommendations were published later.⁵

Glycaemic control recommendation is to avoid hyperglycaemia (within a range of 150–180 mg/dL), and mild and severe hypoglycaemia in order to reduce mortality and morbidity. For this recommendation, indicators N° 55 and N° 56 are good tools to achieve it.

Indicators N° 57 and N° 58 are representative of ESPEN recommendations for assessing nutritional risk and nutritional status of every patient in the ICU, but there is not a specific tool that can be recommended. The measure most frequently used to evaluate nutritional status is the general clinical assessment (anamnesis, physical examination, body composition, muscle mass and strength).

ESPEN also recommends starting with caloric inputs of 70% of total energy needed within the first 3 days to achieve 100% during the first week, to prevent overfeeding while the acute phase persists, and protein intake should be at least 1.3 g/kg/day. These standards were used to calculate indicator N° 59.

Early enteral nutrition is defined by ESPEN as the enteral nutrition initiated in the first 48 hours and it is recommended for every patient who needs enteral feeding at admission to ICU. In this sense, SEMICyUC indicator N° 60 represents a good quality standard for this recommendation.

Refeeding syndrome should be assessed for every patient at admission to ICU, a recommendation present in both SEMICyUC quality indicator N° 64 and the ESPEN guideline.

However, indicator N° 63 is not explicitly found in the ESPEN recommendations, but there are some recommendations about the use of complementary parenteral nutrition as well as conditions which make delaying the enteral nutrition necessary. These recommendations were considered in the development of this work.

Data were gathered from the hospital prescription programme (Athos APD) and clinical record system (Diraya) on: patient identifier (NUHSA code), age, sex, weight, height, glycaemia, diagnosis at admission, therapeutic techniques (mechanical ventilation, vasoactive drugs, dialysis), artificial nutrition (EN, PN, or both), insulin treatment, date/time of admission, date of EN onset, and presence of refeeding syndrome.

R commander (version 2.5–1) was used for univariate statistical analysis, calculating means with SD, maximum and minimum values, and IQR.

Results

The study included 110 patients with mean±SD age of 62.3±14.7 years (IQR=19; max=89; min=27); 73 patients (66.4%) were male and 37 (33.6%) female. The mean weight was 74.98±16.71 kg (IQR=25.12; max=120; min=49) and mean height was 164.77±17.46 cm (IQR=15; max=188; min=157), with a mean body mass index (BMI) of 26.69±5.7 kg/m² (RIC=5.5; max=41.52; min=18.71). ICU admission was medical in 71% of patients, surgical in 24%, and traumatic in 5%; vasoactive drugs were received by 57% of patients, mechanical ventilation by 38%, and extrarenal clearance by 4%; EN was received by 38.18% and PN by 29%. Table 2 exhibits the main results for each indicator.

Table 2.

Main results for each indicator

Indicator	Objective	Compliance
N° 55: maintenance of appropriate glycaemic levels	≥80%	90.7%
N° 56: severe hypoglycaemia	<0.5%	0%
N° 57: identification of nutritional risk	100%	58.2%
N° 58: assessment of nutritional status.	100%	58.2%
N° 59: calorie–protein requirements	≥85%	77.8%
N° 60: early enteral nutrition	100%	96.4%
N° 63: adequate use of parenteral nutrition	16% TPN and 25% CPN	37.8%TPN and 15.6% CPN
N° 64: refeeding syndrome	100%	8.9%

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CPN, complementary parenteral nutrition; TPN, total parenteral nutrition.

Discussion

This study revealed that there is room for improvement in the compliance of our ICU with some important quality indicators related to the nutrition and metabolism of patients. Few data are available for comparison with these findings, and we could only trace six studies on quality indicators for the nutritional care of critically ill patients, four in Spain^9–12 and two in Brazil.^{13 14}

There was excellent compliance in our ICU with the indicator related to glycaemic control (N° 55), which was maintained in 90.7% of the patients. In a previous Spanish study, Bermejo et al reported that glycaemia was monitored in a similarly high proportion of patients receiving EN.¹⁰ Only 43 (39%) of the patients in our study had hyperglycaemia, a lower percentage than previously observed by Oliveira et al (42.6% and 68.1% in consecutive years) and below the reference standard of 70–80% that they proposed.¹⁴ With regard to the presence of “severe hypoglycaemia” (indicator N° 56), no patient had a value <40 mg/dL. Likewise, a level below 40 mg/dL was reported in only 3.7% of the 6104 patients in the NICE-SUGAR clinical trial,²¹ and in only 0.1% of 144 patients in another retrospective study. Oliveira et al also described hypoglycaemia in 31.9% and 29.8% of their patients, but defined this state as <70 mg/dL.²² The excellent compliance with glycaemic control in our ICU reflects the well-established protocols for this practice in our ICU, which are understood and systematically applied by all medical and nursing staff.

In contrast, there was poor compliance with the identification of nutritional risk (N° 57) and the assessment of nutritional status (N° 58), conducted in only 58.2% of our patients, while refeeding syndrome (N° 64) was evaluated in only 8.9%. A recent national survey on the assessment of nutritional status and refeeding syndrome in 107 Spanish ICUs²³ found that only 56 (47.5%) assessed this status at admission, 47 (49%) measured phosphorus levels, and 54 (16.1%) had encountered an occasional case of refeeding syndrome. BMI was the measure most frequently used to evaluate nutritional status, followed by subjective global assessment (SGA). In our ICU, assessment of nutritional status was based on the BMI and analytical findings of a non-specific inflammatory response, with no utilisation of SGA or nutritional risk screening methods such as Nutritional Risk Screening 2002 (NRS-2002), Nutrition Risk in Critically Ill (NUTRIC) score, or Malnutrition Universal Screening Tool (MUST). Our ICU protocols do not include the measurement of admission phosphorus levels to detect possible refeeding syndrome, and the suspicion of this risk in four patients was mainly based on the anamnesis and on hydroelectrolytic disorders detected in blood analyses at admission; none of these patients developed the syndrome.

The lack of compliance with nutritional indicators may have various explanations. For instance, ICU admission itself carries a high nutritional risk on the NRS-2002 scale, so that the scale scores are not affected by compliance, although it does allow the identification of patients at risk of refeeding syndrome. Clinicians may also consider that the evaluation and identification of nutritional risk is not useful for patients in the ICU because they systematically receive nutritional therapy. Given the present findings, nursing protocols in our ICU now include mandatory screening of nutritional risk and status at admission, using the NRS-2002 scale and modified NUTRIC score (without interleukin 6), and the measurement of phosphorus to assess possible refeeding syndrome.

There was also inadequate compliance (77.8%) with the indicator on calorie–protein needs (n°59), although it was not far below the reference standard (85%). Non-compliance was related to the lack of data on the height of patients or on their ideal weight in some cases. Although not included among indicators, an imprecise calculation can lead to the immediate administration of an insufficient or excessive amount, with the former being more frequent in observational studies and clinical trials, as demonstrated by De Jonghe et al.²⁴ In the present study, 78% of the required kilocalories were prescribed and 71% were actually administered.

There was optimal compliance with indicators related to the type of nutrition. Compliance with early EN (N° 60) was 96.4%, close to the reference standard of 100%. De la Calle et al reported compliance with this indicator of 70.2% in one study,⁹ and of 50%²⁵ and 95%²⁶ in two other studies. Although a highly relevant indicator, there are many reasons why the initiation of EN may not be possible within 24 hours of admission. Thus, early EN was not administered in three patients who were initially candidates for EN: in one case because of a poor prognosis, leading to a wait-and-see approach; in another case because immediate post-admission surgery was followed by 2 days in the post-surgical recovery room; and in the third because vasoactive drug treatment required adjustment during the first 2 days before haemodynamic stability was achieved. This last situation appears to be frequent, prompting debate on the approach to haemodynamically unstable patients due to the risk of intestinal ischaemia. The consensus of ASPEN and ESPEN is that the receipt of vasoactive drugs does not contraindicate EN, which can be initiated after stabilisation of the drug dosage, closely monitoring the patient to detect any signs of intestinal ischaemia. Excluding these three patients from the calculation of compliance with this indicator, there was only one case in which EN was indicated but not initiated within 48 hours of admission.

In regard to the appropriate use of PN (indicator N° 63), it is not clear whether the reference standard in the SEMICyUC document represents a limit or a simple guideline. The standard was taken from a survey on PN management in Spanish ICUs in 2013,²⁷ before the publication and implementation of more recent recommendations by international societies. Furthermore, the number of patients indicated for complementary parenteral nutrition (CPN) and total parenteral nutrition (TPN) can vary widely according to the types of patient admitted during a given period. PN was used in 53.3% of the present sample of patients, a higher percentage than reported (41%) in the aforementioned survey.

An international study of nutritional practices in ICUs investigated 9777 patients over 7 years and observed the application of TPN in <15% and CPN in <10%.²⁸ The authors observed that ICU patients were frequently nourished below their needs, often due to complications in EN administration, and they proposed the increased use of parenteral nutrition (CPN or TPN) to meet the nutritional requirements of patients.

In conclusion, our analysis of the compliance with nutrition and metabolism quality indicators in our unit stimulated improvements in certain clinical practices. There appears to be a need to revise some reference standards applied in the light of new scientific evidence.

Conclusion

Compliance with indicators related to glycaemic control and artificial nutrition (EN and PN) was higher than reference standards, but there is a need to improve compliance with indicators related to nutritional risk and status at ICU admission. The hospital pharmacist integrated into the ICU multidisciplinary team can add value to nutrition monitoring and quality indicators of the nutritional process of the critical patient, providing safe and effective nutritional therapy to patients.

Key messages.

What is already known on this subject

Critically ill patients represent a heterogeneous group in terms of diagnosis, severity or metabolic alterations.
The evidence indicates that nutritional treatment in critically ill patients determines, among others, hospital stay and mortality.
This diversity makes it difficult to define indicators and standards to evaluate patient care and treatment.

What this study adds

This study shows the deviation between ideal and real compliance of nutrition and metabolism quality indicators in ICU patients.
Integration of hospital pharmacists into the ICU teams is a good strategy to measure and ensure nutritional care in critically ill patients.

Footnotes

Contributors: PNG and RMR designed the research study and drafted the manuscript. EPP, JCB, and MCR coordinated and prepared the database and analysed the data. All authors have read and approved the final manuscript.

Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests: None declared.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

No data are available.

Ethics statements

Patient consent for publication

Obtained.

References

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

No data are available.

[R1] 1. Faisy C, Lerolle N, Dachraoui F, et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Br J Nutr 2009;101:1079–87. 10.1017/S0007114508055669 [DOI] [PubMed] [Google Scholar]

[R2] 2. Villet S, Chiolero RL, Bollmann MD, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005;24:502–9. 10.1016/j.clnu.2005.03.006 [DOI] [PubMed] [Google Scholar]

[R3] 3. Ridley E, Gantner D, Pellegrino V. Nutrition therapy in critically ill patients- a review of current evidence for clinicians. Clin Nutr 2015;34:565–71. 10.1016/j.clnu.2014.12.008 [DOI] [PubMed] [Google Scholar]

[R4] 4. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. JPEN J Parenter Enteral Nutr 2016;40:159–211. 10.1177/0148607115621863 [DOI] [PubMed] [Google Scholar]

[R5] 5. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38:48–79. 10.1016/j.clnu.2018.08.037 [DOI] [PubMed] [Google Scholar]

[R6] 6. Critical Care Nutrition . Canadian Clinical Practice Guidelines 2015 - Summary of Revisions to the Recommendations. CritcareNutr [Internet], 2015. Available: http://www.criticalcarenutrition.com/docs/CPGs%25202015/Summary%25 [Accessed 8th Jun 2019].

[R7] 7. Rhodes A, Moreno RP, Azoulay E, et al. Prospectively defined indicators to improve the safety and quality of care for critically ill patients: a report from the task force on safety and quality of the European Society of Intensive Care Medicine (ESICM). Intensive Care Med 2012;38:598–605. 10.1007/s00134-011-2462-3 [DOI] [PubMed] [Google Scholar]

[R8] 8. Sociedad Española de Medicina Crítica Intensiva y Unidades Coronarias (SEMICYUC) . Manual de indicadores de calidad en el enfermo crítico 2017. [Internet], 2017. Available: http://www.semicyuc.org/files/INDICADORES_DECALIDAD_2017.pdf [Accessed 8th Jun 2019].

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PERMALINK

Evaluation of quality indicators for nutrition and metabolism in critically ill patients: role of the pharmacist

Pelayo Nieto-Gómez

Rocío Morón Romero

Elena Planells del Pozo

Jose Cabeza-Barrera

Manuel Colmenero Ruiz

Abstract

Objective

Patients and methods

Results

Conclusion

Introduction

Methods

Table 1.

Results

Table 2.

Discussion

Conclusion

Key messages.

What is already known on this subject

What this study adds

Footnotes

Data availability statement

Ethics statements

Patient consent for publication

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

Cite

Add to Collections

PERMALINK

Evaluation of quality indicators for nutrition and metabolism in critically ill patients: role of the pharmacist

Pelayo Nieto-Gómez

Rocío Morón Romero

Elena Planells del Pozo

Jose Cabeza-Barrera

Manuel Colmenero Ruiz

Abstract

Objective

Patients and methods

Results

Conclusion

Introduction

Methods

Table 1.

Results

Table 2.

Discussion

Conclusion

Key messages.

What is already known on this subject

What this study adds

Footnotes

Data availability statement

Ethics statements

Patient consent for publication

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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