The validation of a questionnaire to assess barriers to enteral feeding in critically ill patients: a multicenter international survey

BMC Health Services Research

Daren K Heyland¹  Deborah Cook³  Andrew G Day²  Miao Wang²  Lauren Murch²  Naomi E Cahill² 

[1]Department of Medicine, Queen’s University, 99 University Ave, Kingston, ON K7L 3N6, Canada

[2]Clinical Evaluation Research Unit, Kingston General Hospital, 76 Stuart Street, Kingston, ON K7L 2 V7, Canada

[3]Departments of Medicine, Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main St W, Hamilton, ON L8S 4L8, Canada

关键词: Validity;    Multi-level regression analysis;    Quality improvement;    Nutrition therapy;    Instrument development;    Enteral nutrition;    Critical care;    Barriers;   

Others  :  1132633
DOI  :  10.1186/1472-6963-14-197

 received in 2013-04-17, accepted in 2014-04-25,  发布年份 2014

【 摘 要 】

Background

A growing body of literature supports the need to identify and address barriers to knowledge use as a strategy to improve care delivery. To this end, we developed a questionnaire to assess barriers to enterally feeding critically ill adult patients, and sought to gain evidence to support the construct validity of this instrument by testing the hypothesis that barriers identified by the questionnaire are inversely associated with nutrition performance.

Methods

We conducted a multilevel multivariable regression analysis of data from an observational study in 55 Intensive Care Units (ICUs) from 5 geographic regions. Data on nutrition practices were abstracted from 1153 patient charts, and 1439 critical care nurses completed the ‘Barriers to Enterally Feeding critically Ill Patients’ questionnaire. Our primary outcome was adequacy of calories from enteral nutrition (proportion of prescribed calories received enterally) and our primary predictor of interest was a barrier score derived from ratings of importance of items in the questionnaire.

Results

The mean adequacy of calories from enteral nutrition was 48 (Standard Deviation (SD)17)%. Evaluation for confounding identified patient type, proportion of nurse respondents working in the ICU greater than 5 years, and geographic region as important covariates. In a regression model adjusting for these covariates plus evaluable nutrition days and APACHE II score, we observed that a 10 point increase in overall barrier score is associated with a 3.5 (Standard Error (SE)1.3)% decrease in enteral nutrition adequacy (p-values <0.01).

Conclusion

Our results provide evidence to support our a priori hypothesis that barriers negatively impact the provision of nutrition in ICUs, suggesting that our recently developed questionnaire may be a promising tool to identify these important factors, and guide the selection of interventions to optimize nutrition practice. Further research is required to illuminate if and how the type of barrier, profession of the provider, and geographic location of the hospital may influence this association.

【 授权许可】

   
2014 Cahill et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

【 参考文献 】

• [1]McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA: The quality of health care delivered to adults in the United States. N Engl J Med 2003, 348(26):2635-2645.
• [2]Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, Robinson N: Lost in knowledge translation: time for a map? J Contin Educ Health Prof 2006, 26(1):13-24.
• [3]Grimshaw JM, Thomas RE, MacLennan G, Fraser C, Ramsay CR, Vale L, Whitty P, Eccles MP, Matowe L, Shirran L: Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess 2004, 8(6):1-72.
• [4]Baker R, Camosso-Stefinovic J, Gillies C, Shaw EJ, Cheater F, Flottorp S, Robertson N: Tailored interventions to overcome identified barriers to change: effects on professional practice and health care outcomes. Cochrane Database Syst Rev 2010., 3CD005470
• [5]Cochrane LJ, Olson CA, Murray S, Dupuis M, Tooman T, Hayes S: Gaps between knowing and doing: understanding and assessing the barriers to optimal health care. J Contin Educ Health Prof 2007, 27(2):94-102.
• [6]Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR: Why don't physicians follow clinical practice guidelines? A framework for improvement. Jama 1999, 282(15):1458-1465.
• [7]Academy of Nutrition and Dietetics: Critical Illness Evidence-Based Nutrition Practice Guideline 2006 (Update 2012). http://andevidencelibrary.com/topic.cfm?cat=4840 webcite
• [8]Doig G, Simpson F: Evidence-Based Guidelines for Nutritional Support of the Critically Ill: Results of A Bi-National Guideline Development Conference. 2005. http://www.evidencebased.net/files/ webcite
• [9]Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P: Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003, 27(5):355-373.
• [10]Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, DGEM (German Society for Nutritional Medicine), Ebner C Hartl W, Heymann C, Spies C, ESPEN (European Scoiety for Parenteral and Enteral Nutrition): ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006, 25(2):210-223.
• [11]McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G: Guidelines for the provision and assessment of nutrition support therapy in the adult critically Ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009, 33(3):277-316.
• [12]Heyland DK, Heyland J, Dhaliwal R, Madden S, Cook D: Randomized trials in critical care nutrition: look how far we've come! (and where do we go from here?). JPEN J Parenter Enteral Nutr 2010, 34(6):697-706.
• [13]Cahill NE, Dhaliwal R, Day AG, Jiang X, Heyland DK: Nutrition therapy in the critical care setting: what is "best achievable" practice? An international multicenter observational study. Crit Care Med 2010, 38(2):395-401.
• [14]Heyland DK, Schroter-Noppe D, Drover JW, Jain M, Keefe L, Dhaliwal R, Day A: Nutrition support in the critical care setting: current practice in canadian ICUs–opportunities for improvement? JPEN J Parenter Enteral Nutr 2003, 27(1):74-83.
• [15]O'Meara D, Mireles-Cabodevila E, Frame F, Hummell AC, Hammel J, Dweik RA, Arroliga AC: Evaluation of delivery of enteral nutrition in critically ill patients receiving mechanical ventilation. Am J Crit Care 2008, 17(1):53-61.
• [16]Rice TW, Swope T, Bozeman S, Wheeler AP: Variation in enteral nutrition delivery in mechanically ventilated patients. Nutrition 2005, 21(7–8):786-792.
• [17]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, 22(4):449-457.
• [18]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, 34(6):616-624.
• [19]Cahill NE, Day AG, Cook D, Heyland DK: Development and psychometric properties of a questionnaire to assess barriers to feeding critically ill patients. Implement Sci 2013, 8:140. BioMed Central Full Text
• [20]Cahill NE, Narasimhan S, Dhaliwal R, Heyland DK: Attitudes and beliefs related to the Canadian critical care nutrition practice guidelines: an international survey of critical care physicians and dietitians. JPEN J Parenter Enteral Nutr 2010, 34(6):685-696.
• [21]Critical Care Nutrition[http://www.criticalcarenutrition.com webcite]
• [22]Francis JJ, Eccles MP, Johnston M: Constructing Questionnaires Based on the Theory of Planned Behaviour. 2004. [A Manual for Health Service Researchers.Quality of Life and Management of Living Resources] http://pages.bangor.ac.uk/~pes004/exercise_psych/downloads/tpb_manual.pdf webcite
• [23]Funk SG, Champagne MT, Wiese RA, Tornquist EM: BARRIERS: the barriers to research utilization scale. Appl Nurs Res 1991, 4(1):39-45.
• [24]Larson E: A tool to assess barriers to adherence to hand hygiene guideline. Am J Infect Control 2004, 32(1):48-51.
• [25]Peters MAJ, Harmsen M, Laurant MGH, Wensing M: Barriers to and facilitators for improvement of patient care. The Netherlands: Nijmegen; 2002.
• [26]Dillman DA: Mail and Internet Surveys: The Tailored Design Method. Don Wiley and Sons Inc; 2000.
• [27]Cahill NE, Murch L, Cook D, Heyland DK: Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically Ill patients: results of a multicenter feasibility study. Crit Carein press
• [28]Cahill NE, Murch L, Cook D, Heyland DK: Improving the provision of enteral nutrition in the intensive care unit: a description of a multifaceted intervention tailored to overcome local barriers. Nutr Clin Pract 2014, 29(1):110-117.
• [29]Maldonado G, Greenland S: Simulation study of confounder-selection strategies. Am J Epidemiol 1993, 138(11):923-936.
• [30]Greenland S: Modeling and variable selection in epidemiologic analysis. Am J Public Health 1989, 79(3):340-349.
• [31]Alberda C, Gramlich L, Jones N, Jeejeebhoy K, Day AG, Dhaliwal R, Heyland DK: The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009, 35(10):1728-1737.
• [32]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, 23(3):301-307.