Introduction:The recently published 2018 ESPEN Guidelines on Clinical Nutrition in the Intensive Care Unit [1] represents a valuable revision of the 2006 Enteral Nutrition Guidelines [2] and the 2009 Parenteral Nutrition Guidelines [3] published earlier by this European group. The guidelines committee members have done an excellent job in putting thismanuscript together, providing directives that are clear, concise, brief, and most importantly, transparent. They included only studies published since 2000 for use in their meta-analyses, commenting that this time of transition heralded a new era in the literature involving higher quality randomized control trials (RCTs) and methodologic innovations such as trial registry. Not mentioned (but felt by many within the nutrition community) was the sense that this particular time was a tipping point, following the publication of Van den Berghe’s seminal paper on intensive insulin therapy [4]. Studies published in nutrition prior to this date were felt to reflect an older more antiquated style of management that was less effective. These authors utilized the persistent inflammation catabolism syndrome (PICS) system where four parameters (the patient, intervention, controls, and outcomes) are clearly described, which in turn direct the questions that the guideline committee members were to address. Quality of evidence was assessed by GRADE methodology, and a cut-off date of August 2017 for data entry from the literature was clearly identified. Not all of the recommendations were based on RCTs. The authors are to be commended in that they provided recommendations based on Level 4 low-quality evidence, in areas where RCTs were not available, clearly taking advantage of the group of experts on the committee to provide practical guidance for clinicians where there was a paucity of literature to support evidence-based practices.
BackgroundCritically ill patients are subject to severe skeletal muscle wasting during intensive care unit (ICU) stay, resulting in impaired short- and long-term functional outcomes and health-related quality of life. Increased protein provision may improve functional outcomes in ICU patients by attenuating skeletal muscle breakdown. Supporting evidence is limited however and results in great variety in recommended protein targets.MethodsThe PRECISe trial is an investigator-initiated, bi-national, multi-center, quadruple-blinded randomized controlled trial with a parallel group design. In 935 patients, we will compare provision of isocaloric enteral nutrition with either a standard or high protein content, providing 1.3 or 2.0 g of protein/kg/day, respectively, when fed on target. All unplanned ICU admissions with initiation of invasive mechanical ventilation within 24 h of admission and an expected stay on ventilator support of at least 3 days are eligible. The study is designed to assess the effect of the intervention on functional recovery at 1, 3, and 6 months following ICU admission, including health-related quality of life, measures of muscle strength, physical function, and mental health. The primary endpoint of the trial is health-related quality of life as measured by the Euro-QoL-5D-5-level questionnaire Health Utility Score. Overall between-group differences will be assessed over the three time points using linear mixed-effects models.DiscussionThe PRECISe trial will evaluate the effect of protein on functional recovery including both patient-centered and muscle-related outcomes.Trial registrationClinicalTrials.gov Identifier: NCT04633421. Registered on November 18, 2020. First patient in (FPI) on November 19, 2020. Expected last patient last visit (LPLV) in October 2023.
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BackgroundTo use advanced medical technologies (AMTs) correctly and safely requires both specialist knowledge and skills, and an awareness of risks and how those can be minimized. Reporting safety concerns about AMTs in home care can contribute to an improved quality of care. The extent to which a health care organization has integrated the reporting, evaluation and learning from incidents is a key element of that organization's patient safety culture.ObjectivesTo explore nurses' experiences regarding the education followed in the use of AMTs in the home setting, and their organizations' systems of reporting.DesignDescriptive cross-sectional design.Methods209 home care nurses from across the Netherlands who worked with infusion therapy, parenteral nutrition and/or morphine pumps responded to the online questionnaire between July 2018 and February 2019. The analysis of the data was mainly descriptive.ResultsEducational interventions that are most often used to learn how to use AMTs were, as an average over the three AMTs, instruction by a nurse (71%), practical training in the required skills (71%) and acquiring information to increase theoretical knowledge (69%). Considerable attention is paid to patient safety (88%) and the home setting (89%). However, a substantial proportion of the nurses (up to 29%) use AMTs even though they had not been tested on their skills. 95% of the respondents were well acquainted with the incident reporting protocol of their organization, but only 49% received structural or regular feedback on any actions taken as a result of event reporting.ConclusionsThis study revealed aspects of nurses' education that imply risk factors for patient safety. Practical training is not always given, additional or retraining is often voluntary, and the required skills are not always tested. However, the results show that nurses do have a good awareness of patient safety. Incidents are mainly discussed within the team, but less at the organizational level.
