Practice Guidelines
Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT).
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Summary
Posted By: Gordon S. Doig
E-Mail: gdoig@med.usyd.edu.au
Posted Date: 26 May 2004
Title: Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT).
Authors: Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ; Southwestern Ontario Critical Care Research Network.
Reference: CMAJ. 2004 Jan 20;170(2):197-204.
Link: Click here for a direct link to the paper. A password may be required for access to fulltext.
Abstract: BACKGROUND: The provision of nutritional support for patients in intensive care units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence-based algorithms to improve nutritional support in the ICU would improve patient outcomes.
METHODS: A cluster-randomized controlled trial was performed in the ICUs of 11 community and 3 teaching hospitals between October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study (n = 499). Evidence-based recommendations were introduced in the 7 intervention hospitals by means of in-service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutritional support, preferably enteral.
RESULTS: Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals (n = 214), the patients in the intervention hospitals (n = 248) received significantly more days of enteral nutrition (6.7 v. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 v. 35 days; p = 0.003) and showed a trend toward reduced mortality (27% v. 37%; p = 0.058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 v. 11.8 days; p = 0.7).
INTERPRETATION: Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes.
 
Are the results of the study valid?
Were all important options and outcomes clearly specified?
Yes. The guideline development process considered the provision of enteral and parenteral nutrition in critically ill patients. The consequences of considering options was assessed in a prospective clinical trial of the guideline.
Was an explicit and sensible process used to identify, select, and combine evidence?
Yes. The authors used Browman's 8-step Clinical Practice Guideline Development Cycle. This is an evidence-based process that requires an extensive literature search, critical appraisal and the genderation of evidence-based recommendations.
Was an explicit and sensible process used to consider the relative value of different outcomes?
Yes. All clinically meaningful outcomes were considered.
Is the guideline likely to account for important recent developments?
The guideline was evaluated in a trial conducted from 1997 to 1998. It was based on the best available evidece at the time. It is possible that the consideration of more recent evidence could result in changes to some of the recommendations.
Has the guideline been subject to peer review and testing?
Yes. The impact of the guideline on clinically meaningful outcomes has been evaluated in a cluster randomized controlled trial (cRCT) involving 14 hospitals and 492 patients. A cRCT is the 'gold standard' method for evaluating the impact of a clinical practice guideline.
What were the results?
Are practical, clinically important, recommendations made?
Yes. The guideline is presented in a series of easy to follow algorithms.
How strong are the recommendations?
Each individual recommendation was based on information from the most recent RCTs. At best, the strongest recommendations were Grade B+ (based on Level II evidence). Since the cRCT evaluating the impact of the guideline as a whole can be considered a Level II trial, the cRCT validates all content as a Grade B recommendation. For more information on Grades of recommendation and Levels of Evidence, please see the EBR section of this site.
What is the impact of uncertainty associated with the evidence and values used in the guidelines?
Because the guideline itself was evaluated in a cRCT, uncertainty can be assessed by reviewing the results of the trial.
Implementation of the guideline resulted in:
  • a 10% reduction in hospital mortality. (p=0.058) and
  • a 10 day reduction in hospital lenght of stay (p=0.003)
  • Will the results help me in caring for my patients?
    Is the primary objective of the guideline consistent with your objective?
    Yes. It appears that implementation of the guideline resulted in improved patient outcomes (decreased mortality) and reduced hospital LoS. It is likely the reduced hospital LoS offset any extra costs due to the provision of more EN or PN.
    Are the recommendations applicable to your patients?
    Yes. The recommendations are simple, explicit and can be applied in any hospital ICU.

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    Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT).

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