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Critical Care Nutrition at the Clinical Evaluation Research Unit (CERU)

is dedicated to improving nutrition therapies in the critically ill through knowledge generation, synthesis, and translation. We engage in a broad range of research activities and promote a culture of best practices in critical care nutrition. Ultimately, this will result in improved clinical outcomes for critically ill patients and increased efficiencies to our health care systems.

Frequently Asked Questions

Below are some frequently asked questions about the International Nutrition Survey. If you have a question not yet listed here, please feel free to This email address is being protected from spambots. You need JavaScript enabled to view it.. We will continue to expand this page with any new questions that arise. Questions are organized by the following topics: 

 


Eligibility Criteria

  1. If a patient is ventilated prior to their admission to the ICU do they meet the criteria? What if they are extubated, but remain in the ICU? Answer

  2. What if a patient was admitted to the ICU and included in the study, then discharged or transferred and then readmitted again? Answer

  3. Can I enroll patients who have already been in the ICU already for a few days/weeks/months? Answer

  4. Do I need to keep a record of excluded patients in the Screening Log? Answer

  5. If a patient did not meet inclusion criteria, was discharged from ICU and later readmitted, can I screen them again? Answer

 

Site and User Registration

  1. I registered 2 days ago and have not received an e-mail with my username. Is there a problem? Answer

  2. How do I register a second ICU at my hospital? Answer

  3. If 3 ICUs in my hospital are registered separately, will they each get their own site report? Answer

  4. Will I still be able to participate in the Survey if my ICU has < 8 beds? Answer

  5. How was the sample size of 15 or 20 chosen? Answer

  6. Should I use the CRFs for burn sites or non-burn sites? Answer

 

Patient Information

  1. If a patient is transferred from another ICU does ‘first 24 hours of admission to ICU' refer to their initial admission to another ICU or admission to our ICU? Answer

  2. For APACHE II values and highest/lowest blood glucose on the Patient Information form, does ‘first 24 hours of admission to ICU' refer to study day 1 only? Answer

  3. If a patient is admitted to hospital for an elective hip replacement but experiences a respiratory arrest post-op which requires ICU admission, what do I complete for admission category and admission diagnosis? Answer

  4. When do I complete head of the bed elevation? Answer

  5. We record blood glucose in mg/dL at our ICU. Can I enter blood glucose online in these units? Answer

  6. Our hospital uses APACHE III scores. Can I enter these instead of APACHE II? Answer

  7. I do not work in the ICU every day/weekends, do I exclude these days from the survey? Answer

  8. Should patients in the ICU be screened every day even if they have not been in the ICU for 72 hours? This could potentially results in patients being screened 3 times prior to enrollment. Answer

 

Baseline Nutrition Assessment

  1. I am unable to obtain actual height and weight, what do I do? Answer

  2. Does the nutrition assessment have to be from day 1? If it didn't take place until day 4, what do I do? Answer

  3. If a nutritional assessment was not completed, do I leave the nutritional assessment form blank? Answer

  4. When asked to specify the initial order for nutrition, does this include suggestions/requests? Answer

 

Daily Nutrition Data

  1. Do we count 'day 1' as day of admission into ICU, or first 24 hr period (i.e. 2300hrs on day of admission to next day 2300hrs)? Answer

  2. If a patient is prescribed an enteral formula containing glutamine (e.g. Crucial) is this considered a glutamine supplement? Answer

  3. If a patient is prescribed a parenteral solution containing glutamine, is this considered a glutamine supplement? Answer

  4. Do I include the protein from glutamine and supplements in the total amount of protein received? Answer

  5. Do I include calories received from IV dextrose? Answer

  6. Does the route or type of insulin provided matter? Answer

  7. If a patient leaves the ICU and comes back within 48 hours, do we count it as the next ICU day or do we collect data from when the patients were in a step down unit? Answer

  8. Can I record study days based on my flow sheet schedule, not midnight to midnight? Answer

  9. Do I need to adjust the patient's nutrition prescription if the patient is receiving propofol? Answer
  10. Are there forms to record the nutrition received orally from food and beverages? Answer

  11. On the Supplemental Nutrients form, do we indicate that a supplement was given if they are in a multivitamin? Answer

  12. If insulin was administered to treat hyperkalemia, is this insulin included in the 24 hour amount or should we just record insulin given for blood glucose control? Answer


Outcomes

  1. If a transfer order is written but no bed outside of the ICU is available right away, do I record discharge date/time as when the transfer order was written, or when the patient is actually transferred? Answer

  2. Mechanical ventilation was discontinued for the patient, but 72 hours later the patient was reintubated. Then they were extubated again a few days later. What date for discontinuation of mechanical ventilation do I use on the outcomes form? Answer

  3. What if the patient is discharged from the ICU on mechanical ventilation? Answer


REDCap

  1. How do I find our site number? Answer

  2. I want to edit my EN data for Patient 23-4, Day 6, how do I do this? Answer

  3. When I enter the patient's weight as 57Kg, I receive the error message ‘This value you provided is not a number. Please try again'. This is the correct weight, so why do I receive an error message? Answer

  4. Why am I being queried for data I have not yet collected? Answer


Study Timelines

  1. Is there an end date for this Survey, or do we keep going until we have sufficient patients included? Answer 


Eligibility Criteria

If a patient is ventilated prior to their admission to the ICU do they meet the criteria? What if they are extubated, but remain in the ICU?

Yes, if they are still ventilated on admission to the ICU and stay in the ICU >72 hours, they meet the criteria. When completing the case report forms select ‘ventilation started prior to ICU admission'. Please note that duration of ventilation does not matter: if the patients are ventilated at any point in the first 48 hours of admission, they meet this criteria.

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What if a patient was admitted to the ICU and included in the study, then discharged or transferred and then readmitted again? Do you collect data for this patient as if it was a single admission, or register the patient separately for each admission?

If the patient was re-admitted to the ICU within 48 hours of discharge/transfer consider this as if the patient never left the ICU. For the time that the patient was outside the ICU, attempt to collect data from hospital records, and once they return to the ICU continue data collection as if for a single ICU admission. If more than 48 hours elapsed between discharge/transfer and readmission, record this first date of ICU discharge on the outcomes form. Do not screen the patient a second time, and move on to the next eligible patient.

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 Can I enroll patients who have already been in the ICU already for a few days/weeks/months?

Yes, you can enroll these patients. The data will need to be collected retrospectively, except head of the bed elevation which is observed and recorded when the patient is screened. Remember, Study Day 1 = ICU Admission day, so you must always go back to the ICU admission day and start collecting data for the first 12 days in ICU. 

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 Do I need to keep a record of excluded patients in the Screening Log?

Yes, this log is to help you keep track of which patients you need to collect data on. You should log every patient that is admitted to your ICU in the Screening Log, indicating with an ‘x' if they do not meet an inclusion criteria, a ‘?' if they do meet an inclusion criteria, and ultimately indicating if they were enrolled. You will use your Screening Logs at the end of the survey when you complete the Site Finalization form on REDCap. You do NOT enter the screening log into REDCap and you do NOT send your screening log to us. 

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If a patient did not meet inclusion criteria, was discharged from ICU and later readmitted, can I screen them again? 

You may screen the patient again if they were readmitted >48 hours after their first ICU discharge (if readmitted within 48 hours we consider it the same admission). If they can be enrolled in the INS, use the ICU admission date and time for their current admission.


Site/User Registration

I registered 2 days ago and have not received an e-mail with my username. Is there a problem?

Usernames are generated automatically and you should receive an email shortly after completing the Site Registration form. If you do not receive an email with your username and password, please first check to make sure the message was not sent directly to your "spam" folder. If you still cannot find the email, contact Margot at This email address is being protected from spambots. You need JavaScript enabled to view it. for assistance. 

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How do I register a second ICU at my hospital?

Fill out the registration form once for each ICU you wish to register for the survey. You will receive a separate username/password for each participating ICU.

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If 3 ICUs in my hospital are registered separately, will they each get their own site report?

Yes, they will receive their own site reports as long as each ICU finalizes a minimum of 20 patients to be eligible for the Best of the Best Award or 15 patients to just receive a site report. If you wish to only receive one site report for multiple ICUs in your hospital, please still register each ICU separately, and contact Margot at This email address is being protected from spambots. You need JavaScript enabled to view it.

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Will I still be able to participate in the Survey if my ICU has < 8 beds?

Yes! We encourage all sites to participate. To be eligible for the Best of the Best Award, data must be collected on a minimum of 20 patients. To just receive a site report, data must be collected on a minimum of 15 patients.

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How was the sample size of 15 or 20 chosen?

The sample size was selected to provide sites with a site report that is meant to give accurate feedback on nutrition practices while keeping the quantity of data collection feasible. No statistical methods were done to come up with the sample size. 

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Should I use the CRFs for burn sites or non-burn sites?

If you plan to enroll any patient type in your ICU, which may or may not include burn patients, use the non-burn CRFs. In this case, when registering your site you should select 'no' to question 15 'Is your unit specifically a burn unit?'. The burns CRFs are to be used if only burn patients are enrolled at your site. In this case, when registering your site you should select 'yes' to question 15 'Is your unit specifically a burn unit?'.

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 Patient Information



If a patient is transferred from another ICU does ‘first 24 hours of admission to ICU' refer to their initial admission to another ICU or admission to our ICU?

For the purposes of data collection, ‘first 24 hours of admission to ICU' refers to admission to your ICU. This is because it would be difficult to obtain all the necessary data required for patient registration (i.e. admission diagnosis, ARDS, Apache II) for their initial admission at another institution.

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For APACHE II values and highest/lowest blood glucose on the Patient Information form, does ‘first 24 hours of admission to ICU' refer to study day 1 only?

No, these specific questions on the Patient Information form ask for data from the full 24 hour period following ICU admission. Since study day 1 starts at time of admission and ends at midnight it may not correspond to a full 24 hour period (e.g. 18:00 ? 11:59), and therefore 'first 24 hours from admission to the ICU' may also include data from study day 2 (e.g. 18:00-11:59 on day 1, and 00:00 ? 17:59 on day 2). In contrast, all questions on the Daily Nutrition forms for Study Day 1 refer to information from time of admission until the end of that calendar day, which is midnight (e.g. 18:00-11:59 only) and not the full 24 hour period.

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If a patient is admitted to hospital for an elective hip replacement but experiences a respiratory arrest post-op which requires ICU admission, what do I complete for admission category and admission diagnosis?

Use the category and diagnosis that resulted in the admission to the ICU i.e. medical and respiratory arrest.

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When do I complete head of the bed elevation?

Head of bed elevation should be observed at the time of screening (i.e. when the patient is included in the study). This can be at any time of day. This observation also includes patients who were admitted to the ICU >12 days prior to screening and whose 12 days of daily data will consequently not include the day of screening. If a patient is admitted and discharged from the ICU before screening and therefore cannot be observed, please review the patient chart, if no HOB elevation is recorded in the chart, leave this field blank.

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We record blood glucose in mg/dL at our ICU. Can I enter blood glucose online in these units?

Yes, REDCap allows you to specify either mg/dL or mmol/L for blood glucose. You no longer have to convert all values to mmol//L. Note that the first time you record blood glucose for any given patient (on the Patient Information form) you will have to indicate which units you are using for blood glucose. All subsequent blood glucose measurements for that patient will be presumed to be recorded in the same units. 

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Our hospital uses APACHE III scores. Can I enter these instead of APACHE II?

No, please calculate APACHE II scores.

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I do not work in the ICU every day/weekends, do I exclude these days from the survey?

No, please review the patient chart retrospectively and collect the necessary data for each consecutive day.

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Should patients in the ICU be screened every day even if they have not been in the ICU for 72 hours? This could potentially results in patients being screened 3 times prior to enrollment.

It is OK to screen patients once they have been in the ICU 72 hours to ensure you do not accidentally enroll patients that do not meet the inclusion criteria. 

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Baseline Nutrition Assessment

I am unable to obtain actual height and weight, what do I do?

Observe the patient and estimate height/weight, ask family members or nursing staff for an estimated height/weight, or review the patient chart for previous documentation of height/weight. When entering data online check the ‘estimated?' box beside the appropriate field. You should not leave height and weight blank.

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Does the nutrition assessment have to be from day 1? If it didn't take place until day 4, what do I do?

While the baseline nutrition form is positioned at “day 1” on the “grid” in REDCap, you may enter the nutrition assessment on the baseline nutrition form regardless of when it occurred. You should always enter information about the nutrition assessment (if one occurred in the 1st 12 days of the patient's ICU stay) in preference to selecting “no assessment completed” or calculating a prescription of 25kcal/kg and 1g/kg for protein..

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If a nutritional assessment was not completed, do I leave the nutritional assessment form blank?

If a standard regimen is prescribed at your ICU when assessments are not completed please enter this information. Alternatively if a nutritional assessment was not completed, you can choose "no assessment completed" on REDCap and the prescription will be calculated for you. REDCap will automatically calculate the prescription as 25 kcals/kg for energy and 1g/kg protein. (e.g. an 80Kg male patient would have a prescription of 2000kcals and 80g protein). Actual body weight will be used in individuals with normal BMIs, while adjusted and ideal body weight will be used for obese and underweight individuals, respectively. 

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When asked to specify the initial order for nutrition, does this include suggestions/requests?

Select the official order for nutrition, not suggestions or requests. 

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Daily Nutrition Data

Do we count 'day 1' as day of admission into ICU, or first 24 hr period (i.e. 2300hrs on day of admission to next day 2300hrs)?

Day 1 is the date and time of admission to the ICU until midnight on that calendar day (this might not be a full 24 hours).  Day 2 and subsequent days begin and end at midnight (ie. study days = calendar days). This means that if your flowsheet does not begin and end at midnight, each study day may consist of the last half of one flow sheet and the first half of the next. For example, if a patient is admitted to ICU Sept 9 @ 02:00:

  • Day 1 = September 9 (02:00 until 23:59)
  • Day 2 = September 10 (00:00 until 23:59
  • Day 3 = September 11 (00:00 until 23:59)

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If a patient is prescribed an enteral formula containing glutamine (e.g. Crucial) is this considered a glutamine supplement?

No, only include glutamine supplementation over and above what is present in the prescribed enteral formula.

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If a patient is prescribed a parenteral solution containing glutamine, is this considered a glutamine supplement?

Glutamine added to a TPN solution is considered glutamine supplementation, so select ‘yes' and click ‘IV/PN' for the route.

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Do I include the protein from glutamine and supplements in the total amount of protein received?

Include protein from additional supplements, if applicable. Do NOT include glutamine, as it is an amino acid, not a complete protein, and because there is a separate field in the daily nutrition data for you to record how much glutamine was given.

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Do I include calories received from IV dextrose?

No, only include kcals from EN / PN. IV glucose only is not considered parenteral nutrition.

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Does the route or type of insulin provided matter?

No, please provide total units of insulin received per 24 hours regardless of type or route.

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If a patient leaves the ICU and comes back within 48 hours, do we count it as the next ICU day or do we collect data from when the patients were in a step down unit?

If they come back within 48 hours, try to collect the nutrition data for the intervening time (when they would have been outside the ICU) from patient records if at all possible. If the patient was admitted on May 1, and left the ICU for May 3 and was back on the 4th, you would collect as much data as possible from the time they spent in the step down unit on May 3 (day 3) and enter that online. May 4 would still be day 4 no matter how much data was missing from May 3.

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Can I record study days based on my flow sheet schedule, not midnight to midnight?

No, all sites must follow the midnight to midnight schedule. All of the checks and queries programmed into REDCap follow this schedule, therefore, we have no flexibility. Sorry!

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Do I need to adjust the patient's nutrition prescription if the patient is receiving propofol?

No, the nutrition prescription would not change because the goal regimen (ie. full caloric and protein needs) of the patient have not changed. The prescribed energy intake should be based on the goal rate the patient requires to meet their needs, regardless if propofol is providing some of these calories. On the Daily Nutrition Data 2 form, we ask for the calories provided for propofol. On the Daily EN Form, we ask for the calories received from the feeding formula not including calories from propofol.

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Are there forms to record the nutrition received orally from food and beverages?

No, we do not collect data on the calories and protein patients receive orally. Please continue to complete the Case Report Forms and indicate if oral, enteral or parenteral nutrition was received each day.

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On the Supplemental Nutrients form, do we indicate that a supplement was given if they are in a multivitamin?

No, only include supplements if prescribed on their own, not if in a general multivitamin.


If insulin was administered to treat hyperkalemia, is this insulin included in the 24 hour amount or should we just record insulin given for blood glucose control?

Only record insulin administered for blood glucose control


 Outcomes



If a transfer order is written but no bed outside of the ICU is available right away, do I record discharge date/time as when the transfer order was written, or when the patient is actually transferred?

Continue collecting data on patients physically located in your ICU. The discharge date for data entry would then have to be the date/time that the patient is actually transferred, not the date/time the order was written.

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Mechanical ventilation was discontinued for the patient, but 72 hours later the patient was reintubated. Then they were extubated again a few days later. What date for discontinuation of mechanical ventilation do I use on the outcomes form?

If the patient was extubated for >48 hours before being mechanically ventilated again, use this first date and time for discontinuation of mechanical ventilation on the outcomes form. If they were intubated again <48 hours after being extubated, you would consider this as if the patient had never been extubated, and enter the next date/time of extubation on the outcomes form.

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What if the patient is discharged from the ICU on mechanical ventilation?

Select “no” in answer to the question “was mechanical ventilation discontinued in the ICU.” You will subsequently be asked questions regarding the patient's mechanical ventilation after ICU discharge.

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REDCap

 


 

How do I find out our site number? Is it generated with the patient number when we enroll a patient online?

Yes, the patient number will include the site number. For example, patient number 248-1 is site 248 and patient 1. Remember to record these patient numbers in your screening log, so that you can easily figure out which patient on REDCap corresponds to patients in your paper data collection.

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I want to edit my EN data for Patient 23-4, Day 6, how do I do this?

On the “data entry” page select 23-4 from the drop down menu. You will be directed to this patient's “grid” where you can access all forms for that patient. Simply click on the “daily nutrition” form corresponding to day 6. Scroll down to the EN information section of the form. Be sure to scroll to the bottom of the page to “save” the form before navigating away from the page.

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When I enter the patient's weight as 57Kg, I receive the error message ‘This value you provided is not a number. Please try again'. This is the correct weight, so why do I receive an error message?

The data field only supports numeric data and will not recognize the unit suffix. Please enter all data without the units (e.g. kg, m, %). All units are displayed next to the appropriate data field.

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Why am I being queried for data I have not yet collected?

The new query system runs in real time. If you save a form and leave a field blank because you are unable to answer it at this time (ie. 12 days of data collection are not complete) you may ignore the query until you have completed the field or are ready to submit the patient's data.

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Study Timelines


Is there an end date for this Survey, or do we keep going until we have sufficient patients included?

Please continue screening patients until you have enrolled sufficient patients. We will provide a specific date by which all data, including outcomes data and resolving any queries, should be completed online. If you wish to be eligible for the Best of the Best award, you must adhere to these deadlines. If you are concerned that you may not be able to recruit enough patients in these timelines in order to receive a site report, please contact Margot at This email address is being protected from spambots. You need JavaScript enabled to view it.

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