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

Claudio M. Martin, Gordon S. Doig, Daren K. Heyland, Teresa Morrison and William J. Sibbald for The Southwestern Ontario Critical Care Research Network

From the Department of Medicine, Faculty of Medicine, University of Western Ontario, London, Ont. (Martin, Doig, Sibbald); the Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia (Doig); the Department of Medicine, Faculty of Medicine, Queen's University, Kingston, Ont. (Heyland); the Department of Medicine, University of Toronto, Toronto, Ont. (Sibbald); and the Critical Care Research Network, London Health Sciences Centre, London, Ont. (Martin, Doig, Morrison, Sibbald)

Correspondence to: Dr. Claudio M. Martin, London Health Sciences Centre, 375 South St., London ON N6A 4G5; fax 519 667-6698;

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.




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