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We appreciate the insightful comments by Wappel et al (1) regarding the limited energy/protein intake provided in our study (2), particularly in the context of difficulty in trusting the accuracy of recorded intake when using the intake/output record as the source document.
The intake that we have used in our analyses was that reported to us from the 202 distinct participating ICUs (2). Information about exactly how the data were obtained in a site was not collected during the International Nutrition Survey. However, it seems doubtful that feeding pump history would have been available extensively in sites around the world.
Your observations from your pump audit that the nursing intake records were in error by under-reporting the actual delivery of the prescribed volume are interesting and may be important. A pump audit was also reported by Musillo et al (3), in which 14% actually received “more than” 10% more than the nursing record, and 26% received more than 10% “less than” the nursing record, suggesting that 40% were misrecorded by nurses. After retraining nurses in documentation, our local experience was that the pump history was 85–90% of that reported in the nursing records (4). We agree that electronic transfer of pump history to the medical record and to our research portal would be ideal.
We concur with your concern about the inaccuracy of information about oral intake. That is the reason we stopped recording all protein/energy intake once the diet was advanced. Because this occurred at variable times during the 12-day window of observation of protein/energy intake, we adjusted our analysis of mortality in those who stayed more than 4 days but less than 12 days by a variable signifying the number of days of intake recording.
The International Nutrition Survey was a description of existing practice conditions, rather than a proscriptive protocol. We have noted in prior versions of this survey a variety of approaches to targeting energy needs, but no differences in mortality were noted on this basis, and the use of weight-based equations was associated with shorter time to discharge alive than when complex equations were used (5). However, a limitation of this study (2) was that the reported intake levels were only 60% of the prescribed goal. Because we believe that the feeding received is much more important to survival than the prescription that directed the intake, we have used what was reported as actual intake of energy/protein in this current article (2). In such a large survey, with data entered by volunteers, it is not possible to guarantee the accuracy of the intake records.
We share your value for multidisciplinary, coordinated models of care. Clearly, full engagement by all providers should result in higher quality of care.
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