Implementation of Dietitian Recommendations for Enteral Nutrition Results in Improved Outcomes

[Evaluation of the role of an advanced practice dietitian in the intensive care unit]

BACKGROUND

In Swiss intensive care units (ICUs), nutritional management is hardly or not at all supported or supervised by dietitians. Nutritional management in the ICU is mainly performed by ICU nursing staff and intensive care specialists. In 2022, the role of an advanced practice dietitian (APD) was newly defined, created, and implemented in a Swiss ICU as part of a pilot project. In contrast to other countries, APDs are still scarce in Switzerland. Evaluation of the APD role is essential to further define the position and adapt it to needs. The aim of this survey was to evaluate the impact of the APD role 8 months after implementation.

MATERIALS AND METHODS

The survey was conducted via online survey in February and March 2023. A total of 34 members of the ICU team participated, including physicians (n = 11), nurses (n = 20), and speech therapists (n = 3). In addition to workload, years worked in the company, and shiftwork, questions were asked about the level of awareness of the new APD position, integration of the APD into the ICU team, and the impact of the APD on nutritional management and the situation of the participants, as well as regarding documentation and prescribing skills. A descriptive analysis of the data was carried out in Microsoft Excel (Microsoft Corporation, Redmond, WA, USA).

RESULTS AND CONCLUSION

The majority are aware of the APD and consider her as part of the ICU team. From the treatment team's point of view, the quality of the nutritional care provided as by the APD has improved and there is added value for patients and the ICU team. The delegated prescribing competence seems to improve nutritional management noticeably and is perceived as helpful and relieving by a majority. How the position will develop in terms of the competence profile remains to be seen.

Nutritional profile and risk assessment of inorganic elements in enteral and parenteral nutrition formulas

The contents of essential (Ca, Fe, K, Na, P, and Zn) and potentially toxic inorganic elements (As, Al, Cd, Cr, Cu, Mn, and Pb) in enteral and parenteral nutrition formulas were evaluated by inductively coupled plasma optical emission spectrometry (ICP OES) and graphite furnace atomic absorption spectrometry (GFAAS). A total of 30 enteral formulas, 23 parenteral solution components, and 3 parenteral solutions were analyzed. The elements Ca and K presented the higher contents (72-2918 mg L-1 and 235-2760 mg L-1) while the lowest concentration levels were found for As and Cd (<0.68 µg L-1 and <0.01-0.62 µg L-1) in the studied samples. The validated analytical methods presented an accuracy of 75-116% and RSD values lower than 9.8%. Calcium gluconate and magnesium sulfate, which are used as raw materials in parenteral solution, are potential sources of Al and Mn contamination. A Hazard Quotient (HQ) >1 was obtained for Al (27 ± 1 µg L-1) in one of the parenteral samples, whereas the established limit is 25 µg L-1. Enteral samples were considered safe for consumption regarding the Al, As, and Cd levels. One healing-specific and pediatric formula contained Pb at levels above 0.25 µg kg-day-1, too high for safe consumption. The enteral formulas (pediatric, diabetes-specific, renal-specific, healing-specific, and standard formula with addition of fiber) presented risks in relation to the consumption of Cr and Mn (>250 µg day-1 and >11 mg day-1). The results indicate the need for strict monitoring, considering that these formulations are often the single patient's food source.

Exploring paediatric dietetic resources available for critically ill children in the UK and Ireland: A multicentre survey

BACKGROUND

A dedicated intensive care dietitian, as part of the intensive care unit (ICU) multidisciplinary team, contributes to improved delivery of nutrition support. The Paediatric Critical Care Society recommends a minimum dietetic staffing to critical-care bed ratio of 1:10, led by an Agenda for Change (AfC) Band 7.

METHODS

A cross-sectional study was conducted using an electronic survey that was available for 12 weeks. The Paediatric Intensive Care Audit Network database was used to identify all hospitals with paediatric intensive care unit (PICU) beds (n = 28).

RESULTS

Only 14% (n = 4/28) of trusts met the recommended 1:10 dietitian to bed ratio. PICU dietetic whole time equivalent was 0.7 ± 0.4, with a staff to bed ratio of 1:23.7 ± 10.7, compared to adult staff to bed ratio of 1:24.7. Some 92.8% (n = 26/28) had a AfC Band 7 Lead and only 7% (n = 2/28) had an AfC Band 8a Lead compared to adult services where 12.5% (n = 15/122) had an AfC Band 8a (p < 0.05).

CONCLUSIONS

There is a significant disparity between adult versus paediatric services with regard to seniority of dietitians. Dietitians in well-resourced centres were more likely to review patients without the need for a referral, which may improve nutrition outcomes.

Enteral nutrition practice in the prone position in patients with coronavirus disease 2019: An international one-day point prevalence analysis

BACKGROUND & AIMS

Enteral nutrition (EN) in the prone position for severe respiratory failure is considered possible with care. However, the extent to which it is feasible, especially its association with the length of intensive care unit (ICU) stay, is unclear. Therefore, we investigated the relationship between the duration of prone position therapy and adequacy of EN delivery and explored factors associated with this relationship in an observational study of critically ill patients with coronavirus disease 2019 (COVID-19) who were actively treated in the prone position.

METHODS

This study was a secondary analysis of a worldwide one-day prevalence study in the COVID-19 era. We investigated the care and nutritional therapy provided to critically ill patients with COVID-19 admitted to ICU, along with ICU-related information. We targeted patients who received only tube feeding and analyzed the relationship between the duration of prone position, length of ICU stays, and nutrition delivery via EN. In addition, a multivariate analysis was performed to examine factors affecting the achievement of EN delivery of 20 kcal/kg/day or more in patients who were placed in the prone position for at least 6 h.

RESULTS

A total of 399 patients who received only EN, excluding parenteral nutrition and oral intake, were included, of whom 58 % received EN energy delivery of ≥20 kcal/kg/day; this rate increased with the length of ICU stay, regardless of the duration of prone position. In a multivariate analysis of 121 patients who were in the prone position for at least 6 h, the presence of dedicated dietitians in the ICU (OR = 6.91, 95 % CI = 1.98 to 24.1, p < 0.01) was associated with a higher energy delivery. Conversely, the use of muscle relaxants (OR = 0.32, 95 % CI = 0.11 to 0.98, p = 0.04) and presence of nutrition protocols (OR = 0.24, 95 % CI = 0.07 to 0.77, p = 0.02) was associated with a lower energy delivery.

CONCLUSIONS

Patients with COVID-19 received adequate nutrition by EN even during prone position. Target EN delivery would be achieved with the introduction of prone position.

The status of clinical nutrition in hospitals of Guilan province, Iran - A mixed-method study

Introduction

Background: nutritional therapy has an important role in the development of medical care services, and quantitative and qualitative assessments of the status of clinical nutrition in hospitals is crucial. This study aimed to explore the current status of clinical nutrition in hospitals of Guilan province, Iran. Methods: this quantitative-qualitative (mixed method) study was performed on public hospitals in Guilan province, Iran (n = 26). The required information was collected by visiting the hospitals and interviewing with hospital dietitians. The data collection tool had two quantitative and qualitative subscales. The quantitative subscale included a 21-item checklist containing information about the referral system, cooperation of hospital staff in clinical nutrition, clinical nutrition staff status, enteral nutrition, and parenteral nutrition. Results: in more than 55 % of hospitals the patients were not adequately referred to a dietitian. In about 31.2 % of hospitals, cooperation of other departments in the field of clinical nutrition was insufficient. In 37 % of hospitals with intensive care unit (ICU), enteral nutrition was not provided properly. Only 27 % of the hospital properly provided parenteral nutrition for their patients. The most important problems mentioned by hospital dietitians included noncompliance of the food services employers with recommended diets, insufficient number of hospital dietitians, and lack of per case payment method for dietitians. Coverage of diet services by health insurance was the most common suggestion of dietitians to promote diet therapy in public hospitals. Conclusion: the situation of providing nutritional services to patients in public hospitals is not favorable in terms of quantity and quality in Guilan province, Iran. Designing the necessary policies and reorient the clinical nutrition system in hospitals to promote patients' health and accelerate patient recovery is warranted.

Factors Associated with Interruptions of Enteral Nutrition and the Impact on Macro- and Micronutrient Deficits in ICU Patients

BACKGROUND AND AIM

Feeding interruptions in critical care patients are often unjustified. We aimed to determine the causes, duration, and frequency of enteral nutrition interruptions (ENIs) and to assess macronutrients and antioxidant deficits according to European Society of Parenteral Enteral Nutrition (ESPEN) guidelines.

METHODS

We prospectively enrolled Intensive Care Unit (ICU) patients admitted for more than 48 h with an inability to orally eat from April to December 2019. The type of enteral nutrition, the number of calories administered, the time of feeding initiation, the reasons for delaying feeding, and the causes for ENI were recorded.

RESULTS

81 patients were enrolled, with a median duration of ENIs of 5.2 (3.4-7.4) hours/day. Gastric residual volume (GRV) monitoring-a highly controversial practice-was the most common cause of ENI (median duration 3 (2.3-3) hours/day). The mean energy intake was 1037 ± 281 kcal/day, while 60.5% of patients covered less than 65% of the total energy needs (1751 ± 295 kcal/day, according to mean Body Mass Index (BMI)). The median daily protein intake did not exceed 0.43 ± 0.3 gr/kg/day of the actual body weight (BW), whereas ESPEN recommends 1.3 gr/kg/day for adjusted BW (p < 0.001). The average administration of micronutrients and antioxidants (arginine, selenium, zinc, vitamins) was significantly less than the dietary reference intake (p < 0.01).

CONCLUSION

ENIs lead to substantial caloric, protein, and antioxidant deficits.

Prevalence of hospital-acquired malnutrition and modifiable determinants of nutritional deterioration during inpatient admissions: A systematic review of the evidence

BACKGROUND

Malnutrition affects between 20% and 50% of hospital inpatients on admission, with further declines expected during hospitalisation. This review summarises the existing literature on hospital-acquired malnutrition that examines the magnitude of nutritional deterioration amongst adult inpatients and identifies preventable barriers to optimising nutrition support during episodes of care.

METHODS

A systematic review was conducted to answer the question: Among adult hospital inpatients, the presence of which modifiable factors contribute to hospital-acquired malnutrition? A database search was conducted between the 24 April and 30 June 2020 using CINAHL, MEDLINE, Scopus and PubMed databases according to a protocol registered with PROSPERO (CD42020182728). In addition, issues of the 10 top clinical nutrition journals published during the period of from 1 April 2015 to 30 March 2020 were hand-searched.

RESULTS

Fifteen articles were eligible for inclusion from a total of 5944 retrieved abstracts. A narrative synthesis of evidence was completed because of the high level of heterogeneity in methodologies. Nutritional deterioration is common among previously well-nourished and nutritionally compromised patients, with studies reporting that 10%-65% of patients experienced nutritional decline. Frequently reported barriers were mealtime interruptions, meal dissatisfaction, procedure-related fasting, effects of illness or treatment, chewing difficulties, poor appetite and malnutrition as a low clinical priority.

CONCLUSIONS

The findings of this review support the need for routine nutritional risk screening throughout each hospital admission with hospital-acquired malnutrition affecting up to 65% of inpatients. Clear establishment of the roles and responsibilities of each member within multidisciplinary healthcare teams in the provision of nutrition care and cost-benefit analyses are recommended to demonstrate the effectiveness of changes to models of care.

Dieticians' practices in intensive care: A national survey

BACKGROUND & AIMS

A real public health problem, namely, malnutrition in the hospital, also concerns intensive care patients. The diagnosis and prevention of malnutrition are major issues in the multidisciplinary management of patients hospitalized in the intensive care unit (ICU). To our knowledge, few data describe dietary management in French ICUs, and few international scientific publications mention professional practices or how dieticians are integrated in this type of specialized and technical sector. The objective of this study is to identify the practices of dieticians in the ICU at a national level.

METHODS

This study is based on the use of an electronic questionnaire distributed to registered dietician nutritionists practising in intensive care.

RESULTS

A total of 185 dieticians participated in this survey, which allowed us to describe the practices of 174 ICUs. Among the respondents (n = 185), 95% were women with a median age of 37 [31; 52]. The respondents graduated a median of 14 years ago [8.5; 30] and have been practising in intensive care for 5 years [2; 10]. With a median number of 12 beds [10; 18] (n = 174), the ICU has a median of 0.1 [0.05; 0.25] (n = 185) full-time equivalent dieticians. The solicitation of the dietitian is variable in different ICUs. Nevertheless, information from dietitians is frequently sought. Dietary initiatives mainly concern acts relating to oral nutrition and enteral nutrition. A nutrition protocol was present in 38% of the ICUs (n = 174). The integration felt by dieticians in the service is heterogeneous. Statistical analysis reveals that a dietitian who spends more than 4 h a week in the ICU, has a nutrition protocol in his or her department and does not encounter any obstacles, such as the absence of a doctor's prescription, is more likely to be integrated into an ICU.

CONCLUSIONS

This research work has made it possible to describe and make visible the role and involvement of dieticians working in ICUs in France and oversea departments and territories. Proposals to increase the involvement of dieticians in these sectors were reported at the end of this analysis.

Predictors of Dietitian Referrals in Hospitals

Dietitian involvement has considerable benefits for hospitalized patients, resulting in better health outcomes and improved quality of life. However, dietitian referral routines are often inappropriate in hospitals. The aim of this study was to identify predictors for dietitian referrals in hospitalized patients. This study was performed on data collected in an annually conducted cross-sectional study (in the years 2017, 2018, 2019). A standardized questionnaire was used to collect data, and logistic regression and a generalized estimating equation (GEE) model were used to calculate the associations between the patient characteristics and dietitian referrals. In the final GEE model, the following predictors for dietitian referrals remained significant: diabetes diagnosis (OR 1.80), cancer diagnosis (OR 1.76), digestive disease diagnosis (OR 2.03), presence of a pressure injury (OR 1.58), risk of malnutrition based on body mass index (BMI) and weight loss (OR 1.72), risk of malnutrition based on the malnutrition universal screening tool (MUST) (2.55), and the application of any malnutrition screening at admission to hospital (2.20). Total dietitian referral rate was 16.8%. The highest rate of dietitian referrals was found in patients with a risk of malnutrition (37%). This study included a large sample of hospitalized adult patients and revealed a low dietitian referral rate among these patients. These results indicate that dietitian involvement in hospitalized patients with nutrition-related conditions urgently needs to be improved.

Normalized measures and patient characteristics to identify undernutrition in infants and young children treated for cancer

BACKGROUND

Various measures and definitions for undernutrition are used in pediatrics. Younger children treated for cancer are at high risk, but lack well-defined risk-based screening and intervention.

METHODS

A retrospective study collected weight longitudinally for patients less than three years-old over two years after initiating cancer treatment. We included those diagnosed 2007-2015 at a large pediatric cancer center. Exclusion criteria included treatment starting outside our system, secondary or relapsed malignancy, or incomplete information. A decrease ≥1 in weight-for-age or weight-for-height z-score signified clinically significant weight loss. Univariate and multivariate models assessed hazards for developing first episode of clinically significant weight loss.

RESULTS

Of 372 patients, only 24.6% of patients lost 10% of weight, but 58.6% lost weight-for-age z-score ≥1 and 64.8% lost ≥1 weight-for-height z-score within two years of treatment initiation. Patients who lost weight were younger (median age 15 vs. 24 months, p < 0.001). Compared to patients diagnosed in the first year of life, those diagnosed 24-35 months were less likely to lose weight (HR 0.62, p < 0.001) and lost weight later (median time to weight loss 144 vs. 35 days). Higher treatment intensity increased weight loss risk (HR 2.30, p < 0.001) and decreased time to weight loss (35 vs. 154 days). No differences were found based on sex, diagnosis, enteral or parenteral nutrition, gastroenterology consults, or intensive care admissions.

CONCLUSIONS

Using normalized z-scores is more sensitive for identifying weight loss. Younger children are more likely to lose weight with higher intensity cancer therapy. Patient and treatment specific information should be used in risk stratifying weight loss screening and nutritional interventions.

Assignment of Registered Dietitians and Other Healthcare Professionals Positively Affects Weight Change of Underweight Patients in Convalescent (Kaifukuki) Rehabilitation Wards: A Secondary Analysis of a Nationwide Survey

This study aimed to verify the relationship between assignment of professional registered dietitians (RDs) and other healthcare professionals and body weight or functional outcome in underweight patients. This was a secondary analysis of the nation-wide survey data from Kaifukuki (convalescent) rehabilitation wards (KRWs). Data of patients aged ≥20 y with disabilities and body mass index (BMI) <18.5 kg/m² and who were discharged from 1,099 KRWs were analyzed. The primary outcome was BMI at discharge. Secondary outcomes were Functional Independence Measure (FIM) at discharge and returning to home. Patients were divided into two groups: those in KRWs with ≥1 or <1 dedicated RD per ward (KRW/RD+ and KRW/RD-, respectively). Of 5,843 eligible participants (female, 63%; median age, 82 y; hip/vertebral/knee fracture, 47%; stroke, 34%; disuse syndrome secondary to acute illness, 11%; others, 8%), 1,288 and 4,555 were from the KRW/RD+ and KRW/RD- groups, respectively. At discharge, KRW/RD+ patients had higher FIM (93 vs. 90) and BMI (17.1 vs. 17.0 kg/m²) than did KRW/RD- patients. Multivariable analysis showed that assignment of dedicated RDs (B=0.213, 95% confidence interval [CI], 0.036-0.389), number of nurses (B=0.023, 95% CI, 0.003-0.043), and daily rehabilitation dose were significantly associated with changes in body weight. Furthermore, these factors positively affected BMI at discharge. Number of nurses and rehabilitation dose correlated with FIM, but assignment of RDs did not correlate with FIM. In conclusion, assignment of RDs, nurses, and sufficient rehabilitation dose may contribute to BMI gain. Nurses and daily rehabilitation dose may positively affect functional recovery.

Blenderized Tube Feeding: A Survey of Dietitians' Perspectives, Education, and Perceived Competence

Increasingly, patients and their caregivers desire blenderized tube feeding (BTF) as an alternative or adjunct to commercial enteral formula. Although dietitians are central in the care of tube fed patients, they do not necessarily have training or experience with BTF and may therefore find it challenging to manage the nutrition of patients who opt for this enteral nutrition approach. To describe dietitians' perspectives, perceived competence, and education on BTF, a cross-sectional survey was conducted by use of an original questionnaire. Dietitians with the authority to practice enteral nutrition in the province of British Columbia, Canada, were included in the study (n = 715). Of the 221 respondents (31% response rate), 28% reported being knowledgeable about BTF, and 24% reported confidence managing patients on BTF. Few agreed they had the expertise to design, administer, or teach administration of BTF (29%, 15%, and 24%, respectively). In regards to education, 27% of respondents did not have BTF education of any kind, and those with BTF education reported it to be primarily derived from informal sources such as self-directed study and learning from colleagues or patients. These results indicate that among dietitians, formal BTF education is uncommon, and there is limited perceived competence on BTF practice.

Utilization of Intensive Care Unit Nutrition Consultation Is Associated With Reduced Mortality

BACKGROUND

The aim of this project was to investigate the prevalence of nutrition consultation (NC) in U.S. intensive care units (ICUs) and to examine its association with patient outcomes.

METHODS

Data from the Healthcare Cost and Utilization Project's state inpatient databases was utilized from 2010 - 2014. A multilevel logistic regression model was used to evaluate the relationship between NC and clinical outcomes.

RESULTS

Institutional ICU NC rates varied significantly (mean: 14%, range: 0.1%-73%). Significant variation among underlying disease processes was identified, with burn patients having the highest consult rate (P < 0.001, mean: 6%, range: 2%-25%). ICU patients who received NC had significantly lower in-hospital mortality (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.48-0.74, P < 0.001), as did the subset with malnutrition (OR 0.72, 95% CI 0.53-0.99, P = 0.047) and the subset with concomitant physical therapy consultation (OR 0.53, 95% CI 0.38-0.74, P < 0.001). NC was associated with significantly lower rates of intubation, pulmonary failure, pneumonia, and gastrointestinal bleeding (P < 0.05). Furthermore, patients who received NC were more likely to receive enteral or parenteral nutrition (ENPN) (OR 1.8, 95% CI 1.4-2.3, P < 0.001). Patients who received follow-up NC were even more likely to receive ENPN (OR 3.0, 95% CI 2.1-4.2, P < 0.001).

CONCLUSIONS

Rates of NC were low in critically ill patients. This study suggests that increased utilization of NC in critically ill patients may be associated with improved clinical outcomes.

Effect of Registered Dietitian Nutritionist Order-Writing Privileges on Enteral Nutrition Administration in Selected Intensive Care Units

BACKGROUND

Adequate nutrition is linked to improved patient outcomes during critical illness. Nutrition care is further enhanced by registered dietitian nutritionist (RDN) order-writing privileges, which improve the implementation of nutrition interventions. The purpose of this performance improvement project was to evaluate the effect of RDN order-writing privileges on enteral nutrition (EN) order compliance and nutrition delivery in selected intensive care units (ICUs) at a university-affiliated teaching hospital.

METHODS

Patients admitted to selected ICUs from January 23, 2018, to January 25, 2018, were screened for eligibility. Demographic and nutrition data were collected retrospectively from the electronic health record. Percent of energy and protein needs met were calculated. Data were compared with historical internal controls identified prior to RDN order-writing privileges.

RESULTS

Fifty adult patients (150 EN days) were included in data analysis, with 93 patients (279 EN days) included in historical data. Compared with historical data, cumulative EN order compliance increased by 17% and tube feed infusion rate compliance by 15% post-RDN order-writing privileges. Mean (± SD) protein needs delivered significantly increased from 72.1 ± 28.6% to 89.1 ± 24.8% after RDN order-writing implementation (P < 0.001).

CONCLUSIONS

RDN order-writing privileges improved EN order compliance and significantly improved protein delivery in selected ICUs. Future studies are recommended to confirm these results and determine if other variables besides protein delivery are statistically significant with a larger sample size.

Impact of gaps in care for malnourished patients on length of stay and hospital readmission

BACKGROUND

Few published articles have focused on identifying the gaps in care that follow a malnutrition diagnosis and their effects on length of stay (LOS) and 90-day readmission. We hypothesized that length of stay and readmission were associated with these gaps in care.

METHODS

Two registered dietitians retrospectively reviewed charts of 229 adult malnourished patients admitted to a medicine unit to determine their system level gap in care: communication, test delay, or discharge planning. In this secondary analysis, both readmission and length of stay were regressed on each gap in care.

RESULTS

Any system level gap was associated with a greater length of stay (β: 1.48, 95% CI: 1.15-1.91) and specifically the gap related to procedure/testing (β: 2.01, 95% CI: 1.62-2.47) resulted in a two-fold increase in length of stay. There was no association between 90-day readmission and any of the gaps in care.

CONCLUSIONS

There was a strong association between those who had any gap in their care and increased length of stay. Mitigating gaps in care may decrease length of stay and, in turn, result in less risk of infection and could potentially lead to reduced healthcare costs.

Adherence to a Nurse-Driven Feeding Protocol in a Pediatric Intensive Care Unit

BACKGROUND

Patients admitted to pediatric intensive care units (PICUs) often experience prolonged periods without nutrition support, which may result in hospital-induced malnutrition and longer length of stay. Nurse-driven feeding protocols have been developed to prevent unnecessary interruptions or delays to nutrition support. The primary objective of this study was to identify compliance and reasons for noncompliance to a feeding protocol at a tertiary care hospital PICU in Canada. The secondary aim was to determine the mean time (hours) spent without any form of nutrition and to identify reasons for time spent without nutrition.

MATERIALS AND METHODS

This was a prospective cohort audit, consisting of 150 consecutive PICU admissions (January-February 2016). Exclusion criteria consisted of patient mortality within 48 hours (n = 1) and patients who were still admitted at the end of the data collection timeframe (n = 7). The remaining cohort consisted of 142 consecutive admissions. Data collection took place in real time and included patient demographics, diagnostic categories, time spent without nutrition, reasons for interruptions to nutrition support, and reasons for noncompliance to the protocol. Observations were obtained through paper and computer charts and conversing with clinicians.

RESULTS

There was a 95% compliance rate to the protocol and an average of 25.6 hours spent without nutrition per patient. The most prevalent reason for noncompliance was an avoidable delay to restart feeds before/after procedures or after surgery.

CONCLUSIONS

A nurse-driven feeding protocol may reduce time spent without nutrition. Future research is required to examine the relationship between adherence to feeding protocols and clinical outcomes.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

[Organization and the Role of Nutirition Support Team]

With the development of specialized nutrition therapy and the need for interdisciplinary approach, nutrition support teams (NSTs) were created to optimize effectiveness and safety of nutritional therapy. NSTs are interdisciplinary support teams with specialty training in nutrition that are typically comprised of physicians, dietitians, nurses, pharmacists, and others. Their role includes nutrition screening, assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, management of nutrition support therapy, and monitoring. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by NSTs. Organization and the role of NSTs are discussed in this review.

The prevalence and consequences of malnutrition risk in elderly Albanian intensive care unit patients

PURPOSE

Many investigators have reported rising numbers of elderly patients admitted to the intensive care units (ICUs). The aim of the study was to estimate the prevalence of malnutrition risk in the ICU by comparing the prevalence of malnutrition between older adults (aged 65 years and above) and adults (aged 18-64 years), and to examine the negative consequences associated with risk of malnutrition in older adults.

MATERIALS AND METHODS

A prospective cohort study in the ICU of the University Hospital Center of Tirana, Albania, was conducted. Logistic regression analysis was used to analyze the effect of malnutrition risk on the length of ICU stay, the duration of being on the ventilator, the total complications, the infectious complications, and the mortality.

RESULTS

In this study, 963 patients participated, of whom 459 patients (47.7%) were aged ≥65 years. The prevalence of malnutrition risk at the time of ICU admission of the patients aged ≥65 years old was 71.24%. Logistic regression adjusted for confounders showed that malnutrition risk was an independent risk factor of poor clinical outcome for elderly ICU patients, for 1) infections (odds ratio [OR] =4.37; 95% confidence interval [CI]: 2.61-7.31); 2) complications (OR =6.73; 95% CI: 4.26-10.62); 3) mortality (OR =2.68; 95% CI: 1.72-4.18); and 4) ICU length of stay >14 days (OR =5.18, 95% CI: 2.43-11.06).

CONCLUSION

Malnutrition risk is highly prevalent among elderly ICU patients, especially among severely ill patients with malignancy admitted to the emergency ward. ICU elderly patients at malnutrition risk will have higher complication and infection rates, longer duration of ICU stay, and increased mortality. Efforts should be made to implement a variety of nutritional care strategies, to change the nutritional practices not only at ward level, but nationally, according to the best clinical practice and recent guidelines.

Predictors of dietitian consult on medical and surgical wards

BACKGROUND & AIM

Guidelines promote dietitian consult (DC) for nutrition support. In Canada, dietitians are involved in the assessment of malnutrition and provide specialized dietary counseling. It is unknown however, what leads to a DC for patients fed orally. This study identifies independent predictors for a DC and determines what is the proportion of malnourished patients seeing a dietitian.

METHODS

The Canadian Malnutrition Task Force conducted a prospective cohort study in medical and surgical wards of 18 Canadian hospitals. 947 patients who did not receive enteral or parenteral nutrition were analyzed. At admission, subjective global assessment (SGA), body mass index, patient demography were collected. During hospitalization clinical data, including dietary intake and presence of a DC were obtained. Multivariate logistic regression was completed with dietitian consult ≤ 3 days and 4 + days as the outcome variables.

RESULTS

The prevalence of malnutrition (SGA B + C) was 45%. Dietitians were consulted for 23% of patients, and of these consults 44% were well nourished (SGA-A), 37% were mildly/moderately malnourished (SGA-B), and 19% were severely malnourished (SGA-C). DC missed 75% of the SGA-B and 60% of SGA-C patients. Predictors of consultation within 3 days of hospitalization were: renal diet (OR 5.75) modified texture diet (OR 5.38), metabolic diagnosis (3.91), ONS use pre-admission (OR 2.33), severe malnutrition (SGA-C, OR 1.88) and age (OR 0.98). Predictors for 4 + days were: dysphagia (OR 11.4), a new medical diagnosis (OR 2.3), severe malnutrition (OR 2.17), constipation (OR 2.16), more than one diagnosis (OR 1.8), antibiotic use (OR 1.6), and male gender (OR 1.6). Consuming < 50% of food in the first week was not a predictor as only 19% of those with low intake had a DC at 4 + days.

CONCLUSIONS

Overall predictors of DC were appropriate but SGA B and C patients and those eating <50% were missed. Screening at admission with algorithms of care that include referral to the dietitian are needed to improve the process of nutrition care.

Nutrition support and deficiencies in children with severe traumatic brain injury

OBJECTIVE

Adequate nutrition support is considered important to recovery after pediatric traumatic brain injury. The 2003 Pediatric Guidelines recommend initiation of nutrition within 72 hrs after traumatic brain injury. We examined our local experience with nutritional support in severe pediatric traumatic brain injury patients (cases) and non-traumatic brain injury patients (controls).

DESIGN

A retrospective review of pediatric patients with severe traumatic brain injury over an 11-yr period (1997-2009) and without traumatic brain injury over a 3-yr period (2007-2009).

SETTING

Level I pediatric trauma center pediatric intensive care unit.

PATIENTS

Patients with severe pediatric traumatic brain injury (age <15 yrs, Glasgow Coma Scale score of <9) and admitted to the pediatric intensive care unit for >7 days and patients without traumatic brain injury (age <15 yrs, head Abbreviated Injury Scale score of 0) and admitted to pediatric intensive care unit.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data from 101 severe traumatic brain injury and 92 non-traumatic brain injury patients were analyzed. Traumatic brain injury patients: All received enteral nutrition while 13 (12%) also received parenteral nutrition. Nutrition was started 53 ± 20 hrs (range 12-162) after pediatric intensive care unit admission. Fifty patients (52%) received nutrition within the first 48 hrs, and 83 (82%) received nutrition support within the first 72 hrs. Caloric and protein intakes were 47% and 40% of the goals on pediatric intensive care unit day 7 and 76% and 70% of the goals on pediatric intensive care unit day 14. Caloric and protein goals were met in 26% ± 16% and 18% ± 19% of pediatric intensive care unit stay, respectively. Patients whose intake met nutritional goals on pediatric intensive care unit day 7 had earlier initiation of nutrition support at admission than patients who never met the goals (calorie goal met vs. unmet by day 7, 44 ± 23 hrs vs. 67 ± 31 hrs; p < .001; protein goal met vs. unmet by day 7, 43 ± 17 hrs vs. 65 ± 29 hrs; p = .001). Patients gained 0.6% ± 11% weight by pediatric intensive care unit day 7 and lost 7% ± 11% weight by pediatric intensive care unit day 14. Non-traumatic brain injury patients: The time to start of nutrition for the non-traumatic brain injury group was earlier only for patients with isolated orthopedic injuries (24 ± 6 hrs; p = .02). The average caloric and protein intakes were less for the traumatic brain injury (n = 20) group (caloric 52% ± 16% of goal and protein 42% ± 18% of goal) than for the non-traumatic brain injury (n = 23) group (65% ± 11% of goal and protein 51% ± 20% of goal; both p < .01) for pediatric intensive care unit days 0-7. For pediatric intensive care unit days 8-14, there was no difference in average caloric (82% ± 22% vs. 79% ± 18% of goal) or protein (77% ± 6% vs. 79% ± 7% of goal) between the traumatic brain injury (n = 12) and non-traumatic brain injury (n = 10) groups. Addition of a nutritionist was associated with earlier time to nutrition start (p = .02).

CONCLUSIONS

Nutritional support was initiated in most patients within 72 hrs of pediatric intensive care unit admission. Although daily caloric and protein goals were not achieved in the first 2 wks of pediatric intensive care unit stay and nutritional deficiencies were common, earlier start of nutritional support was associated with involvement of a nutritionist and with meeting both caloric and protein goals by pediatric intensive care unit day 7.

Development of a tool to measure dietitians' involvement in the intensive care setting

BACKGROUND

Intensive care is a relatively new work area for dietitians in Australasia, and the role of the dietitian appears to differ widely between facilities. This may create difficulties with multicenter research collaboration and workforce planning. The aim of this study was to develop a validated survey tool to assess dietitians' involvement in their intensive care teams.

METHODS

A full list of all 182 adult intensive care units in Australia and New Zealand was obtained from the Australian and New Zealand Intensive Care Society, and all of these units were contacted. A survey tool was developed, piloted, and validated using correlation tests of construct validity; factor analysis was used to develop a 5-item short-form survey tool.

RESULTS

At least 1 dietitian participated from each of the 182 hospitals that were contacted, and no dietitians declined to participate in the survey (100% response rate). The survey had strong validity and test-retest reliability in the population surveyed.

CONCLUSIONS

The survey tools presented here can be used to assess dietitians' involvement in their intensive care team. The short-form tool developed in this study is conveniently brief and easy to administer, but it will need to be validated for use outside the Australian and New Zealand health systems prior to conduct of a large-scale survey.

Creating a culture of clinical excellence in critical care nutrition: the 2008 "Best of the Best" award

OBJECTIVE

To develop, validate, and implement a system to reward top performers in critical care nutrition practice and to illuminate characteristics of top-performing intensive care units (ICUs).

DESIGN

An international, prospective, observational, cohort study conducted in May 2008.

SETTING

179 ICUs from 18 countries.

PATIENTS

2956 consecutively enrolled mechanically ventilated adult patients who stayed in the ICU for at least 72 hours.

INTERVENTIONS

To qualify for the "Best of the Best" (BOB) award, sites had to have implemented a nutrition protocol and contributed complete data on a minimum of 20 patients.

MEASUREMENTS AND MAIN RESULTS

Data on nutrition practices were collected from ICU admission to ICU discharge for a maximum of 12 days. Eligible sites were ranked based on their performance on the following 5 criteria: adequacy of provision of energy, use of enteral nutrition (EN), early initiation of EN, use of promotility drugs and small bowel feeding tubes, and adequate glycemic control. Of the 179 participating ICUs, 81 qualified for the BOB award. Overall, the average nutrition adequacy across sites was 56.2% (site range, 20.3%-90.1%). The top 10 performers were identified and publicly recognized. Regression analysis suggested that the presence of a dietitian in the ICU was associated with a high BOB award ranking, whereas being located in the United States or China, relative to other participating countries, was associated with worst performance.

CONCLUSIONS

There is variable performance with respect to critical care nutrition practices across the world.

Nutritional assessment of residents in long-term care facilities (LTCFs): recommendations of the task force on nutrition and ageing of the IAGG European region and the IANA

Unintentional weight loss and Undernutrition are major problems among older people living in Long-Term Care Facilities (LTCF). Undernutrition manifests in LTCF particularly as weight loss and low Body Mass Index (BMI) and is associated with increased morbidity and mortality as well as with functional decline. There are many factors associated with poor nutritional status and affecting protein-energy intake and/or energy expenditure. These include age of 85 years or older, low nutrient intake, loss of ability to eat independently, swallowing and chewing difficulties, becoming bed-ridden, pressure ulcers, history of hip fracture, dementia, depressive symptoms and suffering from two or more chronic illnesses. Nutritional evaluation is an essential part of the Comprehensive Geriatric Assessment (CGA). This evaluation ranges from methods such as BMI to several validated tools such as Mini-Nutritional Assessment (MNA). After diagnosis, the management of undernutrition in LTCF requires a multidisciplinary approach which may involve dietary and environmental improvements and managing multiple co-morbidities, while avoiding polypharmacy as far as possible. Finally, the need for supplementation or artificial (tube) feeding may be considered taking into account the CGA and individual needs. This document presents a succinct review and recommendations of evaluation and treatment of undernutrition.

Dietetic service provision for burn care in the United Kingdom: are nutrition support standards being met?

BACKGROUND

Catabolism and lean body mass losses in severe burn injury present an extreme challenge to the dietitian. A high level of nutritional intervention is often required, but service levels have not been described in the UK. This study aimed to identify levels of current dietetic services with respect to burns and to assess adequacy against existing nutrition support standards.

METHODS

A postal survey of 34 UK dietetic departments known to provide care to burned adult and paediatric admissions was undertaken. Data were collected on burns settings, hospital service characteristics, staffing and caseload issues, and absence cover. Comparison was made between funding and activity to National Health Service standards for the nutritional care of inpatients.

RESULTS

The response rate was 71% and data were analysed for 20 departments Clinical settings were either burn units or plastic surgery wards. Dietetic care was provided to critically ill burned patients in 16 hospitals. Most hospitals had no dietetic funding assigned for burn care. The funding deficit for critical care compared to recommendations was 5.9 full-time equivalents and no individual hospital met funding standards. Thirty-seven percent of dietitians were unable to provide daily follow up for critically ill patients. Absence cover was limited in 60% of cases. Approximately one-third of dietitians were members of a nutrition support team.

CONCLUSIONS

Compared to national guidelines for nutrition support, deficiencies of dietetic service provision exist within UK burns settings. This is further reinforced when practice is compared with existing multi-professional burns management standards.

Adequacy of dietetic service provision to adult critical care: a survey of 33 centres in Northern England

BACKGROUND

Nutrition interventions improve morbidity, mortality and length of stay in the critically ill. Dietitians play a central role in facilitating these interventions. However, data regarding the current level and adequacy of dietetic service provision to critical care in the UK is lacking. This study aimed to clarify current service trends in Northern England for critical care, in relation to dietetic funding, grading and activity characteristics and comparisons with nationally recognized standards of care.

METHODS

A work profile questionnaire was sent to 53 dietitians in Northern England. Data was collected on funding, activity patterns, organization of nutrition support, pay banding/grade and arrangements for cover during absence.

RESULTS

The response rate was 66% (35/53). Thirty-three hospitals were represented. No critical care centre funding or actual activity achieved national guidance for funded dietetic full-time equivalents (FTE). Total sample deficit for funding against recommendations was 32.9 FTE. Staff pay bands/grades were inconsistent. Routine patient review occurred on a daily basis by 31% dietitians and 23% were members of a nutrition support team. Cover during absence was limited or provided by a dietitian at a lower staff grade in 67% of centres.

CONCLUSIONS

Serious deficiencies exist in dietetic services to critical care in the sample studied. Further work is now required to identify inter-regional and national trends and to define appropriate dietetic job profiles for critical care.