Guidelines, guidelines, guidelines: what are we to do with all of these North American guidelines?

The Dutch chaos case: A scoping review of knowledge and decision support tools available to clinicians in the Netherlands

BACKGROUND

To keep clinicians up-to-date with the latest evidence, clinical practice and patient preferences, more and more knowledge tools - aiming to synthesise knowledge and support (shared) decision-making - are being developed. Unfortunately, it seems that in the Netherlands, and possibly elsewhere, the amount of different knowledge tool types makes it difficult to see the forest through the trees.

METHODS

A scoping review, exploring types of knowledge tools available to Dutch clinicians (and patients) and how these tools are described. The search terms were collected from thesauri and textbooks, and used to search the websites and documents of selected national tool developing organisations.

RESULTS

The review yielded 126 tool types. We included 67 different tool types, such as guidelines, protocols, standards and clinical pathways. Half of those tool types were aimed at clinicians, 14 at patients and 18 at both. In general, descriptions of the tool types were hard to find or incomplete.

CONCLUSIONS

There exists a myriad of knowledge tool types and their descriptions are mostly unclear. The information overload experienced by clinicians is not addressed effectively by developing numerous unclearly defined knowledge tools. We recommend limiting the number of tool types and making a greater effort in clearly defining them. This abundance of poorly defined tools does not seem to be restricted to the Netherlands.

Increased Efficacy and Safety of Enteral Nutrition Support with a Protocol (ASNET) in Noncritical Patients: A Randomized Controlled Trial

BACKGROUND

Unintentional underfeeding is common in patients receiving enteral nutrition (EN), and is associated with increased risk of malnutrition complications. Protocols for EN in critically ill patients have been shown to enhance adequacy, resulting in better clinical outcomes; however, outside of intensive care unit (ICU) settings, the influence of a protocol for EN is unknown.

OBJECTIVE

To evaluate the efficacy and safety of implementing an EN protocol in a noncritical setting.

DESIGN

Randomized controlled clinical trial.

PARTICIPANTS AND SETTINGS

This trial was conducted from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of EN were excluded.

INTERVENTION

The intervention group received EN according to a protocol, whereas the control group was fed according to standard practice.

MAIN OUTCOME MEASURES

The proportion of patients receiving ≥80% of their caloric target at Day 4 after EN initiation.

STATISTICAL ANALYSES PERFORMED

Student t test or Wilcoxon rank-sum test were used for continuous variables and the difference between the groups in the time to receipt of the optimal amount of nutrition was analyzed using Kaplan-Meier curves.

RESULTS

Forty-five patients were randomized to each group. At Day 4 after EN initiation, 61% of patients in the intervention arm had achieved the primary end point compared with 23% in the control group (P=0.001). In malnourished patients, 63% achieved the primary end point in the intervention group compared with 16% in the control group (P=0.003). The cumulative deficit on Day 4 was lower in the intervention arm compared with the control arm: 2,507 kcal (interquartile range [IQR]=1,262 to 2,908 kcal) vs 3,844 kcal (IQR=2,620 to 4,808 kcal) (P<0.001) and 116 g (IQR=69 to 151 g) vs 191 g (IQR=147 to 244 g) protein (P<0.001), respectively. The rates of gastrointestinal complications were not significantly different between groups.

CONCLUSIONS

Implementation of an EN protocol outside the ICU significantly improved the delivery of calories and protein when compared with current standard practice without increasing gastrointestinal complications.

International Variation in Asthma and Bronchiolitis Guidelines

BACKGROUND AND OBJECTIVES

Guideline recommendations for the same clinical condition may vary. The purpose of this study was to determine the degree of agreement among comparable asthma and bronchiolitis treatment recommendations from guidelines.

METHODS

National and international guidelines were searched by using guideline databases (eg, National Guidelines Clearinghouse: December 16-17, 2014, and January 9, 2015). Guideline recommendations were categorized as (1) recommend, (2) optionally recommend, (3) abstain from recommending, (4) recommend against a treatment, and (5) not addressed by the guideline. The degree of agreement between recommendations was evaluated by using an unweighted and weighted κ score. Pairwise comparisons of the guidelines were evaluated similarly.

RESULTS

There were 7 guidelines for asthma and 4 guidelines for bronchiolitis. For asthma, there were 166 recommendation topics, with 69 recommendation topics given in ≥2 guidelines. For bronchiolitis, there were 46 recommendation topics, with 21 recommendation topics provided in ≥2 guidelines. The overall κ for asthma was 0.03, both unweighted (95% confidence interval [CI]: -0.01 to 0.07) and weighted (95% CI: -0.01 to 0.10); for bronchiolitis, it was 0.32 unweighted (95% CI: 0.16 to 0.52) and 0.15 weighted (95% CI: -0.01 to 0.5).

CONCLUSIONS

Less agreement was found in national and international guidelines for asthma than for bronchiolitis. Additional studies are needed to determine if differences are based on patient preferences and values and economic considerations or if other recommendation-level, guideline-level, and condition-level factors are driving these differences.

Critical Care Nutrition Support Best Practices: Key Differences Between Canadian and American Guidelines

Since 2015, Society of Critical Care Medicine/American Society for Parenteral and Enteral Nutrition and Canadian critical care nutrition support guidelines have both been updated. Despite a similar evidentiary basis, there remain key differences between guideline recommendations. These differences in recommendations may pose confusion for the clinician and may encumber widespread applicability. The aim of this review was to enhance practitioner confidence in applying critical care nutrition support guidelines to patient care in their settings by outlining the similarities and differences between the American and Canadian methods for guideline development and describing the key differences and reasons behind the differences.

The intensive care medicine research agenda in nutrition and metabolism

Purpose

The objectives of this review are to summarize the current practices and major recent advances in critical care nutrition and metabolism, review common beliefs that have been contradicted by recent trials, highlight key remaining areas of uncertainty, and suggest recommendations for the top 10 studies/trials to be done in the next 10 years.

Methods

Recent literature was reviewed and developments and knowledge gaps were summarized. The panel identified candidate topics for future trials in critical care nutrition and metabolism. Then, members of the panel rated each one of the topics using a grading system (0–4). Potential studies were ranked on the basis of average score.

Results

Recent randomized controlled trials (RCTs) have challenged several concepts, including the notion that energy expenditure must be met universally in all critically ill patients during the acute phase of critical illness, the routine monitoring of gastric residual volume, and the value of immune-modulating nutrition. The optimal protein dose combined with standardized active and passive mobilization during the acute phase and post-acute phase of critical illness were the top ranked studies for the next 10 years. Nutritional assessment, nutritional strategies in critically obese patients, and the effects of continuous versus intermittent enteral nutrition were also among the highest-ranking studies.

Conclusions

Priorities for clinical research in the field of nutritional management of critically ill patients were suggested, with the prospect that different nutritional interventions targeted to the appropriate patient population will be examined for their effect on facilitating recovery and improving survival in adequately powered and properly designed studies, probably in conjunction with physical activity.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-017-4711-6) contains supplementary material, which is available to authorized users.

Effectiveness and efficacy of nutritional therapy: A systematic review following Cochrane methodology

BACKGROUND & AIMS

Disease-related malnutrition has deleterious consequences on patients' outcome and healthcare costs. The demonstration of improved outcome by appropriate nutritional management is on occasion difficult. The European Society of Clinical Nutrition and Metabolism (ESPEN) appointed the Nutrition Education Study Group (ESPEN-NESG) to increase recognition of nutritional knowledge and support in health services.

METHODS

To obtain the best available evidence on the potential effects of malnutrition on morbidity, mortality and hospital stay; cost of malnutrition; effect of nutritional treatment on outcome parameters and pharmaco-economics of nutritional therapy, a systematic review of the literature was performed following Cochrane methodology, to answer the following key questions: Q1) Is malnutrition an independent predictive factor for readmission within 30 days from hospital discharge? Q2) Does nutritional therapy reduce the risk of readmission within 30 days from hospital discharge? Q3) Is nutritional therapy cost-effective/does it reduce costs in hospitalized patients? and Q4) Is nutritional therapy cost effective/does it reduce costs in outpatients?

RESULTS

For Q1 six of 15 identified observational studies indicated that malnutrition was predictive of re-admissions, whereas the remainder did not. For Q2 nine randomized controlled trials and two meta-analyses gave non-conclusive results whether re-admissions could be reduced by nutritional therapy. Economic benefit and cost-effectiveness of nutritional therapy was consistently reported in 16 identified studies for hospitalized patients (Q3), whereas the heterogeneous and limited corresponding data on out-patients (Q4) indicated cost-benefits in some selected sub-groups.

CONCLUSIONS

This result of this review supports the use of nutritional therapy to reduce healthcare costs, most evident from large, homogeneous studies. In general, reports are too heterogeneous and overall of limited quality for conclusions on impact of malnutrition and its treatment on readmissions.

Optimal use of external demands in hospitals - a Delphi study from the Netherlands

Background

Regulatory authorities focus on promoting compliance of hospitals with a variety of external demands. Due to the amount of these external demands, hospitals might prioritise to cope with the external demands. In this study, we explore to what extent a risk-based prioritisation system developed by one Dutch hospital, is applicable in other hospitals as well. The specific research question was: can a risk-based prioritisation system help hospitals cope with the pressures of external demands?

Methods

We conducted a Delphi study, containing three rounds with seven quality and safety managers. All participants were experienced in coping with external demands in Dutch hospitals in general and their own hospital specifically. These experts were granted access to a sample selection of a database containing about 1500 external demands (January 2014). Prior to the Delphi study, a baseline measurement was carried out, where all participants answered open-ended questions aimed at identifying existing practices, possible challenges concerning external demands and to prepare the survey for the group Delphi study.

Results

We identified a high level of consensus during our Delphi research. The experts agreed that at present, Dutch hospitals do not cope with external demands systematically. The participants agreed that the database and the risk-based prioritisation system are useful tools to cope with the amount of external demands and indicated that they would also like to use these tools themselves in the future.

Conclusions

In this study, the participants agreed that the database and the risk-based prioritisation system are both applicable and useful tools to cope with the amount of external demands. Further research addressing the use of the risk-based-priority system for specific subsets of external demand is also needed.

Changes in plasma ET-1 and NO in patients with severe acute pancreatitis and effect of alprostadil on ET-1 and NO

AIM: To detect the changes in plasma endothelin-1 (ET-1) and nitric oxide (NO) in patients with severe acute pancreatitis and to observe the effect of alprostadil on ET-1 and NO levels.

METHODS: Sixty patients with SAP were randomly divided into two groups: a control group (n = 30) or a combination group (n = 30). The control group received intravenous infusion of somatostatin on the basis of conventional therapy, and the combination group received intravenous infusion of alprostadil and somatostatin on the basis of conventional therapy. Plasma levels of ET-1 and NO were measured at admission, 12 h, 48 h, 72 h, and 1 week after onset, and ET-1/NO ratio was calculated.

RESULTS: Plasma levels of ET-1 and NO initially increased, peaked at 12 h, were still maintained at high levels at 72 h, and then declined at 1 week below the levels at admission. The trend of changes of ET-1 and NO were similar between the two groups from admission to 24 h (ET-1 at admission: 97.7 ng/L ± 14.9 ng/L vs 98.8 ng/L ± 15.6 ng/L; 12 h: 157.4 ng/L ± 14.4 ng/L vs 160.3 ng/L ± 15.8 ng/L; 24 h: 146.0 ng/L ± 18.8 ng/L vs 146.4 ng/L ± 19.2 ng/L; NO at admission: 29.0 µmol/L ± 4.4 µmol/L vs 29.7 µmol/L ± 6.0 µmol/L; 12 h: 40.2 µmol/L ± 3.9 µmol/L vs 41.2 µmol/L ± 5.5 µmol/L; 24 h: 39.7 µmol/L ± 4.7 µmol/L vs 39.7 µmol/L ± 4.6 µmol/L; P > 0.05 for all). The levels of ET-1 decreased more significantly from 48 h to 1 week in the combination group (48 h: 134.1 ng/L ± 18.5 ng/L vs 128.3 ng/L ± 17.8 ng/L; 72 h: 99.5 ng/L ± 16.6 ng/L vs 109.8 ng/L ± 17.3 ng/L; 1 wk: 71.4 ng/L ± 12.1 ng/L vs 78.8 ng/L ± 13.3 ng/L; P < 0.05 for all), while the levels of NO decreased more significantly in the control group (48 h: 30.1 µmol/L ± 4.9 µmol/L vs 33.8 µmol/L ± 4.1 µmol/L; 72 h: 22.2 µmol/L ± 4.8 µmol/L vs 28.0 µmol/L ± 4.2 µmol/L; 1 wk: 17.0 µmol/L ± 3.7 µmol/L vs 20.2 µmol/L ± 3.4 µmol/L; P < 0.05 for all).

CONCLUSION: ET-1 and NO are important factors mediating microcirculation disturbance in SAP. Alprostadil can ameliorate pancreatic microcirculation possibly by altering ET-1 and NO expression.

Role of serum IL-6, IL-8 and procalcitonin in diagnosis of secondary infection in severe acute pancreatitis

AIM: To explore the value of serum interleukin-6 (IL-6), IL-8 and procalcitonin in the diagnosis of secondary infection in severe acute pancreatitis (SAP).

METHODS: Eighty-five patients with SAP were divided into either an experimental group (n = 45) or a control group (n = 40) based on the presence of secondary infection or not. Serum levels of IL-6, IL-8 and PCT were measured, and their sensitivity, specificity, positive predictive value, negative predictive value and accuracy for diagnosis of secondary infection in SAP were determined.

RESULTS: Serum levels of IL-6, IL-8 and PCT were significantly higher in the experimental group than in the control group (135.02 pg/mL ± 99.11 pg/mL vs 60.06 pg/mL ± 40.19 pg/mL, 107.19 pg/mL ± 35.26 pg/mL vs 88.05 pg/mL ± 18.50 pg/mL, 2.58 μg/L ± 1.35 μg/L vs 1.48 μg/L ± 0.65 μg/L; P < 0.01 or < 0.05). The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of serum PCT for diagnosis of secondary infection in SAP were higher (55.62%, 93.36%, 88.29%, 70.02%, and 75.41%, respectively) than those of serum IL-6 or IL-8. The specificity, positive predictive value, and accuracy of IL-6 in combination with IL-8 and PCT were the highest (96.71%, 94.42%, and 80.68%, respectively).

CONCLUSION: Serum levels of IL-6, IL-8 and PCT are important indexes for diagnosis of secondary infection in SAP. Combined detection of serum IL-6, IL-8 and PCT has the highest diagnostic accuracy.

Effect of ghrelin on serum levels of amylase, interleukin-6 and tumor necrosis factor-α in rats with severe acute pancreatitis

AIM: To explore the effect of ghrelin on serum levels of amylase (AMY), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) in rats with severe acute pancreatitis.

METHODS: Sixty Wistar rats were randomly divided into four groups: A, B, C and D. Groups B, C and D were treated with sodium taurocholate hydrate to induce SAP, while group A did not. Before induction of SAP, group D was treated with [D-Lys3]GHRP-6. After induction of SAP, groups C and D were treated with ghrelin. Serum levels of AMY, IL-6, and TNF-α, the moisture content of the pancreas, and the pathological changes in the pancreatic tissue were determined and compared between different groups.

RESULTS: Serum levels of AMY, IL-6 and THF-α in group C were significantly lower than those in group B (3806.02 U/L ± 536.27 U/L vs 4794.86 U/L ± 477.98 U/L, 167.22 pg/mL ± 11.75 pg/mL vs 204.96 pg/mL ± 17.44 pg/mL, 2.62 pg/mL ± 0.72 pg/mL vs 3.25 pg/mL ± 0.92 pg/mL; P < 0.05 for all). Serum levels of AMY, IL-6 and THF-α in group D were significantly higher than those in group C (4451.16 U/L ± 238.86 U/L vs 3806.02 U/L ± 536.27 U/L, 197.73 pg/mL ± 17.38 pg/mL vs 167.22 pg/mL ± 11.75 pg/mL, 3.17 pg/mL ± 0.69 pg/mL vs 2.62 pg/mL ± 0.72 pg/mL; P < 0.05 for all). The moisture contents of the pancreas in groups C and D were significantly lower than that in group B (28.65% ± 0.77% vs 35.41% ± 0.78%, 29.30% ± 0.40% vs 35.41% ± 0.78%; P < 0.01 for both). The edema, inflammation, hemorrhage and necrosis scores in group C were significantly lower than those in group B (2.06 ± 0.41 vs 2.82 ± 0.55, 2.52 ± 0.63 vs 3.18 ± 0.47, 1.93 ± 0.64 vs 2.79 ± 0.58, 2.22 ± 0.74 vs 2.84 ± 0.63; P < 0.01 for all), while edema, inflammation, hemorrhage and necrosis scores in group D were significantly higher than those in group C (2.66 ± 0.32 vs 2.06 ± 0.41, 3.09 ± 0.78 vs 2.52 ± 0.63, 2.42 ± 0.39 vs 1.93 ± 0.64, 2.63 ± 0.26 vs 2.22 ± 0.74, P < 0.05 for all).

CONCLUSION: Ghrelin can improve serum levels of AMT, IL-6 and TNF-α and the pathological injury in the pancreas in rats with SAP.

Implementing a multifaceted tailored intervention to improve nutrition adequacy in critically ill patients: results of a multicenter feasibility study

Introduction

Tailoring interventions to address identified barriers to change may be an effective strategy to implement guidelines and improve practice. However, there is inadequate data to inform the optimal method or level of tailoring. Consequently, we conducted the PERFormance Enhancement of the Canadian nutrition guidelines by a Tailored Implementation Strategy (PERFECTIS) study to determine the feasibility of a multifaceted, interdisciplinary, tailored intervention aimed at improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Methods

A before-after study was conducted in seven ICUs from five hospitals in North America. During a 3-month pre-implementation phase, each ICU completed a nutrition practice audit to identify guideline-practice gaps and a barriers assessment to identify obstacles to practice change. During a one day meeting, the results of the audit and barriers assessment were reviewed and used to develop a site-specific tailored action plan. The tailored action plan was then implemented over a 12-month period that included bi-monthly progress meetings. Compliance with the tailored action plan was determined by the proportion of items in the action plan that was completely implemented. We examined acceptability of the intervention through staff responses to an evaluation questionnaire. In addition, the nutrition practice audit and barriers survey were repeated at the end of the implementation phase to determine changes in barriers and nutrition practices.

Results

All five sites successfully completed all aspects of the study. However, their ability to fully implement all of their developed action plans varied from 14% to 75% compliance. Nurses, on average, rated the study-related activities and resources as ‘somewhat useful’ and a third of respondents ‘agreed’ or ‘strongly agreed’ that their nutrition practice had changed as a result of the intervention. We observed a statistically significant 10% (Site range -4.3% to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5% to 17.9%) and 4% (-8.3% to 18.2%) increase in the adequacy of total nutrition from calories and protein, respectively.

Conclusions

The multifaceted tailored intervention appears to be feasible but further refinement is warranted prior to testing the effectiveness of the approach on a larger scale.

Trial registration

ClinicalTrials.gov NCT01168128. Registered 21 July 2010.

The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies

Clinical practice guidelines (CPGs) are systematically developed statements to assist practitioners and patient decisions about appropriate healthcare for specific clinical circumstances, and are designed to minimize practice variation, improve costs, and improve clinical outcomes. The Canadian Critical Care Practice Guidelines (CCPGs) were first published in 2003 and most recently updated in 2013. A total of 68 new randomized controlled trials were identified since the last version in 2009, 50 of them published between 2009 and 2013. The remaining articles were trials published before 2009 but were not identified in previous iterations of the CCPGs. For clinical practice guidelines to be useful to practitioners, they need to be up-to-date and be reflective of the current body of evidence. Herein we describe the process by which the CCPGs were updated. This process resulted in 10 new sections or clinical topics. Of the old clinical topics, 3 recommendations were upgraded, 4 were downgraded, and 27 remained the same. To influence decision making at the bedside, these updated guidelines need to be accompanied by active guideline implementation strategies. Optimal implementation strategies should be guided by local contextual factors including barriers and facilitators to best practice recommendations. Moreover, evaluating and monitoring performance, such as participating in the International Nutrition Survey of practice, should be part of any intensive care unit's performance improvement strategy. The active implementation of the updated CCPGs may lead to better nutrition care and improved patient outcomes in the critical care setting.

Analysis of an electromagnetic tube placement device versus a self-advancing nasal jejunal device for postpyloric feeding tube placement

BACKGROUND

Initiation of enteral feeding is an important part of the best practice model for critically ill patients. Although nasogastric feeding is appropriate for the majority of patients requiring short-term nutrition support, certain patients benefit greatly from postpyloric feeding.

OBJECTIVE

To determine which of 2 specialized enteral tube systems achieved postpyloric placement on initial insertion attempt most efficiently.

DESIGN

Retrospective study comparing the Tiger 2 tube (T2T) and Cortrak Enteral Access System (C-EAS).

SETTING

Academic medical center, mixed intensive care unit (ICU).

PATIENTS

All patients admitted to the ICU between 2009 and 2013 who had either a C-EAS or T2T placed.

MEASUREMENTS

Success rate for postpyloric placement, congruency of real-time tube placement with x-ray confirmation for C-EAS, and complication rates.

RESULTS

Seventy-one T2T and 74 C-EAS patients were included. The T2T was postpyloric 62% (44/71) of attempted placements. C-EAS was postpyloric 43% (32/74) of attempted placements (P = 0.03). C-EAS tracings accurately reflected chest x-ray findings 83% and 82% for postpyloric and non-postpyloric insertion, respectively. During the entire study period, no adverse events were recorded.

CONCLUSION

Our institution evaluated 2 different systems designed to ensure postpyloric placement of a small bore feeding tube. No literature exists directly comparing the 2 systems. Our retrospective review, although limited, showed that the T2T was more effective at postpyloric placement on first attempt. Although 1 benefit of the C-EAS system may be real-time visualization, our practice showed this system to be user dependent, which likely led to less success with postpyloric placement.

Enteral nutritional therapy in septic patients in the intensive care unit: compliance with nutritional guidelines for critically ill patients

OBJECTIVE

Evaluate the compliance of septic patients' nutritional management with enteral nutrition guidelines for critically ill patients.

METHODS

Prospective cohort study with 92 septic patients, age ≥ 18 years, hospitalized in an intensive care unit, under enteral nutrition, evaluated according to enteral nutrition guidelines for critically ill patients, compliance with caloric and protein goals, and reasons for not starting enteral nutrition early or for discontinuing it. Prognostic scores, length of intensive care unit stay, clinical progression, and nutritional status were also analyzed.

RESULTS

The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2 to 18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores, and had 39.1% mortality. Enteral nutrition was initiated early in 63% of patients. Approximately 50% met the caloric and protein goals on the third day of intensive care unit stay, a percentage that decreased to 30% at day 7. Reasons for the late start of enteral nutrition included gastrointestinal tract complications (35.3%) and hemodynamic instability (32.3%). Clinical procedures were the most frequent reason to discontinue enteral nutrition (44.1%). There was no association between compliance with the guidelines and nutritional status, length of intensive care unit stay, severity, or progression.

CONCLUSION

Although the number of septic patients under early enteral nutrition was significant, caloric and protein goals at day 3 of intensive care unit stay were met by only half of them, a percentage that decreased at day 7.

Nutrition in the hospitalized patient

Almost 50% of patients are malnourished on admission; many others develop malnutrition during admission. Malnutrition contributes to hospital morbidity, mortality, costs, and readmissions. The Joint Commission requires malnutrition risk screening on admission. If screening identifies malnutrition risk, a nutrition assessment is required to create a nutrition care plan. The plan should be initiated early in the hospital course, as even patients with normal nutrition become malnourished quickly when acutely ill. While the Harris-Benedict equation is the most commonly used method to estimate calories, its accuracy may not be optimal in all patients. Calculating the caloric needs of acutely ill obese patients is particularly problematic. In general, a patient's caloric intake should be slightly less than calculated needs to avoid the metabolic risks of overfeeding. However, most patients do not receive their goal calories or receive parenteral nutrition due to erroneous practices of awaiting return of bowel sounds or holding feeding for gastric residual volumes. Patients with inadequate intake over time may develop potentially fatal refeeding syndrome. The hospitalist must be able to recognize the risk factors for malnutrition, patients at risk of refeeding syndrome, and the optimal route for nutrition support. Finally, education of patients and their caregivers about nutrition support must begin before discharge, and include coordination of care with outpatient facilities. As with all other aspects of discharge, it is the hospitalist's role to assure smooth transition of the nutrition care plan to an outpatient setting.

Monitoring for intolerance to gastric tube feedings: a national survey

BACKGROUND

Confusion about how to assess for intolerance to feedings often results in unnecessary feeding interruptions.

OBJECTIVES

To report findings from a national survey of methods used by critical care nurses to assess tolerance to gastric tube feedings and to discuss the findings in light of current enteral nutrition guidelines.

METHODS

A paper-and-pencil survey was mailed to 1909 members of the American Association of Critical-Care Nurses. In addition, the same survey was posted online in a newsletter circulated to association members. Results from both surveys were pooled for data analysis.

RESULTS

A total of 2298 responses were obtained; most respondents reported using a combination of methods to assess tolerance to gastric tube feedings (listening for bowel sounds, measuring gastric residual volumes, observing for abdominal distention/discomfort and for nausea and vomiting). More than 97% of the nurses reported measuring gastric residual volumes; the most frequently cited threshold levels for interrupting feedings were 200 mL and 250 mL. About 25% of the nurses reported interrupting feedings for gastric residual volumes of 150 mL or less; only 12.6% of the respondents reported allowing gastric residual volumes of up to 500 mL before interrupting feedings.

CONCLUSIONS

Practice among the 2298 critical care nurses varied widely. Many of the survey respondents are practicing in ways that can unnecessarily diminish the delivery of calories to patients. Protocols based on current enteral nutrition guidelines must be developed and implemented in practice settings.