Enteral nutrition administration in a surgical intensive care unit: Achieving goals with better strategies

An evaluation of nasogastric (NG) tube removal practices and nutritional intake parameters in an acute neurosurgical population: The development of an NG Transition Feeding Protocol

BACKGROUND

As a result of the complex nature of neurosurgical patients, nasogastric (NG) tube feeding is often implemented for patients who are unable to consume adequate oral intake. During recovery, patients on enteral nutrition (EN) are progressed to oral nutrition, which can result in NGT removal and discontinuation of supportive feeding plans. This is often before patients become established on sufficient oral intake to meet their nutritional requirements.

METHODS

We conducted an exploration of current NG removal practices in patients (n = 23) across five neurosurgical wards over a 3-month period to assess practitioner review response times, NG feeding duration, decision making on NG removal, and the influence of dietary recommendations and differing EN protocols on patients' ability to meet their nutritional requirements. Our aim was to use this data to design and implement a protocol to improve consistency of these practices.

RESULTS

After oral intake was commenced, only those receiving supplementary EN achieved nutritional targets immediately. Conversely, no patient who had their NGT removed at this stage achieved these targets. Following NG removal, the likelihood of a patient meeting nutritional targets was influenced by the decision maker, supporting the practice of registered dietitian led cessation of NG feeding. These findings led us to develop an "NG Transition Feeding Protocol" to serve as a simple, clear pathway which treating teams can utilise to guide NG feeding decisions.

CONCLUSIONS

NG feeding supports neurosurgical patients to meet nutritional requirements in the early stages following commencement of oral intake. The development of an "NG Transition Feeding Protocol" may help to improve consistency of transition feeding on neurosurgical wards, allowing time for nutrition assessment to support informed decisions around NG removal. The aim of this protocol is to improve the efficiency of transition feeding, improve dietetic workload efficiency, nursing staff confidence and avoid compromising nutritional status of patients as a result of the early cessation of EN.

Improving nutrition care for neurosurgery patients through a nurse-led transition feeding protocol

AIM

Neurosurgical patients often transition from enteral nutrition (EN) to oral nutrition (ON) as they recover. Implementing a nurse-led feeding protocol to guide this transition may improve consistency of nutrition care and dietitian workload efficiency. This pragmatic study aimed to evaluate the effect of such a protocol on these outcomes and on nurses' nutrition care attitudes, practices and knowledge.

METHODS

Data were collected retrospectively for 1 year pre- and prospectively for 1 year post-implementation of the transition feeding protocol (TFP). Participants who transitioned from EN to ON were included in the study. Post-implementation nurses in the neurosurgery ward were invited to complete a self-administered questionnaire to investigate attitudes, practices and knowledge.

RESULTS

One hundred and thirteen participants, 55 pre- and 58 post-implementation, took part in the study. Significantly more patients received transition feeding (TF) post-implementation (58% vs 93%, P < 0.001), there was a statistically significant improvement in the commencement of TF (0 vs 1 day after ON clearance; P = 0.029), and all patients consumed adequate oral intake 1-week post-EN cessation (92.3% vs 100%, P = 0.078). There was no difference in dietetic occasions of service post-implementation (2 vs 1.5; P = 0.204). A 38% survey response rate from nursing staff (n = 15) was achieved. More nurses were found to be initiating TF (P < 0.001) and a majority reported a perceived increase in knowledge and confidence in providing nutrition support.

CONCLUSIONS

A TFP can optimise the transition from EN to ON by improving consistency and commencement of TF and nurses' confidence and knowledge in overall nutrition care.

Improvement of Nutritional Intake in Intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol

BACKGROUND

Enteral nutrition in intensive care unit patients has important prognostic clinical value. Feeding protocols are recommended by clinical practice guidelines as a key strategy to maximize the benefits and minimize the risks of enteral feedings.

OBJECTIVE

To examine whether enteral nutrition in critically ill patients could be improved by implementation of a nurse-led evidence-based feeding protocol.

METHODS

An interprofessional group of intensive care unit nurses, physicians, and a clinical dietitian designed a protocol to address and correct the shortcomings of enteral feeding. Data on feeding and clinical outcomes were collected retrospectively for patients for 12 months before (control group) and then for 12 months after (interventional group) implementation of the protocol.

RESULTS

Enteral feeding was started significantly earlier (P = .007) after admission to the intensive care unit in the intervention group (52.3 hours; SD, 42.6) than in the control group (70.3 hours; SD, 65.2). Use of the protocol resulted in a significant increase in nutritional intake; 90% of patients in the intervention group but only 34% in the traditional feeding group achieved their caloric target within 96 hours after admission (P < .001). After implementation of the protocol, cessation of feeding due to intolerance was significantly less (P = .03) in the intervention group (6%) than in the traditional feeding group (14 %), and no adverse events were detected.

CONCLUSIONS

Adherence to standardized guidelines with a written protocol for an early start and timely escalation of enteral feeding can improve nutritional intake among intensive care unit patients.

Studying the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units

Background

The main problem of hospitalized patients in intensive care units is feeding, and if the patient does not receive the daily caloric intake required to his body, he will have malnutrition and problems related to it. Abdominal massage is a method used to improve digestive function in various studies, but few studies have been conducted in intensive care units, and sometimes, contradictory results have been obtained. Therefore, the present study is conducted with the aim of determining the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units.

Methods

This study was conducted as a clinical trial in Ahwaz, in 2017. Samples were 60 patients hospitalized in intensive care units who were randomly divided into case and control groups. The intervention period for the case group was 3 days and twice daily for 20 min. Measuring the gastric residual volume was investigated before the intervention and 1 hour after the second massage each day. Data were entered into the checklist designed by the researcher and were analyzed using SPSS version 24 and descriptive and inferential tests.

Results

The gastric residual volume on the second and third day after the intervention was less than before the intervention (p value< 0.05), the gastric residual volume before intervention with after intervention in the control group during different days, on each of the 3 days after the intervention, was more than before the intervention (p value< 0.05), and the gastric residual volume after the intervention in different days and the mean of different days in the case group was lower than the control group (p value> 0.05).

Conclusion

Results represent the effect of abdominal massage on reducing the gastric residual volume in patients hospitalized in intensive care units. Therefore, it is suggested that this method can be considered as a caring method in the daily care program for these patients.

Trial registration

IRCT2017062134641N2, registered 26 July 2017.

Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: A before and after study

BACKGROUND AND OBJECTIVE

Enteral nutrition (EN) feeding protocol was proposed to have positive impact on critically ill patients. However, current studies showed conflicting results. The present study aimed to investigate whether enteral feeding protocol was able to improve clinical outcomes in critically ill patients.

METHODS

A before (stage 1) and after (stage 2) interventional study was performed in 10 tertiary care hospitals. All patients expected to stay in the intensive care unit (ICU) for over three days were potentially eligible. Clinical outcomes such as 28-day mortality, ICU length of stay, duration of mechanical ventilation (MV), and nosocomial infection were compared between the two stages.

MAIN RESULTS

A total of 410 patients were enrolled during the study period, including 236 in stage 1 and 174 in stage 2. EN feeding protocol was able to increase the proportion of EN in day 2 (41.8±22.3 vs. 50.0±28.3%; p = 0.006) and day 6 (70.3±25.2 vs. 77.6±25.8%; p = 0.006). EN percentages tended to be higher in stage 1 than that in stage 2 on other days, but statistical significance was not reached. There was no difference in 28-day mortality between stage 1 and 2 (0.14 vs. 0.14; p = 0.984). Implementation of EN feeding protocol marginally reduced ICU length of stay (19.44±18.48 vs. 16.29±16.19 days; p = 0.077). There was no difference in the duration of MV between stage a and stage 2 (14.24±14.49 vs. 14.51±17.55 days; p = 0.877).

CONCLUSIONS

The study found that the EN feeding protocol was able to increase the proportion of EN feeding, but failed to reduce 28-day mortality, incidence of nosocomial infection or duration of MV.