Nurse-driven Enteral Feedings in ICU

Nurse-driven Enteral Feedings in ICU

Deborah HongRutgers University

BackgroundDuring their hospital stays, several critically ill patients depend on enteral feedings for sustenance.Standard enteral feeding protocols fail to properly nourish patients This lack of proper nourishment indicates the need for nurse-driven enteral feeding protocols which will help patients maintain ideal caloric intake

The Reasons For Insufficient Enteral Feeding In An Intensive Care Unit: A Prospective Observational Study, Study design Prospective Observational StudySampling technique, sample size, & characteristics Eighty-seven patients were screened for 707 patient days. Nurses documented 141 instances of insufficient enteral nutrition in 49 patients (Kuslapuu, 2015). Kuslapuu verifies the validity of this study by listing the methods the ICU nurses used when collecting data. The follow-up assessment performed to fully study the effects of the standard enteral feeding protocol, was performed once daily between 12:00 and 14:00. Data were collected through a specially developed electronic survey that was completed by the nurses, (Kuslapuu, 2015). Statistical Analysis Based on the nurses assessments, 49 of the 87 patients were not meeting their caloric methods through standard enteral feeding protocol. Tartus nurses observed that the most common reasons for decisions to stop or delay enteral nutrition were high feeding residual volume, recent GI surgery, an acute abdomen, and ongoing procedures such as weaning off ventilators and CT scans. (Kuslapuu, Jogela, Starkopf, & Blaser, 2015 )

Nurse-Driven Enteral Feeding Protocol Improves Caloric Intake in Critically Ill Patients Study design This was a non-randomized controlled prospective study. The method used in this study was to compare caloric intake of 50 critically ill patients whose nutrition was managed by hospital standard enteral feeding protocol vs. that of 50 patients who nutrition was managed by a nurse-driven protocol with caloric requirement targets. The nurse-driven feeding protocol would consist of caloric requirement targets and would require nurses to start feeding within 48 hours, unless specified not to feed by the physician (Demian, 2007). This review of caloric intake was performed randomly by searching through patients charts. Statistical AnalysisDemian summarizes the studys results by stating that after the nurse-driven feeding protocol was implemented, the percentage of patients who had their feedings started before they spent 48 hours in the ICU increased from 50% to 94% (Demian, 2007). The article also makes the case for Demians argument by sharing that the nurse-driven protocol helped the percentage of patients reaching 80% of their caloric requirements go from 44 to 90% (Demian, 2007).

(Demian, Halawa, Nisar, & Ahmed, 2007)

Evaluation of enteral nutrition in critically ill patients at LUMC utilizing a 24-hour, nurse driven, volume-based feeding protocol Overview of StudyThis was also a quantitative review describing Loyola University Medical Centers findings when treating their patients with a nurse-driven volume based enteral feeding protocol instead of the standard rate/hr protocol. Eiden concludes that a volume-based EN protocol allowed nurses to initiate feedings at twice the rate they normally did with the standard hospital protocol. On average, the time it took for nurses to reach their goal feeding rate was 10 hours shorter with a volume based protocol rather than a rate/hour protocol. (Eiden, Kinn, Martin, Palmer, Pudelek, & Varner, n.d.)

Improvement of enteralnutrition in intensive care unit patients by a nurse-driven feeding protocol Purpose of study/Study aimsThe aim of this study was to examine whether EN was started earlier and met caloric goals more often following this change in management. The purpose was to display if a nurse led protocol resulted in earlier initiation of EN and subsequently increased caloric intake in the interventional ICU population.Study designBefore and after retrospective design comparison; single site.Sampling technique, sample size, & characteristicsThe patients who were studied were ICU patient in an unnamed British Hospital in a 13 bed unit and receiving enteral nutrition.Statistical AnalysisThe two groups were compared using Students t-test for the time to start of enteral feeding and for the daily calories and Pearsons chi squared test for the frequency of protocol-conform EN. It was displayed that the non-experimental group only 24.8% received prescribed caloric intake within the initial 24 hours EN was initiated vs 63.9% of patients receiving total prescribed caloric intake within 24 hours of EN initiation when a nurse driven feeding protocol was instituted in the experimental group.

(Friesecke, Schwabet, Stechert, & Abel, 2014)

Proposed InterventionAn enteral feeding protocol will be designed and implemented by ICU nurses Unless contraindicated by physicians, the enteral feeding protocol will be initiated on ICU patients within 6 hours of admission. Enteral feedings will be started on patients at 20 ml/hr for 6 hours.The nurses thenwill check for gastric residual volume (GRV). Ifit isless than 200 mL, feedings will be increased by 10 mL/hr up to the ordered goal rate. If the GRV is between 200-500 mL, feedings will be continued. If GRV is greater than 500 mL, gastric feedings will be discontinued and the GRV will be checked again in 6 hours.

Proposed Intervention (cont)We would determine that patients were malnourished if at the time of assessment the actual infusion rate was less than 50 kcal/hr and this rate had not increased during the previous 12 hours (Kuslapuu, 2015). Another method we could use to determine if patients were properly fed would be by calculating their caloric needs. The caloric needs of all consecutive patients admitted during the study period were calculated as 20 kcal/kg ideal body weight for the first two days in ICU and 25 kcal/kg ideal BW for the remainder of the time (Kuslapuu, 2015). (Kuslapuu, Jogela, Starkopf, & Blaser, 2015 )

ObjectiveOur objective would be to implement the previously discussed nurse-driven enteral feeding protocol on randomly selected ICU patients for three months.Staff nurses would be expected to calculate and document specific values every 12 hours such as their patients current enteral feeding rate (both in mL/hr and kcal/hr) at time of assessment.The level of nourishment for patients treated with the nurse-driven enteral feeding protocol would be compared to the level of nourishment for patients fed by the standard hospital EN protocol. My hope is that the patients difference in progress with level in caloric intake, protein and even admission length would be discussed in staff meetings. This shared knowledge of overwhelming evidence could further motivate hospitals to implement nurse-driven EN protocols throughout all their critical care units.

ReferencesAmerican Psychological Association (2009). Publication Manual of the American Psychological Association (6th ed). Washington, DC: American Psychological AssociationDemian ST, Halawa NN, Nisar B, Ahmed R. (2007). Nurse-driven enteral feeding protocol improves caloric intake in critically ill patients. Chest. 132(4), 442c-443. Eiden, K., Kinn, T., Martin, J., Palmer, L., Pudelek, B., and Varner, E. (n.d.) Evaluation of enteral nutrition in critically ill patients at LUMC utilizing a 24-hour, nurse driven, volume-based feeding protocol. Retrieved from http://www.luhs.org/depts/cce/projects/qf13_storyboards/eval_enteral_nutrition_crit_ill_pts.pdf Friesecke, S., Schwabet, A., Stechert, S.S., & Abel, P. (2014). Improvement of enteral nutrition in intensive care unit patients by a nurse-driven feeding protocol. British Association of Critical Care Nurses, 19: 4, 204 210. doi: 10.1111/nicc.12067Heyland, D.K, Murch, L., Cahill, N., McCall, M., Muscedere, J., Stelfox, H.T., Bray, T., Tanguay, T., Jiang, X., Day, A.G. (2013). Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: Results of a cluster randomized trial. Critical Care Medicine, 41, 12. 2748-53. doi: 10.1097/CCM.0b013e31829efef5 https://www.ncbi.nlm.nih.gov/pubmed/23982032Kuslapuu, M., Jogela, K., Starkopf, J., & Blaser, A.R. (2015). The reasons for insufficient feeding in an intensive care unit: A prospective observational study. Intensive Critical Care Nurse. 31(5), 309-214. https://www.ncbi.nlm.nih.gov/pubmed/25864368Moran, K., Burson, R. & Conrad, D. (2014). The Doctor of Nursing Practice Scholarly Project: A Framework for Success. Burlington, MA: Jones & Barlett Learning.