Original articleEvaluation of current feeding practices in the critically ill: A retrospective chart review
Introduction
Malnutrition is reported in approximately 22–43% of hospitalised patients internationally (Lazarus and Hamlyn, 2005, Pirlich et al., 2005, Imoberdorf et al., 2010). Critically ill patients are at increased risk for the development of malnutrition due to alterations in protein and energy metabolism displayed in response to sepsis, burns, trauma and major surgery (Gramlich and Kutsogiannis, 2002). Malnutrition is an important issue in the care of the critically ill which is associated with increased costs of care and poor patient outcomes.
Risk for malnutrition identified at admission and worsening nutritional status during hospitalisation have been found to be strongly associated with prolonged length of stay (Caccialanza et al., 2010). In Singapore, Lim et al. (2012) found that malnourished patients are more likely to be readmitted within 15 days of discharge. Additionally a Portuguese study found the cost of treating a nutritionally at-risk patient to be 20% higher than average (Amaral et al., 2007). Malnutrition leads to not only increased economic burden, but to poor patient outcomes.
Globally, malnutrition in the critically ill has been found to be associated with poor patient outcomes including nosocomial bloodstream infections (Rubinson et al., 2004), pressure ulcer development (Banks et al., 2010, Eman et al., 2010) and increased mortality (Alberda et al., 2009, Sorensen et al., 2008, Lim et al., 2012). In the Netherlands, Weijs et al. (2012) found that reaching protein and energy targets in the critically ill, mechanically ventilated patient was associated with a 50% decrease in 28-day mortality, whereas only reaching energy targets was not. In support of these findings, an international study including 37 countries, Alberda et al. reported a Body Mass Index (BMI)-dependent effect between increased protein and energy intake and improved clinical outcomes in the critically ill in patients with a BMI less than 25 or greater than or equal to 35. The provision of parenteral and/or enteral nutrition provides a method to reach protein and energy targets in the critically ill.
Section snippets
Literature review
Enteral nutrition (EN) is recognised internationally as the feeding method of choice in the critically ill patient who is not able to receive oral nutrition (Bankhead et al., 2009, Kreymann et al., 2006, Heyland et al., 2003). Administration of EN assists in the restoration of intestinal motility, maintains gastrointestinal integrity and function, minimises translocation of bacteria and other organisms, improves wound healing and has been associated with a decreased incidence of infection (
Purpose
This study was conducted to evaluate the current state of EN delivery in the critically ill in the U.S. in comparison to international standards. The results of this study will be utilised to identify barriers to timely receipt of enteral nutrition and develop interventions intended to decrease time to feeding and increase protein and energy received to prescribed amounts.
Design
After receiving institutional review board approval, a retrospective chart audit was performed utilising a 10% random sample of all patients admitted to the Pulmonary Medicine Service at a large 600-bed southeastern U.S. academic medical centre from 1/1/11 to 12/31/11. Inclusion criteria included ages 18–89, mechanical ventilation, an intensive care unit (ICU) stay of seven days or greater, an inability to tolerate oral nutrition and no contraindications to enteral feeding (e.g. active
Data analysis
SPSS® software (version 20) was utilised to perform statistical analysis. Continuous variables were summarised by using means and standard deviations, with minimum and maximum values and 95% confidence intervals reported. Group comparisons for categorical variables were performed utilising the Fischer exact test or a χ2 test. Group comparisons for quantitative variables were performed by using t tests. Paired t tests were used to evaluate differences between calories ordered and received.
Demographics
A total of 732 medical records were provided by the Biomedical Informatics Service data retrieval. Of these cases, 688 met the criteria for inclusion. A 10% random sample was selected and 69 charts were audited. Baseline demographics from our cohort are shown in Table 2 along with demographics of selected international studies for comparison. Mortality in the sample was 26.1% (18 of 69 patients) and ventilator-associated pneumonia was diagnosed in 4.3% (3 of 69 patients).
Receipt of enteral nutrition
Patients were fed by
Discussion
The findings of this study confirm those previously conducted internationally describing nutritional inadequacy in the critically ill (O’Meara et al., 2008, Alberda et al., 2009, Van den Broek et al., 2009, Cahill et al., 2010). International guidelines from Canada, Europe and the U.S. recommend early EN (initiated within 24–48 hours of ICU admission) in appropriate patients (Heyland et al., 2003, Kreymann et al., 2006, Bankhead et al., 2009). Delayed time to feeding, greater than 48 hours after
Recommendations for practice
Inadequate protein and energy delivery and delays in initiation of EN have been confirmed in this U.S. sample. The utilisation of a nutrition support protocol, computerised order sets for EN delivery and expansion of the number of providers able to place feeding tubes may assist in decreasing the time to feed and increasing protein and energy delivery to prescribed levels. Nutrition support algorithms have been shown to be effective in increasing the amount of nutrients provided to the
Conclusion
Critically ill patients continue to experience delays in enteral feeding initiation and are frequently not meeting nutrition targets for protein and energy delivery. Critical care nurses are poised to decrease wait times to feeding and increase delivered EN to prescribed levels due to their role as liaison between provider and patient. Similar issues with delays to feeding and achievement of nutritional goals are seen internationally. The utilisation of nutrition support protocols, computerised
Funding
The authors have no sources of funding to declare.
Conflict of interest
The authors have no conflict of interest to declare.
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