PRACTICE DEVELOPMENT doi: 10.1111/nicc.12107
A practice change initiative to improve the provision of enteral nutrition to intensive care patients Rebecca J Jarden and Lynsey J Sutton ABSTRACT Aim: To describe a practice change initiative that improved the provision of enteral nutrition (EN) to patients in a New Zealand tertiary intensive care unit (ICU). Methods: The project reviewed and summarized EN literature, amended local policy, and an evidence-based EN delivery algorithm was developed. The EN practice change initiative was implemented and evaluated. Data was collected and analyzed in a pre-audit (2009) and a post-audit (2013). Results: Comparison of the pre-audit (N = 25) and the post-audit (N = 40) data demonstrated improvements in three areas of EN delivery. The commencement of early EN within 24 h of admission was evident for a large proportion of patients in both 2009 and 2013 audits. There was a large reduction in time between the two audits for both ICU admission to achievement of EN goal rate (M = 57⋅71 h versus M = 33⋅79 h, p = 0⋅006) and also for EN commencement to achievement of EN goal rate (M = 31⋅65 h versus M = 10⋅15 h, p = 0⋅000). The volume of prescribed EN delivered on days 2, 4 and 6 was greater in the 2013 audit in comparison to the 2009 audit. Staff compliance with adhering to the EN policy and algorithm improved from 46% in 2009, to 95% in 2013. Conclusions: The practice change has significantly improved the practice delivery of EN for patients in the local ICU resulting in optimal care. Relevance to clinical practice: Malnutrition is highly prevalent among intensive care patients. Strategies and initiatives that improve the delivery of enteral nutrition to the critical care population is therefore vitally important. This article describing such an initiative is thus highly relevant to all health care professionals delivering enteral nutrition in intensive and critical care units. Key words: Enteral nutrition • Gastric residual volumes • Intensive care • Literature review • Practice change
INTRODUCTION Nutritional support is a fundamental aspect of care in the critically ill (Kozier et al., 2000), historically considered as an adjunct to intervention and supportive care but more recently repositioned as a therapeutic intervention (McClave and Heyland, 2005, Leonard, 2009). Physiologically, enteral nutrition (EN) plays an essential role in maintaining the structure and function of the gastrointestinal mucosal barrier, promoting gut motility and avoiding the infectious complications
Authors: RJ Jarden, RN, MN, BHSc, BA, DipGrad, Lecturer, AUT University, Auckland 1142, New Zealand; LJ Sutton, MN(Clinical), PGcert, RNdip, Associate Charge Nurse Manager, Intensive Care Unit, Wellington Regional Hospital, Wellington 6018, New Zealand Address for correspondence: LJ Sutton, MN(Clinical), PGcert, RNdip, Associate Charge Nurse Manager, Intensive Care Unit, Wellington Regional Hospital, Wellington 6018, New Zealand E-mail: [email protected]
© 2014 British Association of Critical Care Nurses
and costs associated with parenteral nutrition (Jolliet et al., 1998; Kudsk, 2001; Kudsk, 2002; Eckmann, 2006; Grant, 2006; Johansen et al., 2006). Enhanced immune defences, restoration of intestinal anatomy and function and the amelioration of septic complications are all associated with EN delivery (Moore et al., 1992). Therefore, the effective delivery of EN is essential to the promotion of health in the critically ill patient. The context of this practice change initiative is now described.
CONTEXT This practice change initiative was developed in the context of an 18-bed general intensive care unit (ICU) in a New Zealand regional hospital providing tertiary care facilities. The adapted Plan-Do-Study-Act (PDSA) (Ministry of Health, 2002) quality improvement model provided a framework for the project (Figure 1). The first stage involved an evaluation of EN 1
Improving enteral nutrition through practice change
Figure 1 Project outline.
2
© 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
practices in the local ICU. This evaluation comprised a needs assessment (Lazenbatt et al., 2001; Owen, 2006) and retrospective audit of patient clinical records in 2009.
Ethical considerations Audits were registered locally and medical records were accessed in accordance with local policy. Practice changes were reviewed and accepted by the local Clinical Practice Change Governance Group.
Pre practice change audit (2009) Sample The local ICU admissions database was used to obtain a sample of patients admitted to the ICU in 2009. Patients were selected for initial screening if they had been in the unit for longer than 3 days, in order to capture those most likely to have received EN. Patients were excluded if they did not have a nasogastric (NG) tube in place, were receiving total parenteral nutrition (TPN), or were less than 16 years of age. Twenty-five patients were included in the analysis. Data collected during this 2009 audit included patient demographics, the volume of prescribed EN delivered each day, time to goal rate and factors impeding EN delivery. This audit was instrumental in identifying which aspects of EN delivery in the local ICU were less than optimal.
databases were searched with Boolean functions and were set human and adult limiters. There were no date limiters set in the search to ensure all relevant studies were identified. Following removal of irrelevant articles the following numbers of articles were retained; PubMed (105), EMBASE (144) and Cochrane (0). After duplicates were removed, and a further manual sort for relevancy was conducted, 144 articles remained for screening. An internet search using the same keywords in Google Scholar was also conducted. International committees and expert groups published guidelines were also screened (13), and in addition a manual search of the reference lists from relevant publications (6). Search two focussed on GRV and used the following key terms such as gastric residual monitoring, gastric aspirate, residual volume and EN. This enabled identification of articles specific to GRV for the policy amendments. Following removal of irrelevant articles the following were retained; PubMed (30), EMBASE (19) and Cochrane (0). After duplicates were removed, and a further manual sort for relevancy was conducted, 17 articles remained for review, 12 original studies, 4 reviews and 1 systematic review. The literature was then reviewed by both authors and summarized. Where possible, only papers reporting original research, meta-analyses, evidence-based guidelines and systematic reviews were utilized to inform the policy changes.
Factors impeding EN delivery The 2009 audit results identified three key factors impeding EN delivery: the frequent interruption of EN delivery prior to procedures, EN delivery algorithms which were not evidence-based resulting in slow advancement to goal rate and conservative gastric residual volume (GRV) management strategies. Notably, no patient received 100% of prescribed EN, even after adjusting for the algorithm regime of advancement to the hourly prescribed rate (goal rate). A systematic search highlighted these factors are also commonly identified barriers in the international literature. This initiative began with a comprehensive search of the literature focusing on the key factors identified in the 2009 audit. The search strategy is now presented.
SEARCH STRATEGY The literature review incorporated two searches. Search one used the following key terms such as EN, tube feeding, enteral feeding, NG feeding and ICU or critical care unit. The PubMed, Cochrane and EMBASE © 2014 British Association of Critical Care Nurses
REVIEW OF THE LITERATURE Use of an algorithm to guide EN delivery Early effective EN is beneficial for critically ill patients. Outcomes such as reduced mortality, morbidity, infectious complications and length of stay have been reported (Adam and Batson, 1997; Marik and Zaloga, 2001; Martin et al., 2004; Bowman et al., 2005; MacKenzie et al., 2005; Doig et al., 2008; Doig et al., 2009; Khalid et al., 2010; Doig et al., 2011). When patients receive close to their daily prescribed calories, beneficial outcomes are even more pronounced (Heyland et al., 2011). Attempts to deliver early optimum nutrition are often unsuccessful because of conservative policies around arbitrary GRV thresholds and slow advancement to goal rates (Lichtenberg et al., 2010; Martins et al., 2012). The effective use of an algorithm has been shown to improve the delivery of prescribed EN in order to guide EN advancement to goal rate (Adam and Batson, 1997; McClave and Snider, 2002; MacKenzie et al., 2003; Martin et al., 2004; Bowman et al., 2005; MacKenzie et al., 2005). Algorithms that utilize evidence-based practices such as early commencement of EN, rapid titration to goal 3
Improving enteral nutrition through practice change
rate, management of appropriate gastric residual thresholds and shorter fasting times have been shown to increase EN delivery closer to nutritional goals (Martin et al., 2004). The first of the three components of the EN delivery algorithm addressed was how the rate of EN is advanced to goal rate.
Table 1 Recommendations from key professional groups for GRV management in the enterally fed ICU adult patient Professional groups
GRV and action recommended
European Society for Parenteral and Enteral Nutrition (ESPEN) (Kreymann et al., 2006)
Consider IV administration of metoclopramide or erythromycin in patients with intolerance to enteral feeding (e.g. with high gastric residuals) GRV >500 mL: avoid holding EN in the absence of other signs of intolerance
Advancement of EN to goal rate The rapid rate advancement of EN to goal rate is one strategy that may improve the nutritional intake of critically ill patients. Traditionally, the titration of feeds has been gradual, prolonging the time the patient receives less than their nutritional requirements (Heyland et al., 2010). In addition, there are wide variations in the method of EN rate advancement among different institutions and no single approach has been validated or standardized (Parrish and McCray, 2003b). International EN guidelines have historically suggested very reserved approaches to increasing EN by only 10–20 mL every 8–12 h (Bankhead et al., 2009). However, Heyland et al. (2010) performed a prospective pre- and post-pilot study to evaluate a regime of immediate commencement of EN at goal rate, along with a compensatory increase in EN delivery rate if EN was withheld for procedures or surgery. Whilst this study showed improved EN delivery in a way that was safe and feasible, it was a small pilot study (before group, N = 20; after group, N = 30). The most recent clinical practice guidelines suggest EN be advanced rapidly to achieve goal rate (Dhaliwal et al., 2013). However, there remains poor consensus regarding the specifics of EN delivery such as the rate and volume which should be advanced. Next we consider how GRV management might be addressed within the algorithm to reduce their impact on the delivery of EN.
Gastric residual volume The measurement of GRV (withdrawing residual gastric contents from the patient’s naso- or oro-gastric tube at specified timeframes) to assess tolerance to nutrition is standard practice in the management of EN (Metheny et al., 2012). As part of the literature review to inform the practice change initiative, a review of clinical research trials, professional recommendations and guidelines was conducted (Tables 1 and 2). The methodological quality of nutritional support trials in the critically ill patient population has been reported as poor (Doig et al., 2005). Despite a paucity of scientific data (Parrish and McClave, 2008) and inherent flaws in the argument for using GRV to demonstrate tolerability or intolerability of EN (Lin and Van Citters, 1997; 4
Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition (SCCM & ASPEN) (Martindale et al., 2009; McClave et al., 2009) Canadian Clinical Practice Guidelines for Critical Care Nutrition, in association with the Canadian Critical Care Trials Group (Dhaliwal et al., 2013) National Collaborating Centre for Acute Care (2006)
National Institute for Health and Clinical Excellence (2006)
GRV of either 250 mL or 500 mL: prokinetics at initiation and consider post pyloric feeding tubes GRV >200–300 mL: consider as a high aspirate, reduce continuous feeding rate and/or introduce prokinetics GRV = 200–300 mL: consider as ‘large’, depending on local policy, reduce infusion rate or consider prokinetics
ICU, intensive care unit; GRV, gastric residual volume.
McClave and Snider, 2002; Parrish and McCray, 2003a; Kompan et al., 2004; McClave et al., 2005; Bochicchio et al., 2006; Chang et al., 2007; Landzinski et al., 2008; MacLaren et al., 2008; Metheny, 2008), high GRVs have been identified as a primary reason for discontinuing EN (McClave et al., 1999) and ceasing GRV measurements improves the delivery (Poulard et al., 2010). Recent literature continues to dispel historical precedents and beliefs regarding GRV management, for example, the belief that there is a causal relationship between an elevated GRV and the development of ventilator-associated pneumonia (VAP) (Poulard et al., 2010). Ensuring the existing practices related to GRVs are evidence-based is crucial in improving patient outcomes. Inconsistencies in recommendations are evident between acceptable GRVs, both in the literature (Cerra et al., 1997; Pinilla et al., 2001; McClave and Snider, 2002; McClave et al., 2002; Parrish and McCray, 2003b; Keithley and Swanson, 2004; Bowman et al., 2005; Marshall, 2005; Zaloga, 2005; Kattelmann et al., 2006; Bourgault et al., 2007; Metheny, 2008; Parrish and McClave, 2008; Montejo et al., 2010; Soroksky et al., 2010; Kuppinger et al., 2013; Reignier et al., 2013; Williams et al., 2013), and in recommendations of clinical practice guidelines (Cerra et al., 1997; Jolliet et al., © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Table 2 Conclusions from key clinical trials for GRV management in the enterally fed adult ICU patient Clinical trials McClave et al. (2005) Prospective study
Pinilla et al. (2001) Randomized controlled trial
Metheny et al. (2008) Prospective observational study
Soroksky et al. (2010). Pilot prospective study
Montejo et al. (2010). Open, prospective, randomized study
Reignier et al. (2013). Randomized non-inferiority, open-label, multicenter trial
Conclusions Comparison of two groups: Intervention group: GRV >400 mL. Control group: GRV >200 mL. Converting to PEGG feeding may reduce the risk of aspiration. GRV is a poor marker for risk of aspiration. Comparison of two groups: Group 1: GRV 150 mL with an optional prokinetic. Group 2: GRV 250 mL with a mandatory prokinetic. Elevating the GRV and administering a prokinetic significantly reduced the incidence of high GRV. It also improved the time to reach goal rate and increased the % of nutrition requirements. Non-interventional. But compared three overlapping groups: GRV of at least 150 mL. GRV of at least 200 mL. GRV of at least 250 mL. High incidence of aspiration among all patients in the study. Aspiration still occurred frequently in the absence of high GRV. Not consistent relationship between aspiration and GRV, other than aspiration frequency increased as GRV increased. Delivery strategy included commencing at full goal rate and accepting GRV of 500 mL or less measured once daily. 42 < 500 mL GRV. 10 > 500 mL GRV. Allowing large GRV measured once a day did not lead to an increase in adverse effects and resulted in fewer interruptions of delivery. Control group = GRV 200 mL. Intervention group = GRV 500 mL. A limit of 500 mL GRV does not increase duration of mechanical ventilation, ICU LOS, incidence of pneumonia, or an increased risk of gastrointestinal complications. By using an upper limit of GRV 500 mL there may be a modest increase in the delivery of diet volume ratio. A GRV of 500 mL is recommended as a normal limit for GRV. Control group = 250 mL. Intervention group = absence of GRV monitoring The absence of GRV monitoring was not inferior to routing GRV monitoring related to the development of VAP.
VAP, ventilator-associated pneumonia; GRV, gastric residual volume.
1998; American Society for Parenteral and Enteral Nutrition Board of Directors and The Clinical Guidelines Task Force, 2002; McClave et al., 2002; Heyland et al., 2003; Stroud et al., 2003; Heyland et al., 2004; Kreymann et al., 2006; National Collaborating Centre for Acute Care, 2006; Critical Care Nutrition, 2007; Martindale et al., 2009; McClave et al., 2009; Dhaliwal et al., 2013). The recommended acceptable GRVs vary widely, from 150 mL to 500 mL, and recommended interventions in response to these GRVs are equally as disparate. The most common recommended action was to reduce the EN infusion rate (Cerra et al., 1997; Jolliet et al., 1998; Stroud et al., 2003; National Collaborating Centre for Acute Care, 2006; National Institute for © 2014 British Association of Critical Care Nurses
Health & Clinical Excellence, 2006). Other recommendations included to cease the EN (American Society for Parenteral and Enteral Nutrition Board of Directors and The Clinical Guidelines Task Force, 2002; Bowman et al., 2005; Kattelmann et al., 2006), to introduce prokinetics (Jolliet et al., 1998; Heyland et al., 2003; National Collaborating Centre for Acute Care, 2006; National Institute for Health & Clinical Excellence, 2006), to monitor the patient closely (Edwards and Metheny, 2000; McClave and Snider, 2002), or to implement aspiration risk reduction methods (McClave and Snider, 2002; Martindale et al., 2009). Next we consider how the interruptions to EN delivery prior to procedures might be addressed. 5
Improving enteral nutrition through practice change
Reducing the interruption of EN delivery prior to procedures One of the most frequently reported reasons for inadequate EN delivery is interruption of EN, with lengthy fasting times prior to procedures or surgery (McClave et al., 1999; Roberts et al., 2003; O’Leary-Kelley et al., 2005; Bourgault et al., 2007). Schneider et al. (2009) report wide inconsistencies and lengthy fasting times prior to procedures. Internationally, EN guideline authors acknowledge a lack of clear definitions of fasting times as a major issue for critically ill patients (McClave et al., 2009). Locally developed policies and guidelines are encouraged in clinical practice to focus on reducing pre-procedural interruptions to EN (McClave et al., 2009). Ho and Culhane (2013) and Pousman et al. (2009), report improved delivery of EN with the use of a protocol to guide reduced EN fasting times prior to procedures and surgery. They found EN delivery was improved with no increase in adverse outcomes or events when these protocols were used. To explore the extent of procedural-related EN interruptions in our local patient population, a supplementary audit was performed (in addition to the pre- and post-practice change audits) in our ICU. This involved 20 separate patients selected from a convenience sample from the local ICU admissions database. Patients in the ICU for longer than 3 days were selected as the most likely to have required transport to radiology, theatre, or who had tracheostomies placed. In total, there were 23 episodes where EN was ceased for procedures, and EN management strategies were inconsistent throughout. The total mean time EN was interrupted for was 5⋅41 h (SD = 4⋅23). Despite the lack of clarity in advancement to goal rate strategies, GRV limits, and pre-procedural EN interruptions, an algorithm needs to provide some practical guidance to EN delivery. Thus, local experts were consulted in an effort to define these specific parameters in the form of an algorithm that could be used at the bedside.
PRACTICE CHANGES AND IMPLEMENTATION Algorithm development Local experts were consulted in an interdisciplinary review of these key areas of the policy. This consultation period led to agreement on these aspects which were incorporated into an algorithm and a practical guide to achieving improved EN delivery at the bedside. These included strategies such as commencement of EN volume, titration of EN, management of GRVs and on-going monitoring for signs of EN intolerance such as regurgitation and vomiting (Figures 2 and 3). 6
Practice change An EN practice change team was formed which included two ICU senior nurses, a nurse educator, a staff nurse and a dietician. The focus of the EN group was to disseminate the policy changes and algorithm to approximately 120 nurses and 20 doctors in the local ICU, promote evidence-based knowledge and practices around EN delivery, and dispel myths related to GRVs, which were widely prevalent in clinical practice. A teaching package was developed, and an education programme commenced during ‘EN month’. This included small group teaching via a standardized tool, dedicated EN boards with information and literature, a bulletin board and handover messages, posters, laminated flowcharts and algorithms for bedside references, and a page on the local hospital’s intranet. On completion of EN month, education session feedback forms and the results of a post-education test were collated. Ninety-five percent of all staff received the teaching and all scored 100% on the post-education test questions (n = 94).
EVALUATION OF PRACTICE CHANGE INITIATIVE (2013) Sample In 2013, a retrospective audit of patients’ clinical records was performed on a simple random sample selected from the local ICU admissions database. To enable comparison with the 2009 audit data, the same process for patient selection was performed in 2013. From the 70 patient’s clinical records screened, 28 were not enterally fed, and two patient’s clinical records had incomplete data and were excluded. In total, there were 40 patients included in the final analysis.
Data collection and analysis Data from clinical records was manually entered into a Microsoft Excel spreadsheet and analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS 17) (Pallant, 2007; Miller et al., 2009). The main aim of analysis was to identify if the practice change initiative had impacted on the proportion of patients with early EN instituted (i.e. within 24 h), the time to EN goal rate from admission and start of EN, and the volume of EN delivered per ICU day. The data collected included patient demographics, time of initiation of EN (hours from admission to EN start), time to goal rate, percentage of prescribed EN delivered each day, vomiting and regurgitation episodes, and mean GRVs. This was in accordance with the data collected in 2009. © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Nasogastric/orogastric feeding flowchart Obtain prescription from Dr's & refer to dietitian
Start feeds at 30 mls hour.
Check GRV after 4 hours.
GRV >500 mls.
GRV 500mls?
NO
YES YES
NO
Is goal rate achieved? Return up to 500 mls. Decrease rate by 30 mls. Discuss prokinetic with ICU medical staff.
Continue to monitor GRV every 4 hours and increase feed rate by 30 mls until goal rate achieved. Measure GRV 4 hours later. Are GRV still >500mls?
No Once at goal rate if the GRV are less than 100 mls for 24 -48 hours, reduce GRV checks to once every 12 hours and continue at goal rate.
YES
Reduce by a further 30 mls/hour to a minimum of 10 mls/hour. D/W medical team RE other interventions/medications.
START AGAIN AT THE BLUE DIAMOND.
Monitor and assess patients tolerance to feed. If GRV increase and or there is evidence of feed intolerance * 1. revert back to 4 hourly GRV checks 2. discuss with registrar and/or SMO. 3.
START AGAIN AT THE BLUE DIAMOND.
* Abdominal pain, cramping & distension, regurgitation of feed into oral cavity and spont vomiting. If there is vomiting or feed regurgitation, stop feeds, administer appropriate antiemetics/prokinetics, rest briefly and rev ert back to the start of the flowchart.
Figure 2 Enteral nutrition bedside algorithm.
© 2014 British Association of Critical Care Nurses
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Improving enteral nutrition through practice change
ENTERAL NUTRITION PRE-PROCEDURAL CESSATION GUIDELINE
Prior to OT (secure airway insitu): For patients who are going to OT with a secure airway (ETT or Tracheostomy) and where there is to be no manipulation of the airway during the operative period, do not stop feeds. Aspirate NG/OG tube just prior to OT and discard aspirate.
Prior to OT (unsecure airway in situ): For patients who are going to OT with an unsecure airway: Routine NBM guidelines. E.G: 6 hours for solids, 2 hours for clear fluids prior to surgical procedure.
Prior to extubation: Do not stop feeds. Aspirate NG/OG tube prior to extubation and discard aspirate.
Prior to percutaneous tracheostomy: Do not stop feeds. Aspirate NG/OG tube prior to procedure and discard aspirate.
Prior to surgical tracheostomy: For patients who are going to OT for surgical tracheostomy and who are currently intubated do not stop feeds. Aspirate NG/OG tube prior to OT and discard aspirate.
If the patient has a fine bore nasogastric tube you will not be able to aspirate from it. Please refer to the routine NBM guidelines of 2 hours fluids, 6 hours feed/solids for these patients prior to OT.
Figure 3 Pre-procedural cessation of enteral nutrition guidelines.
RESULTS Institution of early EN and achievement of goal rate The duration of time from admission to the commencement of EN was not significantly less in 2013 (M = 23⋅41), when compared to 2009 (M = 26⋅08, NS), with 56% of patients commencing EN within 24 h in 2009, compared with 64% in 2013, 𝜒 2 (1, N = 25 versus N = 39) = 0⋅42, p = 0⋅60. Similarly, 32% of patients commenced EN within 12 h post admission in 2009, compared to 38% in 2013, and this was also not significant, 𝜒 2 (1, N = 25 versus N = 39) = 0⋅276, p = 0⋅79. There was a significant reduction in the duration of time for both ICU admission to achievement of EN goal rate (M = 57⋅71 versus M = 33⋅79, p = 0⋅006) and also for EN commencement to achievement of EN goal rate (M = 31⋅65 versus M = 10⋅15, p = 0⋅000) when the 2009 and 2013 results were compared. Both of these statistically significant differences have large effect sizes 8
(Cohen’s d = 0⋅82 and Cohen’s d = 1⋅14, respectively), as illustrated in Table 3.
Volume of prescribed EN delivered The volume of prescribed EN delivered on days 4, 5 and 6 was larger in the 2013 audit in comparison to the 2009 audit. These statistically significant differences had medium (ICU days 4 and 6) to large (ICU day 2) effect sizes, as illustrated in Table 4. The volume of prescribed EN delivered over ICU days 0–7 for both the 2009 and 2013 audits is illustrated in Figure 4.
Gastric residual volumes, vomiting and regurgitation episodes The impact of the increased volume of prescribed EN delivered in the 2013 audit was not reflected in either the number of episodes of vomiting or regurgitation (five episodes in both audits), or in considerable © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Table 3 Independent samples t-tests between participants in the initial audit (2009) and the re-audit (2013) for the hours from admission to commencement, commencement to goal rate and admission to goal rate M
Time from admission to commencement (hours) Time from commencement to goal rate (hours) Time from admission to goal rate (hours)
SD
Audit 2009
Audit 2013
Audit 2009
Audit 2013
T
p
d
26⋅08 31⋅65 57⋅71
23⋅41 10⋅15 33⋅79
22⋅364 21⋅906 32⋅202
23⋅814 14⋅101 26⋅780
0⋅448 4⋅433 2⋅887
0⋅656 0⋅000** 0⋅006**
0⋅13 1⋅14 0⋅82
**p ≤ 0⋅05. Table 4 Independent samples t-test for daily percentage of prescribed enteral nutrition volume delivered N ICU day of stay
M
SD
2009 Audit
2013 Audit
2009 Audit
2013 Audit
2009 Audit
2013 Audit
t
p
d
8 13 14 17 13 11 8 5
14 30 32 31 25 20 16 13
42⋅6 74⋅2 55⋅6 85⋅2 74⋅0 76⋅8 68⋅7 93⋅5
57⋅4 73⋅5 86⋅3 93⋅9 93⋅0 91⋅8 91⋅4 95⋅0
30⋅4 40⋅1 38⋅3 37⋅2 37⋅0 30⋅0 38⋅9 6⋅1
20⋅7 24⋅5 23⋅2 16⋅9 14⋅7 14⋅2 14⋅0 7⋅7
−1⋅451 0⋅065 −3⋅362 −1⋅108 −2⋅260 −1⋅900 −2⋅116 −0⋅386
0⋅162 0⋅948 0⋅002** 0⋅274 0⋅030** 0⋅067 0⋅046** 0⋅704
0⋅63 0⋅00 0⋅96 0⋅31 0⋅67 0⋅64 0⋅75 0⋅14
0 1 2 3 4 5 6 7 **p ≤ 0⋅05.
differences in GRVs over ICU days 0–7, as demonstrated in no statistically significant differences calculated in t-tests.
Procedural-related interruptions to EN delivery (supplementary audit) An additional component to the audit in 2013 was a separate audit (N = 14) to assess the time of procedural-related interruptions to EN delivery. This was a supplementary audit to the main evaluation and involved a convenience sample of 14 patients, with 16 episodes of procedural-related interruptions to EN. The post-practice change initiative results showed a reduction in the length of time of procedural-related interruptions to EN delivery (M = 3⋅00 h, SD = 3⋅41) when compared to the pre-practice change initiative audit data (M = 5⋅41 h, SD = 4⋅23). This result did not reach statistical significance (p = 0⋅66), and involved a very small sample size.
DISCUSSION Our results showed improvement in several aspects of EN delivery when the 2013 audit data was compared to the 2009 audit. Most notably, improvements were related to categories of early institution of EN, faster advancement to goal rate and increased percentage of prescribed EN volume delivered. Raising the GRV threshold may have influenced these improvements. Furthermore, this may have been a direct result of the © 2014 British Association of Critical Care Nurses
Figure 4 Mean percentage of prescribed enteral nutrition delivered over intensive care unit (ICU) days 0–7 in the 2009 and 2013 audits.
increase in staff compliance with the EN policy and algorithm. Staff compliance with adhering to the EN policy and algorithm improved from 46% compliance in 2009, to 95% compliance in 2013.
Institution of early EN and achievement of goal rate As Doig et al. (2009) have demonstrated, EN provided within 24 h of injury or admission to the ICU results in improvements in patient outcomes such as reduced mortality rates. The practice of instituting early EN was evident in both the 2009 and 2013 audits; however, there was a trend towards a greater proportion starting EN within 24 h in 2013. In addition, there was a small 9
Improving enteral nutrition through practice change
increase in the proportion of patients who are starting EN as early as 12-h post admission when compared to 2009, although this was not statistically significant. When the mean time to goal rate was measured, improvements were clearly highlighted. In 2009, 32% of patients never reached goal rate. Of the 68% of patients that did, it took approximately 72 h. In 2013, the local ICU was achieving goal rate on average within 10 h of commencement of EN (and within 31 h post admission to the ICU) for nearly 80% of patients. The reduced time to goal rate may have occurred due to a combination of the early institution of EN and of the delivered volume being increased within the algorithm.
Volume of prescribed EN delivered The enhanced percentage of prescribed EN delivered was remarkable in that it exceeded international expectations (Martindale et al., 2009). As Heyland et al. (2011) convey, patient outcomes may not just be influenced by the early initiation of EN but by the percentage of calories and volume prescribed that is delivered to the patient each day. The mean percentage of EN delivered to patients had increased from 2% to 31%. A mean delivery of 57⋅4% was achieved as early as day 0 (admission day) with 73⋅5% on day 1, increasing to 86% on day 2 and greater than 90% thereafter. This may again reflect the early commencement and rapid titration strategy utilized in the local algorithm. Procedural-related interruptions before and after the practice change initiative were also compared.
Procedural-related interruptions to EN delivery Procedural-related interruptions were not greatly reduced as a result of the practice change initiative and the results indicate that EN is still paused prior to procedures for extended periods of time. The rationale for these lengthy periods was not collected during this audit and it is unknown if there are factors present that may have necessitated longer pre-procedural interruptions to EN in these patients. The reduction in hours following the practice change initiative did not reach statistical significance (p = 0⋅66), and involved small sample sizes (N = 20 and N = 14). Complications including aspiration, diarrhoea, constipation or patient outcome measures including ventilation times, mortality and length of stay were not collated in the evaluations. However, these complications and outcome measures have been attended to elsewhere in the literature (Kortbeek et al., 1999; McClave et al., 1999; Montejo, 1999; Taylor et al., 1999; Kearns et al., 2000; Esparza et al., 2001; Mentec et al., 2001; Pinilla et al., 2001; Davies et al., 2002; Montejo et al., 2002; Neumann and DeLegge, 2002; Elpern 10
et al., 2004; Fiaccadori et al., 2004; Kompan et al., 2004; McClave et al., 2005; Bochicchio et al., 2006; Desachy et al., 2008; Metheny et al., 2008; Montejo et al., 2010; Soroksky et al., 2010; Reignier et al., 2013) and were beyond the scope of this project.
Limitations of project There were potential sources of bias in the audits conducted: authors collected audit data from their own practice and workplace, this may have resulted in a data collection bias from under- or over-interpretation of the documentation; bias related to what was/was not documented in the patient clinical records may have also influenced the results. Some of this potential bias was minimized by use of retrospective data collection utilizing two audit data collectors otherwise unrelated to the project. The impact of the practice change initiative was evaluated using audit and small sample sizes, this may limit generalizability of the results to other facilities. Furthermore, the time period elapsed between the 2009 audit and the 2013 audit may have resulted in contextual implications for the results, including changes to medical and nursing staff, and changes in the philosophy and practice of managing nutrition in the critically ill patient. These contextual implications may be of lesser significance as the dietician and policy did not change prior to the practice change initiative.
CONCLUSION The development of an evidence-based, standardized policy and algorithm for the delivery of EN has been described. This algorithm provides the ICU nurse with a current, evidence-based, procedural guideline and framework to use when delivering EN, informing and supporting clinical and evidence-based practice. The audit, evaluation and literature review identified specific focal points to enhance in the policy and algorithm. These were integrated and adapted, producing a detailed methodical framework for the delivery of EN to the ICU patient with the aim of improving EN delivery. The local strategy for imparting the key practice changes through an intensive teaching programme during ‘EN month’ was an effective tool in the NZ tertiary ICU context. The 2013 audit, which illustrates the practice changes have significantly improved the delivery of EN for ICU patients in the local ICU, supports this finding. These results could not have been achieved without the efforts of a team approach to educate, inform and change practice. The next step will be to continue to appraise emerging evidence and review and adapt local policy and algorithms to ensure that our critical care remains abridge of current best practice.
© 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
WHAT IS KNOWN ABOUT THIS TOPIC • •
•
Improved patient outcomes are evident when the critically ill patient receives as close to their daily prescribed EN volume. There are multiple factors identified which impede the delivery of prescribed EN volume for critically ill patients. Pre-procedural interruptions to EN and lower GRV thresholds in the absence of clinical signs of intolerance are two factors which are highlighted both locally and internationally. An evidence-based algorithmic approach which guides titration of EN to goal rate provides a practical way of managing EN and can improve delivery in this patient group.
WHAT THIS PAPER ADDS • •
This paper has shown that improved EN delivery can be achieved with a team approach dedicated to practice change. Utilizing evidence-based algorithms at the bedside to manage higher GRV thresholds, reducing pre-procedural interruptions to EN and facilitating rapid achievement of goal rate are three strategies which can improve EN delivery to the critically ill patient.
ACKNOWLEDGEMENTS The authors acknowledge the support of David Aveyard and Terryn Natoli in the collection of the audit data; Kate Boulton, Dr Chris Poynter and Dr Peter Hicks in the review of current local standards and drawing together the team of local experts; Ruby Kopelov in developing the teaching presentation; Ruby Kopelov, Kevin O’Donnell and Thomas Andrews in providing the teaching presentations; Dr Dalice Sim in reviewing our reported statistics, and Professor Maureen Coombs, Dr Aaron Jarden and Richard Smith in project and editorial support.
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A practice change initiative to improve the provision of enteral nutrition to intensive care patients Rebecca J Jarden and Lynsey J Sutton ABSTRACT Aim: To describe a practice change initiative that improved the provision of enteral nutrition (EN) to patients in a New Zealand tertiary intensive care unit (ICU). Methods: The project reviewed and summarized EN literature, amended local policy, and an evidence-based EN delivery algorithm was developed. The EN practice change initiative was implemented and evaluated. Data was collected and analyzed in a pre-audit (2009) and a post-audit (2013). Results: Comparison of the pre-audit (N = 25) and the post-audit (N = 40) data demonstrated improvements in three areas of EN delivery. The commencement of early EN within 24 h of admission was evident for a large proportion of patients in both 2009 and 2013 audits. There was a large reduction in time between the two audits for both ICU admission to achievement of EN goal rate (M = 57⋅71 h versus M = 33⋅79 h, p = 0⋅006) and also for EN commencement to achievement of EN goal rate (M = 31⋅65 h versus M = 10⋅15 h, p = 0⋅000). The volume of prescribed EN delivered on days 2, 4 and 6 was greater in the 2013 audit in comparison to the 2009 audit. Staff compliance with adhering to the EN policy and algorithm improved from 46% in 2009, to 95% in 2013. Conclusions: The practice change has significantly improved the practice delivery of EN for patients in the local ICU resulting in optimal care. Relevance to clinical practice: Malnutrition is highly prevalent among intensive care patients. Strategies and initiatives that improve the delivery of enteral nutrition to the critical care population is therefore vitally important. This article describing such an initiative is thus highly relevant to all health care professionals delivering enteral nutrition in intensive and critical care units. Key words: Enteral nutrition • Gastric residual volumes • Intensive care • Literature review • Practice change
INTRODUCTION Nutritional support is a fundamental aspect of care in the critically ill (Kozier et al., 2000), historically considered as an adjunct to intervention and supportive care but more recently repositioned as a therapeutic intervention (McClave and Heyland, 2005, Leonard, 2009). Physiologically, enteral nutrition (EN) plays an essential role in maintaining the structure and function of the gastrointestinal mucosal barrier, promoting gut motility and avoiding the infectious complications
Authors: RJ Jarden, RN, MN, BHSc, BA, DipGrad, Lecturer, AUT University, Auckland 1142, New Zealand; LJ Sutton, MN(Clinical), PGcert, RNdip, Associate Charge Nurse Manager, Intensive Care Unit, Wellington Regional Hospital, Wellington 6018, New Zealand Address for correspondence: LJ Sutton, MN(Clinical), PGcert, RNdip, Associate Charge Nurse Manager, Intensive Care Unit, Wellington Regional Hospital, Wellington 6018, New Zealand E-mail: [email protected]
© 2014 British Association of Critical Care Nurses
and costs associated with parenteral nutrition (Jolliet et al., 1998; Kudsk, 2001; Kudsk, 2002; Eckmann, 2006; Grant, 2006; Johansen et al., 2006). Enhanced immune defences, restoration of intestinal anatomy and function and the amelioration of septic complications are all associated with EN delivery (Moore et al., 1992). Therefore, the effective delivery of EN is essential to the promotion of health in the critically ill patient. The context of this practice change initiative is now described.
CONTEXT This practice change initiative was developed in the context of an 18-bed general intensive care unit (ICU) in a New Zealand regional hospital providing tertiary care facilities. The adapted Plan-Do-Study-Act (PDSA) (Ministry of Health, 2002) quality improvement model provided a framework for the project (Figure 1). The first stage involved an evaluation of EN 1
Improving enteral nutrition through practice change
Figure 1 Project outline.
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practices in the local ICU. This evaluation comprised a needs assessment (Lazenbatt et al., 2001; Owen, 2006) and retrospective audit of patient clinical records in 2009.
Ethical considerations Audits were registered locally and medical records were accessed in accordance with local policy. Practice changes were reviewed and accepted by the local Clinical Practice Change Governance Group.
Pre practice change audit (2009) Sample The local ICU admissions database was used to obtain a sample of patients admitted to the ICU in 2009. Patients were selected for initial screening if they had been in the unit for longer than 3 days, in order to capture those most likely to have received EN. Patients were excluded if they did not have a nasogastric (NG) tube in place, were receiving total parenteral nutrition (TPN), or were less than 16 years of age. Twenty-five patients were included in the analysis. Data collected during this 2009 audit included patient demographics, the volume of prescribed EN delivered each day, time to goal rate and factors impeding EN delivery. This audit was instrumental in identifying which aspects of EN delivery in the local ICU were less than optimal.
databases were searched with Boolean functions and were set human and adult limiters. There were no date limiters set in the search to ensure all relevant studies were identified. Following removal of irrelevant articles the following numbers of articles were retained; PubMed (105), EMBASE (144) and Cochrane (0). After duplicates were removed, and a further manual sort for relevancy was conducted, 144 articles remained for screening. An internet search using the same keywords in Google Scholar was also conducted. International committees and expert groups published guidelines were also screened (13), and in addition a manual search of the reference lists from relevant publications (6). Search two focussed on GRV and used the following key terms such as gastric residual monitoring, gastric aspirate, residual volume and EN. This enabled identification of articles specific to GRV for the policy amendments. Following removal of irrelevant articles the following were retained; PubMed (30), EMBASE (19) and Cochrane (0). After duplicates were removed, and a further manual sort for relevancy was conducted, 17 articles remained for review, 12 original studies, 4 reviews and 1 systematic review. The literature was then reviewed by both authors and summarized. Where possible, only papers reporting original research, meta-analyses, evidence-based guidelines and systematic reviews were utilized to inform the policy changes.
Factors impeding EN delivery The 2009 audit results identified three key factors impeding EN delivery: the frequent interruption of EN delivery prior to procedures, EN delivery algorithms which were not evidence-based resulting in slow advancement to goal rate and conservative gastric residual volume (GRV) management strategies. Notably, no patient received 100% of prescribed EN, even after adjusting for the algorithm regime of advancement to the hourly prescribed rate (goal rate). A systematic search highlighted these factors are also commonly identified barriers in the international literature. This initiative began with a comprehensive search of the literature focusing on the key factors identified in the 2009 audit. The search strategy is now presented.
SEARCH STRATEGY The literature review incorporated two searches. Search one used the following key terms such as EN, tube feeding, enteral feeding, NG feeding and ICU or critical care unit. The PubMed, Cochrane and EMBASE © 2014 British Association of Critical Care Nurses
REVIEW OF THE LITERATURE Use of an algorithm to guide EN delivery Early effective EN is beneficial for critically ill patients. Outcomes such as reduced mortality, morbidity, infectious complications and length of stay have been reported (Adam and Batson, 1997; Marik and Zaloga, 2001; Martin et al., 2004; Bowman et al., 2005; MacKenzie et al., 2005; Doig et al., 2008; Doig et al., 2009; Khalid et al., 2010; Doig et al., 2011). When patients receive close to their daily prescribed calories, beneficial outcomes are even more pronounced (Heyland et al., 2011). Attempts to deliver early optimum nutrition are often unsuccessful because of conservative policies around arbitrary GRV thresholds and slow advancement to goal rates (Lichtenberg et al., 2010; Martins et al., 2012). The effective use of an algorithm has been shown to improve the delivery of prescribed EN in order to guide EN advancement to goal rate (Adam and Batson, 1997; McClave and Snider, 2002; MacKenzie et al., 2003; Martin et al., 2004; Bowman et al., 2005; MacKenzie et al., 2005). Algorithms that utilize evidence-based practices such as early commencement of EN, rapid titration to goal 3
Improving enteral nutrition through practice change
rate, management of appropriate gastric residual thresholds and shorter fasting times have been shown to increase EN delivery closer to nutritional goals (Martin et al., 2004). The first of the three components of the EN delivery algorithm addressed was how the rate of EN is advanced to goal rate.
Table 1 Recommendations from key professional groups for GRV management in the enterally fed ICU adult patient Professional groups
GRV and action recommended
European Society for Parenteral and Enteral Nutrition (ESPEN) (Kreymann et al., 2006)
Consider IV administration of metoclopramide or erythromycin in patients with intolerance to enteral feeding (e.g. with high gastric residuals) GRV >500 mL: avoid holding EN in the absence of other signs of intolerance
Advancement of EN to goal rate The rapid rate advancement of EN to goal rate is one strategy that may improve the nutritional intake of critically ill patients. Traditionally, the titration of feeds has been gradual, prolonging the time the patient receives less than their nutritional requirements (Heyland et al., 2010). In addition, there are wide variations in the method of EN rate advancement among different institutions and no single approach has been validated or standardized (Parrish and McCray, 2003b). International EN guidelines have historically suggested very reserved approaches to increasing EN by only 10–20 mL every 8–12 h (Bankhead et al., 2009). However, Heyland et al. (2010) performed a prospective pre- and post-pilot study to evaluate a regime of immediate commencement of EN at goal rate, along with a compensatory increase in EN delivery rate if EN was withheld for procedures or surgery. Whilst this study showed improved EN delivery in a way that was safe and feasible, it was a small pilot study (before group, N = 20; after group, N = 30). The most recent clinical practice guidelines suggest EN be advanced rapidly to achieve goal rate (Dhaliwal et al., 2013). However, there remains poor consensus regarding the specifics of EN delivery such as the rate and volume which should be advanced. Next we consider how GRV management might be addressed within the algorithm to reduce their impact on the delivery of EN.
Gastric residual volume The measurement of GRV (withdrawing residual gastric contents from the patient’s naso- or oro-gastric tube at specified timeframes) to assess tolerance to nutrition is standard practice in the management of EN (Metheny et al., 2012). As part of the literature review to inform the practice change initiative, a review of clinical research trials, professional recommendations and guidelines was conducted (Tables 1 and 2). The methodological quality of nutritional support trials in the critically ill patient population has been reported as poor (Doig et al., 2005). Despite a paucity of scientific data (Parrish and McClave, 2008) and inherent flaws in the argument for using GRV to demonstrate tolerability or intolerability of EN (Lin and Van Citters, 1997; 4
Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition (SCCM & ASPEN) (Martindale et al., 2009; McClave et al., 2009) Canadian Clinical Practice Guidelines for Critical Care Nutrition, in association with the Canadian Critical Care Trials Group (Dhaliwal et al., 2013) National Collaborating Centre for Acute Care (2006)
National Institute for Health and Clinical Excellence (2006)
GRV of either 250 mL or 500 mL: prokinetics at initiation and consider post pyloric feeding tubes GRV >200–300 mL: consider as a high aspirate, reduce continuous feeding rate and/or introduce prokinetics GRV = 200–300 mL: consider as ‘large’, depending on local policy, reduce infusion rate or consider prokinetics
ICU, intensive care unit; GRV, gastric residual volume.
McClave and Snider, 2002; Parrish and McCray, 2003a; Kompan et al., 2004; McClave et al., 2005; Bochicchio et al., 2006; Chang et al., 2007; Landzinski et al., 2008; MacLaren et al., 2008; Metheny, 2008), high GRVs have been identified as a primary reason for discontinuing EN (McClave et al., 1999) and ceasing GRV measurements improves the delivery (Poulard et al., 2010). Recent literature continues to dispel historical precedents and beliefs regarding GRV management, for example, the belief that there is a causal relationship between an elevated GRV and the development of ventilator-associated pneumonia (VAP) (Poulard et al., 2010). Ensuring the existing practices related to GRVs are evidence-based is crucial in improving patient outcomes. Inconsistencies in recommendations are evident between acceptable GRVs, both in the literature (Cerra et al., 1997; Pinilla et al., 2001; McClave and Snider, 2002; McClave et al., 2002; Parrish and McCray, 2003b; Keithley and Swanson, 2004; Bowman et al., 2005; Marshall, 2005; Zaloga, 2005; Kattelmann et al., 2006; Bourgault et al., 2007; Metheny, 2008; Parrish and McClave, 2008; Montejo et al., 2010; Soroksky et al., 2010; Kuppinger et al., 2013; Reignier et al., 2013; Williams et al., 2013), and in recommendations of clinical practice guidelines (Cerra et al., 1997; Jolliet et al., © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Table 2 Conclusions from key clinical trials for GRV management in the enterally fed adult ICU patient Clinical trials McClave et al. (2005) Prospective study
Pinilla et al. (2001) Randomized controlled trial
Metheny et al. (2008) Prospective observational study
Soroksky et al. (2010). Pilot prospective study
Montejo et al. (2010). Open, prospective, randomized study
Reignier et al. (2013). Randomized non-inferiority, open-label, multicenter trial
Conclusions Comparison of two groups: Intervention group: GRV >400 mL. Control group: GRV >200 mL. Converting to PEGG feeding may reduce the risk of aspiration. GRV is a poor marker for risk of aspiration. Comparison of two groups: Group 1: GRV 150 mL with an optional prokinetic. Group 2: GRV 250 mL with a mandatory prokinetic. Elevating the GRV and administering a prokinetic significantly reduced the incidence of high GRV. It also improved the time to reach goal rate and increased the % of nutrition requirements. Non-interventional. But compared three overlapping groups: GRV of at least 150 mL. GRV of at least 200 mL. GRV of at least 250 mL. High incidence of aspiration among all patients in the study. Aspiration still occurred frequently in the absence of high GRV. Not consistent relationship between aspiration and GRV, other than aspiration frequency increased as GRV increased. Delivery strategy included commencing at full goal rate and accepting GRV of 500 mL or less measured once daily. 42 < 500 mL GRV. 10 > 500 mL GRV. Allowing large GRV measured once a day did not lead to an increase in adverse effects and resulted in fewer interruptions of delivery. Control group = GRV 200 mL. Intervention group = GRV 500 mL. A limit of 500 mL GRV does not increase duration of mechanical ventilation, ICU LOS, incidence of pneumonia, or an increased risk of gastrointestinal complications. By using an upper limit of GRV 500 mL there may be a modest increase in the delivery of diet volume ratio. A GRV of 500 mL is recommended as a normal limit for GRV. Control group = 250 mL. Intervention group = absence of GRV monitoring The absence of GRV monitoring was not inferior to routing GRV monitoring related to the development of VAP.
VAP, ventilator-associated pneumonia; GRV, gastric residual volume.
1998; American Society for Parenteral and Enteral Nutrition Board of Directors and The Clinical Guidelines Task Force, 2002; McClave et al., 2002; Heyland et al., 2003; Stroud et al., 2003; Heyland et al., 2004; Kreymann et al., 2006; National Collaborating Centre for Acute Care, 2006; Critical Care Nutrition, 2007; Martindale et al., 2009; McClave et al., 2009; Dhaliwal et al., 2013). The recommended acceptable GRVs vary widely, from 150 mL to 500 mL, and recommended interventions in response to these GRVs are equally as disparate. The most common recommended action was to reduce the EN infusion rate (Cerra et al., 1997; Jolliet et al., 1998; Stroud et al., 2003; National Collaborating Centre for Acute Care, 2006; National Institute for © 2014 British Association of Critical Care Nurses
Health & Clinical Excellence, 2006). Other recommendations included to cease the EN (American Society for Parenteral and Enteral Nutrition Board of Directors and The Clinical Guidelines Task Force, 2002; Bowman et al., 2005; Kattelmann et al., 2006), to introduce prokinetics (Jolliet et al., 1998; Heyland et al., 2003; National Collaborating Centre for Acute Care, 2006; National Institute for Health & Clinical Excellence, 2006), to monitor the patient closely (Edwards and Metheny, 2000; McClave and Snider, 2002), or to implement aspiration risk reduction methods (McClave and Snider, 2002; Martindale et al., 2009). Next we consider how the interruptions to EN delivery prior to procedures might be addressed. 5
Improving enteral nutrition through practice change
Reducing the interruption of EN delivery prior to procedures One of the most frequently reported reasons for inadequate EN delivery is interruption of EN, with lengthy fasting times prior to procedures or surgery (McClave et al., 1999; Roberts et al., 2003; O’Leary-Kelley et al., 2005; Bourgault et al., 2007). Schneider et al. (2009) report wide inconsistencies and lengthy fasting times prior to procedures. Internationally, EN guideline authors acknowledge a lack of clear definitions of fasting times as a major issue for critically ill patients (McClave et al., 2009). Locally developed policies and guidelines are encouraged in clinical practice to focus on reducing pre-procedural interruptions to EN (McClave et al., 2009). Ho and Culhane (2013) and Pousman et al. (2009), report improved delivery of EN with the use of a protocol to guide reduced EN fasting times prior to procedures and surgery. They found EN delivery was improved with no increase in adverse outcomes or events when these protocols were used. To explore the extent of procedural-related EN interruptions in our local patient population, a supplementary audit was performed (in addition to the pre- and post-practice change audits) in our ICU. This involved 20 separate patients selected from a convenience sample from the local ICU admissions database. Patients in the ICU for longer than 3 days were selected as the most likely to have required transport to radiology, theatre, or who had tracheostomies placed. In total, there were 23 episodes where EN was ceased for procedures, and EN management strategies were inconsistent throughout. The total mean time EN was interrupted for was 5⋅41 h (SD = 4⋅23). Despite the lack of clarity in advancement to goal rate strategies, GRV limits, and pre-procedural EN interruptions, an algorithm needs to provide some practical guidance to EN delivery. Thus, local experts were consulted in an effort to define these specific parameters in the form of an algorithm that could be used at the bedside.
PRACTICE CHANGES AND IMPLEMENTATION Algorithm development Local experts were consulted in an interdisciplinary review of these key areas of the policy. This consultation period led to agreement on these aspects which were incorporated into an algorithm and a practical guide to achieving improved EN delivery at the bedside. These included strategies such as commencement of EN volume, titration of EN, management of GRVs and on-going monitoring for signs of EN intolerance such as regurgitation and vomiting (Figures 2 and 3). 6
Practice change An EN practice change team was formed which included two ICU senior nurses, a nurse educator, a staff nurse and a dietician. The focus of the EN group was to disseminate the policy changes and algorithm to approximately 120 nurses and 20 doctors in the local ICU, promote evidence-based knowledge and practices around EN delivery, and dispel myths related to GRVs, which were widely prevalent in clinical practice. A teaching package was developed, and an education programme commenced during ‘EN month’. This included small group teaching via a standardized tool, dedicated EN boards with information and literature, a bulletin board and handover messages, posters, laminated flowcharts and algorithms for bedside references, and a page on the local hospital’s intranet. On completion of EN month, education session feedback forms and the results of a post-education test were collated. Ninety-five percent of all staff received the teaching and all scored 100% on the post-education test questions (n = 94).
EVALUATION OF PRACTICE CHANGE INITIATIVE (2013) Sample In 2013, a retrospective audit of patients’ clinical records was performed on a simple random sample selected from the local ICU admissions database. To enable comparison with the 2009 audit data, the same process for patient selection was performed in 2013. From the 70 patient’s clinical records screened, 28 were not enterally fed, and two patient’s clinical records had incomplete data and were excluded. In total, there were 40 patients included in the final analysis.
Data collection and analysis Data from clinical records was manually entered into a Microsoft Excel spreadsheet and analysis of the data was conducted using the Statistical Package for the Social Sciences (SPSS 17) (Pallant, 2007; Miller et al., 2009). The main aim of analysis was to identify if the practice change initiative had impacted on the proportion of patients with early EN instituted (i.e. within 24 h), the time to EN goal rate from admission and start of EN, and the volume of EN delivered per ICU day. The data collected included patient demographics, time of initiation of EN (hours from admission to EN start), time to goal rate, percentage of prescribed EN delivered each day, vomiting and regurgitation episodes, and mean GRVs. This was in accordance with the data collected in 2009. © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Nasogastric/orogastric feeding flowchart Obtain prescription from Dr's & refer to dietitian
Start feeds at 30 mls hour.
Check GRV after 4 hours.
GRV >500 mls.
GRV 500mls?
NO
YES YES
NO
Is goal rate achieved? Return up to 500 mls. Decrease rate by 30 mls. Discuss prokinetic with ICU medical staff.
Continue to monitor GRV every 4 hours and increase feed rate by 30 mls until goal rate achieved. Measure GRV 4 hours later. Are GRV still >500mls?
No Once at goal rate if the GRV are less than 100 mls for 24 -48 hours, reduce GRV checks to once every 12 hours and continue at goal rate.
YES
Reduce by a further 30 mls/hour to a minimum of 10 mls/hour. D/W medical team RE other interventions/medications.
START AGAIN AT THE BLUE DIAMOND.
Monitor and assess patients tolerance to feed. If GRV increase and or there is evidence of feed intolerance * 1. revert back to 4 hourly GRV checks 2. discuss with registrar and/or SMO. 3.
START AGAIN AT THE BLUE DIAMOND.
* Abdominal pain, cramping & distension, regurgitation of feed into oral cavity and spont vomiting. If there is vomiting or feed regurgitation, stop feeds, administer appropriate antiemetics/prokinetics, rest briefly and rev ert back to the start of the flowchart.
Figure 2 Enteral nutrition bedside algorithm.
© 2014 British Association of Critical Care Nurses
7
Improving enteral nutrition through practice change
ENTERAL NUTRITION PRE-PROCEDURAL CESSATION GUIDELINE
Prior to OT (secure airway insitu): For patients who are going to OT with a secure airway (ETT or Tracheostomy) and where there is to be no manipulation of the airway during the operative period, do not stop feeds. Aspirate NG/OG tube just prior to OT and discard aspirate.
Prior to OT (unsecure airway in situ): For patients who are going to OT with an unsecure airway: Routine NBM guidelines. E.G: 6 hours for solids, 2 hours for clear fluids prior to surgical procedure.
Prior to extubation: Do not stop feeds. Aspirate NG/OG tube prior to extubation and discard aspirate.
Prior to percutaneous tracheostomy: Do not stop feeds. Aspirate NG/OG tube prior to procedure and discard aspirate.
Prior to surgical tracheostomy: For patients who are going to OT for surgical tracheostomy and who are currently intubated do not stop feeds. Aspirate NG/OG tube prior to OT and discard aspirate.
If the patient has a fine bore nasogastric tube you will not be able to aspirate from it. Please refer to the routine NBM guidelines of 2 hours fluids, 6 hours feed/solids for these patients prior to OT.
Figure 3 Pre-procedural cessation of enteral nutrition guidelines.
RESULTS Institution of early EN and achievement of goal rate The duration of time from admission to the commencement of EN was not significantly less in 2013 (M = 23⋅41), when compared to 2009 (M = 26⋅08, NS), with 56% of patients commencing EN within 24 h in 2009, compared with 64% in 2013, 𝜒 2 (1, N = 25 versus N = 39) = 0⋅42, p = 0⋅60. Similarly, 32% of patients commenced EN within 12 h post admission in 2009, compared to 38% in 2013, and this was also not significant, 𝜒 2 (1, N = 25 versus N = 39) = 0⋅276, p = 0⋅79. There was a significant reduction in the duration of time for both ICU admission to achievement of EN goal rate (M = 57⋅71 versus M = 33⋅79, p = 0⋅006) and also for EN commencement to achievement of EN goal rate (M = 31⋅65 versus M = 10⋅15, p = 0⋅000) when the 2009 and 2013 results were compared. Both of these statistically significant differences have large effect sizes 8
(Cohen’s d = 0⋅82 and Cohen’s d = 1⋅14, respectively), as illustrated in Table 3.
Volume of prescribed EN delivered The volume of prescribed EN delivered on days 4, 5 and 6 was larger in the 2013 audit in comparison to the 2009 audit. These statistically significant differences had medium (ICU days 4 and 6) to large (ICU day 2) effect sizes, as illustrated in Table 4. The volume of prescribed EN delivered over ICU days 0–7 for both the 2009 and 2013 audits is illustrated in Figure 4.
Gastric residual volumes, vomiting and regurgitation episodes The impact of the increased volume of prescribed EN delivered in the 2013 audit was not reflected in either the number of episodes of vomiting or regurgitation (five episodes in both audits), or in considerable © 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
Table 3 Independent samples t-tests between participants in the initial audit (2009) and the re-audit (2013) for the hours from admission to commencement, commencement to goal rate and admission to goal rate M
Time from admission to commencement (hours) Time from commencement to goal rate (hours) Time from admission to goal rate (hours)
SD
Audit 2009
Audit 2013
Audit 2009
Audit 2013
T
p
d
26⋅08 31⋅65 57⋅71
23⋅41 10⋅15 33⋅79
22⋅364 21⋅906 32⋅202
23⋅814 14⋅101 26⋅780
0⋅448 4⋅433 2⋅887
0⋅656 0⋅000** 0⋅006**
0⋅13 1⋅14 0⋅82
**p ≤ 0⋅05. Table 4 Independent samples t-test for daily percentage of prescribed enteral nutrition volume delivered N ICU day of stay
M
SD
2009 Audit
2013 Audit
2009 Audit
2013 Audit
2009 Audit
2013 Audit
t
p
d
8 13 14 17 13 11 8 5
14 30 32 31 25 20 16 13
42⋅6 74⋅2 55⋅6 85⋅2 74⋅0 76⋅8 68⋅7 93⋅5
57⋅4 73⋅5 86⋅3 93⋅9 93⋅0 91⋅8 91⋅4 95⋅0
30⋅4 40⋅1 38⋅3 37⋅2 37⋅0 30⋅0 38⋅9 6⋅1
20⋅7 24⋅5 23⋅2 16⋅9 14⋅7 14⋅2 14⋅0 7⋅7
−1⋅451 0⋅065 −3⋅362 −1⋅108 −2⋅260 −1⋅900 −2⋅116 −0⋅386
0⋅162 0⋅948 0⋅002** 0⋅274 0⋅030** 0⋅067 0⋅046** 0⋅704
0⋅63 0⋅00 0⋅96 0⋅31 0⋅67 0⋅64 0⋅75 0⋅14
0 1 2 3 4 5 6 7 **p ≤ 0⋅05.
differences in GRVs over ICU days 0–7, as demonstrated in no statistically significant differences calculated in t-tests.
Procedural-related interruptions to EN delivery (supplementary audit) An additional component to the audit in 2013 was a separate audit (N = 14) to assess the time of procedural-related interruptions to EN delivery. This was a supplementary audit to the main evaluation and involved a convenience sample of 14 patients, with 16 episodes of procedural-related interruptions to EN. The post-practice change initiative results showed a reduction in the length of time of procedural-related interruptions to EN delivery (M = 3⋅00 h, SD = 3⋅41) when compared to the pre-practice change initiative audit data (M = 5⋅41 h, SD = 4⋅23). This result did not reach statistical significance (p = 0⋅66), and involved a very small sample size.
DISCUSSION Our results showed improvement in several aspects of EN delivery when the 2013 audit data was compared to the 2009 audit. Most notably, improvements were related to categories of early institution of EN, faster advancement to goal rate and increased percentage of prescribed EN volume delivered. Raising the GRV threshold may have influenced these improvements. Furthermore, this may have been a direct result of the © 2014 British Association of Critical Care Nurses
Figure 4 Mean percentage of prescribed enteral nutrition delivered over intensive care unit (ICU) days 0–7 in the 2009 and 2013 audits.
increase in staff compliance with the EN policy and algorithm. Staff compliance with adhering to the EN policy and algorithm improved from 46% compliance in 2009, to 95% compliance in 2013.
Institution of early EN and achievement of goal rate As Doig et al. (2009) have demonstrated, EN provided within 24 h of injury or admission to the ICU results in improvements in patient outcomes such as reduced mortality rates. The practice of instituting early EN was evident in both the 2009 and 2013 audits; however, there was a trend towards a greater proportion starting EN within 24 h in 2013. In addition, there was a small 9
Improving enteral nutrition through practice change
increase in the proportion of patients who are starting EN as early as 12-h post admission when compared to 2009, although this was not statistically significant. When the mean time to goal rate was measured, improvements were clearly highlighted. In 2009, 32% of patients never reached goal rate. Of the 68% of patients that did, it took approximately 72 h. In 2013, the local ICU was achieving goal rate on average within 10 h of commencement of EN (and within 31 h post admission to the ICU) for nearly 80% of patients. The reduced time to goal rate may have occurred due to a combination of the early institution of EN and of the delivered volume being increased within the algorithm.
Volume of prescribed EN delivered The enhanced percentage of prescribed EN delivered was remarkable in that it exceeded international expectations (Martindale et al., 2009). As Heyland et al. (2011) convey, patient outcomes may not just be influenced by the early initiation of EN but by the percentage of calories and volume prescribed that is delivered to the patient each day. The mean percentage of EN delivered to patients had increased from 2% to 31%. A mean delivery of 57⋅4% was achieved as early as day 0 (admission day) with 73⋅5% on day 1, increasing to 86% on day 2 and greater than 90% thereafter. This may again reflect the early commencement and rapid titration strategy utilized in the local algorithm. Procedural-related interruptions before and after the practice change initiative were also compared.
Procedural-related interruptions to EN delivery Procedural-related interruptions were not greatly reduced as a result of the practice change initiative and the results indicate that EN is still paused prior to procedures for extended periods of time. The rationale for these lengthy periods was not collected during this audit and it is unknown if there are factors present that may have necessitated longer pre-procedural interruptions to EN in these patients. The reduction in hours following the practice change initiative did not reach statistical significance (p = 0⋅66), and involved small sample sizes (N = 20 and N = 14). Complications including aspiration, diarrhoea, constipation or patient outcome measures including ventilation times, mortality and length of stay were not collated in the evaluations. However, these complications and outcome measures have been attended to elsewhere in the literature (Kortbeek et al., 1999; McClave et al., 1999; Montejo, 1999; Taylor et al., 1999; Kearns et al., 2000; Esparza et al., 2001; Mentec et al., 2001; Pinilla et al., 2001; Davies et al., 2002; Montejo et al., 2002; Neumann and DeLegge, 2002; Elpern 10
et al., 2004; Fiaccadori et al., 2004; Kompan et al., 2004; McClave et al., 2005; Bochicchio et al., 2006; Desachy et al., 2008; Metheny et al., 2008; Montejo et al., 2010; Soroksky et al., 2010; Reignier et al., 2013) and were beyond the scope of this project.
Limitations of project There were potential sources of bias in the audits conducted: authors collected audit data from their own practice and workplace, this may have resulted in a data collection bias from under- or over-interpretation of the documentation; bias related to what was/was not documented in the patient clinical records may have also influenced the results. Some of this potential bias was minimized by use of retrospective data collection utilizing two audit data collectors otherwise unrelated to the project. The impact of the practice change initiative was evaluated using audit and small sample sizes, this may limit generalizability of the results to other facilities. Furthermore, the time period elapsed between the 2009 audit and the 2013 audit may have resulted in contextual implications for the results, including changes to medical and nursing staff, and changes in the philosophy and practice of managing nutrition in the critically ill patient. These contextual implications may be of lesser significance as the dietician and policy did not change prior to the practice change initiative.
CONCLUSION The development of an evidence-based, standardized policy and algorithm for the delivery of EN has been described. This algorithm provides the ICU nurse with a current, evidence-based, procedural guideline and framework to use when delivering EN, informing and supporting clinical and evidence-based practice. The audit, evaluation and literature review identified specific focal points to enhance in the policy and algorithm. These were integrated and adapted, producing a detailed methodical framework for the delivery of EN to the ICU patient with the aim of improving EN delivery. The local strategy for imparting the key practice changes through an intensive teaching programme during ‘EN month’ was an effective tool in the NZ tertiary ICU context. The 2013 audit, which illustrates the practice changes have significantly improved the delivery of EN for ICU patients in the local ICU, supports this finding. These results could not have been achieved without the efforts of a team approach to educate, inform and change practice. The next step will be to continue to appraise emerging evidence and review and adapt local policy and algorithms to ensure that our critical care remains abridge of current best practice.
© 2014 British Association of Critical Care Nurses
Improving enteral nutrition through practice change
WHAT IS KNOWN ABOUT THIS TOPIC • •
•
Improved patient outcomes are evident when the critically ill patient receives as close to their daily prescribed EN volume. There are multiple factors identified which impede the delivery of prescribed EN volume for critically ill patients. Pre-procedural interruptions to EN and lower GRV thresholds in the absence of clinical signs of intolerance are two factors which are highlighted both locally and internationally. An evidence-based algorithmic approach which guides titration of EN to goal rate provides a practical way of managing EN and can improve delivery in this patient group.
WHAT THIS PAPER ADDS • •
This paper has shown that improved EN delivery can be achieved with a team approach dedicated to practice change. Utilizing evidence-based algorithms at the bedside to manage higher GRV thresholds, reducing pre-procedural interruptions to EN and facilitating rapid achievement of goal rate are three strategies which can improve EN delivery to the critically ill patient.
ACKNOWLEDGEMENTS The authors acknowledge the support of David Aveyard and Terryn Natoli in the collection of the audit data; Kate Boulton, Dr Chris Poynter and Dr Peter Hicks in the review of current local standards and drawing together the team of local experts; Ruby Kopelov in developing the teaching presentation; Ruby Kopelov, Kevin O’Donnell and Thomas Andrews in providing the teaching presentations; Dr Dalice Sim in reviewing our reported statistics, and Professor Maureen Coombs, Dr Aaron Jarden and Richard Smith in project and editorial support.
REFERENCES Adam S, Batson S. (1997). A study of problems associated with the delivery of enteral feed in critically ill patients in five ICUs in the UK. Intensive Care Medicine; 23: 261–266. American Society for Parenteral and Enteral Nutrition Board of Directors & The Clinical Guidelines Task Force. (2002). Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. Journal of Parenteral and Enteral Nutrition; 26: 1SA–137SA. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J. (2009). Enteral nutrition practice recommendations. JPEN Journal of Parenteral and Enteral Nutrition; 33: 122–167. Bochicchio G, Bochicchio K, Nehman S, Casey C, Andrews P, Scalea T. (2006). Tolerance and efficacy of enteral nutrition in traumatic brain-injured patients induced into barbiturate coma. Journal of Parenteral and Enteral Nutrition; 30: 503–506. Bourgault A, Ipe L, Weaver J, Swartz S, O’Dea P. (2007). Development of evidence-based guidelines and critical care nurses’ knowledge of enteral feeding. Critical Care Nurse; 27: 17–29. Bowman A, Greiner J, Doerschug K, Little S, Bombei C, Comried L. (2005). Implementation of an evidence-based feeding protocol and aspiration risk reduction algorithm. Critical Care Nursing Quarterly; 28: 324–333. Cerra F, Benitez M, Blackburn G, Irwin R, Jeejeebhoy K, Katz D, Pingleton S, Pomposelli J, Rombeau J, Shronts E, Wolfe R, Zaloga G. (1997). Applied nutrition in ICU patients: a consensus statement of the American College of Chest Physicians. Chest; 111: 769–778.
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Chang WK, McClave SA, Hsieh CB, Chao YC. (2007). Gastric residual volume (GRV) and gastric contents measurement by refractometry. JPEN Journal of Parenteral and Enteral Nutrition; 31: 63–68. Critical Care Nutrition. (2007). Updated recommendations from the Canadian clinical practice guidelines for nutrition support. Davies AR, Froomes PR, French CJ, Bellomo R, Gutteridge GA, Nyulasi I, Walker R & Sewell RB (2002). Randomized comparison of nasojejunal and nasogastric feeding in critically ill patients. http://www.mrw.interscience.wiley.com/ cochrane/clcentral/articles/931/CN-00379931/frame.html (accessed 26/11/08). Desachy A, Clavel M, Vuagnat A, Normand S, Gissot V, Francois B. (2008). Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Medicine; 34: 1054–1060. Dhaliwal R, Cahill N, Lemieux M, Heyland DK. (2013). The Canadian critical care nutrition guidelines in 2013: an update on current recommendations and implementation strategies. Nutrition in Clinical Practice; 29: 29–43. Doig G, Simpson F, Delaney A. (2005). A review of the true methodological quality of nutritional support trials conducted in the critically ill: time for improvement. Anesthesia Analgesia; 100: 527–533. Doig GS, Simpson F, Finfer S, Delaney A, Davies AR, Mitchell I, Dobb G. (2008). Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. Journal of the American Medical Association; 300: 2731–2741. Doig GS, Heighes PT, Simpson F, Sweetman EA, Davies AR. (2009). Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Medicine; 35: 2018–2027. Doig GS, Heighes PT, Simpson F, Sweetman EA. (2011). Early enteral nutrition reduces mortality in trauma patients requiring intensive care: a meta-analysis of randomised controlled trials. Injury; 42: 50–56. Eckmann L. (2006). Innate immunity. In: Johnson L, Barrett K, Ghishan F, Merchant J, Said H, Wood J, (eds), Physiology of the Gastrointestinal Tract. Vol. 2. Burlington: Elsevier. Edwards S, Metheny N. (2000). Measurement of gastric residual volume: State of the science. Medsurg Nursing; 9: 125. Elpern EH, Stutz L, Peterson S, Gurka DP, Skipper A. (2004). Outcomes associated with enteral tube feedings in a medical
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