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research-article2014
NCPXXX10.1177/0884533614531047Nutrition in Clinical PracticeMcCall et al
Clinical Research
Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies
Nutrition in Clinical Practice Volume 29 Number 4 August 2014 510–517 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614531047 ncp.sagepub.com hosted at online.sagepub.com
Michele McCall, RD, MSc1; Naomi Cahill, RD, MSc, PhD2,3; Lauren Murch, MSc2; Tasnim Sinuff, MD, PhD4; Tricia Bray, RN, MN5; Teddie Tanguay, RN, NP, MN5; and Daren K. Heyland, MD, MSc2,3,6
Abstract Background: This study describes the results of an evaluation of educational strategies used to implement a novel enteral feeding protocol in 9 North American intensive care units (ICUs). Materials and Methods: Members of the protocol implementation teams at each ICU distributed a questionnaire to ICU nurses after the implementation of the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP) protocol. Eight different educational strategies were evaluated. Questionnaires were distributed in both paper and electronic format to all nursing staff and used both a visual analog Likert-type scale and open-ended questions. Results: The response rate to the questionnaire was 166 of 434 or 38.2%. More than 70% of respondents rated 5 of the educational strategies as very useful or somewhat useful, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 and group bedside teaching, and a self-learning module. The percentage of nurses who found the bedside protocol tools of the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either “very easy” or “somewhat easy” to use were 64.0%, 60.5%, and 59.1%, respectively. Conclusion: The use of multiple teaching formats, including the long and short PowerPoint presentations and self-teaching module, appeared to meet the learning needs of most of the group. The majority of the bedside tools developed to facilitate the implementation of the PEP uP protocol were considered easy to use. (Nutr Clin Pract. 2014;29:510-517)
Keywords enteral nutrition; education; education research; clinical protocols; questionnaires
Successful implementation of best practices in healthcare settings is a challenging process. Little is known regarding the optimal methods to implement best practices, including nutrition care best practices at the bedside. Systematic reviews of the evidence outside the critical care setting suggest that education is an important intervention that may augment the use of protocols.1 Within the intensive care unit (ICU) setting, education appears to be the most important intervention added to a protocol that can increase protocol adherence.2 A number of important barriers to best practice implementation in the ICU have also been identified by ICU clinicians, including ICU workload, complexity of patient illness, high patient care responsibilities, and time- and labor-intensive tasks required for patient care.3 Importantly, ICU clinicians identified education tailored to the learning preferences of different professional groups and repeated educational sessions as key interventions to overcome potential barriers to clinician adherence to best practices in the ICU.3 We developed a novel feeding protocol entitled Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP).4 The PEP uP study was a repeated cross-sectional cluster randomized trial of 18 ICUs in North America. Its objective was to determine
if the implementation of this new protocol for enteral feeding combined with a nursing educational intervention would improve energy and protein delivery in critically ill patients compared with usual care.5 The results of the study demonstrated improved mean intake for protein and calories of 14% (95% confidence interval [CI], 5%–23%; P = .005) and 12% (95% CI, 5%–20%; P = .004), respectively, for the PEP uP sites compared with the control sites. There was also a trend From the 1Medical/Surgical Intensive Care Unit, St Michael’s Hospital, Toronto, Ontario, Canada; 2Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; 3Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada; 4 Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; 5Canadian Association of Critical Care Nurses, London, Ontario; and 6Department of Medicine, Queen’s University, Kingston, Ontario, Canada. Financial disclosure: This work was supported by Nestlé. This article originally appeared online on April 22, 2014. Corresponding Author: Daren K. Heyland, MD, MSc, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7, Canada. Email: [email protected]
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toward decreased average time from ICU admission to the start of enteral nutrition (EN) in the PEP uP group compared with the control group (40.7–29.7 hours vs 33.6–35.2 hours; P = .10).5 When implementing the PEP uP protocol in the intervention groups, attention was given to the development of educational strategies used for training the ICU nurses and staff. From our previous research, we observed that a multifaceted educational plan tailored to the needs of the ICU and individual healthcare team member could maximize chances of adherence to new practices.6 This article explains the educational strategies used and the results of an evaluation of the educational strategies by ICU nurses who participated in the PEP uP study intervention group. The objectives of this study were (a) to describe educational strategies used to educate ICU nurses for the implementation of the PEP uP study and (b) to present the results of the evaluation of these educational strategies by nursing staff from the various ICU sites.
feeding and addresses the high kcal:N ratio of most enteral formulas. d. Use of semi-elemental formula—enteral feeding was initiated with Peptamen 1.5 (Nestlé Nutrition). This was felt to maximize the chances of tolerance and absorption over the broadest range of patients admitted to the ICU. This is reassessed and altered as per dietitian recommendations. e. Reporting nutrition adequacy—nurses and dietitians were encouraged to report on the percentage of energy and protein delivered on the previous day during patient care rounds with the ICU team. All of these aspects were included on a preprinted order sheet that was used by the 9 intervention sites. Suggestions for routine blood work, water flushes, and tube patency medication (pancreatic enzyme) were also on the order set but could be altered to suit the routine practice of each ICU.
Educational Materials and Implementation Tools
Methods PEP uP Study Details Forty-five North American ICUs that had participated in our 2009 International Nutrition Audits were invited to take part, from which 18 sites agreed. The ICUs were randomized to either the PEP uP protocol (described below) or usual care and recruited patients who were mechanically ventilated within 6 hours of ICU admission and eligible for enteral feeding. Each site was to recruit 30 eligible, consecutive patients and collected data daily for a maximum of 12 days. Data were collected at baseline and 6–9 months after PEP uP protocol implementation in the intervention group and at baseline and again 6 months later in the usual care group. The 2 primary outcomes of the PEP uP study were the proportion of the protein and calorie prescriptions received by study patients via EN over the first 12 days in the ICU.
Novel Aspects of the PEP uP Protocol The key aspects of the PEP uP protocol included the following: a. Volume based feeding—this replaced rate-based feeding, allowing nurses to calculate the remaining daily volume to be delivered and adjusting the rate of feeding to accommodate time lost to tests, procedures, airway management, and so on. b. Use of prokinetic agents—prokinetics are started on day 1 of enteral feeding instead of waiting for intolerance to occur. These medications would be reassessed daily. c. Use of protein supplements—all patients are prescribed protein supplements (Beneprotein; Nestlé Nutrition) at the same time as starting enteral feeding. This allows for a higher protein intake immediately upon initiating enteral
The content of the PEP uP protocol, educational materials, and implementation tools were developed by the study steering committee based on experience and staff feedback from the original single-centered feasibility study on 50 patients and a subsequent pilot study at another hospital in Oslo, Norway.4 The materials and tools are summarized in Tables 1 and 2.
Training of Protocol Implementation Teams Each intervention ICU was asked to create a Protocol Implementation Team (known as the PIT crew), which was responsible for implementing the study intervention at the local site. The PIT crew was composed of the ICU dietitian, a nurse, and intensivist. In February 2012, the PIT crew attended a 1- day training meeting in Vancouver, BC, Canada. These training sessions were comprehensive, including the specific role of the PIT crew, data abstraction and data entry, study eligibility, and study timelines. Participants were instructed on how to use the educational materials and how to implement the educational material evaluations. Time was provided for participants to ask questions and share their experiences to date. See Table 3 for details about the PIT crew training session. For the 2 sites that could not attend, we trained staff by telephone, using the same agenda as in Table 3. Two 90-minute follow-up conference calls were also provided so researchers could ask questions and share their experiences around data entry, protocol implementation, education implementation, and any other problem or solution that had occurred. All educational and bedside resources were provided as hard copies or electronic files as appropriate. The PIT crew
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Table 1. Educational Tools Used to Increase Knowledge and Awareness for Implementation of the PEP uP Protocol. Educational Tool PowerPoint presentations
Self-learning module
Study information sheets
Frequently asked questions (FAQ) document Posters Electronic reminder messages Monthly newsletters
Description
Rationale for Use
Information about the study rationale and how to implement the PEP uP protocol. A long (30–40 minute) and short (10–15 minute) version were available. Information about the PEP uP protocol and case example to work through independently. Information about the study rationale and guidelines for implementation of the PEP uP protocol. Three versions of the sheets were developed targeted at nurses, physicians, and patients’ family, respectively. Document addresses common questions about the PEP uP protocol.
A variety of posters were available to hang in the ICU during the study. Animated reminder messages about key elements of the PEP uP protocol to be displayed on a monitor in the ICU. Monthly circular with updates about the study.
Long version for more formal rounds sessions in lecture format. Short version for quick bedside teaching sessions with 2–3 nurses at a time. Allows nurses/staff who missed in-services to review the material on their own and work through a case example. Short 1-page information sheets that serve as quick reminders of the main points of the study to help maintain awareness and interest.
A quick reference for the most commonly asked questions about the study protocol. Allows staff to find the answers without needing a PIT crew member. Placed around the ICU to help maintain awareness and interest in the study. Active screen saver program used to maintain awareness and interest in the study and also remind staff of key protocol points. Sent to PIT crew members with information about protocol implementation, dates for training, ethics board submissions, and other protocol-related topics.
ICU, intensive care unit; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; PIT, Protocol Implementation Team.
Table 2. Bedside Written Materials to Operationalize the PEP uP Protocol. Bedside Written Material
Description
Rationale for Use
Enteral feeding initiation orders Gastric feeding flowchart
Physician standardized order sheet for starting enteral feeding. Flow diagram illustrating the procedure for management of gastric residual volumes. Table for determining goal rates of enteral feeding based on the 24-hour goal volume. Excel spreadsheet used to monitor the progress of enteral nutrition.
To ensure consistent and accurate implementation of the protocol and efficient order writing. To promote a consistent, evidence-based approach to management of gastric residual volumes. To enable the bedside nurse to easily calculate hourly feeding rates. Electronic tool for the dietitian to maintain an ongoing record of enteral intake and issues.
Volume-based feeding schedule Daily monitoring checklist
was responsible for planning and conducting the education sessions for all staff. Sites were encouraged to select and adapt the educational materials to their local context.
Evaluation of Educational Materials and the PEP uP Protocol Evaluation of the educational materials and the PEP uP protocol was completed using a questionnaire. This questionnaire was adapted from a questionnaire used to evaluate the PEP uP protocol single-center pilot study at Kingston General Hospital, Canada, later revised for the clustered RCT.4 The revised
version was pilot tested with nurses working in the ICU at Rikshospitalet Hospital, Norway. The questionnaire was divided into 2 parts. The first part evaluated the usefulness of the educational tools (9 items). Nurses were asked whether or not they had ever been exposed to the specific tool and, if exposed, to rank the usefulness of the tool on a 5-point visual analog Likert-type scale of very useful, somewhat useful, neutral, somewhat useless, or useless. At the end of this section, participants were asked to provide open-ended comments to the questions, “How easy or difficult to understand was the information in any of the educational materials?” and “What changes to the educational materials would you like to see?”
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Table 3. Program Details for the PIT Crew Training Session. Introduction Overview of the background and rationale for the PEP uP study Review of eligibility criteria Role of the PIT crew Implementation of the PEP uP Protocol Detailed instruction on how to use the bedside tools, including (1) enteral feeding initiation orders, (2) gastric feeding flowchart, (3) volume-based feeding schedule, and (4) daily monitoring checklist Piloting the PEP uP Protocol Shared experiences of implementing the PEP uP protocol from a research nurse at a Norwegian hospital Review of Nutrition Information Byte (NIBBLE) and Family Brochure Review of 2 materials developed to educate ICU physicians about the PEP uP study (NIBBLE) and families of patients enrolled in the trial Educating Your Nurses to Use the PEP uP Protocol Instruction on how to use the PowerPoint presentations and the self-learning module when conducting educational sessions/rounds/ bedside instructions with your nursing team Review of additional information documents (posters, screen shots/pointers) and how to use them to promote implementation of the protocol Evaluation of the PEP uP Protocol Review of the PEP uP protocol evaluation questionnaire and instructions on how to administer the questionnaire in your ICU Questions and Discussion Opportunity for participants to ask the research team any questions or discuss any concerns that that they may have regarding implementing the PEP uP protocol ICU, intensive care unit; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; PIT, Protocol Implementation Team.
The second part of the questionnaire evaluating the PEP uP protocol comprised 3 sections: ease of use of the bedside tools (5 questions), acceptability of the various novel characteristics of the protocol (6 questions), and perception of the safety of the protocol (1 question). Ease of use of educational tools was rated with a 5-point Likert-type scale end anchored with “very easy” to “very difficult.” Acceptability was rated with a 10-point Likert-type scale anchored with “totally unacceptable” to “totally acceptable” and space for comments. Protocol safety was evaluated using an open-ended question that asked, “In trying to implement the new PEP uP feeding protocol, did you have any situation or event that, in your opinion, compromised patient safety”? A detailed instruction sheet for distribution of the evaluation questionnaire was provided for each PIT crew. The PIT crews were instructed to distribute either a paper or online web-based version of the questionnaire (Survey MonkeyTM) to every member of their nursing staff during the follow-up phase of the study. The goal was to have 30 completed questionnaires submitted per site. Paper copies were handed directly to nurses or left in their mailboxes, and electronic copies were sent to their email addresses. Nurses were given 2 weeks to complete the questionnaire with a reminder sent 1 week after the initial distribution and 1 day prior to the due date. Nurses who completed paper questionnaires were asked to deposit them in a secure box in the ICU while the web-based questionnaires were automatically submitted to the researchers. After the completion of the PEP uP study, a face-to-face meeting was held to elicit feedback from all the participating ICUs that implemented the protocol.
Analysis The analysis of this study is primarily descriptive. Responses for statements with Likert scales were tabulated and medians and ranges are reported. Comments from open-ended questions, minutes of conference calls, and closed-out feedback sessions were reviewed and responses were organized into common themes.
Ethics Board Approvals All participating ICUs obtained local ethics board approval. At one site, investigators were required to obtain informed consent from next of kin to collect patient data, but consent was not required to receive the feeding protocol. All other sites waived the need for informed consent. We considered the return of the questionnaire as consent from the nurses for use of the data in this study.
Results The questionnaire was distributed to 434 nurses across the 9 interventional sites that implemented the PEP uP protocol. Of these, 166 nurses completed the questionnaire, resulting in a response rate of 38.2%. The response rate varied between 8.3% and 70.0% depending on the ICU.
Educational Materials Figure 1 shows the responses from nurses regarding their exposure to each educational tool and evaluation of its
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% of Nurses
514
90 80 70 60 50 40 30 20 10 0
Exposure Useful Neutral Useless
Figure 1. Nursing evaluation of the usefulness of each educational tool. Percentages related to ratings of utility refer to only those nurses who had been exposed to the educational tool. LPP-CC Rnd, long PowerPoint for critical care rounds; LPP-inserv, long PowerPoint for inservices; PP via Email, long PowerPoint presentation sent by email; Short 1-on-1 PP, short PowerPoint for bedside 1-on-1 education; Short Group PP, short PowerPoint for bedside group education; Self-Learning, self-learning module.
usefulness. Five of the 8 teaching strategies were evaluated as very useful or somewhat useful by more than 70% of respondents, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 bedside teaching and group bedside teaching, and the self-learning module. The proportion of nurses who responded that they were “never exposed to” or “never used” a specific educational strategy ranged from 24%–74%, depending on the strategy. When asked how easy or difficult the information in the educational tools was to understand, 72.4% of respondents said they were “very easy” or “somewhat easy” to understand. The open-ended section resulted in 11 comments. Five responses stated they found the material conflicting or confusing, and 2 responses suggested the materials were too wordy. Other comments included the need for more 1-on-1 teaching, more visual aids, too much information in too little time, and no chance to ask questions or do examples. Respondents were also asked to suggest any changes that would improve the educational materials. Of the 34 openended comments, 7 comments revolved around the need for more frequent in-services to staff, and several expanded to include that small group or 1-on-1 teaching would be preferred. Six respondents felt no changes were needed. The need to improve communication about the existence of the study to nursing and physician staff was identified by 3 respondents.
Bedside Written Materials The results of the nurses’ evaluation of the bedside written materials are summarized in Table 4. The percentages of nurses who found the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either “very easy” or “somewhat easy” to use were 64.0%, 60.5%, and 59.1%, respectively. As shown in Table 4, 20%–32% of respondents chose the “neutral” response for all 4 bedside tools. Of note, 90% of respondents found the volume-based feeding schedule a useful tool. When asked if the PEP uP protocol increased daily workload, 54.0% responded “increased workload a bit,” 4.3% responded “increased workload considerably,” and 36.6% responded “neutral.” Open-ended comments were not elicited for this portion of the questionnaire.
PEP uP Protocol Acceptability A 10-point Likert-type scale was used for this section of the questionnaire where a score of 1 represented totally unacceptable and a score of 10 totally acceptable. The use of a 24-hour volume goal instead of an hourly rate for enteral feeding was given a mean score of 6.9 ± 1.8. The most common ideas expressed in the comments were the need for good communication among team members and concerns regarding a patient’s ability to tolerate it, but this was not elaborated upon. Starting
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Table 4. Nursing Evaluation of Ease of Use of the Bedside Written Materials. PEP uP Protocol Enteral feeding order set Gastric feeding flowchart Volume-based feeding schedule Diarrhea guideline
Very Easy, n/N (%)
Somewhat Easy, n/N (%)
Neutral, n/N (%)
Somewhat Difficult, n/N (%)
Very Difficult, n/N (%)
39/161 (24.2) 39/162 (24.1)
64/161 (39.8) 59/162 (36.4)
32/161 (19.9) 34/162 (21.0)
15/161 (9.3) 13/162 (8.0)
3/161 (1.9) 1/162 (0.6)
31/161 (19.3)
64/161 (39.8)
33/161 (20.5)
23/161 (14.3)
4/161 (2.5)
14/156 (9.0)
33/156 (21.1)
50/156 (32.1)
6/156 (3.9)
5/156 (3.2)
N = total number of nurses who evaluated this material; n = number of nurses who chose each answer. PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients.
Table 5. Nursing Evaluation of Acceptability of Special Attributes of the PEP uP Protocol. Level of Acceptability to Nurses, Mediana (Range)
No. of Comments Received
Use of 24-hour volume goal (n = 116)
7 (2–9)
15
Start at high hourly rates (n = 123)
5 (2–9)
24
Start motility agent right away (n = 96)
7 (2–9)
12
Start protein supplements right away (n = 98)
7 (2–9)
12
Overall protocol (n = 118)
7 (2–9)
16
PEP uP Protocol Factor
Summary of Comments RNs + MDs must work together with clearly stated orders Some discomfort with using high rate for small number of hours when EN interrupted 15 of 24 comments about discomfort with starting at high hourly rate due to concerns regarding aspiration/tolerance/ vomiting Each patient is unique and should be assessed individually Assists with tolerating EN much better Concerns that it would promote diarrhea Concerns about giving a medication that may not be needed and effect on QT interval Three comments regarding need for extra fluid to be given Three comments that protein powder may clog feeding tubes
Two comments regarding concern about high gastric residual volumes and communication among team members Three comments regarding concern around adjustments in rate to achieve goal volumes
EN, enteral nutrition; MD, medical doctor; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; RN, registered nurse. a Likert-type scale where 1 = totally unacceptable and 10 = totally acceptable.
EN at high rates was not as easily accepted by the nurses. The mean score of acceptability was 5.6 ± 2.0. Half of respondents (49.6%) ranked this practice between 4 and 6, and only 37.9% ranked it between 7 and 9. There were 24 comments provided, 15 of which revolved around concerns about high gastric residual volumes, aspiration, or vomiting. Nurses expressed a level of discomfort with starting EN at the goal rate right away and felt slow increases to goal would be preferable. Starting to provide protein powder and administering motility agents as soon as EN was initiated seem to both be acceptable practices, with mean scores of 6.8 ± 2.0 and 6.4 ± 2.2, respectively. Of the few comments provided about these 2 practices, several nurses mentioned that giving protein powder resulted in clogged tubes or significant extra fluid intake and that giving motility agents right away might cause diarrhea. Several nurses also
commented favorably about both of these components of the protocol. When asked to rank the protocol for overall acceptability, the mean response was 6.6 ± 2.0. Details about the comments can be found in Table 5.
Perceptions of PEP uP Protocol Safety When asked if implementing the PEP uP Protocol caused any situation or event that could have compromised patient safety, 11% (16/145) of respondents said yes. When asked to explain the event in an open-ended comment area, 22 comments were provided. Only 3 of these alluded to any actual event, which was vomiting, but it was unclear if patients actually did vomit, or if the respondent was just concerned that it may occur. Six nurses made nonspecific comments about concerns around
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high gastric residual volumes, 3 nurses described common issues around enteral feeding not related to the protocol, and 4 nurses wrote that they did not experience any safety concerns. One respondent felt that the protocol could result in more variable blood glucose values. Five other comments could not be interpreted.
Discussion Our evaluation revealed that of the wide variety of educational tools used, the didactic methodology of a 30- to 40-minute slide presentation at rounds or in-services and the short 10-minute 1-on-1 and group bedside slide presentations and the selflearning module were evaluated as useful methods of instruction by >70% of surveyed nurses. Research examining the most optimal methods for teaching a heterogeneous group of learners such as a large nursing staff reveals that many factors affect successful learning. These include inherent characteristics of the learner such as generational group, learning style, level of practical experience,7,8 and educational program characteristics such as the use of needs assessment, teaching methodology, and frequency of followup.9 Thus, one method of instruction will not suit every learner or learning environment, and our educational tools were chosen with different purposes in mind. The long presentations could reach many people at once and provide a high level of detail about the PEP uP protocol. The short presentations address the reality of the busy bedside nurse who only has 10– 15 minutes for an in-service and needs a form of education highlighting the main points without too much detail. The posters and computer taglines serve to keep the profile of the study high and to communicate training session locations. In a systematic review of educational interventions to teach nurses about identifying delirium, Yanamadala et al10 found that enabling and reinforcing strategies such as the use of champions, providing feedback on performance, and implementing protocols were particularly effective. In our study, the PIT crews included several staff members who were acting as champions of the PEP uP protocol at each ICU. Feedback from the close-out sessions revealed that having a dedicated resource person to champion the protocol, whether a nurse or dietitian, helped overcome barriers to implementation at the bedside and kept enthusiasm for the change in practice high. This is particularly important since several aspects of the PEP uP protocol would be unfamiliar for the nurses, putting them beyond their usual comfort zone. This was reflected in the open-ended comments on the evaluation. A common theme from the evaluation and conference calls was the importance of communication and continuous follow-up to ensure that all staff members, particularly nurses and physicians, knew about the protocol. The use of web-based educational formats has been well studied in the healthcare field, and these have been shown to provide several benefits compared with lecture-style teaching.11 These benefits include flexibility in the timing of learning to fit
work or home schedules and individualized pacing of learning based on previous experience or expertise of the learner.11,12 In a busy work environment like an ICU, the reality is that not all nurses will be able to attend prescheduled lectures or in-services. Thus, we developed a computer-based self-learning tool that included all the background information on PEP uP and case examples. Nurses were encouraged to complete the tool at their own convenience during their work day, and over 70% of nurses who used it rated it as a useful method of teaching. It was also noted that units that embedded the enteral feeding order set into their current system (ie, electronic orders or an official printed order set) had greater success with the protocol vs those units who just had it available as a guideline. This is probably because the embedded order sets became part of the usual ordering practice to which the staff were already accustomed and helped facilitate communication about the protocol details.
Study Strengths and Limitations This study has several limitations. The total response rate was low at only 38.2%. The low response rate may introduce a bias as nonrespondents may have a different view on the usefulness of these materials. This bias limits the validity of our results. As well, our results revealed that many of the nurses who completed the evaluation had actually not been exposed to many of the educational tools on the questionnaire, making the actual number of responses about each teaching method or bedside written material relatively small. We are not able to link the success or failure of the educational tools with the acceptability of the protocol since we do not know if those nurses who described poor acceptability received adequate education about the protocol. Members of the PIT crews may have chosen to emphasize one tool over another. Two sites received PIT crew training via telephone instead of in person with all the other sites. This may not have been as effective and may have led to poorer implementation of the educational strategies. Finally, the open-ended comments were not well answered by the nurses. Many of the comments were uninterpretable or did not answer the question posed. A strength of this study was the extensive effort made to educate the key leaders at each research site. This included site visits, follow-up conference calls, and the detailed, comprehensive educational materials provided for the PIT crews. Another strength of our study is that it measured the impact of the educational strategies and protocol on the ICU staff. We were unable to find any evaluations of teaching strategies used to implement enteral protocols or algorithms from other centers. Several other reports in the literature describe the effects of new enteral protocols or algorithms on clinical outcomes related to EN delivery and adherence to protocol guidelines, but none mention the educational strategies used to educate their ICU staff.13-16 One study by Reeves et al17 used focus groups to evaluate the strengths and weaknesses of their enteral feeding algorithm, but teaching strategies were not evaluated.
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Conclusions We used a variety of educational tools to instruct a large group of ICU nurses and staff on the PEP uP feeding protocol. Large and small group lecture-style formats were evaluated as useful methodologies. The use of multiple teaching formats, including the self-teaching module, appeared to meet the learning needs of most of the group.
References 1. Grimshaw JM, MacLennan G, Fraser C, et al. Effectiveness and efficiency of guideline dissemination and implementation strategies. Health Technol Assess. 2004;8:1-72. 2. Sinuff T, Muscedere J, Adhikari NKJ, et al, for the KRITICAL Working Group, the Canadian Critical Care Trials Group, and the Canadian Critical Care Society. Knowledge translation interventions for critically ill patients: a systematic review. Crit Care Med. 2013;41:2627-2640. 3. Sinuff T, Cook DJ, Giacomini M, Heyland D, Dodek P. Facilitating guideline adherence in the ICU: a qualitative study. Crit Care Med. 2007;35:2085-2089. 4. Heyland D, Cahill N, Dhaliwal R, et al. Enhanced protein-energy provision via the enteral route in critically ill patients: a single center feasibility trial of the PEP uP protocol. Crit Care. 2010;14(2):R78. 5. Heyland D, Murch L, Cahill N, et al. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013;41:1-11. 6. Cahill NE, Suurdt J, Ouellette-Kuntz H, Heyland DK. Understanding adherence to guidelines in the intensive care unit: development of a comprehensive framework. JPEN J Parenter Enteral Nutr. 2010;34:616-624.
7. Robinson J, Scollan-Koliopoulos M, Kamienski M, Burke K. Generational differences and learning style preferences in nurses from a large metropolitan medical center. J Nurs Staff Dev. 2012;28:166-172. 8. Paterson T. Generational considerations in providing critical care education. Crit Care Nurs Q. 2010;33:67-74. 9. Lobo RD, Levin AS, Oliveira MS, et al. Evaluation of interventions to reduce catheter-associated bloodstream infection: continuous tailored education versus one basic lecture. Am J Infect Control. 2010;38: 440-448. 10. Yanamadala M, Wieland D, Heflin MT. Educational interventions to improve recognition of delirium: a systematic review. J Am Geriatr Soc. 2013;61:1983-1993. 11. Herman H, Comer L, Putnam L, Freeman H. Blended versus lecture learning. J Nurs Staff Dev. 2012;28:186-190. 12. Ireland J, Martindale S, Johnson N, et al. Blended learning in education: effects on knowledge and attitude. Br J Nurs. 2009;18:124-130. 13. Dobson K, Scott A. Review of ICU nutrition support practices: implementing the nurse-led enteral feeding algorithm. Nurs Crit Care. 2007;12: 114-123. 14. Woien H, Bjork IT. Nutrition of the critically ill patient and effects of implementing a nutrition support algorithm in ICU. J Clin Nurs. 2006;15:168-177. 15. Mackenzie SL, Zygun DA, Whitmore BL, Doig CJ, Hameed SM. Implementation of a nutrition support protocol increases the proportion of mechanically ventilated patients reaching nutrition support targets in the adult intensive care unit. JPEN J Parenter Enter Nutr. 2005;29:74-80. 16. Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ. 2004;170:197-204. 17. Reeves A, White H, Sosnowski K, et al. Multidisciplinary evaluation of a critical care enteral feeding algorithm. Nutr Diet. 2012;69:242-249.
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research-article2014
NCPXXX10.1177/0884533614531047Nutrition in Clinical PracticeMcCall et al
Clinical Research
Lessons Learned From Implementing a Novel Feeding Protocol: Results of a Multicenter Evaluation of Educational Strategies
Nutrition in Clinical Practice Volume 29 Number 4 August 2014 510–517 © 2014 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533614531047 ncp.sagepub.com hosted at online.sagepub.com
Michele McCall, RD, MSc1; Naomi Cahill, RD, MSc, PhD2,3; Lauren Murch, MSc2; Tasnim Sinuff, MD, PhD4; Tricia Bray, RN, MN5; Teddie Tanguay, RN, NP, MN5; and Daren K. Heyland, MD, MSc2,3,6
Abstract Background: This study describes the results of an evaluation of educational strategies used to implement a novel enteral feeding protocol in 9 North American intensive care units (ICUs). Materials and Methods: Members of the protocol implementation teams at each ICU distributed a questionnaire to ICU nurses after the implementation of the Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP) protocol. Eight different educational strategies were evaluated. Questionnaires were distributed in both paper and electronic format to all nursing staff and used both a visual analog Likert-type scale and open-ended questions. Results: The response rate to the questionnaire was 166 of 434 or 38.2%. More than 70% of respondents rated 5 of the educational strategies as very useful or somewhat useful, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 and group bedside teaching, and a self-learning module. The percentage of nurses who found the bedside protocol tools of the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either “very easy” or “somewhat easy” to use were 64.0%, 60.5%, and 59.1%, respectively. Conclusion: The use of multiple teaching formats, including the long and short PowerPoint presentations and self-teaching module, appeared to meet the learning needs of most of the group. The majority of the bedside tools developed to facilitate the implementation of the PEP uP protocol were considered easy to use. (Nutr Clin Pract. 2014;29:510-517)
Keywords enteral nutrition; education; education research; clinical protocols; questionnaires
Successful implementation of best practices in healthcare settings is a challenging process. Little is known regarding the optimal methods to implement best practices, including nutrition care best practices at the bedside. Systematic reviews of the evidence outside the critical care setting suggest that education is an important intervention that may augment the use of protocols.1 Within the intensive care unit (ICU) setting, education appears to be the most important intervention added to a protocol that can increase protocol adherence.2 A number of important barriers to best practice implementation in the ICU have also been identified by ICU clinicians, including ICU workload, complexity of patient illness, high patient care responsibilities, and time- and labor-intensive tasks required for patient care.3 Importantly, ICU clinicians identified education tailored to the learning preferences of different professional groups and repeated educational sessions as key interventions to overcome potential barriers to clinician adherence to best practices in the ICU.3 We developed a novel feeding protocol entitled Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients (PEP uP).4 The PEP uP study was a repeated cross-sectional cluster randomized trial of 18 ICUs in North America. Its objective was to determine
if the implementation of this new protocol for enteral feeding combined with a nursing educational intervention would improve energy and protein delivery in critically ill patients compared with usual care.5 The results of the study demonstrated improved mean intake for protein and calories of 14% (95% confidence interval [CI], 5%–23%; P = .005) and 12% (95% CI, 5%–20%; P = .004), respectively, for the PEP uP sites compared with the control sites. There was also a trend From the 1Medical/Surgical Intensive Care Unit, St Michael’s Hospital, Toronto, Ontario, Canada; 2Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada; 3Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario, Canada; 4 Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, and Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; 5Canadian Association of Critical Care Nurses, London, Ontario; and 6Department of Medicine, Queen’s University, Kingston, Ontario, Canada. Financial disclosure: This work was supported by Nestlé. This article originally appeared online on April 22, 2014. Corresponding Author: Daren K. Heyland, MD, MSc, Kingston General Hospital, Angada 4, Kingston, ON K7L 2V7, Canada. Email: [email protected]
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toward decreased average time from ICU admission to the start of enteral nutrition (EN) in the PEP uP group compared with the control group (40.7–29.7 hours vs 33.6–35.2 hours; P = .10).5 When implementing the PEP uP protocol in the intervention groups, attention was given to the development of educational strategies used for training the ICU nurses and staff. From our previous research, we observed that a multifaceted educational plan tailored to the needs of the ICU and individual healthcare team member could maximize chances of adherence to new practices.6 This article explains the educational strategies used and the results of an evaluation of the educational strategies by ICU nurses who participated in the PEP uP study intervention group. The objectives of this study were (a) to describe educational strategies used to educate ICU nurses for the implementation of the PEP uP study and (b) to present the results of the evaluation of these educational strategies by nursing staff from the various ICU sites.
feeding and addresses the high kcal:N ratio of most enteral formulas. d. Use of semi-elemental formula—enteral feeding was initiated with Peptamen 1.5 (Nestlé Nutrition). This was felt to maximize the chances of tolerance and absorption over the broadest range of patients admitted to the ICU. This is reassessed and altered as per dietitian recommendations. e. Reporting nutrition adequacy—nurses and dietitians were encouraged to report on the percentage of energy and protein delivered on the previous day during patient care rounds with the ICU team. All of these aspects were included on a preprinted order sheet that was used by the 9 intervention sites. Suggestions for routine blood work, water flushes, and tube patency medication (pancreatic enzyme) were also on the order set but could be altered to suit the routine practice of each ICU.
Educational Materials and Implementation Tools
Methods PEP uP Study Details Forty-five North American ICUs that had participated in our 2009 International Nutrition Audits were invited to take part, from which 18 sites agreed. The ICUs were randomized to either the PEP uP protocol (described below) or usual care and recruited patients who were mechanically ventilated within 6 hours of ICU admission and eligible for enteral feeding. Each site was to recruit 30 eligible, consecutive patients and collected data daily for a maximum of 12 days. Data were collected at baseline and 6–9 months after PEP uP protocol implementation in the intervention group and at baseline and again 6 months later in the usual care group. The 2 primary outcomes of the PEP uP study were the proportion of the protein and calorie prescriptions received by study patients via EN over the first 12 days in the ICU.
Novel Aspects of the PEP uP Protocol The key aspects of the PEP uP protocol included the following: a. Volume based feeding—this replaced rate-based feeding, allowing nurses to calculate the remaining daily volume to be delivered and adjusting the rate of feeding to accommodate time lost to tests, procedures, airway management, and so on. b. Use of prokinetic agents—prokinetics are started on day 1 of enteral feeding instead of waiting for intolerance to occur. These medications would be reassessed daily. c. Use of protein supplements—all patients are prescribed protein supplements (Beneprotein; Nestlé Nutrition) at the same time as starting enteral feeding. This allows for a higher protein intake immediately upon initiating enteral
The content of the PEP uP protocol, educational materials, and implementation tools were developed by the study steering committee based on experience and staff feedback from the original single-centered feasibility study on 50 patients and a subsequent pilot study at another hospital in Oslo, Norway.4 The materials and tools are summarized in Tables 1 and 2.
Training of Protocol Implementation Teams Each intervention ICU was asked to create a Protocol Implementation Team (known as the PIT crew), which was responsible for implementing the study intervention at the local site. The PIT crew was composed of the ICU dietitian, a nurse, and intensivist. In February 2012, the PIT crew attended a 1- day training meeting in Vancouver, BC, Canada. These training sessions were comprehensive, including the specific role of the PIT crew, data abstraction and data entry, study eligibility, and study timelines. Participants were instructed on how to use the educational materials and how to implement the educational material evaluations. Time was provided for participants to ask questions and share their experiences to date. See Table 3 for details about the PIT crew training session. For the 2 sites that could not attend, we trained staff by telephone, using the same agenda as in Table 3. Two 90-minute follow-up conference calls were also provided so researchers could ask questions and share their experiences around data entry, protocol implementation, education implementation, and any other problem or solution that had occurred. All educational and bedside resources were provided as hard copies or electronic files as appropriate. The PIT crew
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Table 1. Educational Tools Used to Increase Knowledge and Awareness for Implementation of the PEP uP Protocol. Educational Tool PowerPoint presentations
Self-learning module
Study information sheets
Frequently asked questions (FAQ) document Posters Electronic reminder messages Monthly newsletters
Description
Rationale for Use
Information about the study rationale and how to implement the PEP uP protocol. A long (30–40 minute) and short (10–15 minute) version were available. Information about the PEP uP protocol and case example to work through independently. Information about the study rationale and guidelines for implementation of the PEP uP protocol. Three versions of the sheets were developed targeted at nurses, physicians, and patients’ family, respectively. Document addresses common questions about the PEP uP protocol.
A variety of posters were available to hang in the ICU during the study. Animated reminder messages about key elements of the PEP uP protocol to be displayed on a monitor in the ICU. Monthly circular with updates about the study.
Long version for more formal rounds sessions in lecture format. Short version for quick bedside teaching sessions with 2–3 nurses at a time. Allows nurses/staff who missed in-services to review the material on their own and work through a case example. Short 1-page information sheets that serve as quick reminders of the main points of the study to help maintain awareness and interest.
A quick reference for the most commonly asked questions about the study protocol. Allows staff to find the answers without needing a PIT crew member. Placed around the ICU to help maintain awareness and interest in the study. Active screen saver program used to maintain awareness and interest in the study and also remind staff of key protocol points. Sent to PIT crew members with information about protocol implementation, dates for training, ethics board submissions, and other protocol-related topics.
ICU, intensive care unit; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; PIT, Protocol Implementation Team.
Table 2. Bedside Written Materials to Operationalize the PEP uP Protocol. Bedside Written Material
Description
Rationale for Use
Enteral feeding initiation orders Gastric feeding flowchart
Physician standardized order sheet for starting enteral feeding. Flow diagram illustrating the procedure for management of gastric residual volumes. Table for determining goal rates of enteral feeding based on the 24-hour goal volume. Excel spreadsheet used to monitor the progress of enteral nutrition.
To ensure consistent and accurate implementation of the protocol and efficient order writing. To promote a consistent, evidence-based approach to management of gastric residual volumes. To enable the bedside nurse to easily calculate hourly feeding rates. Electronic tool for the dietitian to maintain an ongoing record of enteral intake and issues.
Volume-based feeding schedule Daily monitoring checklist
was responsible for planning and conducting the education sessions for all staff. Sites were encouraged to select and adapt the educational materials to their local context.
Evaluation of Educational Materials and the PEP uP Protocol Evaluation of the educational materials and the PEP uP protocol was completed using a questionnaire. This questionnaire was adapted from a questionnaire used to evaluate the PEP uP protocol single-center pilot study at Kingston General Hospital, Canada, later revised for the clustered RCT.4 The revised
version was pilot tested with nurses working in the ICU at Rikshospitalet Hospital, Norway. The questionnaire was divided into 2 parts. The first part evaluated the usefulness of the educational tools (9 items). Nurses were asked whether or not they had ever been exposed to the specific tool and, if exposed, to rank the usefulness of the tool on a 5-point visual analog Likert-type scale of very useful, somewhat useful, neutral, somewhat useless, or useless. At the end of this section, participants were asked to provide open-ended comments to the questions, “How easy or difficult to understand was the information in any of the educational materials?” and “What changes to the educational materials would you like to see?”
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Table 3. Program Details for the PIT Crew Training Session. Introduction Overview of the background and rationale for the PEP uP study Review of eligibility criteria Role of the PIT crew Implementation of the PEP uP Protocol Detailed instruction on how to use the bedside tools, including (1) enteral feeding initiation orders, (2) gastric feeding flowchart, (3) volume-based feeding schedule, and (4) daily monitoring checklist Piloting the PEP uP Protocol Shared experiences of implementing the PEP uP protocol from a research nurse at a Norwegian hospital Review of Nutrition Information Byte (NIBBLE) and Family Brochure Review of 2 materials developed to educate ICU physicians about the PEP uP study (NIBBLE) and families of patients enrolled in the trial Educating Your Nurses to Use the PEP uP Protocol Instruction on how to use the PowerPoint presentations and the self-learning module when conducting educational sessions/rounds/ bedside instructions with your nursing team Review of additional information documents (posters, screen shots/pointers) and how to use them to promote implementation of the protocol Evaluation of the PEP uP Protocol Review of the PEP uP protocol evaluation questionnaire and instructions on how to administer the questionnaire in your ICU Questions and Discussion Opportunity for participants to ask the research team any questions or discuss any concerns that that they may have regarding implementing the PEP uP protocol ICU, intensive care unit; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; PIT, Protocol Implementation Team.
The second part of the questionnaire evaluating the PEP uP protocol comprised 3 sections: ease of use of the bedside tools (5 questions), acceptability of the various novel characteristics of the protocol (6 questions), and perception of the safety of the protocol (1 question). Ease of use of educational tools was rated with a 5-point Likert-type scale end anchored with “very easy” to “very difficult.” Acceptability was rated with a 10-point Likert-type scale anchored with “totally unacceptable” to “totally acceptable” and space for comments. Protocol safety was evaluated using an open-ended question that asked, “In trying to implement the new PEP uP feeding protocol, did you have any situation or event that, in your opinion, compromised patient safety”? A detailed instruction sheet for distribution of the evaluation questionnaire was provided for each PIT crew. The PIT crews were instructed to distribute either a paper or online web-based version of the questionnaire (Survey MonkeyTM) to every member of their nursing staff during the follow-up phase of the study. The goal was to have 30 completed questionnaires submitted per site. Paper copies were handed directly to nurses or left in their mailboxes, and electronic copies were sent to their email addresses. Nurses were given 2 weeks to complete the questionnaire with a reminder sent 1 week after the initial distribution and 1 day prior to the due date. Nurses who completed paper questionnaires were asked to deposit them in a secure box in the ICU while the web-based questionnaires were automatically submitted to the researchers. After the completion of the PEP uP study, a face-to-face meeting was held to elicit feedback from all the participating ICUs that implemented the protocol.
Analysis The analysis of this study is primarily descriptive. Responses for statements with Likert scales were tabulated and medians and ranges are reported. Comments from open-ended questions, minutes of conference calls, and closed-out feedback sessions were reviewed and responses were organized into common themes.
Ethics Board Approvals All participating ICUs obtained local ethics board approval. At one site, investigators were required to obtain informed consent from next of kin to collect patient data, but consent was not required to receive the feeding protocol. All other sites waived the need for informed consent. We considered the return of the questionnaire as consent from the nurses for use of the data in this study.
Results The questionnaire was distributed to 434 nurses across the 9 interventional sites that implemented the PEP uP protocol. Of these, 166 nurses completed the questionnaire, resulting in a response rate of 38.2%. The response rate varied between 8.3% and 70.0% depending on the ICU.
Educational Materials Figure 1 shows the responses from nurses regarding their exposure to each educational tool and evaluation of its
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% of Nurses
514
90 80 70 60 50 40 30 20 10 0
Exposure Useful Neutral Useless
Figure 1. Nursing evaluation of the usefulness of each educational tool. Percentages related to ratings of utility refer to only those nurses who had been exposed to the educational tool. LPP-CC Rnd, long PowerPoint for critical care rounds; LPP-inserv, long PowerPoint for inservices; PP via Email, long PowerPoint presentation sent by email; Short 1-on-1 PP, short PowerPoint for bedside 1-on-1 education; Short Group PP, short PowerPoint for bedside group education; Self-Learning, self-learning module.
usefulness. Five of the 8 teaching strategies were evaluated as very useful or somewhat useful by more than 70% of respondents, including the long PowerPoint presentation at in-services and critical care rounds, the short PowerPoint presentation for 1-on-1 bedside teaching and group bedside teaching, and the self-learning module. The proportion of nurses who responded that they were “never exposed to” or “never used” a specific educational strategy ranged from 24%–74%, depending on the strategy. When asked how easy or difficult the information in the educational tools was to understand, 72.4% of respondents said they were “very easy” or “somewhat easy” to understand. The open-ended section resulted in 11 comments. Five responses stated they found the material conflicting or confusing, and 2 responses suggested the materials were too wordy. Other comments included the need for more 1-on-1 teaching, more visual aids, too much information in too little time, and no chance to ask questions or do examples. Respondents were also asked to suggest any changes that would improve the educational materials. Of the 34 openended comments, 7 comments revolved around the need for more frequent in-services to staff, and several expanded to include that small group or 1-on-1 teaching would be preferred. Six respondents felt no changes were needed. The need to improve communication about the existence of the study to nursing and physician staff was identified by 3 respondents.
Bedside Written Materials The results of the nurses’ evaluation of the bedside written materials are summarized in Table 4. The percentages of nurses who found the enteral feeding order set, gastric feeding flowchart, and volume-based feeding schedule either “very easy” or “somewhat easy” to use were 64.0%, 60.5%, and 59.1%, respectively. As shown in Table 4, 20%–32% of respondents chose the “neutral” response for all 4 bedside tools. Of note, 90% of respondents found the volume-based feeding schedule a useful tool. When asked if the PEP uP protocol increased daily workload, 54.0% responded “increased workload a bit,” 4.3% responded “increased workload considerably,” and 36.6% responded “neutral.” Open-ended comments were not elicited for this portion of the questionnaire.
PEP uP Protocol Acceptability A 10-point Likert-type scale was used for this section of the questionnaire where a score of 1 represented totally unacceptable and a score of 10 totally acceptable. The use of a 24-hour volume goal instead of an hourly rate for enteral feeding was given a mean score of 6.9 ± 1.8. The most common ideas expressed in the comments were the need for good communication among team members and concerns regarding a patient’s ability to tolerate it, but this was not elaborated upon. Starting
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Table 4. Nursing Evaluation of Ease of Use of the Bedside Written Materials. PEP uP Protocol Enteral feeding order set Gastric feeding flowchart Volume-based feeding schedule Diarrhea guideline
Very Easy, n/N (%)
Somewhat Easy, n/N (%)
Neutral, n/N (%)
Somewhat Difficult, n/N (%)
Very Difficult, n/N (%)
39/161 (24.2) 39/162 (24.1)
64/161 (39.8) 59/162 (36.4)
32/161 (19.9) 34/162 (21.0)
15/161 (9.3) 13/162 (8.0)
3/161 (1.9) 1/162 (0.6)
31/161 (19.3)
64/161 (39.8)
33/161 (20.5)
23/161 (14.3)
4/161 (2.5)
14/156 (9.0)
33/156 (21.1)
50/156 (32.1)
6/156 (3.9)
5/156 (3.2)
N = total number of nurses who evaluated this material; n = number of nurses who chose each answer. PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients.
Table 5. Nursing Evaluation of Acceptability of Special Attributes of the PEP uP Protocol. Level of Acceptability to Nurses, Mediana (Range)
No. of Comments Received
Use of 24-hour volume goal (n = 116)
7 (2–9)
15
Start at high hourly rates (n = 123)
5 (2–9)
24
Start motility agent right away (n = 96)
7 (2–9)
12
Start protein supplements right away (n = 98)
7 (2–9)
12
Overall protocol (n = 118)
7 (2–9)
16
PEP uP Protocol Factor
Summary of Comments RNs + MDs must work together with clearly stated orders Some discomfort with using high rate for small number of hours when EN interrupted 15 of 24 comments about discomfort with starting at high hourly rate due to concerns regarding aspiration/tolerance/ vomiting Each patient is unique and should be assessed individually Assists with tolerating EN much better Concerns that it would promote diarrhea Concerns about giving a medication that may not be needed and effect on QT interval Three comments regarding need for extra fluid to be given Three comments that protein powder may clog feeding tubes
Two comments regarding concern about high gastric residual volumes and communication among team members Three comments regarding concern around adjustments in rate to achieve goal volumes
EN, enteral nutrition; MD, medical doctor; PEP uP, Enhanced Protein-Energy Provision via the Enteral Route Feeding Protocol in Critically Ill Patients; RN, registered nurse. a Likert-type scale where 1 = totally unacceptable and 10 = totally acceptable.
EN at high rates was not as easily accepted by the nurses. The mean score of acceptability was 5.6 ± 2.0. Half of respondents (49.6%) ranked this practice between 4 and 6, and only 37.9% ranked it between 7 and 9. There were 24 comments provided, 15 of which revolved around concerns about high gastric residual volumes, aspiration, or vomiting. Nurses expressed a level of discomfort with starting EN at the goal rate right away and felt slow increases to goal would be preferable. Starting to provide protein powder and administering motility agents as soon as EN was initiated seem to both be acceptable practices, with mean scores of 6.8 ± 2.0 and 6.4 ± 2.2, respectively. Of the few comments provided about these 2 practices, several nurses mentioned that giving protein powder resulted in clogged tubes or significant extra fluid intake and that giving motility agents right away might cause diarrhea. Several nurses also
commented favorably about both of these components of the protocol. When asked to rank the protocol for overall acceptability, the mean response was 6.6 ± 2.0. Details about the comments can be found in Table 5.
Perceptions of PEP uP Protocol Safety When asked if implementing the PEP uP Protocol caused any situation or event that could have compromised patient safety, 11% (16/145) of respondents said yes. When asked to explain the event in an open-ended comment area, 22 comments were provided. Only 3 of these alluded to any actual event, which was vomiting, but it was unclear if patients actually did vomit, or if the respondent was just concerned that it may occur. Six nurses made nonspecific comments about concerns around
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high gastric residual volumes, 3 nurses described common issues around enteral feeding not related to the protocol, and 4 nurses wrote that they did not experience any safety concerns. One respondent felt that the protocol could result in more variable blood glucose values. Five other comments could not be interpreted.
Discussion Our evaluation revealed that of the wide variety of educational tools used, the didactic methodology of a 30- to 40-minute slide presentation at rounds or in-services and the short 10-minute 1-on-1 and group bedside slide presentations and the selflearning module were evaluated as useful methods of instruction by >70% of surveyed nurses. Research examining the most optimal methods for teaching a heterogeneous group of learners such as a large nursing staff reveals that many factors affect successful learning. These include inherent characteristics of the learner such as generational group, learning style, level of practical experience,7,8 and educational program characteristics such as the use of needs assessment, teaching methodology, and frequency of followup.9 Thus, one method of instruction will not suit every learner or learning environment, and our educational tools were chosen with different purposes in mind. The long presentations could reach many people at once and provide a high level of detail about the PEP uP protocol. The short presentations address the reality of the busy bedside nurse who only has 10– 15 minutes for an in-service and needs a form of education highlighting the main points without too much detail. The posters and computer taglines serve to keep the profile of the study high and to communicate training session locations. In a systematic review of educational interventions to teach nurses about identifying delirium, Yanamadala et al10 found that enabling and reinforcing strategies such as the use of champions, providing feedback on performance, and implementing protocols were particularly effective. In our study, the PIT crews included several staff members who were acting as champions of the PEP uP protocol at each ICU. Feedback from the close-out sessions revealed that having a dedicated resource person to champion the protocol, whether a nurse or dietitian, helped overcome barriers to implementation at the bedside and kept enthusiasm for the change in practice high. This is particularly important since several aspects of the PEP uP protocol would be unfamiliar for the nurses, putting them beyond their usual comfort zone. This was reflected in the open-ended comments on the evaluation. A common theme from the evaluation and conference calls was the importance of communication and continuous follow-up to ensure that all staff members, particularly nurses and physicians, knew about the protocol. The use of web-based educational formats has been well studied in the healthcare field, and these have been shown to provide several benefits compared with lecture-style teaching.11 These benefits include flexibility in the timing of learning to fit
work or home schedules and individualized pacing of learning based on previous experience or expertise of the learner.11,12 In a busy work environment like an ICU, the reality is that not all nurses will be able to attend prescheduled lectures or in-services. Thus, we developed a computer-based self-learning tool that included all the background information on PEP uP and case examples. Nurses were encouraged to complete the tool at their own convenience during their work day, and over 70% of nurses who used it rated it as a useful method of teaching. It was also noted that units that embedded the enteral feeding order set into their current system (ie, electronic orders or an official printed order set) had greater success with the protocol vs those units who just had it available as a guideline. This is probably because the embedded order sets became part of the usual ordering practice to which the staff were already accustomed and helped facilitate communication about the protocol details.
Study Strengths and Limitations This study has several limitations. The total response rate was low at only 38.2%. The low response rate may introduce a bias as nonrespondents may have a different view on the usefulness of these materials. This bias limits the validity of our results. As well, our results revealed that many of the nurses who completed the evaluation had actually not been exposed to many of the educational tools on the questionnaire, making the actual number of responses about each teaching method or bedside written material relatively small. We are not able to link the success or failure of the educational tools with the acceptability of the protocol since we do not know if those nurses who described poor acceptability received adequate education about the protocol. Members of the PIT crews may have chosen to emphasize one tool over another. Two sites received PIT crew training via telephone instead of in person with all the other sites. This may not have been as effective and may have led to poorer implementation of the educational strategies. Finally, the open-ended comments were not well answered by the nurses. Many of the comments were uninterpretable or did not answer the question posed. A strength of this study was the extensive effort made to educate the key leaders at each research site. This included site visits, follow-up conference calls, and the detailed, comprehensive educational materials provided for the PIT crews. Another strength of our study is that it measured the impact of the educational strategies and protocol on the ICU staff. We were unable to find any evaluations of teaching strategies used to implement enteral protocols or algorithms from other centers. Several other reports in the literature describe the effects of new enteral protocols or algorithms on clinical outcomes related to EN delivery and adherence to protocol guidelines, but none mention the educational strategies used to educate their ICU staff.13-16 One study by Reeves et al17 used focus groups to evaluate the strengths and weaknesses of their enteral feeding algorithm, but teaching strategies were not evaluated.
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Conclusions We used a variety of educational tools to instruct a large group of ICU nurses and staff on the PEP uP feeding protocol. Large and small group lecture-style formats were evaluated as useful methodologies. The use of multiple teaching formats, including the self-teaching module, appeared to meet the learning needs of most of the group.
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