Evidence Review
Nutrition Support Protocols and Their Influence on the Delivery of Enteral Nutrition: A Systematic Review Melissa Lottes Stewart, RN, DNP
ABSTRACT Keywords nutrition, malnutrition, critically ill, protocol, feeding, enteral, guidelines, algorithm
Background: Malnutrition remains prevalent in critically ill adults and is associated with poor outcomes and increased cost of hospitalization. Aim: To (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support based on a protocol have better outcomes than those who do not. Methods: CINHAL and PUBMED databases were searched utilizing keywords “model,” “nutrition,” intensive care,” “algorithm,” “critical care,” “protocol,” and “feeding guidelines.” Selection criteria included original studies published in English with publication date between January 1, 2005, and December 31, 2010; a critically ill adult population; and level 1 or 2 studies. Studies were collected and reviewed by a single reviewer. Data extraction and quality assessment were assured utilizing a standardized form. A narrative description of results was provided due to variability in methods and outcome measures of included studies. Results: Ninety-nine studies emerged and 22 studies were considered for inclusion. Four studies were selected. Use of a nutrition support protocol was found to lead to increased efficacy in the delivery of nutrients via the enteral route. Linking Evidence to Action: The use of a nutrition support protocol appears to increase the efficacy of enteral nutrition delivery. Further research is needed to determine the effect of increased enteral nutrition adequacy on patient outcomes. The use of an evidenced-based protocol is recommended to improve protein and energy delivery in the critically ill.
INTRODUCTION Risk for malnutrition at admission and worsening nutritional status during hospitalization have been found to be strongly associated with prolonged length of stay (Caccialanza et al., 2010). The cost of treating a patient with disease-related malnutrition has been estimated at 20% higher than treating a patient without malnutrition (Amaral et al., 2007). Older patients, those with malignant disease, and patients receiving polypharmaceutical interventions have been found to be at increased risk for the development of malnutrition while hospitalized (Pirlich et al., 2005). Internationally, the reported prevalence of malnutrition in hospitalized patients varies from 22% to 43% (Lazarus & Hamlyn, 2005; Pirlich et al., 2005). In a follow-up study of intensive care unit patients, Kvale, Ulvik, and Flaatten (2003) found that 40% of patients included in the study sample lost more than 10 kg of weight during and after intensive care unit admission. Malnutrition remains underreported in the hospital setting (Lazarus & Hamlyn, 2005; Bavelaar, Otter, van Bodegraven, Thijs, & van Bokhorst-de van der Schueren, 2008), preventing patients from receiving appropriate intervention.
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Enteral nutrition delivery is the feeding method of choice in critically ill adult patients due to an increase in infectious complications associated with parenteral nutrition (Bankhead et al., 2009; Gramlich et al., 2004; Heyland, Dhaliwal, Drover, Gramlich, & Dodek, 2003). Administration of enteral nutrition restores intestinal motility, maintains gastrointestinal integrity and function, minimizes translocation of bacteria and other organisms, improves wound healing, and decreases the incidence of infection (Heyland, 1998). The practice of delivering enteral nutrition varies broadly (Heyland, Dhaliwal, Day, Jain, & Drover, 2004), even within a single hospital (Rice, Swope, Bozeman, & Wheeler, 2005). Despite strong evidence that early enteral feeding, within 24– 48 hours of admission, is beneficial to critically ill patients (Artinian, Krayem, & DiGiovine, 2006; Doig, Heighes, Simpson, Sweetman, & Davies, 2009; Khalid, Doshi, & DiGiovine, 2010; Woo et al., 2010), average time to enteral feeding remains high (Cahill, Dhaliwal, Day, Jiang, & Heyland, 2010). Increasing energy and protein intake in critically ill patients has been shown to decrease mortality in certain populations (Alberda et al., 2009). Critically ill patients receiving Worldviews on Evidence-Based Nursing, 2014; 11:3, 194–199. C 2014 Sigma Theta Tau International
Evidence Review enteral feeding are commonly not achieving nutritional targets (Cahill et al., 2010; Petros & Engelmann, 2006; Rice et al., 2005). In an effort to prevent and treat malnutrition in critically ill patients, nutrition support protocols have been developed and implemented to increase the efficacy of nutrient delivery.
Potentially relevant studies identified and screened n = 135
Studies eliminated due to duplication n = 37
PURPOSE OF THIS REVIEW The purpose of this study was to review the evidence on nutrition support protocols and their influence on the delivery of enteral nutrition, and to answer the question, “Should the use of a nutrition support protocol be recommended in the critically ill?” Aims of the review are to (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support directed by a protocol have better outcomes than those who do not.
METHODS Search Strategy CINHAL and PUBMED databases were searched utilizing the terms “model,” “nutrition,” “intensive care,” “algorithm,” “critical care,” “protocol,” and “feeding guidelines,” with filters set to limit results to the adult population and date of publication between January 1, 2005, and December 31, 2010. A total of 136 articles were identified, including 37 duplicates, for a total of 99 unique results. Studies that were not in the English language were excluded. Titles and abstracts of 99 articles were evaluated to determine appropriateness for inclusion. Twenty-two studies were fully examined for inclusion (Figure 1).
Outcomes of Interest Principal outcomes of interest included patient variables, including mortality, length of stay, ventilator-associated pneumonia rates, and aspiration rates. Nutrition delivery outcomes included time to initiation of feeds, time to goal rate, percentage of protein and energy requirements delivered, and time spent without nutrition.
Selection Criteria Inclusion criteria included those studies involving the adult critically ill population and utilization of a nutrition support protocol. Studies that involved an exclusively pediatric population or that did not address the above outcomes of interest were excluded. Studies of any design were evaluated for inclusion. Four studies that were graded as either level 1 or 2 design according to the Strength of Recommendation Taxonomy (SORT) system and that met inclusion criteria were chosen for inclusion.
Methods for Quality Assessment and Data Abstraction A standardized form was used to determine the study eligibility for inclusion. The standardized form contained a series of Worldviews on Evidence-Based Nursing, 2014; 11:3, 194–199. C 2014 Sigma Theta Tau International
Unique studies identified for review of abstract n = 99
Studies reviewed for more detailed analysis n = 22
Studies eliminated n = 77
Studies eliminated n = 18
Studies included in systematic review n=4
Figure 1. Process of studies selected for inclusion in this review.
questions allowing the reviewer to determine eligibility. Information of interest included whether the study addressed the population of interest (critically ill adults), whether the study was a level I or II study as classified by the SORT grading system, and whether the study attempted to evaluate the effect of a nutrition support protocol on either nutrient delivery or patient outcomes. A single reviewer determined the study eligibility. The SORT system was used to grade evidence. The SORT system evaluates the quality, quantity, and consistency of evidence and can be used to evaluate single studies or a body of evidence on a topic. Individual studies can be graded by assigning a numerical value from 1 to 3. Level 1 studies are good quality, patient-oriented studies with a strong design. Systematic reviews or meta-analyses of high-quality consistent evidence, randomized controlled trials (RCTs), and well-designed cohort studies are level 1 studies. Level 2 studies are of limited quality and include lower quality systematic reviews, meta-analyses, RCTs, and cohort studies. Level 3 studies include case studies, opinion, or consensus guidelines (Ebell et al., 2004).
195
Nutrition Support Protocols
Table 1. Studies Examining the Use of a Nutrition Support Protocol
Author and date
Key findings: study Design
N
Sample
Protocol components
protocol versus no protocol
Woien & Bjork, Prospective 2006 cohort
42
Critically ill adults
Mackenzie Prospective et al., 2005 cohort
123
Critically ill, mechanically Early EN (
Nutrition Support Protocols and Their Influence on the Delivery of Enteral Nutrition: A Systematic Review Melissa Lottes Stewart, RN, DNP
ABSTRACT Keywords nutrition, malnutrition, critically ill, protocol, feeding, enteral, guidelines, algorithm
Background: Malnutrition remains prevalent in critically ill adults and is associated with poor outcomes and increased cost of hospitalization. Aim: To (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support based on a protocol have better outcomes than those who do not. Methods: CINHAL and PUBMED databases were searched utilizing keywords “model,” “nutrition,” intensive care,” “algorithm,” “critical care,” “protocol,” and “feeding guidelines.” Selection criteria included original studies published in English with publication date between January 1, 2005, and December 31, 2010; a critically ill adult population; and level 1 or 2 studies. Studies were collected and reviewed by a single reviewer. Data extraction and quality assessment were assured utilizing a standardized form. A narrative description of results was provided due to variability in methods and outcome measures of included studies. Results: Ninety-nine studies emerged and 22 studies were considered for inclusion. Four studies were selected. Use of a nutrition support protocol was found to lead to increased efficacy in the delivery of nutrients via the enteral route. Linking Evidence to Action: The use of a nutrition support protocol appears to increase the efficacy of enteral nutrition delivery. Further research is needed to determine the effect of increased enteral nutrition adequacy on patient outcomes. The use of an evidenced-based protocol is recommended to improve protein and energy delivery in the critically ill.
INTRODUCTION Risk for malnutrition at admission and worsening nutritional status during hospitalization have been found to be strongly associated with prolonged length of stay (Caccialanza et al., 2010). The cost of treating a patient with disease-related malnutrition has been estimated at 20% higher than treating a patient without malnutrition (Amaral et al., 2007). Older patients, those with malignant disease, and patients receiving polypharmaceutical interventions have been found to be at increased risk for the development of malnutrition while hospitalized (Pirlich et al., 2005). Internationally, the reported prevalence of malnutrition in hospitalized patients varies from 22% to 43% (Lazarus & Hamlyn, 2005; Pirlich et al., 2005). In a follow-up study of intensive care unit patients, Kvale, Ulvik, and Flaatten (2003) found that 40% of patients included in the study sample lost more than 10 kg of weight during and after intensive care unit admission. Malnutrition remains underreported in the hospital setting (Lazarus & Hamlyn, 2005; Bavelaar, Otter, van Bodegraven, Thijs, & van Bokhorst-de van der Schueren, 2008), preventing patients from receiving appropriate intervention.
194
Enteral nutrition delivery is the feeding method of choice in critically ill adult patients due to an increase in infectious complications associated with parenteral nutrition (Bankhead et al., 2009; Gramlich et al., 2004; Heyland, Dhaliwal, Drover, Gramlich, & Dodek, 2003). Administration of enteral nutrition restores intestinal motility, maintains gastrointestinal integrity and function, minimizes translocation of bacteria and other organisms, improves wound healing, and decreases the incidence of infection (Heyland, 1998). The practice of delivering enteral nutrition varies broadly (Heyland, Dhaliwal, Day, Jain, & Drover, 2004), even within a single hospital (Rice, Swope, Bozeman, & Wheeler, 2005). Despite strong evidence that early enteral feeding, within 24– 48 hours of admission, is beneficial to critically ill patients (Artinian, Krayem, & DiGiovine, 2006; Doig, Heighes, Simpson, Sweetman, & Davies, 2009; Khalid, Doshi, & DiGiovine, 2010; Woo et al., 2010), average time to enteral feeding remains high (Cahill, Dhaliwal, Day, Jiang, & Heyland, 2010). Increasing energy and protein intake in critically ill patients has been shown to decrease mortality in certain populations (Alberda et al., 2009). Critically ill patients receiving Worldviews on Evidence-Based Nursing, 2014; 11:3, 194–199. C 2014 Sigma Theta Tau International
Evidence Review enteral feeding are commonly not achieving nutritional targets (Cahill et al., 2010; Petros & Engelmann, 2006; Rice et al., 2005). In an effort to prevent and treat malnutrition in critically ill patients, nutrition support protocols have been developed and implemented to increase the efficacy of nutrient delivery.
Potentially relevant studies identified and screened n = 135
Studies eliminated due to duplication n = 37
PURPOSE OF THIS REVIEW The purpose of this study was to review the evidence on nutrition support protocols and their influence on the delivery of enteral nutrition, and to answer the question, “Should the use of a nutrition support protocol be recommended in the critically ill?” Aims of the review are to (a) determine whether implementation of a nutrition support protocol improves delivery of nutrients in critically ill patients, and (b) evaluate whether patients receiving nutrition support directed by a protocol have better outcomes than those who do not.
METHODS Search Strategy CINHAL and PUBMED databases were searched utilizing the terms “model,” “nutrition,” “intensive care,” “algorithm,” “critical care,” “protocol,” and “feeding guidelines,” with filters set to limit results to the adult population and date of publication between January 1, 2005, and December 31, 2010. A total of 136 articles were identified, including 37 duplicates, for a total of 99 unique results. Studies that were not in the English language were excluded. Titles and abstracts of 99 articles were evaluated to determine appropriateness for inclusion. Twenty-two studies were fully examined for inclusion (Figure 1).
Outcomes of Interest Principal outcomes of interest included patient variables, including mortality, length of stay, ventilator-associated pneumonia rates, and aspiration rates. Nutrition delivery outcomes included time to initiation of feeds, time to goal rate, percentage of protein and energy requirements delivered, and time spent without nutrition.
Selection Criteria Inclusion criteria included those studies involving the adult critically ill population and utilization of a nutrition support protocol. Studies that involved an exclusively pediatric population or that did not address the above outcomes of interest were excluded. Studies of any design were evaluated for inclusion. Four studies that were graded as either level 1 or 2 design according to the Strength of Recommendation Taxonomy (SORT) system and that met inclusion criteria were chosen for inclusion.
Methods for Quality Assessment and Data Abstraction A standardized form was used to determine the study eligibility for inclusion. The standardized form contained a series of Worldviews on Evidence-Based Nursing, 2014; 11:3, 194–199. C 2014 Sigma Theta Tau International
Unique studies identified for review of abstract n = 99
Studies reviewed for more detailed analysis n = 22
Studies eliminated n = 77
Studies eliminated n = 18
Studies included in systematic review n=4
Figure 1. Process of studies selected for inclusion in this review.
questions allowing the reviewer to determine eligibility. Information of interest included whether the study addressed the population of interest (critically ill adults), whether the study was a level I or II study as classified by the SORT grading system, and whether the study attempted to evaluate the effect of a nutrition support protocol on either nutrient delivery or patient outcomes. A single reviewer determined the study eligibility. The SORT system was used to grade evidence. The SORT system evaluates the quality, quantity, and consistency of evidence and can be used to evaluate single studies or a body of evidence on a topic. Individual studies can be graded by assigning a numerical value from 1 to 3. Level 1 studies are good quality, patient-oriented studies with a strong design. Systematic reviews or meta-analyses of high-quality consistent evidence, randomized controlled trials (RCTs), and well-designed cohort studies are level 1 studies. Level 2 studies are of limited quality and include lower quality systematic reviews, meta-analyses, RCTs, and cohort studies. Level 3 studies include case studies, opinion, or consensus guidelines (Ebell et al., 2004).
195
Nutrition Support Protocols
Table 1. Studies Examining the Use of a Nutrition Support Protocol
Author and date
Key findings: study Design
N
Sample
Protocol components
protocol versus no protocol
Woien & Bjork, Prospective 2006 cohort
42
Critically ill adults
Mackenzie Prospective et al., 2005 cohort
123
Critically ill, mechanically Early EN (
