Use of a Nutrition Support Protocol to Increase Enteral Nutrition Delivery in Critically Ill Patients Friederike Compton, Christian Bojarski, Britta Siegmund and Markus van der Giet Am J Crit Care 2014;23:396-403 doi: 10.4037/ajcc2014140 © 2014 American Association of Critical-Care Nurses Published online http://www.ajcconline.org Personal use only. For copyright permission information: http://ajcc.aacnjournals.org/cgi/external_ref?link_type=PERMISSIONDIRECT
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AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
Nutrition in Critical Care
U
SE OF A
NUTRITION
SUPPORT PROTOCOL TO INCREASE ENTERAL NUTRITION DELIVERY IN CRITICALLY ILL PATIENTS By Friederike Compton, MD, Christian Bojarski, MD, Britta Siegmund, MD, and Markus van der Giet, MD
©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014140
396
Background Early enteral nutrition is recommended for patients in intensive care units, but nutrition provision is often hindered by a variety of unit-specific problems. Objectives To evaluate the impact of a nutrition support protocol on nutrition prescription and delivery in the intensive care unit. Methods Nutrition-related data from 73 patients receiving mechanical ventilation who were treated in an adult medical intensive care unit before introduction of an enteral nutrition support protocol were retrospectively compared with data for 87 patients admitted after implementation of the protocol. Results After implementation of the protocol, enteral nutrition was started significantly earlier (P = .007) and enteral feeding goals were reached significantly faster (6 vs 10 days, P < .001) than before. Prescription of enteral nutrition on the first day of invasive mechanical ventilation increased from 38% before to 54% after (P = .03) implementation of the protocol. Prescribed and delivered nutrition doses on the first 2 days of mechanical ventilation also increased significantly (P < .001) after the protocol was implemented. Nasojejunal feeding tubes were used in 52% of patients before and 56% of patients after protocol implementation P = .63). Jejunal tubes were placed earlier after the protocol was implemented than before (median 5 vs 6.5 days), and when a jejunal tube was in place, feeding goals were reached faster (median 2 vs 3 days, P = .002). Conclusion Implementing an enteral nutrition support protocol shortened the time to reach feeding goals. Jejunal feeding tubes were necessary in more than half of the patients, and with a jejunal feeding tube in place, feeding goals were reached rapidly. (American Journal of Critical Care. 2014;23:396-403)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
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E
nteral nutrition of critically ill patients has become a standard of care in intensive care units (ICUs), and early initiation of enteral feeding is recommended in international guidelines.1-4 Practical nutrition management, however, is often difficult in ICU patients for a variety of reasons, including gastroparesis with regurgitation of undigested feedings.5,6 In patients intolerant of gastric feeding, use of a nasojejunal feeding tube is recommended and can improve nutrient delivery.1-4,7,8 The implementation of structured nutrition support protocols improves nutrition practices, and several protocols published to date include placement of a postpyloric feeding tube but do not specifically report use or influence of this measure on nutrition outcomes.9-13
The adult medical ICU of the Charité Campus Benjamin Franklin university hospital is a 16-bed maximum care facility specializing predominantly in the care of patients with respiratory failure and multiple organ dysfunction. Nutrition support is necessary in a high percentage of patients, and gastric motility disorders frequently require the use of a nasojejunal feeding tube to achieve enteral feeding goals. The enteral nutrition protocol developed therefore focused on early initiation of nutrition and placement of a nasojejunal tube if rapid increase of gastric feedings was not possible. The aim of the present study was to evaluate the impact of this nutrition support protocol on the timing and amount of nutrition prescription and delivery in our ICU.
Methods Study Design and Patient Population Data from patients treated at the Charité Campus Benjamin Franklin university hospital’s adult medical ICU before and after implementation of the protocol in the second half of 2011 were compared retrospectively. The study period before implementation of the nutrition protocol consisted of patients admitted to the ICU between January 1 and June 30, 2011; for comparison, the study period after implementation of the protocol consisted of patients admitted between January 1 and June 30, 2012. The data analyzed were retrieved from the electronic
About the Authors Friederike Compton is director of the intensive care unit and Markus van der Giet is a nephrologist in the Department of Nephrology at Charité University Medicine Berlin, Germany. Christian Bojarski is a gastroenterologist in and Britta Siegmund is the head of the Department of Gastroenterology and Infectious Diseases at Charité University Medicine Berlin. Corresponding author: Dr Friederike Compton, Department of Nephrology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany (e-mail: [email protected]).
www.ajcconline.org
chart system (COPRA 5, Coprasystem GmbH) used in the ICU. All patients receiving invasive mechanical ventilation and treated in the ICU for a minimum of 5 days during the period before or after implementation of the protocol were included in the study. Patients treated with noninvasive ventilatory support only were excluded from the study, as were patients who were able to continue sufficient oral food intake despite mechanical ventilation (eg, patients with a tracheostomy). Additional exclusion criteria were as follows: contraindications to enteral nutrition, patients already on enteral nutrition or transferred from another ICU, and patients in whom enteral nutrition was withheld in the context of palliative care. Nutrition prescription and delivery were evaluated starting when invasive mechanical ventilation was begun in each patient. The study protocol was approved by the local ethics committee, who waived the need for informed consent.
Early initiation of enteral feeding is recommended in international guidelines.
Nutrition Support Protocol Before implementation of the nutrition support protocol, the standard practice in the ICU had been to prescribe nutrition at the discretion of the treating physician, and the provision of feedings had been the responsibility of the nurse taking care of the patient. The new nutrition protocol was developed by a multidisciplinary team consisting of the principal investigator (director of the ICU), consulting gastroenterologists, and several ICU nurses, and it was based on the available guidelines as well as experiences and problems identified with the provision of enteral nutritional support in our ICU.1-4 As gastric feeding had been unsuccessful in a considerable number of our patients, the protocol was focused
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
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397
Hemodynamic stabilization Circulatory shock treated
Parenteral nutrition
No oral nutrition intake possible for more than 24 hours
Yes
Contraindications for enteral nutrition? Acute gastrointestinal bleeding, mechanical ileus, short-bowel syndrome, massive diarrhea, planned surgery, planned endoscopy, postoperative patients (at the discretion of the surgeon) No
Yes
Contraindications for gastric feeding? Acute pancreatitis, severe risk for aspiration, history of aspiration with gastric feeding No Gastric feeding Begin with 50 mL every 3 hours and increase by 50 mL every 3 hours daily until feeding goal is reached (25 kcal/kg) Check gastric aspirate before each bolus
Gastric aspirate > 500 mL Aspirate containing undigested feedings means dose increase is not possible
Endoscopic placement of jejunal feeding tube and jejunal feeding Begin feeding at 25 mL/h, increase daily by 25 mL/h until feeding goal is reached (25 kcal/kg)
Figure Nutrition support protocol.
on early initiation of nutrition and rapid identification of patients who required placement of a nasojejunal feeding tube (see Figure). Indications and contraindications for enteral or gastric nutrition, respectively, were specified as well as timing of nutrition initiation (ie, after initial stabilization), initial dose (50 mL every 3 hours), and daily increase increments (50 mL every 3 hours) of gastric nutrition, including conditions specifying when to withhold gastric feeding (gastric residuals containing undigested feedings or >500 mL before each feeding). When a daily increase in gastric nutri-
398
tion doses was not possible because of contraindications or signs of gastroparesis, endoscopic placement of a nasojejunal feeding tube (Freka-Sil silicone rubber nasointestinal feeding tube, Fresenius Kabi) was performed by using grasping forceps (push-andpull technique) to advance the tube into the proximal jejunum. After verifying correct positioning, jejunal feedings were started at a rate of 25 mL/h and increased by 25 mL/h daily until the feeding goal was reached. The enteral feeding goal was defined as 25 kcal/kg Broca index (weight determined by subtraction of 100 from the height in centimeters). All patients with nasojejunal feeding tubes also received a gastric tube for decompression. The enteral nutrition protocol was introduced in July 2011, and physicians as well as nurses received repeated formal instructions concerning background, implementation, and goals of the new protocol, which was also made available at the bedside through the local electronic quality management handbook and printed instructions. Nasojejunal feeding tubes were placed endoscopically, so the endoscopy department was included in the implementation process, emphasizing the priority of the placement of nasojejunal tubes when requested by the ICU. Standard 1-kcal/mL whole-protein nutrition formula was used in the ICU before and after the implementation of the nutrition support protocol. Supplemental parenteral nutrition was provided until the enteral feeding goal was reached. Definition of Variables Diagnostic categories were summarized from the diagnoses on admission to the ICU. Vasopressor therapy was defined as a continuous infusion of norepinephrine, epinephrine, or high doses of dopamine (>5 µg/kg per minute). Body mass index (calculated as weight in kilograms divided by height in meters squared) and the Broca index (height in centimeters minus 100) were calculated from the estimated height and weight documented in the patients’ charts. Enteral nutrition variables were defined and calculated as follows: The timing of enteral nutrition initiation was calculated from the start of invasive mechanical ventilation (day 1) to the time of the first prescription of enteral nutrition. The time when the enteral nutrition goal was reached was derived from the chart either as an explicit statement by the responsible physician or from the fact that any additional parenteral nutrition was stopped and enteral nutrition was not increased any further. The dose of enteral nutrition delivered at this time was recorded in kilocalories per day and also expressed
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
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Table 1 Characteristics of patients in the study Characteristic
Before implementation
Number of patients
After implementation
P
73
87
Age, mean (SD); median
67.9 (14.1); 70
68.0 (14.4); 70
.93a
Male sex, No. of patients
45 (62)
48 (55)
.43b
24.8 (15.5); 24
23.0 (18.1); 19
.22a
20 (27)
33 (38)
.18b
51.5 (19.3); 51
59.3 (18.1); 60
.009a
55 (64) 8 (11) 15 (17) 15 (18)
.87b .23b .65b .69b
Length of ICU stay, mean (SD); median, days ICU mortality, No. (%) of patients SAPS, mean (SD); median Diagnostic categories, No. (%) of patients Sepsis Pulmonary disease Cardiac arrest Neurological disease
48 12 13 15
(66) (16) (18) (21)
Mechanical ventilation Ventilator days, mean (SD); median Invasive ventilation on admission, No. (%) of patients
20.6 (14.1); 21 70 (96)
17.4 (14.8); 13 82 (94)
.09a .29b
Vasopressor therapy on admission, No. (%) of patients
70 (96)
80 (92)
.29b
Weight, mean (SD); median), kg
80.1 (20.7); 75
85.2 (32.9); 80
.84a
Height, mean (SD); median, cm
172.3 (8.5); 170.5
169.3 (18.1); 172
.58a
26.8 (6.1); 26.0
31.1 (13.7); 26.2
.16a
Body mass
index,c
mean (SD); median
Abbreviations: ICU, intensive care unit; SAPS, Simplified Acute Physiology Score. a Mann-Whitney U test. b χ2 test. c Calculated as weight in kilograms divided by height in meters squared.
in kilocalories per day per kilogram body weight and kilocalories per day per kilogram Broca index. The numbers of patients for whom enteral nutrition was prescribed and delivered on day 1 and 2 were calculated, as well as nutrition doses in kilocalories per hour prescribed and delivered on the first 2 days. In addition, variables related to the placement and operability of a nasojejunal feeding tube were defined and calculated: number of patients receiving a nasojejunal feeding tube, timing of the first nasojejunal feeding tube placement, number of days needed to reach enteral feeding goals after placement of a nasojejunal feeding tube, number of days the first nasojejunal feeding tube was operational, number of patients in whom a jejunal feeding tube had to be removed because of dislocation or malfunction (occlusion or leakage), and, for the patients with a nasojejunal feeding tube, number of nasojejunal tube placements in the course of their ICU stay. Statistical Analysis The data were analyzed by using SPSS statistical software (version 19, SPSS Inc). Results of continuous variables are expressed as mean (standard deviation) and median and were compared by using the nonparametric Mann-Whitney U test (Wilcoxon rank sum test). For categorical variables, the absolute
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numbers and percentages are given, differences were assessed for significance with the χ2 test. A P value less than .05 was considered significant.
Results Patient Characteristics Before and after implementation of the nutrition protocol, 246 and 290 patients were admitted to the ICU, respectively, of whom 107 and 119 received mechanical ventilation and stayed in the ICU for the required 5-day period. Sixteen patients before protocol implementation and 21 patients after implementation were excluded because of contraindications for enteral nutrition (gastrointestinal bleeding, postsurgery, placement of feeding tubes not possible, n = 15), oral food intake (n = 9), noninvasive ventilation only (n = 11), jejunal feeding tube placed before admission (n = 2), or transfer from another ICU (n = 29). The resulting study population consisted of 73 patients before implementation and 87 patients after implementation (Table 1). No significant differences between the 2 groups were found in age, sex, length of ICU stay, ventilator days, height, weight, or body mass index. In almost all patients (96% vs 94%), invasive mechanical ventilation was begun on the day of ICU admission, and almost all patients received vasopressors when
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
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399
Table 2 Enteral nutrition parameters Before implementation
After implementation
P
0.8 (0.8); 1
0.5 (0.6); 0
.007a
Enteral feeding goal reached during stay, No. (%) of patients
54 (74)
64 (74)
>.99b
Time to reach enteral feeding goal, mean (SD); median, days Patients with gastric feeding onlyc Patients with a nasojejunal feeding tubec
11.3 (5.1); 10 9.6 (6.1); 9 12.0 (4.5); 12.5
7.9 (4.2); 6 5.7 (2.8); 5.5 8.8 (4.4); 8
Subscription Information http://ajcc.aacnjournals.org/subscriptions/ Information for authors http://ajcc.aacnjournals.org/misc/ifora.xhtml Submit a manuscript http://www.editorialmanager.com/ajcc Email alerts http://ajcc.aacnjournals.org/subscriptions/etoc.xhtml
AJCC, the American Journal of Critical Care, is the official peer-reviewed research journal of the American Association of Critical-Care Nurses (AACN), published bimonthly by The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Telephone: (800) 899-1712, (949) 362-2050, ext. 532. Fax: (949) 362-2049. Copyright © 2014 by AACN. All rights reserved.
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
Nutrition in Critical Care
U
SE OF A
NUTRITION
SUPPORT PROTOCOL TO INCREASE ENTERAL NUTRITION DELIVERY IN CRITICALLY ILL PATIENTS By Friederike Compton, MD, Christian Bojarski, MD, Britta Siegmund, MD, and Markus van der Giet, MD
©2014 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ajcc2014140
396
Background Early enteral nutrition is recommended for patients in intensive care units, but nutrition provision is often hindered by a variety of unit-specific problems. Objectives To evaluate the impact of a nutrition support protocol on nutrition prescription and delivery in the intensive care unit. Methods Nutrition-related data from 73 patients receiving mechanical ventilation who were treated in an adult medical intensive care unit before introduction of an enteral nutrition support protocol were retrospectively compared with data for 87 patients admitted after implementation of the protocol. Results After implementation of the protocol, enteral nutrition was started significantly earlier (P = .007) and enteral feeding goals were reached significantly faster (6 vs 10 days, P < .001) than before. Prescription of enteral nutrition on the first day of invasive mechanical ventilation increased from 38% before to 54% after (P = .03) implementation of the protocol. Prescribed and delivered nutrition doses on the first 2 days of mechanical ventilation also increased significantly (P < .001) after the protocol was implemented. Nasojejunal feeding tubes were used in 52% of patients before and 56% of patients after protocol implementation P = .63). Jejunal tubes were placed earlier after the protocol was implemented than before (median 5 vs 6.5 days), and when a jejunal tube was in place, feeding goals were reached faster (median 2 vs 3 days, P = .002). Conclusion Implementing an enteral nutrition support protocol shortened the time to reach feeding goals. Jejunal feeding tubes were necessary in more than half of the patients, and with a jejunal feeding tube in place, feeding goals were reached rapidly. (American Journal of Critical Care. 2014;23:396-403)
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
E
nteral nutrition of critically ill patients has become a standard of care in intensive care units (ICUs), and early initiation of enteral feeding is recommended in international guidelines.1-4 Practical nutrition management, however, is often difficult in ICU patients for a variety of reasons, including gastroparesis with regurgitation of undigested feedings.5,6 In patients intolerant of gastric feeding, use of a nasojejunal feeding tube is recommended and can improve nutrient delivery.1-4,7,8 The implementation of structured nutrition support protocols improves nutrition practices, and several protocols published to date include placement of a postpyloric feeding tube but do not specifically report use or influence of this measure on nutrition outcomes.9-13
The adult medical ICU of the Charité Campus Benjamin Franklin university hospital is a 16-bed maximum care facility specializing predominantly in the care of patients with respiratory failure and multiple organ dysfunction. Nutrition support is necessary in a high percentage of patients, and gastric motility disorders frequently require the use of a nasojejunal feeding tube to achieve enteral feeding goals. The enteral nutrition protocol developed therefore focused on early initiation of nutrition and placement of a nasojejunal tube if rapid increase of gastric feedings was not possible. The aim of the present study was to evaluate the impact of this nutrition support protocol on the timing and amount of nutrition prescription and delivery in our ICU.
Methods Study Design and Patient Population Data from patients treated at the Charité Campus Benjamin Franklin university hospital’s adult medical ICU before and after implementation of the protocol in the second half of 2011 were compared retrospectively. The study period before implementation of the nutrition protocol consisted of patients admitted to the ICU between January 1 and June 30, 2011; for comparison, the study period after implementation of the protocol consisted of patients admitted between January 1 and June 30, 2012. The data analyzed were retrieved from the electronic
About the Authors Friederike Compton is director of the intensive care unit and Markus van der Giet is a nephrologist in the Department of Nephrology at Charité University Medicine Berlin, Germany. Christian Bojarski is a gastroenterologist in and Britta Siegmund is the head of the Department of Gastroenterology and Infectious Diseases at Charité University Medicine Berlin. Corresponding author: Dr Friederike Compton, Department of Nephrology, Charité Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany (e-mail: [email protected]).
www.ajcconline.org
chart system (COPRA 5, Coprasystem GmbH) used in the ICU. All patients receiving invasive mechanical ventilation and treated in the ICU for a minimum of 5 days during the period before or after implementation of the protocol were included in the study. Patients treated with noninvasive ventilatory support only were excluded from the study, as were patients who were able to continue sufficient oral food intake despite mechanical ventilation (eg, patients with a tracheostomy). Additional exclusion criteria were as follows: contraindications to enteral nutrition, patients already on enteral nutrition or transferred from another ICU, and patients in whom enteral nutrition was withheld in the context of palliative care. Nutrition prescription and delivery were evaluated starting when invasive mechanical ventilation was begun in each patient. The study protocol was approved by the local ethics committee, who waived the need for informed consent.
Early initiation of enteral feeding is recommended in international guidelines.
Nutrition Support Protocol Before implementation of the nutrition support protocol, the standard practice in the ICU had been to prescribe nutrition at the discretion of the treating physician, and the provision of feedings had been the responsibility of the nurse taking care of the patient. The new nutrition protocol was developed by a multidisciplinary team consisting of the principal investigator (director of the ICU), consulting gastroenterologists, and several ICU nurses, and it was based on the available guidelines as well as experiences and problems identified with the provision of enteral nutritional support in our ICU.1-4 As gastric feeding had been unsuccessful in a considerable number of our patients, the protocol was focused
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
397
Hemodynamic stabilization Circulatory shock treated
Parenteral nutrition
No oral nutrition intake possible for more than 24 hours
Yes
Contraindications for enteral nutrition? Acute gastrointestinal bleeding, mechanical ileus, short-bowel syndrome, massive diarrhea, planned surgery, planned endoscopy, postoperative patients (at the discretion of the surgeon) No
Yes
Contraindications for gastric feeding? Acute pancreatitis, severe risk for aspiration, history of aspiration with gastric feeding No Gastric feeding Begin with 50 mL every 3 hours and increase by 50 mL every 3 hours daily until feeding goal is reached (25 kcal/kg) Check gastric aspirate before each bolus
Gastric aspirate > 500 mL Aspirate containing undigested feedings means dose increase is not possible
Endoscopic placement of jejunal feeding tube and jejunal feeding Begin feeding at 25 mL/h, increase daily by 25 mL/h until feeding goal is reached (25 kcal/kg)
Figure Nutrition support protocol.
on early initiation of nutrition and rapid identification of patients who required placement of a nasojejunal feeding tube (see Figure). Indications and contraindications for enteral or gastric nutrition, respectively, were specified as well as timing of nutrition initiation (ie, after initial stabilization), initial dose (50 mL every 3 hours), and daily increase increments (50 mL every 3 hours) of gastric nutrition, including conditions specifying when to withhold gastric feeding (gastric residuals containing undigested feedings or >500 mL before each feeding). When a daily increase in gastric nutri-
398
tion doses was not possible because of contraindications or signs of gastroparesis, endoscopic placement of a nasojejunal feeding tube (Freka-Sil silicone rubber nasointestinal feeding tube, Fresenius Kabi) was performed by using grasping forceps (push-andpull technique) to advance the tube into the proximal jejunum. After verifying correct positioning, jejunal feedings were started at a rate of 25 mL/h and increased by 25 mL/h daily until the feeding goal was reached. The enteral feeding goal was defined as 25 kcal/kg Broca index (weight determined by subtraction of 100 from the height in centimeters). All patients with nasojejunal feeding tubes also received a gastric tube for decompression. The enteral nutrition protocol was introduced in July 2011, and physicians as well as nurses received repeated formal instructions concerning background, implementation, and goals of the new protocol, which was also made available at the bedside through the local electronic quality management handbook and printed instructions. Nasojejunal feeding tubes were placed endoscopically, so the endoscopy department was included in the implementation process, emphasizing the priority of the placement of nasojejunal tubes when requested by the ICU. Standard 1-kcal/mL whole-protein nutrition formula was used in the ICU before and after the implementation of the nutrition support protocol. Supplemental parenteral nutrition was provided until the enteral feeding goal was reached. Definition of Variables Diagnostic categories were summarized from the diagnoses on admission to the ICU. Vasopressor therapy was defined as a continuous infusion of norepinephrine, epinephrine, or high doses of dopamine (>5 µg/kg per minute). Body mass index (calculated as weight in kilograms divided by height in meters squared) and the Broca index (height in centimeters minus 100) were calculated from the estimated height and weight documented in the patients’ charts. Enteral nutrition variables were defined and calculated as follows: The timing of enteral nutrition initiation was calculated from the start of invasive mechanical ventilation (day 1) to the time of the first prescription of enteral nutrition. The time when the enteral nutrition goal was reached was derived from the chart either as an explicit statement by the responsible physician or from the fact that any additional parenteral nutrition was stopped and enteral nutrition was not increased any further. The dose of enteral nutrition delivered at this time was recorded in kilocalories per day and also expressed
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
www.ajcconline.org
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
Table 1 Characteristics of patients in the study Characteristic
Before implementation
Number of patients
After implementation
P
73
87
Age, mean (SD); median
67.9 (14.1); 70
68.0 (14.4); 70
.93a
Male sex, No. of patients
45 (62)
48 (55)
.43b
24.8 (15.5); 24
23.0 (18.1); 19
.22a
20 (27)
33 (38)
.18b
51.5 (19.3); 51
59.3 (18.1); 60
.009a
55 (64) 8 (11) 15 (17) 15 (18)
.87b .23b .65b .69b
Length of ICU stay, mean (SD); median, days ICU mortality, No. (%) of patients SAPS, mean (SD); median Diagnostic categories, No. (%) of patients Sepsis Pulmonary disease Cardiac arrest Neurological disease
48 12 13 15
(66) (16) (18) (21)
Mechanical ventilation Ventilator days, mean (SD); median Invasive ventilation on admission, No. (%) of patients
20.6 (14.1); 21 70 (96)
17.4 (14.8); 13 82 (94)
.09a .29b
Vasopressor therapy on admission, No. (%) of patients
70 (96)
80 (92)
.29b
Weight, mean (SD); median), kg
80.1 (20.7); 75
85.2 (32.9); 80
.84a
Height, mean (SD); median, cm
172.3 (8.5); 170.5
169.3 (18.1); 172
.58a
26.8 (6.1); 26.0
31.1 (13.7); 26.2
.16a
Body mass
index,c
mean (SD); median
Abbreviations: ICU, intensive care unit; SAPS, Simplified Acute Physiology Score. a Mann-Whitney U test. b χ2 test. c Calculated as weight in kilograms divided by height in meters squared.
in kilocalories per day per kilogram body weight and kilocalories per day per kilogram Broca index. The numbers of patients for whom enteral nutrition was prescribed and delivered on day 1 and 2 were calculated, as well as nutrition doses in kilocalories per hour prescribed and delivered on the first 2 days. In addition, variables related to the placement and operability of a nasojejunal feeding tube were defined and calculated: number of patients receiving a nasojejunal feeding tube, timing of the first nasojejunal feeding tube placement, number of days needed to reach enteral feeding goals after placement of a nasojejunal feeding tube, number of days the first nasojejunal feeding tube was operational, number of patients in whom a jejunal feeding tube had to be removed because of dislocation or malfunction (occlusion or leakage), and, for the patients with a nasojejunal feeding tube, number of nasojejunal tube placements in the course of their ICU stay. Statistical Analysis The data were analyzed by using SPSS statistical software (version 19, SPSS Inc). Results of continuous variables are expressed as mean (standard deviation) and median and were compared by using the nonparametric Mann-Whitney U test (Wilcoxon rank sum test). For categorical variables, the absolute
www.ajcconline.org
numbers and percentages are given, differences were assessed for significance with the χ2 test. A P value less than .05 was considered significant.
Results Patient Characteristics Before and after implementation of the nutrition protocol, 246 and 290 patients were admitted to the ICU, respectively, of whom 107 and 119 received mechanical ventilation and stayed in the ICU for the required 5-day period. Sixteen patients before protocol implementation and 21 patients after implementation were excluded because of contraindications for enteral nutrition (gastrointestinal bleeding, postsurgery, placement of feeding tubes not possible, n = 15), oral food intake (n = 9), noninvasive ventilation only (n = 11), jejunal feeding tube placed before admission (n = 2), or transfer from another ICU (n = 29). The resulting study population consisted of 73 patients before implementation and 87 patients after implementation (Table 1). No significant differences between the 2 groups were found in age, sex, length of ICU stay, ventilator days, height, weight, or body mass index. In almost all patients (96% vs 94%), invasive mechanical ventilation was begun on the day of ICU admission, and almost all patients received vasopressors when
AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2014, Volume 23, No. 5
Downloaded from ajcc.aacnjournals.org at TAUBMAN MEDICAL LIBRARY on October 16, 2014
399
Table 2 Enteral nutrition parameters Before implementation
After implementation
P
0.8 (0.8); 1
0.5 (0.6); 0
.007a
Enteral feeding goal reached during stay, No. (%) of patients
54 (74)
64 (74)
>.99b
Time to reach enteral feeding goal, mean (SD); median, days Patients with gastric feeding onlyc Patients with a nasojejunal feeding tubec
11.3 (5.1); 10 9.6 (6.1); 9 12.0 (4.5); 12.5
7.9 (4.2); 6 5.7 (2.8); 5.5 8.8 (4.4); 8
