Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy

Nursing staff adherence to guidelines on nutritional management for critically ill patients with cancer: A service evaluation

BACKGROUND

Critically ill patients with cancer are at high risk of developing malnutrition, negatively affecting their outcome.

AIM

To critically analyse nursing staff's adherence to nutrition management guidelines for critically unwell patients with cancer and identify barriers which prevent this. Two areas of nutrition management were evaluated: early initiation (<48 h from admission) of enteral nutrition (EN) and continuation of EN without interruption.

STUDY DESIGN

A retrospective data analysis was performed on mechanically ventilated adult patients admitted to a single cancer centre. Data from electronic patient records (EPR) were collected. Health care professionals' (HCP) documentation was analysed, and a nursing staff focus group (n = 5) was undertaken.

RESULTS

Sixty-four patient records were included. Early EN was not administered in 67% (n = 43) of cases. The reasons for the three longest interruptions to EN feed were as follows: delays in EN tube insertion, gastric residual volumes (GRVs) less than the recommended feed discontinuation threshold and endotracheal intubation. Four main themes relating to barriers to practice were identified from the focus group data analysis: HCPs' approach towards nutrition management, the patient's physiological condition and stability, multi-disciplinary team (MDT) communication and guidance on nutrition management, and practical issues with patient care.

CONCLUSIONS

Multi-disciplinary communication difficulties, lack of clear guidelines and inadequate awareness of the importance of nutrition for critically ill patients with cancer were barriers identified preventing optimal nutrition management.

RELEVANCE TO CLINICAL PRACTICE

Nursing education is fundamental to help break down the barriers to practice which prevent critically ill patients from receiving optimal nutrition management.

Nurses' decision-making around gastric residual volume measurement in UK adult intensive care: A four-centre survey

BACKGROUND

Despite increasing evidence of the potential inaccuracy and unwarranted practice of regular GRV measurement in critically in adults, this practice persists within the United Kingdom.

AIM

To explore adult intensive care nurses' decision-making around the practice of GRV measurement to guide enteral feeding.

METHODS

A cross-sectional 16 item electronic survey in four adult intensive care units (ICUs) in England and Wales.

RESULTS

Two hundred and seventy-three responses were obtained across four ICUs with acceptable response rates for most [Unit 1 74 /127 = 58.2%; Unit 2 87/129 = 67.4%; Unit 3 77/120 = 64.1%; Unit 4 35/168 = 20.8%]. Most (243/273 (89%) reported measuring GRV 4-6 hourly, with most (223/273 82%) reporting that the main reason was to assess feed tolerance or intolerance and 37/273 (13.5%) saying their unit protocol required it. In terms of factors affecting decision-making, volume obtained was the most important factor, followed by the condition of the patient, with aspirate colour and appearance less important. When asked how they would feel about not measuring GRV routinely, the majority (78.2%) of nurses felt worried (140/273 = 51.2%) or very worried (74/273 = 27%).

CONCLUSIONS

Factors affecting the nurses' decision-making around GRV were based largely on fear of risk (around vomiting and pulmonary aspiration) and compliance with unit protocols.

RELEVANCE TO CLINICAL PRACTICE

Despite increasing evidence suggesting it is unnecessary, nurses' beliefs around the value of this practice persist and it continues to be embedded into unit protocols around feeding.

Enteral nutrition management in critically ill adult patients and its relationship with intensive care unit-acquired muscle weakness: A national cohort study

OBJECTIVE

To assess the incidence and determinants of ICU-acquired muscle weakness (ICUAW) in adult patients with enteral nutrition (EN) during the first 7 days in the ICU and mechanical ventilation for at least 48 hours.

METHODS

A prospective, nationwide, multicentre cohort study in a national ICU network of 80 ICUs. ICU patients receiving invasive mechanical ventilation for at least 48 hours and EN the first 7 days of their ICU stay were included. The primary outcome was incidence of ICUAW. The secondary outcome was analysed, during days 3-7 of ICU stay, the relationship between demographic and clinical data to contribute to the onset of ICUAW, identify whether energy and protein intake can contribute independently to the onset of ICUAW and degree of compliance guidelines for EN.

RESULTS

319 patients were studied from 69 ICUs in our country. The incidence of ICUAW was 153/222 (68.9%; 95% CI [62.5%-74.7%]). Patients without ICUAW showed higher levels of active mobility (p = 0.018). The logistic regression analysis showed no effect on energy or protein intake on the onset of ICUAW. Overfeeding was observed on a significant proportion of patient-days, while more overfeeding (as per US guidelines) was found among patients with obesity than those without (42.9% vs 12.5%; p<0.001). Protein intake was deficient (as per US/European guidelines) during ICU days 3-7.

CONCLUSIONS

The incidence of ICUAW was high in this patient cohort. Early mobility was associated with a lower incidence of ICUAW. Significant overfeeding and deficient protein intake were observed. However, energy and protein intake alone were insufficient to explain ICUAW onset.

RELEVANCE TO CLINICAL PRACTICE

Low mobility, high incidence of ICUAW and low protein intake suggest the need to train, update and involve ICU professionals in nutritional care and the need for early mobilization of ICU patients.

Prevalence, Risk Factors and Impact of Nutrition Interruptions in Critically Ill Children

Background: Enteral nutrition interruptions (ENI) are prevalent in the pediatric intensive care unit (PICU), but there is little evidence of their characteristics. Methods: This is a cross-sectional multicenter study including critically ill children on enteral nutrition. ENIs were classified as PICU procedures, procedures performed outside the PICU (PPOP), feeding intolerance and other criteria. The number and features of ENIs were collected. Results: A total of 75 children were enrolled. There were 41 interruptions affecting 37.3% of the patients with a median duration of 5 ± 9.4 h. The most common reason for ENI was PPOP (41.5%), followed by other criteria. Interruptions were considered preventable in 24.4% of the cases, but only eight were compensated. ENIs were more prevalent among children with cardiac disease (p = 0.047), higher PRISM (p = 0.047) and longer PICU stay (p = 0.035). There was association between PRISM and total interruption time (p = 0.02) and lower caloric intake (p = 0.035). Patients with respiratory illness (p = 0.022) and on noninvasive ventilation (p = 0,028) had fewer ENIs. ENI total time was associated with lower caloric (p = 0.001) and protein (p = 0.02) intake. Conclusions: ENIs are prevalent in PICU, especially in children with higher PRISM, longer PICU stays and cardiac disease, and result in lower caloric and protein intake.

When is enteral nutrition indicated?

Enteral nutrition (EN) is a vital component of nutrition around the world. EN allows for delivery of nutrients to those who cannot maintain adequate nutrition by oral intake alone. Common questions regarding EN are when to initiate and in what scenarios it is safe. The answers to these questions are often complex and require an evidence-based approach. The Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) established an Enteral Nutrition Committtee to address the important questions surrounding the indications for EN. Consensus recommendations were established based on eight extremely clinically relevant questions regarding EN indications as deemed by the Enteral Nutrition Committee. These consensus recommendations may act as a guide for clinicians and stakeholders on difficult questions pertaining to indications for EN. This paper was approved by the ASPEN Board of Directors.

Improving nutrition practices for postoperative high-risk heart transplant and ventricular assist device implant patients in circulatory compromise: A quality improvement pre- and post-protocol intervention outcome study

BACKGROUND

Patients undergoing heart transplant (HT) and ventricular assist device (VAD) implant may experience intra- and postoperative complications requiring high-dose vasopressor agents and/or mechanical circulatory support. These complications increase the risk of nonocclusive bowel ischemia (NOBI) and inadequate enteral nutrition (EN) delivery, and guidance for this high-risk patient population is limited. To optimize nutrition support practices in this patient population at our institution, we created the High-Risk Nutrition Support Protocol (HRNSP) to improve nutrient delivery and promote safer EN practices in the setting of NOBI risk factors after HT and VAD implant.

METHODS

We developed and implemented a nutrition support protocol as a quality improvement (QI) initiative. Data were obtained before (n = 62) and after (n = 52) protocol initiation. We compared nutrition and clinical outcomes between the pre- and post-intervention groups.

RESULTS

Fewer calorie deficits (P < 0.001), fewer protein deficits (P < 0.001), a greater proportion of calorie/protein needs met (P < 0.001), zero NOBI cases (0%), and decreased intensive care unit (ICU) length of stay (LOS) (P = 0.005) were observed with 100% (n = 52 of 54) HRNSP implementation success. Increased use of parenteral nutrition did not increase central line-associated bloodstream infections (P = 0.46). There was no difference in hospital LOS (P = 0.44) or 90-day and 1-year mortality (P = 0.56, P = 0.35).

CONCLUSION

This single-center, QI pre- and post-protocol intervention outcome study suggests that implementing and adhering to a nutrition support protocol for VAD implant/HT patients with hemodynamic complications increases nutrient delivery and is associated with reduced ICU LOS and NOBI.

Malnutrition and Pressure Injury Risk in Vulnerable Populations: Application of the 2019 International Clinical Practice Guideline

ABSTRACT

Nutrition plays a vital role in promoting skin integrity and supporting tissue repair in the presence of chronic wounds such as pressure injuries (PIs). Individuals who are malnourished are at greater risk of polymorbid conditions, adverse clinical outcomes, longer hospital lengths of stay, PI development, and mortality, and incur increased healthcare costs compared with patients who are adequately nourished. In addition, some patient populations tend to be more vulnerable to PI formation, such as neonates, patients with obesity, older adults, and individuals who are critically ill. Accordingly, this article aims to review the latest nutrition care recommendations for the prevention and treatment of PIs, including those recommendations tailored to special populations. A secondary objective is to translate nutrition recommendations into actionable steps for the healthcare professional to implement as part of a patient plan of care.Implementing an evidence-based plan of care built around individualized nutrition interventions is an essential step supporting skin integrity for these populations. The 2019 Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline (CPG) affirms that meeting nutrient requirements is essential for growth, development, maintenance, and repair of body tissues. Many macronutrients and micronutrients work synergistically to heal PIs. Registered dietitian nutritionists play an important role in helping patients identify the most nutrient dense foods, protein supplements, and oral nutrition supplements to meet their unique requirements.

Systematic review of clinicians' knowledge, attitudes, and beliefs about nutrition in intensive care

Nutrition is a key component of care for critically ill patients; yet nutrition delivery is below international recommendations. In order to improve nutrition delivery to critically ill patients, an understanding of the barriers that prevent guideline adherence is required. It is known that clinicians' knowledge, attitudes, and beliefs of the role of nutrition may act as a potential barrier to nutrition delivery, but whether this remains true in critical care is unknown. The aim of this systematic scoping review was to summarize the literature exploring the knowledge, attitudes, and beliefs of clinicians around nutrition support in critically ill patients. A search of four online databases (MEDLINE via Ovid, Emcare via Ovid, PsycINFO, and CINAHL via EBSCOhost) was conducted on August 14, 2020, to identify literature that reported on clinicians' knowledge, attitudes, and beliefs of nutrition in adult intensive care patients. Data were extracted on study and participant characteristics, methodology, and key study outcomes related to nutrition. Eighteen articles met eligibility criteria and were included in the review. Key findings included the following: nutrition was seen as a priority that ranked below life-saving interventions; differences in perceived clinician responsibilities exist; common barriers to nutrition delivery included inadequate resourcing, lack of nutrition protocols, and gastrointestinal intolerance; and identified facilitators included nutrition education and the presence of a supportive multidisciplinary team. The implementation of nutrition protocols, enhanced clinical nutrition education, and further clarification of roles and responsibilities pertaining to nutrition may assist in improving nutrition delivery in critical care.

Prevalence of malnutrition risk and its association with mortality: nutritionDay Latin America survey results

BACKGROUND & AIMS

Across the globe, the prevalence of hospital malnutrition varies greatly depending on the population served and on local socioeconomic conditions. While malnutrition is widely recognized to worsen patient outcomes and add financial burdens to healthcare systems, recent data on hospital malnutrition in Latin America are limited. Our study objectives were: (1) to quantify the prevalence of malnutrition risk in Latin American hospital wards, and (2) to explore associations between nutritional risk status, in-hospital food intake, and health outcomes.

METHODS

On nutritionDay (nDay), a specific day every year, hospital wards worldwide can participate in a one-day, cross-sectional audit. We analyzed nDay data collected in ten Latin American countries from 2009 to 2015, including demographic and nutrition-related findings for adult patients (≥18 years) from 582 hospital wards/units. Based on patient-reported responses to questions related to the Malnutrition Screening Tool, we determined the prevalence of malnutrition risk (MST score ≥2). We also summarized patient-reported food intake on nDay, and we analyzed staff-collected outcome data at 30 days post-nDay.

RESULTS

The prevalence of malnutrition risk in the Latin American nDay study population (N = 14,515) was 39.6%. More than 50% of studied patients ate one-half or less of their hospital meal, ate less than normal in the week before nDay, or experienced weight loss in the prior three months. The hospital-mortality hazard ratio was 3.63 (95% CI [2.71, 4.88]; P < 0.001) for patients eating one-quarter of their meal (compared with those who ate the full meal), increasing to 6.6 (95% CI [5.02, 8.7]; P < 0.0001) for patients who ate none of the food offered.

CONCLUSIONS

Based on compilation of nDay surveys throughout Latin America, 2 of every 5 hospitalized patients were at risk for malnutrition. The associated risk for hospital mortality was up to 6-fold higher among patients who ate little or none of their meal on nDay. This high prevalence showed scant improvement over rates two decades ago-a compelling rationale for new focus on nutrition education and training of professionals in acute care settings.

SAPS 3 in the modified NUTrition RIsk in the Critically ill score has comparable predictive accuracy to APACHE II as a severity marker

Objetivo

Avaliar o Simplified Acute Physiology Score 3 (SAPS 3) como substituto do Acute Physiology and Chronic Health Evaluation II (APACHE II) como marcador de gravidade na versão modificada do escore NUTrition RIsk in the Critically ill (mNUTRIC; sem interleucina 6), com base em uma análise de sua capacidade discriminativa para predição de mortalidade hospitalar.

Métodos

Este estudo de coorte retrospectiva avaliou 1.516 pacientes adultos internados em uma unidade de terapia intensiva de um hospital geral privado entre abril de 2017 e janeiro de 2018. A avaliação de desempenho incluiu as análises Kappa de Fleiss e correlação de Pearson. A capacidade discriminativa para estimar a mortalidade hospitalar foi avaliada com a curva Característica de Operação do Receptor.

Resultados

A amostra foi dividida aleatoriamente em dois terços para o desenvolvimento do modelo (n = 1.025; idade 72 [57 - 83]; 52,4% masculino) e um terço para avaliação do desempenho (n = 490; idade 72 [57 - 83]; 50,8 % masculino). A concordância com o mNUTRIC foi Kappa de 0,563 (p < 0,001), e a correlação entre os instrumentos foi correlação de Pearson de 0,804 (p < 0,001). A ferramenta mostrou bom desempenho para prever a mortalidade hospitalar (área sob a curva de 0,825 [0,787 - 0,863] p < 0,001).

Conclusão

A substituição do APACHE II pelo SAPS 3 como marcador de gravidade no escore mNUTRIC mostrou bom desempenho para predizer a mortalidade hospitalar. Esses dados fornecem a primeira evidência sobre a validade da substituição do APACHE II pelo SAPS 3 no mNUTRIC como marcador de gravidade. São necessários estudos multicêntricos e análises adicionais dos parâmetros de adequação nutricional.

Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey

Background and Aim

According to previously reported studies in the literature, a significant number of patients do not receive enteral nutrition in pediatric intensive care unit (PICU) because of avoidable barriers. Optimal nutrition is a fundamental goal in PICU. This study aims to identify the barriers of enteral nutrition in PICU.

Setting and Design

A cross-sectional study of the results of a 25-item questionnaire-based survey distributed during the Annual International Critical Care Conference by the Saudi Critical Care Society.

Methods and material

A 7-point Likert-type scale was used to rank the participants’ responses, and the relative importance index (RII) approach was used to analyze the relative contribution of each indicator to its main theme.

The factor and parallel analysis methods were used to assess the factorial and unidimensionality of the enteral feeding barriers scale.

Results

A total of 223 PICU healthcare workers from various intensive care settings responded to the survey. The top-three perceived barriers for commencing enteral feeding were due to the patient being hemodynamically unstable (M = 3.6 and SD = 1.70), delays and difficulties in obtaining small bowel access in patients not tolerating other types of enteral nutrition (M = 3.4 and SD = 1.52), or severe fluid restriction, particularly in postoperative cardiac surgery (M = 3.3 and SD = 1.59). The top perceived overall barriers to enteral feeding were the dietician-related issues (M = 3.3, SD = 1.32), barriers related to enteral feeding delivery (M = 3.16 and SD = 1.13), and medical practice-related (M = 3 and SD = 1.10) issues. The lowest reported overall barriers were the resource-related obstacles (M = 2.7 and SD = 1.26).

Conclusion

Being hemodynamically unstable and other dietician-related reasons were the top overall barriers in commencing enteral feeding.

Comparison of Modified NUTRIC, NRS-2002, and MUST Scores in Iranian Critically Ill Patients Admitted to Intensive Care Units: A Prospective Cohort Study

BACKGROUND

There are no data on the validity of the modified Nutrition Risk in the Critically Ill (m-NUTRIC)-score and Nutritional Risk Screening 2002 (NRS-2002)-score in Iranian intensive care unit (ICU) patients. The Malnutrition Universal Screening Tool (MUST) is still used in most Iranian ICUs. Our goal was to test the validity of these tools in the Iranian ICU population.

METHODS

The association between nutrition risk scores and outcomes (longer length of stay [LOS], prolonged mechanical ventilation [MV], and 28-day mortality) was assessed using the multivariable logistic regression. The performance of nutrition risk tools to predict 28-day mortality was assessed using the receiver operating characteristic curve. A logistic regression model was used to test the interaction between nutrition risk category, energy adequacy, and 28-day mortality.

RESULTS

Four hundred forty patients were included. Both the m-NUTRIC and NRS-2002 scores were significantly associated with all 3 outcomes (all P < .001). However, no significant association was identified between the MUST and all 3 outcomes (P > .05). The area under the curve for predicting 28-day mortality was 0.806 (95% CI, 0.756-0.851), 0.695 (95% CI, 0.632-0.752), and 0.551 (95% CI, 0.483-0.612) for m-NUTRIC, NRS-2002, and MUST, respectively. Greater energy adequacy was associated with a lower 28-day mortality rate in patients with high m-NUTRIC but not in those with low m-NUTRIC score (P interaction = .015).

CONCLUSION

In the Iranian ICU population, the m-NUTRIC score may be a valid tool for identifying patients who would benefit from more aggressive nutrition therapy.

Impact of enteral nutrition interruptions on underfeeding in intensive care unit

BACKGROUND & AIMS

Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care.

METHODS

This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available.

RESULTS

In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001).

CONCLUSIONS

The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.

Orogastric intubation with dental fixation for enteral nutrition: a proof-of-concept study

In this crossover trial, we evaluated a new technique for enteral nutrition using orogastric intubation. Twelve volunteers were randomly assigned to both orogastric (OGI) and conventional nasogastric intubation (NGI) with a 15-day interval. The tip of the orogastric tube was fixed intraorally into an upper molar. Participants were asked to remain intubated for 24 hours and rated efficacy and safety using a Likert scale (1: worst / 10: best). Tolerance in hours was longer during OGI (median 21 versus 12.5; p=0.022). OGI was superior in comfort (median 7 versus 3; p=0.002), aesthetic (median 10 versus 1; p=0.002), speech (median 5.5 versus 3; p=0.014) and swallowing (median 8 versus 2; p=0.004). Both procedures were tolerated with mild local complaints. Diet volume through the tube was greater during NGI (p = 0.014). In healthy participants, orogastric intubation with dental fixation showed greater efficacy and similar safety to nasogastric intubation. CLINICAL TRIALS NUMBER: NCT03670238.

Effect of early enteral nutrition on outcomes of trauma patients requiring intensive care

PURPOSE

To investigate the effect of early enteral nutrition on outcomes of trauma patients in the intensive care unit (ICU).

METHODS

Clinical data of trauma patients in the ICU of Daping Hospital, China from January 2012 to December 2017 was retrospectively analyzed, including patient age, gender, injury mechanism, injury severity score (ISS), nutritional treatment, postoperative complications (wound infection, abdominal abscess, anastomotic rupture, pneumonia), mortality, and adverse events (nausea, vomiting, abdominal distention). Only adult trauma patients who developed bloodstream infection after surgery for damage control were included. Patients were divided into early enteral nutrition group (<48 h) and delayed enteral nutrition group (control group, >48 h). Data of all trauma patients were collected by the same investigator. Data were expressed as frequency (percentage), mean ± standard deviation (normal distribution), or median (Q₁, Q₃) (non-normal distribution) and analyzed by Chi-square test, Student's t-test, or rank-sum test accordingly. Multiple logistic regression analysis was further adopted to investigate the significant variables with enteral nutrition.

RESULTS

Altogether 876 patients were assessed and 110 were eligible for this study, including 93 males and 17 females, with the mean age of (50.0 ± 15.4) years. Traffic accidents (46 cases, 41.8%) and fall from height (31 cases, 28.2%) were the dominant injury mechanism. There were 68 cases in the early enteral nutrition group and 42 cases in the control group. Comparison of general variables between early enteral nutrition group and control group revealed significant difference regarding surgeries of enterectomy (1.5% vs. 19.0%, p = 0.01), ileum/transverse colon/sigmoid colostomy (4.4% vs. 16.3%, p = 0.01) and operation time (h) (3.2 (1.9, 6.1) vs. 4.2 (1.8, 8.8), p = 0.02). Other variables like ISS (p = 0.31), acute physiology and chronic health evaluation≥20 (p = 0.79), etc. had no obvious difference. Chi-square test showed a much better result in early enteral nutrition group than in control group regarding morality (0 vs. 11.9%, p = 0.03), length of hospital stay (days) (76.8 ± 41.4 vs. 81.4 ± 44.7, p = 0.01) and wound infection (10.3% vs. 26.2%, p = 0.03). Logistic regression analysis showed that the incidence of wound infection was related to the duration required to achieve the enteral nutrition standard (OR = 1.095, p = 0.002). Seventy-six patients (69.1%) achieved the nutritional goal within a week and 105 patients (95.5%) in the end. Trauma patients unable to reach the enteral nutrition target within one week were often combined with abdominal infection, peritonitis, bowel resection, intestinal necrosis, intestinal fistula, or septic shock.

CONCLUSION

Early enteral nutrition for trauma patients in the ICU is correlated with less wound infection, lower mortality, and shorter hospital stay.

Effects of abdominal massage on gastrointestinal function in ICU patients: a meta-analysis

Objective

To evaluate the effects of abdominal massage on gastrointestinal function in the intensive care unit (ICU) patients.

Methods

Randomized controlled trials about the effects of abdominal massage on gastrointestinal function in ICU patients were included from multiple electronic databases: PubMed, Web of Science, the Cochrane Library, Embase, CINAHL, China Academic Journals Full-Text Database (CNKI), Wanfang Database, and CQVIP, until November 2018. Studies were selected according to inclusion and exclusion criteria, extracting data and assessing. Data were analyzed by RevMan 5.3.

Results

Nine studies with 720 patients were included. The results of meta-analysis in the intervention group were as follows: abdomen circumference: mean difference (MD)=-4.22, 95% confidence interval (CI)=(-6.20, -2.24), P<0.00001; abdominal distension: MD=0.34, 95% CI=(0.22, 0.52), P<0.00001; gastric residual: MD=-41.51, 95% CI=(-55.86, -29.15), P=0.001; gastric retention: MD=-0.23, 95% CI (-0.30, -0.15), P<0.00001; and vomiting: MD=0.12, 95% CI=(0.04, 0.35), P=0.0001.

Conclusions

Abdominal massage is effective in reducing abdominal distension, gastric residual, and vomiting. When the intervention period was <7 days, abdominal massage could not reduce the abdominal circumference in ICU patients, and when the intervention period was equal to 7 days, abdominal massage could reduce the abdominal circumference in ICU patients.

Optimizing Nutrition Care for Pressure Injuries in Hospitalized Patients

Significance: It is estimated that up to 50% of hospitalized patients are malnourished. Malnutrition can lead to longer hospital stays, altered immune function, and impaired skin integrity and wound healing. Malnutrition has been found to be a significant factor influencing pressure injury (PI) risk and wound healing. While PI prevention requires multidimensional complex care using a variety of evidence-based strategies, hospitalized patients benefit from interventions that focus on improving oral nutrition to reduce PI risk and enhance wound healing. Unfortunately, malnutrition is often under-recognized and inadequately managed in hospitalized patients and this can lead to higher rates of complications such as PI. Recent Advances: Recent studies suggest that nutritional care has a major impact in PI prevention and management. Strategies, including early identification and management of malnutrition and provision of specially-formulated oral nutritional interventions to at-risk patients, optimization of electronic health record systems to allow for enhanced administration, monitoring, and evaluation of nutritional therapies, and implementation of protocol-based computerized decision support systems, have been reported to improve outcomes. Critical Issues: Unfortunately, there are gaps in the implementation of nutritional care in hospitals. Timely identification and management of malnutrition is needed to advance quality care for hospitalized patients and reduce malnutrition and associated PI. Future Directions: Further research on effective, evidence-based strategies for implementation of all stages of the nutrition care process is needed to reduce pressure injuries and malnutrition in hospitalized patients.

Effect of Registered Dietitian Nutritionist Order-Writing Privileges on Enteral Nutrition Administration in Selected Intensive Care Units

BACKGROUND

Adequate nutrition is linked to improved patient outcomes during critical illness. Nutrition care is further enhanced by registered dietitian nutritionist (RDN) order-writing privileges, which improve the implementation of nutrition interventions. The purpose of this performance improvement project was to evaluate the effect of RDN order-writing privileges on enteral nutrition (EN) order compliance and nutrition delivery in selected intensive care units (ICUs) at a university-affiliated teaching hospital.

METHODS

Patients admitted to selected ICUs from January 23, 2018, to January 25, 2018, were screened for eligibility. Demographic and nutrition data were collected retrospectively from the electronic health record. Percent of energy and protein needs met were calculated. Data were compared with historical internal controls identified prior to RDN order-writing privileges.

RESULTS

Fifty adult patients (150 EN days) were included in data analysis, with 93 patients (279 EN days) included in historical data. Compared with historical data, cumulative EN order compliance increased by 17% and tube feed infusion rate compliance by 15% post-RDN order-writing privileges. Mean (± SD) protein needs delivered significantly increased from 72.1 ± 28.6% to 89.1 ± 24.8% after RDN order-writing implementation (P < 0.001).

CONCLUSIONS

RDN order-writing privileges improved EN order compliance and significantly improved protein delivery in selected ICUs. Future studies are recommended to confirm these results and determine if other variables besides protein delivery are statistically significant with a larger sample size.

Nutritional Risk Screening 2002 Cut-Off to Identify High-Risk Is a Good Predictor of ICU Mortality in Critically Ill Patients

BACKGROUND

The Nutritional Risk Screening 2002 (NRS-2002) is a widely recommended nutrition risk indicator. Two cut-offs have been proposed for intensive care unit (ICU) patients to classify nutrition risk: ≥3-<5, at risk and ≥5, high risk. To date, no study has directly compared these cut-offs. The aim of this study is to compare the NRS-2002 ICU nutrition risk cut-offs as predictors of clinical outcomes including infections, ICU and hospital mortality, length of stay (LOS), duration of mechanical ventilation (MVd), weaning failure, tracheotomy for prolonged MVd, and chronic critical illness (CCI).

METHODS

Adult patients were screened and stratified according to NRS-2002 ICU criteria. Clinical, epidemiologic, and nutrition data were extracted from medical records. Statistical analysis for independent samples and Poisson regression were performed.

RESULTS

A total of 185 patients were screened: 1 (0.54%) no risk; 96 (51.89%) at risk, and 88 (47.56%) high risk. High-risk patients were older, had higher Simplified Acute Physiology Score 3 (62.0 ± 14.1 vs 53.0 ± 12.9, respectively; P < .001) and Sequential Organ Failure Assessment (6.9 ± 3.7 vs 5.1 ± 3.1, respectively; P < .001), and developed more infections (42 [47.8%] vs 27 [28.1%]; P = .010). No differences were found for ICU and hospital LOS, MVd days, weaning failure, tracheotomy, and CCI. ICU and hospital mortality were higher in high-risk patients. The high-risk cut-off was predictor of ICU mortality (relative risk 2.10, 95% confidence interval 1.07-4.14; P = .032).

CONCLUSION

Our data suggest that the NRS-2002 high-risk cut-off is associated with worse clinical outcomes and is a predictor for ICU mortality.

Studying the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units

Background

The main problem of hospitalized patients in intensive care units is feeding, and if the patient does not receive the daily caloric intake required to his body, he will have malnutrition and problems related to it. Abdominal massage is a method used to improve digestive function in various studies, but few studies have been conducted in intensive care units, and sometimes, contradictory results have been obtained. Therefore, the present study is conducted with the aim of determining the effect of abdominal massage on the gastric residual volume in patients hospitalized in intensive care units.

Methods

This study was conducted as a clinical trial in Ahwaz, in 2017. Samples were 60 patients hospitalized in intensive care units who were randomly divided into case and control groups. The intervention period for the case group was 3 days and twice daily for 20 min. Measuring the gastric residual volume was investigated before the intervention and 1 hour after the second massage each day. Data were entered into the checklist designed by the researcher and were analyzed using SPSS version 24 and descriptive and inferential tests.

Results

The gastric residual volume on the second and third day after the intervention was less than before the intervention (p value< 0.05), the gastric residual volume before intervention with after intervention in the control group during different days, on each of the 3 days after the intervention, was more than before the intervention (p value< 0.05), and the gastric residual volume after the intervention in different days and the mean of different days in the case group was lower than the control group (p value> 0.05).

Conclusion

Results represent the effect of abdominal massage on reducing the gastric residual volume in patients hospitalized in intensive care units. Therefore, it is suggested that this method can be considered as a caring method in the daily care program for these patients.

Trial registration

IRCT2017062134641N2, registered 26 July 2017.