Volume-based feeding improves nutritional adequacy in surgical patients

Increasing the Volume of Delivered Enteral Feeds Using a Volume-Based Feeding Protocol in a Neuroscience Intensive Care Unit

BACKGROUND

Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

LOCAL PROBLEM

This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

METHODS

This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members' attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members' attitudes were assessed using a survey before and after the project.

RESULTS

During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

CONCLUSIONS

Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

Quality indicators for hospital burn care: a scoping review

BACKGROUND

Burn treatments are complex, and for this reason, a specialised multidisciplinary approach is recommended. Evaluating the quality of care provided to acute burn patients through quality indicators makes it possible to develop and implement measures aiming at better results. There is a lack of information on which indicators to evaluate care in burn patients. The purpose of this scoping review was to identify a list of quality indicators used to evaluate the quality of hospital care provided to acute burn patients and indicate possible aspects of care that do not have specific indicators in the literature.

METHOD

A comprehensive scoping review (PRISMA-ScR) was conducted in four databases (PubMed, Cochrane Library, Embase, and Lilacs/VHL) between July 25 and 30, 2022 and redone on October 6, 2022. Potentially relevant articles were evaluated for eligibility. General data and the identified quality indicators were collected for each included article. Each indicator was classified as a structure, process, or outcome indicator.

RESULTS

A total of 1548 studies were identified, 82 were included, and their reference lists were searched, adding 19 more publications. Thus, data were collected from 101 studies. This review identified eight structure quality indicators, 72 process indicators, and 19 outcome indicators listed and subdivided according to their objectives.

CONCLUSION

This study obtained a list of quality indicators already used to monitor and evaluate the hospital care of acute burn patients. These indicators may be useful for further research or implementation in quality improvement programs.

TRIAL REGISTRATION

Protocol was registered on the Open Science Framework platform on June 27, 2022 ( https://doi.org/10.17605/OSF.IO/NAW85 ).

Optimizing enteral nutrition delivery by implementing volume-based feeding protocol for critically ill patients: an updated meta-analysis and systematic review

BACKGROUND

This study aims to provide an updated assessment of the efficacy of optimized enteral nutrition (EN) delivery by implementing the volume-based feeding (VBF) protocol in critically ill patients.

METHODS

We updated our previous literature retrieval with no language restrictions. The inclusion criteria were:1) Participants: Critically ill patients (Patients who was admitted in ICU; 2) Intervention: The VBF protocol was adopted for EN administration; 3) Comparison: The rate-based feeding (RBF) protocol was adopted for EN administration; 4) Major outcomes: EN nutrition delivery. The exclusion criteria included participants aged < 18 years, duplicated literature, animal and cellular experiments, and studies lacking any of the outcomes mentioned in the inclusion criteria. The databases included MEDLINE (through PubMed), Web of Science, Cochrane Library, Chinese Biomedical Literature Service System (SinoMed), Wanfang Data Knowledge Service Platform, and China National Knowledge Infrastructure.

RESULT

Sixteen studies involving a total of 2896 critically ill patients are included in the updated meta-analysis. Compared with the previous meta-analysis, nine new studies were added that included 2205 more patients. The VBF protocol significantly improved energy (MD = 15.41%, 95% CI: [10.68, 20.14], p < 0.00001) and protein (MD = 22.05%, 95% CI: [10.89, 33.22], p = 0.0001) delivery. The patients in the VBF group stayed in the ICU for a shorter time (MD = 0.78, 95% CI: [0.01, 1.56], p = 0.05). The VBF protocol did not increase the risk of death (RR = 1.03, 95% CI: [0.85, 1.24], p = 0.76) or prolong the mechanical ventilation duration (MD = 0.81, 95% CI: [-0.30,1.92], p = 0.15). In addition, the VBF protocol did not affect EN complications, such as diarrhea (RR = 0.91, 95% CI: [0.73, 1.15], p = 0.43), emesis (RR = 1.23, 95% CI: [0.76, 1.99], p = 0.41), feeding intolerance (RR = 1.14, 95% CI: [0.63, 2.09], p = 0.66), and gastric retention (RR = 0.45, 95% CI: [0.16, 1.30], p = 0.14).

CONCLUSION

Our study revealed that the VBF protocol significantly improved calorie and protein delivery in critically ill patients with no additional risk.

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.

Forty-Fourth ASPEN Presidential Address: The 2020 Overture-A New Tune for the Future

The provision of safe nutrition care to patients is the fundamental vision of the American Society for Parenteral and Enteral Nutrition (ASPEN). Yet we are facing important challenges in our field and society, requiring us to reflect, rethink, and adjust to make new breakthroughs to meet the needs for the future. In developing new plans to address these challenges, we must focus on 2 critical elements: people and the scientific process. Government and organizations cannot carry on their missions without people. But with the challenges of healthcare finance, biotechnology disruption, the desire to facilitate knowledge transfer and now the impact of the global pandemic, we need to develop a forward-thinking and sustainable approach to connect people and foster continued learning. Burnout is a recognized occupational problem that affects providers and researchers across all disciplines. The coronavirus disease 2019 pandemic has amplified the challenges associated with burnout. Supporting the needs and promoting the well-being of people, therefore, are critical to move forward successfully. At the same time, the scientific advances in our field rely on sound scientific principles and integrity. Information overload, pressure to produce immediate outcomes (such as cost-saving initiatives), and misinformation can compromise the scientific process and research evidence. The two common missteps that affect researchers, clinicians, and administrators include premature factulation and binary thinking. We will discuss how these missteps can occur and the approaches to minimize their influence in making sound decisions and policies to meet the future's needs.

Volume-Based Protocol Improves Delivery of Enteral Nutrition in Critically Ill Trauma Patients

BACKGROUND

Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase delivery of EN over the conventional hourly rate method (CM).

METHODS

This study compared patients on CM to those on VP. The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours, hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube.

RESULTS

We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%, P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM 2.04% vs VP 1.61%; P = .51).

CONCLUSION

Implementation of a VP significantly increased delivery of EN by 8.3% over that given by the CM in critically ill trauma patients with no difference in feeding-related complications.