Targeted Physician Education Positively Affects Delivery of Nutrition Therapy and Patient Outcomes: Results of a Prospective Clinical Trial

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.

Nutrition and physical activity knowledge, attitudes, and practices of inpatient cirrhosis care providers

BACKGROUND

Hospitalization is a high-risk period for cirrhosis-associated sarcopenia and frailty. This study aimed to measure the knowledge, attitudes, and practice patterns (KAP) of multidisciplinary cirrhosis providers about inhospital nutrition and physical activity care.

METHODS

We conducted an online survey of cirrhosis care providers at a combination of 38 hospitals and healthcare centres in Alberta, Canada. Analysis included descriptive statistics and content analysis.

RESULTS

Three hundred thirty-eight responses were analyzed. Across all providers, nutrition and physical activity knowledge and attitude (KA) scores were higher than practice (P) scores. Physicians had lower nutrition KA ( P = 0.010) and nutrition P ( P < 0.001) scores than nonphysicians. Previous cirrhosis-related nutrition or physical activity education was associated with higher nutrition KA ( P < 0.001), nutrition P ( P = 0.036), and physical activity P scores ( P < 0.001). Over half of the participants reported not providing patients with educational resources for nutrition or physical activity and not carrying out nutrition screening. Participant suggestions to optimize care included enhancing patient and provider education, standardizing screening and intervention processes, increasing patient-centered support, and promoting collaboration within the healthcare team. Eighty percentage of participants were willing to provide patients with resources if these were readily available.

CONCLUSION

While provider knowledge and attitudes about the importance of nutrition and physical activity in hospitalized patients with cirrhosis are reasonable, there is considerable room to optimize the delivery of best practices in this patient population. Optimization will require readily available educational and personnel resources and interdisciplinary collaboration to promote system change.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.

The role of the dietitian in the management of malnutrition in the elderly: A systematic review of current practices

AIM

The prevalence of age-related malnutrition is increasing in almost all Western countries. Because of their expertise, dietitians should have a central role in the management of malnutrition. This review aimed to synthesise the literature on the role of the dietitian in the management of malnutrition in the elderly in comparison with other health professionals.

METHODS

In November 2018, a search of Embase, Medline Ovid, Cinahl Ebscohost, Cochrane Central, Web of Science and Google Scholar was undertaken using 'dietitian', 'elderly' and 'malnutrition' as the main search terms. Qualitative and quantitative empirical research studies that focussed on the role of dietitians as the (main) subject of the study were included. Data extraction and data synthesis were performed by the three authors using a thematic synthesis approach.

RESULTS

Three themes emerged from the coding and synthesis of the 21 included studies. The first theme demonstrates that other health professionals' time for, and knowledge of, screening policies negatively affects the role of the dietitian. The second theme demonstrates that the importance of nutritional care is acknowledged. However, this does not always imply familiarity with dietetics nor does it always mean that other health professionals think involving dietitians is worth the effort. The third theme demonstrates that issues of workload appeared to be especially important in crossing or guarding role boundaries.

CONCLUSIONS

The role of dietitians in managing age-related malnutrition is not always clear and coherent. Therefore, how dietitians shape their role to provide optimal management of malnutrition in the elderly is open to debate.

Survey of nil per os duration of patients admitted to the emergency department due to vomiting

During the acute phase of vomiting, even a small amount of water may not be tolerated by mouth. Early refeeding may cause re-vomiting in patients, whereas late refeeding may result in dehydration and hypoglycemia. Nil per os (NPO) may be generally recommended by primary physicians, but the appropriate NPO duration for these patients is still unclear.The study aimed to identify the ideal NPO duration for patients with acute vomiting.We prospectively recruited patients with vomiting who underwent NPO management and were administered antiemetic agents in the emergency department (ED) and the pediatric ED. The demographics, final diagnosis, clinical manifestations, medical management, NPO duration, and laboratory data were collected and analyzed to identify the ideal NPO durationA total of 304 patients with vomiting who were admitted in the ED were enrolled. The major diagnosis was acute gastroenteritis (AGE) (82.9%), followed by acute gastritis and colitis. Most patients were younger than 6 years (43.8%). Apart from abdominal pain and vomiting, nausea was the most common symptom (93.1%). NPO duration of 4 to 6 hours had the lowest rate of refeeding failure (3.7%) compared to the other NPO durations.For patients with acute vomiting who are admitted to the ED, NPO duration of 4 to 6 hours may be necessary and should be recommended by primary ED physicians.

Full Nutrition or Not?

Enteral nutrition (EN) is widely used in intensive care units around the world, but the optimal dosing strategy during the first week of critical illness is still controversial. Numerous studies in the past decade have provided conflicting recommendations regarding the roles of trophic and permissive/intentional underfeeding strategies. Further complicating effective medical decision making is the widespread, yet unintentional and persistent underdelivery of prescribed energy and protein, in addition to the trend for recommending ever-higher amounts of protein delivery. We postulate that the key to appropriate enteral strategy lies within an accurate and patient-specific assessment. Patients with a baseline high nutrition risk and those with increased nutrition demands, such as those with wounds, surgery, or burns, likely require full nutrition support, in contrast with medical patients, such as those with acute respiratory distress syndrome, who may selectively be appropriate for trophic strategies. In this analysis, we review several key trials for and against full EN in the first week of critical illness, as well as key issues such as the role of autophagy and immunonutrition in enteral dose selection.

Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit

OBJECTIVES

Intensive care unit (ICU) enteral nutrition (EN) can involve frequent feeding interruption (FI). The prevalence, causes, and duration of such interruption were investigated.

METHODS

Reasons for EN FI identified from extensive literature review were prospectively collected in adult mechanically ventilated critically ill patients. Results were reported by descriptive statistics. Baseline and nutritional characteristics between patients who died and those alive at day 60 were compared.

RESULTS

A total of 148 patients receiving ≥1 day of EN for the full 12-day observational period were included in the analysis. About 332 episodes of EN FI were recorded and contributed to 12.8% (4190 hours) of the total 1367 evaluable nutrition days. For each patient, FI occurred for a median of 3 days and the total duration of FI for the entire ICU stay was 24.5 hours. Median energy and protein deficits per patient due to FI for the entire ICU stay were -1780.23 kcal and -100.58 g, respectively. Duration of FI, days with FI, and the amount of energy and protein deficits due to FI were not different between patients who had died and those who were still alive at day 60 (all P > 0.05). About 72% of the total duration of EN FI was due to procedural-related and potentially avoidable causes (primarily human factors), while only about 20% was due to feeding intolerances.

CONCLUSIONS

EN FI occurred primarily due to human factors, which may be minimized by adherence to an evidence-based feeding protocol as determined by a nutrition support team.

Nutrition Support Protocols: Enhancing Delivery of Enteral Nutrition

In critical care, malnutrition has a significant, negative impact on a patient's ability to respond to medical treatment. Enteral nutrition is known to counteract the metabolic changes associated with critical illness that increase the risk for serious complications and poor clinical outcomes. Inadequate delivery of nutrition support and underfeeding persist in intensive care units despite the availability of guidelines and current research for best practice. Recent studies have shown that nutrition support protocols are effective in promoting nutritional goals in a wide variety of intensive care patients. It is essential to find approaches that enhance early delivery of enteral nutrition that meets requirements and supports improved outcomes. Nurses are in a unique position to take an active role in promoting the best nutritional outcomes for their patients by using and evaluating nutrition support protocols.

Hospital Malnutrition Related to Fasting and Underfeeding: Is It an Ethical Issue?

Hospital malnutrition is a relevant clinical issue present in about 50% of patients that is associated with increased morbidity, mortality, and cost of care. Because of the relation of malnutrition with chronic and acute inflammatory processes secondary to disease, nutrition therapy is considered an important medical treatment. However, there is little discussion about the impact of another critical issue related to hospital malnutrition, that is, lack of appropriate food or nutrition therapy given to the patients. Unnecessary fasting practices and the use of inappropriate nutrition prescriptions result in underfeeding that can be a related or direct cause of hospital malnutrition, independent of disease or inflammatory state. Suboptimal prescription of oral, enteral, and parenteral nutrition should be analyzed and discussed from an ethical perspective since this practice has the potential to harm patients. In addition, absence or inadequate provision of nutrition may present barriers for improved patient outcomes and could be prevented by simply recognizing lack of knowledge, skills, or experience in nutrition and entrusting nutrition prescription to interdisciplinary teams with clinicians well prepared in nutrition sciences. This article reviews potential barriers to the prevention or treatment of hospital malnutrition and proposes specific actions that can help clinicians to overcome and implement optimal nutrition not just as medical therapy but also as a basic comfort care that may help patients nutritionally, clinically, physically, and emotionally.

Clinical nutrition in the hepatogastroenterology curriculum

Gastroenterology (GE) used to be considered a subspecialty of internal medicine. Today, GE is generally recognized as a wide-ranging specialty incorporating capacities, such as hepatology, oncology and interventional endoscopy, necessitating GE-expert differentiation. Although the European Board of Gastroenterology and Hepatology has defined specific expertise areas in Advanced endoscopy, hepatology, digestive oncology and clinical nutrition, training for the latter topic is lacking in the current hepatogastroenterology (HGE) curriculum. Given its relevance for HGE practice, and being at the core of gastrointestinal functioning, there is an obvious need for training in nutrition and related issues including the treatment of disease-related malnutrition and obesity and its associated metabolic derangements. This document aims to be a starting point for the integration of nutritional expertise in the HGE curriculum, allowing a central role in the management of malnutrition and obesity. We suggest minimum endpoints for nutritional knowledge and expertise in the standard curriculum and recommend a focus period of training in nutrition issues in order to produce well-trained HGE specialists. This article provides a road map for the organization of such a training program. We would highly welcome the World Gastroenterology Organisation, the European Board of Gastroenterology and Hepatology, the American Gastroenterology Association and other (inter)national Gastroenterology societies support the necessary certifications for this item in the HGE-curriculum.