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Andersen S, Fichera R, Banks M, Brown T, Kennedy G, Weber N, Williams D, Bauer J. Proactive enteral nutrition for patients undergoing allogeneic stem cell transplantation- implementation and clinical outcomes. Eur J Clin Nutr 2024; 78:251-256. [PMID: 37968417 DOI: 10.1038/s41430-023-01367-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 10/21/2023] [Accepted: 10/30/2023] [Indexed: 11/17/2023]
Abstract
BACKGROUND/ OBJECTIVES Nutrition support is frequently required post allogeneic haematopoietic progenitor cell transplantation (HPCT) however the tolerance of enteral nutrition (EN) can vary. This mixed methods study aimed to explore staff perceptions, barriers and enablers to the use of EN post HPCT and report the implementation and outcomes of a nutrition protocol. SUBJECT/ METHODS A survey on barriers and enablers to the use of EN was developed and distributed to medical and nursing staff. Data on nutrition and clinical outcomes was collected for 12 months post implementation of a new nutrition protocol. RESULTS Thirty staff completed the survey, key barriers identified included uncertain EN tolerance, lack of confidence in nasogastric tube placement and insufficient training and resources. Eighty-four patients commenced EN, 23 changed to PN (27%) and 61 received EN only (73%). In total 36 patients received PN and eight patients oral nutrition support only. There was a difference in type of conditioning (p = 0.025) and nutritional status (p = 0.016) between patients who received PN vs EN only, with a higher proportion of malnourished patients receiving PN (23% vs 5%). Patients who received PN had a longer length of hospital stay (median 22 vs 19 days, p = 0.012) and lower rate of survival to day 100 (81% vs 95%, p = 0.036) than patients who received EN. CONCLUSION The use of EN may lead to improved clinical outcomes compared to PN therefore should be implemented as first line nutrition support.
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Affiliation(s)
- Sarah Andersen
- School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, QLD, 4072, Australia.
- Department of Dietetics and Foodservices, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia.
| | - Rebecca Fichera
- Department of Dietetics and Foodservices, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Merrilyn Banks
- School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, QLD, 4072, Australia
- Department of Dietetics and Foodservices, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Teresa Brown
- School of Human Movement and Nutrition Sciences, University of Queensland, St Lucia, QLD, 4072, Australia
- Department of Dietetics and Foodservices, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Glen Kennedy
- Department of Clinical Haematology, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Nicholas Weber
- Department of Clinical Haematology, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - David Williams
- Department of Clinical Haematology, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4029, Australia
| | - Judy Bauer
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, VIC, 3168, Australia
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Zaher S, Sumairi FA, Ajabnoor SM. Understanding nursing perspective towards barriers to the optimal delivery of enteral nutrition in intensive care settings. BMC Nurs 2024; 23:42. [PMID: 38221619 PMCID: PMC10789044 DOI: 10.1186/s12912-024-01715-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 01/04/2024] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND The management process of Enteral Nutrition (EN) typically involves the interaction between a team of health care practitioners. Nurses being the closest to the patients, have crucial responsibilities and play a major role in feeding delivery along with other medical treatments. This study was conducted to investigate the perception of the nurses working in adult and paediatric intensive care Units (ICUs) regarding the EN barriers and identify the factors that influenced their perception. METHODS The data in this cross-sectional study was collected via online survey between 15 October 2021 and January 2022. All nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The tool used for the data collection was adapted from Cahill et al. (2016) and then reviewed and modified by the researchers. The survey collected information about the demographics of the nurses, and it included 24 potential EN barriers where the participants were asked to rate their importance on a scale from 1 to 5. Descriptive statistics were performed to describe the variables, univariant analysis were performed to compare the perceptions of the nurses regarding the EN barriers based on their characteristics followed by stepwise linear regression analysis. RESULTS A total of 136 nurses working in adult and paediatric ICUs were included in this study. The results showed that the most important barriers as perceived by the nurses was "Frequent displacement of feeding tube, requiring reinsertion" [3.29 ± 1.28], "Delays in initiating motility agents in patients not tolerating enteral nutrition" [3.27 ± 1.24] and "Enteral formula not available on the unit". [3.27 ± 1.24]. Our results showed that the responses of the participants statistically varied based on their work settings, gender, region, and educational level for some items in the survey (P-value ≤ 0.05). In the regression analysis, gender was the only variable statistically influenced the total Likert rating scores of the participants (r = -0.213, p-value = 0.013). CONCLUSION This study identified several barriers that exist in the nursing practice of EN in critical care settings. There are distinct differences in the perception of the nurses to these barriers based on their characteristics. Understanding such differences is important for implementing future strategies for units that needed the most help in prioritizing EN delivery.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia.
| | - Futoon Al Sumairi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, P.O. Box 344, Madinah, 42353, Kingdom of Saudi Arabia
| | - Sarah M Ajabnoor
- Department of Clinical Nutrition, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
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Zaher S. Barriers to Delivery of Enteral Nutrition in Intensive Care Settings in Saudi Arabia: A Comparative Study of the Perceptions of Health Care Providers Working in Adult and Paediatric ICUs. Risk Manag Healthc Policy 2022; 15:2357-2370. [PMID: 36544506 PMCID: PMC9762403 DOI: 10.2147/rmhp.s394035] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
Background and Aims Achieving optimal nutrition prescription is challenging in critically ill patients. Many factors can hinder the adequate delivery of enteral nutrition (EN) in intensive care units (ICUs). In this study, we aim to describe EN barriers and compare the perceptions of health care practitioners working in adult and paediatric ICUs regarding these barriers. Methods In this cross-sectional study, data were collected via online survey. All physicians, dietitians, and nurses working in adult or paediatric ICUs across Saudi Arabia were eligible to participate. The survey contained 24 potential EN barriers and participants were asked to rate their importance on a scale from 1 to 5. A total Likert rating score of the 24 items was later calculated. Results We recruited 244 health care providers working in adult and paediatric ICUs. The most important perceived barriers were "Delay in physician ordering EN initiation" (3.33 ±1.32), and 'Waiting for dietitians to assess patients' (3.22 ±1.20). There was a statistical difference between the responses of health care providers based on their work settings for the following items; "Nurses failing to progress feeds according to feeding protocol" (p=0.006) and 'Feeding being held too far prior procedures or operating-room visits' (p=0.021). Profession significantly influenced the total Likert rating score of the 24 items (r=-0.234, p=0.001). Conclusion This study identified some barriers of EN delivery in ICUs and showed that participants' perceptions regarding these barriers were influenced by their roles. These findings shed light on the nutritional practices in Saudi hospitals and identify areas of improvement in EN practice and advancements in the field of critical care nutrition in the region.
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Affiliation(s)
- Sara Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Kingdom of Saudi Arabia
- National Nutrition Committee (NNC), Saudi Food and Drug Authority (Saudi FDA), Riyadh, Saudi Arabia
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Mirhosiny M, Arab M, Shahrbabaki PM. How do physicians and nurses differ in their perceived barriers to effective enteral nutrition in the intensive care unit? Acute Crit Care 2021; 36:342-350. [PMID: 34380289 PMCID: PMC8907455 DOI: 10.4266/acc.2021.00185] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/24/2021] [Indexed: 11/30/2022] Open
Abstract
Background Patients hospitalized in intensive care units are susceptible to chronic malnutrition from changes in protein and energy metabolism in response to trauma. Therefore, nutritional support, especially enteral nutrition, is one of the most important treatment measures for these patients. However, there are several barriers in the hospitals in treating patients with enteral nutrition. This study was performed to compare the perceptions of care providers (physicians and nurses) on the barriers to enteral nutrition in intensive care units. Methods This was a cross-sectional descriptive and analytic study. This study included 263 nurses and 104 physicians in the intensive care units of XXXX southeast hospitals. A questionnaire of enteral nutrition barriers in intensive care units was used. IBM SPSS ver. 19 was used to analyze data. Results There was a significant difference between the two groups in the three subscales of intensive care units (P=0.034), dietician support (p=0.001>) and critical care provider attitudes and behavior (P=0.031). There was also a significant difference between having completed educational courses and the score of enteral nutrition barriers in the two groups (P<0.05); the people who received an educational course had a better perception of enteral nutrition barriers. Conclusion Physicians and nurses agreed with the perception of enteral nutrition barriers, but there was a difference in their perception on some barriers. Strategies such as in-service training and increasing the knowledge and skills of physicians and nurses can reduce these differences.
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Affiliation(s)
| | - Mansour Arab
- Critical Care Nursing, Faculty of Nursing and Midwifery, Bam University of Medical Sciences, Bam, Iran
| | - Parvin Mangolian Shahrbabaki
- Nursing Research Center, Faculty of Razi School of Nursing and Midwifery, Department of Critical Care Nursing, Kerman University of Medical Sciences, Kerman, Iran
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Burslem R, Parker A. Medical nutrition therapy for patients with malnutrition post-intensive care unit discharge: A case report of recovery from coronavirus disease 2019 (COVID-19). Nutr Clin Pract 2021; 36:820-827. [PMID: 34245599 PMCID: PMC8441791 DOI: 10.1002/ncp.10728] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Patients discharged from an intensive care unit (ICU) are frequently malnourished and experience ongoing inadequate nutrition intake because of a variety of barriers, which may lead to further declines in nutrition status. The coronavirus disease 2019 (COVID-19) pandemic has drawn increased awareness to this vulnerable patient population and the importance of nutrition rehabilitation to promote optimal recovery from acute illness. Despite this, there are no formal guidelines addressing medical nutrition therapy during the post-ICU recovery phase. This review provides an overview of the nutrition management of patients during the post-ICU recovery phase with a specific focus on COVID-19. A case study will demonstrate how medical nutrition therapy improved the nutrition status and quality of life for a patient who became severely malnourished after a prolonged hospitalization for COVID-19.
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Affiliation(s)
- Ryan Burslem
- School of Health Professions, Department of Clinical and Preventive Nutrition SciencesRutgers UniversityNewarkNew JerseyUSA
| | - Anna Parker
- School of Health Professions, Department of Clinical and Preventive Nutrition SciencesRutgers UniversityNewarkNew JerseyUSA
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Alsohime F, Assiry G, AlSalman M, Alabdulkareem W, Almuzini H, Alyahya M, Allhidan R, Al-Eyadhy A, Temsah MH, Al Sarkhy AA. Barriers to the delivery of enteral nutrition in pediatric intensive care units: A national survey. Int J Pediatr Adolesc Med 2020; 8:186-190. [PMID: 34350333 PMCID: PMC8319679 DOI: 10.1016/j.ijpam.2020.12.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 11/24/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Fahad Alsohime
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ghadeer Assiry
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Wejdan Alabdulkareem
- Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Hissah Almuzini
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Malak Alyahya
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Reema Allhidan
- College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ayman Al-Eyadhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Mohamad-Hani Temsah
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Pediatric Intensive Care Unit, Pediatric Department, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
| | - Ahmed A Al Sarkhy
- College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Gastroenterology Unit, Pediatric Department, King Khalid University Medical City, King Saud University, Riyadh, Saudi Arabia.,Prince Abdullah Bin Khalid Celiac Disease Research Chair, College of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia
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Abstract
OBJECTIVES To explore the perceived barriers by pediatric intensive care healthcare professionals (nurses, dieticians, and physicians) in delivering enteral nutrition to critically ill children across the world. DESIGN Cross-sectional international online survey adapted for use in pediatric settings. SETTING PICUs across the world. SUBJECTS PICU nurses, physicians, and dietitians. INTERVENTIONS The 20-item adult intensive care "Barriers to delivery of enteral nutrition" survey was modified for pediatric settings, tested, and translated into 10 languages. The survey was distributed online to pediatric intensive care nurses, physicians, and dieticians via professional networks in March 2019 to June 2019. Professionals were asked to rate each item indicating the degree to which they perceived it hinders the provision of enteral nutrition in their PICUs with a 7-point Likert scale from 0 "not at all a barrier" to 6 "an extreme amount." MEASUREMENT AND MAIN RESULTS Nine-hundred twenty pediatric intensive care professionals responded from 57 countries; 477 of 920 nurses (52%), 407 of 920 physicians (44%), and 36 of 920 dieticians (4%). Sixty-two percent had more than 5 years PICU experience and 49% worked in general PICUs, with 35% working in combined cardiac and general PICUs. The top three perceived barriers across all professional groups were as follows: 1) enteral feeds being withheld in advance of procedures or operating department visits, 2) none or not enough dietitian coverage on weekends or evenings, and 3) not enough time dedicated to education and training on how to optimally feed patients. CONCLUSIONS This is the largest survey that has explored perceived barriers to the delivery of enteral nutrition across the world by physicians, nurses, and dietitians. There were some similarities with adult intensive care barriers. In all professional groups, the perception of barriers reduced with years PICU experience. This survey highlights implications for PICU practice around more focused nutrition education for all PICU professional groups.
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Carrasco V, Freitas MIPD, Oliveira-Kumakura ARDS, Almeida EWSD. Construção e validação de instrumento para avaliar o conhecimento do enfermeiro sobre terapia nutricional enteral. Rev Esc Enferm USP 2020; 54:e03646. [DOI: 10.1590/s1980-220x2019024003646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 02/06/2020] [Indexed: 11/22/2022] Open
Abstract
RESUMO Objetivo: Construir e validar instrumento para avaliar o conhecimento do enfermeiro sobre terapia nutricional enteral. Método: Estudo metodológico, com revisão de literatura, validação de conteúdo e pré-teste. Para a revisão, foram incluídos trabalhos publicados de 2008 a 2018 a respeito da terapia de nutrição enteral. O material foi apreciado por 6 juízes, seguindo os critérios da psicometria. Calculou-se percentual de concordância. O pré-teste foi realizado com 30 enfermeiros, a fim de verificar a adequação e o entendimento para uso na prática clínica. Resultados: Instrumento construído continha quatro domínios, com 10 itens cada. Os domínios Indicação da terapia enteral e Monitoramento da administração da dieta enteral apresentaram melhores percentuais de concordância - 0,94 e 0,93, respectivamente. As categorias que obtiveram valores abaixo de 0,90 foram reformuladas ou retiradas, resultando em 38 categorias distribuídas em 4 domínios. No pré-teste, a concordância foi de 0,90, sendo o instrumento considerado de fácil entendimento e adequado para a prática. Conclusão: O instrumento construído foi validado quanto ao conteúdo e à aplicação na prática pelos enfermeiros.
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Huang J, Yang L, Zhuang Y, Qi H, Chen X, Lv K. Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study. J Clin Nurs 2018; 28:677-685. [PMID: 30182514 DOI: 10.1111/jocn.14667] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 08/06/2018] [Accepted: 08/11/2018] [Indexed: 01/07/2023]
Abstract
AIMS AND OBJECTIVES To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. Our objectives are to provide tailored interventions for addressing identified barriers and propose an optimal enteral nutrition (EN) practice in intensive care unit (ICU). BACKGROUND Despite the availability of numerous verified clinical practice guidelines focusing on enteral feeding of critically ill patients, a wide gap remains between the guideline recommendations and actual nutrition performances. Underfeeding is also a global problem. Therefore, to further understand the reasons of the systemic iatrogenic underfeeding in ICUs, several potential issues are investigated. DESIGN This research is a cross-sectional descriptive study. METHODS A total of 808 nurses were recruited from 10 comprehensive hospitals from different districts in China. The nursing staff demographic, the unit's EN management information and the Chinese version of barriers to enteral feeding critically ill patients questionnaire were the parameters used to collect data via WeChat app. Moreover, the collected data were analysed by descriptive and correlative statistical analysis methods. RESULTS Results obtained by multiple linear regression showed that frequency of EN-related training, full-time ICU nutritionist, hospital level, specific protocols for enteral feeding and position were significantly influencing the enteral feeding of ICU patients. CONCLUSIONS Enteral feeding barriers of ICU patients are at a moderate level and are influenced by multiple aspects. Hence, hospital departments should strengthen standardisation and systematic EN training, provide ICU full-time nutritionists and distribute medical resources and personnel rationally. Moreover, construction of a localised feeding process and exerting subjective initiative of clinical nurses from an evidence-based guideline are important. Multifaceted tailored interventions should be implemented to address these barriers. RELEVANCE TO CLINICAL PRACTICE The findings of this study can be used to inform future intervention and guidelines aimed at addressing these barriers systematically and improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.
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Affiliation(s)
- Jingying Huang
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lili Yang
- Nursing Education Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yiyu Zhuang
- Nursing Department, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Haiou Qi
- Operating Room, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiangpin Chen
- Intensive Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Kai Lv
- Postanesthesia Care Unit, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Kozeniecki M, Pitts H, Patel JJ. Barriers and Solutions to Delivery of Intensive Care Unit Nutrition Therapy. Nutr Clin Pract 2018; 33:8-15. [PMID: 29323759 DOI: 10.1002/ncp.10051] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/10/2017] [Accepted: 11/21/2017] [Indexed: 01/01/2023] Open
Abstract
Despite recommendations for early enteral nutrition (EN) in critically ill patients, numerous factors contribute to incomplete delivery of EN, including insufficient nutrition risk screening in critically ill patients, underutilization of enteral feeding protocols, fixed rate-based enteral infusion targets with frequent EN interruption, and suboptimal provider practices regarding nutrition support therapy. The purpose of this narrative review is to identify common barriers to optimizing and delivering nutrition in critically ill patients, and suggest strategies and solutions to overcome barriers.
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Affiliation(s)
- Michelle Kozeniecki
- Department of Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Heather Pitts
- Department of Nutrition Services, Cone Health, Greensboro, North Carolina, USA
| | - Jayshil J Patel
- Department of Medicine, Division of Pulmonary & Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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