Barriers to Nutrition Intervention for Patients With a Traumatic Brain Injury: Views and Attitudes of Medical and Nursing Practitioners in the Acute Care Setting

Evaluating physiological barriers to oral intake in hospitalized patients: A secondary analysis

BACKGROUND

Oral intake in hospitalized patients is frequently below estimated targets. Multiple physiological symptoms are proposed to impact oral intake, yet many have not been quantified objectively.

AIM

To describe the challenges of objectively measuring physiological nutrition-impacting symptoms in hospitalized patients.

METHOD

A secondary analysis of data from a single-center, descriptive cohort study of physiological nutrition-impacting symptoms in intensive care unit (ICU) survivors and general medical patients was conducted. Demographic and clinical characteristics were extracted for patients who completed the original study and collected retrospectively for those who were screened and recruited but did not complete the original study. Reasons for patient exclusion from the original study were quantified from the screening database. Descriptive data are reported as mean ± SD, median [interquartile range], or number (percentage).

RESULTS

ICU survivors and general medical patients were screened for inclusion in the original study between March 1 and December 23, 2021. Of the 644 patients screened, 97% did not complete the study, with 93% excluded at screening. Of the 266 ICU survivors and 398 general medical patients screened, 89% and 95% were excluded, respectively. Major exclusion criteria included the inability to follow commands or give informed consent (n = 155, 25%), the inability to consume the easy-to-chew and thin-fluid buffet meal, and imminent discharge (both, n = 120, 19%).

CONCLUSION

Understanding physiological factors that drive reduced oral intake in hospitalized patients is challenging. Exclusion criteria required to objectively quantify physiological nutrition-impacting symptoms significantly preclude participation and likely act as independent barriers to oral intake.

Enteral nutrition on discharge from intensive care and 30-day unplanned readmission: An exploratory, retrospective study of association

BACKGROUND & AIMS

Individuals who survive critical illness are often malnourished with inadequate oral nutrient intake after leaving the intensive care unit (ICU). Enteral nutrition (EN) improves nutrient intake but there is limited evidence on the impact of maintaining EN after discharge from the ICU. The objective of this exploratory study was to understand the association between EN maintenance after ICU and 30-day unplanned hospital re-admission, to inform on future prospective research into the effects of post-ICU nutrition.

METHODS

This was a single-centre, retrospective study of ICU patients, requiring ventilation, who received EN for at least 3 days in ICU and were discharged to the ward.

RESULTS

102 patients met the inclusion criteria; 45 (44.1%) maintained EN and 57 (55.9%) discontinued EN after ICU discharge; there were no significant differences in demographics or clinical measures at ICU admission. Reason for EN discontinuation was documented in 38 (66.7%) patients, with 27 (71%) discontinuing EN due to a routine ward practice of feeding tube removal. Unplanned 30-day hospital re-admission occurred in 17 (16.7%) patients overall, 5 (11.1%) in the EN group and 12 (21.1%) in the non-EN group (crude odds ratio [OR] 0.47, 95% CI 0.15, 1.45, p = 0.188). After adjusting for age, sex, BMI and length of stay, there was a persistent trend to lower re-admission rates in the EN group (OR 0.37, 95% CI 0.09, 1.57, p = 0.176).

CONCLUSIONS

EN maintenance after ICU discharge was associated with a trend to lower 30-day unplanned hospital re-admission rates. The clinically relevant reduction of about 50% in unplanned re-admission rates in this exploratory study warrants larger, prospective studies of post-ICU nutrition strategies based on clear discontinuation criteria to optimize nutrition and evaluate patient-centred outcomes.

An evaluation of nasogastric (NG) tube removal practices and nutritional intake parameters in an acute neurosurgical population: The development of an NG Transition Feeding Protocol

BACKGROUND

As a result of the complex nature of neurosurgical patients, nasogastric (NG) tube feeding is often implemented for patients who are unable to consume adequate oral intake. During recovery, patients on enteral nutrition (EN) are progressed to oral nutrition, which can result in NGT removal and discontinuation of supportive feeding plans. This is often before patients become established on sufficient oral intake to meet their nutritional requirements.

METHODS

We conducted an exploration of current NG removal practices in patients (n = 23) across five neurosurgical wards over a 3-month period to assess practitioner review response times, NG feeding duration, decision making on NG removal, and the influence of dietary recommendations and differing EN protocols on patients' ability to meet their nutritional requirements. Our aim was to use this data to design and implement a protocol to improve consistency of these practices.

RESULTS

After oral intake was commenced, only those receiving supplementary EN achieved nutritional targets immediately. Conversely, no patient who had their NGT removed at this stage achieved these targets. Following NG removal, the likelihood of a patient meeting nutritional targets was influenced by the decision maker, supporting the practice of registered dietitian led cessation of NG feeding. These findings led us to develop an "NG Transition Feeding Protocol" to serve as a simple, clear pathway which treating teams can utilise to guide NG feeding decisions.

CONCLUSIONS

NG feeding supports neurosurgical patients to meet nutritional requirements in the early stages following commencement of oral intake. The development of an "NG Transition Feeding Protocol" may help to improve consistency of transition feeding on neurosurgical wards, allowing time for nutrition assessment to support informed decisions around NG removal. The aim of this protocol is to improve the efficiency of transition feeding, improve dietetic workload efficiency, nursing staff confidence and avoid compromising nutritional status of patients as a result of the early cessation of EN.

Nutrition practices in critically ill adults receiving noninvasive ventilation: A quantitative survey of Australian and New Zealand intensive care clinicians

BACKGROUND

Noninvasive ventilation (NIV) is frequently used in the intensive care unit (ICU), yet there is a paucity of evidence to guide nutrition management during this therapy. Understanding clinicians' views on nutrition practices during NIV will inform research to address this knowledge gap.

OBJECTIVE

The objective of this study was to describe Australian and New Zealand clinicians' views and perceptions of nutrition management during NIV in critically ill adults.

METHODS

A cross-sectional quantitative online survey of Australian and New Zealand medical and nursing staff with ≥12 months ICU experience was disseminated through professional organisations via purposive snowball sampling from 29 August to 9 October 2022. Data collection included demographics, current practices, and views and perceptions of nutrition during NIV. Surveys <50% complete were excluded. Data are represented in number (%).

RESULTS

A total of 152 surveys were analysed; 71 (47%) nursing, 69 (45%) medical, and 12 (8%) not specified. There was limited consensus on nutrition management during NIV; however, most clinicians (n = 108, 79%) reported that nutrition during NIV was 'important or very important'. Oral intake was perceived to be the most common route (n = 83, 55%), and 29 (21%) respondents viewed this as the safest. Most respondents (n = 106, 78%) reported that ≤50% of energy targets were met, with gastric enteral nutrition considered most likely to meet targets (n = 55, 40%). Reported nutrition barriers were aspiration risk (n = 87, 64%), fasting for intubation (n = 84, 62%), and nutrition perceived as a lower priority (n = 73, 54%). Reported facilitators were evidence-based guidelines (n = 77, 57%) and an NIV interface compatible with enteral nutrition tube (n = 77, 57%).

CONCLUSION

ICU medical and nursing staff reported nutrition during NIV to be important; however, there was a lack of consensus on the route of feeding considered to be the safest and most likely to achieve nutrition targets. Interventions to minimise aspiration and fasting, including an interface with nasoenteric tube compatibility, should be explored.

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

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.

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.

Protein prescription and delivery practices in critically ill adults: A survey of Australian and New Zealand intensive care dietitians

BACKGROUND

Protein provision is thought to be integral to attenuating muscle wasting in critical illness, yet patients receive half of that prescribed. As international guidelines lack definitive evidence to support recommendations, understanding clinicians' views relating to protein practices is of importance.

OBJECTIVES

The objective of this study was to describe Australia and New Zealand intensive care unit (ICU) dietitians' protein prescription and perceived delivery practices in critically ill adults, including common barriers and associations between ICU clinical experience and protein prescriptions for different clinical conditions.

METHODS

A 42-item descriptive quantitative survey of Australian and New Zealand intensive care dietitians was disseminated through nutrition and ICU society e-mailing lists. Data were collected on respondent demographics and reported protein practices including questions related to a multitrauma case study. Data were analysed using descriptive and content analysis and reported as n (%). Fisher's exact tests were used to compare experience and protein prescriptions.

RESULTS

Of the 67 responses received (one excluded due to >50% missing data), more than 80% of respondents stated they would prescribe 1.2-1.5 g protein/kg bodyweight/day for most critically ill patients, most commonly using European Society of Clinical Nutrition and Metabolism (ESPEN) guidelines to support prescriptions (n = 61/66, 92%). Most respondents (n = 49/66, 74%) thought their practice achieved 61-80% of protein prescriptions, with frequently reported barriers including fasting periods (n = 59/66, 89%), avoiding energy overfeeding (n = 50/66, 76%), and gastrointestinal intolerance (n = 47/66, 71%). No associations between years of ICU experience and protein prescriptions for 14 of the 15 predefined clinical conditions were present.

CONCLUSIONS

Australian and New Zealand ICU dietitians use international guidelines to inform protein prescriptions of 1.2-1.5 g/kg/day for most clinical conditions, and protein prescriptions do not appear to be influenced by years of ICU experience. Key perceived barriers to protein delivery including avoidance of energy overfeeding and gastrointestinal intolerance could be explored to improve protein adequacy.

Clinical observation of individualized nutritional formula on inflammation index, immune status and gastrointestinal tolerance in patients with severe head injury

Objectives:

To evaluate the clinical significance of individualized nutritional formulas on inflammatory factors, immune status and gastrointestinal tolerance in patients with severe head injury.

Methods:

A total of 80 patients with severe head injury who were hospitalized in Baoding No.1 Central Hospital from March 2017 to March 2020 were randomly divided into two groups with 40 cases in each group. Patients in both groups were given enteral nutrition (EN), the control group was given conventional enteral nutrition formula through nasointestinal tube, and the experimental group was given individualized nutrition formula. All patients were tested for tumor necrosis factor(TNF-α), C-reactive protein(CRP), interleukin 6(IL-6), IgA, IgM, IgG, serum intestinal fatty acid binding protein(I-FABP) and D-lactic acid concentration before and after enteral nutrition treatment. The incidence of adverse reactions such as abdominal distension, diarrhea, constipation, and gastric retention within seven days after treatment of two groups were compared and analyzed.

Results:

There was no significant difference in inflammatory factors such as TNF-a, CRP, IL-6, immunoglobulin levels, I-FABP and D-lactic acid concentration between the two groups before treatment (p>0.05). After treatment, the above indicators of the two groups of patients were better than before treatment, the difference was statistically significant (p<0.05), and the experimental group was significantly better than the control group (p<0.05). The experimental group had a gastrointestinal adverse reaction rate of 10%, and the control group had 27.5%, the difference was statistically significant (p=0.04).

Conclusions:

Individualized nutritional formula has more significant advantages than conventional nutritional formula for patients with severe head injury, which can reduce inflammatory response, increase the patient’s immune level, improve the intestinal mucosal barrier function, have good gastrointestinal tolerance, and have a low incidence of adverse reactions.

Determination of calorie and protein intake among acute and sub-acute traumatic brain injury patients

PURPOSE

Malnutrition is a common problem among hospitalized patients, especially among traumatic brain injury (TBI) patients. It is developed from hypermetabolism and the condition may worsen under the circumstance of underfeeding or incompatible dietary management. However, the data of nutrient intake especially calorie and protein among TBI patients were scarce. Hence, this study aimed to determine the calorie and protein intake among acute and sub-acute TBI patients receiving medical nutrition therapy in hospital Sultanah Nur Zahirah, Terengganu.

METHODS

This observational study involved 50 patients recruited from the neurosurgical ward. Method of 24 h dietary recall was utilized and combined with self-administered food diaries for 2-8 days. Food consumptions including calorie intake and protein intake were analyzed using Nutritionist PRO™ (Woodinville, USA) and manual calculation based on the Malaysian food composition database (2015).

RESULTS

Patients consisted of 56% males and 44% females with the median age of 28.0 (IQR = 22.8-36.5) years, of which 92% were diagnosed as mild TBI and the remaining (8%) as moderate TBI. The Glasgow coma scale (GCS) was adopted to classify TBI severity with the score 13-15 being mild and 9-12 being moderate. The median length of hospital stay was 2 (IQR = 2.0-3.3) days. Calorie and protein intake improved significantly from day 1 to discharge day. However, the intake during discharge day was still considered as suboptimal, i.e. 75% of calorie requirement, whilst the median protein intake was only 61.3% relative to protein requirement. Moreover, the average percentages of calorie and protein intakes throughout hospitalization were remarkably lower, i.e. 52.2% and 41.0%, respectively.

CONCLUSION

Although the calorie and protein intakes had increased from baseline, hospitalized TBI patients were still at a risk to develop malnutrition as the average intakes were considerably low as compared to their requirements. Optimum nutrient intakes especially calorie and protein are crucial to ensure optimum recovery process as well as to minimize risks of infection and complications.

Health practitioner practices and their influence on nutritional intake of hospitalised patients

Objectives

In the hospital setting, poor dietary intake interacts with disease and represents a major and modifiable cause of malnutrition. Understanding barriers to adequate dietary intake is an important strategy to guide the development of interventions to improve nutrition intake. The aim of this study reported in this paper was to explore patient, family and health care professionals' perceptions of barriers to and enablers of adequate nutrition care and dietary intake of medical inpatients.

Methods

An exploratory qualitative study design incorporating group and individual interviews of patients (n = 14), their family members (n = 4), and health care professionals (n = 18) was undertaken. Participants were recruited pragmatically, using a mix of convenience and purposive sampling. A theoretically informed, semi-structured interview schedule was based on observations of practice and the Theoretical Domains Framework. Interviews were audio-recorded, transcribed verbatim and analysed inductively using a general inductive approach.

Results

Three key themes emerged from analysing participant interviews. Siloed approaches to nutrition care reflected the diverse range of health care professionals responsible for nutrition care but who often worked in isolation from their colleagues. Competing work priorities for nurses reflected the challenge in prioritise nutrition care which was often constrained because of other care needs or work-related pressures. Helping patients to eat highlighted that nurses were often the only health care professional who would provide assistance to patients at mealtimes and lack of available staff could negatively influence patients' nutrition intakes.

Conclusions

We have identified many complex and interrelated barriers which preclude adequate dietary intake in acute medical patients. These predominantly reflect issues inherent in the hospital culture and environment. Multi-faceted and sustainable interventions that support a facilitating nutrition culture and multidisciplinary collaboration, inclusive of patients and families, are needed to address these underlying barriers.

What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults

BACKGROUND

Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults.

METHODS

This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]).

RESULTS

Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m² , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement.

CONCLUSIONS

Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.