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

Determining pre-procedure fasting alert time using procedural and scheduling data

Before a medical procedure requiring anesthesia, patients are required to not eat or drink non-clear fluids for 6 h and not drink clear fluids for 2 h. Fasting durations in standard practice far exceed these minimum thresholds due to uncertainties in procedure start time. The aim of this retrospective, observational study was to compare fasting durations arising from standard practice with different approaches for calculating the timepoint at which patients are instructed to stop eating and drinking. Scheduling data for procedures performed in the cardiac catheterization laboratory of an academic hospital in Canada (January 2020 to April 2022) were used. Four approaches utilizing machine learning (ML) and simulation were used to predict procedure start times and calculate when patients should be instructed to start fasting. Median fasting duration for standard practice was 10.08 h (IQR 3.5) for both food and clear fluids intake. The best performing alternative approach, using tree-based ML models to predict procedure start time, reduced median fasting from food/non-clear fluids to 7.7 h (IQR 2) and clear liquids fasting to 3.7 h (IQR 2.4). 97.3% met the minimum fasting duration requirements (95% CI 96.9% to 97.6%). Further studies are required to determine the effectiveness of operationalizing this approach as an automated fasting alert system.

Impact of Visual Nutritional Indicator on the Nutritional Therapy in Intensive Care Unit

Background

We wanted to evaluate if a visual nutritional indicator (VNI), which shows the total amount of calories and protein, can improve the quality of nutritional therapy (NT) and result in better clinical outcomes prospectively.

Materials and methods

We randomly assigned patients to VNI or non-VNI (NVNI) groups. In the VNI group, VNI was attached to the patient's bed for the attending physician. The primary goal was a higher supply of calories and proteins. The secondary goals were the shorter length of intensive care unit (ICU) stay, mechanical ventilation, and renal replacement therapy.

Results

The total calorie supply was 18.6 kcal/kg and 15.6 kcal/kg in the VNI and NVNI groups, respectively (p = 0.04). The total protein supply was 0.92 g/kg and 0.71 g/kg, respectively (p = 0.05). The length of ICU stay was 5.6 days and 5.3 days in the VNI and NVNI groups, respectively (p = 0.09). The length of mechanical ventilation was 3.6 days and 3.8 days, respectively (p = 0.07). The length of renal replacement therapy was 5.7 days and 6.3 days, respectively (p = 0.13). The mortality on the seventh day was 14.6% and 16.1% in the VNI and NVNI groups, respectively (p = 0.08). The mortality on the thirtieth day was 20 and 20.8%, respectively (p = 0.87).

Conclusion

Visual nutritional indicator, indicating the total amount of calories and protein provided, can improve the quality of NT but fail to obtain a better clinical outcome.

How to cite this article

Mun S. Impact of Visual Nutritional Indicator on the Nutritional Therapy in Intensive Care Unit. Indian J Crit Care Med 2023;27(6):392-396.

LOSS et al.Nutrition as a risk for mortality and functionality in critically ill older adultsNutrition as a risk for mortality and functionality in critically ill older adults

BACKGROUND & AIMS

There is no specific recommendation for nutrition therapy for critically ill older adults. However, targeting caloric and protein balance and avoiding fasting could improve outcomes in this high-risk nutritional population. This study aimed to evaluate the associations between nutrition and mortality/functionality in critically ill older patients.

METHODS

Single-center retrospective observational study of critically ill patients aged 65 years or older. We extracted data from the dietician evaluations about calories, proteins, and the type of diet (fasting, oral, enteral, parenteral) prescribed in the first week of intensive care unit admission. Primary outcomes were intrahospital mortality and independence and functional capacity evaluated after hospital discharge.

RESULTS

Out of the 2,043 patients screened, 533 were included in the study. Most patients were men (52.1%), with a median age of 73 (68-78) years. Overall, the intrahospital mortality rate was 53.8%. SAPS-3, albumin, C-reactive protein, and surgical patients were independently associated with fasting in a multivariate analysis. The multivariate regression analyses showed that SAPS-3, albumin, and fasting were independently associated with mortality. Each fasting day increases the risk of mortality by 16.7%. Also, independence and functional capacity were not related to nutritional prescription.

CONCLUSION

Older adults (65 years or older) constitute a fragile population in which nutritional breaks were associated with increased hospital mortality. Furthermore, a prospective clinical trial is necessary to establish the best strategy to feed this population. This article is protected by copyright. All rights reserved.

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.

Older Adults' and Their Informal Caregivers' Experiences and Needs regarding Nutritional Care Provided in the Periods before, during and after Hospitalization: A Qualitative Study

To enhance prevention and treatment of malnutrition in older adults before, during and after hospitalization, deeper understanding of older adults' and informal caregivers' perspective on nutritional care is important. One-time in-depth interviews were conducted with 15 older adults who had been discharged from hospital, and seven informal caregivers. We explored their experiences and needs regarding nutritional care provided in the periods before, during and after hospitalization. Five themes emerged from the data: (1) dietary intake, (2) food service during hospitalization, (3) nutrition-related activities, (4) whose job it is to give nutritional care, and (5) competing care priorities. Further, several opinions about nutritional issues were identified. Older adults and informal caregivers did not always experience optimal nutritional care. When discussing nutritional care, they mainly focused on the in-hospital period. When providing nutritional care and developing guidelines, older adults' and informal caregivers' perspective on nutritional care should be incorporated. Here, the periods before, during and after hospitalization should be taken into account equally.

Hospital nutrition care informs potential cost-savings for healthcare: A budget impact analysis

BACKGROUND AND AIM

In Mexico, about half of hospitalized patients are malnourished or at risk of malnutrition upon hospital admission, while many others experience deterioration of their nutritional status while in the hospital. Such patients often experience poor health outcomes and have increased hospital costs. The aim of our budget-impact analysis was to estimate potential savings associated with the implementation of a Mexican hospital-based program of nutrition care for patients at malnutrition risk or malnourished.

METHODS

The budget-impact model was based on data published previously. Our model compared patients assigned to receive individualized early nutrition therapy (initiated within 24-48 h of hospital admission) with those who received standard delayed nutrition therapy (not initiated early). Outcomes included length of stay, infectious complications, and 30-day readmissions. We modeled a 30-day time-horizon, estimated event probabilities on the basis of published data, and projected costs in 2020 US dollars.

RESULTS

Average total healthcare costs over 30-days were $3527 for patients with early nutrition therapy vs $6032 for patients with standard nutrition therapy-a savings of $2505 per early nutrition-treated patient (41.5% lower). Cost differences between the groups were $2336 vs $3065 for hospital-associated costs (23.8% lower), $262 vs $780 for 30-day readmissions (66.4% lower) and $1348 for malnutrition-associated infections. Applying these potential savings from individualized early nutrition care to a one-year estimate of 3.22 million Mexican hospital patients with malnutrition or its risk, the total overall savings for public health expenditures was equivalent to $8.1 billion per year or 32.1% of total healthcare expenditures.

CONCLUSIONS

The results demonstrated the potential for hospital-based nutrition care programs to reduce costs of patient hospitalizations. These notable findings provide a rationale for Mexican healthcare institutions to implement programs of comprehensive nutrition-focused care for inpatients with malnutrition or its risk. To this end, we advise implementation of professional programs for education and training in order to increase awareness of patients' nutritional needs and to better prepare clinical personnel to identify, treat, and monitor patients at-risk/malnourished.

Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study

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.

Association Between Enteral Feeding, Weight Status, and Mortality in a Medical Intensive Care Unit

BACKGROUND

Clinical practice guidelines recommend enteral nutrition for most patients receiving mechanical ventilation. However, recently published evidence on the effect of enteral nutrition on mortality, particularly for patients who are well nourished, is conflicting.

OBJECTIVES

To examine the association between enteral feeding and hospital mortality in critically ill patients receiving mechanical ventilation and to determine if body mass index mediates this relationship.

METHODS

A retrospective cohort study of patients receiving mechanical ventilation admitted to a medical intensive care unit in 2013. Demographic and clinical variables were collected. Cox proportional hazards regression was used to examine the relationship between an enteral feeding order and hospital mortality and to determine if the relationship was mediated by body mass index.

RESULTS

Of 777 patients who had 811 hospitalizations requiring mechanical ventilation, 182 (23.4%) died in the hospital. A total of 478 patients (61.5%) received an order for enteral tube feeding, which was associated with a lower risk of death (hazard ratio, 0.41; 95% CI, 0.29-0.59). Body mass index did not mediate the relationship between mortality and receipt of an order for enteral feeding. Median stay in the unit was 3.6 days. Most deaths (72.0%) occurred more than 48 hours after admission.

CONCLUSION

The finding of a positive association between an order for enteral feeding and survival supports enteral feeding of patients in medical intensive care units. Furthermore, the beneficial effect of enteral feeding appears to apply to patients regardless of body mass index.