Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Med. Feb 4, 2017; 6(1): 56-64
Published online Feb 4, 2017. doi: 10.5492/wjccm.v6.i1.56
Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study
Martin Padar, Gerli Uusvel, Liis Starkopf, Joel Starkopf, Annika Reintam Blaser
Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia
Liis Starkopf, Department of Public Health, Section of Biostatistics, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
Joel Starkopf, Annika Reintam Blaser, Department of Anaesthesiology and Intensive Care, University of Tartu, 51014 Tartu, Estonia
Annika Reintam Blaser, Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, Lucerne Cantonal Hospital, 6000 Lucerne, Switzerland
Author contributions: Padar M, Starkopf J and Reintam Blaser A designed the study; Uusvel G and Starkopf L participated in the data collection and analysis; Padar M, Starkopf J and Reintam Blaser A participated in the interpretation of the results and drafted the manuscript; all the co-authors participated in the development of the final version of the manuscript.
Supported by the Ministry of Education and Research of Estonia (IUT34-24).
Institutional review board statement: The study was approved by the institutional review board of Tartu University Hospital.
Informed consent statement: Waiver of informed consent was approved by the Ethics Committee of University of Tartu due to the observational design of the study.
Conflict-of-interest statement: ARB received honoraria for participation in the advisory board meetings of Nestlé, Fresenius and Nutricia. JS has received honoraria for advisory board participation from B. Braun Melsungen AG. The authors declare that they have no conflicts of interest regarding this particular study.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Annika Reintam Blaser, MD, PhD, Researcher, Department of Anaesthesiology and Intensive Care, University of Tartu, L. Puusepa 8, 51014 Tartu, Estonia. annika.reintam.blaser@ut.ee
Telephone: +372-5142281
Received: August 28, 2016
Peer-review started: September 1, 2016
First decision: October 20, 2016
Revised: November 8, 2016
Accepted: January 11, 2017
Article in press: January 14, 2017
Published online: February 4, 2017
Processing time: 147 Days and 13.3 Hours
Abstract
AIM

To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients.

METHODS

An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital’s Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed.

RESULTS

In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7% vs 93.1% in the Before group, P = 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P = 0.026) and 120-d (P = 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P = 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P = 0.049) and a lower cumulative amount of parenterally (P < 0.001) provided calories by day 7, with an overall reduction in caloric provision (P < 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Before vs 76.9% After (P < 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition.

CONCLUSION

The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension.

Keywords: Gastrointestinal symptoms; Underfeeding; Nutrition protocol; Feeding protocol; Enteral feeding; Enteral nutrition; Parenteral nutrition; Critical care

Core tip: Following implementation of a nurse-driven enteral feeding protocol in a mixed medical-surgical intensive care unit (ICU) with a high baseline underfeeding rate, caloric intake via the enteral route was significantly increased during the first week in the ICU without concomitant increases in the frequency of gastrointestinal symptoms, intra-abdominal hypertension or use of prokinetic medication.