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Running head: ENTERAL
Enteral Nutrition in Adult Patients in the Critical Care Setting
Mindy Blodgett
Paul Jackman
Melissa Ziesman
Creighton University
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Abstract
Guidelines have been established on when to initiate enteral nutrition, but current
research indicates multiple inconsistencies. This scholarly project sought to determine when
health care providers were initiating enteral nutrition for adults 19 years of age and older in the
critical care setting. It explored if there was a correlation between the timing of enteral nutrition
and outcomes including length of stay, 30-day readmissions, mortality, and other clinical
complications. A retrospective chart review was completed examining patients admitted or
transferred into a 25-bed intensive care unit (ICU) between January 1, 2013 and June 30, 2013.
A total of 104 charts were collected based on the billable procedure code enteral
infusion/nutrition, with 55 being eligible. The average number of days in the ICU was 3.3 days
before enteral nutrition was initiated. The timing of when enteral nutrition was started had no
statistical significance on mortality (p=0.54, 95% CI), 30-day readmissions (p= 0.58, 95% CI) or
ICU length of stay (p= 0.20, 95% CI). Although the results of this scholarly project do not
provide clear indication for early enteral nutrition, it does recognize some challenges to the
current standards for recognizing, diagnosing, and treating malnutrition in the critical care
setting. Future studies would benefit from a prospective study in order to standardize processes
related to nutrition. Standardized processes and a larger sample size would perhaps lead to
improved quality of data.
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Enteral Nutrition in Adult Patients in the Critical Care Setting
Since 1993, the number of patients discharged from the hospital with a diagnosis of
malnutrition has tripled (Corkins et al., 2014). This may be related to several factors such as
higher acuity, the aging population, and increased knowledge and recognition of malnutrition
among health care providers. Malnutrition is the "result of a relative or absolute deficiency of
energy and protein" (Baron, 2014, p. 1212). It can develop in several ways such as neglect,
starvation due to economic status, poor dietary choices/intake, eating disorders, or in association
with illness.
In a consensus statement by the American Society of Parenteral and Enteral Nutrition
(ASPEN) and the Academy of Nutrition and Dietetics, Skipper (2012) reports that the onset of
malnutrition may be accelerated by infection and inflammation. Malnutrition alters the immune
system by causing an increase in cytokines such as interleukin 6 and tumor necrosis factor (Eve
& Sair, 2009). The gut has more bacterial growth because of decreased contractility and
increased permeability (McClave, 2012). This, along with hyperglycemia, elevates the infection
risk.
In 2009, Jensen, Bistrian, Roubenoff, and Heimburger (2009) reported the need to update
the standards for recognizing and diagnosing malnutrition. Serum albumin and pre-albumin
levels are often used as markers for malnutrition and commonly used in diagnosis. However, low
albumin or pre-albumin levels may be due to inflammation, a systemic inflammatory response
and/or injury. Meaning, malnutrition may not be the sole indicator for a low level (Jensen,
Bistrian, Roubenoff, & Heimburger, 2009). Six clinical characteristics have currently been
identified in diagnosing malnutrition. These clinical characteristics include: "(1) insufficient food
and nutrition intake compared with nutrition requirements, (2) weight loss over time, (3) loss of
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muscle mass, (4) fluid accumulation, (5) loss of fat mass, and (6) measurably diminished grip
strength", with any two of these characteristics indicating malnutrition (Skipper, 2012, p. 261).
Multiple studies have demonstrated malnourished patients in the hospital are at risk for
poor outcomes. These outcomes include increased lengths of stay, readmissions, mortality, and
higher costs. Agarwal et al. (2013) found malnourished patients stay five days longer than wellnourished patients. Malnourished patients are at greater risk for readmission within at least 15
days (Lim, Ong, Chan, Ferguson, & Daniels, 2012). These patients are twice as likely to be
discharged with home care (Corkins et al., 2014). In addition, malnutrition nearly doubles the
chance of mortality in the hospital at 90 days (Agarwal et al., 2013). It also significantly
increases the likelihood of mortality post discharge at one, two, and three years (Lim et al.,
2012). The total hospital costs for patients with malnutrition are $26,944, which is nearly three
times higher than for patients without this diagnosis (Corkins et al., 2014). Within a population
group of interest, the elderly patient is particularly vulnerable, as 29% of patients 65 years and
older are malnourished at surgical or medical intensive care unit admission (Sheean et al., 2013).
The health care provider can treat and prevent malnutrition through oral, parenteral, or
enteral nutrition. It is widely accepted that patients who are critically ill have greater caloric and
protein requirements (Hoffer & Bistrian, 2013). Critically ill patients are defined as "those who
are at high risk for actual or potential life threatening health problems and are highly vulnerable,
unstable and complex" (American Association of Critical-Care Nurses, 2014, para. 2). Being
critically ill causes the body to become hypermetabolic with an increase in protein catabolism
and decrease of muscle (Eve & Sair, 2009). As a result, the critically ill patient requires more
protein and energy (Klein, 2011). Additionally, these patients are often unable to safely consume
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oral nutrition due to a non-functioning gastrointestinal tract, mechanical ventilation, facial
trauma, dysphagia, unconsciousness, or altered mental status.
If a patient has a functioning gastrointestinal tract, enteral nutrition can be provided
through a feeding tube that is inserted into either the stomach or bowel (American Society for
Parenteral and Enteral Nutrition, 2014). This is the preferred method for delivery (McClave et.
al., 2009). The feeding tube can be inserted via the nasal or oral cavities or by direct surgical
placement through the skin. In comparison, parenteral nutrition can be administered via a
peripheral vein if the anticipated need for nutritional support is less than seven days (Pertkiewicz
& Dudrick, 2009). If nutritional support is anticipated for greater than two weeks, parenteral
nutrition should be delivered through a catheter placed into a central vein that extends into the
superior vena cava (Baron, 2014).
Enteral nutrition has a particular benefit in helping reduce some of the inflammatory
responses to lack of nutrition. It can increase intestinal contractility, which helps control bacterial
overgrowth (McClave, 2012). Enteral nutrition can stimulate immunoglobulin A to be released
(McClave, 2012). Immunoglobulin A is important because it prevents bacteria from adhering to
the wall of the gut. Finally, enteral nutrition can actually help stimulate more blood flow into the
gut (McClave, 2012). Without enteral nutrition, the critically ill body becomes proinflammatory
(McClave, 2012).
Early enteral nutrition is not without adverse reactions. According to Heyland, Dhaliwal,
Gramlich, Dodek, and the Canadian Critical Care Practice Guidelines Committee (2003), there
can be problems with early enteral nutrition in the critically ill. In fact, early enteral nutrition can
be associated with high gastric residual volumes (GRVs), increased bacterial settlement in the
stomach, and an increased risk of aspiration.
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Patients in the intensive care unit (ICU) may not receive any nutrition on nearly 20% of
their days, and it takes an average of 46.5 hours to start enteral feedings after admission (Cahill,
Dhaliwal, Day, Jiang, & Heyland, 2010). These findings, along with others in the literature, gave
compelling reason to study enteral nutrition. This scholarly project sought to determine when
health care providers were initiating enteral nutrition in adults 19 years of age and older in the
critical care setting. It explored the correlation between the time of initiating enteral nutrition and
the clinical outcomes of ICU length of stay (LOS), readmission rates within 30 days of
discharge, and mortality. Also examined in this scholarly project were the clinical complications
of hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and aspiration
events.
Review of the Literature
The literature review was completed to explore the current knowledge about nutritional
options, timing of enteral nutrition, and complications of enteral nutrition in the critical care
setting. Patients in the critical care setting have unique challenges related to nutrition. PubMed
and Summon were the databases used for this literature review. The key words in the searches
were enteral nutrition, parenteral nutrition, nutrition, early enteral feeding, early enteral nutrition,
delayed enteral nutrition, timing of enteral nutrition, critically ill, intensive care unit, mechanical
ventilation and trauma.
Nutritional Options
For patients who cannot safely consume oral nutrition for medical reasons, enteral or
parenteral nutrition are alternative choices. Current literature reveals parenteral nutrition has
demonstrated some benefit. Adult patients who received early parenteral nutrition did have more
adequate protein and calorie intake than those receiving early enteral nutrition alone
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(Kutsogiannis et al., 2011). Yet, early enteral nutrition was linked to lower 60-day mortality
rates, ICU and hospital stays, and days requiring mechanical ventilation than those receiving
parenteral nutrition at any time. Chung et al. (2013) reported similar findings among adult ICU
patients who suffered blunt trauma. In these patients, many were unable to obtain caloric goals
with enteral nutrition only (Chung et al., 2013). Furthermore, if providers attempted to pursue
aggressive enteral nutrition within the first week of admission, this led to VAP. However, using
parenteral nutrition was associated with mortality and VAP as well.
Altintas, Aydin, Turkoglu, Abbasoglu, and Topeli (2011) did not find length of stay or
mortality differences between early enteral nutrition and parenteral nutrition. This study was
conducted on patients in the medical ICU requiring mechanical ventilation. Adult patients
provided with parenteral nutrition actually reached feeding goals before those with enteral
nutrition. However, parenteral nutrition in this study was also associated with increased time on
the ventilator. Overall, Altintas et al. (2011) stated parenteral nutrition is a safe alternative
treatment when enteral nutrition cannot be provided.
Enteral nutrition is still preferred in most circumstances, and all current guidelines
recommend its use if appropriate. Enteral nutrition provides support to the structural integrity of
the gut and helps to lessen stress, the systemic immune response, and disease severity (McClave
et al., 2009). Even providing at least 10% or more of total caloric intake with enteral feedings
was significant enough to lower mortality compared to those with 90% or more of total caloric
intake from parenteral nutrition in adult patients in a surgical ICU (Hsu et al., 2012). Based on
these findings, Hsu et al. (2012) favored enteral nutrition and recommended it should be
provided if possible.
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Cahill et al. (2011) and Doig et al. (2013) determined parenteral nutrition was not
superior even when administered to adult patients who were unable to have enteral nutrition.
Receiving parenteral nutrition at any point during the ICU admission did not decrease the
hospital or ICU stay (Cahill et al., 2011). Early parenteral nutrition was associated with a
decreased number of days on the ventilator, but there were no differences in 60-day mortality
rates (Doig et al., 2013). Also, the fewer number of days on the ventilator did not reduce length
of stay in the ICU or hospital. Casaer et al. (2011) concluded starting parenteral nutrition after
eight days, or late parenteral nutrition, correlated with decreased ICU length of stay and time
requiring mechanical ventilation in adult patients. These patients also developed
hyperbilirubinemia and hypoglycemia more often, but had lower total costs versus early
parenteral nutrition. There were no differences in ICU, hospital, or 90-day mortality rates
(Casaer et al., 2011).
It is important to note Strack van Schijndel et al. (2009) found critically ill, mechanically
ventilated adult female patients reaching nutritional goals of optimal energy and protein showed
decreased mortality, most significantly at 28 days. The same conclusions were not reached for
the male population. This study highlights the need for providers to address caloric, energy, and
protein goals.
Initiation of Enteral Nutrition
In 2009, ASPEN and the Society of Critical Care Medicine (SCCM), published
guidelines regarding nutritional therapy specifically directed towards the critically ill medical or
surgical patient (McClave et al., 2009). These guidelines are for adult patients who are likely to
be in the ICU for more than two days, admitted for more than observation, and have some degree
of traumatic or metabolic stress. According to the guidelines by ASPEN and SCCM, enteral
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feedings should be initiated early (within 24-48 hours of admission) and only after hemodynamic
stability is achieved (McClave et al., 2009). Providers should not start enteral nutrition that will
be going to the small bowel if a patient has a mean arterial pressure below 60 mm/Hg (McClave
et al., 2009). This is especially relevant for patients who require vasopressor agents such as
norepinephrine or titration of these medications to sustain an adequate blood pressure.
The European Society for Clinical Nutrition and Metabolism (ESPEN) published
guidelines on the use of enteral nutrition in critically ill patients in 2006. The guidelines state
patients should be administered enteral nutrition if it is unlikely they will tolerate a full diet
orally within at least three days (Kreymann et al., 2006). At the time of publication, there was
insufficient scientific data to support a correlation between early enteral feedings and improved
outcomes. Nevertheless, it is still recommended to start early enteral feedings within 24 hours in
hemodynamically stable patients (Kreymann et al., 2006). In addition to being hemodynamically
stable, the patient should also have adequate gastrointestinal function. Enteral feedings are
preferred to parenteral feedings due to decreased infection rates and lower costs; however,
Kreymann et al. (2006) stated parenteral feedings can be added to enteral feedings if the patient
is not meeting the target caloric and protein intake.
As with the American and European guidelines, the Canadian guidelines recommend
early enteral feedings within 24-48 hours after admission in patients receiving mechanical
ventilation who are hemodynamically stable (Heyland et al., 2003). In making this
recommendation, the committee reviewed several different trials comparing the use of early
enteral feedings versus delayed feedings (oral, enteral or parenteral), as well as parenteral
nutrition both alone and in conjunction with enteral feedings (Heyland et al., 2003). The
committee could not recommend the use of parenteral nutrition in conjunction with enteral
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nutrition in patients with an intact gastrointestinal tract and discouraged its use routinely
(Heyland et al., 2003).
Researchers have found a correlation between early enteral feedings and improved
outcomes in ICU patients. Woo et al. (2010) conducted an observational study with 36 adult
patients in a medical ICU in which half received enteral feedings within 24 hours of admission.
The other 18 patients had delayed enteral feedings. The patients receiving early enteral feedings
had shorter lengths of stay in the ICU, lower hospital mortality, and less days receiving
mechanical ventilation. There were no statistically significant differences in hospital stay or
bacteremia.
In another study, patients with delayed nutrition had a longer ICU stay and time on the
ventilator, but there were no differences in mortality rates (Nguyen et al., 2012). This was a
prospective study with 28 patients 17 years and older in a medical-surgical ICU. Patients were
excluded if they had another ICU admission within the past 14 days, had a history of stomach or
esophageal surgeries, surgery on the abdominal cavity within the past four weeks, or were being
provided parenteral nutrition. The first group received enteral feedings within the first 24 hours
of ICU admission. The second group received no nutritional support within four days of their
ICU admission.
Huang, Hsu, Kang, Liu, and Chang (2012) found no correlation between the start of
enteral feedings and hospital mortality of adult patients in a medical ICU. The only factor that
influenced mortality was illness severity. More severely ill patients who received early enteral
nutrition had longer ICU length of stay, although this did not influence the overall hospital length
of stay. Interestingly, these patients also had higher albumin levels, but increased nitrogen loss.
This retrospective study consisted of 108 patients divided into groups depending on the timing of
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feeding and severity of their illness. The Acute Physiology and Chronic Health Evaluation, or
APACHE II score, was used to determine severity of illness. Patients with abdominal
complications such as an ileus, bleeding, or acute pancreatitis were excluded. Enteral feedings
were early if they were started within two days of ICU admission.
Although limited, some research suggests patients typically considered inappropriate for
early enteral feedings may actually benefit from its use. While all of the standard guidelines
recommend against early enteral feeding for hemodynamically unstable patients, Khalid, Doshi,
and DiGiovine (2010) found early enteral feedings might be helpful for this specific population.
In the study, patients receiving early enteral feedings had decreased ICU mortality and hospital
mortality. The 1,174 adult patients included in this study were mechanically ventilated with
hemodynamic instability. Hemodynamic instability was defined as requiring vasopressor agents
such as norepinephrine, epinephrine, or phenylephrine within the first two days of receiving
mechanical ventilation. All of the patients were nonsurgical. Patients were divided into groups
depending on when enteral feedings were started. The early enteral feeding group received
nutrition within two days of mechanical ventilation, while those beyond two days were in the late
group. This difference in the literature gives a compelling reason to study the effects of enteral
nutrition initiation on malnutrition, mortality rates, readmission rates, days on mechanical
ventilation as well as other clinical complications discussed in the next section.
Enteral Feeding Complications
Complications associated with enteral feeding are highly variable. Complications can
range from common formula-related intolerances such as diarrhea, gastroparesis, gastrointestinal
discomfort, nausea, vomiting, electrolyte disturbances, hyperglycemia, hypervolemia, and
hyperosmolarity. Other more serious and potentially life-threatening complications consist of
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mesenteric ischemia, peritonitis, aspiration, pneumonia, and tube-related problems such as
damage or irritation upon tube placement or brain trauma associated with misplacement of a
nasogastric tube intracranially (Thomas, 2013).
Huang, Hsu, Kang, Liu, and Chang (2012) performed a retrospective observational study
in which they defined enteral feeding complications to specific parameters. Gastric residual
volume (GRV) was considered elevated if >250 mL. Vomiting was termed as feeding contents in
the pharynx or mouth. Diarrhea consisted of ≥3 bowel movements in patients who did not
receive laxatives or hyperosmolar medications in the previous 24 hours. Gastrointestinal
bleeding was paired with hematemesis, frank bloody stools, melena, and coffee ground material
in the feeding tube (Huang et al., 2012). Metheny (2006) describes further that GRV
measurements are frequently used to assess feeding intolerance and therefore risk for aspiration.
Micro-aspirations, defined as bronchial secretions containing pepsin, are far more common than
witnessed large volume aspirations. Risk for aspiration is increased with impaired gastric
emptying, sizeable GRV, and enteral nutrition delivery in the supine position. It was found that
patients who aspirated frequently while receiving enteral nutrition were four times as likely to
develop pneumonia (Metheny, 2006). The REGANE study was developed to determine a safe
limit to GRV that would not place the patient at higher risk of aspiration or pneumonia and
would also minimally interfere with meeting the caloric needs of patients receiving enteral
nutrition. It was determined that a GRV greater 500 mL would indicate a need to stop and
reevaluate the current enteral nutrition plan. Values less than 200 mL indicate tolerance while
consecutive values between 200 and 500 mL warrant careful observation (Montejo et al., 2010).
Other studies have suggested that checking GRVs is unnecessary. Published in JAMA, a
study was conducted that challenged the current standard for checking GRV in patients requiring
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mechanical ventilation that received early enteral feeding and their association with VAP
(Reignier, 2013). In this study, early enteral nutrition was defined as being initiated within 36
hours of intubation. A control group supporting a GRV limit of 250 mL showed no superiority in
preventing VAP and vomiting compared to the experimental group who did not check GRV.
Further, the experimental group also did not have interruptions in enteral nutrition allowing the
patients to reach their caloric goals in shorter time (Reignier, 2013).
Summary
The health care provider may choose to start enteral or parenteral nutrition for patients in
the critical care setting who cannot tolerate oral nutrition. Although current literature indicates
enteral nutrition is more advantageous than parenteral nutrition, the health care provider must
recognize patients do not always reach caloric or protein goals with enteral nutrition alone. There
is also conflicting research regarding the most optimal time to initiate enteral nutrition while
preventing complications. Therefore, it was determined more research was needed on nutritional
practices with a focus on early enteral nutrition. The purpose of this scholarly project was to
acquire evidence-based knowledge regarding the appropriate time to begin enteral nutrition, and
determine if there was a correlation to clinical outcomes and complications in the critical care
setting for patients 19 years of age and older.
Framework
Quality standards are necessary to encourage health care organizations to provide
excellent care and services to their patients. Donabedian developed the three components of
structure, process, and outcome to assess quality (Donabedian, 2002). Structure “is meant to
designate the conditions under which care is provided” (Donabedian, 2002, p. 46). This can refer
to the organizational and staff variables that influence outcomes. Examples of structure
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components are the health care facility, qualifications of the individuals providing care, and
equipment (Donabedian, 2002). Process is the actual administration of health care services like
delivering medical treatment and patient education (Donabedian, 2002). Finally, outcomes are
the measurable end points of the health care system that are divided into several classifications
including, but not limited to, physical, clinical, and psychological (Donabedian, 2002).
Outcomes are not always positive (Donabedian, 2002).
In this scholarly project, the focus was to contribute to the knowledge regarding the
appropriate time to initiate enteral nutrition using the Donabedian model. In recognizing the
structure and process components affecting the initiation of enteral nutrition, this scholarly
project sought to help the health care provider identify ways to improve outcomes and avoid
potential complications that occur.
Methods
Design and Sample
This scholarly project was conducted by completing a retrospective chart review.
Subjects were collected using a billable procedure code for enteral infusion/nutrition by Health
Information Management. Patients were admitted or transferred into the ICU between January 1,
2013 and June 30, 2013. Only patients 19 years of age or older were reviewed. The number of
subjects initially collected was 104. Of the 104 patients, 55 were eligible for the study. Subjects
were excluded for various reasons including transfer or death less than 48 hours after ICU
admission, oral or enteral nutrition prior to ICU admission, or documented inadequate bowel
function. Patients who electively chose to withdrawal enteral nutrition or had advance directives
with specific instructions to not initiate enteral nutrition were excluded from the study as well.
Patients who met criteria that were not discharged or transferred from the ICU prior to June 31,
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2013 were observed past this date to assess outcomes if applicable. The non-probability method
of convenience sampling was used.
Setting
The setting for this study was an ICU at an academic, Level One trauma center located in
a mid-sized city in the Midwest. The ICU had 25 beds, and patients were admitted with a variety
of diagnoses including cardiovascular, neurological, medical, surgical, and trauma conditions.
Data Collection
The demographic information obtained from the medical records of patients meeting
inclusion criteria included age, gender, weight (in kilograms) upon hospital or ICU admission,
discharge weight (in kilograms) from the hospital, and if mechanical ventilation was required at
any time during the ICU stay. Other data collected was ICU LOS and the number of days in the
ICU prior to initiation of enteral nutrition. Due to the data limitations of a retrospective chart
review, this scholarly project used albumin and pre-albumin levels as indicators for malnutrition.
As a result, admission serum pre-albumin, last known admission serum pre-albumin, serum
albumin, and last known serum albumin were also collected. See Appendix A for information on
the data collection tool.
It was necessary to determine how long after admission or transfer to the ICU that the
enteral nutrition was initiated. The outcome variables including ICU LOS, readmission within 30
days of discharge to the same facility, and mortality were then assessed. The complications
reviewed were aspiration (documented as pneumonitis), HAP, VAP, and tube feeding residuals
greater than 500 mL. These complications had to be documented as a diagnosis by a provider or
in the nursing assessment for inclusion in the study data.
Privacy Considerations
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Medical charts with protected health information were reviewed for this scholarly project.
As a result, there were potential threats to privacy and confidentiality of the patients. However,
no patient identifiers were collected and stored that would enable the data to be traced to a
specific patient. Therefore, encryption of stored data was not necessary. Only the investigators
conducting this study had access to the data, which will remain with a primary investigator of
this research not to exceed three years from the study completion as per IRB policy. This
scholarly project was submitted to the Creighton University Institutional Review Board (IRB) for
approval. In regards to informed consent from patients, a HIPAA waiver was not deemed
necessary by IRB.
Results
Statistical analysis was completed with the SAS System analytical software using a chisquare hypothesis testing. The mean age of the subjects was 58.27 years, with a SD of 15.63.
There were 37 males and 18 females. The median ICU LOS was 11 days. The average number of
days in the ICU prior to initiating enteral nutrition was 3.3 days. Six patients were readmitted to
this hospital within 30 days of discharge. Information regarding readmission to another hospital
was not available. Pre-albumin levels were collected on ten patients. As a result, pre-albumin
levels were no longer included in the study due to lack of values. As noted, weights were
collected upon admission to the hospital. However, weights upon discharge or transfer out of the
ICU were inconsistent. Therefore, discharge weights from the hospital were used for
comparison.
The 55 subjects were also screened for various complications. Eleven subjects developed
either aspiration pneumonitis or HAP/VAP. It should be noted, 50 of the subjects required
mechanical ventilation at some point. No subjects had tube feedings residuals greater than 500
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mL as documented by nursing staff, and many health care providers specified in the orders to be
notified if tube feeding residuals were greater than 200 to 250 mL.
The number of days prior to initiating enteral nutrition had no impact on mortality
(p=0.54, 95% CI) or 30-day readmission rates (p= 0.58, 95% CI). There was also no statistical
significance between the time of initiating enteral nutrition and ICU LOS (p= 0.20, 95% CI).
Furthermore, it was determined weight had no statistical significance on ICU LOS (N=55, df 1)
= 1.13, p=0.11, mortality (p=0.32, 95% CI) or 30-day readmissions to this facility (p=0.82, 95%
CI).
Discussion
The results of our scholarly project were not consistent with the results of previous
studies that showed benefit to early enteral nutrition. However, the results did support the need to
update the standards for recognizing and diagnosing malnutrition as Jensen et al. reported in
2009. Of clinical significance, weights were extremely variable. Certain patients had at least a 30
kg weight difference from admit to discharge. It was unclear from this retrospective chart review
to know if the weights were standardized or if this variability was due to operator error such as
not zeroing beds properly or using different scales (e.g. bed scale versus standing scale). One
clinical practice change may be to standardize how patients are weighed throughout an
institution to ensure accuracy.
As noted, guidelines support the initiation of enteral nutrition within 24 to 48 hours of
admission. Our study demonstrated it took an average of 3.3 days for health care providers to
initiate enteral nutrition. There also appeared to be no consistency to when health care providers
were starting the enteral nutrition. Pre-albumin levels, a marker for malnutrition, were not drawn
routinely. We found little documentation from health care providers on how the decision was
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made to initiate enteral nutrition. There was also no indication of why a certain enteral nutrition
formula was started or why a specific rate was chosen. Finally, we were unable to find
documentation of nitrogen balance or calculation of caloric needs by the health care provider.
Nitrogen balance can be used as a marker for adequate nutrition. Therefore, another potential
future change to clinical practice may involve developing a protocol to monitor this value.
Limitations
There were several limitations to this scholarly project. Our sample size was small, and
more subjects may have been helpful to establish an accurate evaluation and correlation. In
addition, this scholarly project was also limited by not taking into consideration if the patients
had been NPO prior to ICU admission or transfer, which could have impacted overall nutrition.
We did not account for severity of illness and how or if this affected nutrition.
Conclusion
Historically, malnourished patients experience longer hospital stays, frequent
readmissions, high mortality, and increased medical costs. In an attempt to acquire evidencebased knowledge about the documented benefits to early enteral nutrition, this retrospective chart
review did not reveal a correlation between the time of initiation of enteral nutrition and affect on
mortality, 30-day readmissions, or ICU LOS. Although the results of this scholarly project failed
to provide clear indication for early enteral nutrition, it did show challenges to the current
standards for recognizing, diagnosing, and treating malnutrition in the critical care setting.
Furthermore, this scholarly project indicated there was no consistency to when health care
providers were initiating enteral nutrition. Future studies would benefit from a prospective study
in order to standardize processes related to nutrition. Standardized processes and a larger sample
size would perhaps lead to improved quality of data.
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Appendix A
Data Collection Tool