Background

Routine gastric residual volume monitoring remains common in nursing practice. However, current evidence supports using a focused nursing assessment to identify signs and symptoms of enteral feeding intolerance such as abdominal pain, abdominal distension, and vomiting.

Local Problem

At the author’s institution, nurses and other clinicians began reporting inconsistencies in gastric residual volume monitoring along with frequent interruptions in the delivery of enteral nutrition.

Interventions

The quality improvement project included patients in the medical intensive care unit receiving enteral nutrition. Gastric residual volume monitoring was eliminated. Instead, enteral nutrition was suspended on the basis of signs and symptoms of enteral feeding intolerance. Multimodal education was provided to nurses, nurse practitioners, and physicians caring for these patients. Formative evaluation occurred via staff rounds, summative evaluation occurred through a staff survey, and nutritional adequacy was evaluated by tracking patient weight.

Results

The 6-week project included 37 patients on the medical intensive care unit service. Of these patients, 28 gained weight; the mean change in weight was +6.2%. The practice change was well perceived by staff and is now an established part of care for any patient receiving enteral feedings at the study hospital.

Conclusions

The deimplementation of routine gastric residual volume monitoring is supported by evidence. Use of a focused gastrointestinal nursing assessment to identify enteral feeding intolerance is safe, feasible, and effective and improves nutrition delivery and nurses’ workflow.

Nutrition plays a vital role in recovery for patients receiving care in the intensive care unit (ICU), and each patient’s nutritional goals must be individually tailored to fit their specific needs.1  Adequate nutritional intake in critically ill patients has been found to shorten stays, prevent complications, and improve outcomes, whereas underfeeding puts patients at risk for complications such as infection, impaired healing, loss of body mass, and impaired muscle function.1,2  When a patient cannot maintain adequate nutrition with oral intake, enteral feedings may be necessary to meet the patient’s nutritional needs. However, enteral feeding intolerance is a common complication in critically ill patients. Enteral feeding intolerance is defined as gastrointestinal dysfunction that interrupts the patient’s prescribed nutrition.3  Traditionally, nurses have monitored gastric residual volume (GRV) to identify slowed gastric emptying and enteral feeding intolerance. Routine GRV monitoring generally occurs at timed intervals per facility policy and measures the volume of content in the patient’s stomach either by gravity drainage or aspiration with a syringe; however, current evidence suggests this practice is outdated.4 

At the study hospital, routine GRV monitoring has been a long-standing practice. However, nursing staff in the medical ICU (MICU) began reporting inconsistencies in GRV monitoring along with frequent interruptions in the delivery of enteral nutrition. As a result, the available evidence was reviewed to support the deimplementation of this nursing practice (see Table).

Table

Sources included in literature review

Sources included in literature review
Sources included in literature review

The practice of GRV monitoring has never been standardized. The definition of a large GRV may vary by facility.6  Although the average threshold for suspending enteral feedings is about 250 mL of GRV, some facilities may suspend enteral feedings for volumes as small as 75 mL, whereas others may allow volumes up to 500 mL.4  Current clinical guidelines from the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition suggest that if GRV monitoring is used, enteral feedings should not be suspended for a GRV of less than 500 mL if the patient is asymptomatic.5,12 

Measurements obtained with GRV monitoring are often inaccurate and may be affected by various factors.7  These factors may be related to the feeding tube, patient, or investigator.4,11  Tube size may substantially affect the nurse’s ability to aspirate GRV.1  For example, a large GRV is more likely to be aspirated through a double-lumen tube than through a tube with a smaller diameter. One patient-related factor is positioning.4  For example, if the enteral tube terminates in the right side of the patient’s stomach but the patient is turned to the left, the nurse may not aspirate any GRV. However, the nurse may aspirate GRV when the patient is turned to the right. Investigator-related factors include the time and effort spent by the person measuring GRV. Intermittent, slow, and controlled aspiration using a syringe has been shown to yield larger volumes than other techniques.4 

The literature suggests that GRV monitoring does not affect patient outcomes such as rate of ventilator-associated pneumonia (VAP) and is an unreliable predictor of aspiration events.8  In one study, investigators found that the incidence of VAP was 15.8% in patients who received GRV monitoring and 16.7% in patients after this practice was eliminated, suggesting that no significant difference in rates of VAP was found in patients who had GRV monitoring compared with patients who did not have GRV monitoring.9  The American College of Gastroenterology clinical guideline for enteral nutrition suggests that GRV monitoring can accurately detect an aspiration event only 2% to 8% of the time.1 

Gastric residual volume monitoring is commonly associated with decreased nutrition delivery and underfeeding.9  In patients receiving enteral nutrition, evidence shows that the use of routine GRV monitoring is 10 times more likely to clog the enteral tube compared with no GRV monitoring, which may delay the delivery of enteral nutrition.1  A recent survey of nurses found that 25% reported interrupting enteral nutrition when a patient’s GRV was 125 mL or less; patients received 21.4% more of their prescribed nutrition when GRV monitoring was eliminated.6,7 

On the basis of the evidence, clinical practice guidelines published by the American College of Gastroenterology and jointly published by the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition suggest that routine GRV monitoring be eliminated and replaced with a focused nursing assessment for signs and symptoms of enteral feeding intolerance such as vomiting, abdominal distension, and abdominal pain.1,5  In response to these guidelines, members of the health care team in our MICU conducted a quality improvement project that replaced routine GRV monitoring with a focused nursing assessment for signs and symptoms of enteral feeding intolerance. The purpose of this project was to modify common nursing practice to improve the delivery of enteral nutrition and ultimately decrease complications related to malnutrition in critically ill patients.

Clinical practice guidelines suggest that routine GRV monitoring be replaced with a focused nursing assessment for signs and symptoms of enteral feeding intolerance.

Context

The MICU service treats patients with various conditions, such as respiratory disease or multiorgan dysfunction, who require critical care. Patients on the MICU service often require multiple forms of life support such as mechanical ventilation, continuous renal replacement therapy, and life-sustaining intravenous medications. The MICU is a 25-bed unit that is staffed around the clock with various interdisciplinary team members such as nurses, respiratory therapists, pharmacists, nurse practitioners, resident physicians, fellows, and attending physicians. The unit was also used as the primary COVID-19 ICU. Although many patients on the MICU service receive care on this unit, the volume of patients placed on this service means that these patients may also receive care on other units throughout the facility. The project included patients who received enteral feedings and were admitted to the MICU service for at least 7 days from January 28 to March 11, 2021. Other units that provided care for MICU patients included the medical critical care unit, coronary care unit, and bone marrow transplant unit.

Interventions

The quality improvement project eliminated routine GRV monitoring for patients on the MICU service receiving enteral nutrition. Instead, nurses were responsible for performing a gastrointestinal assessment every 4 hours to identify signs and symptoms of enteral feeding intolerance (abdominal pain, abdominal distension, or vomiting5 ). To deimplement the practice of GRV monitoring, interprofessional collaboration among nurses, physicians, advanced practice providers, nutritionists, and informatics specialists was required. Clinical informatics specialists played an essential role in ensuring that the order sets and nursing documentation were revised appropriately and made available to staff members in a timely manner. Registered dieticians continued to perform nutritional assessments and recommend prescribed nutrition. Nurses, physicians, and advanced practice providers received verbal and written education and were actively involved in implementing the project.

The project was approved by the assistant medical director and defined by 3 phases: electronic health record (EHR) updates, staff education, and implementation. In the first phase, nurses, physicians, and clinical informatics staff members worked together to modify the enteral nutrition orders written in the EHR. This phase included eliminating existing orders for routine GRV monitoring and adding new orders to pause enteral nutrition in patients with signs and symptoms of enteral feeding intolerance. These modifications were placed into an order set, or power plan, that was made available in the EHR to clinicians. The section for documentation of an enteral tube was updated to include a new drop-down box allowing nurses to indicate that the enteral feeding was suspended and document the patient’s signs and symptoms of enteral feeding intolerance (Figure 1).

Figure 1

Modifications to the electronic health record.

Figure 1

Modifications to the electronic health record.

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Nurses were responsible for performing a gastrointestinal assessment every 4 hours to identify signs and symptoms of enteral feeding intolerance.

In the second phase, education about the current evidence was provided to physicians, advanced practice providers, and nursing staff members who cared for MICU patients. Attending physicians received written instructions from the assistant medical director about how to order the modified power plan. Advanced practice providers received written education from the lead nurse practitioner for the MICU service about how to order the modified power plan. Nurses who provided care for MICU patients received more specific information about the change to nursing practice and the documentation changes in the EHR. A brief written overview of the practice change was provided to nursing staff via email and posted handouts (Figure 2). Verbal education to provide more detailed information about the current evidence and documentation changes in the EHR also took place during shift huddles or staff meetings for nurses on all units in which MICU patients were treated. Education occurred in January 2021 over multiple weeks and across both shifts.

Figure 2

One-page education for nurses and other clinicians in the medical intensive care unit.

Figure 2

One-page education for nurses and other clinicians in the medical intensive care unit.

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The new power plan and practice change were implemented on January 28, 2021. Patients on the MICU service with enteral access and new orders for enteral nutrition were included. These patients no longer had orders for GRV monitoring every 4 hours; instead, the nurse was responsible for using clinical judgment to assess for signs and symptoms of enteral feeding intolerance. If any of these were noted, the nurse suspended enteral feedings and notified the physician or advanced practice provider. The nurse was also responsible for documenting the suspension of enteral feeding and the patient’s signs and symptoms in the EHR.

Measures

Staff rounds occurred after implementation on January 28, 2021, and included the nursing staff and other clinicians administering care to patients on the MICU service. The purpose of these rounds was to address questions or barriers related to the elimination of GRV monitoring. Rounds with MICU physicians and advanced practice providers were informal and unstructured, whereas rounds with the nursing staff were guided by the brief written education handout that had been provided.

At the end of the project, an online, investigator-generated, 6-question survey was administered to nursing staff members via a survey platform (SurveyMonkey). The questions used either yes/no responses or a Likert scale and also provided respondents an option to leave additional comments. The survey’s main goal was to evaluate whether nurses thought that the elimination of GRV monitoring affected patient nutrition, nursing workflow, and interprofessional collaboration.

The effectiveness of the intervention was evaluated in March 2021 according to patient weight, as supported by the 2012 consensus statement provided by the American Society for Parenteral and Enteral Nutrition and the Academy of Nutrition and Dietetics. These recommendations, which are currently used by registered dieticians at the study hospital, provide an interpretation of weight loss and explain how to identify malnutrition in the context of acute illness or injury.10  On the basis of this information, each patient’s weight was measured up to 3 times over 4 weeks. The data were obtained from retrospective medical record reviews. Each patient’s baseline weight was established on admission to the MICU service. The second weight was recorded 1 week after admission. At this time, moderate malnutrition was considered a weight loss of greater than 1% from baseline, and severe malnutrition was considered a weight loss of greater than 2%. The last weight was recorded 30 days after admission. At this time, malnutrition was considered a weight loss of 5% or greater from baseline.10 

Staff Rounds

The MICU physicians generally did not pose any questions or mention barriers during rounds and readily accepted the modifications to the power plan in the EHR. Physicians and advanced practice providers gave positive feedback about the practice change, reported being notified less often about episodes of enteral feeding intolerance, and perceived that patients received more of their prescribed nutrition. The most common barrier identified among nursing staff at the beginning of the project was resistance to change. In response, we discussed the supporting evidence with the staff. The questions most commonly asked by nursing staff members were related to the changes in EHR documentation. These questions and concerns diminished over time, as evidenced by continued rounds and the staff survey results.

Staff Survey

The staff survey included responses from 83 nurses. Sixty-seven respondents (81%) thought the elimination of GRV monitoring improved patient nutrition, and 79 respondents (95%) reported improved nursing work-flow. Respondents generally said that the practice change did not positively or negatively influence interdisciplinary collaboration.

Data Collection

Weight data were collected over the 6-week project. Staff members received education about the importance of ensuring that the bed’s weighing scale was set to 0 before patient admission and that all extra items, such as pillows and Foley catheter bags, were removed from the bed before obtaining a weight. However, weight data may still have been affected by clinical conditions such as renal or hepatic failure. During the 6 weeks, 201 patients were admitted to the MICU service, and 54 patients on the MICU service received enteral feedings. Of these 54 patients, 37 were on the MICU service for at least 7 days and staff members could obtain at least 2 weight values for comparison. On day 7 after admission, 28 of these patients had gained weight. Four patients had lost less than 1% of body weight from baseline, indicating no malnutrition. Five patients had lost more than 2% of body weight from baseline, indicating severe malnutrition. According to these data, only 13.5% of patients met the criteria for malnutrition on day 7 on the basis of weight. The mean patient weight was 93.7 kg on day 1 and 100 kg on day 7. The mean change in weight among these patients was +6.2%. Of the 37 patients, only 2 were on the MICU service for 30 days. One patient gained weight, and another lost more than 5% of body weight from baseline, indicating severe malnutrition according to weight.

Additional Outcomes

Changes to the EHR allowed nursing staff members to document pauses in enteral feedings and signs and symptoms of enteral feeding intolerance. As a result, additional data collection included the reported incidence of enteral feeding intolerance. During the 6-week study period, nurses caring for MICU patients documented 66 instances of enteral feeding intolerance. Of these reported instances, enteral feedings were paused 37 times for abdominal distension, 1 time for abdominal pain, and 28 times for vomiting. Variables such as total feeding time, feeding volume, and time to reach the prescribed feeding rate may have been beneficial; however, these data were not collected.

After the 6-week project, meetings with physicians and nursing leaders were held to deimplement routine GRV monitoring throughout the study hospital. In these meetings, the group created an algorithm for nursing staff to follow for patients who developed signs and symptoms of enteral feeding intolerance (Figure 3). The power plan from the project was modified accordingly (Figure 4), the policy and procedure were updated in the hospital’s online database, educational materials were distributed to nurses via email, and the routine use of GRV monitoring was deimplemented across the study hospital in June 2021.

Figure 3

Tube feeding intolerance algorithm.

Figure 3

Tube feeding intolerance algorithm.

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Figure 4

Tube feeding power-plan.

Figure 4

Tube feeding power-plan.

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Changes to the EHR allowed nursing staff members to document pauses in enteral feedings and signs and symptoms of enteral feeding intolerance.

Current evidence acknowledges that routine GRV monitoring is outdated because it is ineffective in identifying enteral feeding intolerance and may also result in frequent, unnecessary interruptions in nutrition delivery.1  Although a large volume of evidence supports eliminating routine GRV monitoring, the literature contains few examples of how GRV monitoring has been deimplemented in practice.4  Deimplementation occurs in multiple steps. These steps include establishing a new process for identifying enteral feeding intolerance, eliminating routine GRV monitoring by nursing staff, and executing the new process in clinical practice. One strength of this project is that it describes an established process for the deimplementation of routine GRV monitoring that can be easily replicated across various acute care settings at minimal to no cost to the facility. Due to improved nursing workflow, staff members may also be less resistant to changing their practice.

Other studies on the deimplementation of GRV monitoring have measured different variables, such as caloric intake or percentage of prescribed nutrition, to quantify the value of this practice change.6,11  For our project, weight data were used to identify malnutrition. According to weight data, only 13.5% of patients met the criteria for malnutrition on day 7 after admission. This finding is consistent with the current evidence that supports the deimplementation of routine GRV monitoring. However, the data may have more significance when compared with other factors such as body fat, muscle mass, feeding volume, or recommended caloric intake, as opposed to being measured in isolation.10 

Overall, this project translates current evidence from paper to practice and demonstrates a relatively simple change in nursing practice that can make a significant impact. The positive outcomes of this project for both patients and staff members helped pave the way for an institution-wide change in nursing practice at the study hospital. This project complements the current literature and, as a result, may positively influence the adoption of this practice at other acute care facilities.

Some limitations of this project should be noted. The project was implemented during the COVID-19 pandemic, which affected data collection in various ways. The pandemic did not allow for data collection before the deimplementation of routine GRV monitoring, so we could not compare malnutrition rates before and after this practice change. Multiple variables such as sample size and patient diagnoses may have been affected. The short time frame of the pilot study resulted in a small sample size. The high volume of patients with COVID-19 on the MICU service may have resulted in less variety in the patient population than may have been present before the pandemic. Data collection revealed that 43% of the patients included in this project had COVID-19.

Although health care is often slow and resistant to change, the elimination of routine GRV monitoring is a safe, sustainable, and feasible modification to nursing practice that is long overdue. Areas for future study include the relationships between the deimplementation of routine GRV monitoring and variables such as feeding volume, prescribed caloric intake, and time to meet the prescribed feeding rate. Future studies on this topic should be considered, but current evidence combined with the results of this quality improvement project demonstrate that acute care facilities can deimplement routine GRV monitoring to increase the delivery of prescribed enteral nutrition, improve nursing workflow, and positively impact patient outcomes.

The author thanks Ellen Buckner, PhD, RN, CNE, AE-C, FNAP, for academic support and project and manuscript assistance; Daniel Kelmenson, MD, for project approval and support; Bonny Joly, MSN, RN, CCRN, for project support; Jennifer Oswald, MSN, RN, for project support and for playing a pivotal role in the housewide implementationof the practice change.

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Footnotes

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 27071 Aliso Creek Rd, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, reprints@aacn.org.

 

Financial Disclosures

None reported.

 

See Also

To learn more about gastric residual volume in the critical care setting, read “Gastric Residual Volume Measurement: Necessary for Safe Practice?” by Williams in AACN Advanced Critical Care, 2021;32(1): 110-112. https://doi.org/10.4037/aacnacc2021663. Available at www.aacnacconline.org.