Background

Iatrogenic malnutrition is a significant burden to patients, clinicians, and health care systems. Compared with well-nourished patients, underfed patients (those who receive less than 80% of their daily energy requirement) have more adverse outcomes related to nutritional status. Volume-based protocols allow for catch-up titrations, are consistently superior to rate-based protocols, and can be implemented in most settings.

Local Problem

This project was conducted in an 8-bed neuroscience intensive care unit in which up to 41% of patients who required enteral feeding were underfed.

Methods

This quality improvement clinical practice change project used a before-and-after design to evaluate (1) the effect of implementing a volume-based feeding protocol on the delivery of enteral feeds and (2) the effect of a nutrition-based project on staff members’ attitudes regarding nutrition in critical care. The effectiveness of a volume-based feeding titration protocol was compared with that of a rate-based feeding protocol for achieving delivery of at least 80% of prescribed nutrition per 24-hour period. Staff members’ attitudes were assessed using a survey before and after the project.

Results

During 241 enteral feeding days (n = 40 patients), the percentage of delivered enteral feeding volume and the percentage of days patients received at least 80% of the prescribed volume increased after volume-based feeding was implemented. After project implementation, 74 staff members reported increased emphasis on nutrition delivery in their practice and a higher level of agreement that nutrition is a priority when caring for critically ill patients.

Conclusions

Using a volume-based feeding protocol with supplemental staff education resulted in improved delivery of prescribed enteral feeding.

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Volume-Based Feeding Protocol to Increase Enteral Feeds

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Volume-Based Feeding Protocol to Increase Enteral Feeds

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This article has been designated for CE contact hour(s). The evaluation tests your knowledge of the following objectives:

  1. Summarize the undesirable outcomes associated with iatrogenic malnutrition.

  2. Differentiate a rate-based enteral feeding strategy from a volume-based feeding protocol.

  3. Describe 3 strategies that lead to successful implementation of a volume-based feeding protocol in the intensive care unit.

To complete evaluation for CE contact hour(s) for activity C2463, visit aacnjournals.org/ccnonline/ce-articles. No CE fee for AACN members. See CE activity page for expiration date.

The American Association of Critical-Care Nurses is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation, ANCC Provider Number 0012. AACN has been approved as a provider of continuing education in nursing by the California Board of Registered Nursing (CA BRN), CA Provider Number CEP1036, for 1 contact hour.

Iatrogenic malnutrition—malnutrition related to action or inaction on the part of caregivers and clinicians in the acute care setting—is a common clinical problem for critically ill patients.14  Factors leading to malnutrition in the intensive care unit (ICU) include clinical conditions, increased metabolic demand due to disease processes, and therapeutic interventions that prevent sufficient calorie intake (eg, mechanical ventilation, dysphagia, or neuromuscular weakness).2,3  Iatrogenic malnutrition is not only a common problem but also a significant one; malnourished patients have more days receiving mechanical ventilation, higher infection rates, longer stays, and worse mortality rates than their well-nourished counterparts.17  Due to these poor outcomes, malnutrition is associated with an almost 300% increase in baseline health care costs, resulting in an estimated disease-associated economic impact of between $11 billion and $15 billion annually.3,5,7 

Medical nutrition therapy may be prescribed for critical care patients who are malnourished or at risk for malnutrition.2,4  Nutrition therapy is targeted so patients receive at least 80% of their daily energy expenditure.1,812  Patients who receive less than 80% of the prescribed nutrition therapy are considered underfed.1,8,1012  In the ICU, where patients may be unable to safely take nutrition by mouth as a result of disease (eg, stroke) or intervention (eg, mechanical ventilation), clinicians may use enteral feeding (EF) to meet patients’ nutritional needs. However, despite this effort, up to 78% of patients remain underfed, primarily due to feeding interruptions during EF delivery.24,6,7,9,12,13  Feeding interruptions happen for a variety of reasons, including periprocedural fasting, transport for radiologic examinations or testing, pauses for administration of medication (eg, phenytoin) or performance of nursing tasks, gastrointestinal intolerances (eg, nausea, vomiting, and high gastric residual volumes), and a lack of emphasis on nutrition in the ICU.2,6,8,14 

An evaluation of feeding practices in our neuroscience ICU revealed that up to 41% of patients were underfed, and a multidisciplinary quality improvement team convened to improve nutrition practices. A literature review revealed that for patients who require EF, underfeeding may result from using rate-based feeding (RBF), the strategy in place at the time of this initial evaluation.2,6,8,14,15  Rate-based feeding is the traditional and most common method for EF delivery.2,4  Prescriptions of RBF provide a constant delivery rate (eg, 40 mL/h) and result in underfeeding because they do not account for the volume not delivered during feeding interruptions.2,8,14,15 

A volume-based feeding (VBF) protocol is an alternative to RBF that is easily implemented in ICU settings and performed by trained nurses.6,14,1629  Volume-based feeding protocols account for feeding interruptions by titrating the delivery rate to achieve a 24-hour volume target (eg, 1300 mL in 24 hours).17,25,30  Volume-based feeding protocols compensate for volume lost during feeding interruptions by allowing titration of the delivery rate.6,14,1629  Multiple reports, including a recent meta-analysis, concluded that VBF is not more likely than RBF to cause adverse events (eg, feeding intolerance, hypoglycemia, or aspiration).6,14,1629  When compared with RBF, VBF is consistently superior in delivering at least 80% of prescribed EF.6,14,1629  Volume-based feeding implementation is most successful when the unit culture prioritizes nutrition.3032 

Malnourished patients have more days receiving mechanical ventilation, higher infection rates, longer stays, and worse mortality rates than their well-nourished counterparts.

This article describes a quality improvement clinical practice change project that improved nutrition practice in the ICU by implementing a VBF protocol to answer the following question: For ICU patients who require EF, does the implementation of a VBF protocol, compared with RBF, increase (1) the percentage of delivered EF volume and (2) the percentage of EF days on which patients receive at least 80% of the prescribed volume? Knowing that unit culture affects nutrition delivery, we also sought to determine whether implementing a nutrition-based project affected (1) staff awareness of the importance of nutrition and (2) the emphasis placed on nutrition delivery.2,8,14 

Lewin’s33  theory of planned change informed the planning and implementation of this project. This theory models change in 3 stages:

  1. Unfreezing: realizing the need for change and preparation to move away from the current equilibrium

  2. Moving: initiating a detailed action plan toward the desired outcome

  3. Refreezing: sustaining the change by incorporating it into the existing system3335 

Successful change requires an analysis of the environment to identify forces that will promote the desired change (driving forces) and those that hinder the change (restraining forces) and strategic planning to enhance and mitigate the impact of these forces on change.3335 Figure 1 illustrates the application of Lewin’s theory of planned change to this project.

Although many VBF protocols are described in the literature, no single protocol is superior to the others; using a titration protocol tailored to the local institution is more important than the protocol’s specifics.

This project was conducted over 24 weeks in an 8-bed neuroscience ICU at a 741-bed tertiary-level acute care hospital in the southeastern United States. The neuroscience ICU cares for adult patients with acute neurologic or neurosurgical diagnoses. Patients are treated by a multidisciplinary team including registered nurses (RNs), advanced practice providers, physicians, registered dietitians, and clinical pharmacists.

To compare the existing practice (RBF) with the desired change (VBF), we collected 12 weeks’ worth of electronic data for patients who received RBF; then we implemented the VBF protocol and collected an additional 12 weeks’ worth of data. The VBF protocol, developed by a multidisciplinary committee including RNs, advanced practice providers, physicians, registered dietitians, and pharmacists, was designed to ensure that it fit within the unit’s established workflow. Before implementation, unit and facility leaders, the facility department of research, and the institutional review board approved the protocol.

Protocol Development

Although many VBF protocols are described in the literature, no single protocol is superior to the others; using a titration protocol tailored to the local institution is more important than the protocol’s specifics.2,8,1012,30 Figure 2 illustrates the evidence-based protocol developed for this project. In our protocol, the clinician consults the registered dietitian on the morning a patient is initially identified as requiring EF. By noon, the registered dietitian enters EF orders for the desired patient-specific enteral nutrition formula and the 24-hour volume goal. On this initial day, EF delivery begins when the formula is delivered to the bedside, and the RN titrates the delivery rate every 2 hours to reach the target rate (the rate that would provide the total volume goal in 24 hours if uninterrupted) by midnight. Registered nurses then titrate the delivery rate every 4 hours to achieve the 24-hour volume target.

A review of published protocols highlighted several elements to consider when developing the protocol. First, although titration protocols are presented differently across studies (some as a chart, others as a formula), protocols derive the titrations using the following formula: adjusted rate = (24-hour volume goal – volume already infused) / hours remaining.14,1618,21,25,28,30  Our RNs used a bedside worksheet based on this formula to assist with titrations (Figure 3). Second, the published protocols showed that delivery rates as high as 150 mL/h were safe.14,16,17  However, because of traditional practices, planning committee members were hesitant to allow rates this fast, and the maximum delivery rate allowed was 75 mL/h. Evidence-based practices for the delivery of EF, including early initiation of feeding, avoidance of gastric residual volume assessment, and the use of prokinetic agents, were routine practice in the local environment.2,4,8,36 

Protocol Education and Assessment

Successful protocol adoption required front-end education to ensure competency with its use.14,16,17,21,28,30  We provided multiple in-person education sessions for staff members during the 3 weeks before VBF implementation (timed to minimize the impact on baseline data and allow sufficient time to educate the entire staff). Education sessions were provided at shift-change huddles and at additional times during day and night shifts. The sessions covered general information regarding nutrition therapy in critical care, an orientation to the improvement project, and specific information regarding the VBF protocol. The presentations were recorded and available electronically throughout the project. Participants completed an author-developed online knowledge assessment (multiple-choice and true/false questions) and demonstrated the correct use of the titration worksheet after these sessions. The online evaluation also included 4 Likert-type questions to assess participants’ beliefs regarding the importance of nutrition in the ICU. Participants then completed the same Likert-type questions after the end of the 12-week VBF period. Seventy-four unit staff members (10 physicians, 12 advanced practice providers, 5 registered dietitians, 3 pharmacists, and 44 RNs) completed the education sessions and assessments.

Measures and Analysis

We used EF days to evaluate the primary outcomes. An EF day was defined as any day a patient had an EF order at midnight and the order persisted for 24 hours.14  Each EF day was specific to an individual patient, so if 8 patients had orders for EF for the next 24-hour period, we counted 8 EF days for those 24 hours. Using EF days excluded days with less than 24 hours’ worth of data (typically the day EF was initiated and the day EF was discontinued) and allowed us to compare the volume fed between days.14  For the primary outcomes, we evaluated EF days in 2 ways: (1) delivered volume as a percentage of prescribed volume and (2) the percentage of EF days on which at least 80% of the prescribed volume was delivered. We used spreadsheet software (Excel, Microsoft) to evaluate descriptive statistics and run charts. Secondary outcomes regarding participants’ beliefs about the importance of medical nutrition therapy were assessed using Likert-type questions on the author-developed preimplementation and postimplementation assessments, and the answers were displayed graphically.

Forty-two patients required EF during the project period. Registered nurses used RBF during the first 12 weeks of the project and VBF during the second 12 weeks. Two patients were excluded from the analysis because they received only trophic feeds (feedings ordered as small volumes [eg, 10 mL/h] not meant to meet the patient’s nutritional needs but believed to produce some gastrointestinal benefit).2,4  Forty patients (19 in the RBF group and 21 in the VBF group) were included in the final analysis. The 3 most common diagnoses for patients were ischemic stroke, seizure, and intraparenchymal hemorrhage. The total population had 241 EF days (107 in the RBF group and 134 in the VBF group). In the total population, the mean number of EF days per patient was 6.03 (range, 1-21). The mean number of EF days per patient was slightly lower in the RBF group (mean, 5.6 [range, 1-15]) compared with the VBF group (mean, 6.4 [range, 1-21]). For the first outcome, we looked at the results in 2 ways: (1) as a total volume for each group and (2) in weekly increments for each of the 12 weeks. In the RBF group, 87 810 mL of a total of 147 480 mL prescribed volume (59.54%) was delivered, whereas in the VBF group, 157 538 mL of a total of 176 040 mL prescribed volume (89.48%) was delivered. Figure 4A illustrates the increase in delivered volume after the switch to VBF and displays the weekly trends. Results for our second outcome, the percentage of days during which at least 80% of the prescribed volume was delivered, were equally as promising. At least 80% of the prescribed volume was delivered on 29 EF days (27.10%) in the RBF group and on 115 EF days (85.82%) in the VBF group (Figure 4B). Additional analysis showed that 100% of the prescribed volume was delivered on 13 EF days (12.15%) in the RBF group and on 42 EF days (30.60%) in the VBF group.

The preimplementation and postimplementation surveys both received responses from 74 clinicians (Figure 5). Participant responses to the statements “Nutrition is an important consideration in the overall care of critically ill patients” and “Providing appropriate levels of nutrition to critically ill patients should be a priority” were categorized as “agree” (including “agree” and “strongly agree” responses), “neutral,” or “disagree” (including “disagree” and “strongly disagree” responses). Figure 5 illustrates a response shift toward more substantial agreement after the project.

We asked additional questions regarding staff members’ beliefs about nutrition delivery and the level of emphasis that they perceived the unit culture placed on nutrition delivery. Responses were categorized as “minimal,” “neutral,” or “high.” Figure 5 illustrates increases in both personal awareness of the importance of nutrition delivery and the perceived emphasis on nutrition delivery by the unit culture.

Iatrogenic malnutrition is a costly but solvable problem that affects outcomes at the patient and system levels. Critically ill patients are the most acutely vulnerable patients in the hospital setting and receive the most attention from clinicians; however, nutrition delivery is often grossly inadequate.1,2,4,6  Patients who require EF are at high risk for malnutrition secondary to underfeeding.2,4,11  Reasons for underfeeding in patients requiring EF include using an RBF strategy, not believing nutrition is essential, and not emphasizing nutrition delivery.2,6,8,14  Planning to mitigate these barriers allowed for project success; these results encourage others to do the same. In our project, VBF increased the volume of delivered EF and the percentage of days on which patients received at least 80% of the prescribed volume. This finding enhances the knowledge that VBF protocols consistently improve the delivery of EF.14,1618,21,25,28 

Most VBF projects reported in North America occurred in medical, surgical, or trauma units,14,1619,2228  whereas others have reported success in multiunit settings that included a neuroscience ICU.20,21,29  Although all critically ill patients who require EF are at risk for underfeeding, patients with acute neurologic disease may have a higher incidence of underfeeding due to hospital transfers for specialized care, severity of illness, oropharyngeal dysphagia, frequency of off-unit transport for radiologic examinations, and impaired mental status.37  This report strengthens VBF’s place in the neuroscience ICU as a viable way to provide adequate nutrition to these vulnerable patients. Because our project was successful and the evidence shows that VBF is successful in other unit types, our institution plans to expand the VBF protocol to other ICUs (medical, surgical, and cardiovascular).

We also evaluated whether the nutrition-based project impacted the staff’s beliefs about the importance of nutrition and the emphasis that the unit culture placed on nutrition delivery. The results suggest that nutrition-based projects increase awareness of the importance of nutrition delivery and the perceived level of unit emphasis on delivering nutrition to critically ill patients. Nutrition delivery in the ICU is a task sensitive to nursing care, and the increases in nurses’ awareness of the importance of nutrition delivery and the level of emphasis on delivering nutrition are promising results.15,31,32  An additional success of this project was the preimplementation and postimplementation assessment completion rates, which we attribute to the live, in-person education sessions in which we encouraged staff members to complete the evaluations before leaving the sessions. We provided at least 1 computer on which an assessment was preloaded and QR code links that participants could scan to complete the assessment on personal devices.

Although this project improved the primary outcomes, some considerations limit its generalizability and may inform future improvement efforts. The limitations of this project fall into 2 categories: (1) barriers related to EF and the VBF protocol and (2) barriers related to staff. General aspects of the project that limit its generalizability include the nonblinded, single-center, single-unit design. Also, although the numbers of patients and EF days were generally on par with those of similar studies, the sample size was small.28 

Barriers Related to EF and the VBF Protocol

One potential barrier identified during the literature search was feeding interruption due to high gastric residual volume and other gastric intolerances.2,4,8,15,36  Routinely assessing gastric residual volume and pausing EF according to the result is common in the ICU.2,15,36  Several authors have reported that forgoing this practice is safe; eliminating it altogether may also be safe.8,36  Updates to the local standard of care had discontinued the routine assessment of gastric residual volume before project implementation. Other routine practices on the unit to limit feeding interruptions include minimizing feeding pauses for position changes, bathing, and other procedures. Volume-based feeding is not associated with increased rates of gastric intolerance compared with RBF, and strategies such as using prokinetic agents and early mobility were in place to alleviate gastric intolerances.2,8,11,12  During the project we did not gather data regarding the reasons for or length of feeding interruptions during implementation, although doing so would have strengthened the report.

One unexpected limitation of this project was that the maximum rate for VBF titration (75 mL/h) might limit its success. Several project committee members were hesitant to allow higher rates because of tradition-based concerns. They required limiting the maximum delivery rate as a safety measure to prevent unexpected complications (eg, nausea, vomiting, or aspiration). Limiting the maximum delivery rate affected 2 patients (4 EF days) who would have required delivery rates greater than 75 mL/h. This project was successful; however, it would have been more successful without this limitation. Tradition and the desire to maintain established practices are barriers to change, but evidence-based practice requires health care professionals to evaluate current practices and keep an accepting mindset for change.38  Because we know that higher titration rates are safe, future implementations of the project will allow a higher maximum titration rate (150 mL/h).14,1618,21,25,28 

VBF is not associated with increased rates of gastric intolerance compared with RBF, and strategies such as using prokinetic agents and early mobility were in place to alleviate gastric intolerances.

Barriers Related to Staff

Previous studies evaluating the success of VBF protocols have identified staff-related barriers including VBF competency, protocol compliance, and staff turnover.16,17,25,28  Nurses’ protocol competency (knowledge about the protocol) and compliance (protocol use and accurate adjustment of EF rate according to the protocol) affect the impact of VBF on nutrition delivery.25,28  We verified competency with a knowledge assessment and return demonstration of titration calculation and pump programming. Tailoring the protocol to fit within the established workflow empowered the staff during the project’s design and encouraged compliance with the new workflow.28,30  Although we did not formally collect data related to protocol compliance, informal assessment of completed titration worksheets showed accurate rate adjustments throughout the project. Formal assessment and reporting of compliance data would strengthen the report. The potential impact of ongoing education requirements due to the rising use of short-term contract staff members and high staff turnover was minimized by timing the project start date to coincide with the onboarding of new contract and employed staff members.30,39  In the future, VBF education and competency verification will occur during new employee orientation and annual competency assessments.

A surprising staff-related limitation of the project became evident when we analyzed the preimplementation education assessment data: several respondents disagreed that nutrition is essential when caring for critically ill patients. This answer was surprising because multidisciplinary guidelines agree that providing nutrition for hospitalized patients is important.1,8,12  Unfortunately, follow-up that might allow for a deeper understanding of these attitudes is unavailable. Perhaps these responses reflect the consequences of waning formalized nutrition education across health profession curricula.40  As a result, clinicians are unprepared to identify and treat undernourished hospitalized patients.40  Thankfully, as shown in this project and others, educational initiatives focused on nutrition can change attitudes and improve nutritional outcomes.32,40 

Malnutrition caused by underfeeding is a clinically relevant problem with outcome effects at the patient and system levels. A VBF protocol increases the volume of delivered EF. Implementing a VBF protocol requires significant education and competency validation before implementation and has few or no additional costs; common barriers can be overcome with planning before the project starts. Efforts that ensure awareness of the importance of nutrition and increase the emphasis on nutrition delivery will likely be rewarded with successful implementation of VBF projects. Areas for future study include implementing VBF in units other than the ICU and examining the attitudes of bedside clinicians regarding nutrition delivery.

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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, [email protected].

 

Financial Disclosures

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare–affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

 

See also

To learn more about nutrition in the critical care setting, read “Fasting Versus a Heart-Healthy Diet Before Cardiac Catheterization: A Randomized Controlled Trial” by Woods et al in the American Journal of Critical Care, 2024;33(1):29-33. https://doi.org/10.4037/ajcc2024115. Available at www.ajcconline.org.