Question 3
If you were a new dietitian staring in a hospital setting and wanted to start providing only 80 percent of goal calories for ICU patients, what would you say to a doctor to get them to agree with your recommendations? On the other hand, if you do not agree with this method of feeding, why not?
posted by blradwan @ 1:21 PM
55 comments
55 Comments:
If I were a new dietitian I would probably start off following protocol (if there is one) until I had rapport and respect from the doctors. If I were to recommend providing 80% of goal calories (or any other new or controversial therapy) I would make sure to have a good handle on what the research says. Evidence based practice is the way to go. Then the doctor and I could have a discussion about what to do for the patient based on research and our experise.
I would make sure I had enough evidence to support my decision to only give 80% of recommended calories and discuss this with the physicians (and possibly initiate this as a protocol in the ICU). However, like other types of feedings, I would like to start off slowly and gradually increase kcals if needed. I think slightly underfeeding in most patients would be safer than going straight to the goal kcal reqs...especially if they are receiving IV fluids and are not at nutritional risk or losing weight. Furthermore, We only have energy "estimates" and they are not definite metabolic measurements tailored to each individual that we calculate ones needs by.
Another thing to consider is that, in the surgical ICU primarily, pts have undoubtedly received anesthesia which does lead to a post-operative ileus in most pts. Starting refeeding off slowly is best to determine pts tolerance. Furthermore, medications must also be considered. Many pts in the ICU receive analgesics and/or PCA pumps. Most of these medications are opioid derivatives and can slow the bowels over long periods of time which could exacerbate gastroparesis and hyperglycemia as well as cause other side effects.
Nisa and Andrea I agree with you that it is important to follow protocol especially if you are a new dietitian. Andrea thanks for pointing out the importance of establishing rapport with the doctors so they are more willing to listen to your suggestions.
I agree with Andrea regarding following necessary protocol if applicable. Otherwise if ICU RDs are given free range with their recommendations, before recommending an 'x' amount of calories for the patient, I would approach the physician (oh holy decision maker) to show him the outcomes research to back my recommendations. Even then keep in mind that "recommending" 80% of goal calories does not ensure that is what the patient will ultimately receive. Too many factors play a role in how much nutrition support patients receive. Just because you walk into a patient’s room and see they are at goal rate, does not mean they are receiving their total goal intake.
As a new dietitian I would be very hesitant to start off providing just 80% of the goal calories for ICU patients. As research and new findings change often in the field of nutrition I feel that is important to have firm support and evidence that 80% of calories is the way to go. As a new dietitian I wouldn’t’ feel comfortable enough to provide the 80% of calories. I think with time and experience I might become more confident in recommending less calories as I develop the knowledge and the experience to recommend something like that to a doctor.
Andrea- I agree with you that you need to follow protocol until you had respect from the doctors. It is important that we have a good relationship with the doctors and they do know that we are the nutrition experts. With gaining respect, they will trust us to give the right diets and know the patients needs. But first I think it's important for us to gain experience, build trust, and become familiar enough to feel confident enough to make recommendations to the doctors.
I don't agree with this method of feeding because I think that more research needs to be done. I think that it is very important not to overfeed, but i'm not certain that only providing 80% of the patients calorie needs is the answer.
My initial response to this would be that more research needs to be done before this becomes protocol in the hospital. However, it makes more sense to me to start off at a lower end of kcal requirements, and increase the numbers as needed. With the current research, yes it does show that consuming less than the required number of calories produces a positive effect on patients in many ways. But again, more research needs to be done before I would discuss this with the physician. A novice dietitian, and also an experienced one for that matter, needs to keep up with research going on in order to have the knowledge of topics such as this.
Andrea,
I totally agreed with what you said about following protocol in the hospital when you are a new dietitian. As new dietitians, we have got to keep up with new research. Once we have enough evidence and knowledge on new practices and ideas, and we have gained the respect of our physician we are working with, then we can go ahead and make recommendations to them. After all, in health care, it is imperative that physicians, nurses, dietitians, and others work in cooperation and collaboration.
If I were a new dietitian I would probably start off feeding the patient more than 80% of the goal calories. I would also think to start at a lower percentage and gradually increase as needed. I feel I would act in such a way until I had more experience, knowledge and confidence to recommend only 80% of goal calories. I would want to make sure that I had enough evidence to support my decision before I were to discuss this with the doctors.
I do not agree with this method of feeding. There isn’t enough evidence to illustrate that reduced length of stay is dependent upon inadequate calorie intake. I don’t doubt there is a possible correlation between the two variables, however I think it is likely that there are other contributing factors that may promote early discharge.
As a new dietitian, I would not base my caloric recommendations for ICU patients on any one single study. The possible confounding variables for this study should be given great consideration when determining the accuracy and usefulness of this study. Furthermore, as a new dietitian, I will try to learn as much from the experienced dietary professionals who have worked in the field for many years. To question the authority of an experienced dietitian and a reputable health care provider/employer based on one rather questionable study would be arrogant of me to pursue. Though, gathering different RDs opinions on this matter could be beneficial in sparking a lively debate amongst dietetic professionals if one felt strongly enough about the findings of this article.
As a new dietician I would follow the hospital protocol that is already in placed. As of now, I would need to see further evidence that providing 80% of the calorie needs is best for the patient. If there was enough research and evidence, I would then show this to the doctors and hope that they would take this research into consideration. Having a research supported argument is important for assuring that the doctor takes your recommendations seriously. I would also keep in mind that each patient needs to be assessed on an individual basis and some may do better with more or less caloric intake.
Nisa-
I agree with what you said that energy needs are estimated and they can be adjusted based on need. I also agree with what you said about starting with underfeedings and gradually increasing these to see if they are needed. It is important to keep in mind what the estimates are, however the needs should be individualized based on what the patient needs.
I would look at each patient as a separate case and not decide to give everyone in the ICU 80% of needs unless it was warranted. If it was necessary, I would explain the benefits of giving the patient only 80% of their needs (i.e. Decreased risk of complications of certain conditions, quicker recovery, etc.) If the doctor agreed, I would begin slowly and monitor their progress. If the patient was losing weight, I would gradually increase as needed.
All comments have been great and most feel following protocol is very important. Most agree that more research need to be completed before establishing hypocaloric feedings. Also Shanell's comment is good because each patient is different and what works for one may not work for another.
If I was a new dietitian at an ICU I would follow what the protocol is for the hospital. If I was unsure what to do I would ask other dietitians that are working there what they would recommend. As for only providing a patient with 80 percent of goal calories I am undecided at this time if this would be a good thing for patients. I can see how it could work but also I feel there needs to be more research on this topic before it should become common in a hospital ICU.
Andrea,
I agree with you that following protocol is very important. Also, having rapport and respect from the doctors would be beneficial in making your opinion and suggestions be heard and listened to.
I would only make this recommendation if I was already trusted by the doctors. I am sure they would not agree with a controversial method unless I had proven myself previously. I would tell the doctors all I knew about the benefits of providing this caloric intake. I would make sure to provide them with evidence on the benefits so that they knew what I was basing my plan from. I would make sure I was prepared and sure of the diet because I would never want to lose the doctors trust in my work.
I would provide current research to doctors that might not agree with me. I think it would be hard to try something new with patients because people can be so rigid in their ways and used to a routine. It would be important to assess each person specifically and reassess as needed. Not everyone should receive 80% of needs, some may benefit from 60% for awhile, and others may need 90-100% based on their condition and tolerance to the nutrition support.
I would definitely think that this could be beneficial with some patients. As the article pointed out, several studies have shown this method of underfeeding to be beneficial for severely ill or traumatized patients. Obviously, this isn’t going to work with every patient; and each individual should be monitored closely for any signs of malnutrition, or intolerance. I would point that out to the physician and then offer some possible reasons for the more positive outcomes, such as that the body can spend more time healing and less on dealing with unnecessary metabolism (ex- lipogenesis). Patients also experience fewer bouts of hyperglycemia and/or hyperlipidemia, which could be used as clinical proof of the benefit of feeding at 80% of the recommendation.
Karlie - Great point: it is important to look at each patient on a case by case basis. Every patient will present with a different past medical history, reason for admission, etc. Others mentioned following protocol as the means for their decision, but as dietitians we also need to be leaders in our field - that means confronting other health care professionals regarding evidence based research. Be an active instead of passive!
I would first make sure I did a lot of research on the diet to make sure I knew everything I possible could so that when I presented it to the doctor I would know what I was talking about and be able to answer all of their questions. I would then provide the doctor with strong research that proved that by reducing the calories of ICU patients it helped reduce the amount of time they stayed in the hospital and it also reduced the complications they had while they were in the hospital. Lastly I would provide the doctor with a list comparing the benefits of the reduced calorie diet to the current diet to show how much it could improve ICU patients health.
If I wanted to gain the respect of the doctor and have him value my opinion as a new dietitian then I would need to back up my reason for restricting calories with research. I would give a brief explanation of why I believe the patient should have his/her calories restricted. Then provide evidence based research to back up my opinion. Being professional about conflicts of opinion can be crucial for a dietitian when working with the rest of the health care team.
Nicholas,
I agree that one should not base his beliefs on just one study. There needs to be considerable evidence with several studies before using new approaches. There are too many variables to consider to when basing ones opinion off just one article.
Jamie said...
I believe this method of feeding can be justified, however, as a newcomer into the dietetic career, I would not propose such an idea. To me, this only shouts trouble for the dietetic team, hospital, and patients. I would think that a drastic change such as this, would need to be well examined and a “newcomer” should not propose the idea (because of lack of accreditation and such).
The idea of providing only a percentage of a patients calorie needs for an effective treatment is a relatively new one and until further research is conducted I am hesitant that this is the correct protocol. This topic is like anything else in the field of nutrition and research is always informing us of new ways to deal with different situations, but requirements in such treatments never change until there is ample evidence to back up this change. If I were to recommend this diet plan for a patient I would want to acquire a wealth of knowledge on the subject before I mentioned the change in procedure to a doctor. If I was to put myself out there on a new procedure I would want to be the "expert" on this topic before putting it to the test. I would also want to be ready for the range of questions and comments I would more than likely receive from the doctors and other staff to show that I do indeed know what I am talking about and think this is the best way to treat this patient. I would want to be as prepared as I could possibly be but also take the doctor's and other professional's opinions into account when suggesting any time of new procedure.
This comment has been removed by the author.
Lauren,
You make a good point about more evidence on the subject. Since this question is about a new dietitian, the physicians in the hospital have not built a relationship with you yet and therefore, when starting a new treatment, you will definitely need to be an "expert" (as Lauren stated)on the subject. I agree that there should be further studies done on this topic to show firm evidence.
I would wait until more research had been done. ICU patients have a lot of health variables that hospitals want to be careful about. I would not want to reduce the patient’s calorie intake to 80% and risk them not getting enough energy or nutrients. The most important thing to me would be making sure I do my parent in helping them recover and meet their nutritional needs. If there was more research done saying that proving 80% of the calories goal helps reduce the patient’s hospital stay and did not compromise their nutritional health, then I might bring the issue of to the doctor.
I would do a lot of research before recommending something like that. Since I have only read this study, and it seems a little vague and inconclusive, I don't think I would immediately jump to recommend 80% to all ICU patients. It is important to look at each case individually. I know it is easy to say that now because I am not in a hospital with very little time, but I don't think it is good to generalize.
DMF,
I think thats a good idea. It is important to check with people who have been there a lot longer than you have, but it is also important to bring in new ideas and innovations.
If I were a new dietitian in a hospital then I would be sure to follow the established practices of that institution. I think that this research brings up an interesting new point but I believe more support is needed before putting it into standard practice. Especially for a new practicing dietitian who does not have all the experience that may be necessary to make this kind of judgment call. I agree with what's been said about needing to have established rapport with the physicians.
If I were a new RD, I would follow the hospital guidelines, if this was part of the them I would have no problem explaining it to the doctor. I would show the calculation for energy requirements of basic metabolic processes, I would explain that I would not add an activity or injury factor, because I wanted to keep the kcals at about 80% of needs. This is because providing too many calories will only put more stress on the pt and increase the length of recovery. At this point I am not sure how many hospitals actually follow this as it seems to be fairly new research.
I would first research this area further and support my opinion with evidence that this method decreases length of stay, etc. I would also explain that it is important to initially start feedings lower than calculated (ie/ 50% of goal rate) and to increase as tolerated. Once increased to 80% of the goal rate, I might suggest that we closely monitor the patient's weight, lab values, and overall health status. If the patient shows signs of malnourishment, we can adjust the calories accordingly.
Although Lori brings up a good point that she would not share her opinion unless already trusted by the doctors, it is hard for some doctors to listen to dietitians as they feel they "know all" or like to stick to their tried and true methods. It might take a convincing argument with supporting evidence (after being thoroughly researched) to make them see otherwise and to ultimately build respect. I also feel that a compromise might be helpful--to note that starting calories lower than the goal rate is key to check feeding tolerance and to slowly increase until at about 80% of needs then monitor for signs of malnourishment and increase calories as necessary.
Starting out in a new hospital, I would want to follow protocol. When I felt that it was necessary (and I felt comfortable giving my opinion) about only giving 80% of the requirements I would make sure to have research, studies, and examples of how and when this recommendation would be beneficial. As previously stated, this is one study and would need further research. This should be used as another option to use on a case to case basis. We have seen that it can increase recovery rate and reduce the patients stay; however, giving only 80% of caloric needs will not be the best option for all patients.
While working with patients it sometimes feels that it is a trial and error process to figure out the best treatment plan for the patient. It is crucial to recognize and understand this and to keep the patient needs in mind.
Vanessa,
I like what you wrote about what you would tell the Dr...starting low then increasing until 80% and checking tolerance. I also agree that it might be hard to convince a Dr., and supporting research would be needed. Hopefully, over time Dr.'s will learn to respect our opinion more!
Mary Ellen,
I agree with what you said about presenting the current research to the doctors, but also recognizing that every patient is different and some patients would benefit from more calories while others from less. It is still important to treat everyone individually.
With enteral and parenteral feedings it is recommended to start the patient at a slow rate to ensure that they will tolerate the feeding being given, not just because the article believes that this approach is better for the patient. When explaining to the doctor I would state my case by saying if the patient is not tolerating the feeding situation, it will be harder to bring their body back to a "normal" level, a very good reason when enteral and parenteral feedings should not be started at full strength right off the bat!
Breine:
I agree with your motion to be more active!! I think a lot of times people get stuck into ruts with their professions and don't continuously look for new research to alter/change their approaches. I'm not saying this new research finding is the end-all of nutrition support, but it, as well as various other research sources, should be considered in your final decision.
Jamie said…
Andrea, I had a difficult time in answering this question. I believe that ‘evidence-based practice is the way to go’ also, however, it would be very difficult to propose this idea being such a new member to the professional team. Then again, if there was an ample amount of evidence, the doctors may take the proposal into consideration. So, all and all, good point!
Nisa & Andrea: I agree that you want to make sure that the evidence is there before putting something so sensitive into practice.
Breine: You make another good point with patients not neccessarily receiving the entire amount intented. In fact, most ICU patients will not have the tube feeding or TPN running continously secondary to procedures or other issues. This was often a concern with our ICU patients.
In some facilities, physicians aren't even provided specifics about the feeding, in which case, the RD is soley responsible for the success or failure of the feeding. The only way to truely ensure positive outcomes with practices such as providing 80% of feedings would be to monitor the patient tightly. For instance, monitoring toleration and I & O's are important.
Jodee,
I agree with you in your approach to being very prepared in your presentation. Doctors may feel superior to you but it is our job to convince them that we know what we are talking about. Evidence-based seems like the best way to go.
Mary Ellen,
I agree that people can become resistant to change after following the same methods for so long. That is where hopefully the research can help persuade someone to take another view or at least consider it. I also like how you remind us that each patient is different and what works for one may not be beneficial for another—good thoughts Mary Ellen!
Steph and Vanessa, I agree with both of you on how it could be hard to convince a Dr. about a new research in the nutrition field without strong supporting evidence. Also agree with Steph that hopefully in the future dietitians will receive more respect.
Breine has made a great point that if the evidence based research is there then we as dietitians do need to be active. Change is a good thing when research is there to back it up.
Jodee:
I agree with. If I had current research that supported underfeeding, I would have to present it to the doctor. It is ultimately his decision anyway. He may not be aware of all the latest information
In response to the number of comments on following protocol in the hospital, I am not sure how many hospitals have protocol about the percentage of nutrient needs to be provided. In the two hospitals that I have had rotations at there is no such protocol. Also the dietitian is being consulted for their opinion of the situation and I think it is important to voice your opinion. There has been some additional research on permissive underfeeding in the short term for trauma, and critically ill patients.
I agree with brittney when she said that more research needs to be done. I don’t think any changes should be make until you have plenty of research from more than one source to make sure your requirements are correct. (this is pam moore)
It is reasuring to see that everyone would need more than a few studies to push a protocal onto a patient. This question could be applied to other areas of health such as doctors, nurses, endodonists, etc wondering if they would experiment with their patients based on one study.
I believe Nick brings up a great point that this method cannot be based off of just one study. When working in a hospital setting, it is important to remember to follow protocol, and just as Nick says, the RD should learn and base their experiences on those RD's who are knowledgable in the field as they are probably one of the greatest sources of knowledge.
Andrea-
I think you bring up a good point about how you should gain the respect of others before you try to start something new. If you have their respect they will be more willing to listen to you and take you seriously.
Mary Ellen,
Thank you for your insite into hospital protocol. I agree that a dietitian should voice their opinion in a hospital. That is why we are there.
Andrea,
I definately agree with you about following protocol. If I am to prescribe a diet that is less than the recommended servings, I would make sure I had enough evidence before I went to the doctor to discuss the situation. Evidence is key in these types of situations. (Pam Moore)
Post a Comment
<< Home