January: Enteral Nutrition Support Procedures
Happy 2018, friends! It will be a great
year for us, and I am thankful for all of you future RDNs! The provision of
enteral nutrition is an important skill set we work to develop during our clinical
rotations. ASPEN and the Academy continue to forge the path for best practice
in this arena, and it is interesting what they are learning. The focus seems to
be on the critical patients, as nutrition support is more rapidly indicated and
initiated “within 24-48 hours following onset of critical illness (Taylor et
al., 2016).”
This month’s selected continuing education
article looks at non-critical patients, comparing enteral nutrition protocol intervention
to standard practice, or rate-based feeding. Follow the link http://jandonline.org/article/S2212-2672(17)31610-6/pdf;
at the top of the web page, you can sign in using your AND membership login to
access the article in full.
Ortiz-Reyes,
L.A., Castillo-Martinez, L., Lupian-Angulo, A. I., Yeh, D. D., Rocha-Gonzalez,
H. I., Serralde-Zuniga, A. E. (2017). Increased efficacy and safety
of enteral nutrition support with a protocol (ASNET) in noncritical patients: A
randomized controlled trial. Journal of
the Academy of Nutrition and Dietetics, 118(1), 52-61.
Here
are the details, according to the abstract:
Background: Unintentional underfeeding
is common in patients receiving enteral nutrition (EN), and is associated with
increased risk of malnutrition complications. Protocols for EN in critically
ill patients have been shown to enhance adequacy, resulting in better clinical
outcomes; however, outside of intensive care unit (ICU) settings, the influence
of a protocol for EN is unknown.
Objective: To evaluate the efficacy
and safety of implementing an EN protocol in a noncritical setting.
Design: Randomized controlled clinical
trial.
Participants and settings: This trial was conducted
from 2014 to 2016 in 90 adult hospitalized patients (non-ICU) receiving
exclusively EN. Patients with carcinomatosis, ICU admission, or <72 hours of
EN were excluded.
Intervention: The intervention group
received EN according to a protocol, whereas the control group was fed
according to standard practice.
Main outcome measures: The proportion of patients
receiving !80% of their caloric target at Day 4 after EN initiation.
Statistical analyses
performed:
Student t test or Wilcoxon rank-sum test were used for continuous variables and
the difference between the groups in the time to receipt of the optimal amount
of nutrition was analyzed using Kaplan-Meier curves.
Results: Forty-five patients were
randomized to each group. At Day 4 after EN initiation, 61% of patients in the
intervention arm had achieved the primary end point compared with 23% in the control
group (P1⁄40.001). In malnourished patients, 63% achieved the primary end point
in the intervention group compared with 16% in the control group (P1⁄40.003).
The cumulative deficit on Day 4 was lower in the intervention arm compared with
the control arm: 2,507 kcal (interquartile range [IQR]1⁄41,262 to 2,908 kcal)
vs 3,844 kcal (IQR1⁄42,620 to 4,808 kcal) (P<0.001) and 116 g (IQR1⁄469 to
151 g) vs 191 g (IQR1⁄4147 to 244 g) protein (P<0.001), respectively. The
rates of gastrointestinal complications were not significantly different
between groups.
Conclusions: Implementation of an EN
protocol outside the ICU significantly improved the delivery of calories and
protein when compared with current standard practice without increasing
gastrointestinal complications.
Please discuss your thoughts on the
article. You can utilize any of the questions below as a launch pad, talk
about the study design, methods you would have done differently, what you
see as the next steps for researchers and for those of us who may practice
within this area, etc.
Q: EN protocols are defined as “different
interventions such as initiation at goal rate instead of gradual increase (ramp-up),
prophylactic use of prokinetic medications, and provision of compensatory
feeding when EN is interrupted.” The article was written in light of the fact
that less nutrition support protocols are in place for the noncritical patient,
and more research is focused on the critically-ill/ICU population. Explain why
you believe this is the case. Is this all bad? What do you think can and should
be done?
Q: The
article did not provide any insight into clinical outcomes/benefits of a
noncritical EN protocol, rather simply that the patients received more adequate
calories and protein. Do you believe that the successes of EN protocol in the critical
care setting can be utilized to predict outcomes of similar practices in the
non-ICU setting?
Q: At Memorial, each intern is tasked to
complete a tube feeding worksheet, with the goal of determining whether their
current practice of rate-based feeding is meeting the estimated energy needs
they have set for the patients to receive or if they need to consider
volume-based administration. The worksheet, as some of us are familiar with,
has you fill in the patients’ estimated nutrition needs, information about the
feeding (formula and rate), as well as, once the goal rate has been maintained,
how many mL of formula the pump administered over the previous 24 hours and how
many calories and protein were indeed provided. The final step is to determine
if the tube feeding met of the patients’ needs, and to what degree.
If you have completed your Memorial
rotation, what did you discover from completing your worksheet? Were your
results similar to the researchers’? If you have not yet done this project,
what do you predict may be the result? What do you see as some variables or
barriers to either approach (rate-based or volume-based tube feeding)?
Q: Do you have any other experiences or
knowledge of unintentional underfeeding? Are there additional articles you can
find to support, or refute, the findings and applications from this research?
Work
Cited Above:
Taylor,
B. E., McClave, S. A., Martindale, R. G., Warren, M. M., Johnson, D. R., Braunschweig, C., … Compher, C. (2016). Guidelines for the provision and
assessment of nutrition support therapy in the adult critically ill patient: Society of
Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition
(ASPEN). Critical Care Medicine, 44(2), 390-438.
posted by Kaitlyn Kavan @ 2:25 PM
21 comments
21 Comments:
I would suspect that the EN literature has predominantly focused on critical care patients due to the particular characteristics of that population being more conducive to EN research. Broadly speaking, I would suspect that critical care patients are under greater metabolic stress and more likely to be unable to maintain adequate oral intake. I would further speculate that the effects of nutrition support might be more readily evident in this population due to factors related to the above, thus making it a more attractive population for studies as well.
I do not think the focus on critical care patients is necessarily a bad thing, but greater attention to non-critical care patients is certainly warranted. Surely there must be some difference in needs in the general hospital population that merit more studies.
I am not sure the success of EN protocols in the critical care population can be used to predict success in a more general population. I think it can insofar as improving means of providing adequate calories and protein generally improves an individual's well-being, but as to more specific measures, such as LOS and mortality, I am unsure.
From my experience at Memorial, I found that the EN provided to the patients was always close to the patient's estimated needs. I think the lowest percent of needs met I came across was in the upper 80% range. With that said, I sadly do not remember any patterns or differences between patients whose feeding I recorded in the ICU versus the general beds.
To me, the results are pretty straight forward. ASPEN has guidelines that tell when to initiate EN in both critical and non-critical patients mostly because non-critical nourished (at least not malnourished) patients are able to hang out a bit longer without EN. But, I think the goal is always the same. Using the same criteria for all patients might be easier for hospitals to initiate and follow protocols.
At DMH, I was able to provide EN for non-critical and critical patients. I felt frustrated for non-critical patients because I felt as though their conditions were worsening without having proper nutrition. Some doctors tend to ignore nutrition until they can't any longer, and then we have to bother them to no end. It was much easier to initiate and monitor the provision of EN for critical-care patients RDNs play a more primary role in the interdisciplinary team in ICU settings, so I had a lot of the doctors put in consults or ask me when to initiate EN.
Overall, I think it would be beneficial to establish protocols for EN initiation in non-critical units. In my experience, some members of the interdisciplinary team weren't exactly sure what the protocol was and getting the correct labs to be drawn to monitor for refeeding syndrome was like pulling hair. With proper protocols, these frustrations for all members of the interdisciplinary team can be avoided.
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I just completed my first week of clinical and have not yet been introduced to the EN protocol at BroMenn, so I will use my classroom knowledge to try and develop an opinion/response to this article.
In my opinion, the hypothesis and corresponding results make complete sense. The ASNET protocol was highly successful in this study compared to standard practice. The standard of care uses several estimations, whereas the protocol has more definite guidelines.
When I think of a critically ill patient who is in need of EN, I consider a patient who is physically unable to intake food orally due to the progression of their chronic illness or severity of their trauma. This leads me to understand why researchers have spent the majority of their time focusing on the critically-ill population. On the other hand, when I consider non-critical patients, I think of those patients who are unwilling to take any food orally due to the negative side effects from medication or from just feeling lousy. For example, loss of appetite, taste alterations, and nausea are all symptoms that might cause patients to refuse a PO diet.
Based on what I already know about EN, I assumed you should not automatically initiate EN on a non-critical patient if you have not done all that you could to encourage PO intake and oral nutrition supplements. Based on what Jamey mentioned above, I can see where a protocol would be beneficial. I feel that in most cases, EN would be a last resort for a non-critical patient having limited or refusing oral intake, but EN could be initiated earlier and help everyone along the way.
When I get more in depth in my clinical rotation, I will continue to think more about the benefits an EN protocol for non-critical patients could demonstrate.
Like Rachel, I am just preparing to start my clinical work, so don’t have any first-hand experiences to share. However, I would agree with much of what has been said above by Mike, Jamey, and Rachel. To me, I think when a group of medical professionals including doctors, nurses, PAs, etc. think of critical-care patients their instincts automatically go to assessing nutritional status and the initiation of nutrition therapy methods like EN. However, when we have a non-critical care patient, nutritional status or the need for nutritional therapy doesn’t seem to be as pressing or as critical, for lack of a better word, to assess or consider. This may completely be a stereotype, but I don’t doubt that this is the vibe that I will get during my clinical experience based on what other interns have said. While I don’t think we can assume or predict that the results or successes of EN protocol within the critical-care population can be generalized to or assumed to be the same for the non-critical care population, I certainly think this is a topic worthy of more research and investigation.
In my opinion developing, establishing, and refining clear feeding and nutrition-related protocols is one of the best things we as RDNs can do to help get the rest of the medical world on the same page as us and to encourage them to give more attention to the importance of nutrition during illness/injury. While I know this is certainly no easy feat, it is one that we as RDNs can continue to work towards.
Very much looking forward to gaining more in-depth knowledge and real-world application experiences regarding MNT feeding protocols this semester @ UPH and MMC.
Although critically ill patients may be at higher likelihood of being on EN, eventually those patients become more stable and can transition down floors and don’t always have appropriate EN management/care when they move floors and staff. Or there are EN patients on general floors who will be on long term nutrition support that are not provided the care that they need. As we are always seeking the best possible patient outcomes, it doesn’t make sense for there to be clear protocols only for the ICUs without coinciding appropriate general floor protocols in place.
During my Memorial rotation, I found that my patients (general and ICU) achieved their goal intake about 90% of the time. Although there are multiple ways to achieve appropriate feeds, I found Memorial’s 21-hour rate prediction to be a good estimate to ensure patients get enough EN, while still account for time lost during procedures and such. Because some hospitals and nursing staff are better versed in EN, I think they may have more success at achieving EN goals and ensuring appropriate progression and EN protocol maintenance. The Memorial dietitians do a great job of being involved in rounding and are accessible when discussing patient care, which I think helps the nursing staff feel comfortable following their EN management recommendations. This relationship may also provide greater opportunity for other staff to ask questions and become more knowledgeable in EN management. As EN continues to impact patient outcomes and is a large component of patient care, I appreciate the idea of providing protocols for all floors. I also think continuing to improve staff awareness and knowledge about EN will assist in ensuring patients get appropriate EN management in the ICU or a general floor.
I wholeheartedly agree with Jamey, as some patients on general floors are overlooked and not able to heal appropriately due to poor EN initiation/management. Although general patients may not be our primary focus, the amount of patients on general floors I saw with EN running consistently during their stay or with needs for home EN management and recommendations was higher than I would have anticipated. I think we can often time underestimate the needs of general patients in terms of nutrition. Considering the strong emphasis we can place on tray line and general food service for patients in the hospital, why would we not place as much weight on EN as a source of nutrition? All of our patients need energy to heal right? Jenni highlights the main point very well, saying we need clearly defined practices to follow to ensure positive patient outcomes. As we progress in the amount of research we have for critical patients, I look forward to more research focused within the realms of non-critical patients and EN management.
Q: Explain why you believe this is the case. Is this all bad? What do you think can and should be done?
I believe that in the hospital setting, it is only natural to consider the more critically ill patients a priority over those that are less critical. That being said, the patient who is less critically ill doesn't deserve to have less quality care either. I completely agree with the need for a standard EN protocol to be in place even for patients that are not critically ill.
Q: Do you believe that the successes of EN protocol in the critical care setting can be utilized to predict outcomes of similar practices in the non-ICU setting?
I do not think that the data collected from a critically ill patient would be adequate to cover or equate to the conditions of a non-critically ill patient. There are so many cofounding factors that take place in the critical setting that are not present in the non critical setting.
Q: If you have completed your Memorial rotation, what did you discover from completing your worksheet? Were your results similar to the researchers’? If you have not yet done this project, what do you predict may be the result? What do you see as some variables or barriers to either approach (rate-based or volume-based tube feeding)?
The experiment at Memorial was very interesting in that the time taken for testing and other daily activities were taken into consideration and applied to the rate of the formula being administered. The study at Memorial did find that the patients were meeting nearly 100% of their estimated needs using these 22 hours for formula administration instead of 24 hours.
I agree with many of you that the noncritical patient population is under researched and could benefit from further examination. Consider a patient that is not getting adequate intake and their conditions worsen so that they become critical. Is it then neglect from the hospital and their team from providing subpar service?
I also agree that the conditions in both settings vary greatly would not act as adequate parallel comparisons. Yet again, the circumstances are very different and there are many additional factors that play a role in calculating estimated needs in the critical patient vs. the non-critical patient.
After reading this article, especially the introduction where the authors state how important it is to deliver 80% or more of calorie and protein requirements via EN in order to maintain gut integrity and decrease oxidative stress and inflammation, I wondered why there isn’t already a widespread EN protocol for noncritical patients. Although these patients are noncritical, they are receiving EN and in the hospital, which means there is obviously something wrong and their body needs to heal. We know that adequate nutrition, calories and protein help the body heal, therefore I believe there should be a EN protocol for noncritical patients. Since, at the current moment, there isn’t a set protocol, the RDN/doctor/nurse should be checking their patients to ensure they are receiving the correct amount of calories and protein.
While I do not believe the statistics from EN protocols for ICU patients can directly predict what the outcomes would be if EN protocols were created for noncritical patients, I do think it is worth researching the difference between EN protocol and standard of practice for noncritical patients. As there is already some research on this topic, I believe it would be beneficial to implement EN protocols for noncritical patients now and continue to research how these protocols influence patients’ healing.
Mike – I am very happy to hear the lowest you found at MMC was in the upper 80%s, that’s great!
Jenni- I completely agree with you that RDNs should work towards creating and utilizing scientifically sounds nutrition protocols and feeding practices, and that this would help the medical field immensely in regards to healing illness/injury.
Lauren, I hadn’t thought about what happens to ICU EN patients when they move floors and become noncritical. Thanks for bringing that up – this is definitely an important reason to have noncritical EN protocols. It would be a shame to help a patient recover partially due to ICU EN protocols only to have them relapse/decline in health because they moved floors and were no longer receiving adequate calories/protein from EN.
Lauren,
You picked a great article to get us interns about to start clinical in the right mindset!
I have not started clinical rotations yet so can only apply what I have learned in class to this topic. However, from my interpretation of the article, I think the authors purposefully picked the non-critically ill population to study since limited studies have focused on this population. I do not think this is all bad. I feel that it is actually beneficial to the body of research to know the effects protocols can have in this population. It would seem to me that a protocol that has been designed for critical patients would not translate very effectively to the non-critical patient or vice versa. Because of this I am not sure if successes of EN protocol in the critical care setting can accurately predict the outcomes in non-ICU settings. That is why research is both areas is beneficial. In other words, while the focus may be on critical care, non-critical patients should not be ignored. More evidence for proper EN protocols are needed in all settings. I think researchers should continue on this quest to discover what the differences between these two populations are and how these differences influences the separate protocols that are put into place.
Though I have not been to Memorial yet, it sounds like the worksheet they have each intern complete is a wonderful learning experience and may help me better understand the needs to patients on EN.
Erin- I agree with you. I was a little surprised that the non-critical population does not have more research backing up EN protocols. I feel like if more non-ICU patients were able to follow a set EN protocol they may recover faster. Some may even be prevented from down-grading to an ICU status if they were getting the nutrition support they need from the beginning. That is why research in non-ICU patients is just as important.
Jenni- I completely agree that RDNs have a wonderful opportunity and even a responsibility to continue contributing our knowledge about this topic to the medical community. We have to bring this topic to light so that other professionals can clearly see how important nutrition support is, not just for ICU patients but for general floor patients as well.
It is really great to see those who have already done clinical look at this topic on a new level. I can really tell you learned a lot during your time at the hospitals. I am looking forward to learning more about all topics related to clinical myself!
Jamey: I sympathize with your experience in trying to get labs drawn to monitor for re-feeding syndrome. I do believe it would be much easier to approach the interdisciplinary team if we could refer to a specific protocol for non-critical patients.
Rachel: Your assumptions about the use of EN are pretty accurate at least to my experience at Proctor. Often we would encourage supplements and snacks when intake was poor (as we should). If intake continued to be poor, we would try changing the supplement schedule and types. Generally, only if after this failed to improve intake would EN be initiated. Though I think we did a good job of deciding when to pull the trigger on EN, a more specific protocol for these non-critical patients could have been beneficial in this sense as well.
Lauren, I like that you bring up the relationship between the RDNs and the medical team. I am happy to hear that you observed such a great working relationship between the two during your time at Memorial, as I know this is often not the case. It got me thinking about how we could facilitate better working relationships within the medical setting, as individuals ourselves. While this is no doubt intimidating as an intern, it is something I will continue to ponder and consider during my clinical rotations. I hear or read about a lot of RDNs complaining about doctors/nurses and their attitude towards, and attention to, nutrition, but what are we doing to change this? What action(s) can we take? Should there be some sort of conference or workshops that physicians and dietitians attend together to help bridge this gap? Maybe something like this already exists…maybe some hospitals and clinics are better with this than others. After all, every hospital/health care facility or agency seems to have a different “culture”.
From my first two weeks at Decatur Memorial, I have gotten to experience the RD’s speak with the MD’s on multiple occasions regarding TF for individuals who are not in the critical care units. Though the RD’s have order writing privileges, it is ultimately the MD who has the final say in whether or not the patient will be placed on TF. This is very few and far between and I think the idea of placing patients who are not in critical care would be unwelcomed by MD’s. This may be one reason why research has not studied a non-critical patient population. I also think that MD’s overlook nutritional quality of care in patients who aren’t in a critical condition because they will be discharged sooner than someone who is critically ill. The RD has a more prominent role on a critical care floor than on a general floor. A.S.P.E.N. research suggests that approximately 15-60% of hospitalized patients are malnourished. I think this calls for reason to study and establish EN protocol for a non-critical population in order to see effects on LOS, readmissions, and disease progression secondary to heightened nutrition care and support. I believe the main reason behind research focusing on ICU patients related to the heightened nutritional risk these patients are susceptible to due to the high percentage of hypermetabolic and inflammatory diseases and injuries these patient present with. Also, like I stated earlier, I believe that RD’s have a more prominent role in the ICU setting so there is more research in order to give RD’s the tools to be successful and prove to MD’s that we are an asset to the interdisciplinary team.
As Jennie mentioned, along with what a lot of you are talking about, developing, establishing, and refining clear protocol is one of the best things for us as RDN’s. I believe the RDN’s get questioned a lot and the MD’s are less likely to get on board with aggressive nutrition care such as EN. If we have evidence to prove that our nutrition support diagnosis can provide a benefit to a non-critical patient, they may have more faith in our plan of action. It’s hard to argue with someone who can say, “I believe this patient needs EN because of (A) and research shows (B)”.
It seems like we are all very much in agreement that non-critical protocols need to be established. A good point was made that it is important to involve hospital management and other medical staff in this endeavor. Without their support and follow-through, RDNs would basically just be blowing smoke. Additionally, how do we consider the way that this impacts others and how they do their jobs? What do the conclusions of the article mean for the dietitians, physicians, and particularly the nurses? Another thing to think about is that even if we put in protocols (with a lot of time and work), how would we combat the lack of protocol adherence that is mentioned in the article?
Erin - I felt the same as you. It seemed obvious to me that having proper protocol would be advantageous to all patients in a hospital, not just ICU.
Austin - I agree that RDNs get questioned a lot in certain settings, especially when the pt is not an ICU. RDNs play a more important role in the interdisciplinary time in the ICU. We has loads of research and evidence to back us up--just look at our ASPEN guidelines! We can talk and spew these out left and right, but I think the greatest impact would be made if it was provided as education to all members of the interdisciplinary team. All employees have to do CBLs and go to in-services. I think performing in-services like the ones I lead for malnutrition and Nutrition Risk Screens but for nutrition interventions would be very helpful and would clear up a lot of confusion.
I am in agreement with the comment that this is not just a one-man's job and that efforts from other hospital staff must be involved. After being about four weeks into my clinical rotation, I have witnessed the incredible rapport that the RD's have with the RNs and MDs, and I am beginning to notice a necessary protocol for nutrition support in non-critical patients. I have only dipped my toes into tube feedings, but the from what I have noticed thus far at BroMenn, nutrition support is mainly initiated in critically ill patients. Those who are not critically ill, are pushed oral nutrition supplements. This basically just reiterates what we have all mentioned, a protocol needs to be established.
I love Erin’s comment that any non-critical protocol is better than no protocol at all. Additionally, as Rachel mentioned, there are certain “protocols” or steps taken in cases, but something more specific needs to be implemented. As the article stated, one study found that 71% of noncritical patients on exclusive EN received an average of 61% of their estimated calorie requirements. Thanks for the insight this month, everyone!
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