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Abstract

Introduction: The delivery of enteral nutrition (EN) is often late and insufficient despite evidence that early and adequate enteral feeding reduces mortality, decreases the risks of gut atrophy, systemic infections, prolonged intubation and ICU stay, and may improve neurologic outcomes in head-injured patients. A review of case records of 83 intubated Neuro-ICU patients admitted to our institution TTSH, National Healthcare Group, Singapore, from July to December 2010, revealed that only 25% of patients received at least 80% of their estimated energy requirements in the pre-implementation phase. Hypothesis: This study hopes to determine the effectiveness of an evidence-based proactive nutrition protocol in improving patients’ nutrition in the neurointensive care unit (NICU). Methods: Using Clinical Practice Improvement Programme (CPIP) methodology, a multidisciplinary team of doctors, nurses and ICU dietician created a cause and effect (fish-bone) diagram to identify the root causes. The Pareto chart revealed the major causes as: 1. Excessive peri-procedural fasting for surgery and diagnostic scans; 2. High gastric residual volumes; 3. Delayed initiation or not stepping up to goal rate of enteral feeding; 4. Excessive fasting prior to and post-extubation. Interventions adhering to Plan-Do-Study-Act principles were implemented: electronic nutrition charting, adopting best practice guidelines for cut-off values for high gastric residual volumes, ICU dietician review for all new intubated admissions, protocol standardisation and dissemination including standardized peri-procedural fasting times and the use of electronic nutrition advisory alerts. This nutrition support protocol was subsequently implemented from January to June 2011, and the impact of this protocol was evaluated prospectively in 88 consecutive intubated neuro-intensive patients. Results: The time to initiation of EN was significantly improved. The percentage of adequately-fed patients significantly improved from 25% (pre-implementation) to 40% (post-implementation), p< 0.05. Conclusions: Application of an evidence-based nutrition protocol, standardization and strict enforcement of feeding/fasting protocols, continual education, frequent reminders and multidisciplinary collaboration can improve nutrition in intubated Neuro-ICU patients. We need to recognize of importance of nutritional care as critical to patient-centric ICU outcomes. Application of present & firm evidence to direct patient care (transfer to practice), standardisation/optimisation of processes, leveraging on IT to facilitate best practices, and multidisciplinary collaboration can help to improve patients’ nutritional therapy.