A clinical audit to evaluate the effectiveness of, and adherence to a current trust protocol for enteral feeding

Abstract

Background: Enteral nutrition (EN) is the preferred route of feeding in intensive care unit (ICU) patients and has extensive benefits. The audit explored the main challenges associated with EN nutrition in ICU patients; accuracy of estimation of energy requirements and reasons for discrepancies between feed volume prescribed and delivered. A negative energy balance of ≥ 41 840 kJ (10 000 kcal) during ICU hospitalisation is associated with a significant increase in mortality and complications (Bartlett, 1982). The primary aim of the audit was to measure the cumulative energy deficit (CED) experienced by patients and assess the impact on two outcomes; ICU length of stay (LOS) and the number of complications. Methods: All neurosurgical patients admitted to the surgical ICU (SICU) between 24 September 2010 and 19 November 2010, who were receiving EN nutrition for ≥6 days and were ≥18 years of age were included. Fifteen SICU patients, who were mechanically ventilated, were followed, over a combined total of 291 nutrition days. Estimation of energy requirements was calculated by the Protocol recommendation of 105 kJ kg−1 day−1 (25 kcal kg−1 day−1) and compared with the Schofield predictive equation. CED was calculated by the difference between energy prescribed and delivered. Statistical analysis included multiple regression and t-tests. Results: The mean CED was 43 447 kJ (10 384 kcal). The main reason for feed volume discrepancies was a result of surgery or procedures taking place (31% of disruptions). The mean number of hours (NOH) before the feed was started was 25.3 (15.5) h. Patients spent between 24 and 187 h off the feed during their ICU stay. The NOH off the feed during the ICU stay (r2 = 0.631) and the NOH before EN feeding started (r2 = 0.249) showed a positive, moderately strong, linear relationship with the CED. The number of complications was not significantly associated with the CED. Combining LOS data from previous audits on the SICU found that patients with a CED >41 840 kJ (10 000 kcal) had a significantly longer ICU LOS (P = 0.013). Using the Protocol calculation or Schofield estimation for energy requirements was not significantly different. Discussion: There was a lack of adherence to the protocol. The protocol effectively estimates energy requirements for the SICU population. The initial feed volume, rate of advancement and catch-up rates varied drastically. The gastric residual volume threshold of ≥200 mL hindered EN nutrition delivery. Time off the feed for procedures was extended and inconsistent between patients. A similar audit found that a large volume of enterally administered nutrients was wasted because of inadequate timing in stopping and starting EN feeding (De Jonghe et al., 2001). Conclusions: The audit measured the effect of the CED on two outcomes; ICU LOS and the number of complications. There was no correlation with the CED and number of complications. The CED was correlated with an increased LOS on ICU. All patients experienced a CED during their ICU stay. The CED was a result of insufficient feed delivery as a result of reduced compliance with protocol guidelines and guidance not covering all aspects of EN thoroughly.