Abstract
Critically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Having observed that despite the presence of a nutrition protocol and dieticians, the patients with persistent critical illness (PCI) had been underfed during their ICU stay and particularly during the first 10 days, the aim was to analyse the impact of the organisational changes that were proposed to prevent the observed malnutrition. Before (Period A) and after (Period B) study enrolling critically ill patients consecutively admitted, requiring >10 days of ICU treatment. The intervention consisted in increasing the early morning interactions between dieticians, nurses, and physicians, while modifying the computer visualisation of the dietician proposals. The primary endpoint was a reduction in the cumulative energy balance in period B. The ICU stay was divided in early ICU stay (first 10 days) and late ICU stay (day 11 to day 30). Other variables: protein, glucose, and prealbumin. Altogether, 205 patients (150 and 55 in period A and B respectively) were enrolled in the PCI program. Patient characteristics were similar over both periods except for lower SAPSII score in period B. There was no difference in nutritional pattern in the first 10 days between periods. The cumulate energy balance was less negative from day 11-30 in period B than in A (-884 vs-1566 kcal; p=0.033). There was a one-day reduction in the median duration of fasting in period B (p<0.0001). Overall compliance with nutrition protocol improved in period B with an earlier first indirect calorimetry (p=0.003) and prealbumin measurement (p<0.001), the latter increasing significantly more during ICU stay. Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances.
Highlights
Background & aimsCritically ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome
Compared to patients admitted during period A, those admitted during period B had a lower critical illness severity (SAPSII: 51 vs 43; p 1⁄4 0.01) and a higher proportion of admissions for infection and sepsis (70.9% vs 52.0%; p 1⁄4 0.02)
The daily physical presence at the morning meetings increased the team's conscience about nutrition therapy resulting in more questions to the dieticians, improved the integration of the dieticians in the intensive care unit (ICU)-team resulting in a subjective significant time and efficiency gain. This cohort study shows that organisational measures are associated with an enhanced efficiency of feeding protocols, albeit modest: the early presence of the dieticians changed the way nutrition was delivered, resulting in significantly less negative energy balances after the first 10 days, the first being characterised by a progression of the intakes [2], and a closer monitoring of energy and protein intakes during the second period [13]
Summary
Ill patients requiring prolonged intensive care (ICU) treatment are at high risk of malnutrition, which latter contributes to worsening outcome. Conclusion: Organizational changes that allowed an early identification of patients at nutritional risk, an increased targeted dieticians intervention and a better inter-disciplinary work was associated with a reduction in undue fasting, and significantly improved energy balances. Patients with “persistent critical illness” (PCI) [3] are characterized by prolonged need of life support [4,5] and are at particular risk of malnutrition [4,6,7] After surviving their initial insult, these patients remain dependent on techniques exclusively available in the ICU and require up to several months before they can be discharged to a lower intensity ward.
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