Objective To evaluate the impact of implementing an enteral nutrition (EN) algorithm on achieving optimal EN delivery in the Pediatric Intensive Care Unit (PICU). Design Prospective pre/post implementation audit of EN practices. Setting One 29-bed medical/surgical PICU in a free standing, university affiliated children’s hospital. Patients Consecutive patients admitted to the PICU over two 4-week periods pre and post implementation, with a stay of > 24 hours who received EN. Interventions Based on the results of our previous study, we developed and systematically implemented a stepwise, evidence and consensus-based algorithm for initiating, advancing and maintaining EN in critically ill children. Three months after implementation, we prospectively recorded clinical characteristics, nutrient delivery, EN interruptions, parenteral nutrition (PN) use, and ability to reach energy goal in eligible children over a 4-week period. Clinical and nutritional variables were compared between the pre and post-intervention cohorts. Time to achieving energy goal was analyzed using Kaplan Meier statistical analysis. Measurements and Main Results Eighty patients were eligible for this study and were compared to a cohort of 80 patients in the pre-implementation audit. There were no significant differences in median age, gender, need for mechanical ventilation, time to initiating EN, or use of post-pyloric feeding between the 2 cohorts. We recorded a significant decrease in the number of avoidable episodes of EN interruption (3 vs. 51, p0.0001) and the incidence and duration of PN dependence in patients with avoidable EN interruptions in the post-intervention cohort. Median time to reach energy goal decreased from 4 days to 1 (p<0.0001), with a higher proportion of patients reaching this goal (99% vs. 61%, p = 0.01). Conclusions The implementation of an EN algorithm significantly improved EN delivery and decreased reliance on PN in critically ill children. Energy intake goal was reached earlier in a higher proportion of patients.

We demonstrate that our institution's Pediatric Early Warning Score is highly correlated with the need for unplanned PICU transfer in hospitalized oncology and hematopoietic stem cell transplant patients. Furthermore, we found an association between higher scores and PICU mortality. This is the first validation of a Pediatric Early Warning Score specific to the pediatric oncology and hematopoietic stem cell transplant populations, and supports the use of Pediatric Early Warning Scores as a method of early identification of clinical deterioration in this high-risk population.