Implementing Volume-Based Feeding to Optimize Delivery of Enteral Nutrition

Abstract

Background At least 80% of ordered enteral nutrition should be delivered to improve outcomes in critical care patients. However, these patients typically receive 60% to 70% of ordered enteral nutrition volume. In a practice review within a 28-bed medical-surgical adult intensive care unit, patients received a median of 67.5% of ordered enteral nutrition with standard rate-based feeding. Volume-based feeding is recommended to deliver adequate enteral nutrition to critically ill patients. Objective To use a quality improvement project to increase the volume of enteral nutrition delivered in the medical-surgical intensive care unit. Methods Percentages of target volume achieved were monitored in 73 patients. Comparisons between the rate-based and volume-based feeding groups used nonparametric quality of medians test or the χ2 test. A customized volume-based feeding protocol and order set were created according to published protocols and then implemented. Standardized education included lecture, demonstration, written material, and active personal involvement, followed by a scenario-based test to apply learning. Results Immediately after implementation of this practice change, delivered enteral nutrition volume increased, resulting in a median delivery of 99.8% of ordered volume (P = .003). Delivery of a mean of 98% ordered volume was sustained over the 15 months following implementation. Conclusions Implementation of volume-based feeding optimized enteral nutrition delivery to critically ill patients in this medical-surgical intensive care unit. This success can be attributed to a comprehensive, individualized, and proactive process design and educational approach. The process can be adapted to quality improvement initiatives with other patient populations and units.

Contribution to the Validation of the Portuguese Version of the “Barriers to Enterally Feeding Critically Ill Patients” Questionnaire and Its Application in a Hospital Context

“…38 Soguel et al 39 found that teaching and continuous training provided by a nutritionist dedicated to the ICU, combined with the implementation of an optimized EN protocol, could improve the energy intake of critically ill patients by approximately 32%. Bonomo et al 40 observed an increase in the volume of EN provided to critically ill patients through the creation of protocols and training of HCPs through the teaching, demonstration, active involvement, and dissemination of educational materials.…”

Small bowel feeding: do you pay the price for bypassing the stomach?

“…Whenever adopted into clinical practice, this approach has seen substantial improvements in the mean and median volumes of enteral nutrition delivered to patients [47 ▪▪ ,48,49]. For example, Bonomo et al [47 ▪▪ ] in 2021 adopted this approach in a study of 73 patients admitted to critical care and were able to achieve a median rate of delivery of 99.8% of ordered volume of enteral nutrition. Adopting such new practices can be a challenge; however, a study from 2020 used quality improvement methodology to implement change subsequently demonstrated that more patients on a volume-based regime received adequate nutrition than those on rate-based feeding during the first crucial 7 days of nutrition support.…”

“…This represents a shift from an hourly rate target of enteral nutrition to a 24 h volume goal, therefore, limiting calorie and protein deficit [34]. Whenever adopted into clinical practice, this approach has seen substantial improvements in the mean and median volumes of enteral nutrition delivered to patients [47 ▪▪ ,48,49]. For example, Bonomo et al [47 ▪▪ ] in 2021 adopted this approach in a study of 73 patients admitted to critical care and were able to achieve a median rate of delivery of 99.8% of ordered volume of enteral nutrition.…”