Who Took My Food? - NorthBay
Who took my food?
Your Nurse did!!! What?
How much nutrition does your patient really receive? Total ordered: 1000 mL Actual delivered: 700 mL
Presented by Jennifer Veler, MSN, RN, CNL, CCRN Evidence-Based Practice Fellow NorthBay Healthcare ICU Project August 2, 2018
Underfeeding: Silent Starvation Syndrome Learning Objectives After completing the presentation: The learner will be able to describe how the project was developed and implemented The learner will be able to identify the significance of the results and the implications for practice change The learner will be able to explain the gastric residual volume (GRV) threshold and volume-based enteral nutrition (VBEN)
PICOT Question In adult critical care patients, how does a nurse-driven protocol for volume-based enteral nutrition compared to rate-based enteral nutrition without a nurse-driven protocol affect percentage of daily caloric intake goals and accuracy of nursing documentation?
Attain Definition: to reach as an end; gain, achieve (MerriamWebster, 2019) Objectives Implementation: Education PowerPoint & handouts ICU Skills Day Pilot the EBP project PDSA Implement in both ICU’s
Implementation Primary stakeholder meeting: nurse, Clinical Nurse Specialist, Registered Dietitian, Intensivist Formulate an algorithm Algorithm approval by Critical Care Medical Director & Registered Dietitian Algorithm approval by Nursing Director and Manager of Critical Care Services Formulate Daily Caloric Intake Tracking Sheet
Implementation Education sessions at the June Intensive Care Unit (ICU) Skills Day meetings Initial launch at VacaValley Hospital Intensive Care Unit Pilot for one month PDSA Implement project at NorthBay Medical Center Intensive Care Unit
Underfeeding: Silent Starvation Syndrome EBP Project Learning Objectives After completing the lesson: The nurse will be able to explain the gastric residual volume (GRV) threshold and volume-based enteral nutrition. The nurse will also be able to compute the volume to recover and make adjustments in the tube feeding rate.
Underfeeding: Silent Starvation Syndrome Problem: current standard of practice is rate-based enteral nutrition without a nurse driven protocol patient’s tube feeding turned off; assessment of gastric residual volume (GRV), tasks, diagnostics patient deprived of nutrition creating a caloric deficit patient’s daily nutrition goals are not met Purpose: an evidence-based quality improvement project implement a nurse-driven volume-based protocol for enteral nutrition increase caloric intake achievement of daily nutrition goals
Underfeeding: Silent Starvation Syndrome Significance: Majority of ICU patients are not fed enough calories or protein to allow for healing (61.2% calories, 57.6% protein) Statistics: Proportion of prescribed energy from EN according to initial EN delivery strategy. Heyland et al. (2015)
Underfeeding: Silent Starvation Syndrome Individual Studies of Importance Heyland, D., Dhaliwal, R., Wang, M., Day, A. found volume-based feeding met target of 80% caloric intake recommend initiate EN early using a protocol McClave, S., Mohamed, S., Esterle, M., Anderson, M., Jotautas, A., Franklin, G., Heyland, D., Hurt, R. found the greater the caloric deficit led to worsened patient outcomes, increased ICU LOS recommend volume-based EN Taylor, B., Roberts. P. found amounts of GRV for holding EN inconsistent recommend continued feeding if GRV 500 mL
Underfeeding: Silent Starvation Syndrome Operational Definitions Nurse-driven protocol – the nurse initiates the detailed plan of the medical/nursing treatment according to a set protocol. Barto ( ) Volume-based – allows for adjustment in the feeding rate to make up for interruptions or periods of feeding cessation. McClave et al. (2015) Rate–based - 24 hour estimated or measured requirements are provided continuously by a consistent hourly rate of infusion. This method does not allow for any means of correcting the deficit should cessation of feeds occur. McClave et al. (2015)
Underfeeding: Silent Starvation Syndrome Looking Ahead Implications for nursing: Empowerment Autonomy Decision-making Provision of care Evidence-based practice Principle stakeholders: Patient Improved outcomes Nurses Point of Care Intensivist Orders enteral nutrition, route, restrictions Registered Dietician Calculates daily caloric intake
Underfeeding: Silent Starvation Syndrome Algorithm Nurse-Driven Protocol for Volume-Based Enteral Nutrition Goal: Achieve 80% infusion of goal volume of enteral tube feeding by allowing RN to adjust infusion rate to recover interruptions in tube feeds. Intensivist orders volume-based tube feeding via nasogastric/orogastric route Registered Dietitian specifies formula Registered Dietitian calculates ‘Estimated Energy Needs High’ Kcal/day -Recovery of Missed Tube Feeding: Every 8 hours Nurse advances tube feeding by 20ml/hr q hr at most Nurse initiates tube feeding at goal (Ex: Goal 1200 mL/24 hours, initiate feeds at 50mL/hr) -Maximum Infusion Rate: 150ml/hr -Reset the 24 hour goal at 0700 Check GRV q4h Maximum Gastric Residual Volume (GRV) threshold: 500 mL Is GRV 500 mL? NO O Refeed GRV & continue tube feedings YES Consider Prokinetic Medications: Refeed to maximum of 500 mL; discard excess; hold feeds; recheck residual in 1 hour -Metoclopramide HCl 10 mg IV q6hrs : -Metoclopramide HCl 5 mg IV q6hrs (renal impairment) -Erythromycin 250 mg NGT/OGT q8hrs Rechecked GRV 500mL? NO Consult Intensivist for Prokinetic medication &/or post-pyloric/small bore feeding tube YES
Physician orders Enteral Feeding continuous
Free Text: Volumebased Feeding Protocol
Find the Total Volume Goal
Click box to expand menu
Check Re-fed Feeding Residual
Document Re-fed amount including “O” for zero mL
Enter Enteral Feeding amount from the feeding pump
8 hour Shift Total should match the feeding pump intake Do NOT enter the feeding rate every hour
False amount: This is NOT the amount of tube feeding the patient received This method gives the RD an incorrect calorie count: the patient is actually being underfed Volume off the feeding pump: Actual amount of tubed feeding patient received This method is accurate and provides the RD with the exact calories the patient was fed
Nurse-Driven Protocol for Volume-Based Enteral Nutrition Goal: Achieve 80% infusion of goal volume of enteral tube feeding by allowing RN to adjust infusion rate to recover interruptions in tube feeds. Intensivist orders volume-based tube feeding via nasogastric/orogastric route Registered Dietitian specifies formula Registered Dietitian calculates ‘Estimated Energy Needs High’ Kcal/day -Recovery of Missed Tube Feeding: Every 8 hours Nurse advances tube feeding by 20ml/hr q hr at most Nurse initiates tube feeding at goal (Ex: Goal 1200 mL/24 hours, initiate feeds at 50mL/hr) -Maximum Infusion Rate: 150ml/hr -Reset the 24 hour goal at 0700 Check GRV q4h Maximum Gastric Residual Volume (GRV) threshold: 500 mL Is GRV 500 mL? NO O Refeed GRV & continue tube feedings YES Consider Prokinetic Medications: Refeed to maximum of 500 mL; discard excess; hold feeds; recheck residual in 1 hour -Metoclopramide HCl 10 mg IV q6hrs : -Metoclopramide HCl 5 mg IV q6hrs (renal impairment) -Erythromycin 250 mg NGT/OGT q8hrs Rechecked GRV 500mL? NO Consult Intensivist for Prokinetic medication &/or post-pyloric/small bore feeding tube YES
Daily Caloric Intake Tracking Sheet 24 hr Goal Volume in mL Date Time 6/5/18 Calculated Shift Tube Feeding: Goal Rate x 8 hrs 0700 AM Shift: 07001500 Record Volume Fed from Feeding Pump (50mL x 8 ) 400mL PM Shift: 1500 – 2300: Shift Tube Feeding Volume to Recover 350 mL PM Shift: 15002300 Record Volume Fed from Feeding Pump 1200 mL Calculated Volume to Recover: AM Shift Tube Feeding – Volume Fed Calculated Starting Goal rate: Goal Volume/ 24hrs (1200mL/24 ) 50mL Hours Needed to Recover Missed Feeds: Volume to Recover/20 mL (Maximum Increase Rate 20 mL/hr) (400mL - 350mL ) (50mL/20mL ) 50 mL 2.5 hrs Calculated Volume to Recover: PM Shift Tube Feeding – Volume Fed Hours Needed to Recover Missed Feeds: Volume to Recover/20 mL (Maximum Increase Rate 20 mL/hr) 1st Hr 20m mL 50 mL goal rate Rate 70 mL 1st Hr 20m mL 50 mL goal rate 2nd Hr 20 mL 50 mL goal rate Rate 70 mL 2nd Hr 20 mL 50 mL goal rate 3rd Hr 10 mL 50 mL goal rate Rate 60 mL 3rd Hr 10 mL 50 mL goal rate (400mL 50mL ) 450mL NOC Shift: 2300-0700: Shift Tube Feeding Volume to Recover NOC Shift: 2300-0700 Record Volume Fed from Feeding Pump Calculated Volume Never Recovered: Shift Tube Feeding – Volume Fed Patient Sticker 4th Hr 5th Hr Rate Rate 4th Hr 5th Hr
24 Hour Total Volume of Tube Feeding 1. Look up the 24 Hour Total Volume of Tube Feeding in the Enteral Feeding Order Ex: 1200 ml 2. Verify the tube feeding hourly goal Ex: 1200ml / 24 hours 50 mL/hr 3. Calculate the amount of Shift Tube Feeding (STF) Ex: 50ml x 8 hours 400 mL 4. End of Shift record Volume Fed (VF) off the feeding Pump Ex: 350mL 5. Subtract: STF – VF Volume to Recover (VR) Ex: STF 400mL – VF 350mL VR 50mL 6. On-coming RN On-coming RN Add: STF VR new STF Ex: 400mL 50mL 450mL 7. Divide VR/20mL hours to recover missed feedings Ex: 50mL/20mL 2.5 hrs 8. Calculate increased hourly rate for the 2.5 hrs if TF is increased at 20mL/hr every hr 1st hour: 70mL (20mL recovered), 2nd hour: 70 mL (20mL recovered), 3rd hour: 60 mL (10 mL recovered) Total recovered: 20 20 10 VR 50 mL 9. Decrease rate to original goal rate Ex: 50 mL/hr 10. Repeat from Step 3
Underfeeding: Silent Starvation Syndrome Time to practice filling out the sheet and calculating the tube feeding adjustment Use the tracking sheet and the 24 Hr Volume instructions to calculate the PM shift tube feeding Question and answer session?
Engrain Definition: to work indelibly into the natural texture or mental or moral constitution (Merriam-Webster, 2019) Champions Establish a habit in daily routine Standardized workflow
Standardized Work PROJECT TEAM: EBP Project Leader: Jennifer Veler, RN Clinical Mentor: 1 CNS Change Team Members: Opinion Leaders: 2 Day shift RN’s, 1 PM shift RN, 1 RD, 1 MD Change Champions: 1 RN/shift (Day, PM, NOC), 12-hr RN’s 2/shift (Day, NOC) Core Group: 2 Day shift RN’s, 1 PM shift RN, 1 NOC RN NorthBay Healthcare Preceptor: 1 CNS Faculty Advisor: 1 Statistician: 1
Sustain Definition: to give support or relief to ; keep up, prolong Continue new habit Communication, communication, communication Rounding with the stakeholders Nurses Registered dietitian Intensivists Leadership
Daily Caloric Intake Results
Results Table 1: Description of Caloric Intake Intervention Mean CAL pre- intervention 76% CAL post-intervention 97% Improvement 21% P-value 0.001 Confidence Interval 95%
Results Table 2: Description of Gastric Residual Volume Measurements Intervention Documentation of GRV GRV pre-intervention 18/30 GRV post-intervention 29/30 Improvement 21% P-value 0.0005 Confidence Interval 95%
Results Table 3: Description of Tube Feeding Volume Documented from Pump Intervention Documentation preintervention Documentation postintervention Improvement in Documentation P-value Confidence Interval Recorded Volume Off Pump 1/30 24/30 76% 0.0005 95%
Sustainment Plan Track data monthly (metrics) Round with nurses to identify barriers, reinforce education, clarification Develop a Power Plan for Volume-Based Enteral Nutrition Transition paper charting to the electronic environment Build a calculator for auto-calculation of tube feed rate changes
Sustainment Plan Regular meetings with stakeholders to PDSA the process Reassess GRV element of protocol SCCM recommendation to cease GRV assessments Hardwire orientation of new staff to VBEN protocol
Significance? Rate-based method is not effective in providing optimum nutrition Volume-based enteral nutrition with a nurse-driven protocol is a more effective method Impact Nursing practice alignment with most current EBP for enteral nutrition Standardization of practice guided nursing decisions drove nursing interventions Patients received greater daily caloric intake contributes to the healing process holistic care decreases LOS in ICU
References Barto, D., ( ). Let’s be the driver of this bus: nurse – driven protocols in acute care. AACN Session # 211 PP, dbarto@virtua.org Haskins, I., Baginsky, M., Gamsky, N., Sedghi, K., Yi, S., Amdur, R., Gergely, M., Sarani, B. (2017). Volume-Based Enteral Nutrition Support Regimen Improves Caloric Delivery but May Not Affect Clinical Outcomes in Critically Ill Patients. Journal of Parenteral and Enteral Nutrition, 41(4), 607- 611. Heyland, D., Dhaliwal, R., Wang, M., Day, A. (2015). The prevalence of iatrogenic underfeeding in the nutritionally ‘at risk’ critically ill patient: Results of an international, multicenter, prospective study. Clinical Nutrition, 34, 659-666. McClave, S., Mohamed, S., Esterle, M., Anderson, M., Jotautas, A., Franklin, G., .Hurt, R. (2015). Volume-based feeding in the critically ill patient. Journal of Parenteral and Enteral Nutrition, 39(6), 707- 712. Merriam-Webster Dictionary (2019). https://www.merriam-webster.com/dictionary
References O’Leary-Kelley, C., Bawel-Brinkley, K. (2017). Nutrition Support Protocols: Enhancing Delivery of Enteral Nutrition. Critical Care Nurse, 37(2), e15- e23. Orinovsky, I., Raizman, E. (2018). Improvement of Nutritional Intake in intensive Care Unit Patients via a Nurse-Led Enteral Nutrition Feeding Protocol. Critical Care Nurse, 38(3), 38- 44. Reignier, J., Mercier, E., Le Gouge, A., Boulain, T., Desachy, A., Bellec, F., Lascarrou, J. (2013). Effect of Not Monitoring Residual Gastric Volume on Risk of Ventilator-Associated Pneumonia in Adults Receiving Mechanical Ventilation and Early Enteral Feeding. Journal of the American Medical Association, 309(3), 249 – 256. Taylor, B., Roberts. P. (2016). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Critical Care Medicine Journal, 44(2), 390-438.
1. Look up the 24 Hour Total Volume of Tube Feeding in the Enteral Feeding Order Ex: 1200 ml 2. Verify the tube feeding hourly goal Ex: 1200ml / 24 hours 50 mL /hr 3. Calculate the amount of Shift Tube Feeding (STF) Ex: 50ml x 8 hours 40 0 mL 4. End of Shift record Volume Fed (VF) off the feeding Pump Ex: 350mL 5.
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