Running head: OUTCOME MEASURES PROJECT

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Nutrition Intervention and Patient Outcomes Study Laura Ewoldt The University of Southern Mississippi

Outcome Measures Project Table of Contents I. II. III. IV. V. VI. Introduction Study Questions and Objectives Methodology and Procedures Conclusion and Dissemination References Appendix 3 6 7 8 10 11

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Outcome Measures Project Introduction At South Central Regional Medical Center (SCRMC), one of the top three medical nutrition therapies used by the registered dietitians (RDs) is enteral feeding. Enteral feedings may be initiated by a physician or recommend by a RD or speech pathologist who feels that a patient would benefit from an alternate feeding. The main reason that a RD would recommend a tube feeding is if the patient cannot meet his or her nutritional requirements by mouth for longer than three or more days. A speech pathologist may recommend alternate feeding for a patient if he or she has completed a swallow study and determined that the patient is at risk for aspiration and cannot meet nutritional requirements by mouth due to swallowing difficulties. When a physician recommends or begins an enteral feeding, the RDs get consulted to recommend a tube feeding prescription which includes the type of formula, initial and goal rate, and advancement of administration. The prescription will also state the number of calories and protein the tube feeding will provide (G. McCraw, personal communication, September 12, 2013). According to the RDs standard practice at SCRMC, if a patient does not have a home

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enteral feeding and an enteral feeding is initiated, it will be prescribed at a low rate and increased 10mL every 8-12 hours as tolerated by the patient. At times, when the RDs followed up on a patient who had begun an enteral feeding, they found that the tube feeding had not been advanced to the goal rate, which they found to be frustrating. Excluding feedings that were not advanced due to patient intolerance, the RDs noticed that the nurses were not always advancing the rate as recommended by the RDs. Thus, it would be beneficial for SCRMC to have a standard protocol that the nurses would follow that stated the rate and times for enteral feedings to be advanced as determined by the RDs. Without a standard protocol, patients whose tube

Outcome Measures Project feeding rates are overlooked are at risk for becoming malnourished (G. McCraw, personal communication, September 12, 2013).

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Barriers to intervening on malnutrition include a lack of protocol for nursing staff related to nutrition as well as a lack of focus on dietitian recommendations due to a doctor or nurse being focused on other issues. These barriers can be overcome by creating a standard protocol related to nutrition for patients at risk of or who are malnourished. For example, a standard hospital protocol for initiating and progressing enteral nutrition orders can decrease the number of patients whose enteral feedings are not progressed as fast as the patient can tolerate the feeding. Increasing the feeding rate to the goal amount can decrease the number of patients who are at risk for malnutrition due to an inadequate amount of calories and protein (Tappenden et al., 2013). Malnutrition, defined as overnutrition or undernutrition, is highly prevalent in hospital settings. Undernutrition is the main cause of malnutrition, which is usually attributed to decreased appetite, gastrointestinal symptoms, a lack of ability to chew or swallow, an NPO status, or increased nutrient needs. Malnutrition can lead to increased risks of unwanted complications which can include impaired wound healing, immune suppression, increased infection, muscle wasting, functional losses, longer hospital stays, higher treatment costs, higher readmission rates, and increased mortality. Many of these complications can be prevented through proper nutrition (Tappenden et al., 2013). Dobson and Scott (2007) completed a study to determine if a nutrition algorithm in the intensive care unit (ICU) was safe and effective as well as to determine how compliant the nursing staff was to the algorithm. Data was collected for three months to determine the prescribed feed type and infusion rate as well as the actual volume received of tube feedings in

Outcome Measures Project

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the ICU. In 58 patients who were solely using the nurse-led nutritional algorithm, 2% of patients were receiving the correct types and volumes of feed and had an accurate documented weight and feeding prescription; however, in patients who did not have an accurate feed prescription or weight recorded, 60% of patients were actually receiving the correct type and volume of feed. Other patients who required dietitian referral were separated into a different group. These 48 patients were referred to the dietitian due to requirements for parenteral nutrition or failing enteral nutrition. The nutritional algorithm in ICU provided earlier and safer nutrition support by not waiting to initiate or progress tube feedings, which before could have taken 72 hours or greater. In a similar study, Barr, Hecht, Flavin, Khorana, and Gould (2004), aimed to determine if a nutrition protocol in the ICU would lead to increased enteral nutrition, earlier feedings, and improved outcomes in patients. Authors collected data on 100 patients before a nutrition protocol was set in place and on 100 patients after it was set in place. Patients in the group after implementation of the nutrition protocol had less mechanical ventilations, ICU length of stay, hospital length of stay, lower calorie target levels, and lower protein target levels. In addition, these patients were also twice as likely to receive enteral nutrition as the patients before the nutrition protocol was implemented. Another study completed by Woien and Bjork (2006) sought to establish whether patients who were in the hospital after a nutritional support algorithm had been put into place had better nutrition support outcomes than patients who were in the hospital before the algorithm. The researchers used patients in the ICU to collect nutritional data, which included the total amount of calories prescribed and actually received, the beginning of enteral feedings, enteral versus parenteral nutrition, and the use and size of feeding tubes. Patients whose nurses used the

Outcome Measures Project nutritional algorithm had higher amounts of prescribed and actual amounts of nutrients. They also had a higher number of enteral feedings than parenteral feedings. Using a nutritional algorithm created better outcomes in the ICU related to aspiration as well as rate of increase of tube feedings. Nutrition therapy in the critical ill patient population requires the medical team to recognize nutrition as an important aspect of treatment. Factors that can increase outcomes of treatment for these patients include discussion throughout the medical team on nutrition related factors, early administration of enteral nutrition, constant monitoring of nutritional therapy, and individualized care for each patient. Algorithms or protocols can be helpful to a multiprofessional team when integrating new practices for treatment. Algorithms and protocols should be easily accessible as well as comprehensive so that they can be easily implemented. New algorithms and protocols must also be used every day and become part of the normal treatment routine (Araujo-Junqeria and De-Souza, 2012).

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According to the previously stated research, patients in the ICU at SCRMC could benefit from having a nutritional protocol that started enteral feedings within 48 hours of being placed in the ICU and advanced the feedings as tolerated and prescribed by the RDs to reach the goal rate as soon as possible. Better outcomes that were seen in the previous research when a nutritional protocol was implemented include fewer instances of malnutrition, shorter lengths of stay in the ICU, and faster progression of enteral feedings. Study Questions and Objectives Study Question: Do patients in the ICU who follow a nutritional protocol that begins enteral feedings within 48 hours of being placed in the ICU and that advances enteral feedings to goal

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rate as fast as tolerated by patient have higher albumin levels and shorter ICU stays than patients who are not following the nutritional protocol? Objective 1: Determine the albumin levels of patients receiving enteral nutrition in the ICU. Objective 2: Determine the length of stay in the ICU of patients on enteral nutrition. Objective 3: Determine the amount of time from admission to the ICU to initiation of enteral feeding of patients who are placed on enteral feeding when admitted. Objective 4: Determine the progression rate of the patients’ enteral feedings in ICU. Methodology and Procedures This prospective sequential study will determine the effectiveness of a nutritional protocol for enteral nutrition in the ICU. Specifically, the study will focus on the amount of time it takes to begin an enteral feeding after a patient is admitted to the ICU, the progression rate of the enteral feeding, and patient outcomes after the use of enteral feedings, including the average albumin level and length of stay in ICU. The study will last for six months and aim to include 50 patients. The inclusion criteria will include adult patients who are being admitted to the ICU. Exclusion criteria will include patients that have a home diet of tube feeding, have already begun enteral feeding upon admission to the ICU, are able to intake nutrition by mouth, are receiving any parenteral nutrition, have any contraindications for receiving enteral nutrition, or who have a code status of comfort measures. All patients who are admitted to the ICU will be screened for eligibility in the study. Patients who are eligible for the study will be marked by nursing staff and will be referred to nutrition services. The study will last from January 1, 2014 to July 1, 2013. The first 25 participants who are eligible for the study will be a part of the standard procedure control group (CG). After three months, a nutritional protocol will be put into place that states that an enteral feeding should

Outcome Measures Project begin within 48 hours for eligible patients admitted to the ICU, and the enteral feeding will be initiated at a low rate as prescribed by the dietitians for eight to twelve hours and will be

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advanced by ten milliliters every eight hours as tolerated by the patient. The next 25 patients who are eligible for the study will be a part of the intervention group (IG). See appendix A for the current and proposed enteral nutrition procedure flow chart. Data to be collected will include all measured albumin levels, time from admittance to ICU to initiation of enteral feeding, rate of progression of enteral feeding, and length of stay in the ICU. An average albumin level for each patient will be used. Data will be collected from the chart as well as from standard questions for any data missing from the chart (Appendix B) to nursing staff that are caring for the participants. Other data that the dietitian will use for an assessment includes the patient’s height and weight and will also be obtained from the chart. Either nursing staff or a dietitian will visit the patient to obtain consent for the study at the time of admission to the ICU. See appendix C for a spreadsheet data example. Data will be analyzed using SPSS software. The albumin levels and length of stay in the ICU will be compared to the time it takes to initiate enteral feedings as well as the progression rate of the tube feedings for both groups of participants. Statistical significance will be defined as a P value < 0.05. Conclusion and Dissemination Data will be analyzed and organized into tables and graphs for easy reading (Appendix D). The data will be disseminated to the hospital administrators, the nutrition services department, and the ICU staff. At the beginning of the study, the dietitians and the ICU staff will have to work together to implement the study as well as the nutritional protocol. Once a study plan has been approved by the dietitians and ICU staff, it will be presented to the hospital administration in order to be approved before beginning the study. Care of patients in the ICU

Outcome Measures Project will increase in quality with the implementation of a nutritional protocol, according to the previous research; therefore, a new nutritional protocol will help the hospital reach its goal of providing high quality care to all patients.

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Outcome Measures Project References Araujo-Junqueira, L., & De-Souza, D. (2012). Enteral nutrition therapy for critically ill adult patients; critical review and algorithm creation. Hospital Nutrition, 27, 999-1008. doi: 10.3305/nh.2012.27.4.5840 Barr, J., Hecht, M., Flavin, K., Khorana, A., & Gould, M. (2004). Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol. CHEST Journal, 125,1446-1457. Retrieved October 17, 2013, from http://publications.chestnet.org/data/Journals/CHEST/22007/1446.pdf Dobson, K., & Scott, A. (2007). Review of ICU nutrition support practices: Implementing the nurse-led enteral feeding algorithm. Nursing in Critical Care, 12, 114-123. Retrieved October 17, 2013, from

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http://ehis.ebscohost.com.logon.lynx.lib.usm.edu/ehost/pdfviewer/pdfviewer?vid=4&sid= 924d8f22-3465-4228-b594-3cfd146ebadd%40sessionmgr112&hid=109 Tappenden, K. A., Quatrara, B., Parkhurst, M. L., Malone, A. M., Fanjiang, G., & Ziuegler, T. R. (2013). Critical role of nutrition in improving quality of care: An interdisciplinary call to action to address adult hospital malnutrition. Journal of Parenteral and Enteral Nutrition,37, 482-497. doi: 10.1177/0148607113484066 Woien, H., & Bjork, I. T. (2006). Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. Journal of Clinical Nursing, 15, 168-177. Retrieved October 17, 2013, from http://ehis.ebscohost.com.logon.lynx.lib.usm.edu/ehost/pdfviewer/pdfviewer?vid=13&sid =924d8f22-3465-4228-b594-3cfd146ebadd%40sessionmgr112&hid=7

Outcome Measures Project Appendix A

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---Current process ---Proposed process
EN=Enteral nutrition

Upon admission to ICU, patients are assessed for EN eligibility

Patient is referred to dietitian upon order of enteral feeding

Is the pt eligible for EN?

No

Exclude pt from study

Dietitian completes assessment and makes nutritional EN prescription

Yes

Nursing staff completes order, including initiation, progression of feeding, and care of patient

Nursing staff follows nutritional protocol to initiate EN within 48hrs admission to ICU, to progress EN at 10mL/8hr as tolerated to reach goal EN rate and improve other patient outcomes

End patient care

End patient care

Outcome Measures Project Appendix B Questions for Nurses if chart is incomplete 1. How long after admission to the ICU was patient x’s enteral feeding initiated? 2. How often (in hours) was patient x’s enteral feeding progressed and by how many mL was it progressed? 3. How many hours did it take patient x’s enteral feeding to reach the goal rate? 4. How many days was patient x in the ICU?

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Outcome Measures Project Appendix C Example spreadsheet of data to be collected

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Patient ICU Mean Time of Time of Progression Time Weight Height ID LOS Albumin ICU enteral of enteral from (lb) (in) number (days) level Admission feeding feeding initiation (mg/dL) (Date, initiation (#mL/8 of Time) (Date, hours) enteral Time) feeding to goal rate reached (days) 1 5.2 3.4 1/2/14 1/5/14 10mL/8 5.2 167 64 8:45AM 6:52PM hours 2 4.1 2.2 1/3/14 1/6/14 5mL/8 4.1 122 60 11:12AM 5:54AM hours … 50 2.2 4.1 7/29/14 7/30/14 10mL/8 2.2 200 67 12:24PM 8:33AM hours

Outcome Measures Project Appendix D

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Graph one shows the mean albumin levels of the control group and the intervention group. Table one shows the lengths of stay of select patients from the intervention group versus the control group.

Graph one

Mean Albumin Level
5 4 3 2 1 0 Control Group Intervention group Albumin level

Table one Length of stay of participants in the control and intervention groups in days

Patient #
1 2 3 4 5

Control group
5.2 4.1 10.6 3.1 7.1

Intervention group
2.3 3.5 8.9 5.4 7.3

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