l. mageswary lapchmanan - improving nutrition support practices among intensive care unit patients...
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L.Mageswary
Hospital Selayang
Team Members
L.Mageswary
Lapchmanan Adlin Natasya
Mohd said Teong Lee Fang Tan Sing Ean Fathiyah Noor
Osman
SELAYANG HOSPITAL
• 960 inpatient beds and 20 clinical disciplines – provides secondary and national tertiary care services
• The first hospital in Malaysia and the world to operate T.H.I.S. (Total Hospital Information System) covering all aspects of its operation.
• ICU with 24 beds
Introduction – The Stress Response in ICU
• Prevalence 40%
• Worsen by inappropriate feeding practices
Stress response lead to
malnutrition
• Impaired immunological function,
• Impaired ventilatory drive,
• Weakened respiratory muscles,
• Leading to prolonged ventilatory dependence which translate into infection, multi organ failure, prolonged ICU stay, increased morbidity and mortality.
Malnutrition may result in
Introduction – What Happens in ICU?
Introduction- How Can EN Help?
Nutrition support is an important adjunctive therapy with primary goals to prevent malnutrition and to support patients
during treatment.
Enteral Nutrition Support is prefered in critically ill patients
Enteral feeding should be started early within the first 24 – 48 hours following admission.
The feedings should be advanced toward goal over next 48 – 72 hours.
Efforts to provide more than 50 – 65% of goal calories should be made in order to achieve the clinical benefit of Enteral Nutrition over the 1st week of hospitalisation.
Introduction- How Can EN Help?
Enteral nutritional intervention given early and adequately proven to help to : - reduce disease severity,
- minimise infectious complications, - decrease ICU stay and - save cost
Delayed Nutrition Support with frequent and inappropriate cessation of feeding may lead to inadequate nutrition and malnutrition.
Good nutrition support practices by Health Care Team can help to optimise nutrition delivery and reduce feeding barriers.
1. McClave SA et.al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Ault Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N), 2009.
2. Heyland DK, Khaliwal R, Drover JW, Gramlich L, Didek P. Canadian critical care clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adults patients. JPEN. 2003;27:355-373.
3. Dark DS, Pingleton SD. Nutrition and nutritional support in critically ill patients. J Int Care Med.1993;8:16-33. 4. Kattelmann KK, Hise M, Russell M, Charney P, Stikes M Compher C. Preliminary Evidence for Medical Nutrition Therapy Protocol: Enteral
feedings for Critically Ill patients. Am J Dietetics.2006;1226-1241. 5. Medical Nutrition Therapy Guidelines for Critically Ill Adults. Malaysian Dietitians’ Association. 2005.
Every year, 800 - 1000 patients are admitted to Hospital Selayang ICU for therapy, with average length of stay 12.2 days and 4.4 ventilator days
70 – 80% of the patients are requiring enteral nutrition support.
At Selayang Hospital
Despite knowledge of these benefits, the actual NS received by
patients in ICU is not always optimal for various reasons
Objectives
General Objective Provide Optimal Nutrition Support for
All Critical Patients at Intensive Care Unit
Hospital Selayang
Specific Objectives
To determine initiation day of enteral feeding
To evaluate calories achieved within the fifth day of
enteral nutrition support
To identify factors affecting feeding intake
To implement remedial action
To evaluate effectiveness of remedial action
Methodology
Study Design Cross Sectional Study
Study Sample ICU Patients at Hospital Selayang
Sampling Technique Universal Sampling
Inclusion Criteria – All ICU patients on total enteral nutrition
Exclusion Criteria • Patient on partial parenteral nutrition• Patient on partial enteral nutrition• Duration of feeding less than 5 days
Duration of study Verification Study: October 2009 – December 2009Remedial Measures: February – March 2010 1st cycle: April – Jun 20102nd cycle: July – September 2010Track & Trend 1 : Jan – March 2011Track & Trend 2: April – June 2011
Data Collection Technique Observation, IT documentation
Data Collection Tools KPI Form
Data Analysis SPSS Version 13.0
Study on Cost for antibiotic & ventilator done in year 2013
Definition
Data Collection Form
Verification Study
Male (N=39) Female (N=28)
Mean age (years) 47.7 + 18.2 57.6 + 20.6
Weight (kg) 74.2 + 15.5 55.9 + 7.7
Height (cm) 169.5 + 8.2 153.2 + 3.5
BMI (kg/m2) 25.9 + 5.5 23.8 + 2.7
Malay 15 15
Chinese 13 7
Indian 10 5
Others 1 1
What was Our Performance?
0%
10%
20%
30%
40%
50%
60%
70%
Achieved Not Achieved
69%
31%
Achieved
Not Achieved
Only 58.3% of ICU patients initiated with Enteral
Feeding from 24 to 48 hours of admission.
No patients given feeding before 24 hours.
Only 69.0% of patients on Enteral Feeding
achieved goal calorie recommendation on
Day 5 after feeding initiation.
Only 12.5% of patients could not tolerate
Enteral Feeding due to high gastric residual/
patient related factors compared to 87.5%
of patients were not given feeding due to
Inappropriate Feeding Practices.
12.50%
12.50%
12.50%
50%
12.50%
Cycle 2: Day 5 Feeding Barrier
Procedure Hi GRV Feeding Plan Increase Gradually Others
Problem Analysis
Inappropriate
Enteral Nutrition Support
among
Intensive Care Patient
at Hospital Selayang
Gone for procedures
Delay feeding
initiation
Doctor-Dietitian:
No referral from doctors
Nurses busy with
nursing care
Lack of
communication Slow feeding
progress
Prolonged NBM
Lack of knowledge/
awareness among nurses and patients
Proper education
not prepared / given
Too much
documentation time
in IT system
Dietitian-Nurses:
No standard
protocol prepared
Nursing staff
incompetency
Too many
proceduresPoor feeding
tolerance
No standard protocol
Powerchart (IT system)
not fully utilised
Lack of
Dietitian number
Post not
filled
Maternity
leave
Problem Analysis
Inappropriate
Enteral Nutrition Support
among
Intensive Care Patient
at Hospital Selayang
Gone for procedures
Delay feeding
initiation
Doctor-Dietitian:
No referral from doctors
Nurses busy with
nursing care
Lack of
communication Slow feeding
progress
Prolonged NBM
Lack of knowledge/
awareness among nurses and patients
Proper education
not prepared / given
Too much
documentation time
in IT system
Dietitian-Nurses:
No standard
protocol prepared
Nursing staff
incompetency
Too many
proceduresPoor feeding
tolerance
No standard protocol
Powerchart (IT system)
not fully utilised
Lack of
Dietitian number
Post not
filled
Maternity
leave
X
Intervention
Combined Ward Round
with ICU Team
Reintroduce Enteral Feeding Protocol
Conduct CNE
Sessions
Strengthen Dietitian Referral System
Increase Dietitian
Follow-up Rounds
Use Ready to Feed
Formulas
Use Feeding Pumps
Scheduled Seminar
Good Nutrition Support
Phase 1 Phase 2
Enteral Feeding Protocol
Management
of
complications
Enteral
Formula
&
Indication
Guide NBM
for
Procedure
Algorithm for Bolus
&
Intermittent Feeding
- Feeding progress
- Use of prokinetics
- Post pylorus feeding
- TPN
Demographic Data
Cycle 1 Cycle 2 Track & Trend 1 Track & Trend 2
Male
(N=30)
Female
(N=20)
Male
(N=50)
Female
(N=25)
Male
(N=59)
Female
(N=45)
Male
(N=36)
Female
(N=29)
Mean age
(yrs) 54.2±17.9 54.9±17.1 47.0±17.3 57.7±20.5 54.4±17.0 54.3±18.6 48.3±16.0 58.1±18.2
Weight (kg) 65.2±8.6 55.8±9.9 67.5±12.6 59.5±14.0 61.9±7.6 54.8±7.1 61.0±4.5 60.5±7.3
Height (cm) 169.5±6.3 156.5±5.7 170.6±7.8 156.8±6.7 166.8±4.4 156.0±4.9 163.8±4.1 157.3±5.3
BMI (kg/m2) 22.7±2.7 22.7±3.0 23.1±3.3 24.1±4.9 22.3±2.8 22.5±2.3 22.7±1.3 24.5±3.0
Malay 15 15 14 8 26 12 27 25
Chinese 13 7 10 8 11 5 19 11
Indian 10 5 4 4 9 7 12 4
Others 1 1 2 0 4 1 1 5
ABNA (Achievable Benefit Not Achieved)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Standard Verifikasi Cycle 1 Cycle 2
100%
58.40%67.70%
78.50%
Standard
Verif ikasi
Cycle 1
Cycle 2
41.6%
32.3%
21.5%
Feeding Initiation within 24 – 48 hours of
admission had increased from
58.4% to 78.5% during study period.
ABNA was reduced from 41.6% to 21.5%
64%
66%
68%
70%
72%
74%
76%
78%
80%
Standard Verif ikasi Cycle 1 Cycle 2
75%
69%
75%
78.50%
Standard
Verif ikasi
Cycle 1
Cycle 2
6%
0%
- 3.5%
Adequate feeding (more than 70% of calorie
recommendation) delivered increased from
69% to 78.5% at cycle 2.
ABNA was reduced from 6% to (– 3.5%)
Track & Trend
0
10
20
30
40
50
60
70
80
0
47.1
53.849.5
26
58.4
67.7
78.5
71.4
4441.6
32.3
21.5
28.6
56
< 24 hrs
< 48 hrs
> 48 hrs
Enteral feeding initiation time improved from
58.4% to 71.4% . Only 28.6% patients were fed
after 48 hours during track & trend 1. Delayed
feeding mainly due to patient’s disease
condition.
Percentage calorie achieved by 5th day
increased from 69.0% to 78.5%. The standard
further improved to 88.6% and 96.0% during
track & trend.
Percentage feeding initiation time less or more than 48 hrs
Track & Trend
0
10
20
30
40
50
60
Track & Trend 1 Track & Trend 2
35.2
54
44.8
28
8.6
14
Day 1
Day 3
Day 5
3025
5
40
14
21
14
50
0
10
20
30
40
50
60
Procedure High GRV Feeding Not Done
Increase gradually
Track & Trend 1
Track & Trend 2
Percentage type of feeding barriers Percentage calorie achieved compared with day
Patients received adequate feeding within
72 hours (Day 3) once remedial measures were
implemented. 80.0% and 82.0% patients
achieved adequate calories within 3 days during
track & trend 1 and 2 respectively.
During audit quality noted, goal calories not
achieved by Day 5 in some patients due to
slow feeding progress and related to fasting
for procedures
Cost Analysis 2013
Day Feeding
Achieved
Ventilator Hours/ days Cost (RM)
Ventilator Antibiotic Total
Day 1 160.8 hrs/ 6.7 days
6,700.00
170.36
6,870.36
Day 2
216.8 hrs/ 9.0 days
9,000.00 589.15
9,589.05
Day 3
182.4 hrs/ 7.6 days
7,600.00
352.71
7,952.71
Day 4
381.0 hrs/ 15.9 days
15,900.00
1200.00
17,100.00
Treatment cost increases significantly when there is a delay in
achieving adequate Enteral Nutrition Support
Discussion
Enteral nutrition is an important therapeutic strategy to improve outcomes in ICU patients.
There are wide variation in nutrition support practices across ICU and provision of adequate nutrition is sup-optimal.
Lack of evidence-based guidelines,
lack of communication,
lack interdisciplinary team collaboration and continuous nurses education influence Nutrition Support Practices
Discussion
Use of ICU or nurse-driven protocols which define:
goal infusion rate,
Feeding progression
Management of feeding complications such handling gastric residual, diarrhea, vomiting
Guide for fasting before and after procedure
have been shown to be successful in increasing the overall percentage of goal calories provided
Inappropriate cessation of feeding minimized with education and infusion protocol.
Good
Nutrition Support
Practices by Health Care
Professionals
Compliance to Nutrition
Support Protocol
Regular Monitoring
EARLY ENTERAL NUTRITION
ADEQUATE NUTRITION DELIVERY
BETTER OUTCOME
SAVE COST
Conclusion