1. Quality Improvement Project: Meeting Nutritional Needs in the ICU
Early enteral nutrition (EN) in the critically ill patients improves outcomes. It may
improve gut flow, improve gut barrier function (decreased bacterial translocation),
decrease organ injury, improve wound healing, improve immune function, decrease pro-
inflammatory response, decrease mortality, and decrease both the length of hospital stay
and the cost of care.
Once EN has been initiated, there are many factors that contribute to tube feed
holds, limiting the administration of nutrition that is critical to helping the patient heal.
The policy for continuous tube feeds at San Francisco General Hospital is to calculate the
goal rate to run over a total of 24 hours, which may make it unrealistic for many patients
to reach their targeted goals.
Early initiation of enteral nutrition
Based on the Aspen Clinical Guidelines (2009), enteral feeding should be initiated
within the first 24-48 hours following admission (grade of evidence: C). Attaining access
and initiating EN should be considered as soon as the patient is hemodynamically stable.
A “window of opportunity” exists in the first 24-72 hours following admission or the
onset of a hypermetabolic injury. Feedings started within this timeframe are associated
with less gut permeability, and release of inflammatory cytokines, leading to improved
clinical outcomes.
In a sample of 15 ICU patients in the ICU (Units 4E, 5E, and 5R), 5 patients
(33%) had EN initiated within 48 hours of admission. Efforts should be made to increase
this number in patients who are hemodynamically stable.
Meeting needs during the first week of ICU hospitalization
The Aspen Clinical Guidelines (2009) state that efforts to provide greater than
50%-65% of goal calories should be made in order to achieve the clinical benefit of EN
over the first week of hospitalization (grade of evidence: C). The impact of early EN on
patient outcome appears to be a dose-dependent effect. The use of trophic feeds (trickle
of 10-30ml/hr) may be sufficient to prevent mucosal atrophy but may in insufficient to
achieve the usual endpoints desired by EN therapy. Studies suggest that greater than
50%-65% of goal calories may be required to promote faster return of cognitive function
in head injury patients, and to improve outcome from immune-modulating enteral
formulations in critically ill patients.
By implementing chart audits of ICU patients requiring EN, it can be determined
if patients are meeting the targeted 50%-65%, based on the 24 hour continuous cycle. If
rates were to be calculated based on 20 or 22 hour continuous cycle per day, this would
allow time for holds for procedures and nursing functions, while still providing the
patient with the targeted goal volume to meet their estimated needs.
Out of a sample of 15 patients in the ICU (Units 4E, 5E, and 5R), 6 patients
(40%) met a minimum of 50% of goal calories. When adjusting rates to run over a 22
hour continuous cycle, 8 patients (53%) would have been able to reach 50%-65% of goal
calories. When adjusting rates further to run over a 20 hour continuous cycle, 10 patients
(66%) would have met the targeted goal of 50%-65% of goal calories.

2. Based on this sample population, calculating the continuous infusion to run over a
20 hour cycle would significantly improve the ability to meet targeted goals. A 20 hour
cycle would allow for an improvement in meeting needs, as well as allowing for
scheduled breaks for nursing care and procedures.
24 hour EN
(actual delivery)
Amount of goal met
22 hour EN
(projected amount)
Amount of goal met
20 hour EN
(projected amount)
Amount of goal met
Number of patients
that met >50% of
goal calories
6 (40%) 8 (53%) 10 (66%)
Number of patients
that met >65% of
goal calories
3 (20%) 5 (33%) 6 (40%)
Meeting needs during the second week of ICU hospitalization
The Aspen Clinical Guidelines also recommend that if unable to meet the energy
requirement (100% of target goal calories) after 7-10 days by enteral route alone,
supplemental parenteral nutrition (PN) should be considered to reach 100% of goal
(grade of evidence: E). While the strength of evidence in this topic is low, efforts should
be made to meet 100% of goal needs by the second week of hospitalization.
Out of a sample of 5 patients, 2 reached 100% of goal rate within the second week
of admission in the ICU. Two patients met 78% of goal rate, while the last met 43% of
goal rate over the second week of hospitalization. Increasing the hourly rate and
delivering over a 22 or 20 hour continuous cycle would have potentially increased intake
from 43% to 47% and 51% respectively, and would have potentially increased intake
from 78% to 86% and 93%, respectively.
0
20
40
60
80
100
120
Pt 1 Pt 2 Pt 3 Pt 4 Pt 5
24 hour delivery
22 hour delivery
20 hour delivery
24 hour EN
(actual delivery)
Amount of goal met
22 hour EN
(projected amount)
Amount of goal met
20 hour EN
(projected amount)
Amount of goal met
Patient 1 100% 98% 101%
Patient 2 100% 99% 97%
Patient 3 43% 47% 51%
Patient 4 78% 86% 93%

3. Patient 5 78% 85% 92%
The 20 hour continuous cycle shows the highest ability to meet goal rates. Patient
1 shows a projection of meeting 101% of EN goal, as it was based off of 85ml/hr for 20
hour. To accurately match the calculated estimated needs, 84ml/hr for 20 hours would be
recommended. However, the minimal increase in order to keep rounded numbers is ideal
for simplicity, and surpassing estimated needs by 1% is not considered detrimental.
Conclusion
Early enteral nutrition and adequate delivery of EN is beneficial for the overall
clinical outcome. Meeting greater than 50-65% of goal rate should be attempted for the
first week, and efforts should be made to reach 100% of goal by the second week of
hospital stay. Based on the charts reviewed, increasing rates of delivery and using a 20
hour continuous cycle would be beneficial to helping more patients meet these targeted
goals. More data should be collected to determine if the trend remains consistent,
however based on the population sampled, there is a potential benefit to changing to a 20
hour continuous cycle to assist in meeting estimated goals.
Kristi Friesen, Dietetic Intern at San Francisco General Hospital
June 2014
References:
McClave, S., Martindale, R., Et. al. Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition Vol33 no 3, 2009.