NURSING

Nursing

Nursing

Introduction

The incidence of malnutrition in hospital patients is around 40% (Stratton et al., 2003). Chronic illness, treatment side effects, such as constipation and nausea, and periods of enforced nil-by-mouth contribute to exacerbating poor nutritional status. Thus, it is to be expected that many elderly and chronically ill patients admitted to the intensive care unit (ICU) will already have a degree of malnutrition.

Patients who have developed malnutrition as a result of starvation will have depleted fat and protein stores, and as such, have a reduced capability to survive severe illness or short periods without nutrition. The cumulative effects of starvation and stress dramatically increase the basal metabolic rate and the rate of protein catabolism, leading to neuromuscular impairment and impaired immune function.

As a result, malnourished critically ill patients experience significantly more complications and are less likely to be discharged from hospital than normally nourished patients (Giner et al., 1996). In addition to disease-associated problems undernutrition may be in part caused by shortcomings in the provision of nutritional support such as delays in initiating feeding, frequent feed interruptions and the presence of gastrointestinal complications such as delayed gastric emptying (Ritz et al., 2001; Marshall and West, 2006).

The recently published Canadian, European and American evidence-based clinical practice guidelines (Heyland et al., 2003a; Kattleman et al., 2006; Kreymann et al., 2006) advocate early (within 24-48 h of injury or admission to ICU) initiation of enteral feeding as the preferred route of nutrition support in critically ill adults.

The use of enteral feeding protocols in ICUs promote earlier initiation of enteral nutrition (EN), increase volumes of feed delivered (Spain et al., 1999; Adam and Batson, 1997; Martin et al., 2004; Woien and Bjork, 2006), optimizing the number of calories a patient receives (Chapman et al., 1992; Heyland et al., 2003b) which collectively result in shorter hospital stay and improved morbidity and mortality outcomes (Doig et al., 2000; Martin et al., 2004).

Historically, our 22-bed ICU has adhered to an enteral feeding protocol which enables the nursing staff to initiate early enteral feeding using a standard formula feed at low infusion rates and introduce prokinetic agents as indicated for large gastric residual volumes (GRVs). This protocol had limitations as all patients required dietetic assessment to determine target feeding volumes and to monitor nutritional outcomes. As a result, patients took longer to meet their nutritional goals. This underfeeding was particularly apparent in those patients admitted to ICU over the weekend outside of normal office hours. Furthermore, owing to high patient turnover, dietetic review was often not timely and for some patients nutritional intervention was not assessed during their ICU stay. This practice was frustrating for nursing staff, given the known impact of undernutrition on their clinical journey.

With such a large ICU, this practice meant a considerable proportion (0.5 whole time equivalent) of the ICU dietitians' time involved assessing all patient admissions. Valuable dietetic time was consequently limited in supporting the more complex nutritional support patients, in attending ICU multidisciplinary ward rounds and for the implementation of evidence-based practice ...