Infusion protocol improves delivery of enteral tube feeding in the critical care unit

Background: Numerous factors may impede the delivery of enteral tube feedin gs (ETF) in the intensive care unit (ICU). We designed a prospective study to determine whether the use of an infusion protocol could improve the deli very of ETF in the ICU. Methods;: In a prior prospective study, we monitore d all patients admitted to the medical intensive care unit (MICU) or cardia c care unit (CCU) who were made nit per os and placed on ETF (control group ). We found that critically ill patients received only 52% of their goal ca lories, primarily due to physician underordering (66% of goal), frequent ce ssations of ETF (22% of the time), and slow advancement (14% at goal by 72 hours). Based on these findings, we developed an ETF protocol that incorpor ated standardized physician ordering and nursing procedures, rapid advancem ent, and limited ETF interruption. After extensive educational sessions, th e ETF protocol was begun. Again, all patients admitted to the MICU or CCU w ho were made nit per os and placed on ETF were prospectively followed (prot ocol group). Results: Thirty-one patients in the protocol group were follow ed during 312 days of ETF and compared with the control group (44 patients with 339 days of ETF). Despite efforts by the nutritional support team, the infusion protocol was used in only 18 patients (58%). The main reasons for noncompliance with the protocol were physician preference and system failu re (ETF order sheet not placed in chart). When used, the infusion protocol improved physician ordering (control 66% of goal volume, noncompliant 68%, compliant 82%, p <.05); delivery of calories (control 52% of goal, noncompl iant 55%, compliant 68%, p <.05); and advancement of ETF (control 14% at go al by 72 hours, noncompliant 31%, compliant 56% ,p <.05). Although signific ant reduction in ETF cessation due to nursing care was noted, it represente d only a fraction of the total time ETF were stopped. Cessation due to resi dual volumes, patient tolerance, and procedure continued to be a frequent o ccurrence and was often avoidable. Conclusions: An evidence-based infusion protocol improved the delivery of ETF in the ICU, primarily because of bett er physician ordering and more rapid advancement. The nursing staff rapidly assimilated these changes. However, physicians' reluctance to use the prot ocol limited its efficacy and will need continued educational efforts.