Ensuring patients receive adequate nourishment throughout their stay
According to the American Association of Critical-Care Nurses (AACN), more than half of patients admitted to critical care units are malnourished, increasing their risk for serious complications and contributing to longer hospital stays and higher healthcare costs. Yet many of those eligible to receive enteral feedings do not receive adequate nutrition while hospitalized.
Thus, the American Society of Parenteral and Enteral Nutrition (ASPEN) created a new nutrition bundle to ensure that patients’ nutritional needs are met during stays in the ICU. Created in conjunction with the Society of Critical Care Medicine, the bundle is one component of ASPEN’s updated guidelines for assessment and nutritional support for the critically ill.
A June article in Critical Care Nurse addressed all relevant components of nutrition, including assessment and interventions.
Ashleigh VanBlarcom, DNP, RN, AGACNP-BC, and Mary Anne McCoy, PhD, RN, ACNP-BC, collaborated on the article while VanBlarcom was earning a DNP degree at Wayne State University College of Nursing in Detroit. McCoy serves as specialty coordinator of the DNP and AGACNP graduate certificate specialties at Wayne State.
“Malnutrition in hospitals is often overlooked, underdiagnosed and untreated,” VanBlarcom said. “The ASPEN nutrition bundle offers bedside nurses, registered dietitians, providers and other members of the interprofessional team a comprehensive, step-by-step approach to early nutrition.”
The six main components of the nutrition bundle are as follows:
- Assess patients’ nutrition status to identify those at risk for malnutrition.
- Initiate and maintain enteral nutrition.
- Reduce risks for aspiration.
- Implement enteral feeding protocols.
- Avoid the use of gastric residual volumes as an assessment of enteral feeding tolerance
- Consider parenteral nutrition early, when enteral feedings cannot be initiated.
ASPEN introduced the nutrition bundle in the updated guidelines for assessment and implementation of nutrition support in the critically ill.
Nutrition therapy has three main objectives:
- Preservation of lean body mass,
- Maintenance of immune function;
- and avert metabolic complications.
Six primary principles of nutrition therapy should be maintained when the nutrition bundle is implemented. The first step in determining nutrition for a critically ill patient is to determine the patient’s energy requirements in the form of calories. ASPEN guidelines suggest indirect calorimetry as the gold standard to estimate energy needs, but this method is not always available in all intensive care units (ICUs).
ASPEN guidelines emphasize adequate protein delivery to critically ill adults. Protein is the most critical nutrient, as it supports wound healing, immune function, and leads to maintenance lean body mass. A weight-based equation can be used to determine the appropriate daily amount of protein. The value of 1.2 to 2.0 g/kg per day is appropriate for estimating protein needs for most critical care patients.
A thorough nutrition assessment, including a physical examination, is essential. Traditional markers of protein consumption are inadequate and inaccurate in the critical care setting. Any history of nutrition-related problems, gastrointestinal disease, alcohol or drug abuse, or elevated metabolic rate should be considered to determine appropriate protein and caloric needs.
The nutrition bundle takes these concepts and incorporates strategies for nutrient delivery to provide the basis for the assessment and provision of appropriate nutrients to improve patients’ outcomes.
Assessment of Malnutrition
Clearly, identification of patients with malnutrition or undernutrition early in the process is critical in terms of preventing poor long-term outcomes, but the two outcomes are not identified at a desirable rate because of poor screening practices.
Several screening tools can be used to detect malnutrition or nutrition risk, but the most common tools in acute care are the Nutrition Risk Screen 2002, the Nutrition Risk in the Critically Ill, and Malnutrition Universal Screening Tool. These take into consideration a patient’s weight, loss of weight before admission, and severity of disease.
Initiation/Maintenance of Enteral Feeding
Enteral feeding should be initiated within 24-48 hours of admission for anyone unable to continue with traditional feeding. In addition to providing calories, enteral feeding reduces severity of disease while preserving the immune system. Without a food source entering the gastrointestinal tract and stimulating blood flow, control of systemic inflammatory cytokines can be lost, leading to inflammation and other harmful consequences.
Reduction in Aspiration
The prevention of adverse outcomes such as aspiration needs to be an equally critical component of care. Keeping the head of the bed elevated, sparing the use of sedatives, and ensuring adequate bowel function are essential pieces of this puzzle.
Implementation of Enteral Feeding Protocols
According to research, when bedside protocols are used, patients not only receive enteral feedings earlier in their admission but also receive a greater volume of enteral formula. Patients who receive at least 80% of their estimated caloric and protein needs while hospitalized have better short- and long-term outcomes.
Avoid Use of GRVs
Historically, GRVs or gastric residual values were used to mark retention of enteral feedings. Increased GRVs were due to delayed gastric emptying, we believed, and could lead to aspiration and pneumonia.
But new evidence indicates that GRVs do not correlate with gastric emptying, and are poor predictors of intolerance to enteral feedings. Multiple studies indicate that correlation or no correlation between GRV and increased aspiration and pneumonia can be obtained by adjusting the GRV cutoff value.
Early Initiation of Parenteral Feeding
Mortality rates are significantly increased when malnutrition is present at the time of admission to the ICU and when enteral feedings are delayed for a week or longer.
Unfortunately, nutrition is often overlooked in the confusion and haste when a patient is admitted to the ICU. But with nurses and dietitians working hand-in-hand, many poor outcomes can be avoided and altogether reversed.