BEST PRACTICES

Nutrition intervention in ICU improves outcomes

Research dissemination changes nursing practice

If you knew of a way to reduce length of time on a ventilator, cut costs, and improve outcomes for critically ill patients, wouldn’t you do it? Especially if the best practice was something that makes as much intuitive sense as feeding your patients?

But a critical care nurse and a dietitian at Sequoia Health Services in Redwood City, CA, found that the standard of care in their intensive care unit (ICU) did not include across-the-board early nutrition intervention. Colleen O’Leary-Kelley, RN, MS, CCRN, CNSN, a critical care nurse, and Stacey Dunn-Emke, MS, RD, CNSD, clinical nutrition manager, say they suspected nutrition was playing a big part in keeping patients on ventilators longer than necessary, so they teamed up to study the issue.

They found that 26% of patients at the hospital were at moderate to severe risk for malnutrition. Medical records of ventilator-dependent patients were analyzed for a two-year period. The mean length of stay for patients with early nutrition intervention within 24 to 48 hours was 16.9 days, and the median length of ventilation was seven days. For patients with delayed intervention, the mean length of stay was 25.9 days, and the median length of ventilation was 11 days.

"Some physicians are just not tuned in to nutrition," Dunn-Emke says. "It doesn’t give you that quick reaction. If you give a patient IV lasix, you’ll get an immediate outcome, but with nutrition, it’s not that obvious."

Dunn-Emke says physicians are sometimes nervous about tube feedings, and most assume the intubation will not be long-term. If the patient will come off the ventilator tomorrow, why initiate tube feeding? "I can understand why they’re hesitant, but that mindset causes problems," she says. "Those patients are getting no protein and no calories to boost their immune response. Without the nutrition, it’s also harder for the body to metabolize drugs so those drugs are not going to be as effective. The patients end up staying on the ventilator and in the hospital longer."

Besides the drug metabolism issue, malnutrition also can lead to ineffective breathing patterns due to the effects on respiratory muscle structure and function, ventilatory drive, and lung defenses. Adverse effects also include diminished diaphragmatic muscle mass, decreased minute ventilation and vital capacity, decreased inspiration and expiratory muscle strength, and diminished cell-mediated immunity. On the other hand, overfeeding can also cause problems, such as fluid overload, glucose intolerance, and increased carbon dioxide production.

Evaluate patient’s caloric needs

To avoid these complications that can impact weaning outcomes, Dunn-Emke suggests that the caloric requirements of critically ill patients be evaluated by a dietitian within 48 hours of admission and that feedings should start within those first three days, provided patients are hemodynamically stable. Feedings should be started at a fraction of the final volume and advanced over hours or days until the goal volume is met. By day five of intubation, 100% of the patient’s assessed requirements should be met.

Since enteral feeding costs only about $80 per day, the cost savings can be tremendous. In fact, a study from KPMG Peat Marwick LLP of Washington, DC, found appropriate use of inpatient enteral feeding in the care of critically ill or injured patients could save the Medicare program as much as $1.08 billion from 1996 to 2002. The study analyzed Medicare patient records for 13 specific diagnosis-related groups throughout 1994. Another study1 found that malnourished surgical patients experienced a 48% rate of complication, compared to a 23% rate of complication among well-nourished patients.

O’Leary-Kelley didn’t want to just complete the nutrition study; she wanted to make sure the nurses and physicians who work with these patients were well-informed of the results. A critical care nurse and a doctoral student at the University of California, San Francisco, O’Leary-Kelley knew that while research provides a great deal of useful information that could improve outcomes, bedside nurses just don’t have time to read it. So she devised another study to find out if a concerted effort to disseminate research findings would impact nursing practice.

O’Leary-Kelley and Dunn-Emke presented the information from the nutrition study face to face with ICU nurses during shift report four times over a six-week period.

They posted the findings in the unit and also gave nurses a written report. Then each ICU nurse was surveyed. The result: 66% of the nurses said their practice was enhanced by increased awareness of nutritional needs of ventilator-dependent patients and that the information increased the likelihood that they would seek physician orders for early nutrition support.

"Before the nurses had this information, they would most likely just wait until the physician decided what to do about feedings," O’Leary-Kelley says. "Arming them with the findings gave them a basis to stand on when talking to the physicians. Our patients are getting fed earlier and weaning more quickly from the ventilator."

Education sessions were also done with physicians on the critical care committee, and she says the fact that the research was done with their patients made a big difference. "I think the physicians are paying more attention to what the dietitian puts in the notes."

The hospital has also started a new nutrition screening process in which nurses evaluate every patient’s nutritional needs upon admission. If the patient has significant weight loss or a high-risk diagnosis, for example, dietitians are notified. Dunn-Emke is also providing regular inservices with nurses, physicians, physician assistants, and physician and respiratory therapists throughout the hospital. She periodically sets up a nutrition information booth outside the hospital’s cafeteria to give information to both staff and patients.

For more information on the nutrition studies, contact Colleen O’Leary-Kelley, University of California, San Francisco, N611Y — Box 0610, San Francisco, CA 94143-0610. Telephone: (408) 738-4348. E-mail: colear@itsa.ucsf.edu.

Reference

1. Warnold I, Lundholm K. Clinical significance of preoperative nutritional status in 215 noncancer patients. Ann Surg 1984; 199:299-305.