L.Mageswary

Hospital Selayang

Team Members

L.Mageswary

Lapchmanan Adlin Natasya

Mohd said Teong Lee Fang Tan Sing Ean Fathiyah Noor

Osman

SELAYANG HOSPITAL

• 960 inpatient beds and 20 clinical disciplines – provides secondary and national tertiary care services

• The first hospital in Malaysia and the world to operate T.H.I.S. (Total Hospital Information System) covering all aspects of its operation.

• ICU with 24 beds

Introduction – The Stress Response in ICU

• Prevalence 40%

• Worsen by inappropriate feeding practices

Stress response lead to

malnutrition

• Impaired immunological function,

• Impaired ventilatory drive,

• Weakened respiratory muscles,

• Leading to prolonged ventilatory dependence which translate into infection, multi organ failure, prolonged ICU stay, increased morbidity and mortality.

Malnutrition may result in

Introduction – What Happens in ICU?

Introduction- How Can EN Help?

Nutrition support is an important adjunctive therapy with primary goals to prevent malnutrition and to support patients

during treatment.

Enteral Nutrition Support is prefered in critically ill patients

Enteral feeding should be started early within the first 24 – 48 hours following admission.

The feedings should be advanced toward goal over next 48 – 72 hours.

Efforts to provide more than 50 – 65% of goal calories should be made in order to achieve the clinical benefit of Enteral Nutrition over the 1st week of hospitalisation.

Introduction- How Can EN Help?

Enteral nutritional intervention given early and adequately proven to help to : - reduce disease severity,

- minimise infectious complications, - decrease ICU stay and - save cost

Delayed Nutrition Support with frequent and inappropriate cessation of feeding may lead to inadequate nutrition and malnutrition.

Good nutrition support practices by Health Care Team can help to optimise nutrition delivery and reduce feeding barriers.

1. McClave SA et.al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Ault Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N), 2009.

2. Heyland DK, Khaliwal R, Drover JW, Gramlich L, Didek P. Canadian critical care clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adults patients. JPEN. 2003;27:355-373.

3. Dark DS, Pingleton SD. Nutrition and nutritional support in critically ill patients. J Int Care Med.1993;8:16-33. 4. Kattelmann KK, Hise M, Russell M, Charney P, Stikes M Compher C. Preliminary Evidence for Medical Nutrition Therapy Protocol: Enteral

feedings for Critically Ill patients. Am J Dietetics.2006;1226-1241. 5. Medical Nutrition Therapy Guidelines for Critically Ill Adults. Malaysian Dietitians’ Association. 2005.

Every year, 800 - 1000 patients are admitted to Hospital Selayang ICU for therapy, with average length of stay 12.2 days and 4.4 ventilator days

70 – 80% of the patients are requiring enteral nutrition support.

At Selayang Hospital

Despite knowledge of these benefits, the actual NS received by

patients in ICU is not always optimal for various reasons

Objectives

General Objective Provide Optimal Nutrition Support for

All Critical Patients at Intensive Care Unit

Hospital Selayang

Specific Objectives

To determine initiation day of enteral feeding

To evaluate calories achieved within the fifth day of

enteral nutrition support

To identify factors affecting feeding intake

To implement remedial action

To evaluate effectiveness of remedial action

Methodology

Study Design Cross Sectional Study

Study Sample ICU Patients at Hospital Selayang

Sampling Technique Universal Sampling

Inclusion Criteria – All ICU patients on total enteral nutrition

Exclusion Criteria • Patient on partial parenteral nutrition• Patient on partial enteral nutrition• Duration of feeding less than 5 days

Duration of study Verification Study: October 2009 – December 2009Remedial Measures: February – March 2010 1st cycle: April – Jun 20102nd cycle: July – September 2010Track & Trend 1 : Jan – March 2011Track & Trend 2: April – June 2011

Data Collection Technique Observation, IT documentation

Data Collection Tools KPI Form

Data Analysis SPSS Version 13.0

Study on Cost for antibiotic & ventilator done in year 2013

Definition

Data Collection Form

Verification Study

Male (N=39) Female (N=28)

Mean age (years) 47.7 + 18.2 57.6 + 20.6

Weight (kg) 74.2 + 15.5 55.9 + 7.7

Height (cm) 169.5 + 8.2 153.2 + 3.5

BMI (kg/m2) 25.9 + 5.5 23.8 + 2.7

Malay 15 15

Chinese 13 7

Indian 10 5

Others 1 1

What was Our Performance?

0%

10%

20%

30%

40%

50%

60%

70%

Achieved Not Achieved

69%

31%

Achieved

Not Achieved

Only 58.3% of ICU patients initiated with Enteral

Feeding from 24 to 48 hours of admission.

No patients given feeding before 24 hours.

Only 69.0% of patients on Enteral Feeding

achieved goal calorie recommendation on

Day 5 after feeding initiation.

Only 12.5% of patients could not tolerate

Enteral Feeding due to high gastric residual/

patient related factors compared to 87.5%

of patients were not given feeding due to

Inappropriate Feeding Practices.

12.50%

12.50%

12.50%

50%

12.50%

Cycle 2: Day 5 Feeding Barrier

Procedure Hi GRV Feeding Plan Increase Gradually Others

Problem Analysis

Inappropriate

Enteral Nutrition Support

among

Intensive Care Patient

at Hospital Selayang

Gone for procedures

Delay feeding

initiation

Doctor-Dietitian:

No referral from doctors

Nurses busy with

nursing care

Lack of

communication Slow feeding

progress

Prolonged NBM

Lack of knowledge/

awareness among nurses and patients

Proper education

not prepared / given

Too much

documentation time

in IT system

Dietitian-Nurses:

No standard

protocol prepared

Nursing staff

incompetency

Too many

proceduresPoor feeding

tolerance

No standard protocol

Powerchart (IT system)

not fully utilised

Lack of

Dietitian number

Post not

filled

Maternity

leave

Problem Analysis

Inappropriate

Enteral Nutrition Support

among

Intensive Care Patient

at Hospital Selayang

Gone for procedures

Delay feeding

initiation

Doctor-Dietitian:

No referral from doctors

Nurses busy with

nursing care

Lack of

communication Slow feeding

progress

Prolonged NBM

Lack of knowledge/

awareness among nurses and patients

Proper education

not prepared / given

Too much

documentation time

in IT system

Dietitian-Nurses:

No standard

protocol prepared

Nursing staff

incompetency

Too many

proceduresPoor feeding

tolerance

No standard protocol

Powerchart (IT system)

not fully utilised

Lack of

Dietitian number

Post not

filled

Maternity

leave

X

Intervention

Combined Ward Round

with ICU Team

Reintroduce Enteral Feeding Protocol

Conduct CNE

Sessions

Strengthen Dietitian Referral System

Increase Dietitian

Follow-up Rounds

Use Ready to Feed

Formulas

Use Feeding Pumps

Scheduled Seminar

Good Nutrition Support

Phase 1 Phase 2

Enteral Feeding Protocol

Management

of

complications

Enteral

Formula

&

Indication

Guide NBM

for

Procedure

Algorithm for Bolus

&

Intermittent Feeding

- Feeding progress

- Use of prokinetics

- Post pylorus feeding

- TPN

Demographic Data

Cycle 1 Cycle 2 Track & Trend 1 Track & Trend 2

Male

(N=30)

Female

(N=20)

Male

(N=50)

Female

(N=25)

Male

(N=59)

Female

(N=45)

Male

(N=36)

Female

(N=29)

Mean age

(yrs) 54.2±17.9 54.9±17.1 47.0±17.3 57.7±20.5 54.4±17.0 54.3±18.6 48.3±16.0 58.1±18.2

Weight (kg) 65.2±8.6 55.8±9.9 67.5±12.6 59.5±14.0 61.9±7.6 54.8±7.1 61.0±4.5 60.5±7.3

Height (cm) 169.5±6.3 156.5±5.7 170.6±7.8 156.8±6.7 166.8±4.4 156.0±4.9 163.8±4.1 157.3±5.3

BMI (kg/m2) 22.7±2.7 22.7±3.0 23.1±3.3 24.1±4.9 22.3±2.8 22.5±2.3 22.7±1.3 24.5±3.0

Malay 15 15 14 8 26 12 27 25

Chinese 13 7 10 8 11 5 19 11

Indian 10 5 4 4 9 7 12 4

Others 1 1 2 0 4 1 1 5

ABNA (Achievable Benefit Not Achieved)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Standard Verifikasi Cycle 1 Cycle 2

100%

58.40%67.70%

78.50%

Standard

Verif ikasi

Cycle 1

Cycle 2

41.6%

32.3%

21.5%

Feeding Initiation within 24 – 48 hours of

admission had increased from

58.4% to 78.5% during study period.

ABNA was reduced from 41.6% to 21.5%

64%

66%

68%

70%

72%

74%

76%

78%

80%

Standard Verif ikasi Cycle 1 Cycle 2

75%

69%

75%

78.50%

Standard

Verif ikasi

Cycle 1

Cycle 2

6%

0%

- 3.5%

Adequate feeding (more than 70% of calorie

recommendation) delivered increased from

69% to 78.5% at cycle 2.

ABNA was reduced from 6% to (– 3.5%)

Track & Trend

0

10

20

30

40

50

60

70

80

0

47.1

53.849.5

26

58.4

67.7

78.5

71.4

4441.6

32.3

21.5

28.6

56

< 24 hrs

< 48 hrs

> 48 hrs

Enteral feeding initiation time improved from

58.4% to 71.4% . Only 28.6% patients were fed

after 48 hours during track & trend 1. Delayed

feeding mainly due to patient’s disease

condition.

Percentage calorie achieved by 5th day

increased from 69.0% to 78.5%. The standard

further improved to 88.6% and 96.0% during

track & trend.

Percentage feeding initiation time less or more than 48 hrs

Track & Trend

0

10

20

30

40

50

60

Track & Trend 1 Track & Trend 2

35.2

54

44.8

28

8.6

14

Day 1

Day 3

Day 5

3025

5

40

14

21

14

50

0

10

20

30

40

50

60

Procedure High GRV Feeding Not Done

Increase gradually

Track & Trend 1

Track & Trend 2

Percentage type of feeding barriers Percentage calorie achieved compared with day

Patients received adequate feeding within

72 hours (Day 3) once remedial measures were

implemented. 80.0% and 82.0% patients

achieved adequate calories within 3 days during

track & trend 1 and 2 respectively.

During audit quality noted, goal calories not

achieved by Day 5 in some patients due to

slow feeding progress and related to fasting

for procedures

Cost Analysis 2013

Day Feeding

Achieved

Ventilator Hours/ days Cost (RM)

Ventilator Antibiotic Total

Day 1 160.8 hrs/ 6.7 days

6,700.00

170.36

6,870.36

Day 2

216.8 hrs/ 9.0 days

9,000.00 589.15

9,589.05

Day 3

182.4 hrs/ 7.6 days

7,600.00

352.71

7,952.71

Day 4

381.0 hrs/ 15.9 days

15,900.00

1200.00

17,100.00

Treatment cost increases significantly when there is a delay in

achieving adequate Enteral Nutrition Support

Discussion

Enteral nutrition is an important therapeutic strategy to improve outcomes in ICU patients.

There are wide variation in nutrition support practices across ICU and provision of adequate nutrition is sup-optimal.

Lack of evidence-based guidelines,

lack of communication,

lack interdisciplinary team collaboration and continuous nurses education influence Nutrition Support Practices

Discussion

Use of ICU or nurse-driven protocols which define:

goal infusion rate,

Feeding progression

Management of feeding complications such handling gastric residual, diarrhea, vomiting

Guide for fasting before and after procedure

have been shown to be successful in increasing the overall percentage of goal calories provided

Inappropriate cessation of feeding minimized with education and infusion protocol.

Good

Nutrition Support

Practices by Health Care

Professionals

Compliance to Nutrition

Support Protocol

Regular Monitoring

EARLY ENTERAL NUTRITION

ADEQUATE NUTRITION DELIVERY

BETTER OUTCOME

SAVE COST

Conclusion