Constructing the early enteral nutrition management protocol for severely burned adult patients: a Delphi study

Abstract

Background

Early enteral nutrition (EEN) plays a crucial role in the treatment of severely burned adult patients. However, its clinical implementation remains inconsistent and lacks standardization, which may hinder optimal rehabilitation outcomes of severely burned adult patients. This study aims to create a standardized EEN management protocol specifically tailored for severely burned adult patients.

Methods

An initial draft of the EEN management protocol for severely burned adult patients was formulated through a comprehensive literature review and discussions within an expert panel. This was followed by a two-round Delphi study, in which 17 professional experts from eight provinces and municipalities evaluated the importance and feasibility of the protocol’s items using the structured questionnaire. Based on the feedback received from each round of experts, revisions were made to the protocol’s items.

Results

After two rounds of Delphi consultation, 17 experts converged to a consensus. The EEN management protocol for severely burned adult patients included 5 first-level items, organizational management, comprehensive assessment, nutritional intervention, outcome monitoring, and quality control, with 23 second-level items and 66 third-level items. The expert authority coefficient of consultation was 0.924 and 0.919, respectively. In the first round of expert consultation, the Kendall coefficient of concordance (Kendall’s W) for the importance and feasibility of the items was 0.156 and 0.128, respectively (P < 0.001). In the second round of expert consultation, Kendall’s W for the importance and feasibility of the items was 0.142 and 0.122, respectively (P < 0.001).

Conclusions

This Delphi-derived protocol standardizes EEN management for severely burned adult patients by integrating evidence, expert insights, and operational practicality. It serves as a valuable reference for clinical medical staff for providing high-quality nutrition services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-025-01236-6.

Introduction

Burns remain a significant global public health challenge, with an estimated 180,000 deaths annually worldwide attributed to fire- and heat-related injuries. This issue disproportionately affects low- and middle-income countries where access to specialized care and medical resources is severely limited [1]. Furthermore, non-fatal severe burns contribute substantially to morbidity, long-term disability, and economic burdens in these regions. In China alone, approximately 260,000 people suffer from burns annually, with severely burned adults accounting for a proportion of 15.80% of these cases and an associated mortality rate as high as 9.80% [2–4]. Severe burns are defined as second-degree burns covering 31%−50% of the total body surface area (TBSA), or third-degree burns covering 11%−20% TBSA, or burns involving critical regions (such as the airway) [5]. These extensive injuries induce profound oxidative stress alongside a systemic inflammatory response and a persistent hypermetabolic and hypercatabolic state. Collectively, these factors drive complications including secondary sarcopenia, multiorgan dysfunction, sepsis, and an increased risk of mortality [6]. Compounding these pathophysiological disturbances are chronic caloric deficits, negative protein balance, and deficiencies in essential antioxidant micronutrients—all of which have been strongly linked to delayed wound healing processes, prolonged intensive care unit (ICU) stays, elevated infection rates, and poor overall outcomes [7, 8]. Given this high-risk clinical trajectory and the well-established association between nutritional status and survival outcomes in patients with severe burns, standardized nutritional management for this population is both critically important and urgently needed.

Enteral nutrition (EN), tailored to meet the nutritional requirements of patients with inadequate oral intake, is a therapeutic intervention that delivers chemically defined formulas directly into the gastrointestinal tract via oral intake, nasoenteric tubes, or ostomies. The European Society for Clinical Nutrition and Metabolism (ESPEN) recommended that severely burned patients who were unable to initiate oral feeding within 6–12 h post-injury should commence EEN. Ideally, this intervention should be initiated as soon as possible, preferably within 12 h after the injury [9]. The study has demonstrated that implementing EEN for hemodynamically stable severely burned adult patients, who have no contraindications to EN, can effectively reduce the hypermetabolic response following burns, optimize the patients’ nutritional status, and decrease the incidence of complications and mortality rates [10]. Currently, EEN is regarded as the preferred treatment option for severely burned adult patients [11, 12].

Although EEN plays a crucial role in the treatment of severely burned adult patients, implementation barriers persist in clinical practice, mainly manifested as follows: (1) Limited awareness among certain healthcare providers hinders the effective implementation of EEN in clinical settings [13], (2) The lack of standardization in EEN procedures can lead to improper nutritional support, increased risks of complications, limited treatment effectiveness, and wasted medical resources [14], (3) The standards for nutrients supplementation remain inadequately defined, making it difficult for severely burned adult patients to obtain sufficient nutrient [15], (4) Interdisciplinary collaboration often suffers from a lack of close cooperation, resulting in disjointed nutritional plan [16, 17], (5) Insufficient training for healthcare providers perpetuates knowledge-to-practice gaps.

In recent years, the Chinese government has attached great importance to the management of clinical nutrition and has issued some decisive guidelines. The “Healthy China 2030” planning outline, issued by the Central Committee of the Communist Party of China and the State Council in 2016, explicitly underscores the strategic importance of implementing clinical nutrition interventions [18]. The joint notice released by the National Health Commission and the State Administration of Traditional Chinese Medicine in 2023, titled the “Action Plan for Further Improving Nursing Services (2023–2025),” emphasizes the need for nurses to provide personalized health education on diet and nutrition to patients, tailored to their specific disease characteristics, individual differences, and health needs [19]. In 2024, the General Office of the National Health Commission issued a notification titled “Further Promoting Clinical Nutrition Work”, which mandates local medical institutions to enhance and improve their institutional frameworks, strengthen clinical nutrition quality management, and standardize clinical nutrition services [20].

However, existing international and national guidelines advocate early enteral feeding often lack detailed, operational guidance specifically tailored to severely burned adult patients. In particular, these guidelines do not adequately address how EEN should be customized according to burn severity (e.g., total body surface area [TBSA] ≥ 20% versus ≥ 40%), hemodynamic stability, or the dynamic phases of care such as the fluid resuscitation period, during which gastrointestinal perfusion may be compromised and feeding tolerance remains unpredictable. Furthermore, institutional protocols exhibit considerable variability in their definitions of “early” initiation, rates of feeding advancement, criteria for intolerance, and monitoring parameters. This inconsistency contributes to variable clinical practices and suboptimal patient outcomes. The identified gap in condition-specific, phase-sensitive, and implementable guidance highlights the urgent need for a standardized EEN protocol that is grounded in both current evidence and expert consensus.

In this context, our study intends to construct a standardized EEN management protocol for severely burned adult patients, aiming to provide a practical, evidence-informed reference for clinical practice and further promote the rehabilitation of this high-risk population.

Methods

This study included two phases: (1) A literature review and an internal expert group discussion were conducted to formulate an initial protocol for EEN management in severely burned adult patients, and (2) The Delphi method was used to reach a consensus on the EEN management protocol for severely burned adult patients.

Literature review

The initial draft of the EEN protocol was developed based on a systematic review of the literature retrieved from January 2013 to July 2024 from the following databases: Embase, Cochrane Library, PubMed, Web of Science, CINAHL, China National Knowledge Infrastructure, the Chinese Biomedical Literature Database, Wanfang, and the Chinese Medical Journal Full-Text Database. The following search strategies were used to identify studies: (burns OR burn OR thermal burns OR smoke inhalation injury OR severe burns OR major burn OR massive burns) AND (enteral nutrition OR enteral feeding OR tube feeding OR nutrition therapy OR nutritional screening OR nutritional assessment OR nutrition support OR nutritional care). A total of 2226 articles were identified. Firstly, 308 duplicate studies were excluded. Next, 1,812 irrelevant studies were excluded based on title and abstract screening. Following a full-text review for eligibility, an additional 82 studies were eliminated. Finally, 20 English-language articles and 4 Chinese-language articles were included. The Appraisal of Guidelines for Research and Evaluation (AGREE II) [21] and the Joanna Briggs Institute (JBI) Critical Appraisal tools [22] were used to evaluate the quality of the included articles. Two researchers independently reviewed the included articles to extract and integrate evidence. Any disagreements were resolved by consulting a third researcher. The JBI Evidence Pre-grading and Evidence Recommendation Level System 2014 was adopted for grading the extracted evidence [23]. In total, twenty-seven pieces of evidence were summarized in 5 areas: organization and management, comprehensive evaluation, nutrition plan, complication management, and effect evaluation. Table 1 shows the contents and grades of the evidence.

Table 1.

The contents and grades of evidence

Themes of evidence	Contents of evidence	Grades of evidence
I Organizational management
	1. Establishing a nutritional support treatment team (including clinicians, dietitians, specialized nurses, etc.) to implement standardized nutrition diagnosis and treatment.	5b
II Comprehensive assessment
Nutritional risk screening	2. NRS 2002 or NUTRIC or mNUTRIC is recommended for nutritional risk screening.	1a
Nutritional assessment	3. NRS 2002 ≥ 5 points, NUTRIC score > 5 points, or mNUTRIC score ≥ 5 points are classified as being at high nutritional risk. They should undergo immediate nutrition assessment and intervention.	2c
	4. It is recommended to conduct nutritional assessments through a dynamic approach that incorporates multiple indicators, such as physical measurements, laboratory test results, and specific nutrition assessment scales.	3a
	5. Each patient’s energy requirements should be assessed at least once a week. The preferred method for this assessment is indirect calorimetry, with the Toronto equation serving as an alternative when indirect calorimetry is not feasible.	3b
Gastrointestinal function assessment	6. Before and after initiating EEN, it is recommended to assess the patient’s gastrointestinal function dynamically based on their condition. This assessment can be conducted using AGI assessment scale or ultrasonography.	5b
The risk of aspiration assessment	7. Enhancing the assessment of aspiration risk. Factors contributing to a high risk of aspiration include dysphagia, the loss or decline of consciousness, the use of sedatives or muscle relaxants, and transportation both within and outside the hospital.	5b
III Nutrition plan
Energy and nutrients	8. It is recommended to provide a low energy intake (50% to 70% of the target energy) during the initial phase of EEN, gradually reaching the planned energy goal within 48 to 72 h.	5b
	9. It is recommended to provide 1.5–2.0 g/kg of protein every day, limiting fat to 30% of total energy and carbohydrates to 60% of total energy.	1a
	10. It is recommended to supplement with appropriate amounts of trace elements such as zinc, copper, and selenium, as well as vitamins B1, C, D, and E.	1b
	11. If the patient’s gastrointestinal function is generally normal, it is recommended to supplement with glutamine at a dosage of 0.5 g/kg for10 to 15 days.	1a
	12. It is recommended to incorporate ω−3 polyunsaturated fatty acids into EN formulations.	1c
Nutritional support timing	13. Severely burned patients should be prioritized for the initiation of EEN. For patients who are hemodynamically stable and have no contraindications to EEN, it is recommended that they receive EEN within 24 h following the burn injury.	1a
	14. Suggestions for delaying EEN include the following conditions: hypoxemia, acidosis, shock, ineffective control of gastrointestinal bleeding, intestinal ischemia, mechanical bowel obstruction, abdominal compartment syndrome, and GRV > 500 ml/6 h.	1c
Nutritional support pathways	15. For patients capable of oral intake, oral nutritional supplementation (ONS) is the preferred option. In cases where patients are unable to consume food orally or when their combined oral intake and ONS do not meet 60% of their energy target, tube feeding via a nasogastric tube is recommended. For patients with feeding intolerance, contraindications to nasogastric feeding, or a high risk of aspiration, nasoduodenal or nasojejunal feeding is recommended.	1a
	16. SPN is recommended under the following conditions: EEN fails to meet 60% of the physiological energy and protein requirements within 48 to 72 h for patients identified as being at high nutritional risk; after 7 days of EEN support, patients categorized as low nutritional risk have not reached the target feeding volume of 60%.	1c
Feeding methods	17. It is recommended to develop and implement an enteral feeding protocol driven by intensive care unit nurses.	2b
	18. For patients with intact gastrointestinal function, whole protein formulas are recommended; for those with impaired gastrointestinal function, short peptide formulas are recommended.	5b
	19. Feeding should start with low-energy density, low-dose (10–20 kcal/h), and low-rate (10–20 ml/h) administration, with continuous infusion via an enteral nutrition pump for tube-fed patients. If gastrointestinal tolerance is confirmed, gradually increase the rate to achieve the target feeding volume within 5–7 days.	2b
IV Complications management
Complications monitoring	20. Routine monitoring of gastric residual volume is not recommended; however, in cases of feeding intolerance and high aspiration risk, gastric residual volume should be monitored every 4 h, which can be done using gastric ultrasound or syringe aspiration.	1c
	21. It is recommended to monitor patients’ tolerance to EEN daily, which can be determined through a combination of physical examination, gastrointestinal function assessment, and patient self-report.	3b
	22. Regular monitoring of the patient’s liver and kidney functions, electrolytes, blood lipids, and other metabolic indicators.	1a
	23. Dynamic monitoring of blood glucose levels is recommended, with a target range of 4.5 to 8.0 mmol/L.	1a
	24. During the supplementation of trace micronutrients, it is recommended to closely monitor for toxic reactions and antagonistic responses.	1b
Complications prevention	25. Flushing the EN tube with 30 ml of lukewarm water before and after tube feeding, as well as every 4–6 h during infusion.	5b
	26. It is recommended to decrease the level of sedation and analgesia for patients, administer prokinetic agents as necessary, perform regular oral care, and minimize unnecessary out-of-ward examinations.	5b
V Effect evaluation
	27. It is recommended to regularly evaluate the effectiveness of EEN by combining assessments of the patient’s weight changes, laboratory tests, indirect calorimetry measurements, and the clinician’s judgment.	5b

AGI Acute Gastrointestinal Injury, EEN Early enteral nutrition, GRV Gastric residual volume, NRS 2002 Nutritional Risk Screening 2002, NUTRIC Nutrition Risk in the Critically Ill, mNUTRIC Modified Nutrition Risk in the Critically Ill, SPN Supplemental parenteral nutrition

Selection of internal experts for discussions

The internal expert panel comprised nine specialists from a tertiary hospital in Sichuan Province, including burn surgeons (n = 2), clinical dietitians (n = 2), a nurse manager specializing in burn and critical care units (n = 1), clinical nurses with at least five years of burn care experience (n = 2), a pharmacist (n = 1), and an intensivist (n = 1). Internal experts contributed their insights on the development of the initial EEN management protocol for severely burned adult patients based on a literature review as well as their own professional experiences. They also provided specific suggestions on selecting Delphi experts, facilitating feedback discussions, and refining the protocol. The inclusion criteria for the internal experts were as follows: (1) Involvement in clinical nutrition work or research, (2) Holding a master’s degree or higher, (3) Holding an intermediate-level or higher professional title, (4) Ability to provide comprehensive and professional opinions and suggestions, (5) Owing strong motivation and eagerness to participate in this study.

Generation of the initial Delphi draft

Based on a narrative, evidence-informed review of the relevant literature, an internal expert panel conducted multiple discussions and developed an initial EEN management protocol for severely burned adult patients. A systematic review or formal evidence grading was not performed, as the primary aim of this study was to establish expert consensus in a clinical area where high-quality evidence specific to EEN in severe burns remains scarce. The initial protocol outlined core EEN-related items, organized into three hierarchical levels: first-level, second-level, and third-level components. This preliminary protocol served as the foundation for developing the Delphi questionnaire.

Recruitment of the Delphi experts

The Delphi process is an effective group-based judgment and decision-making technique that systematically combines experts’ opinions to reach a consensus on specific questions and issues [24, 25]. In this study, the criteria for selecting Delphi experts were as follows: (1) Eligible experts included professionals from burns, surgical, critical care, nutritional, and nursing disciplines, (2) For those with a bachelor’s degree, a professional title of deputy senior or higher, with more than 10 years of relevant clinical or research experience, (3) For those with a master’s degree or higher, a professional title of intermediate or higher, with more than 5 years of relevant experience, (4) Willingness to participate and commit to completing two rounds of the Delphi survey. To ensure a well-rounded and representative panel, purposive sampling was employed to achieve diversity in clinical expertise, academic background, and geographic location. Experts were recruited from tertiary hospitals and academic institutions across multiple regions of China from July to September 2024. Specifically, the final panel included 17 experts from 8 cities across China, including Beijing, Hangzhou, Wuhan, Hefei, Chengdu, Chongqing, Lanzhou, and Guangzhou. These cities represent the eastern, central, and western regions of the country. This broad geographic representation helps ensure that the consensus reflects varied clinical practices and healthcare contexts. Researchers contacted these experts via e-mail or WeChat, explaining the relevant information about the survey in detail.

The first round of the Delphi consultation

In the first round of Delphi consultation, the questionnaire was dispatched to 20 Delphi experts via email or WeChat. The questionnaire contained four parts: an introduction to this study, the initial EEN management protocol for severely burned adult patients, personal information of experts, and experts’ self-assessment of the survey content. The initial set of EEN management protocol consisted of 5 first-level items, 21 s-level items, and 69 third-level items. The experts’ personal information section of the questionnaire included gender, age, professional experience, educational background, fields of work or research, and professional titles. Experts were required to evaluate each item using a 5-point Likert scale, rating its significance from 1 (not important at all) to 5 (very important) and its feasibility (in terms of ease of operation) from 1 (difficult to operate) to 5 (easy to operate). A blank column for free-text comments was also provided to experts, facilitating them to add, delete, or revise the items of the protocol. The experts’ familiarity with the content was scored on a five-point scale from 0.2 (very unfamiliar) to 1.0 (very familiar). The basis for experts’ judgments included theoretical analysis (0.1 points for minor influence, 0.2 points for medium influence, and 0.3 points for significant influence), practical experience (0.3 points for minor influence, 0.4 points for medium influence, and 0.5 points for significant influence), references to domestic and foreign relevant literature (0.1 points each), and subjective judgment (0.1 points each). In this study, the experts were requested to complete the survey questionnaire within 14 days. If they did not, they would be reminded via email or WeChat. The first round of the Delphi consultation questionnaire is shown in Supplement 1.

The second round of the Delphi consultation

The methodology for the second round of the Delphi consultation was consistent with that of the first round. Experts were invited to respond to the revised questionnaire in order to reach a consensus. The second round of the Delphi consultation questionnaire is shown in Supplement 2. This study achieved a high level of consensus following the second round of the Delphi consultation.

Data analysis

Data entry and analysis were conducted using Excel and SPSS 27.0. Descriptive analysis was conducted using mean, standard deviation, frequency, and proportion. The recovery rate (RR) of the questionnaire was calculated to assess the positivity of the experts, with RR > 70% indicating effective consultation [26]. Expert authority coefficient (Cr) was determined by the coefficient of familiarity (Ca) and the coefficient of judgment (Cs), with Cr ≥ 0.7 generally regarded as reliable [27]. The degree of coordination among experts was expressed by the coefficient of variation (CV) and Kendall’s W. Items were retained if they met al.l of the following criteria: a mean score ≥ 3.50, CV ≤ 0.25, and at least 75.00% of panelists rating the item as “important” (score = 4) or “essential” (score = 5) on the 5-point Likert scale [28]. Otherwise, items were flagged for expert panel review and potential revision or deletion. A p-value < 0.05 was considered to indicate a statistically significant difference.

Quality control

The researchers took the following measures to ensure the quality of the Delphi study [29]: (1) The survey questionnaire included standardized instructions to guide experts in completing it correctly, (2) Returned questionnaires were checked carefully, and any invalid questionnaires with missing information were excluded, (3) Two researchers independently verified and entered the research data to ensure accuracy, (4) Based on anonymized expert feedback and questionnaire analysis, the panel deliberated whether to modify, merge, or remove each item. To minimize dominance bias, all inter-round feedback was fully anonymized. Revisions were guided by structured team discussions and focused on enhancing item clarity, relevance, and contextual applicability.

Results

Demographic and professional characteristics of the Delphi experts

A total of 17 experts participated in this Delphi study. They came from eight cities in China, with a mean age of 46.82 ± 7.67 years (ranging from 36 to 65 years) and an average clinical experience of 24.41 ± 9.94 years (ranging from 11 to 48 years). Table 2 presents the demographic and professional characteristics of the Delphi experts.

Table 2.

The demographic and professional characteristics of the Delphi experts

Demographic and professional characteristics		Frequency	Percentage
Gender	male	8	47.059%
	female	9	52.941%
Age	30–39 years	2	11.765%
	40–49 years	9	52.941%
	≥ 50 years	6	35.294%
Clinical experience	10–19 years	7	41.176%
	20–29 years	4	23.529%
	≥ 30 years	6	35.294%
Educational degree	bachelor	2	11.765%
	master	7	41.176%
	PhD	8	47.059%
Professional titles	intermediate	2	11.765%
	associate senior	7	41.176%
	senior	8	47.059%
Position	department director	4	23.529%
	deputy department director	2	11.765%
	head nurse	2	11.765%
	ward nurse manager	4	23.529%
	other	5	29.412%
Academic background	clinical nutrition management	7	41.176%
	clinical burn care	7	41.176%
	burn nursing	3	17.647%
	nursing management	8	47.059%
	evidence-based nursing	4	23.529%
Geographic distribution	Eastern regions of China	3	37.500%
	Central regions of China	2	25.000%
	Western regions of China	12	37.500%

Reliability of the Delphi method

Expert positive coefficients

In the first round of the Delphi survey, 20 questionnaires were distributed, with 17 valid responses received (85.00% response rate). Among these respondents, 11 experts (64.71% of respondents) provided 56 suggestions. In the second round of the Delphi survey, questionnaires were resent to the 17 initial respondents, yielding 16 valid responses (94.12% response rate). Among these respondents, 4 experts (25.00% of respondents) put forward 16 constructive opinions. The response rates of both rounds of the Delphi survey were > 70%, indicating a high level of experts’ positivity.

Expert authority coefficient

The results of the two rounds of the Delphi survey indicated that the experts’ authority degree was 0.924 (with Cs at 0.882, and Ca at 0.965) and 0.919 (with Cs at 0.875, and Ca at 0.963), respectively. Additionally, the Cr value for both rounds was greater than 0.7, suggesting that the experts possessed a high degree of authority.

Coordination level of experts’ opinions

The results of two rounds of the Delphi survey indicated that Kendall’s W for the evaluations of the importance of the items was 0.156 and 0.142, respectively; and for the feasibility of the items, Kendall’s W was 0.128 and 0.122, respectively. In the two-round Delphi survey, consensus was achieved for all items according to the predefined criteria, despite relatively low concordance coefficients. All items had a mean rating of at least 3.50, and at least 75.00% of experts rated each item as “important” (score = 4) or “essential” (score = 5) on the 5-point Likert scale. And all p-values were less than 0.001. Table 3 presents the experts’ ratings and level of agreement, and Supplement 3 further confirms the attainment of consensus.

Table 3.

The coordination level of experts’ opinions

Content		Delphi round 1					Delphi round 2
		CV	Kendall’s W	X 2	P	Level of agreement	CV	Kendall’s W	X 2	P	Level of agreement
The importance of items	First-level item	0.07～0.14	0.182	12.382	<0.05	94.12%～100.00%	0.00～0.14	0.154	9.887	<0.05	100%
	Second-level item	0.07～0.20	0.160	54.397	<0.001	76.47%～100.00%	0.05～0.16	0.171	60.148	<0.001	87.50%～100.00%
	Third-level item	0.00～0.26	0.156	179.889	<0.001	70.59%～100.00%	0.05～0.26	0.142	147.544	<0.001	75.00%～100.00%
The feasibility of items	First-level item	0.12～0.20	0.146	9.947	<0.05	76.47%～88.24%	0.13～0.23	0.119	10.359	<0.05	93.75%
	Second-level item	0.08～0.21	0.135	45.940	<0.001	76.47%～100.00%	0.09～0.23	0.110	38.875	<0.05	75.00%～100.00%
	Third-level item	0.07～0.33	0.128	147.678	<0.001	58.82%～100.00%	0.08～0.25	0.122	126.493	<0.001	75.00%～100.00%

CV Coefficient of variation, Kendall’s W Kendall coefficient of concordance

The first round of the Delphi consultation

The first round of the Delphi survey included 69 items spanning 5 distinct domains. The Delphi experts provided 56 suggestions regarding modifications to wording or meaning, the deletion or addition of new items, the consolidation of certain duplicate items, and the division of some items. Our expert panel carefully reviewed these suggestions. Additionally, items with CV > 0.25 were discussed for modification, removal, or addition. The specific items identified for discussion included: item 1.1.2, item 1.1.3, item 2.1.2, item 2.1.3, item 2.3.1, item 2.4.3, item 3.2.2, and item 3.4.4.

Totally, 8 additional suggestions proposed by the Delphi experts were not adopted, as they did not align with the study aims or were already encompassed within other items. These suggestions included the deletion of item 2.4 “ Psychosocial assessment”, the addition of three second-level items (“Assessment of nutritional intolerance”, “Parenteral nutrition monitoring”, and “Specific implementation of nutrition plans”), the revision of item 2.4.2 “Financial condition” to “Economic stress”, and item 3.6 “Formulation type” to “Enteral feeding formulation type (nasointestinal tubes feeding)”, an increase in the frequency of nutrition risk screening in item 2.2.3, and the adoption of a scale for assessing psychosocial status in item 2.4.1.

We modified and refined the items based on clinical practice, the internal experts’ discussions, and relevant literature. Finally, a total of 2 s-level items and 6 third-level items were added, 13 third-level items were merged or deleted, and 3 s-level items and 25 third-level items were revised. For example, two experts suggested adding the second-level item “1.1 Establishing Organizational Structure”. After internal expert discussions, this suggestion was adopted, and the redundant third-level item 1.1.3 was deleted. Despite the importance of the CV of item 2.4.3 being > 0.25, we retained this item after internal expert discussion. A Delphi expert suggested increasing the provision of protein in item 3.5.3. After literature review and discussions, we adopted this suggestion and merged item 3.5.1 “Carbohydrates”, item 3.5.2 “Fats”, and item 3.5.3 “Proteins” into a single item “Macronutrients”. For item 3.4.4, two experts believed that Percutaneous Endoscopic Gastrostomy (or Percutaneous Endoscopic Jejunostomy) for EEN was rarely adopted in clinical practice, so we deleted it after discussions. Three experts expressed differing opinions regarding the frequency of oral care in item 3.8.5. After reviewing the expert consensus “Oral Care for Adult Patients in Intensive Care Units” [30], we revised the content of this item in accordance with the recommendations outlined.

After the first round of the Delphi survey, the revised protocol comprised 5 first-level items, 23 s-level items, and 66 third-level items. Based on this, we developed the second round of the expert consultation questionnaire, presenting all retained items as well as newly added and revised items to the experts for evaluation.

The second round of the Delphi consultation

In the second round of the Delphi survey, 16 experts returned valid questionnaires. A total of 16 suggestions were provided by 4 experts. Based on the internal experts’ discussions and a review of relevant literature, 3 suggestions were not adopted because they were not in line with the clinical situation. These suggestions included the deletion of item 2.3.3 “Frequency”, the revision of item 2.4.4 “using metabolic carts or indirect calorimetry” to “using metabolic carts (indirect calorimetry)”, and the revision of item 3.8.1 “For patients undergoing prone position therapy, suspend EEN feeding” to “For patients undergoing prone position therapy, suspend EEN feeding is unnecessary”.

In addition, we fully adopted 8 suggestions and partially adopted 5 suggestions. We modified and refined the items based on clinical practice, the internal experts’ discussions, and relevant literature. Finally, a total of 1 third-level item was added, 2 third-level items were merged, and 15 third-level items were revised. For example, a Delphi expert suggested listing an ultrasound physician in a multidisciplinary team. After discussions, the internal experts thought imaging specialists were more suitable for listing in the multidisciplinary team. And we revised the item 1.2.1 to “Establishing a nutritional support team led by clinical specialists, including burn physicians, dietitians, nutrition specialist nurses (having obtained a certificate qualifying them as specialist nurses and are working in the relevant field), charge nurses, rehabilitation therapists, imaging specialists, pharmacists, psychotherapists, etc., who were jointly responsible for the development, implementation, supervision, and adjustment of the protocol”. An expert suggested adding the third-level item 2.1.1 “Assessing the patient’s current medical history, including the cause of the disease, accompanying symptoms, diagnosis and treatment, and general condition (such as mental status, urination, and defecation)”. An expert pointed out that the infusion method should be used with caution. After internal expert discussions and a review of the literature, item 3.7.2 and item 3.7.3 were merged and revised to item 3.7.2 “Using enteral nutrition pumps for continuous infusion (avoiding a 24-hour continuous infusion), starting at a rate of 20 to 30 ml/h, and then gradually increasing the infusion rate according to the patient’s tolerance”.

By the end of the second round of the Delphi survey, expert opinions had converged. The finalized EEN management protocol for severely burned adult patients comprised 5 first-level items, organizational management, comprehensive assessment, nutritional intervention, outcome monitoring, and quality control, with 23 s-level items and 66 third-level items. Fig. 1 shows the flow diagram of the Delphi process. The complete structure of the protocol is presented in Table 4, and the final hierarchical framework is summarized in Table 5.

Fig. 1.

The flow diagram of the Delphi process

Table 4.

The EEN management protocol for severely burned patients

First-level item	Second-level item	Third-level item	Importance		Feasibility
			Mean±SD	CV	Mean±SD	CV
1. Organizational management	1.1 Establishing the organizational structure	1.1.1 Establishing the organizational structure of EEN management, and clarifying roles and responsibilities	4.50±0.63	0.14	4.12±0.96	0.23
	1.2 Building a multidisciplinary team	1.2.1 Establishing a nutritional support team led by clinical specialists, including burn physicians, dietitians, nutrition specialist nurses ( having obtained a certificate qualifying them as specialist nurses and are working in the relevant field), charge nurses, rehabilitation therapists, imaging specialists, pharmacists, psychotherapists, etc., who were jointly responsible for the development, implementation, supervision, and adjustment of the protocol	4.62±0.50	0.11	4.62±0.72	0.16
	1.3 Developing policies and procedures	1.3.1 Developing EEN management policies (including technical standards, quality control standards, emergency plans and procedures, etc)	4.63±0.50	0.11	4.50±0.63	0.14
		1.3.2 Establishing workflows for EEN management (including assessment, planning, implementation, evaluation, etc)	4.94±0.25	0.05	4.50±1.03	0.23
	1.4 Organizing training and assessment	1.4.1 Developing training plans and assessment standards	4.94±0.25	0.05	4.31±1.01	0.24
		1.4.2 Conducting regular training and assessments, and making detailed records.	4.88±0.34	0.07	4.56±0.73	0.16
2. Comprehensive assessment	2.1 Basic assessment	2.1.1 Assessing the patient’s current medical history, including the cause of the disease, accompanying symptoms, diagnosis and treatment, and general condition (such as mental status, urination, defecation)	4.81±0.40	0.08	4.56±0.63	0.14
		2.1.2 Collecting the patient’s past medical history, including diseases affecting nutritional status (such as diabetes, chronic gastric disease, chronic liver disease, chronic kidney disease), surgical history, allergies, etc	4.75±0.58	0.12	4.44±0.73	0.16
		2.1.3 Assessing the patient’s vital signs and hemodynamics status	4.94±0.25	0.05	4.56±0.63	0.14
		2.1.4 Performing laboratory and imaging examinations in time, and conducting special examinations if necessary, to assess the functions of the patient’s important organs	4.81±0.40	0.08	4.63±0.62	0.13
		2.1.5 Assessing whether the facilities and equipment are complete and in functional position, including oxygen sources, ECG monitors, blood oxygen monitors, enteral nutrition pumps, bedside B-ultrasound machines (if available), weight scales, etc	4.75±0.45	0.09	4.63±0.62	0.13
	2.2 Specialized assessment	2.2.1 Burn severity: assessing the burn area, location, depth, and presence of inhalation injury	4.62±0.62	0.13	4.63±0.62	0.13
		2.2.2 Gastrointestinal function injury: using AGI assessment scale or AGI ultrasound	4.69±0.48	0.10	4.62±0.62	0.13
		2.2.3 Oral injury: for patients with facial burns, assessing oral injuries by a clinician	4.81±0.40	0.08	4.63±0.62	0.13
		2.2.4 Dysphagia: the Kubota Water Swallowing Test is used to assess swallowing function in patients without impaired consciousness, intact pharyngeal reflexes, and normal oropharyngeal anatomy. For those who are not suitable for this test, swallowing function assessments should be conducted by clinicians or rehabilitation therapists	4.44±0.63	0.14	4.50±0.73	0.16
	2.3 Nutritional risk screening	2.3.1 Timing: completed within 24 hours of admission	4.81±0.40	0.08	4.69±0.60	0.13
		2.3.2 Tool: using the NRS 2002 Nutrition Risk Screening Scale	4.94±0.25	0.05	4.81±0.40	0.08
		2.3.3 Frequency: dynamic screening should be conducted based on the patient’s disease progression, surgical status, and nutritional risk level, with a minimum frequency of once a week	4.88±0.34	0.07	4.44±0.81	0.18
	2.4 Nutritional assessment	2.4.1 Anthropometric measurements: height, weight, skeletal muscle or lean body tissue content, etc	4.81±0.40	0.08	4.62±0.81	0.17
		2.4.2 Dietary survey: the type, quantity, and quality of the recent diet, and dietary preferences	4.69±0.48	0.10	4.13±0.96	0.23
		2.4.3 Monitoring of relevant indicators: prealbumin, transferrin, total albumin, C-reactive protein, IGF-1, BUN, creatinine, blood glucose, electrolytes, and acid-base balance, etc	4.50±0.63	0.14	4.50±0.63	0.14
		2.4.4 Energy requirements: assessing at least weekly, preferably using indirect calorimetry or metabolic carts. If unavailable, use the Third Military Medical University Burn Energy Requirement Formula to estimate	4.50±0.63	0.14	4.50±0.63	0.14
	2.5 Psychological and social assessment	2.5.1 Mental and psychological status	4.88±0.34	0.07	4.75±0.58	0.12
		2.5.2 Financial condition	4.94±0.25	0.05	4.75±0.45	0.09
		2.5.3 Sociocultural factors: patients’ and major caregivers’ education level, religious beliefs, etc	4.88±0.34	0.07	4.75±0.58	0.12
3. Nutritional intervention	3.1 Nutritional goals	3.1.1 During the acute stress, following the principle of “allowing low calories ” (providing 50% to 70% of target energy), the feeding volume and rate should be gradually increased as the stress and metabolic status stabilize, ultimately reaching the target feeding volume within 5 to 7 days	4.75±0.58	0.12	4.81±0.40	0.08
	3.2 Nutritional plan	3.2.1 Developing and implementing a nutritional plan in collaboration with the nutrition support team, the patient (conscious and hemodynamically stable), and primary caregivers, including timing of interventions, routes, nutrients, formula types, feeding methods, complication prevention, and health education	4.63±0.72	0.16	4.63±0.81	0.17
	3.3 Intervention timing	3.3.1 After fluid resuscitation and comprehensive assessment, EEN should be initiated within 24 hours of admission if the patient’s condition is deemed appropriate	4.88±0.34	0.07	4.50±0.73	0.16
	3.4 Intervention pathways	3.4.1 Appropriate intervention pathways are selected based on factors such as disease, medical conditions, and patient acceptance. For those who can eat orally, ONS is preferred	4.75±0.45	0.09	4.25±0.86	0.20
		3.4.2 The implementation of tube feeding for EEN is indicated when there is a combination of respiratory tract burns, inability to eat orally, or when dietary intake combined with oral nutritional supplements fails to meet 60% of the target energy requirements	4.56±0.63	0.14	4.38±0.72	0.16
		3.4.3 Administering EEN via a nasogastric tube. If gastric tube feeding is prohibited, feeding intolerance exists, or there is a high risk of aspiration, administering EEN via a nasoenteric tube instead	4.81±0.40	0.08	4.50±0.63	0.14
		3.4.4 Supplemental parenteral nutrition should be given if 60% of the nutritional goals cannot be met by EN within 48 to 72 hours for those at high nutritional risk, or within 7 days for those at low nutritional risk	4.88±0.34	0.07	4.56±0.63	0.14
		3.4.5 If dysphagia is ≤ grade 2 and tube-fed EN has met 50% of the target energy for 3 to 5 days, gradually reduce the provision of EN and make a progressive transition to oral intake	4.25±0.68	0.16	4.12±0.81	0.20
		3.4.6 If the oral diet has met more than 75% of the target energy requirements for 3 to 5 days, the transition should be made from an oral diet with oral nutritional supplements to an oral diet combined with nutritional education	4.31±0.70	0.16	4.37±0.72	0.16
	3.5 Nutrients	3.5.1 Macronutrients: providing 1.5 to 2.0 g/(kg·d) of protein; limiting carbohydrates to within 60% of total daily energy intake; restricting fats to within 30% of total daily energy intake	4.19±0.91	0.22	4.25±0.68	0.16
		3.5.2 Micronutrients: supplementing trace elements such as zinc, copper, and selenium, as well as vitamins B1, A, and D, according to the actual needs determined by the clinicians	4.13±1.09	0.26	4.37±0.72	0.16
		3.5.3 Immunonutrients: supplementing omega-3 polyunsaturated fatty acids and glutamine via the enteral route, with glutamine administered at a dose of 0.5 g/kg/day or 12–14 g/day for at least a 2-week course	5.00±0.00	0.00	4.69±0.60	0.13
	3.6 Formulation type	3.6.1 Appropriate enteral nutrition formulations should be selected based on the patient’s disease condition, gastrointestinal function, tolerance, financial condition, and dietary preference	4.75±0.45	0.09	4.62±0.81	0.17
		3.6.2 Commercial nutrition formulations should be used instead of home-made homogenized diets	4.88±0.34	0.07	4.63±0.62	0.13
		3.6.3 Providing whole-protein formulas for patients with normal gastrointestinal function, short-peptide pre-digested formulas for those with gastrointestinal dysfunction, and if necessary, providing specialized formulas (such as those designed for diabetes)	4.88±0.34	0.07	4.50±0.73	0.16
	3.7 Feeding methods	3.7.1 If ONS is used, start with a small dose and low concentration, adopting methods such as sipping and taking small amounts multiple times. And gradually increase the intake of ONS as tolerance improves	4.81±0.40	0.08	4.50±0.73	0.16
		3.7.2 Using enteral nutrition pumps for continuous infusion (avoiding a 24-hour continuous infusion), starting at a rate of 20-30 ml/h, and then gradually increasing the infusion rate according to the patient’s tolerance	4.81±0.40	0.08	4.31±0.70	0.16
		3.7.3 For EN tolerance scores of 0-2, continue EEN at the current infusion rate (with symptomatic treatment if necessary); for scores of 3-4, reduce the infusion rate of EEN (reassess the patient's condition after 2 hours); for scores of 5 or above, temporarily pause EEN (reassess the patient's condition and consider to change feeding route if necessary)	4.75±0.45	0.09	4.63±0.62	0.13
	3.8 Complications prevention	3.8.1 Position management: if there are no contraindications, elevate the head of the bed during EEN feeding (30°-45° for regular hospital beds, and 15°-30° for turning beds or air-fluidized beds). After feeding is completed, assist the patient to maintain a semi-reclining position for 30-60 minutes. For patients undergoing prone position therapy, suspend EEN feeding 30 minutes before the start of prone position treatment	4.81±0.40	0.08	4.44±0.73	0.16
		3.8.2 Tube flushing: flushing the EN tube with 30 ml of lukewarm water before and after tube feeding, before and after medication administration, and whenever tube feeding is interrupted. Additionally, during infusion, flushing the tube with 30 ml of lukewarm water every 4 hours	4.75±0.45	0.09	4.75±0.45	0.09
		3.8.3 Tube fixation and replacement: checking the depth of tube insertion and fixation status each shift, and replacing the tubes and fixtures devices on time	4.81±4.81	0.08	4.75±0.45	0.09
		3.8.4 Skin care: checking the skin condition of the area where the tube is fixed each shift, and keep it clean and dry	4.88±0.34	0.07	4.63±0.89	0.19
		3.8.5 Oral care: every forming oral care measures in accordance with the Baker Oral Assessment Scale. The frequency of care is determined as follows: for a score of 5, at least once every 12 hours; for scores ranging from 6-10, at least once every 8 hours; for scores ranging from 11-15, at least once every 6 hours; and for scores ranging from 16-20, at least once every 4 hours	4.88±0.34	0.07	4.81±0.40	0.08
		3.8.6 Others: decreasing the level of sedation and analgesia for the patient when their condition permits, as well as minimizing unnecessary out-of-ward examinations, etc	4.62±0.62	0.13	4.50±0.73	0.16
	3.9 Health education	3.9.1 Regularly providing nutrition education, exercise guidance, and daily care instructions to patients and their primary caregivers through diverse methods, such as popular science videos, special lectures, peer education, and individualized guidance	4.75±0.45	0.09	4.69±0.60	0.13
4. Outcome monitoring	4.1 Nutritional status monitoring	4.1.1 Dynamic monitoring includes: energy and protein intake and output; anthropometric measurements, such as total body weight, weight change, and content of skeletal muscle or lean tissue content; laboratory indicators, including serum protein (such as total protein, albumin, prealbumin, transferrin), urea nitrogen, blood glucose, and electrolyte levels (such as potassium, magnesium, phosphorus), etc	4.75±0.45	0.09	4.44±0.63	0.14
	4.2 Enteral nutrition monitoring	4.2.1 Monitoring the use and maintenance of nutritional equipment and access routes in each shift	4.75±0.45	0.09	4.56±0.73	0.16
		4.2.2 Adopting the aspiration risk assessment scale to monitor the risk of aspiration in each shift	4.75±0.45	0.09	4.44±0.89	0.20
		4.2.3 Adopting the enteral nutrition tolerance assessment scale to monitor patients’ tolerance to EEN every day	4.69±0.48	0.10	4.44±0.81	0.18
		4.2.4 Routine monitoring of gastric residual volume is not recommended. However, in cases of feeding intolerance and high aspiration risk, gastric residual volume should be monitored every 4 hours, which can be done using gastric ultrasound or syringe aspiration	4.44±0.73	0.16	4.50±0.63	0.14
	4.3 Complications monitoring	4.3.1 Mechanical complications: skin injury at the tube fixation sites, tube displacement, blockage or slippage, etc	4.81±0.40	0.08	4.75±0.45	0.09
		4.3.2 Metabolic complications: electrolyte disorders, acid-base imbalance, abnormal glucose metabolism, etc	4.56±0.63	0.14	4.62±0.62	0.13
		4.3.3 Infectious complications: intestinal bacterial translocation, aspiration pneumonia, etc	4.81±0.40	0.08	4.81±0.54	0.11
		4.3.4 Gastrointestinal complications: abdominal distention, diarrhea, constipation, nausea, gastric retention, etc	4.69±0.48	0.10	4.50±0.73	0.16
		4.3.5 Mental and psychological issues: anxiety, depression, etc	4.88±0.34	0.07	4.75±0.58	0.12
5. Quality control	5.1 Protocol quality evaluation	5.1.1 Effectiveness evaluation: assessing feeding goal attainment rate, burn wound healing progress, improvement in nutritional status and quality life, and enhancement of nutritional knowledge, etc	4.81±0.40	0.08	4.63±0.81	0.17
		5.1.2 Safety evaluation: checking for abnormalities such as aspiration, tube occlusion, and tube dislodgment, and ensuring these abnormalities are managed correctly	4.75±0.45	0.09	4.63±0.62	0.13
		5.1.3 Adherence evaluation: the degree of collaboration and participation of patients and their primary caregivers	4.94±0.25	0.05	4.44±0.81	0.18
		5.1.4 Satisfaction evaluation: the satisfaction of patients and their primary caregivers	4.81±0.40	0.08	4.56±0.89	0.20
	5.2 Continuous improvement	5.2.1 Adjusting intervention protocols dynamically	4.81±0.40	0.08	4.69±0.60	0.13
		5.2.2 Summarizing and analyzing issues for continuous improvement	4.75±0.45	0.09	4.75±0.58	0.12

AGI Acute Gastrointestinal Injury, BUN Blood Urea Nitrogen, CV Coefficient of variation, ECG Electrocardiogram, EEN Early enteral nutrition, EN Enteral nutrition, IGF-1 Serum insulin-like growth factor-1, ONS Oral nutritional supplement, NRS 2002 Nutritional Risk Screening 2002

Table 5.

The EEN management protocol for severely burned patients

First-level item	Second-level item	Third-level item
1. Organizational management	1.1 Establishing the organizational structure	1.1.1 Establishing the organizational structure of EEN management, and clarifying roles and responsibilities
	1.2 Building a multidisciplinary team	1.2.1 Establishing a nutritional support team led by clinical specialists, including burn physicians, dietitians, nutrition specialist nurses ( having obtained a certificate qualifying them as specialist nurses and are working in the relevant field), charge nurses, rehabilitation therapists, imaging specialists, pharmacists, psychotherapists, etc., who were jointly responsible for the development, implementation, supervision, and adjustment of the protocol
	1.3 Developing policies and procedures	1.3.1 Developing EEN management policies (including technical standards, quality control standards, emergency plans and procedures, etc)
		1.3.2 Establishing workflows for EEN management (including assessment, planning, implementation, evaluation, etc)
	1.4 Organizing training and assessment	1.4.1 Developing training plans and assessment standards
		1.4.2 Conducting regular training and assessments, and making detailed records.
2. Comprehensive assessment	2.1 Basic assessment	2.1.1 Assessing the patient’s current medical history, including the cause of the disease, accompanying symptoms, diagnosis and treatment, and general condition (such as mental status, urination, defecation)
		2.1.2 Collecting the patient’s past medical history, including diseases affecting nutritional status (such as diabetes, chronic gastric disease, chronic liver disease, chronic kidney disease), surgical history, allergies, etc
		2.1.3 Assessing the patient’s vital signs and hemodynamics status
		2.1.4 Performing laboratory and imaging examinations in time, and conducting special examinations if necessary, to assess the functions of the patient’s important organs
		2.1.5 Assessing whether the facilities and equipment are complete and in functional position, including oxygen sources, ECG monitors, blood oxygen monitors, enteral nutrition pumps, bedside B-ultrasound machines (if available), weight scales, etc
	2.2 Specialized assessment	2.2.1 Burn severity: assessing the burn area, location, depth, and presence of inhalation injury
		2.2.2 Gastrointestinal function injury: using AGI assessment scale or AGI ultrasound
		2.2.3 Oral injury: for patients with facial burns, assessing oral injuries by a clinician
		2.2.4 Dysphagia: the Kubota Water Swallowing Test is used to assess swallowing function in patients without impaired consciousness, intact pharyngeal reflexes, and normal oropharyngeal anatomy. For those who are not suitable for this test, swallowing function assessments should be conducted by clinicians or rehabilitation therapists
	2.3 Nutritional risk screening	2.3.1 Timing: completed within 24 hours of admission
		2.3.2 Tool: using the NRS 2002 Nutrition Risk Screening Scale
		2.3.3 Frequency: dynamic screening should be conducted based on the patient’s disease progression, surgical status, and nutritional risk level, with a minimum frequency of once a week
	2.4 Nutritional assessment	2.4.1 Anthropometric measurements: height, weight, skeletal muscle or lean body tissue content, etc
		2.4.2 Dietary survey: the type, quantity, and quality of the recent diet, and dietary preferences
		2.4.3 Monitoring of relevant indicators: prealbumin, transferrin, total albumin, C-reactive protein, IGF-1, BUN, creatinine, blood glucose, electrolytes, and acid-base balance, etc
		2.4.4 Energy requirements: assessing at least weekly, preferably using indirect calorimetry or metabolic carts. If unavailable, use the Third Military Medical University Burn Energy Requirement Formula to estimate
	2.5 Psychological and social assessment	2.5.1 Mental and psychological status
		2.5.2 Financial condition
		2.5.3 Sociocultural factors: patients’ and major caregivers’ education level, religious beliefs, etc
3. Nutritional intervention	3.1 Nutritional goals	3.1.1 During the acute stress, following the principle of “allowing low calories ” (providing 50% to 70% of target energy), the feeding volume and rate should be gradually increased as the stress and metabolic status stabilize, ultimately reaching the target feeding volume within 5 to 7 days
	3.2 Nutritional plan	3.2.1 Developing and implementing a nutritional plan in collaboration with the nutrition support team, the patient (conscious and hemodynamically stable), and primary caregivers, including timing of interventions, routes, nutrients, formula types, feeding methods, complication prevention, and health education
	3.3 Intervention timing	3.3.1 After fluid resuscitation and comprehensive assessment, EEN should be initiated within 24 hours of admission if the patient’s condition is deemed appropriate
	3.4 Intervention pathways	3.4.1 Appropriate intervention pathways are selected based on factors such as disease, medical conditions, and patient acceptance. For those who can eat orally, ONS is preferred
		3.4.2 The implementation of tube feeding for EEN is indicated when there is a combination of respiratory tract burns, inability to eat orally, or when dietary intake combined with oral nutritional supplements fails to meet 60% of the target energy requirements
		3.4.3 Administering EEN via a nasogastric tube. If gastric tube feeding is prohibited, feeding intolerance exists, or there is a high risk of aspiration, administering EEN via a nasoenteric tube instead
		3.4.4 Supplemental parenteral nutrition should be given if 60% of the nutritional goals cannot be met by EN within 48 to 72 hours for those at high nutritional risk, or within 7 days for those at low nutritional risk
		3.4.5 If dysphagia is ≤ grade 2 and tube-fed EN has met 50% of the target energy for 3 to 5 days, gradually reduce the provision of EN and make a progressive transition to oral intake
		3.4.6 If the oral diet has met more than 75% of the target energy requirements for 3 to 5 days, the transition should be made from an oral diet with oral nutritional supplements to an oral diet combined with nutritional education
	3.5 Nutrients	3.5.1 Macronutrients: providing 1.5 to 2.0 g/(kg·d) of protein; limiting carbohydrates to within 60% of total daily energy intake; restricting fats to within 30% of total daily energy intake
		3.5.2 Micronutrients: supplementing trace elements such as zinc, copper, and selenium, as well as vitamins B1, A, and D, according to the actual needs determined by the clinicians
		3.5.3 Immunonutrients: supplementing omega-3 polyunsaturated fatty acids and glutamine via the enteral route, with glutamine administered at a dose of 0.5 g/kg/day or 12–14 g/day for at least a 2-week course
	3.6 Formulation type	3.6.1 Appropriate enteral nutrition formulations should be selected based on the patient’s disease condition, gastrointestinal function, tolerance, financial condition, and dietary preference
		3.6.2 Commercial nutrition formulations should be used instead of home-made homogenized diets
		3.6.3 Providing whole-protein formulas for patients with normal gastrointestinal function, short-peptide pre-digested formulas for those with gastrointestinal dysfunction, and if necessary, providing specialized formulas (such as those designed for diabetes)
	3.7 Feeding methods	3.7.1 If ONS is used, start with a small dose and low concentration, adopting methods such as sipping and taking small amounts multiple times. And gradually increase the intake of ONS as tolerance improves
		3.7.2 Using enteral nutrition pumps for continuous infusion (avoiding a 24-hour continuous infusion), starting at a rate of 20-30 ml/h, and then gradually increasing the infusion rate according to the patient’s tolerance
		3.7.3 For EN tolerance scores of 0-2, continue EEN at the current infusion rate (with symptomatic treatment if necessary); for scores of 3-4, reduce the infusion rate of EEN (reassess the patient's condition after 2 hours); for scores of 5 or above, temporarily pause EEN (reassess the patient's condition and consider to change feeding route if necessary)
	3.8 Complications prevention	3.8.1 Position management: if there are no contraindications, elevate the head of the bed during EEN feeding (30°-45° for regular hospital beds, and 15°-30° for turning beds or air-fluidized beds). After feeding is completed, assist the patient to maintain a semi-reclining position for 30-60 minutes. For patients undergoing prone position therapy, suspend EEN feeding 30 minutes before the start of prone position treatment
		3.8.2 Tube flushing: flushing the EN tube with 30 ml of lukewarm water before and after tube feeding, before and after medication administration, and whenever tube feeding is interrupted. Additionally, during infusion, flushing the tube with 30 ml of lukewarm water every 4 hours
		3.8.3 Tube fixation and replacement: checking the depth of tube insertion and fixation status each shift, and replacing the tubes and fixtures devices on time
		3.8.4 Skin care: checking the skin condition of the area where the tube is fixed each shift, and keep it clean and dry
		3.8.5 Oral care: every forming oral care measures in accordance with the Baker Oral Assessment Scale. The frequency of care is determined as follows: for a score of 5, at least once every 12 hours; for scores ranging from 6-10, at least once every 8 hours; for scores ranging from 11-15, at least once every 6 hours; and for scores ranging from 16-20, at least once every 4 hours
		3.8.6 Others: decreasing the level of sedation and analgesia for the patient when their condition permits, as well as minimizing unnecessary out-of-ward examinations, etc
	3.9 Health education	3.9.1 Regularly providing nutrition education, exercise guidance, and daily care instructions to patients and their primary caregivers through diverse methods, such as popular science videos, special lectures, peer education, and individualized guidance
4. Outcome monitoring	4.1 Nutritional status monitoring	4.1.1 Dynamic monitoring includes: energy and protein intake and output; anthropometric measurements, such as total body weight, weight change, and content of skeletal muscle or lean tissue content; laboratory indicators, including serum protein (such as total protein, albumin, prealbumin, transferrin), urea nitrogen, blood glucose, and electrolyte levels (such as potassium, magnesium, phosphorus), etc
	4.2 Enteral nutrition monitoring	4.2.1 Monitoring the use and maintenance of nutritional equipment and access routes in each shift
		4.2.2 Adopting the aspiration risk assessment scale to monitor the risk of aspiration in each shift
		4.2.3 Adopting the enteral nutrition tolerance assessment scale to monitor patients’ tolerance to EEN every day
		4.2.4 Routine monitoring of gastric residual volume is not recommended. However, in cases of feeding intolerance and high aspiration risk, gastric residual volume should be monitored every 4 hours, which can be done using gastric ultrasound or syringe aspiration
	4.3 Complications monitoring	4.3.1 Mechanical complications: skin injury at the tube fixation sites, tube displacement, blockage or slippage, etc
		4.3.2 Metabolic complications: electrolyte disorders, acid-base imbalance, abnormal glucose metabolism, etc
		4.3.3 Infectious complications: intestinal bacterial translocation, aspiration pneumonia, etc
		4.3.4 Gastrointestinal complications: abdominal distention, diarrhea, constipation, nausea, gastric retention, etc
		4.3.5 Mental and psychological issues: anxiety, depression, etc
5. Quality control	5.1 Protocol quality evaluation	5.1.1 Effectiveness evaluation: assessing feeding goal attainment rate, burn wound healing progress, improvement in nutritional status and quality life, and enhancement of nutritional knowledge, etc
		5.1.2 Safety evaluation: checking for abnormalities such as aspiration, tube occlusion, and tube dislodgment, and ensuring these abnormalities are managed correctly
		5.1.3 Adherence evaluation: the degree of collaboration and participation of patients and their primary caregivers
		5.1.4 Satisfaction evaluation: the satisfaction of patients and their primary caregivers
	5.2 Continuous improvement	5.2.1 Adjusting intervention protocols dynamically
		5.2.2 Summarizing and analyzing issues for continuous improvement

AGI Acute Gastrointestinal Injury, BUN Blood Urea Nitrogen, CV Coefficient of variation, ECG Electrocardiogram, EEN Early enteral nutrition, EN Enteral nutrition, IGF-1 Serum insulin-like growth factor-1, ONS Oral nutritional supplement, NRS 2002 Nutritional Risk Screening 2002

Discussion

This study positively responds to and aligns with China’s relevant policy requirements. The aim of this study was to construct an EEN management protocol for severely burned adult patients, providing clinical practitioners with clear and specific guidance and contributing to the standardization of EEN support. The results of this study indicated that the construction of this EEN protocol was essential, scientific, and feasible.

In recent years, China has placed significant emphasis on the standardized management of clinical nutrition. Several policies have been issued to guide the standardization of relevant clinical nutrition services [18–20]. Patients with severe burns, who are critically ill and exhibit prominent nutritional disorders, constitute an important population for clinical nutrition intervention [31]. In this context, the implementation of standardized EEN management has become particularly urgent. However, there is currently no relevant protocol to guide the clinical practice for healthcare providers, who still lack systematicness and standardization in the EEN management for severely burned adult patients [14]. Previous studies have shown that a scientific EEN management protocol can effectively reduce complication rates and mortality, and accelerate the recovery process of patients [32, 33]. In conclusion, it is essential to develop a management protocol for severely burned adult patients.

This study constructed an EEN management protocol for severely burned adult patients based on the Delphi method. The literature review followed an evidence-based approach, systematically searching relevant domestic and international literature, rigorously conducting literature screening and quality evaluation, and extracting and integrating high-quality evidence on the EEN management for severely burned adult patients. This provided an evidence-based foundation for developing the initial draft of the protocol. In addition, this study revised the initial draft of the protocol through the Delphi method [34]. The experts consulted were well-represented, including 17 experts from 8 cities in the eastern, southern, western, northern, and central regions of China, who made constructive suggestions in the fields of burns treatment, nutritional management, and nursing management. The response rates for the two rounds of the expert consultation questionnaire were 85.00% and 94.12%, respectively. The authority coefficients of the experts were 0.924 and 0.919, respectively. The results of the first round of expert consultation showed that Kendall’s W for the importance and feasibility of items was 0.156 and 0.128 (P<0.001), respectively. The results of the second round of expert consultation showed that Kendall’s W for the importance and feasibility of items was 0.142 and 0.122 (P<0.001), respectively. In the two rounds of the Delphi survey, all items had a mean score of at least 3.50, and over 20% of experts assigned the highest rating. These results confirm that the experts demonstrated strong engagement, authority, and consensus, underscoring the methodological rigor of the Delphi process and lending scientific validity to the final protocol.

This protocol, in terms of organizational management, encompassed the establishment of an efficient organizational structure, the formation of a multidisciplinary panel with complementary strengths, the formulation of scientific and reasonable related systems and processes, as well as the establishment of a comprehensive training and assessment mechanism. These measures collectively aimed to ensure that healthcare providers could effectively and orderly implement EEN management [35]. In terms of the comprehensive evaluation of EEN management, this protocol covered core aspects such as gastrointestinal function assessment, nutritional risk screening, and nutritional assessment. Through internal expert discussions, information on related examinations and psychosocial assessments was refined. Additionally, through the Delphi expert consultation, key assessment elements such as baseline health status, the severity of burns, and the condition of oral injuries were incorporated. This made the protocol more comprehensive and detailed, with enhanced pertinence and feasibility. Regarding nutritional intervention, this protocol was oriented towards nutritional goals, formulating a scientific and reasonable nutritional plan, clarifying the timing of EEN initiation, and elaborating on the implementation pathways of EEN (including oral nutritional supplementation, tube-feeding enteral nutrition, alternative pathways, and transition methods). The supplementation doses of macronutrients, micronutrients, and immunonutrients were listed according to the specific needs of severely burned adult patients. And types of individualized preparations were recommended. Furthermore, feeding techniques, complications prevention, and the content of health education for EEN management were also comprehensively addressed. All these ensured the safety and effectiveness of the EEN management protocol. The proposed EEN protocol is an integral component of comprehensive burn care that requires close coordination across disciplines. Seamless alignment between nutrition, wound care, and infection control teams is essential to maximize clinical outcomes and avoid fragmented or contradictory practices. This protocol also placed a strong emphasis on outcome monitoring and quality control. By systematically assessing the implementation effects of the protocol and conducting thorough quality evaluations, it aimed to consistently optimize and refine the protocol. This further enhanced the feasibility of the protocol.

Notably, this study presents an evidence-based EEN protocol for severely burned adult patients that is fully aligned with the updated ESPEN guideline [36]. It recommends: (1) Initiating enteral nutrition within 6–12 h post-injury, provided hemodynamic stability is achieved; (2) Administering high-protein formulas to deliver 1.5–2.5 g/kg/day, thereby counteracting catabolism and supporting wound healing; and (3) Using a gastric residual volume (GRV) threshold of ≤ 500 mL as acceptable for continuing enteral feeding, rather than routinely interrupting nutrition. Our protocol incorporates all these recommendations and further tailors them to the unique pathophysiology of severe burns, thereby enabling targeted clinical refinements and enhancing applicability to this specialized patient population.

Moreover, to address common challenges during the acute phase of injury (such as impaired feeding tolerance), we proposed a phased and individualized feeding advancement strategy. And we also introduced a nursing-led EEN initiation model that clearly defines nurses’ roles in assessing patient readiness, initiating enteral feeding, and performing real-time monitoring. This structured approach improves protocol adherence, reduces delays in EEN initiation, and strengthens interdisciplinary coordination. Such a nursing-led framework has not been systematically described or widely adopted in current international guidelines, highlighting its novelty and potential impact.

In addition, the protocol demonstrates strong adaptability and scalability across diverse healthcare settings. In well-resourced, high-volume burn centers, it supports advanced interventions such as indirect calorimetry for energy expenditure estimation, immunonutrition with glutamine or omega-3 fatty acids, and ultrasound-guided placement of post-pyloric feeding tubes. In contrast, in resource-limited primary or emergency care facilities, essential components (such as simplified tolerance assessments based on gastric residual volume and abdominal examination) can be implemented effectively without specialized equipment, ensuring safe and timely nutritional support.

Therefore, our protocol provides a standardized, flexible, and context-sensitive framework for EEN in severe burns, balancing scientific rigor with practical feasibility. However, its integration into clinical practice requires context-specific implementation strategies. In the Chinese healthcare system, we recommend a phased rollout beginning with pilot testing in major burn centers, supported by clinical decision support tools (such as EEN checklists, dosing algorithms) embedded in electronic medical records. And multidisciplinary training and audit-with-feedback mechanisms should be implemented to ensure fidelity and continuous improvement. Future efforts should also explore policy integration, such as incorporating EEN benchmarks into national burn care quality indicators, to promote widespread adoption and enhance long-term sustainability.

Strengths and limitations

This study represents the first systematic effort to develop a comprehensive EEN protocol for severely burned adult patients in China, using a rigorous Delphi process that engaged multidisciplinary experts. It offers a context-specific adaptation of existing international recommendations tailored to the Chinese healthcare environment, addressing variations in resources, staffing, and clinical workflows. By achieving a strong consensus on 66 key clinical items across five critical domains, we established the first evidence-informed, standardized framework for EEN management in Chinese burn care. This consensus-based framework responds to an urgent need within a high-burden setting where burn incidence remains significant; historically, standardized protocols have been limited and inconsistently implemented. The Delphi method employed in this study is a well-established approach for reaching expert consensus. It ensures transparency, reproducibility, and multidisciplinary collaboration, enhancing the consistency, safety, and quality of burn care across diverse healthcare settings. These findings lay the groundwork for future national clinical guidelines and support the establishment of a unified high-reliability system for burn management in China.

Despite these strengths, some limitations should be acknowledged. First, although the expert panel was carefully selected to represent key stakeholder groups, not all invited specialists were able to participate due to scheduling constraints, which may affect the comprehensiveness of perspective inclusion. Second, the protocol has not yet been implemented in clinical practice. Therefore, its feasibility, adherence rates, and impact on patient outcomes (such as infection rates and length of hospital stay) require prospective evaluation in real-world settings through pilot testing and validation studies. Third, while the current protocol was developed within the Chinese healthcare context, we recognize that healthcare infrastructure, staffing models, and resource availability vary significantly across regions. Therefore, direct generalizability to low- or middle-income countries or different health systems may be limited. For instance, challenges such as shortages of clinical dietitians, limited access to enteral nutrition formulations, or a lack of advanced monitoring tools may hinder full implementation in resource-limited settings.

To support broader applicability, we recommend context-adapted strategies, such as training designated nursing staff to lead nutritional assessments, using simplified screening tools, incorporating core protocol elements (e.g., EEN initiation within 24 h) into standard order sets, and utilizing locally available nutritional products with close monitoring. Future multinational and multicenter studies are needed to evaluate the adaptability, scalability, and external validity of this framework across diverse settings. Such efforts will be essential to translate this consensus into equitable improvements in burn care globally.

Prospective validation and future implementation

While the current protocol was developed through a rigorous Delphi process to establish expert consensus on EEN in burn care, its translation into practice requires empirical evaluation of feasibility, usability, and clinical impact.

For this purpose, we have designed a phased implementation research program. The first stage will be a prospective, multicenter pilot study involving 4–6 burn units across China, selected to represent diverse settings—including urban tertiary centers, regional hospitals, and facilities with varying resource availability. This pilot will assess: (1) Implementation feasibility, including staff training needs (e.g., standardized onboarding workshops for physicians, nurses, and dietitians), minimum resource requirements (e.g., access to enteral feeding pumps, standardized nutrition formulations, and bedside assessment tools), and institutional readiness; (2) Protocol adherence, particularly timely EEN initiation within 24 h post-admission, using audit-ready documentation templates integrated into routine workflows; (3) Compliance monitoring, supported by simple tracking tools (e.g., EEN checklists, dosing algorithms) and periodic fidelity audits, with feedback provided to clinical teams to support continuous quality improvement.

Concurrently, we will evaluate usability through a mixed-methods approach, combining structured surveys with semi-structured interviews of frontline clinicians to identify context-specific barriers and facilitators. Preliminary clinical outcomes (including energy/protein delivery adequacy, feeding intolerance rates, infection incidence, and length of hospital stay) will also be collected.

Findings from this pilot will inform refinements to both the protocol and its implementation supports (e.g., order sets, monitoring dashboards, training modules), paving the way for a larger-scale prospective cohort study or hybrid implementation-effectiveness trial.

Conclusion

Establishing an EEN management protocol is a critical measure to improve the nutritional status and clinical outcomes of severely burned adult patients. This study developed an EEN management protocol specifically for severely burned adult patients, which encompassed 5 primary items, 23 secondary items, and 66 tertiary items, covering the core aspects of organizational management, comprehensive assessment, nutritional intervention, outcome monitoring, and quality control. This consensus-derived EEN protocol integrates and clarifies the key elements of EEN management for severely burned adult patients, providing a standardized foundation for clinical practice and can guide future multicenter validation studies assessing clinical efficacy and outcomes.

Abbreviations

AGREE II

The Appraisal of Guidelines for Research and Evaluation

Ca

Coefficient of familiarity

Cs

Coefficient of judgment

Cr

Expert authority coefficient

CV

Coefficient of variation

EEN

Early enteral nutrition

EN

Enteral nutrition

ESPEN

The European Society for Clinical Nutrition and Metabolism

ICU

Intensive Care Unit

JBI

the Joanna Briggs Institute

Kendall’s W

Kendall coefficient of concordance

RR

Recovery rate

TBSA

Total body surface area

Authors’ contributions

Conceptualization: Xiaojuan Yang, Rong Li, Xiaorong Mao, Juan Chen. Data curation: Yu Fan, Xiaotao Xu. Methodology: Wei Li, Jing Wang. Software: Qing Wen, Xiaocui Zou. Supervision: Rong Li, Xiaorong Mao. Writing – original draft: Xiaojuan Yang, Xiaocui Zou, Juan Chen. Writing – review & editing: Rong Li, Xiaorong Mao, Xiaocui Zou.

Funding

This study was supported by the Major Nursing Research Project of the Sichuan Provincial Nursing Association (H25011).

Data availability

The data presented in this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

This study received ethical approval from the Ethics Committee of Sichuan Provincial People’s Hospital (Approval No. 2024-2). Written informed consent was obtained from all participants, and the study was conducted in accordance with the Declaration of Helsinki guidelines.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.