TABLE 6.
Descriptive characteristics of the included studies.
| Author, year and country of origin | Aim or focus of the study and setting | Results on guideline implementation | Conclusions |
|---|---|---|---|
| Quasi-experimental study | |||
| Sungur et al. 2015, Pakistan | To determine the effect of the enteral nutrition algorithm on nutritional support in critically ill medical patients in a medical ICU of a university hospital. | 40 mechanically ventilated patients divided into two equal groups of 20 (50%) each. Energy intake of study group was 62% of the prescribed energy requirement on the 1st, 68.5% on the 2nd and 63% on the 3rd day, whereas in the historical group 38%, 56.5% and 60% of the prescribed energy requirement were met, respectively. Consumed energy of the historical group on the 1st, 2nd and 3rd day was significantly different (p = 0.020). | Use of standard algorithms for EN may be an effective way to meet the nutritional requirements of patients. The study showed that historical group patients required more nutrition than the intervention group. |
| Prospective designs | |||
| Barr et al. 2004, United States of America | Determine if protocol use leads to increased EN, earlier feeding and improved outcomes in medical-surgical ICUs of two teaching hospitals. | 200 critically ill adult patients who remained nil per os (NPO) > 48 h after admission to the ICU. 100 patients were enrolled into the pre-implementation group, and 100 patients were enrolled into the post-implementation group. The EN use frequency increased in post-implementation compared to pre-implementation (78% vs. 68%, respectively). | Protocol use increased the patients receiving EN and shortened mechanical ventilation time. About 27% of patients died in the pre-implementation group and 30% died post-implementation. |
| Cahill et al. 2010a, Canada | Describe current nutrition practices and determine ‘best achievable’ practice relative to evidence-based Critical Care Nutrition CPGs in university hospitals adult medical ICU. | The average use of motility agents and small bowel feeding in mechanically ventilated patients who had high gastric residual volumes was 58.7% (site average range, 0% – 100%) and 14.7% (site average range, 0% – 100%), respectively. There was poor adherence to recommendations for the use of EN formulas enriched with fish oils, glutamine supplementation, timing of supplemental parenteral nutrition and avoidance of soybean oil-based parenteral lipids. Average nutritional adequacy was 59% (site average range, 20.5% – 94.4%) for energy and 60.3% (site average range, 18.6% – 152.5%) for protein. | There is a similar performance gap with respect to pharmaconutrition. Large gaps exist between many recommendations and actual practice with resultant suboptimal nutrition therapy. |
| Dervan, 2012, United States of America | See possibility to reduce the incidence of overfeeding by implementation of a ‘weaning’ protocol in a10-bed, med-surgical, adult ICU of a tertiary referral teaching hospital. | The study was conducted in patients who were mechanically ventilated for more than 72 h and receiving nutrition support. Overfeeding noted more frequently than underfeeding prior to protocol use (24.6% vs. 19.5% of feeding days) and significantly more often on days when patients were fed by a combination of routes (p < 0.05). Post protocol, the incidence of overfeeding reduced almost threefold to 9.1% (p < 0.001), and feeding via a combination of routes no longer a significant cause. Underfeeding did not change, and patients being adequately fed increased from 56% to 71% (p < 0.001). Post-implementation, overfeeding reduced by threefold, while underfeeding did not change, with the patients being adequately fed. | A ‘weaning’ protocol helps to improve adequate feeding for energy in critically ill patients. Significant causes of underfeeding include GI intolerance, causing interruption for procedures. |
| Dobson and Scott 2007, United Kingdom | Determine how reliable the updated ICU nurse-led enteral feeding protocol was in medical-surgical ICUs. | Patients who remained PNO > 48 h after their admission to the ICU participated in the study. In all, 90% (n = 43) of referrals received by the dietitian met the referral criteria. Absolute compliance with patients receiving correct type and volumes of feed, with a correct feed prescription and an accurate documented weight was just 2% (n = 1). Despite this finding, 60% of patients were actually receiving the correct feed regimen. Absolute adherence to the nurse-led EN feeding algorithm was 100%. | Nurse-led feeding algorithm reduced the input of a dietitian on patient feeding algorithm use and empowered nurses to timeouly start NS and safely advance EN towards nutritional goals without the input of a dietician. |
| Heyland et al. 2004, United States of America | Test the hypothesis that ICUs consistent with the guidelines would have greater success with EN. Intensive care unit affiliated with a registered dietician. | All ICU patients who were in ICU for 72 h and had been mechanically ventilated for 48 h were observed. The observed stay in ICUs ranged from 1.8% to 76.6% (average 43.0%). Intensive care units with a greater than median utilisation of parenteral nutrition (> 17.5% patient days) had a much lower adequacy of enteral nutrition (32.9 vs. 52.7%, p < 0.0001). Intensive care units that used a feeding protocol tended to have a higher adequacy of enteral nutrition than those that did not (44.9 vs. 38.5%, p = 0.03). Intensive care units that were more consistent with the Canadian CPGs were more likely to successfully feed patients via enteral nutrition. | Consistency with CPGs may translate into better outcomes for critically ill patients receiving nutrition support. Adoption of the Canadian CPGs should lead to improved nutrition support practice in intensive care units. |
| Heyland, 2015, Canada | Describe experience with implementing protocol and the observed improvements in nutrition intake in an ICU with a multidisciplinary team. | Participants were patients who were mechanically ventilated prior to ICU admission or within the first 48 h, who stayed in the ICU for at least 72 h. Patients at PEP uP sites received 60.1% of their prescribed energy requirements from EN compared to 49.9% of patients from control hospitals (p = 0.02). In addition, patients in PEP uP protocol sites received more protein from EN (61.0% vs. 49.7% of prescribed amounts; p = 0.01), were more likely to receive protein supplements (71.8% vs. 47.7%; p = 0.01) and were more likely to receive > 80% of their protein requirements by day 3 (46.1% vs. 29.3%; p = 0.05) compared to patients in control hospitals. | Increased nutrition adequacy could be causally related to improved clinical outcomes of critically ill patients. In the real-life setting, the PEP uP protocol can improve the delivery of EN to critically ill patients. |
| Pasinato, 2013, Brazil | Evaluate the compliance of septic patients’ nutritional management with enteral nutrition guidelines for critically ill patients. Public, university, and tertiary hospital. | The study was conducted on ICU septic patients, age ≥ 18 years. The patients had a mean age of 63.4 ± 15.1 years, were predominantly male, were diagnosed predominantly with septic shock (56.5%), had a mean intensive care unit stay of 11 (7.2–18.0) days, had 8.2 ± 4.2 SOFA and 24.1 ± 9.6 APACHE II scores and had 39.1% mortality. Enteral nutritional therapy was initiated early in 63% of the patients. Approximately 50% met the caloric and protein goals on the 3rd day of ICU stay, a percentage that decreased to 30% on day 7. | Significant number of septic patients was observed on EEN, but caloric and protein goals at day 3 in ICU were met by only 50%, a percentage that decreased at day 7. It was not possible, however, to show a statistically significant association between meeting the goals and the length of hospital stay, mortality or use of MV. |
| Quenot et al. 2010, England | Assess adherence to clinical practice guidelines and investigate factors leading to non-adherence. University and/or regional hospitals and general (non-academic) hospitals, mixed medico-surgical and medical ICUs. | Patients receiving mechanical ventilation and without contraindication to initiation of enteral nutrition were included in this study. The median ratio of prescribed or required calories per day was 43 [37–54] at day 1 and increased until day 7. From day 4 until the end of the study, the median ratio was > 80%. The median ratio of delivered/prescribed per day was > 80% for all 7 days from the start of enteral nutrition. A good ratio of calories was actually delivered/prescribed (> 80%) and calories prescribed/required (> 80%), notably after 72 h. | Variables influencing EN and contributing to non-adherence to CPGs: hospital type, local protocol, sedation, vasoactive drugs, number of interruptions and GRV measurement. Satisfactory translation of research and recommendations for EN into practice was observed, but there is also need for a multidisciplinary approach. |
| Wøien and Bjørk 2006, Norway | Test whether a feeding algorithm could improve the nutritional support of intensive care patients. An ICU staffed for caring for seven patients. | The study participants were patients 20–70 years old who were expected to stay longer than 4 days in ICU. Patients in the intervention group were both prescribed and actually received significantly larger amounts of nutrients than patients in the control group. They also received a larger proportion of their nutrients in the form of EN. In addition, the nutritional support algorithm led to greater consistency in nursing practices with respect to aspiration of gastric content and rate of increment in enteral feeding. Nutrition delivery was higher in intervention group. The algorithm encourages early initiation and rapid increment of NS. | Nurses acted less arbitrarily in executing nutrition orders and aspiration routines for the intervention group. The algorithm resulted in improvements in ICU patients’ nutrition in several areas. |
| Retrospective studies | |||
| Bousie et al. 2016 Europe | Address effects of protocol use on energy and protein adequacy, electrolyte abnormalities, glucose control, staff workload and clinical outcome. Mixed medical-surgical ICU in a tertiary university-affiliated teaching hospital. | In total, 146 mechanically ventilated patients were included (73 patients before and 73 patients after implementation). Before implementation more patients were fed above target (actual caloric intake > 110% of target) than after implementation (during 2–7 days: 12% vs. 3%, p = 0.029) without significant reduction of protein intake (daily means during day 2-7: 1.18 g/kg vs. 1.08 g/kg, p = 0.09). After implementation only significantly more patients were fed on target on day 6 (47% vs. 67%, p = 0.028). Less electrolyte imbalance post-implementation, nurses’ satisfaction improved post protocol and dietitians’ daily workload decreased. | Improved non-significant outcome trends for hospital LOS and for ICU and hospital mortality. Mortality reduction, preventing overfeeding without affecting protein intake and less electrolyte abnormalities were observed after implementation. |
| Compton et al. 2014, United States of America | Evaluate NS protocol impact on nutrition prescription and delivery in the intensive care unit in a university hospital’s adult med-ICU. | Mechanically ventilated patients, treated in the ICU for a minimum of 5 days were the study participants. After EN protocol implementation EN was started significantly earlier (p = 0.007), and EN goals were reached significantly faster (6 vs. 10 days, p < 0.001) than before. Prescription of EN on the 1st day of mechanical ventilation increased from 38% before to 54% after (p = 0.03) implementation of the protocol. Prescribed and delivered nutrition doses on the first 2 days of mechanical ventilation increased significantly (p < 0.001) after the protocol was implemented. Nasojejunal feeding tubes were used in 52% of patients before and 56% of patients after protocol implementation (p = 0.63). Jejunal tubes were placed earlier after the protocol was implemented than before (median 5 vs. 6.5 days), and when a jejunal tube was in place, feeding goals were reached faster (median 2 vs. 3 days, p = 0.002). | Implementation of an NS protocol significantly improved the EN provision in ICU patients receiving mechanical ventilation. Jejunal feeding tubes were necessary in more than half of the patients, and with a jejunal feeding tube in place, feeding goals were reached rapidly. However, the retrospective approach did not allow assessment of appropriateness of clinical decisions and adherence to the developed protocol. |
| Kim, 2017, Asia | Evaluate the impact of implementing an EN protocol on the improvement of EN practices and on the clinical outcomes of critically ill patients. Medical and surgical ICU at a university teaching hospital. | A total of 270 ICU adult patients were included, 134 patients before implementation and 136 after implementation of the protocol. Enteral nutritional therapy was initiated earlier (35.8 vs. 87.1 h, p = 0.001) and more patients received EN within 24 h (59.6% vs. 41.0%, p = 0.002) after implementation of the protocol. | The post-implementation group was given more pro-kinetics and less parenteral nutrition. EN protocol had beneficial effects: EEN, quick achieving target calories, less frequent PN use, and decreasing GI bleeding and diarrhoea. |
| Kiss, 2012, Switzerland | Determine the impact of using an algorithm on nutrition care outcomes in ICU without a designated dietitian. | Two cohorts of critically ill patients before (n = 56) and after (n = 56) implementation of an algorithm based on the guidelines published by the Society of Critical Care Medicine and the American Society for Parenteral and Enteral Nutrition guidelines was observed. Significant differences were noticed between the groups for the mean delivery of total energy in the pre- vs. post-implementation p < 0.001). There were significant differences between groups for the mean delivery of total energy in the pre- vs. post-implementation group. | This was the first report on algorithm implementation with no dietitian or nutrition support team. Algorithm implementation resulted in improved provision of energy and protein delivery. However, unique dietitian expertise in ICU and specific focus on individualised nutrition support remains ideal and would also increase the adherence to nutrition support guidelines. |
| Mackenzie, 2005, Canada | Determine whether implementation of an evidence-based nutrition support (NS) protocol could improve EN delivery in a tertiary-care 22-bed medical-surgical referral ICU. | Adult patients who receive either zero EN or PN were included in the study. The percentage of patients who received at least 80% of their estimated energy requirements in ICU increased from 20% before implementation of the NS protocol to 60% after implementation (p = 0.001). Post-implementation group received significantly more kcal/kg/d than the pre-implementation group (3.71 kcal/kg/d; 95% confidence interval, 1.64–5.78; p= 0.001). | Reduction in the PN use decreased in the post-implementation group. The protocol improved proportion of patients on EN meeting calculated nutrition requirements. |
| Wang, 2017, Taiwan | Compare pre- and post-implementation outcomes of the feeding protocol, and evaluate the effects of total energy delivery on outcomes in these patients in a tertiary medical centre and general hospital. | The study was conducted on TBI patients, older than 20 years, on EN only, and receiving at least 48 h of mechanical ventilation. Compared with delayed feeding, early feeding was associated with a significant reduction in the rate of mortality (relative risk = 0.35; 95% CI, 0.24–0.50), poor outcome (RR = 0.70; 95% CI, 0.54–0.91) and infectious complications (RR = 0.77; 95% CI, 0.59–0.99). Compared with enteral nutrition, parenteral nutrition showed a slight trend of reduction in the rate of mortality (RR = 0.61; 95% CI, 0.34–1.09), poor outcome (RR = 0.73; 95% CI, 0.51–1.04) and infectious complications (RR = 0.89; 95% CI, 0.66–1.22). | Implementation of the feeding protocol could improve energy intake for critically ill patients; however, it had no beneficial effects on reducing the ICU mortality rate. |
| Literature review and expert opinion studies | |||
| National Department of Health 2016, Republic of South Africa | Provides guidelines and practical strategies for successful implementation of EN regime in adult patients in all public healthcare facilities | Recommendations on nutrition assessment, EN use, handling of complications, monitoring and evaluation of EN for all adult patients in all public healthcare facilities. | Once tolerance is established, there is no need for frequent GRV measurement to avoid inappropriate interruption. A multidisciplinary approach to ensure effective assessment and treatment interventions is needed. |
| National Department of Health 2017, Republic of South Africa | Provides recommendations based on the best practice of PN management by care workers for all adult patients in all public healthcare facilities. | Recommendations for PN, the roles and responsibilities of the nutrition therapy team in all adult patients receiving parenteral nutrition therapy in government health facilities. | Monitoring ensures adherence to national guidelines. Evaluation allows comprehensive assessment and PN documentation. Parenteral nutritional therapy CPG should ensure evidence-based and standardised PN prescriptions. |
| Rice 2013, Republic of Ireland | Reviews HPN use and practices, makes proposals for safe, high quality care and equitable access for all suitable candidates in the community health sector. | Deficits identified in coordination, resource planning and clinical governance of the HPN service provision for adult patients who had been mechanically ventilated within 48 h of ICU admission and had been in the ICU for more than 72 h. | GPs and primary care team members lack specialist knowledge of HPN. Recommend for access for all patients in need of HPN. |
EN, enteral nutrition; PN, parenteral nutrition; CPGs, clinical practice guidelines; ICU, intensive care unit; LOS, length of stay; NS, nutritional support.