Discarding Residuals: Implementing a Feeding Algorithm in a Neonatal Intensive Care Unit

Abstract

Problem: Routine gastric residual (RGR) monitoring is not reliable in detecting necrotizing enterocolitis (NEC) or feeding intolerance (FI). This practice remains the primary cause of enteral feeding interruption in premature infants. It delays the achievement of full enteral feeds and increases the threat of poor growth and neurodevelopmental injury. Checking RGRs before feedings was standard practice at the target hospital’s Neonatal Intensive Care Unit (NICU). At baseline, over 40% of preterm infants had at least one checked per week. Purpose: The purpose of this quality improvement project is to implement and evaluate an evidence-based feeding guideline removing the use of RGR as an indicator of FI. Methods: The setting was a 30-bed Level III NICU and included all preterm infants, <37 weeks’ gestation, who required an oral or nasogastric feeding tube. Six weeks of background data and nine weeks of post-implementation data was collected using chart audits and informal interviews with key stakeholders. A survey of attitudes and knowledge was administered to all staff. Implementation consisted of in-service education with multiple visual aids, the dissemination of feeding algorithm cards and a “Fast Feeding Facts” bulletin. Data was collected and analyzed via run charts and descriptive statistics. Results: Data showed a decrease in patients with gastric residuals checked from 42% to 8%. The days to regain birthweight dropped from seven to six days. Staff knowledge of the role of RGRs and comfort with eliminating their routine use increased substantially. Conclusions: Implementation of an updated feeding guideline was associated with a decrease in the frequency of gastric residual checks, days with an IV in place and time to regain birthweight. This supports the research that monitoring of pre-feed RGRs should not be used for preterm infants.