Implementing a Volume-based Feeding Protocol in a Neurosciences Critical Care Unit

Abstract

Problem & Purpose: Enteral nutrition is typically delivered through rate-based feeding (RBF) which predisposes patients to malnutrition by providing tube feeding (TF) at a fixed rate without compensating for feeding interruptions. Patients in a neurosciences critical care unit (NCCU) only meet their nutritional goals 63% of the time. Recent studies of volume-based feeding (VBF) have shown efficiency in meeting daily nutritional goals. To optimize TF delivery, this quality improvement (QI) project aims to integrate VBF into practice by involving nurse-driven TF-rate adjustments to compensate for feeding interruptions and to meet daily TF-volume goals. Methods: VBF was initiated within 48 hours for NCCU patients who meet the inclusion criteria. To facilitate compliance, the implementation team provided virtual in-services, online quiz competencies, and deployment of champions. Sustainability measures included policy adoption, creative posters, and regular quantitative feedback about the project's progress. The primary outcome was the percentage of TF-episodes with 80% of volume goal delivered. Each episode was measured as the number of TF days per patient in each week. Secondary outcomes were protocol compliance and feeding intolerance rates. Results: From a total of 104 patients (RBF=57, VBF=47), there were 194 episodes of tube feeding (RBF=97, VBF=97). The Mann-Whitney U test revealed VBF patients received a higher percentage of TF-days meeting the 80% volume goal than RBF (U=2672, p< 0.00001). The Mann-Whitney U test also showed no significant difference in feeding intolerance episodes between the two groups (U=46586, p=0.90). The average nursing compliance rate was 68%. The weekly compliance rate fluctuated and was threatened by staff turnover during the COVID-19 pandemic, but it improved through sustained staff engagement and frequent training. Conclusions: Implementation of VBF delivered more TF volume than the previous feeding modality with RBF. The QI project posed some sustainability challenges due to the competing unit priorities and staff turnover during the pandemic. However, implementing a policy, deploying champions, providing feedback, and employing frequent training may explain sustained nursing compliance rates. Additional studies may be needed to further optimize nutrition delivery, such as integrating VBF workflow processes in the electronic health record and minimizing preventable feeding interruptions.