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

      Ruccio, Lucy R.; Wilson, Janice (2021-05)
      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.
    • Implementing a Volume-based Feeding Protocol in a Neurosciences Critical Care Unit

      Vallangca, Gimmie J.; Costa, Linda L. (2021-05)
      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.
    • Implementing a Volume-based Feeding Protocol in the Neuroscience Critical Care Unit

      Goularte, Vanlentina A.; Costa, Linda L. (2021-05)
      Problem and Purpose: Intensive care unit patients are at increased risk for hospital acquired malnutrition due to the stress of critical illness, inability to eat by mouth, and enteral feeding interruptions. At a large, urban, academic hospital in the neurological critical care unit (NCCU), sampling showed that only 62% of patients met their enteral nutrition (EN) goals. To address this gap in health care delivery, a volume-based feeding (VBF) protocol was implemented. Studies have shown that VBF protocols are safe and offer more effective nutritional delivery over rate-based protocols, which are the current standard of care. Methods: This is a pre/post intervention performance improvement study. An interdisciplinary approach was adopted and included a team of providers, nurses, and dietitians. A new policy was implemented by the unit to reflect the VBF protocol. Chart audits were conducted to determine baseline performance in EN delivery. Chart audits and data analysis were conducted again after education was completed and the protocol was initiated. Metrics being assessed were nursing and provider education rates, nursing and provider protocol compliance, and the amount of EN delivered daily over a seven-day period. Results: Comparing a total of 104 patients, 57 on a rate based feeding (RBF), were admitted prior to implementation of the VBF protocol and and 47 patients on the VBF protocol. In these groups there were 194 episodes of tube feedings (RBF=97, VBF=97). After 12 weeks of implementation of the VBF protocol, patients had more TF volume delivered and met their minimum volume goal more often compared to baseline data (VBF 82% vs. RBF 62%, p<0.005), and fewer, although not statistically significant episodes of hypoglycemia (VBF 1% vs RBF 4%, p=0.3), and feeding intolerance (VBF 34% vs. 37%, p=0.51). Provider and nursing staff compliance to the protocol were 74% and 68% respectively.