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  1. 1. Top Clin Nutr Vol. 26, No. 4, pp. 335–345 Copyright c 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins DIETETIC PRACTICE PROJECTSMedical Residents andNutrition Support inCritical CareA Survey of Knowledge, Attitudes,and Practice Sandi Westfal, MS, RD, CNSC, CDN; Jerrilynn D. Burrowes, PhD, RD, CDN; Barbara Shorter, EdD, RD, CDN; Josephine Wright, MS, RD, CDN This study surveyed medical residents about their perceived attitudes, knowledge, and practice in the delivery of enteral nutrition (EN) in the critical care setting. An e-mail survey was sent to 693 medical residents; 56 completed the survey for a response rate of 8.7%. Descriptive statistics were used to compare survey responses. Medical residents reported inadequacies in their knowledge of EN despite the fact that 98% agreed that nutrition support in critical care is important. Data analysis also revealed discrepancies between attitude, knowledge, and practice in prescribing EN therapy in the critical care setting. In addition, almost all residents (95%) agreed that a standardized EN feeding protocol should be used. Key words: critical care, enteral nutrition, medical residents, nutrition attitudes, nutrition knowledgeT REATMENT of critically ill patients in the intensive care unit (ICU) is multifacetedand requires extensive education and train- not placed on the prescription and delivery of enteral nutrition (EN) demonstrated by a survey conducted by the National Academying. Nutrition is an integral component of this of Sciences, which found that an average oftreatment; however, it is often overlooked.1 21 hours of nutrition education was requiredMedical residents and physicians are trained in medical schools.1 This number is less thanand educated to prescribe medication prop- the National Academy of Sciences minimumerly. However, the same degree of training is recommendation of 25 hours. In addition, the researchers found that the number of hours dedicated to nutrition decreased considerablyAuthor Affiliations: Lutheran Medical Center, from 18.9 hours (SD = 1.2) in the first and sec-Brooklyn, NY (Ms Westfal); and Department of ond years of medical school to 5.1 hours (SD =Nutrition, C.W. Post Campus of Long Island 0.7) during the third and fourth years, whichUniversity, Brookville, NY (Mss Westfal and Wright,Drs Burrowes, and Shorter). generally are considered the clinical years of education.1The authors have disclosed that they have no signif-icant relationships with, or financial interest in, any Determining the diet prescription for EN iscommercial companies pertaining to this article. complex, and several factors need to be con-Correspondence: Sandi Westfal, MS, RD, CNSC, CDN, sidered such as timing of initiation (early feed-Lutheran Medical Center, 150 55th St, Brooklyn, NY ing within 24-48 hours); formula selection;11210 (swestfal@lmcmc.com). the patient’s nutrient needs, nutritional status,DOI: 10.1097/TIN.0b013e318237932f and disease state; and assessment of gastric 335Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  2. 2. 336 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011residuals and feeding intolerances. Medical MATERIALS AND METHODSresidents and physicians admit to being un- Participantsdereducated and inadequately trained in EN,and they do not feel confident in their knowl- Participants who were enrolled in a med-edge of nutrition in critically ill patients.1-4 ical residency program either as a doctor of Patients may not receive their estimated medicine (MD) or a doctor of osteopathy (DO)caloric and nutrient needs in most ICUs. in the New York tristate area during the studyUnderfeeding is frequently the outcome of period were included. They were requireddelayed initiation of feedings, prolonged ad- to be at least 18 years of age or older. Anvancement of rates to meet feeding goals, and Internet search of major hospitals in the tris-underprescription of the enteral formulas.5-8 tate area was conducted. Medical resident pro-Some of the consequences of underfeeding gram directors or resident program coordina-a critically ill patient are weight loss, muscle tors whose contact information was available,wasting, malnutrition, increased risk and inci- including an e-mail address, were contacteddence of infection, increased length of stay, to request the e-mail addresses of residentsrespiratory distress, and increased morbidity enrolled in their program. If e-mail addressesand mortality.7,9 could not be provided, the directors or coor- The difficulty in overcoming inadequate dinators were asked to forward the survey tofeeding in the ICU has led to the development their medical residents.and implementation of standardized protocols Project designand nutrition support teams (NSTs).10-14 Stan-dardization allows for less decision making The design was cross sectional, using athrough the use of guidelines and/or flow Web-based survey. The medical residents re-charts. The NSTs assist in determining the ceived an e-mail with an electronic informedEN prescription, as well as providing oppor- consent form. By clicking on “agree,” thetunities for education during team rounds, resident gave consent to participate andwhere feeding protocols may be discussed.14 was linked to the survey conducted onThese protocols also provide improved clin- SurveyMonkey.com.15 The e-mail was eitherical outcomes in patients. Studies that have sent to the medical residents directly fromcompared the provision of EN in patients the primary author or was forwarded to thembefore and after the implementation of pro- from their director or coordinator with a timetocols have shown increased caloric intake, frame of 2 weeks to complete the survey. Onedecreased days of mechanical ventilation, week after the initial e-mail was sent, anotherearlier initiation of EN, and decreased inci- survey was sent to the medical residents in andence of feedings being held for increased attempt to increase the response rate. Institu-residuals.5,10,11 tional review board approvals were obtained The question is whether medical residents from the C. W. Post Campus of Long Islandare properly educated and trained about the University and Lutheran Medical Center.EN prescription. Therefore, the purpose ofthis project was to evaluate medical residents’ Instruments for obtaining dataperceived attitudes, knowledge, and practices A 21-item survey was developed after ain the delivery of EN in the critical care setting review of prior studies in EN that includedand to assess the factors used to determine surveys to physicians, medical residents, andthe EN prescription. This project sought to dietitians.16,17 The authors of these originalascertain whether medical residents are con- articles were contacted via e-mail to obtainfident in their knowledge about EN, what fac- permission to use all or some of the ques-tors they consider when prescribing EN, and tions from their survey. Eight questions werewhether they are in favor of adopting feeding modified with permission. The remainingprotocols. 13 questions were developed by the primaryCopyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  3. 3. Medical Residents and Nutrition Support 337author. The survey was sent to 12 registered contacted; 7 responded and agreed to par-dietitians (RDs) and 12 medical residents and ticipate in the study, which resulted in anphysicians who worked in critical care to es- additional 395 surveys sent to medical resi-tablish face and content validity. The survey dents. In total, 11 medical resident directorswas revised based on the recommendations and program coordinators participated in thethat were received. study (Table 1). Nine directors and coordi- The survey consisted of 2 parts. Part I was nators forwarded the survey to their medicala 21-item survey that used a 5-point Likert residents. The survey was sent directly to thescale with a range of scores from 5 (strongly remaining 2 groups of residents via e-mail byagree) to 1 (strongly disagree) to determine the primary author. In total, the survey wasperceived knowledge, attitudes, and practices sent to 643 medical residents; 56 residentsabout EN in the critical care setting and to completed the survey for a response rateassess the factors used to determine the EN of 8.7%.prescription. The 21 items covered the 3 ar- The demographic characteristics of the re-eas of interest: 5 questions related to attitudes; spondents are shown in Table 2. A majority5 questions about knowledge; and the remain- of the respondents are in their first or seconding 11 focused on practice. Part II included year of residency (82%). Most (81.5%) hold ademographic questions such as age, gender, doctor of medicine degree and practice inter-year of residency, medical degree, area of nal medicine (61%).specialty, and additional training in nutrition.Descriptive statistics were used to compare Perceived attitudes aboutsurvey responses. enteral nutrition The survey responses about perceived atti-RESULTS tudes of EN are presented in Table 3. Of the 56 respondents, 98% agreed or strongly agreed Initially, 14 directors were contacted and that “nutrition is important in the treatment4 hospitals agreed to participate in the study. of critically ill patients.” Most respondentsThe survey was sent to a total of 248 med- also disagreed with the statement “early nu-ical residents enrolled in the residency pro- trition support does not impact the outcomegrams. The same process was repeated, with of patient care.” In comparison, 52% agreed oran additional 49 directors and coordinators strongly agreed that “other aspects of criticalTable 1. Participating Hospitals Where Medical Residents Were Surveyed Number of Residents Enrolled Number of Number of Hospital in Program Beds Critical Care Beds Lutheran Medical Center (NY) 115 476 22 St John’s Episcopal Hospital (NY) 68 257 16 Greenwich Hospital (CT) 22 174 10 Stony Brook University Hospital (NY) 21 571 50 Lenox Hill Hospital (NY) 95 652 12 Montefiore Medical Center (NY) 157 396 23 Mountainside Hospital (NJ) 25 365 16 Hoboken University Medical Center (NJ) 26 328 5 Bridgeport Hospital (CT) 44 425 38 Danbury Hospital (CT) 28 371 20 St Francis Hospital and Medical Center (CT) 20 617 39NY, New York; NJ, New Jersey; CT, Connecticut.Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  4. 4. 338 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011Table 2. Summary of Demographic Data of Perceived knowledge aboutMedical Residents (n = 56) enteral nutrition The survey responses about perceived Characteristic n (%) knowledge of EN are presented in Table 4. Gendera Only 4 of the 56 respondents reported that Male 33 (62.3) they had specialized training in nutrition sup- Female 20 (37.7) port (Table 2). Slightly more than half of the Year of residencyb respondents agreed or strongly agreed that Year 1 26 (47.3) “they can function to their full potential in Year 2 19 (34.5) regards to nutrition therapy (57%).” Of the re- Year 3 8 (14.5) maining respondents (n = 24), 10 disagreed Year 4 2 (3.6) that they are capable of functioning to their >Year 4 0 (0) full potential in providing nutrition therapy Age, yc and only 20% agreed that they are familiar 18–20 0 (0) 21–25 5 (9.0) with their hospital formulary. Less than half 26–30 28 (50.9) agreed that they “know how to progress the 31–35 12 (21.8) rate of feeding to goal rate” and “know how to Medical degreed calculate the calories, protein and fluid the pa- Doctor of medicine 44 (81.5) tient receives from an EN prescription.” Most Doctor of osteopathy 10 (18.5) residents indicated that they “would like fur- Area of specialty ther training in EN.” Family practice 14 (25.0) Internal medicine 34 (60.7) Obstetrics-gynecology 0 (0) Practices in enteral nutrition therapy Surgery 5 (8.9) Table 5 presents the survey responses Emergency medicine 0 (0) about practices in EN therapy. When the Gastroenterology 0 (0) residents were asked about EN versus Cardiology 0 (0) parenteral nutrition (PN), most respondents Othere 3 (5.4) (79%) agreed or strongly agreed that “PN Specialized training in nutrition supportf should not be used routinely in patients Yes 4 (7.3) with an intact GI tract” and 84% also No 51 (92.7) agreed that, “EN should be used in pref- erence to PN.” In practice, 69% agreed ora Three survey responses did not indicate gender (n = 53). strongly agreed that “EN should be initiatedb One survey response did not indicate year of residency within the first 24 to 48 hours of admis-(n = 55). sion.” The majority of residents (91%) agreedc One survey response did not indicate age (n = 55).d Two survey responses did not indicate medical degree or strongly agreed with the statement that(n = 54). they take patient characteristics into con-e Other: 2 responses did not specify, 1 neurology. sideration when prescribing EN. Eighty-sixf One survey response did not indicate specialized training percent took formula characteristics into con-(n = 55). sideration, with 73% stating that they dis- agreed or strongly disagreed that they “use thecare take priority over nutrition therapy.” The same infusion rate regardless of the EN for-majority disagreed or strongly disagreed that mula.” Only 66% reported that they “would“the formula prescribed does not affect pa- change a formula based on current labora-tient outcome.” Only 1 respondent disagreed tory values.” To determine the infusion rate,that “a feeding protocol should be utilized in 73% agreed or strongly agreed that they “con-the delivery of EN”; most strongly agreed or sider calorie and protein needs” and 76% dis-agreed with this statement (Table 3). agreed or strongly disagreed that they “useCopyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  5. 5. Medical Residents and Nutrition Support 339Table 3. Summary of Responses to Survey Questions Pertaining to Medical Residents’Perceived Attitudes About Enteral Nutritiona Strongly Neither Agree Strongly Agree or Disagree Disagree Question n (%) Agree n (%) n (%) Disagree n (%) n (%) I believe nutrition 47 (83.9) 8 (14.3) 0 (0.0) 0 (0.0) 1 (1.8) therapy is important in critically ill patients I think that other aspects 9 (16.1) 20 (35.7) 19 (33.9) 7 (12.5) 1 (1.8) of patient care take priority over nutrition Early nutrition support 1 (1.8) 1 (1.8) 7 (12.5) 26 (46.4) 21 (37.5) does not impact the outcome of the patient The enteral nutrition 1 (1.8) 1 (1.8) 11 (20.0) 31 (56.4) 11 (20.0) formula prescribed does not affect the outcome of the patientb An evidence-based 25 (45.5) 27 (49.1) 2 (3.6) 1 (1.8) 0 (0.0) feeding protocol should be considered as a strategy to optimize delivery of enteral nutritionba Highest frequencies are in boldface.b Responses = 55. One respondent did not answer the question.the same rate for all patients.” Eighty-six per- results of other similar studies. Cahill et al16cent of medical residents agreed or strongly surveyed 514 MDs and RDs to evaluate theiragreed that they “take the RD and nutrition attitudes about nutrition and the Canadiansupport recommendations into consideration Critical Care Nutrition Clinical Practice Guide-when prescribing EN.” lines. The researchers found that the majority (91%) of those surveyed considered nutritionDISCUSSION therapy to be very important for critically ill patients. In another study, Behara et al2 re- Nutrition is an important part of treat- ported that medical residents thought that nu-ment in managing critically ill patients. The trition was important in the outcome of ICUattitudes and beliefs of the critical care team patients, with a mean rating of 4.72 (on amay influence the outcome of these patients. scale of 1 [not important] to 5 [very impor-This study surveyed medical residents about tant]), which is similar to the mean score oftheir perceived attitudes, knowledge, and 4.79 found in our study. Similarly, Goiburu-practice in the delivery of EN in the criti- Bianco et al18 stated that 98% of the 60 medicalcal care setting. A group of medical residents residents and physicians who were surveyedin the New York tristate area was surveyed; thought nutrition support were important in98% of the medical residents agreed that nutri- critical care and had an impact on patient out-tion is important, which is consistent with the come.Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  6. 6. 340 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011Table 4. Summary of Responses to Survey Questions Pertaining to Medical Residents’Perceived Knowledge About Enteral Nutritiona Neither Strongly Agree or Strongly Agree Agree Disagree Disagree Disagree Question n (%) n (%) n (%) n (%) n (%) As it pertains to the 4 (7.1) 28 (50.0) 14 (25.0) 8 (14.3) 2 (3.6) provision of nutrition therapy, I am able to function to my full potential, based on my knowledge level, skill, competencies and scope of practice I would like further training 20 (35.7) 32 (57.1) 3 (5.4) 1 (1.8) 0 (0.0) in prescribing enteral nutrition I am familiar with all of the 2 (3.6) 9 (16.4) 13 (23.6) 23 (41.8) 8 (14.5) formulas used for enteral nutrition on the hospital formularyb I know how to progress the 3 (5.5) 22 (40.0) 11 (20.0) 18 (32.7) 1 (1.8) rate of feeding to goal rateb I know how to calculate the 3 (5.5) 20 (36.4) 10 (18.2) 20 (36.4) 1 (3.6) calories, protein and fluid the patient is receiving from an enteral nutrition prescriptionba Highest frequencies are in boldface.*Responses = 55. One respondent did not answer the question. Despite their overwhelming statement of The majority (84%) of medical resident re-the importance of nutrition, medical residents spondents thought that EN should be usedin this project did not perceive their nutrition in preference to PN. Behara et al2 reportedknowledge to be adequate, with more than similar findings, with 94% of the medical res-half (57%) stating that they could provide nu- idents stating that EN is preferred over PN.trition support at their full potential (refer- However, despite medical residents reportingring to their lack of knowledge in EN). In their preference for EN, only 79% agreed thataddition, almost all (93%) agreed that they PN should not be used in a patient with an in-would like further training in nutrition, indi- tact gastrointestinal tract. This finding reflectscating that they do not think their knowledge a similar outcome in a previous study, whereis sufficient. These findings reinforce previous 35% of physicians stated that they would pre-surveys where medical residents, physicians, scribe PN, although no signs of gastrointesti-and even gastroenterology fellows rated their nal dysfunction were present.20understanding of nutrition support as insuffi- An additional discordance between at-cient or average.2,18,19 titude and practice pertains to the earlyCopyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  7. 7. Medical Residents and Nutrition Support 341Table 5. Summary of Responses to Survey Questions Pertaining to Medical Residents’Practices in Enteral Nutrition Therapya Neither Strongly Agree or Strongly Agree Agree Disagree Disagree Disagree Question n (%) n (%) n (%) n (%) n (%) Parenteral nutrition should not be 27 (48.2) 17 (30.4) 6 (10.7) 5 (8.9) 1 (1.8) used routinely in patients with an intact gastrointestinal tract Enteral nutrition should be used 36 (64.3) 11 (19.6) 9 (16.1) 0 (0.0) 0 (0.0) in preference to parenteral nutrition Enteral nutrition should be 24 (43.6) 14 (25.5) 14 (25.5) 3 (5.5) 0 (0.0) initiated early (24-48 hours following admission to the ICU)b When determining target rate of 1 (1.8) 3 (5.4) 11 (19.6) 34 (60.7) 7 (12.5) infusion, I use the same rate regardless of the enteral formula I consider patient characteristics 17 (30.9) 33 (60.0) 5 (9.1) 0 (0.0) 0 (0.0) when choosing an enteral nutrition formula (eg, nutrient needs, digestive and absorptive capacity of GI tract, and disease state)b I consider product characteristics 16 (29.1) 31 (56.4) 8 (14.5) 0 (0.0) 0 (0.0) when choosing an enteral nutrition formula (eg, form of protein, fat content, carbohydrate content)b When determining rate of 1 (1.8) 4 (7.3) 8 (14.5) 29 (52.7) 13 (23.6) infusion, I use the same rate for all patientsb When determining rate of 7 (12.7) 33 (60.0) 10 (18.2) 5 (9.1) 0 (0.0) infusion, I take calorie and protein goals into considerationb When prescribing enteral 33 (60.0) 20 (36.4) 1 (1.8) 0 (0.0) 1 (1.8) nutrition, I consider the recommendation of a registered dietitian or the nutrition support teamb I will change an enteral nutrition 5 (9.1) 31 (56.4) 18 (32.7) 1 (1.8) 0 (0.0) formula based on current laboratory valuesb I will always hold feedings when a 16 (29.6) 29 (53.7) 8 (14.8) 1 (1.9) 0 (0.0) patient shows intolerances (eg, emesis, high residuals)ca Highestfrequencies are in boldface.b Responses = 55. One survey respondent did not answer question.c Responses = 54. Two survey respondents did not answer question.Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  8. 8. 342 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011initiation of EN. Although 84% of the medi- estimated nutrient needs. Although permis-cal residents thought that early initiation of sive underfeeding is practiced with obese pa-EN affects patient outcome, only 69% agreed tients, it is not recommended for criticallythat EN should be initiated within the first 24 ill patients who are of normal weight orto 48 hours after admission (despite evidence- malnourished.9based guidelines stating that EN should be ini- Several studies have found that the EN pre-tiated within this time frame).9 Initiation of scription provides an inadequate amount ofearly EN in practice was not common with energy, ranging from 50% to 78% of the pa-several studies reporting mean times of initia- tients’ needs.6-8,10,22 In addition to not meet-tion ranging from about 40 to 76 hours after ing caloric needs, McClave et al7 also foundadmission.6,8,21 Behara et al2 found that med- that only 14% of the patients reached theirical residents reported waiting an average of goal infusion rate within 3 days, and Chapman2.63 days before evaluating a patient’s nutri- et al5 found a mean of 6.8 days until patientstional status in the ICU. met their goal rate. In this study, less than Despite 76% of medical residents agreeing half (42%) of the medical residents agreed thatthat formula selection impacts the outcome they knew how to calculate calories, protein,of patient care, almost 80% stated that they and fluid delivered in an EN prescription. Onlywere not familiar with their hospitals’ formu- 45% reported that they knew how to progresslary. Most of the medical residents consid- the rate of infusion. Although no studies wereered patient characteristics (91%) and formula found that evaluated perceived knowledge ofcharacteristics (86%) when determining the these aspects of the EN prescription, previ-EN prescription. However, only 66% would ous studies have assessed actual knowledgechange the formula based on current labo- through nutrition examinations that resultedratory values. Therefore, it may be surmised in average test scores ranging from 48.6%that residents considered patient and formula to 56.0%.18-20 Although actual testing andcharacteristics for the initial EN prescription, perceived knowledge cannot be directly com-but many did not reassess the prescription pared, suboptimal test scores support an accu-once it was written. rate assessment of medical residents’ knowl- Studies regarding formula selection were edge of nutrition. Despite their knowledgenot well represented in the literature. One deficit, 73% of residents reported that theystudy, which was conducted almost 25 years considered the patients’ calorie and proteinago, compared the practice of formula se- requirements when determining the infusionlection among RDs and MDs and found that rate. Most choose neither the same rate (76%)MDs were less familiar with formula availabil- nor the same formula (73%) for all patients,ity. They placed slightly less emphasis on for- which indicates that patient and formula char-mula characteristics compared with patient acteristics are taken into consideration.characteristics.17 Almost all of the medical residents con- Selecting a formula is only a part of the sider the recommendations of the dietitianEN prescription. Knowledge about calculat- and/or the NST when prescribing EN. Beharaing the rate of infusion, beginning with the et al2 did not find similar results in that med-start rate and advancing the rate in incre- ical residents were not comfortable with thements until a goal rate is achieved, is impor- recommendations of the NST. The study bytant to ensure that the patients’ energy, pro- Behara et al2 was conducted at a single facil-tein, and fluid needs are met. Only 50% of ity, and the researchers credited the resultsthose surveyed reported that they knew how to a lack of awareness and education aboutto advance the feeding rate. This is important the NST and the composition of the team. Re-because underprescribing EN is a common sults from this study may also be skewed asoccurrence in the ICU that frequently leads there are limitations to this question. Throughto underfeeding and inadequate provision of full disclosure for informed consent, medicalCopyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  9. 9. Medical Residents and Nutrition Support 343residents in this study were aware that this to implement a standardized EN feedingsurvey was being conducted by an RD, which protocol.may have influenced them, consciously or This study also had several limitations.subconsciously, to respond in a positive man- The major limitation was sample size, withner. Second, a differentiation should have only 8.7% responding to the Web-based sur-been established between an RD and an NST. vey. Reliance on the directors and coordina-Although an RD may be part of the NST, the tors to distribute the survey might have alsoteam may also include a registered nurse, an contributed to a low response rate, as theMD, and/or a pharmacist. primary author did not have sole control of Further training for medical residents survey distribution. Similar studies typicallyin EN is required, which also may influ- resulted in low response rates.16 Furthermore,ence patient outcome. Most medical resi- the low response rate indicated that theredents surveyed believed that an evidence- were a number of nonresponders. A nonre-based protocol should be considered to op- sponse bias check was not conducted to de-timize the delivery of EN. Many studies have termine whether the nonresponders were dif-shown improvements in patient outcomes ferent from the responders because the char-after the implementation of a nutrition sup- acteristics of the former group were unknownport protocol; however, the research does to the researchers.not show whether there was a desire from Another limitation may be the result ofthe medical residents for such protocols to be selection bias in that respondents may be indi-developed.5,10-12 viduals with an interest in nutrition. The sur- This project reinforced information previ- vey did not ask whether an EN protocol was al-ously known with regard to a lack of knowl- ready in place at the residents’ facility. If a pro-edge and inappropriate practices in the pre- tocol was in place, it might bias the residents’scription and delivery of EN. It also provided responses. In addition, the majority of the re-insight into the discordance between atti- spondents were internal medicine or familytudes, knowledge, and practice. This project practice residents. Although critical care isfound that the majority of medical residents included among their rotations, exposure tosurveyed were unsure about how to calculate critically ill patients and provision of EN maynutrients; they were unfamiliar with formu- be limited. Lastly, the residents who partici-las prescribed in EN; and they did not always pated in the study were enrolled in programsprovide EN therapy according to established in the New York tristate area, and they wereguidelines. In addition, there is evidence of mainly in family practice or internal medicine.the need for further education in nutrition Therefore, the results may not be general-and a standardized protocol for EN. Future ized to other subspecialties or geographicalresearch should be conducted to determine locations.where the discrepancy lies between attitudes,knowledge, and practice. The research con- CONCLUSIONducted should focus on where further trainingshould be initiated: in medical school; as part Medical residents are authorized to writeof the residency rotations; or daily education EN prescriptions; yet, most of them have min-during rounds with a NST. imal training. The residents who participated This study had some strengths. The use in this study reported inadequacies in theirof a Web-based survey allowed for complete knowledge despite the fact that they thoughtanonymity of the responses. Standard on- that nutrition support in critical care was im-line survey procedures were followed to in- portant. They also demonstrated discrepan-crease the response rate. To the researchers’ cies between attitude, knowledge, and prac-knowledge, this was the first study that tice based on their responses. In addition,surveyed medical residents about a need residents reported that they favored the useCopyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  10. 10. 344 TOPICS IN CLINICAL NUTRITION/OCTOBER–DECEMBER 2011of a standardized feeding protocol. The cur- IMPLICATIONS FOR DIETETIC PRACTICErent system of nutrition education in medi-cal school has changed little in hours devoted As part of a multidisciplinary team involvedto clinical nutrition over the past 20 years.23 in treating critically ill patients, the RD hasA transformation of the nutrition education an opportunity to bring expertise to the pro-curriculum throughout medical school is war- vision of nutrition support. An RD can alsoranted. In the interim, approaches such as work to implement feeding protocols in theirfeeding protocols and daily education through facilities or become a part of the NST. Thismedical rounds, including a dietitian, may provides the opportunity to educate medicalhelp to train medical residents in nutrition residents in EN and nutrition therapy in criti-support. cal care.REFERENCES 1. Adams KM, Lindell KC, Kohlmeiser M, Zeisel SH. Sta- implementation of an evidenced-based nutritional tus of nutrition education in medical schools. Am J management protocol. Chest. 2004;125:1446-1457. Clin Nutr. 2006;83(suppl):941S-944S. 12. Adam S, Batson S. A study of problems associated 2. Behara AS, Peterson SJ, Chen Y, Butsch J, Lateef with the delivery of enteral feed in critically ill pa- O, Komanduri S. Nutrition support in the criti- tients in five ICUs in the UK. Intensive Care Med. cally ill: a physician survey. J Parent Enter Nutr. 1997;23:261-266. 2008;32(2):113-119. 13. Chapman G, Curtas S, Meguid MM. Standard- 3. Taren D, Thomson CA, Koff A, et al. Effect of an in- ized enteral orders attain caloric goals sooner: a tegrated nutrition curriculum on medical education, prospective study. J Parent Enter Nutr. 1992;16(2): student clinical performance, and student percep- 149-151. tion of medical-nutrition training. Am J Clin Nutr. 14. Weinsier RL, Boker JR, Brooks CM, et al. Nutrition 2001;73:1107-1112. training in graduate medical (residency) education: a 4. Vetter ML, Herring SJ, Sood M, Shah NR, Kalet AL. survey of selected training programs. Am J Clin Nutr. What do resident physicians know about nutrition? 1991;54:957-962. An evaluation of attitudes, self-perceived proficiency 15. Survey Monkey. http://www.surveymonkey.com/. and knowledge. J Am Coll Nutr. 2008;27(2):287-298. Published 2010. Accessed March 2, 2010. 5. Chapman G, Curtas S, Meguid MM. Standardized en- 16. Cahill NE, Narasimhan S, Dhaliwal R, Heyland DK. teral orders attain caloric goals sooner: a prospective Attitudes and beliefs related to the Canadian critical study. J Parent Enter Nutr. 1992;16(2):149-151. care nutrition practice guidelines: an international 6. De Jonghe B, Appere-De-Vechi C, Fournier M, et al. survey of critical care physicians and dietitians. J Par- A prospective survey of nutritional support practices ent Enter Nutr. 2010;34(6):685-696. in intensive care unit patients: what is prescribed? 17. Feitelson M, Fitz P, Rovezzi-Carroll S, Bernstein LH. What is delivered? Crit Care Med. 2001;29(1):8-12. Enteral nutrition practices: similarities and differ- 7. McClave SA, Sexton LK, Leslie K, et al. Enteral tube ences between dietitians and physicians in Con- feeding in the intensive care unit: factors imped- necticut. J Am Dietet Assoc. 1987;87(10):1363- ing adequate delivery. Crit Care Med. 1999;27(7): 1368. 1252-1256. 18. Goiburu-Bianco ME, Jure-Goiburu MM, Bianco- 8. O’Meara D, Mireles-Cabodevila E, Frame F, et al. Eval- C´ceres HF, Lawes C, Ortiz C. Nivel di formaci´ n en a o uation of delivery of enteral nutrition in critically ill nutrition de medicos intensivistas. Encuesta en hos- patients receiving mechanical ventilation. Am J Crit pitals p´ blicos de Asunci´ n. [Degree of nutritional u o Care. 2008;17(1):53-61. training of intensive care physicians. A survey in pub- 9. McClave SA, Martindale RG, Vanek VW, et al. Guide- lic hospitals of Asunci´ n.] Nutrici´ n Hospitalaria. o o lines for the provision and assessment of nutrition 2005;20(5):326-330. support therapy in the adult critically ill patient. 19. Raman M, Violato C, Coderre S. How much do gas- J Parent Enter Nutr. 2009;33(3):277-316. troenterology fellows know about nutrition? J Clin10. Arabi Y, Haddad S, Sakkijha M, Shimemeri AA. The Gastroenterol. 2009;43(6):559-564. impact of implementing an enteral tube feeding pro- 20. Vanek VW, Sharnek LK, Snyder DM, Kupensky DT, tocol on caloric and protein delivery in intensive care Rutushin AL. Assessment of physicians’ ability to unit patients. Nutr Clin Pract. 2004;19(5):523-530. prescribe parenteral nutrition support in a commu-11. Barr J, Hecht M, Flavin KE, Khorana A, Gould MK. nity teaching hospital. J Am Diet Assoc. 1997;97(8): Outcomes in critically ill patients before and after 856-859.Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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