This multicenter observational study evaluated the impact of enteral feeding protocols on nutrition delivery in critically ill patients. The study found that sites using a feeding protocol had better enteral nutrition adequacy, started enteral nutrition earlier, and had higher overall nutritional adequacy compared to sites without a protocol. Specifically, sites with a protocol achieved 45.4% enteral nutrition adequacy compared to 34.7% for sites without. The presence of a protocol was associated with a 4.1% increase in enteral nutrition adequacy after adjusting for patient and site characteristics. However, overall nutritional adequacy remained below targets, indicating need for further refinement of feeding protocols.

1. The Impact of Enteral Feeding
Protocols on Enteral Nutrition
Delivery: Results of a multicenter
observational study
Rupinder Dhaliwal, RD
Daren K. Heyland, MD
Naomi E Cahill, RD
Xiaoqun Sun, MSc
Andrew G Day, MSc
Stephen A. McClave, MD
1

2. Background
 Feeding protocols are considered to be an effective strategy
to maximize the benefits and minimize the risks of enteral nutrition
in critically ill patients.
 Components of feeding protocols may include orders for
 Early initiation of enteral nutrition
 Use of motility agents
 Gastric residual volumes
 Head of the bed elevation
 Use of small bowel feeding tubes
 The benefits of such protocols would be:
 to standardize the delivery of EN
 to automate the provision of EN
1

3. 1
“Use of a feeding protocol that incorporates prokinetics at initiation,
higher GRVs (250 mls) and use of post pyloric feeding tubes should
be considered”
What do Guidelines say?
“Evaluating gastric residual volume
(GRV) in critically ill patients is an
optional part of a monitoring plan
to assess tolerance of EN. “ Avoid
holding EN when GRV < 250 mls.
Consensus, imperative
“Use of enteral feeding protocols
increases the overall percentage of
goal calories provided and should
be implemented.” Avoid holding EN
for GRVs < 500 mls. Grade: C, B

4. RCT Level of Evidence
 RCTs of aggressive feeding protocols
 Results in better protein-energy intake
 Associated with reduced complications and improved survival
Taylor et al Crit Care Med 1999; Martin CMAJ 2004; Doig GS JAMA 2008
However, the estimates of their effectiveness are limited due to:
 the nature of small single-center studies
 the bundling with many other interventions in cluster
randomized controlled trials.
1

5. To evaluate the effect of an ICU site-based feeding protocol on
nutrition practices and outcomes in the context of an international
multicenter, observational study.
Objective
To compare the following performance criteria between
sites that did or did not use a feeding protocol:
 Use of EN
 Time to start EN
 Adequacy of enteral nutrition
 Adequacy of overall nutrition
 Clinical outcomes
PurposePurpose
1

6. Primary Outcomes
Overall nutritional adequacy
Enteral nutrition adequacy
Overall nutritional adequacy = as the total amount of calories or protein
received (from EN + appropriate PN + propofol) /prescribed x 100%
Overall EN adequacy = as the total amount of calories or protein
received (from EN) /prescribed x 100%
1

7. Methods
Data from two international, prospectively, observational cohort studies
conducted in 2007 and 2008 were combined.
Patients:
 Consecutively enrolled mechanically ventilated adults
 In ICU > 3 days
Data was collected from ICU admission to a maximum of 12 days:
 sites recorded the presence or absence of a feeding protocol
 timing, type and amount of nutrition received
 strategies utilized to improve nutrition delivery (m. agents, small bowel feeds, HOB)
 60 day mortality, hospital and ICU length of stay and duration of mechanical
ventilation
 Each participating ICU aimed to recruit 20 patients.
Nutrition practices and clinical outcomes were compared between ICUs that
used a feeding protocol and those who did not.
1

8. Data Management
Data entered on to our secure online edcs, built-in range checks
and data query process.
1 www.criticalcarenutrition.com

9. Data Analysis
Data from 2007 and 2008 combined, 334 total sites,
65 sites participated both years, 269 unique
ICUs
Hospital and ICU characteristics compared at the site level
All other variables were compared at the patient level
Clustered 2 stage sample design: patient and site, so
potential for heterogeneity between ICUs.
Advanced statistical methods were done to account for
heterogeneity (adjusted chi square tests, multilevel
modelling).
1

10. Results
269 ICUs participated from 28 countries
2007: 128/167 (77%) used protocol
2008: 132/167 (79%) used protocol
Protocol No Protocol
208/269 (77%) 61/269 (23%)

11. Results
269 ICUs participated from 28 countries
Canada 46/57
(80.7%)
USA
48/77
(62.3%)
UK
19/19
(100%)
Australia
28/28
(100%)
New
Zealand
6/7
(85.7%)
India
5/9
(55.5%)
Brazil
2/4 (50%)
China
16/25
(64%)
Italy
7/7
(100%)
Ireland
7/7
(100%)
29/61 (48%) of the non-protocolized sites being from the United States.

12. Results: Site Characteristics
Table 1. Protocol (n=208)
(77%)
No Protocol (n=61)
(23%)
P value
Hospital Type
Teaching
Non Teaching
162 (77.9%)
46 (22.1%)
51 (83.6%)
10 (16.3%)
0.38
Size hospital
mean (range) 606 (108-2502) 791 (138-4000) 0.004
Multiple ICUs in hospital
yes
107 (51.4%) 45 (73.8%) 0.002
ICU structure
Open
Closed
Other
48 (23.1%)
156 (75.0%)
4 (1.9%)
22 (36.1%)
39 (63.9%)
0 (0%)
0.099
Medical Director 196 (94.2%) 54 (88.5%) 0.15
Case Types
Medical
Surgical
189 (91%)
191 (92%)
44 (72%)
49 (80%)
0.0004
0.017
Size ICU 17 (4-75) 19 (5-48) 0.50
Presence of ICU Dietitian 168 (80.8%) 46 (75.4%) 0.37
FTE RD per 10 beds 0.4 (0.0-6.7) 0.3 (0.0-1.0) 0.42
Avg. # eligible patients
contributed/year
17.0 (range: 1-24) 14.6 (range: 1-25) p=0.001

13. Characteristics Total
n=269
Feeding Protocol
Yes 208 (77%)
Gastric Residual Volume
Tolerated in Protocol
Mean (range) 213 ml (50, 500)
Elements included in Protocol
HOB Elevation 71.2 %
Motility agents 68.5%
Small bowel feeding 55.2%
Results: Feeding Protocols
15.2% using the
recommended
threshold volume
of 250 ml
1

14. Results: Patients n = 5497
Table 2. Protocol No Protocol P value
Number of Patients n=4416 n=1081
age 59.6 (12-96) 58.8 (15-99) 0.38
Gender 1771 (40.1%) 380 (35.2%) 0.013
Admission category
Medical
Surgical
2792 (63.2%)
1624 (36.7%)
633 (58.6%)
448 (41.4%)
0.30
APACHE II 22.4 (1-72) 21.9 (1-46) 0.31
Presence of ARDS 554 (12.5%) 137 (12.7%) 0.96
Mechanical Ventilation
median (IQR) 8 (4-16.2) 7 (3.6-14)
0.089
Hospital LOS 21.9 (12.9-36.0) 20.7 (12.6-32.0) 0.25
Mortality 60 day 1280 (29.0%) 295 (27.3%) 0.37
1
Heyland JPEN 2010 ( in press)

15. Results: Nutrition outcomes
Table 3. Protocol No Protocol P value
Number of Sites 208/269 (77%) 61/269 (23%)
EN alone
PN
EN + PN
None
3108 (70.4%)
322 (7.3%)
785 (17.8%)
201 (4.6%)
688 (63.6% )
116 (10.7%)
184 (17.0%)
93 (8.6%)
0.0036
Time to start of EN from
ICU admission
41.2 hrs 57.1 hrs 0.0003
motility agents use in high
GRVs
811 (64.3%)
patients
103 (49.0%)
patients
0.0028
average head of bead
elevation
32.5o
30.0o
0.017
small bowel feeding in high
GRVs
177 (14.0 %)
patients
35 (16.7%)
patients
0.45
1
Heyland JPEN 2010 ( in press)

16. Results: Nutrition Adequacy
Protocol No Protocol
Adequacy from EN 45.4% 34.7% p<0.0001
Overall nutritional
adequacy
61.2 % 51.7% p=0.0003
1
Heyland JPEN 2010 ( in press)

17. EN adequacy: multilevel model
After adjusting for the effect of:
significant patient characteristics (age, BMI, gender, # days in
ICU, surgical vs. Medical, APACHE II)
site level characteristics of EN adequacy (year of survey, vs.
Non teaching, closed, RD, glycemic protocols)
The expected average EN adequacy over the first 12 ICU days
Unadjusted Adjusted
↑ by 7.4%
(SE=1.8%, p<0.0001) in
patients from sites with
protocols
↑ by 4.1%
(SE=1.8%, p=0.021) in patients
at sites with protocols
1
Heyland JPEN 2010 ( in press)

18. Conclusions
 There is great variation in the use of feeding protocols in ICUs
across the World.
 The presence of an enteral feeding protocol is associated with
significant improvements in the use of EN, timing of initiation of EN,
the use of motility agents and nutrition adequacy delivered.
 We suggest that the use of feeding protocols become standard of
care in ICUs.
 Despite the use of protocols, overall nutrition adequacy is still below
target, further refinement and optimization of the characteristics of
feeding protocols is warranted.
 The positive effect of feeding protocols on clinical outcomes is yet to
be established.
1
Heyland JPEN 2010 ( in press)

19. Strengths and Weaknesses
Weaknesses
 observational nature of the study design
 did not standardize the specific nutrition interventions included in
the feeding protocols
 did not optimize the utilization of protocols at each site. We are
unable to comment on the quality of these existing protocols or
the level of compliance at the bed-side.
Strengths
 large number of participating sites from around the world
 Use of a structured, validated data capture system, which
enhances the generalizability and validity of the observations.
1
Heyland JPEN 2010 ( in press)

20. Efficacy of Enhanced Protein-Energy
Provision via the Enteral Route
in Critically Ill Patients:
The PEP uP Protocol
A Single center feasibility trial

21. Acknowledgements
1
 The authors are grateful to the critical care practitioners
from all participating ICU sites for their dedication and
commitment to collecting data for this study.
 Colleagues at the Clinical Evaluation Research Unit
 Naomi Cahill currently holds a Canadian Institutes
for Health Research (CIHR) Fellowship in
Knowledge Translation.
 All authors declare no conflicts of interest relevant to the
subject of this manuscript.