This quality improvement project evaluated enteral nutrition practices in the ICU at San Francisco General Hospital. The document reviewed recommendations for early initiation of enteral nutrition and achieving calorie goals. An analysis of 15 ICU patients found that adjusting feeding rates to run over a 20-hour continuous cycle, rather than 24 hours, helped more patients meet the recommended calorie goals of 50-65% in the first week and 100% in the second week. The conclusion is that using a 20-hour continuous feeding cycle could help improve delivery of enteral nutrition and support better clinical outcomes for critically ill patients.
Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leimyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis
C. A. Bittencourt, R. dos Santos Simões, W.M. Bernardo, L. F. P. Fuchs,J. M. Soares Júnior, A.R. Pastore and E.C. Baracat
Volume 50, Issue 1, Date: July Pages: 32–39
Slides prepared by Dr Joel Naftalin (UOG Editor-for-Trainees)
Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.17352/full
Addressing severe-acute malnutrition in Rajasthan using community-based strat...POSHAN
This presentation was made by Dr. Deepti Gulati (GAIN) in the session on ‘Implementation research on delivery of preventive and curative interventions during early childhood’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi.
For more information about the conference visit our website: www.poshan.ifpri.info
Community-based management of severe acute malnutrition in India: New evidenc...POSHAN
This presentation was made by Dr. Alan Pereira (Medicins Sans Frontiers) in the session on ‘Implementation research on delivery of preventive and curative interventions during early childhood’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi.
For more information about the conference visit our website: www.poshan.ifpri.info
Accuracy of saline contrast sonohysterography in detection of endometrial polyps and submucosal leimyomas in women of reproductive age with abnormal uterine bleeding: systematic review and meta-analysis
C. A. Bittencourt, R. dos Santos Simões, W.M. Bernardo, L. F. P. Fuchs,J. M. Soares Júnior, A.R. Pastore and E.C. Baracat
Volume 50, Issue 1, Date: July Pages: 32–39
Slides prepared by Dr Joel Naftalin (UOG Editor-for-Trainees)
Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.17352/full
Addressing severe-acute malnutrition in Rajasthan using community-based strat...POSHAN
This presentation was made by Dr. Deepti Gulati (GAIN) in the session on ‘Implementation research on delivery of preventive and curative interventions during early childhood’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi.
For more information about the conference visit our website: www.poshan.ifpri.info
Community-based management of severe acute malnutrition in India: New evidenc...POSHAN
This presentation was made by Dr. Alan Pereira (Medicins Sans Frontiers) in the session on ‘Implementation research on delivery of preventive and curative interventions during early childhood’ at the POSHAN Conference "Delivering for Nutrition in India Learnings from Implementation Research", November 9–10, 2016, New Delhi.
For more information about the conference visit our website: www.poshan.ifpri.info
Ability of a preterm surveillance clinic to triage risk of preterm birth: a prospective cohort study
J Min, HA Watson, NL Hezelgrave, PT Seed and AH Shennan
Volume 48, Issue 1, pages 38–42
Slides prepared Dr Joel Naftalin (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15925/full
Large randomized trial comparing transabdominal ultrasound-guided embryo transfer with a technique based on uterine length measurement before embryo transfer
A. Revelli, V. Rovei, P. Dalmasso, G. Gennarelli, C. Racca, F. Evangelista, C. Benedetto
Volume 48, Issue 3, Pages 289–295
Read the free-access article:http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study
R. Romero, K. H. Nicolaides, A. Conde‐Agudelo, J. M. O'Brien, E. Cetingoz, E. Da Fonseca, G. W. Creasy, S. S. Hassan
Volume 48, Issue 3, Pages 308–317
Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
Dydrogesterone versus progesterone for luteal-phase support: systematic review and meta-analysis of randomized controlled trials
M. W. P. Barbosa, L. R. Silva, P. A. Navarro, R. A. Ferriani, C. O. Nastri and W. P. Martins
Volume 48, Issue 2, Pages 161–170
Slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15814/full
Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open‐label, randomized controlled trial
S Kehl, A Schelkle, A Thomas, A Puhl, K Meqdad, B Tuschy, S Berlit, C Weiss, C Bayer, J Heimrich, U Dammer, E Raabe, M Winkler, F Faschingbauer, MW Beckmann, M Sutterlin
Volume 47, Issue 6, Date: June (pages 674–679)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14924/full
A review of the total knee replacement pathway: Integrated care is quality careApollo Hospitals
A Total Knee Replacement (TKR) Pathway (adapted from the Credit Valley Hospital, Canada) is in place at the Apollo Health city facility since 2011. We re-visited the pathway design and the priority grid that led to its adaptation. We analyzed the data with the aim to analyze repetitive and unique trends and evaluate the performance of the pathway. Even with the increased volume the patient satisfaction rose from 56% at the time of pathway implementation to 77% at the end of the evaluation period of 45 months. The Average Length of Stay reduced by 27% from 7.94 to 5.78 days (the difference between the initial and final recorded values), in the same evaluation time period. The methodology of evaluation of the pathway was adapted from the Leuven Clinical Pathway Compass 5 way approach.
Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure
M. Teixidor Vinas, A. M. Belli, S. Arulkumaran and E. Chandraharan
Volume 46, Issue 3, Date: September, pages 350–355
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14728/full
Surgical treatment for hydrosalpinx prior to in‐vitro fertilization embryo transfer: a network meta‐analysis
A. Tsiami, A. Chaimani, D. Mavridis, M. Siskou, E. Assimakopoulos, A. Sotiriadis
Volume 48, Issue 4, Pages 434–445
Slides prepared by Dr Shireen Meher (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15900/full
Use of the NEDOCS overcrowding scale in a pediatric ED. Marion Sills
Weiss SJ, Ernst AA, Johnson A, Sills MR. Use of the NEDOCS overcrowding scale in a pediatric ED. Society for Academic Emergency Medicine’s Annual Meeting, San Francisco, May 2006.
Sleeve vs Mini-Gastric Bypass
IN EVERY STUDY, by every measure, the Mini-Gastric Bypass is equal to or better than every other form of bariatric surgery
Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal growth restriction at autopsy
J Man, JC Hutchinson, M Ashworth, AE Heazell, S Levine and NJ Sebire
Volume 47, Issue 11; Date: November, pages 574–578
Read the free-access article here: http://onlinelibrary.wiley.com/doi/10.1002/uog.16018/full
Organ weights and ratios for postmortem identification of fetal growth restriction: utility and confounding factors
J Man, JC Hutchinson, M Ashworth, I Jeffrey, AE Heazell, and NJ Sebire
Volume 48, Issue 5; Date: November, pages 585–590
Read the free-access article here: http://onlinelibrary.wiley.com/doi/10.1002/uog.16017/full
Adequacy of Enteral Nutritional Therapy Offered to Patients in an Intensive C...asclepiuspdfs
Introduction: Malnutrition is a common framework in hospitalized patients. Enteral nutritional therapy (ENT) is the most commonly used strategy to treat malnutrition. However, complications related to ENT can make it impossible to reach the nutritional requirements of the patient. Objectives: The objectives of the study are to evaluate the nutritional status of patients receiving exclusive ENT and to assess the adequacy of ENT in an intensive care unit (ICU). Materials and Methods: Retrospective study conducted in an ICU of a private hospital in Cuiabá/MT/Brazil between 2015 and 2016. The sample consisted of 115 patients >18 years of age in exclusive ENT. The nutritional status was evaluated using anthropometric, clinical, dietary, and biochemical measurements, and it was categorized by the subjective global assessment. The calorie and protein requirements were calculated according to the hospital protocol
Ability of a preterm surveillance clinic to triage risk of preterm birth: a prospective cohort study
J Min, HA Watson, NL Hezelgrave, PT Seed and AH Shennan
Volume 48, Issue 1, pages 38–42
Slides prepared Dr Joel Naftalin (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15925/full
Large randomized trial comparing transabdominal ultrasound-guided embryo transfer with a technique based on uterine length measurement before embryo transfer
A. Revelli, V. Rovei, P. Dalmasso, G. Gennarelli, C. Racca, F. Evangelista, C. Benedetto
Volume 48, Issue 3, Pages 289–295
Read the free-access article:http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
Vaginal progesterone decreases preterm birth ≤ 34 weeks of gestation in women with a singleton pregnancy and a short cervix: an updated meta-analysis including data from the OPPTIMUM study
R. Romero, K. H. Nicolaides, A. Conde‐Agudelo, J. M. O'Brien, E. Cetingoz, E. Da Fonseca, G. W. Creasy, S. S. Hassan
Volume 48, Issue 3, Pages 308–317
Read the free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15899/full
Dydrogesterone versus progesterone for luteal-phase support: systematic review and meta-analysis of randomized controlled trials
M. W. P. Barbosa, L. R. Silva, P. A. Navarro, R. A. Ferriani, C. O. Nastri and W. P. Martins
Volume 48, Issue 2, Pages 161–170
Slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15814/full
Single deepest vertical pocket or amniotic fluid index as evaluation test for predicting adverse pregnancy outcome (SAFE trial): a multicenter, open‐label, randomized controlled trial
S Kehl, A Schelkle, A Thomas, A Puhl, K Meqdad, B Tuschy, S Berlit, C Weiss, C Bayer, J Heimrich, U Dammer, E Raabe, M Winkler, F Faschingbauer, MW Beckmann, M Sutterlin
Volume 47, Issue 6, Date: June (pages 674–679)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14924/full
A review of the total knee replacement pathway: Integrated care is quality careApollo Hospitals
A Total Knee Replacement (TKR) Pathway (adapted from the Credit Valley Hospital, Canada) is in place at the Apollo Health city facility since 2011. We re-visited the pathway design and the priority grid that led to its adaptation. We analyzed the data with the aim to analyze repetitive and unique trends and evaluate the performance of the pathway. Even with the increased volume the patient satisfaction rose from 56% at the time of pathway implementation to 77% at the end of the evaluation period of 45 months. The Average Length of Stay reduced by 27% from 7.94 to 5.78 days (the difference between the initial and final recorded values), in the same evaluation time period. The methodology of evaluation of the pathway was adapted from the Leuven Clinical Pathway Compass 5 way approach.
Prevention of postpartum hemorrhage and hysterectomy in patients with morbidly adherent placenta: a cohort study comparing outcomes before and after introduction of the Triple-P procedure
M. Teixidor Vinas, A. M. Belli, S. Arulkumaran and E. Chandraharan
Volume 46, Issue 3, Date: September, pages 350–355
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.14728/full
Surgical treatment for hydrosalpinx prior to in‐vitro fertilization embryo transfer: a network meta‐analysis
A. Tsiami, A. Chaimani, D. Mavridis, M. Siskou, E. Assimakopoulos, A. Sotiriadis
Volume 48, Issue 4, Pages 434–445
Slides prepared by Dr Shireen Meher (UOG Editor for Trainees)
Link to free-access article: http://onlinelibrary.wiley.com/doi/10.1002/uog.15900/full
Use of the NEDOCS overcrowding scale in a pediatric ED. Marion Sills
Weiss SJ, Ernst AA, Johnson A, Sills MR. Use of the NEDOCS overcrowding scale in a pediatric ED. Society for Academic Emergency Medicine’s Annual Meeting, San Francisco, May 2006.
Sleeve vs Mini-Gastric Bypass
IN EVERY STUDY, by every measure, the Mini-Gastric Bypass is equal to or better than every other form of bariatric surgery
Effects of intrauterine retention and postmortem interval on body weight following intrauterine death: implications for assessment of fetal growth restriction at autopsy
J Man, JC Hutchinson, M Ashworth, AE Heazell, S Levine and NJ Sebire
Volume 47, Issue 11; Date: November, pages 574–578
Read the free-access article here: http://onlinelibrary.wiley.com/doi/10.1002/uog.16018/full
Organ weights and ratios for postmortem identification of fetal growth restriction: utility and confounding factors
J Man, JC Hutchinson, M Ashworth, I Jeffrey, AE Heazell, and NJ Sebire
Volume 48, Issue 5; Date: November, pages 585–590
Read the free-access article here: http://onlinelibrary.wiley.com/doi/10.1002/uog.16017/full
Adequacy of Enteral Nutritional Therapy Offered to Patients in an Intensive C...asclepiuspdfs
Introduction: Malnutrition is a common framework in hospitalized patients. Enteral nutritional therapy (ENT) is the most commonly used strategy to treat malnutrition. However, complications related to ENT can make it impossible to reach the nutritional requirements of the patient. Objectives: The objectives of the study are to evaluate the nutritional status of patients receiving exclusive ENT and to assess the adequacy of ENT in an intensive care unit (ICU). Materials and Methods: Retrospective study conducted in an ICU of a private hospital in Cuiabá/MT/Brazil between 2015 and 2016. The sample consisted of 115 patients >18 years of age in exclusive ENT. The nutritional status was evaluated using anthropometric, clinical, dietary, and biochemical measurements, and it was categorized by the subjective global assessment. The calorie and protein requirements were calculated according to the hospital protocol
How to improve enteral feeding tolerance in chronically critically ill patientsDr Jay Prakash
These interruptions to EN result in significant daily and cumulative calorie deficits, thus contributing to underfeeding and malnutrition. Underfed patients have an increased risk of all-cause mortality, bloodstream infections and longer ICU and hospital stays.
1. Quality Improvement Project: Meeting Nutritional Needs in the ICU
Early enteral nutrition (EN) in the critically ill patients improves outcomes. It may
improve gut flow, improve gut barrier function (decreased bacterial translocation),
decrease organ injury, improve wound healing, improve immune function, decrease pro-
inflammatory response, decrease mortality, and decrease both the length of hospital stay
and the cost of care.
Once EN has been initiated, there are many factors that contribute to tube feed
holds, limiting the administration of nutrition that is critical to helping the patient heal.
The policy for continuous tube feeds at San Francisco General Hospital is to calculate the
goal rate to run over a total of 24 hours, which may make it unrealistic for many patients
to reach their targeted goals.
Early initiation of enteral nutrition
Based on the Aspen Clinical Guidelines (2009), enteral feeding should be initiated
within the first 24-48 hours following admission (grade of evidence: C). Attaining access
and initiating EN should be considered as soon as the patient is hemodynamically stable.
A “window of opportunity” exists in the first 24-72 hours following admission or the
onset of a hypermetabolic injury. Feedings started within this timeframe are associated
with less gut permeability, and release of inflammatory cytokines, leading to improved
clinical outcomes.
In a sample of 15 ICU patients in the ICU (Units 4E, 5E, and 5R), 5 patients
(33%) had EN initiated within 48 hours of admission. Efforts should be made to increase
this number in patients who are hemodynamically stable.
Meeting needs during the first week of ICU hospitalization
The Aspen Clinical Guidelines (2009) state that efforts to provide greater than
50%-65% of goal calories should be made in order to achieve the clinical benefit of EN
over the first week of hospitalization (grade of evidence: C). The impact of early EN on
patient outcome appears to be a dose-dependent effect. The use of trophic feeds (trickle
of 10-30ml/hr) may be sufficient to prevent mucosal atrophy but may in insufficient to
achieve the usual endpoints desired by EN therapy. Studies suggest that greater than
50%-65% of goal calories may be required to promote faster return of cognitive function
in head injury patients, and to improve outcome from immune-modulating enteral
formulations in critically ill patients.
By implementing chart audits of ICU patients requiring EN, it can be determined
if patients are meeting the targeted 50%-65%, based on the 24 hour continuous cycle. If
rates were to be calculated based on 20 or 22 hour continuous cycle per day, this would
allow time for holds for procedures and nursing functions, while still providing the
patient with the targeted goal volume to meet their estimated needs.
Out of a sample of 15 patients in the ICU (Units 4E, 5E, and 5R), 6 patients
(40%) met a minimum of 50% of goal calories. When adjusting rates to run over a 22
hour continuous cycle, 8 patients (53%) would have been able to reach 50%-65% of goal
calories. When adjusting rates further to run over a 20 hour continuous cycle, 10 patients
(66%) would have met the targeted goal of 50%-65% of goal calories.
2. Based on this sample population, calculating the continuous infusion to run over a
20 hour cycle would significantly improve the ability to meet targeted goals. A 20 hour
cycle would allow for an improvement in meeting needs, as well as allowing for
scheduled breaks for nursing care and procedures.
24 hour EN
(actual delivery)
Amount of goal met
22 hour EN
(projected amount)
Amount of goal met
20 hour EN
(projected amount)
Amount of goal met
Number of patients
that met >50% of
goal calories
6 (40%) 8 (53%) 10 (66%)
Number of patients
that met >65% of
goal calories
3 (20%) 5 (33%) 6 (40%)
Meeting needs during the second week of ICU hospitalization
The Aspen Clinical Guidelines also recommend that if unable to meet the energy
requirement (100% of target goal calories) after 7-10 days by enteral route alone,
supplemental parenteral nutrition (PN) should be considered to reach 100% of goal
(grade of evidence: E). While the strength of evidence in this topic is low, efforts should
be made to meet 100% of goal needs by the second week of hospitalization.
Out of a sample of 5 patients, 2 reached 100% of goal rate within the second week
of admission in the ICU. Two patients met 78% of goal rate, while the last met 43% of
goal rate over the second week of hospitalization. Increasing the hourly rate and
delivering over a 22 or 20 hour continuous cycle would have potentially increased intake
from 43% to 47% and 51% respectively, and would have potentially increased intake
from 78% to 86% and 93%, respectively.
0
20
40
60
80
100
120
Pt 1 Pt 2 Pt 3 Pt 4 Pt 5
24 hour delivery
22 hour delivery
20 hour delivery
24 hour EN
(actual delivery)
Amount of goal met
22 hour EN
(projected amount)
Amount of goal met
20 hour EN
(projected amount)
Amount of goal met
Patient 1 100% 98% 101%
Patient 2 100% 99% 97%
Patient 3 43% 47% 51%
Patient 4 78% 86% 93%
3. Patient 5 78% 85% 92%
The 20 hour continuous cycle shows the highest ability to meet goal rates. Patient
1 shows a projection of meeting 101% of EN goal, as it was based off of 85ml/hr for 20
hour. To accurately match the calculated estimated needs, 84ml/hr for 20 hours would be
recommended. However, the minimal increase in order to keep rounded numbers is ideal
for simplicity, and surpassing estimated needs by 1% is not considered detrimental.
Conclusion
Early enteral nutrition and adequate delivery of EN is beneficial for the overall
clinical outcome. Meeting greater than 50-65% of goal rate should be attempted for the
first week, and efforts should be made to reach 100% of goal by the second week of
hospital stay. Based on the charts reviewed, increasing rates of delivery and using a 20
hour continuous cycle would be beneficial to helping more patients meet these targeted
goals. More data should be collected to determine if the trend remains consistent,
however based on the population sampled, there is a potential benefit to changing to a 20
hour continuous cycle to assist in meeting estimated goals.
Kristi Friesen, Dietetic Intern at San Francisco General Hospital
June 2014
References:
McClave, S., Martindale, R., Et. al. Guidelines for the Provision and Assessment of Nutrition Support
Therapy in the Adult Critically Ill Patient. Journal of Parenteral and Enteral Nutrition Vol33 no 3, 2009.