Benefits of Nurse Driven EN Protocols

1. Nurse-driven Enteral
Feedings in ICU
Deborah Hong
Rutgers University

2. Background
 During their hospital stays, several critically ill patients
depend on enteral feedings for sustenance.
 Standard enteral feeding protocols fail to properly
nourish patients
 This lack of proper nourishment indicates the need for
nurse-driven enteral feeding protocols which will help
patients maintain ideal caloric intake

3. “The Reasons For Insufficient Enteral Feeding In An
Intensive Care Unit: A Prospective Observational Study,”
Study design
Prospective Observational Study
Sampling technique, sample size, & characteristics
“Eighty-seven patients were screened for 707 patient days. Nurses documented 141 instances
of insufficient enteral nutrition in 49 patients” (Kuslapuu, 2015). Kuslapuu verifies the
validity of this study by listing the methods the ICU nurses used when collecting data. “The
follow-up assessment performed to fully study the effects of the standard enteral feeding
protocol, was performed once daily between 12:00 and 14:00. Data were collected through a
specially developed electronic survey that was completed by the nurses,” (Kuslapuu, 2015).
Statistical Analysis
Based on the nurse’s assessments, 49 of the 87 patients were not meeting their caloric
methods through standard enteral feeding protocol. Tartu’s nurses observed that the most
common reasons for decisions to stop or delay enteral nutrition were high feeding residual
volume, recent GI surgery, an acute abdomen, and ongoing procedures such as weaning off
ventilators and CT scans.
(Kuslapuu, Jogela, Starkopf, & Blaser, 2015 )

4. “Nurse-Driven Enteral Feeding Protocol Improves Caloric Intake in
Critically Ill Patients”
Study design
This was a non-randomized controlled prospective study. The method used in this
study was to compare caloric intake of 50 critically ill patients whose nutrition was
managed by hospital standard enteral feeding protocol vs. that of 50 patients who
nutrition was managed by a nurse-driven protocol with caloric requirement
targets. The nurse-driven feeding protocol would consist of caloric requirement
targets and would require nurses “to start feeding within 48 hours, unless
specified not to feed by the physician” (Demian, 2007). This review of caloric
intake was performed randomly by searching through patient’s charts.
Statistical Analysis
Demian summarizes the study’s results by stating that after the nurse-driven
feeding protocol was implemented, the percentage of patients who had their
feedings started before they spent 48 hours in the ICU “increased from 50% to
94%” (Demian, 2007). The article also makes the case for Demian’s argument by
sharing that the nurse-driven protocol helped the percentage of patients reaching
“80% of their caloric requirements go from 44 to 90%” (Demian, 2007).
(Demian, Halawa, Nisar, & Ahmed, 2007)

5. “Evaluation of enteral nutrition in critically ill patients at
LUMC utilizing a 24-
hour, nurse driven, volume-based feeding protocol”
Overview of Study
This was also a quantitative review describing Loyola
University Medical Center’s findings when treating their
patients with a nurse-driven volume based enteral feeding
protocol instead of the standard rate/hr protocol. Eiden
concludes that a volume-based EN protocol allowed
nurses to initiate feedings at twice the rate they normally
did with the standard hospital protocol. On average, the
time it took for nurses to reach their goal feeding rate was
10 hours shorter with a volume based protocol rather than
a rate/hour protocol.
(Eiden, Kinn, Martin, Palmer, Pudelek, & Varner, n.d.)

6. “Improvement of enteral
nutrition in intensive care unit patients by a nurse-driven feeding
protocol”
Purpose of study/Study aims
The aim of this study was to examine whether EN was started earlier and met caloric goals more often
following this change in management. The purpose was to display if a nurse led protocol resulted in earlier
initiation of EN and subsequently increased caloric intake in the interventional ICU population.
Study design
Before and after retrospective design comparison; single site.
Sampling technique, sample size, & characteristics
The patients who were studied were ICU patient in an unnamed British Hospital in a 13 bed unit and
receiving enteral nutrition.
Statistical Analysis
The two groups were compared using Student’s t-test for the time to start of enteral feeding and for the
daily calories and Pearson’s chi squared test for the frequency of protocol-conform EN. It was displayed that
the non-experimental group only 24.8% received prescribed caloric intake within the initial 24 hours EN
was initiated vs 63.9% of patients receiving total prescribed caloric intake within 24 hours of EN initiation
when a nurse driven feeding protocol was instituted in the experimental group.
(Friesecke, Schwabet, Stechert, & Abel, 2014)

7. Proposed Intervention
 An enteral feeding protocol will be designed and
implemented by ICU nurses
 Unless contraindicated by physicians, the enteral feeding
protocol will be initiated on ICU patients within 6 hours of
admission.
 Enteral feedings will be started on patients at 20 ml/hr for 6
hours. The nurses then will check for gastric residual volume
(GRV). If it is less than 200 mL, feedings will be increased by
10 mL/hr up to the ordered goal rate. If the GRV is between
200-500 mL, feedings will be continued. If GRV is greater
than 500 mL, gastric feedings will be discontinued and the
GRV will be checked again in 6 hours.

8. Proposed Intervention (cont)
 We would determine that patients were malnourished if
“at the time of assessment the actual infusion rate was
less than 50 kcal/hr and this rate had not increased
during the previous 12 hours” (Kuslapuu, 2015).
 Another method we could use to determine if patients
were properly fed would be by calculating their caloric
needs. “The caloric needs of all consecutive patients
admitted during the study period were calculated as 20
kcal/kg ideal body weight for the first two days in ICU
and 25 kcal/kg ideal BW for the remainder of the time”
(Kuslapuu, 2015).
(Kuslapuu, Jogela, Starkopf, & Blaser, 2015 )

9. Objective
 Our objective would be to implement the previously discussed nurse-
driven enteral feeding protocol on randomly selected ICU patients for
three months.
 Staff nurses would be expected to calculate and document specific
values every 12 hours such as their patient’s current enteral feeding
rate (both in mL/hr and kcal/hr) at time of assessment.
 The level of nourishment for patients treated with the nurse-driven
enteral feeding protocol would be compared to the level of
nourishment for patients fed by the standard hospital EN protocol.
 My hope is that the patients’ difference in progress with level in caloric
intake, protein and even admission length would be discussed in staff
meetings. This shared knowledge of overwhelming evidence could
further motivate hospitals to implement nurse-driven EN protocols
throughout all their critical care units.

10. References
American Psychological Association (2009). Publication Manual of the American Psychological
Association (6th ed). Washington, DC: American Psychological Association
Demian ST, Halawa NN, Nisar B, Ahmed R. (2007). Nurse-driven enteral feeding protocol improves
caloric intake in critically ill patients. Chest. 132(4), 442c-443.
Eiden, K., Kinn, T., Martin, J., Palmer, L., Pudelek, B., and Varner, E. (n.d.) Evaluation of enteral
nutrition in critically ill patients at LUMC utilizing a 24-hour, nurse driven, volume-based feeding protocol. Retrieved
from http://www.luhs.org/depts/cce/projects/qf13_storyboards/eval_enteral_nutrition_crit_ill_pts.pdf
Friesecke, S., Schwabet, A., Stechert, S.S., & Abel, P. (2014). Improvement of enteral nutrition in
intensive care unit patients by a nurse-driven feeding protocol. British Association of Critical Care Nurses, 19: 4, 204
– 210. doi: 10.1111/nicc.12067
Heyland, D.K, Murch, L., Cahill, N., McCall, M., Muscedere, J., Stelfox, H.T., Bray, T., Tanguay, T.,
Jiang, X., Day, A.G. (2013). Enhanced protein-energy provision via the enteral route feeding protocol in critically ill
patients: Results of a cluster randomized trial. Critical Care Medicine, 41, 12. 2748-53. doi:
10.1097/CCM.0b013e31829efef5 https://www.ncbi.nlm.nih.gov/pubmed/23982032
Kuslapuu, M., Jogela, K., Starkopf, J., & Blaser, A.R. (2015). The reasons for insufficient feeding in an
intensive care unit: A prospective observational study. Intensive Critical Care Nurse. 31(5), 309-214.
https://www.ncbi.nlm.nih.gov/pubmed/25864368
Moran, K., Burson, R. & Conrad, D. (2014). The Doctor of Nursing Practice Scholarly Project: A
Framework for Success. Burlington, MA: Jones & Barlett Learning.