Nutrition in icu closed system nutrition benefits
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Nutrition in icu closed system nutrition benefits
- 1. Transition to Liquid Nutrition or Ready-to-Hang Enteral Feeding System Evolving Nutritional Care for Critically Ill Patients
- 2. Learning Objectives • To understand the importance of ready-to-hang EN as nutritional support in the management of critically ill patients • To integrate evidence-based principles into the decision-making process EN: Enteral nutrition.
- 3. SECTION Importance of Nutrition in Critically Ill Patients Admitted to ICU ICU: Intensive care unit. 1
- 4. Compromised GI Function in ICU Patients: Far More Common Than We Believe 30%- 70% of ICU patients have GI dysfunction1 GI dysfunction occurs in 50% of MV patients.1 01 02 03 04 Premorbid conditions (traumatic brain injury)2 Ventilation mode1 Altered metabolic state (inflammation, sepsis, circulating stress hormones, gut hypoperfusion)2 ICU medications (catecholamines, sedatives, opioids)3 1. Mutlu GM, et al. Chest. 2001;119:1222–1241. 2. Hill LT. S Afr J Crit Care. 2013;29(1):11-15. 3. Gungabissoon U, et al . JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. GI: Gastrointestinal; Icu:Intensive care unit
- 5. GI Dysfunction Coupled With Inadequate Intake of Nutrition Leads to Malnourishment in ICU Patients GI dysfunction significantly compromises the delivery of enteral nutrition in ICU patients.1-4 GI dysfunction Malabsorption and intolerance Calorie and protein malnutrition 74% of MV patients fail to attain 80% of their energy targets.2 1. Mutlu GM, et al. Chest. 2001;119:1222–1241. 2. Hill LT. S Afr J Crit Care. 2013;29(1):11-15. 3. Gungabissoon U, et al . JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. 4. Mentec H, et al. Crit Care Med. 2001;29(10):1955-1961. GI: Gastrointestinal; MV: Mechanically ventilated; ICU: Intensive care unit.
- 6. Energy deficit or caloric debt is associated with adverse clinical outcomes in critically ill patients. What is the impact of balanced nutritional intake in critically ill patients with poor nutritional status? Discussion
- 7. Relationship Between Nutritional Intake and Clinical Outcomes in Critically Ill Patients Relationship between increasing calories/day and 60-day mortality, by BMI Increased nutritional intake is associated with lower mortality rates and increased ventilator-free days in critically ill patients with poor nutritional status, especially when BMI is <25 or ≥35 kg/m2. BMI: Body mass index. Alberda C, et al. Intensive Care Med. 2009 Oct;35(10):1728-37.
- 8. Well-Documented Benefits of EN Over PN : ASPEN Recommendations ASPEN recommendations Enteral nutrition is preferred over PN in the critically ill patient requiring nutrition support therapy.1 Reduction in infectious morbidity (pneumonia and central line infections, abdominal abscess)2-4 Significant reduction in hospital LOS, cost of nutrition therapy3 Good neurologic outcome (in patients with head injuries)5 Reduction in noninfective complications6 Mortality rates similar to PN7 EN: Enteral nutrition; PN: Parenteral nutrition; ICU: Intensive care unit; ASPEN: American Society for Parenteral and Enteral Nutrition. 1. Taylor BE, et al. Critical Care Med. 2016;44(2):390-438. 2. Kudsk KA, et al. Ann Surg. 1992; 215:503–513. 3. Heyland DK, et al. J Parenter Enteral Nutr. 2003; 27:355–373. 4. Kalfarentzos F, et al. Br J Surg. 1997; 84:1665–1669. 5. Taylor SJ, et al. Crit Care Med. 1999; 27:2525–2531. 6. Peter JV, et al. Crit Care Med. 2005 33:213–220. 7. Gramlich L., et al. Nutrition. 2004;20: 843–848
- 9. Early Trophic EN Associated With Improved Outcomes in Critically Ill Patients Patient outcomes based on stratification of quantity of EN In patients with septic shock, those receiving <600 kcal/d EN within 48 hours had better clinical outcomes (lower DOMS and LOS) compared to patients who did not receive EN or those who received ≥600 kcal/d. Patel JJ, et al. J Intensive Care Med. 2016;31(7):471–7. DOMV: Duration of mechanical ventilation; LOS: Length of intensive care unit stay; IQR; Interquartile range; EN: Enteral nutrition.
- 10. SECTION Choosing the Right EN Formula: Commercial vs. Noncommercial EN Feeds EN: Enteral nutrition. 2
- 11. Comparison of Energy and Nutrient Content of Commercial and Noncommercial Enteral Nutrition Solutions Comparison of nutritional requirements and intake of patients fed noncommercial and commercial EN In patients receiving CENSs, nutrient adequacy ratio was significantly higher compared to patients receiving NCENS (p<0.001). EN: Enteral nutrition; CENSs: Commercial enteral nutrient solutions; NCENSs: Noncommercial enteral nutrient solutions. Jolfaie NR, et al. Adv Biomed Res. 2017;6:131.
- 12. Can EN Feeds Get Contaminated With Microbes? Sources of feed contamination Feed ingredients Administration systems and their designs Mishandling during assembly of systems Hygiene of facility Enteral feeding fluid acts as a good medium for the exponential growth of most foodborne organisms. Jalali M, et al. J Res Med Sci. 2009;14(3):149–156. EN: Enteral nutrition.
- 13. Bacterial Contamination of Noncommercial OR Blenderized EN Feeds in Critical Care The microbial quality of blenderized enteral feedings used in critical care usually does not meet the standards for safety as suggested in practice guidelines and pose a substantial risk for the development of foodborne disease or nosocomial infections. Jalali M, et al. J Res Med Sci. 2009;14(3):149–156. EN: Enteral nutrition. Bacterial contamination of hospital-prepared tube feeding samples in three intensive care units, at the time of food preparation and 18 hours after preparation
- 14. How to reduce the risk of bacterial contamination in EN feeds, which form an integral part of care in critically ill patients admitted to the ICU? Discussion EN: Enteral nutrition; ICU: Intensive care unit.
- 15. SECTION Selecting the Right EN Delivery System What to Consider When Prescribing EN in Critically Ill Patients?— Closed or Open EN System? EN:Enteral nutrition 3
- 16. Attributes to Be Considered When Choosing EN Delivery System in Critically Ill Patients Limitation of microbial contamination of feeds Maintenance of nutritional adequacy of feeds Ease of use and convenience for nurses Cost- effectiveness Sewify K, et al. J Nutr Food Sci. 2017;7:4. EN:Enteral nutrition
- 17. Open vs. Closed/Ready-to-Hang Delivery System Enteral delivery systemOpen RTH Manipulations Hang time Manipulations required from time of feed preparation to administration Manipulations are minimal, as it is available as a ready-to- hang bag. 4 hours 24-48 hours Nursing time Consumes more nursing time due to more manipulations Ease of use reduces nursing time Sewify K, et al. J Nutr Food Sci. 2017;7:4. RTH: Ready-to-hang.
- 18. Beneficial Effects of Ready-to-Hang Delivery System Ease of administration Prolonged hang time Reduced risk of nosocomial infections Reduced healthcare cost RTH improves the nutritional status of the patients and improves patient outcomes. RTH: Ready-to-hang. Sewify K, et al. J Nutr Food Sci. 2017;7:4.
- 19. Does guideline recommends use of ready-to- hang EN formulas as nutritional support in critically ill patients?
- 20. Prevention and control of healthcare-associated infections in primary and community care NICE:National Institute of Health and Care Excellence; NCGC:National Clinical Guideline Centre
- 21. Guidelines Recommend Usage of Liquid Nutrition(Ready-to-Hang) as preferred formulation Commercially produced, pre-filled ready to hang feeds must be used wherever possible as these are least likely to become contaminated during preparation and use.
- 22. SECTION Improved Outcomes After Transition to Ready-to-Hang Enteral Feeding Systems: Clinical Evidence 4
- 23. Bacterial Contamination Highest With OS Compared to Closed/RTH Delivery Systems Bacterial contamination in open and closed EN delivery systems Closed delivery systems could be safely used for up to 24 hours and are associated with reduced bacterial contamination. OS: Open system; CS:Closed system; RTH:Ready-to-hang. Wagner DR, et al. JPEN J Parenter Enteral Nutr. 1994;18(5):453-7.
- 24. Nutritional Adequacy Better Maintained With Closed Feeding System Compared to OS Comparison of average percent ordered volume of formula received per patient in each enteral system Average percent of formula received compared to ordered volume per patient in each enteral nutritional delivery system Patients receiving EN through CS instead of OS receive a higher percentage of ordered volume of formula and thereby achieve nutritional adequacy. EN: Enteral nutrition; OS: Open system; CS: Closed system. Atkins A. MedSurg Matters. 2015:24(4)14-15.
- 25. Cost-Effectiveness of CS vs. OS in Acute Care Setting Comparison of average daily cost to feed adult patients in each enteral system CS formulas have a higher contract price and are associated with an increased potential for wasting of formula feed compared to OS; therefore, a higher daily average cost may be incurred by switching from OS to CS. However, CS is more cost-effective when nursing time is taken into consideration. CS: Closed system; OS: Open system. Phillips W, et al. Nutr Clin Pract. 2013 ;28(4):510-4.
- 26. Reduced Nursing Time With CS Compared to OS Total daily nursing time in OS and CS delivery systems Management of open delivery system of EN consumed almost twice as much nursing time daily as the closed system with supplemental protein flush (36.6±17.1 min vs. 18.6±3.6 min; p=.051). CS: Closed system; OS: Open system; EN: Enteral nutrition. Luther H, et al. J Burn Care Rehabil. 2003;24(3):167-72
- 27. Closed vs. Open Delivery System: Ease of Use With regard to ease of use , the majority of nurses (87.5%) preferred the closed system over the open system. Ease of use of closed and open delivery systems Luther H, et al. J Burn Care Rehabil. 2003;24(3):167-72
- 28. SECTION Ready-to-Hang Liquid Nutrition in Home Care Settings 5
- 29. Tube Feeding Contamination Risk in Home Care Settings Many issues need to be addressed when assessing risk of contamination in home care Ready-to-hang liquid nutrition reduces chances of contamination in home care setting
- 30. Improved Compliance with RTH Liquid Nutrition Ready-to-hang liquid nutrition improves compliance in home care by 20%
- 31. Key Messages Early initiation of enteral nutrition in critically ill patients is associated with improved clinical outcomes. Noncommercial EN feeds are more prone to bacterial contamination and thereby increase the risk of nosocomial infections. Ready-to-hang closed EN systems are sterile, easy to handle, deliver adequate nutrients and, thereby, improve the nutritional status of patients. EN: Enteral nutrition.
Editor's Notes
- Welcome to this presentation entitled, “Transition to Liquid Nutrition or Ready-to-Hang Enteral Feeding System: Evolving Nutritional Care for Critically Ill Patients.”
- By the end of the module, you will be able to: Understand the importance of ready-to-hang EN as nutritional support in the management of critically ill patients and Integrate evidence-based principles into the decision-making process
- In this section, we will discuss the importance of nutrition in critically ill patients.
- Mechanical ventilation can contribute to several gastrointestinal (GI) complications, although it is not clear whether there is a direct causal relationship between mechanically ventilated (MV) and GI complications. The slide shows GI complications and their prevalence in mechanically ventilated patients.1 References Mutlu GM, Mutlu EA, Factor P. GI Complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. Hill LT. Gut dysfunction in the critically ill − Mechanisms and clinical implications. S Afr J Crit Care. 2013;29(1):11-15. Gungabissoon U, Hacquoil K2, Bains C, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448.
- Impaired GI function is associated with malabsorption and intolerance, which in turn can cause calorie and protein malnutrition. Poor clinical outcomes associated with GI dysfunction and intolerance are as follows:1-4 High mortality rates High risk of infectious complications Longer ICU stay Reduced nutritional adequacy References Mutlu GM, Mutlu EA, Factor P. GI Complications in patients receiving mechanical ventilation. Chest. 2001;119:1222–1241. Hill LT. Gut dysfunction in the critically ill − Mechanisms and clinical implications. S Afr J Crit Care. 2013;29(1):11-15. Gungabissoon U, Hacquoil K2, Bains C, et al. Prevalence, risk factors, clinical consequences, and treatment of enteral feed intolerance during critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448. Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically ill patients: Frequency, risk factors, and complications. Crit Care Med. 2001;29(10):1955-1961.
- Energy deficit or caloric debt is associated with adverse clinical outcomes in critically ill patients. What is the impact of balanced nutritional intake in critically ill patients?
- Evidence suggests that inadequate nutritional intake and a calorie deficit results in poor clinical outcomes in critically ill patients. Patients with poor nutritional, as demonstrated by low body mass index, are at increased risk of adverse effects from underfeeding; or benefit the most from receiving an increased nutritional intake, in the forms of protein and energy. In this regard, in a study, the relationship between the amount of energy and protein administered and clinical outcomes, and the extent to which pre-morbid nutritional status influenced this relationship, was evaluated. In this observational cohort study, nutritional practices in 167 intensive care units across 37 countries were assessed. The type and amount of nutrition received by these patients were recorded daily for 12 days. The study involved 2772 mechanically ventilated patients who received 1034 kcal/day and 47g protein/day. These critically ill patients were followed up prospectively to determine 60-day mortality and ventilator-free days. Body mass index was used as a marker to evaluate nutritional status. The study noted that an increase in calorie intake was associated with lower mortality rates and with increased ventilator-free days in critically ill patients with poor nutritional status, with a BMI <25 or ≥35 kg/m2. Reference Alberda C, Gramlich L, Jones N, et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med. 2009 Oct;35(10):1728-37.
- The American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines suggest that enteral nutrition should be preferred over PN in the critically ill patient requiring nutrition support therapy.1 Some of the well-documented benefits of EN over PN are as follows: Reduction in infectious morbidity (pneumonia and central line infections, abdominal abscess)2-4 Significant reduction in hospital LOS, cost of nutrition therapy3 Good neurological outcomes (in patients with head injuries)5 Reduction in noninfective complications6 Mortality rates similar to PN7 References Taylor BE, McClave SA, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Critical Care Med. 2016;44(2):390-438. Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding: Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503–513. Heyland DK, Dhaliwal R, Drover JW, et al. Canadian Critical Care Clinical Practice Guidelines Committee: Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. J Parenter Enteral Nutr. 2003;27:355–373. Kalfarentzos F, Kehagias J, Mead N, et al. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: Results of a randomized prospective trial. Br J Surg. 1997;84:1665–1669. Taylor SJ, Fettes SB, Jewkes C, et al. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med. 1999;27:2525–2531. Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med. 2005:33:213–220. Gramlich L, Kichian K, Pinilla J, et al. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004;20:843–848.
- In a retrospective study, the correlation between early initiation of tropic EN and clinical outcomes was assessed in mechanically ventilated patients with septic shock. The study included 60 patients, of whom 15 received no EN within 48 hours of ICU admission. In all, 37 patients received <600 kcal/d within 48 hours of admission and 14 patients received 600 kcal/d within 48 hours of admission. The median LOS was 5 days, 13 days, and 12 days for patients receiving <600 kcal/day, ≥600 kcal/day, and no EN, respectively (p<0.001). The median DOMV was 3, 7.5, and 7 for patients receiving <600 kcal/ day, ≥600 kcal/day, and no EN, respectively (p<0.001). The mortality rate did not differ between groups. Patients with septic shock receiving <600 kcal/day EN within 48 hours demonstrated lower DOMV and LOS compared to those who did not receive EN or those receiving ≥600 kcal/day. Reference Patel JJ, Kozeniecki M, Biesboer A, et al. Early Trophic enteral nutrition is associated with improved outcomes in mechanically ventilated patients with septic shock: A retrospective review. J Intensive Care Med. 2016;31(7):471–7.
- In this section, we will discuss the right EN formula for critically ill patients.
- The nutritional quality of enteral nutrition is very important, as nutritional support plays a major role in the management of critically ill patients. In this regard, in a cross-sectional study, the nutritional quality of noncommercial and commercial feeds was assessed. The amount of energy and nutrients delivered and required in these patients was analyzed. The study included 150 patients fed noncommercial enteral nutrition solutions (NCENSs) and 120 patients fed commercial enteral nutrition solutions (CENSs). The values of energy and macronutrients delivered in patients who were administeted CENSs was higher compared to patients who were administered NCENS(p<0.001) . The nutrient adequacy ratio and also the mean adequacy ratio were significantly higher in patients receiving CENSs compared to patients receiving NCENSs (p<0.001). Reference Jolfaie NR, Rouhani MH, Mirlohi M, et al. Comparison of Energy and Nutrient Contents of Commercial and Noncommercial Enteral Nutrition Solutions. Adv Biomed Res. 2017;6:131.
- Enteral feeding formulas can get contaminated at several points, including during preparation, storage, and administration of the feeds. The main sources of enteral feed contamination include: the feed ingredients; administration systems and their designs; mishandling during assembly of systems; and inadequate cleanliness of equipment, the kitchen, and the ward environment. Reference Jalali M, Sabzghabaee AM, Badri SS, et al. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. J Res Med Sci. 2009 May-Jun;14(3):149–156.
- In a study, the microbial quality of hospital-prepared blenderized enteral feeds used in critical care was assessed to analyze the safety of these feeds. In the study, 76 samples, each at the time of preparation and 18 hours following preparation, were collected. Standard plate count, coliform count, and Staphylococcus aureus count were conducted for all samples. Samples were also analyzed for the presence of Salmonella species and Listeria species. The study findings, as shown in the on-screen table, suggested that the microbial quality of the samples was not in line with safety standards recommended by the guidelines. The study results suggested that hospital-prepared enteral feeds are not safe and pose a substantial risk for the development of foodborne disease or nosocomial infection. Reference Jalali M, Sabzghabaee AM, Badri SS, et al. Bacterial contamination of hospital-prepared enteral tube feeding formulas in Isfahan, Iran. J Res Med Sci. 2009 May-Jun;14(3):149–156.
- How to reduce the risk of bacterial contamination in EN feeds, which form an integral part of care in critically ill patients admitted to the ICU?
- In this section, we will discuss the benefits of closed EN system compared to open EN system of delivery, in critically ill patients.
- When considering an EN delivery system for critically ill patients, certain attributes need to be taken into consideration: Limitation of microbial contamination of feeds Maintenance of nutritional adequacy of feeds Ease of use for nurses Cost-effectiveness of the feeds Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- Enteral feeds could be delivered to critically ill patients with the aid of an open or closed delivery system. The closed EN delivery system is also referred to as ready-to-hang delivery system. Let us understand the differences between open and closed delivery systems. The open system includes ready-to-use cans and powdered or sterilized formulas that require reconstitution with water. This system involves many manipulations, in terms of selection of ingredients, reconstitution of the mixture with water, storage or transport of the feed, transfer to the container, assembly of the feeding system, and finally administration of the feed. Recommended hang time for these mixtures is 4 hours. This system consumes more nursing time. The other preferred EN delivery system is the ready-to-hang system. This is a completely closed non-air-dependent collapsible bag system requiring minimal handling and minimal manipulations, with a recommended hang time of 24 to 48 hours. The ease of use associated with this system reduces nursing time and is also safe, due to a minimal risk of contamination. Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- In this slide, let us summarize the beneficial effects of ready-to-hang delivery system as compared to open system. Owing to minimal handling and minimal manipulations, the RTH system is associated with a reduced risk of nosocomial infections. Ease of administration reduces the nursing time. Although each unit of RTH is more expensive compared to the open delivery system, due to reduced nursing time, this system significantly reduces healthcare expenditure. Reference Sewify K, Genena D. Open versus closed tube feeding in critically ill patients-Which is the best? J Nutr Food Sci. 2017;7:4.
- Does guideline recommends use of ready-to-hang EN formulas as nutritional support in critically ill patients?
- The NICE guidelines recommends use of pre-packaged, ready-to-use feeds in preference to feeds requiring decanting, reconstitution or dilution. According to the guidelines, the system selected should require minimal handling to assemble, and to be compatible with the patients enteral feeding tube.
- Guidelines recommend use of commercially produced, pre-filled ready to hang feeds to be used wherever possible as these are least likely to become contaminated during preparation and use.
- In this section, we will discuss improved clinical outcomes following transition to ready-to-hang enteral feeding systems, with evidence from clinical trials.
- In a study, the quantitative factors, such as preparation time, waste, and contamination, associated with three different feeding systems for peptide-based diets were analyzed. Critically ill patients admitted to the ICU were randomized to receive a peptide-based diet in 1500 mL prefilled delivery systems including: Sterile closed-system containers (CS) infused for more than 24 hours Open systems decanted from cans (OS-Can) Open systems mixed from powder (OS-Powder) Samples were taken for culture during preparation and after infusion. Preparation time, initial and final microbial concentrations, and total waste were quantified. The study noted that preparation time was significantly shorter for CS than for OS-Can or for OS-Powder (2 minutes vs. 7.5 minutes vs. 13.0 minutes) and that bacterial contamination was highest in the open delivery system. Reference Wagner DR, Elmore MF, Knoll DM, et al. Evaluation of "closed" vs "open" systems for the delivery of peptide-based enteral diets. JPEN J Parenter Enteral Nutr. 1994 Sep-Oct;18(5):453-7.
- Appropriate nutrition delivery is very important for critically ill patients. In this regard, in a study, the nutritional adequacy of EN feeds delivered via OS and CS was assessed in terms of the volume of feeds received by patients. The study collected retrospective data on patients who had received EN through OS. Prospective data included patients who were receiving feeds through CS. In the study, a total of 325 feeding days of 30 patients were analyzed who received formula via OS, as were and 237 feeding days of 30 adults receiving formula via CS. The study noted that patients receiving formula through OS received an average of 74% of ordered volume and that patients receiving formula through CS received an average of 84% of ordered volume. Reference Atkins A. Delivery of enteral nutrition improved after transition to closed enteral feeding system. MedSurg Matters. 2015:24(4)14-15.
- From the slides discussed, it is evident that the closed delivery system has several clinical benefits compared to the open system. However, the cost of potential waste associated with CS is a major concern; and in this context, in a study, the economic impact of switch from OS to CS was analyzed. In the study, when the average daily cost was calculated using delivered EN formula as a measure, OS was found to be more cost-effective. When the average daily cost was calculated considering both delivered volume and wasted formula, OS was found to be more cost-effective compared to CS. However, when nursing time was taken into consideration for calculating the average daily cost, CS was found to be more cost-effective. Reference Phillips W, Roman B, Glassman K. Economic impact of switching from an open to a closed enteral nutrition feeding system in an acute care setting. Nutr Clin Pract. 2013 Aug;28(4):510-4.
- In a study, the time required for nurses for managing both delivery systems in critically ill patients was assessed. Timing for the closed system feeding took into consideration the following tasks: procuring a new feeding container, spiking and hanging the new bottle, and restarting the pump. The timing considered for the open system included the following: securing the mixed formula from the refrigerator, correctly rinsing and flushing the feeding bag and the tubing, addition of 4-hour supply feeding to the bag, and priming and restarting the pump. The study noted that management of open delivery system of EN consumed almost twice as much nursing time daily as the closed system with supplemental protein flush (36.6±17.1 min vs. 18.6±3.6 min; p=0.051). Reference Luther H, Barco K, Chima C, et al. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil. 2003 May-Jun;24(3):167-72; discussion 166.
- In the study, nurses were provided a questionnaire to detail their perceptions on the ease of use of the two delivery systems; the majority of nurses (87.5%) preferred the closed system over the open system. Reference Luther H, Barco K, Chima C, et al. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil. 2003 May-Jun;24(3):167-72; discussion 166.
- In this section, we will discuss the benefits of ready-to-hang liquid nutrition in home care settings.
- Risk of contamination of enteral feedings delivered via tubes, is high in home care settings. Several issues needs to be addressed when assessing risk of contamination in home care settings. The issues that needs to be addressed are listed in the on-screen table. Evidence suggests that ready-to-hang liquid nutrition, is effective in reducing the chances of contamination in the home care settings.
- In home care settings, as in hospital set-up, the modular feeds were significantly more contaminated at the start of administration with over 75% of feeds contaminated compared with 28% of ready-to-use feeds. This significant difference was maintained by the end of administration when all modular feeds were contaminated compared with nearly two thirds of ready-to-use feeds.
- To summarize, Early initiation of enteral nutrition in critically ill patients is associated with improved clinical outcomes. Noncommercial EN feeds are more prone to bacterial contamination and thereby increase the risk of nosocomial infections. Ready-to-hang closed EN systems are sterile, easy to handle, deliver adequate nutrients and, thereby, improve the nutritional status of patients.