Barriers to Optimizing Nutrition Support Initiation and Advancement in Critically Ill Pediatric Patients: A Case Based Quality Improvement

Project
Katy Kakol, Dietetic Intern Ana Abad-Jorge, Ed.D, MS, RDN, CNSC May 22, 2013 ABSTRACT Background: The provision of optimal nutrition support in the Pediatric Intensive Care Units (PICU) is essential for the care and management of critically ill infants and children. It is the fundamental component associated with improving patients overall outcomes. ASPEN nutrition guidelines for PICU patients recommend timely initiation and delivery of energy and protein requirements. Current pediatric literature indicates that many obstacles often exist which prevent timely and effective progression of both parenteral (PN) and enteral nutrition (EN) support in these critically ill patients. Recent studies, however, have found that some of these delays and interruptions are often avoidable. Avoidable interruptions or delays happen most commonly related to lack of nutrition protocols and inconsistent practice among practitioners, thereby preventing critically ill children from receiving PN and EN in a timely, progressive fashion. Use of consistent nutrition protocols can raise awareness and provide guidance for the PICU staff in the provision of adequate nutrition support. Purpose: The purpose of this case series based quality improvement (QI) research study was to determine common delays and interruptions to timely and effective initiation and advancement of PN macronutrients, and to the initiation of EN, within the University of Virginia Health System PICU population. Study Methods: Quantitative data was collected on four patients admitted to the PICU and started on nutrition support between January 15 and March 22, 2013. Patients were in the PICU greater than or equal to 5 days, between the ages of 0-18 years, and required PN or EN. Patient demographics, daily energy intake from PN, EN, and/or oral feeds were recorded for all patients using the electronic medical record (EMR). Nutritional intake data was collected daily and individualized on a patient-case basis, for a minimum of 10 days and a maximum of 20 days. Additional data collection endpoints included: date at which nutrition support was started, length of time required to achieve full nutrition goals, barriers to optimal nutrition support for both PN and EN. Results: Two of the four critically ill PICU patients reached their optimal nutrition goal, and the two patients with cardiorespiratory illness only reached 93% on HD 28 and 87% on HD 16. However, of the patients who met 100% of their goal, only Patient 2 reached her goal on HD 6 whereas the Patient 1-LV, did not reach it until HD 15. Nutrition goals were achieved on one occasion, as inconsistencies, delays, or interruptions occurred causing a decline in the amount of nutrition they were receiving. The common barriers observed among the four patients were 25% related to fluid restriction, 22% preprocedural fasting, 22% NPO related to deterioration of nutritional status, 16% reported due to feeding intolerance and 13% from six other categories, which were infrequent. Conclusion: The nutritional needs of the critically ill PICU patient are not being achieved in a timely, effective manner, because of unavoidable and some avoidable barriers. Based on the outcomes of this study, additional approaches to improving compliance with nutrition orders and consistency with advancement to meeting nutritional needs, will help minimize avoidable delays, and thereby help to ensure that patients have overall improved outcome associated with proactive implementation.