Effective delivery of nutrition therapy is paramount in critical care settings to enhance patient outcomes. Recognizing areas for improvement in critical care nutrition processes is crucial for healthcare professionals. This Critical Care Nursing Nutrition Tool Kit Aspen is designed as a performance improvement resource, aligning with the key recommendations from the 2016 ASPEN/SCCM Critical Care Nutrition Guidelines. This tool kit provides process indicators that managers and clinicians can utilize to assess and strengthen the delivery of critical care nutrition, ultimately promoting positive patient outcomes. Institutions can select indicators based on their specific nutrition goals and monitor them over suitable periods to drive necessary improvements.
Process Indicators to Utilize for Assessing Malnutrition Processes
This section outlines specific process indicators designed to evaluate and improve malnutrition processes within critical care. Each indicator focuses on a different component of care and is paired with a goal of compliance to help guide performance improvement efforts.
1. Early Enteral Nutrition Initiation
Recommendation: Initiate nutrition support therapy with early enteral nutrition (EN) within 24-48 hours for critically ill patients unable to maintain adequate oral intake and who have a functional gastrointestinal tract.
- Indicator: Percentage of admitted patients with a functional gastrointestinal tract, who are unable to maintain volitional intake, and receive EN initiated within 24-48 hours of admission.
- Component of care addressed: Early initiation of Enteral Nutrition.
- Goal of compliance: 90%
- Importance: Early enteral nutrition is crucial for providing nutrients to critically ill patients and supporting gut function, which can significantly impact recovery and reduce complications.
2. Achieving Goal Nutrition in High-Risk Patients
Recommendation: Advance patients identified as high nutrition risk or severely malnourished towards their goal nutritional requirements as quickly as tolerated, ideally within 24-48 hours of EN initiation.
- Indicator: Percentage of patients at high nutrition risk or with severe malnutrition who achieve their goal energy and protein requirements within 24-48 hours following the start of EN.
- Component of care addressed: Timely progression to goal nutrition targets in high-risk patients.
- Goal of compliance: 90%
- Importance: Meeting nutritional goals promptly in high-risk patients is essential to mitigate malnutrition and support their increased metabolic demands during critical illness.
3. Minimizing Inappropriate Holding of Enteral Nutrition for GRVs
Recommendation: In ICUs still utilizing Gastric Residual Volume measurements (GRVs), avoid routine holding of EN for elevated GRVs.
- Indicator: Percentage of patients receiving EN who have feedings withheld due to GRV levels.
- Component of care addressed: Appropriate use of GRVs and minimizing unnecessary interruptions in EN delivery.
- Goal of compliance: (Goal percentage to be determined based on institutional context and baseline data)
- Importance: Unnecessary cessation of enteral feeding can hinder nutrient delivery. This indicator encourages re-evaluation of GRV use and promotes continuous feeding when appropriate.
4. Reducing Interruption of Enteral Nutrition
Recommendation: Avoid inappropriate cessation of EN to ensure consistent nutrient delivery.
- Indicator: Percentage of patients on EN experiencing interruptions in enteral feeding for more than one hour per day.
- Component of care addressed: Consistent delivery of enteral nutrition and minimizing interruptions.
- Goal of compliance: (Goal percentage to be determined based on institutional context and baseline data)
- Importance: Frequent or prolonged interruptions in EN can significantly reduce overall nutrient intake, negatively impacting the benefits of enteral nutrition.
5. Timely Initiation of Parenteral Nutrition in High-Risk Patients When EN is Not Feasible
Recommendation: For patients at high nutrition risk or severely malnourished who cannot receive EN, initiate exclusive parenteral nutrition (PN) as soon as possible after ICU admission.
- Indicator: Percentage of high-risk or severely malnourished patients unable to receive EN who have parenteral nutrition (PN) started within 24-48 hours of ICU admission.
- Component of care addressed: Prompt initiation of PN when EN is contraindicated or not tolerated in high-risk patients.
- Goal of compliance: 90%
- Importance: For patients who cannot receive enteral nutrition, timely initiation of parenteral nutrition is crucial to prevent nutritional deficits, especially in those at high risk or already malnourished.
6. Utilizing Hypocaloric Dosing in Early Parenteral Nutrition
Recommendation: In patients receiving parenteral nutrition, utilize hypocaloric PN dosing (≤ 20 kcals/kg/day or 80% of estimated energy needs) with adequate protein (≥1.2 g protein/kg/day) during the first week of hospitalization.
- Indicator: Percentage of ICU patients receiving PN who are administered 80% of estimated energy requirements or ≤ 20 kcals/kg/day and at least 1.2 g protein/kg/day.
- Component of care addressed: Implementation of appropriate hypocaloric PN dosing strategies in the initial phase of critical illness.
- Goal of compliance: 90%
- Importance: Hypocaloric PN with adequate protein in the early phase of critical illness can help mitigate metabolic complications while still providing essential protein for preserving lean body mass.
7. Achieving Target Blood Glucose Control
Recommendation: Maintain a target blood glucose range of 140–180 mg/dL for the general ICU population.
- Indicator: Percentage of general ICU patients who maintain blood glucose levels between 140 and 180 mg/dL.
- Component of care addressed: Effective blood glucose management in the ICU.
- Goal of compliance: 90%
- Importance: Maintaining appropriate blood glucose control is vital in critical care to improve outcomes and reduce complications associated with hyperglycemia or hypoglycemia.
8. Use of Immune-Modulating Formulas in Trauma and Traumatic Brain Injury
Recommendation: Consider immune-modulating enteral formulations containing arginine and fish oil for patients with severe trauma and traumatic brain injury (TBI).
- Indicator: Percentage of trauma and/or TBI patients who receive an immune-modulating enteral formula.
- Component of care addressed: Appropriate utilization of specialized enteral formulas in specific patient populations.
- Goal of compliance: 90%
- Importance: Immune-modulating formulas may offer benefits in trauma and TBI patients by modulating the inflammatory response and potentially improving clinical outcomes.
9. Use of Immune-Modulating Formulas in Post-Operative Surgical ICU Patients
Recommendation: Utilize immune-modulating enteral formulas containing both arginine and fish oils in the Surgical Intensive Care Unit (SICU) for post-operative patients requiring EN therapy.
- Indicator: Percentage of post-operative SICU patients who receive an immune-modulating enteral formula.
- Component of care addressed: Appropriate utilization of specialized enteral formulas in post-operative SICU patients.
- Goal of compliance: 90%
- Importance: Similar to trauma and TBI, post-operative SICU patients may also benefit from immune-modulating formulas to support recovery and reduce complications.
10. Implementing High-Protein Hypocaloric Feeding in Obese ICU Patients
Recommendation: Implement high-protein hypocaloric feeding for obese ICU patients, providing protein in the range of 2 g/kg ideal body weight (BMI 30-40) and 2.5 g/kg in BMI ≥40.
- Indicator: Percentage of obese patients receiving a hypocaloric high-protein nutrition regimen who achieve the desired protein intake.
- Component of care addressed: Specialized nutrition strategies for obese critically ill patients.
- Goal of compliance: 95%
- Importance: High-protein hypocaloric feeding in obese ICU patients is designed to preserve lean body mass while minimizing overfeeding and associated metabolic complications in this vulnerable population.
Conclusion
This critical care nursing nutrition tool kit aspen, based on the ASPEN/SCCM guidelines, provides a structured approach to continuously improve nutrition therapy in critical care. By utilizing these process indicators, healthcare teams can monitor their performance against established benchmarks, identify areas needing attention, and implement targeted interventions. Consistent use of this tool kit will contribute to enhanced nutrition delivery, better patient outcomes, and a higher standard of care within the critical care environment.
