title: Process-Related Barriers to Optimizing Enteral Nutrition in a Tertiary Medical Intensive Care Unit.
abstract: OBJECTIVE
  Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients.
  
  
  METHODS
  We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori.
  
  
  RESULTS
  Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure.
  
  
  CONCLUSIONS
  Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients.
authors.affiliation: Nutrition Services Department, Froedtert Hospital, Milwaukee, Wisconsin Michelle.Kozeniecki@froedtert.com.
authors.forename: Michelle
authors.initials: M
authors.lastname: Kozeniecki
authors.affiliation: Department of Nursing, Froedtert Hospital, Milwaukee, Wisconsin.
authors.forename: Natalie
authors.initials: N
authors.lastname: McAndrew
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
authors.forename: Jayshil J
authors.initials: JJ
authors.lastname: Patel
mesh_terms: D000368:Aged; D003422:Critical Care / Q000379:methods* / Q000592:standards; D004750:Enteral Nutrition / Q000379:methods* / Q000592:standards; D005215:Fasting; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D007441:Intubation, Gastrointestinal / Q000592:standards; D008297:Male; D008875:Middle Aged; D011300:Preoperative Care / Q000592:standards; D017064:Process Assessment, Health Care; D058996:Quality Improvement; D012189:Retrospective Studies; D013270:Stomach / Q000503:physiopathology; D062606:Tertiary Care Centers / Q000592:standards*
keywords: critical care; critical illness; enteral nutrition; intensive care unit; nutritional support; process assessment