title: Implementation of enteral feeding protocol in an intensive care unit: Before-and-after study.
abstract: OBJECTIVE
  To determine the effects of implementing an enteral feeding protocol on the nutritional delivery and outcomes of intensive care patients.
  
  
  METHODS
  An uncontrolled, observational before-and-after study was performed in a tertiary mixed medical-surgical intensive care unit (ICU). In 2013, a nurse-driven enteral feeding protocol was developed and implemented in the ICU. Nutrition and outcome-related data from patients who were treated in the study unit from 2011-2012 (the Before group) and 2014-2015 (the After group) were obtained from a local electronic database, the national Population Registry and the hospital's Infection Control Service. Data from adult patients, readmissions excluded, who were treated for at least 7 d in the study unit were analysed.
  
  
  RESULTS
  In total, 231 patients were enrolled in the Before and 249 in the After group. The groups were comparable regarding demographics, patient profile, and severity of illness. Fewer patients were mechanically ventilated on admission in the After group (86.7%vs93.1% in the Before group,P= 0.021). The prevalence of hospital-acquired infections, length of ICU stay and ICU, 30- and 60-d mortality did not differ between the groups. Patients in the After group had a lower 90-d (P= 0.026) and 120-d (P= 0.033) mortality. In the After group, enteral nutrition was prescribed less frequently (P= 0.039) on day 1 but significantly more frequently on all days from day 3. Implementation of the feeding protocol resulted in a higher cumulative amount of enterally (P= 0.049) and a lower cumulative amount of parenterally (P< 0.001) provided calories by day 7, with an overall reduction in caloric provision (P< 0.001). The prevalence of gastrointestinal symptoms was comparable in both groups, as was the frequency of prokinetic use. Underfeeding (total calories < 80% of caloric needs, independent of route) was observed in 59.4% of the study days Beforevs76.9% After (P< 0.001). Inclusion in the Before group, previous abdominal surgery, intra-abdominal hypertension and the sum of gastrointestinal symptoms were found to be independent predictors of insufficient enteral nutrition.
  
  
  CONCLUSIONS
  The use of a nurse-driven feeding protocol improves the delivery of enteral nutrition in ICU patients without concomitant increases in gastrointestinal symptoms or intra-abdominal hypertension.
authors.affiliation: Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia.
authors.forename: Martin
authors.initials: M
authors.lastname: Padar
authors.affiliation: Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia.
authors.forename: Gerli
authors.initials: G
authors.lastname: Uusvel
authors.affiliation: Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia.
authors.forename: Liis
authors.initials: L
authors.lastname: Starkopf
authors.affiliation: Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia.
authors.forename: Joel
authors.initials: J
authors.lastname: Starkopf
authors.affiliation: Martin Padar, Gerli Uusvel, Joel Starkopf, Department of Anaesthesiology and Intensive Care, Tartu University Hospital, 51014 Tartu, Estonia.
authors.forename: Annika
authors.initials: A
authors.lastname: Reintam Blaser
keywords: Critical care; Enteral feeding; Enteral nutrition; Feeding protocol; Gastrointestinal symptoms; Nutrition protocol; Parenteral nutrition; Underfeeding