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Outcomes in Critically Ill Patients Before and After the Implementation of an Evidence-Based Nutritional Management Protocol^*

^* From the Department of Veterans Affairs Palo Alto Health Care System (Drs. Barr and Gould, and Ms. Khorana), Palo Alto, CA; and the Department of Anesthesia (Drs. Barr and Hecht) School of Medicine, and the Division of Pulmonary and Critical Care Medicine (Dr. Gould and Ms. Flavin), Stanford University, Stanford, CA.

Correspondence to: Juliana Barr, MD, Associate Professor of Anesthesia, Stanford University School of Medicine, Anesthesiology Service (112A), VA Palo Alto Health Care System, 3801 Miranda Ave, Palo Alto, CA 94304; e-mail: barrj{at}stanford.edu

Objective: To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients.

Design: Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU.

Setting: The medical-surgical ICUs of two teaching hospitals.

Patients: Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group.

Intervention: Implementation of an evidence-based ICU nutritional management protocol.

Measurement and results: Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (± SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 ± 31.3 vs 11.2 ± 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007).

Conclusion: An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.

Key Words: critical care • enteral nutrition • intensive care • nutrition protocols • nutritional management • outcomes research • parenteral nutrition

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