Abstract
Introduction
Severe burn injuries are characterized by elevated metabolic demands. Numerous studies have documented iatrogenic underfeeding of critical care patients, which can lead to malnutrition, impaired wound healing, weakened immune response, and increased risk of infections. Enteral nutrition (EN) support is often utilized to help meet the increased caloric demands of burn patients. However, discrepancies between prescribed and delivered EN can occur due to frequent interruptions, delays initiating EN, gradual advancement of EN rate, and/or physician directed changes. The objective of this quality improvement project is to assess whether a proactive calculation of EN regimens can improve the provision of calories compared to a traditional calculation method.
Methods
A retrospective review of patients in a pediatric acute burn unit that received continuous EN for greater than three days was performed. The pre-protocol group consisted of patients from January 1st, 2017 to November 30th, 2017 who had continuous EN rates calculated by the dietitian based on 24 hours per day. This group was compared to patients from September 1st, 2018 to July 31st, 2019 who had EN rates calculated by the dietitian based on 23 hours per day (post-protocol group). Periods in which parenteral nutrition was administered or the EN regimen was prescribed in a non-continuous fashion were excluded. The primary outcome measure was the percentage of admissions in which patients met at least 85% of calorie estimations. This project was undertaken as a Quality Improvement initiative and, as such, was not formally supervised by an Institutional Review Board.
Results
A total of 132 patients (73 pre- and 59 post-protocol) from 134 separate inpatient admissions (73 pre- and 61 post-protocol) were identified. The average total body surface area burn was 40.9% (SD 18.8) vs. 49.4% (SD 19.8) and average age was 8.6 years (SD 5.9) vs. 7.9 years (SD 5.4) in the pre- and post-protocol groups, respectively. Continuous EN ran for an average of 20 hours a day (SD 2.2, median = 21) vs. 21 hours a day (SD 2.7, median = 22) in the pre- and post-protocol groups, respectively. The average number of days on continuous EN was comparable in both groups. The post-protocol group had 75% of admissions meet at least 85% of calorie estimations compared to the pre-protocol group with 52% of admissions having met the goal.
Conclusions
Due to the heightened metabolic demands of burn patients and the barriers to meeting caloric goals, it is important to minimize calorie deficits with EN support. Although a seemingly small change, calculating continuous EN rates based on 23 hours per day can yield improved caloric provisions compared to rates based on 24 hours per day.
Applicability of Research to Practice
A proactive approach to calculating continuous EN support should be considered to help decrease caloric deficits.
Quality improvement project to optimize enteral nutrition in a tertiary hospital's surgical ICU
