Background: Nutritional support of critically ill patients is an important aspect of critical care. The American Society of Parenteral and Enteral Nutrition (A.S.P.E.N.) and the Society of Critical Care Medicine have developed guidelines for enteral nutrition reflecting the latest evidence-based practice. the guidelines recommended early nutritional support, utilization of protocols, and enteral nutrition (EN) as the preferred choice of nutritional support. The Institute of Medicine also recommends utilization of evidence-based practice, guidelines, and protocols for health care delivery. Foreground: Despite these recommendations, the Medical Intensive Care Unit (MICU) of a community based Magnet recognized hospital had not implemented the guidelines. Incidental observations noted during multidisciplinary rounds in the MICU and a performance improvement review found variability related to ordering and management of EN. These findings supported implementation of an evidence-based EN protocol. Methods: A system change project was implemented with the support of providers, staff, and administration of the MICU. The project consisted of implementation of an EN order form and algorithm for management of gastric residual volumes (GRV). The objectives focused on clinical adherence, the amount of EN received, and the time frame that EN was temporarily discontinued. The objectives and outcomes of the study were related to clinician adherence, but the ultimate outcome was improved nutrition for the MICU patients. Evaluation of the project was based on chart reviews comparing similar groups pre- and post-implementation and focus groups with staff and providers. Evidence-Based Practice (EBP) Framework: To direct and develop the project two theoretical frameworks were utilized. Rogers’ Diffusion of Innovation Theory guides the diffusion of new ideas and provided a general framework. Larrabee’s Model for Change to Evidence-Based Practice was also utilized as it provides a framework specific to implementing EBP. Findings/Results: Clinical adherence to overall utilization of the EN protocol was 67%, which exceeded the project goal. There was a reduction in the time that EN was started in the post implementation group, but it was not statistically significant. There was a statistically significant reduction in the time the patients’ reached their feeding goal rate after EN was implemented. The average time was reduced from 35 to 18.5 hours, with 74% of the patients reaching their goal rate within 24 hours. Conclusions/Recommendations: Implementation of the ENN protocol has positively implacted the nutritional support patients are receiving in the MICU and SICU of the community hospital. The guidelines and protocol provide consistency in the care of the patients. Professionals in the MICU and SICU want to provide the best quality care and the EN protocol provides the avenue to do that. Recommendations for the future involve expansion of the EN protocol use to all adults patient care areas in the community hospital, as well as the hospital system. Also increasing the amount of GRV in which feedings are temporarily discontinued, from the 200mL utilized during the project to 300mL will more closely align with the guidelines.
