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Updated Process Improves Enteral Nutrition, Workflow

Feb 01, 2024

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Article in Critical Care Nurse describes how UAB Hospital in Alabama changed its protocols to eliminate routine gastric residual volume monitoring and use a focused nursing assessment instead


ALISO VIEJO, Calif. - Feb. 1 2024 – When clinical practice guidelines change, revising policies and educating staff about the updates requires a focused approach driven by evidence.

Routine monitoring of gastric residual volume (GRV) has been a long-standing practice to measure the volume of content in a patient’s stomach and identify enteral feeding intolerance, a common complication that can interrupt the patient’s prescribed nutritional needs. But the practice has never been standardized, and thresholds and definitions vary. In addition, results can be inconsistent and delivery of enteral nutrition is frequently interrupted.

Clinical practice guidelines published by the American College of Gastroenterology and jointly published by the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition now recommend that routine GRV monitoring be eliminated and replaced with a focused nursing assessment for signs and symptoms of enteral feeding intolerance, such as vomiting, abdominal distention and abdominal pain.

In response to the updated guidelines, the 25-bed medical intensive care unit (MICU) at UAB Hospital, part of University of Alabama at Birmingham, developed a quality improvement project to replace routine GRV monitoring and modify its current nursing practice. The overall goals were to improve delivery of enteral nutrition and ultimately decrease complications related to malnutrition in critically ill patients.

Deimplementation of Gastric Residual Volume Monitoring to Enhance Patient Nutrition” details the three-phase approach to a smooth transition and implementation of the new guidelines throughout the MICU service, which includes other units that provide care to MICU patients. The study is published in Critical Care Nurse (CCN).

Author Hannah Landgrave, DNP, RN, CCRN, CNE, is an assistant professor at Moffett and Sanders School of Nursing, Samford University, Birmingham, Alabama, and a critical care nurse in the MICU.

“Changing healthcare practice can be slow, but this project demonstrates how a relatively simple change can make a significant impact,” she said. “Our study shows that eliminating routine GRV monitoring can increase delivery of enteral nutrition, improve nursing workflow and positively impact patient outcomes. It’s a change that is long overdue.”

The initial phase of the project focused on updating the electronic health record (EHR) to eliminate existing orders for routine GRV monitoring and add new orders to pause enteral nutrition in patients with signs and symptoms of enteral feeding intolerance. The modifications were placed in an order set, or power plan, and made available in the EHR for clinicians. A dropdown box was also added to the section for nurses to document that enteral feeding was suspended and note indications of feeding intolerance.

The second phase focused on staff education about the current evidence and new process, occurring over multiple weeks and across shifts. Attending physicians and advanced practice providers received written instructions about how to order the new power plan. MICU nurses received more specific information about the changes in nursing practice and EHR documentation. Nursing staff also received a brief overview via email and printed handouts. Verbal education during shift huddles or staff meetings reinforced the information.

During the final phase, the MICU implemented the new power plan and practice change. To evaluate the project’s effectiveness, the research team looked at data from patients who received enteral feedings and were admitted to the MICU for at least seven days between the first day of full implementation, Jan. 28, 2021, through March 11, 2021.

Of the 54 patients admitted to the MICU service who received enteral feedings, 37 met the evaluation criteria. On day 7 after admission, 28 had gained weight. Four patients had lost less than 1% of body weight from baseline, indicating no malnutrition. Five patients had lost more than 2% of body weight from baseline, indicating severe malnutrition.

Only two of the 37 patients were on the MICU service for 30 days. One patient gained weight, while the other lost more than 5% of body weight from baseline.

In addition, a survey of nursing staff found that 81% of the 83 respondents thought patient nutrition had improved, and 95% reported improved nursing workflow.

Changes to the EHR also allowed nursing staff to document pauses in enteral feedings and the specific signs and symptoms of enteral feeding intolerance. During the six-week study period, nurses documented 66 instances of enteral feeding intolerance. Of those, 37 were for abdominal distention, 28 for vomiting and one for abdominal pain.

After the six-week project, meetings with physicians and nursing leaders led to full deimplementation of routine GRV monitoring throughout the hospital within three months. The process included creation of an algorithm to guide nursing staff when patients developed signs and symptoms of enteral feeding intolerance. As part of the change, the power plan in the EHR was modified accordingly, the policy and procedure were updated in the hospital’s online database, and educational materials were provided to nurses.

As the American Association of Critical-Care Nurses’ bimonthly clinical practice journal for acute and critical care nurses, CCN is a trusted source of information related to the bedside care of critically and acutely ill patients. Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The award-winning journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in acute, progressive and critical care settings. CCN enjoys a circulation of about 130,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: For more than 50 years, the American Association of Critical-Care Nurses (AACN) has been dedicated to acute and critical care nursing excellence. The organization’s vision is to create a healthcare system driven by the needs of patients and families in which acute and critical care nurses make their optimal contribution. AACN is the world’s largest specialty nursing organization, with about 130,000 members and nearly 200 chapters in the United States.

American Association of Critical-Care Nurses, 27071 Aliso Creek Road, Aliso Viejo, CA 92656; 949-362-2000; www.aacn.org; facebook.com/aacnface; twitter.com/aacnme