New Process Improves Enteral Nutrition, Nursing Workflow

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.

— Source: American Association of Critical-Care Nurses