Authors: (including presenting author): :
Man CHM(1), Luk CW(1), Chan CSS(1), Tse KYG(1), Yu SYJ(1), Yeung WTA(1)
Affiliation: :
(1)Intensive Care Unit, Department of Medicine & Geriatrics, Ruttonjee & Tang Shiu Kin Hospitals
Keyword 1: :
Enteral Nutrition
Keyword 2: :
Feeding Protocol
Keyword 3: :
Feeding Intolerance
Keyword 4: :
Less Interruption
Keyword 5: :
Patient safety
Keyword 6: :
Symptom-Based
Introduction: :
Routine monitoring of gastric residual volume (GRV) has traditionally been used to assess feeding tolerance in Intensive Care Unit (ICU) patients receiving enteral nutrition (EN). In the ICU of Ruttonjee & Tang Shiu Kin Hospitals (RTSKH), GRV was aspirated every four hours with a threshold of 160 mL, triggering feeding rate reduction, partial refeeding with discarding of excess volume, and administration of prokinetic agents. Emerging evidence suggests that GRV based feeding management may result in unnecessary interruption of EN, reduced caloric delivery, increased use of prokinetic agents, and no demonstrable reduction in aspiration related complications or ventilator-associated pneumonia. This discrepancy between evidence and local practice prompted a continuous quality improvement (CQI) initiative to revise the ICU enteral feeding protocol.
Objectives: :
This CQI project aimed to compare a GRV-based feeding protocol with a symptom-based feeding protocol in terms of the frequency of enteral feeding interruption and the incidence of feeding intolerance in ICU patients receiving EN.
Methodology: :
This project was conducted as a before-and-after study in the ICU of RTSKH. ICU patients receiving EN via a nasogastric tube or percutaneous enterogastric tube were included. Baseline data were retrospectively collected for the six-month period immediately prior to protocol revision, during which routine GRV monitoring guided feeding management. Following an evidence-based literature review, the enteral feeding protocol was revised to eliminate routine GRV monitoring and adopt a symptom-based assessment of feeding tolerance. Post-implementation outcomes were evaluated over a subsequent six-month period. Enteral feeding patient days were calculated as the total number of calendar days during which patients received EN at any time. The primary outcome measure was the frequency of enteral feeding interruption, defined as cessation of EN for ≥1 hour due to suspected feeding intolerance. The secondary outcome measure was the incidence of feeding intolerance, classified as severe (abdominal distension, abdominal pain/tenderness, bloating, vomiting) or mild (nausea, constipation, diarrhoea, excessive ostomy output). Severe intolerance was counted as an episode when documented, while mild intolerance was counted only when it resulted in clinical intervention related to enteral feeding. Outcomes were expressed as episodes per 100 enteral feeding patient days.
Result & Outcome: :
During the post-implementation period, approximately 730 enteral feeding patient days were included. Compared with the six-month baseline period, the frequency of enteral feeding interruption was reduced by approximately 70% following elimination of routine GRV monitoring. The incidence of feeding intolerance remained similar between the pre-and post-implementation periods, with no observed increase after adoption of the symptom-based feeding protocol. This CQI initiative demonstrates that replacing a GRV-based enteral feeding protocol with a symptom-based approach in an adult ICU setting substantially reduces unnecessary feeding interruptions without increasing feeding intolerance. Aligning enteral feeding practice with current evidence supports safer and more consistent nutritional delivery. Continued outcome monitoring is recommended to sustain quality improvement in ICU nutritional care.
