Authors: (including presenting author): :
Ng SKS(1), Cheung CHS(1), Young YSS(1), Wong DYK(2), Yeung SFS(1), Ng ML(1), Lam YF(1), Miu FPL(1), Tsui KL(1)
Affiliation: :
(1) Department of Medicine, Pamela Youde Nethersole Eastern Hospital
(2) Dietetic Department, Pamela Youde Nethersole Eastern Hospital
Keyword 1: :
Enteral feeding
Keyword 2: :
Cardiac Care Unit
Introduction: :
In the Cardiac Care Unit (CCU), patients face high metabolic demands and haemodynmamic instability. Delayed nutrition support correlates with poor clinical outcomes, yet initiating Enteral Nutrition (EN) is often hindered by concerns regarding tolerance and fluid restriction. International guidelines, including ESPEN and ASPEN, strongly recommend initiating EN within 48 hours of admission to reduce mortality and infection in critically ill patients.
However, in the CCU, adherence to this standard is often compromised. In 2023, an audit at Pamela Youde Nethersole Eastern Hospital revealed that nutritional initiation was inconsistent, with only 17.6% of eligible patients commencing feeding within 48 hours. To address this, a multi-disciplinary Enteral Nutrition Protocol was co-developed by nurses and dietitians and implemented on 1 January 2024.
Objectives: :
1. To standardise EN practice in the CCU for critically ill cardiac patients.
2. To optimise patients' nutrition status in high risk cardiac conditions.
3. To improve timeliness of nutrition support and reduce delay in resuming EN after planned or unplanned interruption.
Methodology: :
The revised protocol shifted from physician's order to a standardised, evidence-based pathway involving:
1. Rapid initiation: Initiating EN within 48 hours for haemodynamically stable patients.
2. Regimen standardisation: Starting full-strength high protein formula at 20 ml/hr via continuous feeding to ensure tolerance, escalating by 10 ml/hr every 4 hours.
3. Safety surveillance: Nurse-led safety bundles including head-of-bed elevation, feeding tolerance assessment, and complications monitoring.
4. Collaborative escalation: Early dietitian consultation for high risk patients, e.g. electrolyte disturbance, strict fluid restriction.
Result & Outcome: :
A comparative analysis of patient data from the pre-implementation (2023) and the post-implementation period (2024-25) demonstrate substantial improvement in service delivery:
1. Early initiation compliance: The rate of patients commencing EN within the critical 48-hour window increased significantly from 17.6% in 2023 to 81.8% post-implementation.
2. Service efficiency: The standardisation of workflow reduced clinical variation, empowering nurses to step up the feeding safely.
3. Optimised metabolic support: By standardising the "start slow, go slow" approach, patients receive earlier caloric support without overwhelming compromised cardiac function. Early nutritional optimisation supported metabolic function and recovery, ensuring patients had the energy reserves necessary for rehabilitation.
