Performance Improvement Tools

Critical Care Nutrition Process Improvement Indicator Template

Efforts to identify and improve challenging areas in the delivery of critical care nutrition can be achieved through the performance improvement process. Identification of critical care nutrition processes (what is done and how it is done) and where improvements can be made will only strengthen the delivery of care to promote positive outcomes. The following process indicators cover a variety of aspects of critical care nutrition and are aligned with key recommendations from the 2016 ASPEN/ACCM Critical Care Nutrition Guidelines. Managers and clinicians can choose several of these indicators based on overall critical care nutrition goals. An indicator can be assessed for whatever time period best suits the institution. Results will guide definitive action, if necessary with resultant re-monitoring for improvement.

Process Indicators to Utilize for Assessing Malnutrition Processes

A= Indicator
B= Component of care addressed
C= Goal of compliance

Recommendation: Nutrition support therapy in the form of early enteral nutrition (EN) should be initiated within 24 -48 hours in the critically ill patient who is unable to maintain volitional intake 

a. Percentage of admitted patients unable to maintain volitional intake (with a functional gastrointestinal tract) who have EN initiated within 24 - 48 hours of admission.
b. Identifies whether early EN initiation is being achieved.
c. Goal: 90%

Recommendation: Patients determined to be at high nutrition risk or who are severely malnourished should be advanced towards goal as quickly as tolerated over 24-48 hours 

a. Percentage of patients at high nutrition risk or severe malnutrition who achieve goal energy and protein requirements within 24-48 hours following EN initiation.
b. Identifies if goal energy and protein intakes via EN are being achieved in high risk or malnourished patients.
c. Goal: 90%

Recommendation: In those ICUs where gastric residual volume measurements (GRVs) are still utilized, holding EN for GRVs <500 mL in the absence of signs of intolerance should be avoided.

a. Percentage of patients receiving EN who have feedings held for GRV’s < 500 mL without signs of EN intolerance.
b. Identifies if EN feedings are being inappropriately held for elevated GRV’s.
c. Goal: <10%

Recommendation: Inappropriate cessation of EN should be avoided.

a. Percentage of patients receiving EN with greater than one hour per day of interrupted enteral feeding.
b. Identifies whether cessation of feedings is significantly impacting EN delivery.
c. Goal: <20%

Recommendation: In patients determined to be at high nutrition risk or who are severely malnourished and unable to receive EN, exclusive PN should be initiated as soon as possible following ICU admission.

a. Percentage of high risk or severely malnourished patients unable to receive EN who have parenteral nutrition (PN) initiated within 24-48 hours following ICU admission.
b. Identifies whether high risk or malnourished patients are being started on PN if EN is not feasible.
c. Goal: 90%

Recommendation: In patients receiving parenteral nutrition, hypocaloric PN dosing (≤ 20 kcals/kg/day or 80% of estimated energy needs) with adequate protein (≥1.2 g protein/kg/day) over the first week of hospitalization should be utilized.

a. Percentage of patients receiving PN in the ICU who receive 80% of estimated energy requirements or ≤ 20 kcals/kg/day and a minimum of 1.2 g protein/kg/day.
b. To capture use of hypocaloric PN dosing.
c. Goal: 90%

Recommendation: Target blood glucose range of 140 – 180 mg\dL for the general ICU population.

a. Percentage of general ICU patients who achieve a blood glucose range between 140 and 180 mg/dL.
b. To capture patients achieving desired blood glucose control.
c. Goal: 90%

Recommendation: Immune-modulating formulations containing arginine and fish oil should be considered in severe trauma and traumatic brain injury (TBI).

a. Percentage of trauma and/or TBI patients who receive an immune-modulating formulation.
b. To capture trauma and/or TBI patients receiving recommended enteral formula.
c. 90%

Recommendation: Immune modulating formula containing both arginine and fish oils in the Surgical Intensive Care Unit (SICU) for the post-operative patient who requires EN therapy.

a. Percentage of SICU post-operative patients who received an immune-modulating formulation.
b. To capture post-operative SICU patients receiving recommended enteral formula.
c. 90%

Recommendation: High-protein hypocaloric feeding should be implemented in the care of obese ICU patients – protein should be provided in the range of 2 g/kg ideal body weight (BMI 30-40) and 2.5 g/kg in BMI ≥40.

a. Percentage of obese patients receiving hypocaloric high protein nutrition regimen achieve desired protein intake.
b. To capture hypocalorically fed obese patients who achieve desired protein intakes.
c. 95%