Enteral Nutrition Care Pathway for Critically-Ill Adult Patients

Determine if GI tract is functional, bowel sounds not necessary

Assess that patient is unable to take sufficient oral nutrition

EN provides beneficial effects including decreased infection over PN

Assess for presence of malnutrition

Determine nutrient and therapy goals including macro- and micronutrient and fluid needs

Assess organ function and if it impacts nutrient dosing

Assess for current enteral access and its appropriateness for current clinical condition

Determine aspiration risk and need for small bowel versus gastric feeding

If needed, place small-bore naso-enteric feeding tube with desired gastric or small bowel tip location

Confirm proper tube placement prior to feeding

High caloric requirements and/or fluid restriction - Select a more fluid restricted, energy dense formula

Surgical or trauma patients - Consider use of an immunomodulating formula

Persistent diarrhea - Consider use of a mixed fiber-containing formula

Suspected of malabsorption or lack of response to fiber - Consider a small-peptide formula

Renal impairment - Consider use of an electrolyte altered formula

If none of the above, consider use of a standard formula

Use Computerized Provider Order Entry (CPOE) if available

Use computerized Clinical Decision Support (CDS) tools including algorithms and alerts

Prescribe formula, administration rate or method, and daily volume

Use volume based feeding protocols

Prescribe continuous or intermittent delivery methods as appropriate

Patient information

Formula name (generic and /or trade name)

Delivery site (route) and enteral access device

Administration method and rate

Nurse-driven EN protocols for volume-based feeding

Communicate order to department that supplies EN formulas

Perform hand hygiene and wear gloves

Confirm proper tube placement

Confirm correct formula and verify patient’s name on label; match all components listed on the label against the EN order including route of administration, infusion rate, and expiration date and time

Verify patient identification

Maintain patient head of bed (HOB) up at 45 degrees

Initiate EN infusion

Advance as tolerated using protocols

Deliver medications safely

Initiate monitoring protocol

Evaluate efficacy and goals of therapy

Alter formula, rate, or volume as needed

Document tolerance and advancement to goal feedings

Do not use gastric residual volumes as part of routine care to monitor ICU patients receiving EN

Reassess nutritional status periodically

Identify new care setting

Identify prescriber and new care team

Assess enteral access and if long term access is needed, place gastrostomy, jejunostomy or combined G/J as needed

Determine if patient continues to need current EN prescription

Communicate EN order, labs, frequency, and monitoring parameters to new care team

Develop error reporting program within institution QI/QA department

Implement infection control for EN handling

Monitor use of appropriate EN in ICU population

Monitor tolerance to EN and use of supplemental PN in ICU population

Measure percent of nutrient requirements received by patients