Enteral Nutrition Care Pathway for Critically-Ill Adult Patients

This ASPEN pathway provides steps and resources for managing critically-ill adult patients requiring enteral nutrition (EN), starting at needs assessment through transition out of the ICU.

Overview of Pathway

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Enteral Nutrition Care Pathway

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Determine EN Appropriateness and Beneficial Effects
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
Complete Nutrition Assessment
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 and Place Enteral Feeding Access Device
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
Select Appropriate EN Formula

Consider the following question for formula selection: Does the patient have specific nutrient needs due to their condition?

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
Prescribe EN Correctly Using Standardized Process
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
Required EN Order Elements
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
Procure, Prepare, and Label the Formula
Formulas are supplied as ready-to-hang, closed-system, large volume bags or containers; smaller volume cans, bags, or cartons; and powdered formula
Understand how the formula is ordered, prepared, and delivered to the bedside
Formulas labels should reflect required order elements and include expiration dates
Ready-to-Hang, Closed-System, Large Volume Bags or Containers
Hang time 24-48 hours
Reduced infection risk
Cannot add modular components
Reduced nursing time
Smaller Volume Liquid Cans, Bags, or Cartons: Open System
Hang time 8 hours
Increased infection risk
May add modular components
Increased nursing time
Powdered Formulas Requiring Preparation
Hang time 4 hours
Increased infection risk
Needs to be prepared in special formula room
Requires sterile water
Increased nursing time
Administer EN Safely and Appropriately
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
Monitor and Reevaluate Patient
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
Initiate Discharge Planning for Transition of Care
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
Enteral Nutrition Quality Improvement Program
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