In Our Unit
An Enteral Nutrition Protocol to Improve
Efficiency in Achieving Nutritional Goals
Marian Racco, RN, MSN
I
n our intensive care unit (ICU),
the “traditional order” for enteral
nutrition included 2 pieces of
information:
• Formula
• Starting rate
We were finding that the lack of
standardization of the enteral nutri-
tion order often resulted in patients
getting “stuck” at initiating rates of
30 mL/h because the order was
missing a rate of increase and a goal
rate. Additionally, the traditional
order made no accommodations
for those patients who experienced
elevated gastric residual volumes
(GRVs), resulting in extended with-
holding of feedings. The incomplete-
ness of the traditional order for
enteral nutrition set patients up to
receive suboptimal nutrition.
Inspired by the desire to provide
the best possible nutrition for our
critical care patients, the ICU clinical
coordinator conducted a literature
Author
Marian Racco is the clinical coordinator
of the intensive care unit at Hunterdon
Medical Center in Flemington, New Jersey.
For questions related to this article, contact
Marian Racco at racco.marian@
hunterdonhealthcare.org.
©2012 American Association of Critical-Care Nurses
doi: http://dx.doi.org/10.4037/ccn2012625
72 CriticalCareNurse Vol 32, No. 4, AUGUST 2012
search. It was not surprising that
the literature supported not only
early initiation of enteral nutrition
in critical care patients, but also
timely achievement of nutritional
goals for the most favorable out-
comes for patients. According to the
literature, enteral nutrition proto-
cols facilitate the achievement of
these goals:
• Early enteral nutrition (within
24 to 48 hours) after admis-
sion into ICU is associated
with decreased mortality.1-3
• Actual delivery of 60% to 70%
of enteral feeding goals within
the first week of ICU admission
is associated with a shortened
length of stay, shorter duration
of mechanical ventilation, and
fewer infectious complications.4
• Use of enteral feeding proto-
cols in ICUs promotes earlier
initiation of enteral feedings,
increases the volumes of feed
delivered, optimizes number
of calories received, and results
in shorter hospital stays and
improved morbidity and mor-
tality outcomes.5
• In using enteral feeding pro-
tocols, the incorporation of
prokinetic agents at initiation
and tolerance of a higher GRV
(250 mL) should be considered
as a strategy to optimize deliv-
ery of enteral nutrition in criti-
cally ill adult patients.1,4
• Protocols, algorithms, and
clinical practice guidelines
have been developed to stan-
dardize enteral feeding prac-
tice, and many have resulted
in an improvement in the
delivery of enteral feedings to
patients.1,6
Based on the findings of the
literature review, the ICU clinical
coordinator designed an enteral
nutrition protocol order set to
address and correct the challenges
we faced with the traditional initia-
tion and delivery of enteral feedings
(see Figure—available online only at
www.ccnonline.org). The protocol
still required a physician’s order,
but features designed to improve
efficiency were built into the proto-
col, including the following:
• Starting rate and incremental
increase in rate, based on
patient’s tolerance
• Goal rate as set by dietitian
• Bowel management program
• Prokinetic agent was built into
the order if the patient experi-
enced 3 consecutive elevated
GRVs
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 The inclusion of these entities in
the order set was designed so that
the critical care patient receiving
enteral feedings would have every
chance to achieve target rates with-
out unnecessary delay.
The order set was presented to
our ICU Quality Improvement Com-
mittee and the ICU Committee for
approval and input from committee
members, including the ICU med-
ical director, registered dietitian, ICU
nurse director, and representatives
from the quality improvement depart-
ment. Once approved, it was impor-
tant to educate workers in those
disciplines that would be directly
involved in its use:
• Intensivists
• ICU nurses
• Pharmacy staff
• Registered dietitians
Education was focused on the
major points in the protocol that
were a change in current practice,
such as
• Built-in progressive rate
increase
• Built-in bowel regimen
• Prokinetic agent
• Protocol requires physician’s
order to initiate, but registered
dietitian to set the goal
As is frequently the case with
change, it takes time for the team to
regularly incorporate the change into
their practice. Regular use of the
enteral nutrition protocol order set
was no different. Intensivists would
sometimes forget to use it and resort
to the traditional method of ordering
enteral feedings. This however, pro-
vided an opportunity for the ICU
clinical coordinator to compare both
methods directly in terms of their
efficiency in achieving nutritional
goals. The procedure was as follows:
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Table Comparison of results with and without use of enteral nutrition protocol
Enteral nutrition protocol
Result
Mean time to reach goal
rate in patients without
elevated GRV, hours
Mean time to reach goal
rate in patients with
elevated GRV, hours
Compliance in using
“built-in” prokinetic
agent in patients with
elevated GRV, %
Abbreviations: GRV, gastric residual volume; NA, not applicable.
• The ICU enteral nutrition
protocol order sets were
stocked in the bins in each
patient’s room.
• During the nutrition portion
of the morning rounds discus-
sion, the intensivist could initi-
ate the enteral nutrition protocol
or initiate enteral feedings in
the traditional method. Round-
ing ICU nurses and the ICU
clinical coordinator were
encouraged to remind the
intensivists of the protocol.
• If the intensivist activated the
protocol, the dietitian would
immediately write in the appro-
priate goal for the patient.
• The order set would be scanned
and sent to the pharmacy in
the same manner as all other
orders, and the bowel regimen
and the prokinetic agent
would then be included in the
patient’s medication adminis-
tration record.
Data collection was completed
by the ICU clinical coordinator.
Chart reviews were done on patients
receiving enteral feedings. Data col-
lected for both patients on the
enteral nutrition protocol and
Traditional method
(n = 23) (n = 13)
12 34
56.5 72
75 N/A
Prokinetic agent used but
initiation delayed
patients receiving enteral feedings in
the traditional manner included the
following:
• Mean time to reach goal rate in
patients without elevated GRV
• Mean time to reach goal rate
in patients with elevated GRV
• For patients on the protocol
and with elevated GRV, compli-
ance with the built-in proki-
netic agent use was measured
• For patients receiving enteral
feedings in the traditional
manner and with elevated
GRV, it was noted if a proki-
netic agent was used at all
A total of 36 patients were
reviewed. Twenty-three patients sur-
veyed were on the enteral nutrition
protocol, and 13 patients received
enteral feedings in the traditional
manner (see Table).
The enteral nutrition protocol
was more efficient in achieving
nutritional goals than the tradi-
tional method of initiation and
delivery of enteral feedings in criti-
cal care patients, as evidenced by
the following:
• Protocol patients without
elevated GRV reached goal
rates in about one-third the
Continued on page 75
CriticalCareNurse Vol 32, No. 4, AUGUST 2012 73
 time of nonprotocol patients patients. J Am Diet Assoc. 2006;106(8):
1226-1241.
(12 hours vs 34 hours). 5. Dobson K, Scott A. Review of ICU nutrition
support practices: Implementing the nurse-
• Protocol patients with ele- led enteral feeding algorithm. Nurs Crit Care.
vated GRV reached goal rates 2007;12(3):114-123.
6. Marshall AP, West SH. Enteral feeding in
16 hours sooner than nonpro- the critically ill: Are nursing practices con-
tributing to hypocaloric feeding? Intensive
tocol patients (56.5 hours vs Crit Care Nurs. 2006;22(2):95-105.
72 hours).
• Protocol patients were started
on the prokinetic agent after 3
consecutive elevated GRVs
75% of the time. Only 1 patient
receiving enteral feedings in
the traditional manner experi-
enced elevated GRV. It took
almost 3 days of feeding intol-
erance before a prokinetic agent
was started for that patient.
In our ICU, initiating an enteral
nutrition protocol has enabled our
patients to achieve nutritional goals
sooner than the standard method of
initiation and delivery of enteral
feedings. This is significant as the
literature supports early nutrition
in the critical care environment
because it decreases infectious com-
plications, duration of mechanical
ventilation, length of stay, and mor-
bidity and mortality. CCN

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Financial Disclosures
None reported.

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