Original Communication

Journal of Parenteral and Enteral

Nutrition
Volume-Based Protocol Improves Delivery of Enteral Volume 44 Number 5
July 2020 874–879
Nutrition in Critically Ill Trauma Patients 
C 2019 American Society for

Parenteral and Enteral Nutrition

DOI: 10.1002/jpen.1711
wileyonlinelibrary.com

Gaurav Sachdev, MD1 ; Kehaulani Backes, RD2 ; Bradley Winston Thomas, MD1 ;
Ronald Fong Sing, DO1 ; and Toan Huynh, MD1

Abstract
Background: Critically ill patients on enteral nutrition (EN) often do not receive goal nutrition support. Factors impeding delivery
of EN include interruption for procedures, tube dislodgement, and high gastric residuals. A volume-based feeding protocol (VP) is
designed to adjust the infusion rate to compensate for interruptions. We hypothesize that implementation of a VP would increase
delivery of EN over the conventional hourly rate method (CM). Methods: This study compared patients on CM to those on VP.
The primary outcome measured was percentage of goal EN delivered during the entire intensive care unit (ICU) stay. Inclusion
criteria for the study consisted of patients aged >18 years, traumatic mechanism of injury and admission to the ICU >72 hours,
hemodynamic stability to receive EN per the trauma ICU standard of practice, and EN via nasogastric or post-pyloric feeding tube.
Results: We evaluated 227 patients over a 20-month period. Seventy-nine patients in the VP group were compared with the control
group of 148 patients. Patients on VP received a significantly higher percentage of goal EN than those on CM (73.3% vs 65%,
P = .0002). There was no difference in the incidence of diarrhea (CM 4.16% vs VP 5.19%; P = .29) or tube dislodgment (CM
2.04% vs VP 1.61%; P = .51). Conclusion: Implementation of a VP significantly increased delivery of EN by 8.3% over that given
by the CM in critically ill trauma patients with no difference in feeding-related complications. (JPEN J Parenter Enteral Nutr.
2020;44:874–879)

Keywords
critically ill; enteral nutrition; trauma; volume-based feeding

Clinical Relevancy Statement
Malnutrition in trauma patients results in significant mor-
bidity and mortality. Inadequate feeding results in poor
clinical outcomes in critically ill patients. The presence of
an enteral feeding protocol is associated with significant
improvements in nutrition delivery. Intermittent feeding
regimens have achieved feeding goals earlier than continu-
ous feeds in critically ill patients. A volume-based feeding
protocol has been shown to safely achieve target daily
tube feed goals. The purpose of this study is to observe if
implementation of a volume-based feeding protocol may
improve goal delivery of enteral nutrition without associ-
ated complications.
Background
Nutrition support was historically considered adjunctive
care in the intensive care unit (ICU). More recently, nutri-
tion support has become a therapeutic priority to combat
the catabolism and negative nitrogen balance from the
systemic inflammation of critical illness. The subsequent
malnutrition results in significant morbidity, worsening sys-
temic inflammation, and a catabolic state. Increased intakes
of energy and protein correlate with improved clinical out-
comes in critically ill patients.1 Inadequate nutrition support
may lead to nosocomial bloodstream infections,2 whereas
early enteral nutrition (EN) may reduce the incidence of
major complications.3
From the 1 Department of Surgery, Carolinas Medical Center, Atrium
Health, Charlotte, North Carolina, USA; and 2 Clinical Nutrition,
Carolinas Medical Center, Atrium Health, Charlotte, North
Carolina, USA.
Financial disclosure: None declared.
Conflicts of interest: B. W. Thomas is an educational consultant for
Zimmer Biomet for rib fixation.
R. F. Sing has received research grants and served as an educational
consultant for Cook Medical, CR Bard, Bio2Med, and Argon
Medical for his work on IVC filters.
Received for publication March 15, 2019; accepted for publication
August 28, 2019.
This article originally appeared online on September 18, 2019.
Corresponding Author:
Gaurav Sachdev, MD, FACS, Assistant Professor, Acute Care Surgery,
Carolinas Medical Center, Atrium Health, Medical Education
Building, 6th Floor, 1000 Blythe Blvd., Charlotte, NC 28232, USA.
Email: gaurav.sachdev@atriumhealth.org
Sachdev et al
Despite recent recommendations to provide nutrition
therapy for critically ill patients, variability still exists in
practice.4 Evidence-based protocols have been shown to
increase the efficiency in which nutrition therapy is deliv-
ered to ICU patients.5 Nutrition management protocols
have also been shown to reduce duration of mechanical
ventilation and risk of death.6 Institutions utilizing enteral
feeding protocols have shown significant improvements in
nutrition practice compared with facilities that do not use
such an approach.7 The multisystem injured trauma pop-
ulation provides unique challenges for nutrition support.
Not uncommonly, these patients require multiple operations
on consecutive days, such as repeat debridement of soft
tissue injuries, orthopedic procedures, recurrent abdominal
operations, and diagnostic studies (computed tomography
scans). There are limited data on use of EN protocols in
the trauma patient population. However, severely injured
trauma patients have exhibited good tolerance to EN when
managed using a standardized protocol.8
Our institution is an American College of Surgeons–
verified Level I trauma center with a 29-bed surgical trauma
ICU (STICU) and dedicated dietitian. Nutrition therapy
is prescribed using an evidence-based protocol, utilizing
a conventional EN delivery method at a flat hourly rate.
This rate is calculated based on need using a simplistic
weight-based equation as recommended by the American
Society for Parenteral and Enteral Nutrition (ASPEN)
guidelines.9 Despite having an evidence-based protocol,
historical delivery remained at 65% of prescribed enteral
therapy at our institution. The ASPEN/Society of Critical
Care Medicine guidelines recommend providing at least
80% of prescribed nutrition to critically ill patients.9 This
variance is likely secondary to this unique population of
multiply injured trauma patients since they experience more
frequent interruptions. If EN is withheld for several hours,
there is no method for the lost time to be recovered after
interruption in a conventional prescribed EN feeding rate.
To account for these interruptions, a volume-based pro-
tocol (VP) is prescribed as a daily total goal volume (eg,
1800 mL/day). The hourly rate is subsequently calculated
and adjusted by the bedside critical care nurse. In a fea-
sibility study, a VP was trialed in a single ICU, evaluated
for safety and feasibility by ICU nurses. This pilot study
found that a VP is safe, may be associated with enhanced
delivery of EN, and has similar feeding-related complica-
tions as a conventional method (CM).10 A separate study
implemented a VP in 18 ICUs with low EN delivery and
found increased delivery of EN compared with the control
group with similar feeding-related complications between
the 2 groups.11 This has not been studied extensively in a
trauma ICU population, in which interruptions are more
frequent. We hypothesized a VP improves delivery of EN
to trauma ICU patients without increasing feeding-related
complications.
875
Methods
Data were prospectively collected from September 2013 to
April 2015. This collection involved a dedicated STICU
dietitian manually recording volume delivery data from each
bedside feeding pump. The data were recorded using a
REDCap (Research Electronic Data Capture) database.12
This project was submitted to our institutional review board
and was determined to function as a quality improvement
project. The control group consisted of patients who were
fed using a CM during a baseline period from September
2013 to June 2014. The intervention group consisted of
patients who received a VP during a period from June 2014
to April 2015. Patients during the study period who were
inadvertently not enrolled in VP group were analyzed in the
CM group. The data were also reanalyzed by excluding these
missed patients from the CM group. The data were analyzed
comparing patients on CM only during the baseline period
and on VP during the study period.
The VP was designed to adjust the hourly infusion
rate to compensate for interruptions. The protocol con-
tained specific guidelines for the bedside nurse that included
time to start EN, protein supplementation, checking gas-
tric residuals, and titration of hourly tube feeding goal
(Appendix 1). During the baseline period, a nurse educator
provided education for STICU bedside nurses. This in-
cluded a multiple-choice questionnaire to ensure the bedside
nurses achieved competence in the protocol. During the
study period, additional education was required secondary
to high turnover and decreased compliance. This included
increased frequency of in-service sessions by our dietitian
and nursing educator, morning huddle reinforcement, and
education of newly employed nurses.
Nutrition therapy was calculated based on individual
energy and protein needs using simplistic weight-based
equations as recommended by the 2016 ASPEN guidelines.9
These equations include energy calculation of 25 kcal/kg,
with adjustments for patients with obesity (11–14 kcal/kg
actual weight for body mass index [BMI] 30–50, and 22–25
kcal/kg ideal body weight for BMI >50), and protein
calculation of 1.2–2 g/kg/d, with an adjustment of up to 2.5
g/kg ideal body weight for critically ill individuals with a
BMI >40. The ASPEN guidelines further specify a range of
20–35 kcal/kg for the trauma population, suggesting lower
energy provision for those in the early/resuscitative phase,
and liberalizing energy delivery as the patient enters the
recovery or rehabilitation phase. The goal rate of infusion
may vary on a daily or weekly basis based on the use of
certain medications (eg, propofol, vasopressors) or based
on reevaluation of energy/protein needs based on patient
status changes (eg, initiation of dialysis, development of
pressure injuries, necessity of surgical interventions). The
most commonly prescribed tube feeding formula was a
1.5 kcal/mL, immune-modulating, high-protein formula
876
containing whey protein. This formula was often beneficial
in meeting higher protein needs without the use of protein
modulars and complied with the ASPEN guidelines of
utilizing immune-modulating formulas for patients with
severe trauma.
Inclusion criteria for the study consisted of patients aged
>18 years, traumatic mechanism of injury and admission
to the ICU >72 hours, hemodynamic stability to receive
EN per the trauma ICU standard of practice, and EN
via nasogastric or post-pyloric feeding tube. We excluded
patients aged <18 years, patients not receiving EN, hemody-
namic instability or vasopressor use, intrabdominal injury
requiring bowel anastomosis, orthopedic or spine surgery
prohibiting head of bed >30°, noninvasive positive pressure
ventilation, and ICU length of stay (LOS) <72 hours.
Demographic data included age, gender, BMI, Injury
Severity Score (ISS), mechanism of injury, hospital and ICU
LOS, and ventilator days. Enteral data collected included
location of tube feeds (stomach, duodenum), daily protein
and caloric goals, daily tube feed goals, hourly rates pre-
scribed, and episodes of diarrhea, aspiration, pneumonia,
and emesis. See Table 1.
We retrospectively queried our Trauma Quality Improve-
ment Program (TQIP) database to compare the outcomes
between the CM and VP groups. Differences in demo-
graphics, ISS, ICU LOS, ventilator days, hospital LOS, and
hospital survival were examined.
Data were analyzed using standard statistical methods.
Descriptive statistics including means and standard devia-
tions, or counts and percentages, were used to describe the
study population on all variables. For continuous variables,
comparisons were made between groups using Student’s
t-tests. For categorical variables, comparisons were made
using χ 2 . P-value < .05 was considered significant.
Results
Of the 251 patients, 227 patients met inclusion criteria.
Data were collected over a 20-month period, which was
2264 patient days on EN. Interruption of EN occurred at
a rate of 16% or 366 of total patient days. Reasons for
interruption included procedures (5.6%, 126 days), diarrhea
(4.3%, 97 days), tube dislodgement (1.8%, 24 days), and
emesis (1.1%, 31 days) (Figure 1). Patients on VP received
a significantly higher EN delivery than those on CM (73.3%
vs 65%, P = .0002). Only 32% of patients on VP and 17% of
patients on CM achieved >80% of their prescribed nutrition
therapy. Patients on both arms of the study were receiving
EN for a similar number of days (VP: mean 8.79, median
8; CM: mean 8.84, median 8). There was no difference
regarding incidence of diarrhea (VP 5.2% vs CM 4.2%;
P = .29) or tube dislodgement (VP 1.6% vs CM 2.0%;
P = .51). The VP group had a lower incidence of emesis (VP
0.1% vs CM 1.4%; P = .006). We encountered 7 episodes
Journal of Parenteral and Enteral Nutrition 44(5)
of aspiration/pneumonia, which were all in the CM group.
There were 51 patients during the study period that missed
being enrolled in the VP arm. These patients were excluded
from the results and reanalyzed to show a similar delivery
of EN between VP and the baseline period only CM (73.3%
vs 65%, P = .0005).
Of the 227 patients in the prospective arm of our study,
222 patients had complete data queried from the TQIP
database. There were no differences in gender (VP 19%
vs CM 22% female; P = .66), age (VP 44.3 vs CM 44.9
years; P = .83), and ISS (VP 26.6 vs CM 26.9; P = .86)
(Table 1). Analysis of the TQIP data showed that there were
no differences in ICU LOS (VP 13 vs CM 14 days; P = .08),
ventilator days (VP 13 vs CM 14 days, P = .22), hospital
LOS (VP 23 vs CM 25 days; P = .28), and survival (VP 87%
vs CM 83%; P = .49) (Table 2).
Discussion
A VP compared with a CM improved delivery of EN in
critically ill, multiply injured trauma patients. In addition,
implementation of VP did not result in feeding-related com-
plications. The patient population in this study is the largest
to date and is exclusive to trauma patients. Few studies
have shown this benefit specifically in the trauma ICU
population. Unlike previous studies, our investigation was
a nonrandomized prospective trial. The initial study period
established a baseline for the conventional flat hourly rate of
65% delivery of prescribed EN. This baseline delivery rate is
lower than previous studies that have implemented VP. The
increase in enteral delivery of 8.3% by implementation of
VP is similar to recent studies.10,13
Although VP generated increased EN delivery, we did
not observe improvement in clinical outcomes. Many ben-
efits of adequate nutrition may not be recognized until later
in the patient’s recovery. In examining the TQIP registry to
evaluate outcomes, this study did not look at 1-year mortal-
ity or readmission rates. The improvement in EN delivery
did not surpass the ASPEN recommendations of delivering
at least 80% of prescribed nutrition. This likely blunted any
potential clinical improvement that may have resulted from
the increased EN delivery. It has been shown that patients
with a 6000 kcal deficit in the first week are associated with
worse outcomes.14 We did not calculate this deficit in our
study. The delivery for both arms projects a calorie deficit
and may be a reason the clinical outcome difference could
not be demonstrated. Much of the difference in clinical
outcome may not be demonstrated until the post-discharge
period. It has been shown that high-protein oral nutrition
supplements (ONS) after discharge have been associated
with improved mortality.15-17 Since we did not provide post-
discharge ONS or gather post-discharge outcomes data, this
may be an additional reason a clinical outcome difference
could not be demonstrated.
Sachdev et al 877

Table 1. Patient Demographics.

Volume-Based Protocol Conventional Method All Patients

Patient Demographics (n = 78) (n = 144) (n = 222) P-Value

Female, n (%) 15 (19) 32 (22) 47 (21) .66

Age, years M = 44.3, SD = 18.6 M = 44.9, SD = 17.9 44.7 .83
Height, cm M = 176, SD = 10.2 M = 173, SD = 12.8 174
Weight, kg M = 82, SD = 19.3 M = 87, SD = 22 85
BMI, mean 26.47 28.09 28.08
Blunt mechanism, n (%) 74 (95) 126 (88) 200 (90)
Injury Severity Score M = 26.6, SD = 12.3 M = 26.9, SD = 11.9 26.8 .86

BMI, body mass index; M, mean.

Figure 1. Interruption of enteral nutrition.

There are limitations in this study. First, the data are
prospectively collected and outcomes retrospectively ana-
lyzed. The 2 study arms are not randomized or blinded.
This design was intentional since blinding or randomization
were not possible when the bedside RN altered the delivery
rate. A VP method of EN is established to be safe, and with
delivery of <80% of prescribed EN at our institution, an
update to practice was essential. Second, initial compliance
with the VP decreased and required reeducation of RNs.
This created an unintentional washout period between the
baseline and intervention arm. During this period, nursing
education was increased to improve implementation of VP
and may have contributed to the overall increase of EN
delivery. Nursing education included increased frequency
of in-service sessions by our dietitian and nursing educator,
morning huddle reinforcement of education, and education
of new nurses with turnover. The education sessions use
a simple case-based module with a pretest and posttest to
ensure retention. Third, some patients who met criteria for
VP were missed and enrolled in the CM arm. We deleted
these patients and found no difference (65% P = .0005
vs 64.9% P = .0001) when compared with the VP group
(73%). We analyzed the excluded patients (n = 51), and the
average delivery was also similar: 64.8%, P = 0.0023. We
do not believe the missed patients had characteristics that
kept them from being enrolled in the VP group. Based on
these data, we think the difference in delivery of EN occurs
because of the methodology used (CM vs VP) and not the
time of the study period. Additionally, for some patients
on the VP arm, the RNs were not fully compliant with
the delivery protocol. This may have resulted in a reduced
observed impact of the VP.
Future goals to improve nutrition delivery to >80% of
prescribed nutrition will include stricter adherence to VP,
collaboration with anesthesia services to minimize nothing-
by-mouth times, increased use of post-pyloric feeding tubes,
878 Journal of Parenteral and Enteral Nutrition 44(5)

Table 2. Results.

Volume-Based Protocol Conventional Method All Patients

Results (n = 78) (n = 144) (n = 222) P-Value

Daily protein goals (g) M = 111, SD = 20.5 M = 130, SD = 24.3 128

Daily calorie goals (kcal) M = 2183, SD = 301.8 M = 2150, SD = 344.5 2161
Hospital length of stay (days) M = 23, SD = 14.8 M = 25, SD = 19.4 24 .28
ICU length of stay (days) M = 13, SD = 6.2 M = 14, SD = 7.6 14 .08
Ventilator days M = 13, SD = 7.7 M = 14, SD = 11.3 14 .22
Overall survival 87% 83% .49
Percent of prescribed EN M = 73.3, SD = 13.3 M = 65, SD = 15.3 .0002
delivered
Days on EN (median) M = 8.79, SD = 4.9 (8) M = 8.84, SD = 4.9 (8)
Percent of patients with 32% 17%
>80% delivery
Incidence of diarrheaa 5.2 4.2 .29
Tube dislodgement 1.6 2 .51
Emesis 0.1 1.4 .006

EN, enteral nutrition; ICU, intensive care unit; M, mean.

a Number of episodes as a percentage of days on EN.

and expansion of VP from trauma ICU patients to all
surgical patients.
Conclusion
Our data demonstrate that implementation of a volume-
based nutrition protocol results in increased delivery of
EN by 8.3% over a CM in critically ill trauma patients.
There was no difference in feeding-related complications,
hospital/ICU LOS, ventilator days, or mortality.
Acknowledgement
The authors would like to posthumously acknowledge the
conceptual contributions of Taylor Soloff, RD, to this study
and for her compassionate care of our patients.
Statement of Authorship
G. Sachdev and K. Backes equally contributed to the con-
ception and design of the research. K. Backes contributed to
acquisition and analysis of the data. G. Sachdev, K. Backes,
B. W. Thomas, R. F. Sing, and T. Huynh contributed to the
interpretation of the data. G. Sachdev drafted the manuscript.
All authors critically revised the manuscript, agree to be fully
accountable for ensuring the integrity and accuracy of the
work, and read and approved the final manuscript.
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Appendix 1
Volume-Based Protocol Guideline
If a patient meets inclusion/exclusion criteria, the Nutrition
Support Clinician or RN will contact physicians to begin
volume-based protocol for enteral nutrition. A printed sheet
with the guideline is to be posted in the patient’s room.
10. Residual is acceptable if <500 mL. If >500 mL,
1. Tube placement will be verified either in stomach or
duodenum.
2. The volume-based feeding schedule will be posted
in patient’s room.
879
3. The patient’s diet order will reflect their goal vol-
ume and 24-hour baseline rate.
4. The tube feeds (TF) will be initiated at half the goal
rate and increased to goal after 4 hours if tolerating.
5. Protein supplement will be given daily, starting on
day 1.
6. The RN will utilize the Volume-Based Feeding
Schedule and adjust the patient’s tube feeding rate
to meet the daily volume goal.
7. A nursing task to start every morning at 0700: Reset
TFs to original dietitian 24-hour goal rate and 24-
hour volume.
8. With every interruption of TF, the reinitiation of
TF will be calculated by bedside RN to complete
24-hour volume. The bedside RN will titrate up the
TF rate to achieve this goal with a maximum rate
of 150 mL/hr. There will be a bedside chart to make
this calculation safe and efficient.
9. Gastric residuals will be checked every 4 hours
for first 24 hours, then every 12 hours for the
next 24 hours. After 48 hours of measurement, if
acceptable, check PRN.
hold for 1 hour and recheck.
a If <500 mL, reinfuse and resume TF.
b If >500 mL, reinfuse 250 mL, and discard
remainder. Hold TF and call physician.