Development of Evidence-Based Guidelines and Critical Care Nurses ’

Knowledge of Enteral Feeding

Annette M. Bourgault, Laura Ipe, Joanne Weaver, Sally Swartz and Patrick J. O’Dea

Crit Care Nurse. 2007;27: 17-29

© 2007 American Association of Critical-Care Nurses
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 CoverArticle
Development of
Evidence-Based Guidelines
and Critical Care Nurses ’
Knowledge of
Enteral Feeding
Annette M. Bourgault, RN, MSc, CNCC(C)
Laura Ipe, RD, CD
Joanne Weaver, RN, MSN
Sally Swartz, RN, BC, MSN
Patrick J. O’Dea, MD
E
nteral nutrition in critically ill
patients has been widely debated.
Some of the questions include opti-
mal time to begin enteral feeding,
gastric versus small-bowel tube
placement, and what markers
should be used to measure intoler-
ance to enteral nutrition. Although
some of these questions are yet to
be answered, more evidence has
become available since the 1990s to
guide practice.
For critically ill patients who
cannot consume an oral diet,
enteral nutrition is recommended
rather than parenteral nutrition
because the incidence of infectious
complications and costs are lower
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CE Continuing Education
* This article has been designated for CE credit.
A closed-book, multiple-choice examination
follows this article, which tests your knowledge
of the following objectives:
1. Identify issues related to the administra-
tion of enteral feeding
2. Describe 2 methods to confirm placement
of enteral tubes
with enteral nutrition.1 Enteral feed-
3. Discuss 3 nursing interventions to prevent
ing should be started within the complications of enteral feeding
first 24 to 48 hours of admission in
Authors
Annette M. Bourgault was employed as a clinical nurse specialist in cardiovascular and
critical care at Saint Joseph Regional Medical Center at the South Bend and Mishawaka
campuses in Indiana when this article was written.
Laura Ipe is a clinical dietitian with Saint Joseph Regional Medical Center in South
Bend.
Joanne Weaver is an education specialist with Saint Joseph Regional Medical Center in
South Bend.
Sally Swartz is a medical/surgical/rehabilitation clinical nurse specialist at Saint Joseph
Regional Medical Center at the South Bend and Mishawaka campuses.
Patrick J. O’Dea works with Michiana Gastroenterology Inc in South Bend and is a
gastroenterologist at Saint Joseph Regional Medical Center in South Bend.
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
Corresponding author: Annette M. Bourgault (e-mail: annette64@tricolour.queensu.ca).
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 17
critically ill patients who are receiv-
ing ventilatory support and whose
hemodynamic condition is stable.2-4
Artinian et al5 found a reduction in
intensive care unit (ICU) and hospi-
tal mortality when enteral nutrition
was started within 24 hours of the
start of mechanical ventilation.
Continuous feeding is preferable to
intermittent feeding because the
former may offer additional prophy-
laxis for stress ulcers, although the
mechanism is unknown.6 Full-
strength, undiluted formula should
be used for all enteral feeding.7
At Saint Joseph Regional Med-
ical Center, South Bend, Indiana, we
recognized the need for not only an
evidence-based approach but also a
standardized method to improve
delivery of enteral nutrition. Main-
taining consistency in feeding criti-
cally ill patients was often difficult
because of variations in physicians’
orders and insufficient knowledge
of nurses about enteral feeding. For
example, a physician might order
that enteral feeding be stopped tem-
porarily if a patient had a gastric
residual volume greater than 75 mL.
If the patient’s nurse did not ques-
tion this order, feeding would be
unnecessarily interrupted. Inappro-
priate cessation of enteral feeding
also occurred during patients’ baths
and linen changes. Additionally,
much of the literature on enteral
nutrition has been published in
nutritional and medical journals,
which are not often reviewed by
staff nurses.
In this article, we review the liter-
ature and discuss the development
of evidence-based guidelines for
enteral feeding. In addition, we
address gaps in nurses’ knowledge
related to enteral feeding and strate-
18 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
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gies that can be used by staff nurses
to influence enteral nutrition practice.
Review of Enteral Nutrition
Literature
Barriers to Meeting
Nutritional Goals
Goals for enteral nutrition are
often not achieved in critical care
patients because of avoidable
causes, such as interruptions in
feeding, underordering, and slow
increases in the volume of formula
administered.8-10 In a study by
Elpern et al,8 mean length of inter-
ruptions in enteral feeding was 5.23
hours per patient per day. The top 3
reasons for the interruptions were
preparation for tests (35.7%),
changes in body position (15%), and
high gastric residual volumes
(11.5%). Almost half (36%-45%) of
all interruptions were due to tempo-
rary cessation of feeding during
other procedures.8,9 Of note, in the
study by Elpern et al,8 150 mL was
used as the cutoff point for high gas-
tric residual volumes.
In an investigation by McClave
et al,10 only half of the critically ill
patients in the study received their
calorie goals, and 66% of cessations
in enteral feeding accounted for
19.6% of the potential feeding time.
Expert opinion suggests that enteral
nutrition be maintained until the
start of medical or diagnostic proce-
dures and restarted within 1 hour
after a procedure unless specifically
contraindicated; in addition, peri-
ods longer than 4 hours without
nutrition should be avoided.11
According to anesthesia guide-
lines,12 refraining from liquids for 2
to 4 hours before surgery is ade-
quate. Furthermore, in another
study,13 starting nutritional support
more than 3 days after admission to
the ICU was associated with an
increased length of stay.
Confirmation of Tube Placement
Malposition of feeding tubes
and aspiration are the greatest risks
with enteral nutrition.14,15 The only
reliable method for determining
accurate placement of orogastric/
nasogastric tubes is radiography.16,17
Rassias et al18 found that clinical
assessment methods were ineffective
for detecting inadvertent placement
of feeding tubes in the tracheopul-
monary system. Results of using
capnography and pH testing to assess
placement of feeding tubes have been
inconsistent. Although auscultatory
methods can provide a false assurance
of correct placement, many nurses
still use this method in their daily
practice.17,18 A practice alert16 from
the American Association of Critical-
Care Nurses recommends using a
secondary method to confirm place-
ment of feeding tubes. The method
consists of marking the feeding tube
with indelible ink at the exit site from
the lip or naris at the time of radiog-
raphy. This mark must be confirmed
by a nurse before feeding or admin-
istering medication through the
feeding tube.
Gastric Motility and
Risk of Aspiration
Major risk factors for aspiration
include brain injuries, decreased level
of consciousness, endotracheal intu-
bation, tube malposition, high gastric
residual volumes, vomiting, and flat
body positioning.14,15 An additional
risk factor, which may be influenced
by nursing practice, is poor oral
care.15 In critically ill patients, gastric
motility is impaired by dopamine
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(Intropin), opioids, propofol (Dipri-
van), neuromuscular blocking agents,
and hyperglycemia.15,19 Research cor-
relating bowel sounds with gastric
motility is lacking, yet many health-
care providers still rely on the pres-
ence of bowel sounds to initiate
enteral feeding. Experts in enteral
nutrition suggest that enteral feeding
may be started when bowel sounds
are not present.20,21 Experts also rec-
ommend that enteral feeding be
Although auscultatory methods can provide
a false assurance of correct placement,
many nurses still use this method in their
daily practice.
discontinued during periods of
hemodynamic instability to reduce
risk of aspiration and possible gut
ischemia.15 Although blue food dye
was added to formula in the past for
assessment of the risk for aspiration,
use of the dye has been associated
with metabolic acidosis, refractory
hypotension, and death and is no
longer accepted practice.22
Gastric Residual Volumes
Debate continues about the valid-
ity of gastric residual volumes; opin-
ions vary as to what constitutes a
high gastric residual volume, optimal
frequency for checking residual vol-
ume, time for rechecking, and time
to restart feeding. Although little
evidence supports using gastric
residual volumes to assess gastric
emptying, the method is widely
accepted, although variable target vol-
umes are used in clinical practice.19,23
Gastric residual volumes greater
than 200 to 250 mL are considered
high in critically ill patients who
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have artificial airways in place.3,23,24
Although some findings suggest
that gastric residual volumes greater
than 100 mL may be high for a gas-
trostomy tube,6 this topic is not typ-
ically addressed, possibly because
most critically ill patients receive
enteral nutrition through a nasogas-
tric or an orogastric feeding tube.15
Because secretion of saliva and gas-
tric fluids alone may total 188
mL/h, a gastric residual volume of
250 mL may be too low a cutoff
point for stopping enteral feeding.25
The experts do agree that gastric
residual volumes should be used in
conjunction with clinical assess-
ment to determine risk for aspira-
tion.2,15 Although a high gastric
residual volume may not correlate
directly with gastric motility, follow-
ing trends in gastric residual volume
may be helpful in making clinical
practice decisions.2,23 A single ele-
vated gastric residual volume
should be rechecked within 1 hour,
but feeding should not be automati-
cally stopped for an isolated high
volume.6 In addition, a large 50-
to 60-mL syringe should be used
to check gastric residual volume
to avoid collapsing small-bore feed-
ing tubes.6
Little research is available on
whether the gastric contents aspi-
rated during checks of residual vol-
ume should be returned to the
patient or discarded. In a small
study, Booker et al26 found that
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 19
potassium levels were lower,
although not significant statistically,
when gastric contents were dis-
carded rather than returned after
checks of gastric residual volume. In
addition, tube occlusions were more
frequent in the patients who had
gastric contents reinstilled than in
the patients who had the contents
discarded, reinforcing the need for
routine water flushes after checks of
gastric residual volume.
Prokinetic Agents
Prokinetic agents have been
used to promote gastric motility
and prevent unnecessary cessation
of feeding. After a meta-analysis of
the research literature, Booth et al27
recommended the use of metoclo-
pramide (Reglan) as a prokinetic
agent in patients with consistently
high gastric residual volumes.
Although erythromycin can increase
gastric motility, potential complica-
tions such as bacterial resistance
may outweigh its benefit as a rou-
tine prokinetic agent.4,21,28
Gastric Versus Small-Bowel
Tube Placement
Feeding tubes placed beyond the
gastric pylorus have been associated
with a reduction in both gastro-
esophageal regurgitation and
microaspiration of gastric contents.29
Small-bowel tube placement, in the
duodenum or proximal jejunum,
is recommended for patients with
potential for impaired gastric motil-
ity or high risk of aspiration.30 Place-
ment of feeding tubes in the small
bowel is not feasible for all patients
because of a lack of endoscopy or
fluoroscopy and unreliable blind
insertion methods. For patients
with impaired gastric motility as
indicated by consistently high
gastric residual volumes, small-
bowel feeding is the suggested route
of choice.30
Body Positioning
The American Gastroentero-
logical Association recommends ele-
vating the head of bed to a
minimum of 30º to 45º to reduce
the risk of microaspiration.6,15,31 Ele-
vation to 30º is an accepted stan-
dard of care for patients receiving
mechanical ventilation to minimize
risk of ventilator-associated pneu-
monia,31 although it is unknown
whether placing the head of the bed
at 45º may increase the risk for
shearing injuries to the skin in criti-
cally ill patients.4 Gastric residual
volumes are similar in both prone
and supine positions when the head
of the bed is elevated to 30º.32
Intolerance to Enteral Nutrition
Intolerance to enteral nutrition
may be due to a number of causes,
including diarrhea, constipation,
nausea and vomiting, and the feed-
ing formula itself. Despite the com-
mon belief that enteral nutrition
causes diarrhea, no conclusive
research supports this association.6
Consideration of formula as a cause
of diarrhea is required; however,
other causes such as medications,
stool impaction, bacterial contami-
nation, and the effects of Clostridium
difficile toxin after use of antibiotics
must be ruled out.33 Nausea and
vomiting may also be related to a
variety of causes, such as medications
or conditions that delay gastric
emptying. Recommendations when
a patient has nausea or vomiting
include ruling out constipation or
impaction, ensuring adequate eleva-
20 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
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tion of the head of the bed, adminis-
tering antiemetics, and discontinuing
offending medications if possible.4
Bacterial contamination of the
gastrointestinal tract during enteral
nutrition may also lead to intoler-
ance. Aseptic techniques, such as
cleaning the tops of formula cans
with alcohol swabs before opening,
routinely changing the bedside con-
tainer of formula every 24 hours,
and replacing formula every 4 hours
in open feeding systems, are used to
reduce bacterial contamination.7
Although some institutions use closed
feeding systems, evidence that closed
systems are better than open systems
is lacking.24
Prevention of Feeding
Tube Occlusions
Occlusions inside feeding tubes
are often caused by coagulation of
protein-based formulas as the formula
comes in contact with acidic envi-
ronments or certain medications.34
An increase in tube occlusions is
also associated with the perform-
ance of gastric residual checks.26,35
Although in one study,36 patients
who had gastric placement of small-
bore tubes had a higher incidence
of tube occlusions than did patients
with small-bowel placement, in
another study,37 the incidence of
occlusions in patients with gastric
placement did not differ from that
of patients with small-bowel place-
ment. Routine water flushes are
considered necessary to maintain
tube patency, although the volume
of water used to flush tubes varies
from 20 to 100 mL.38-40 Sterile water,
used by some hospitals for flushing
feeding tubes, is thought to reduce
gastric contamination, although we
found no supporting evidence for
this practice. Water boluses may
also be used during enteral feeding
to aid in meeting fluid volume
requirements or to normalize serum
levels of sodium.
Treating Feeding Tube Occlusions
Numerous methods have been
used in attempts to unblock feeding
tubes. Cranberry juice; the soft
drinks Coca-Cola, Mountain Dew,
Pepsi, and Sprite; and meat tender-
izer have not been consistently
effective.34,37 Acidic products may
precipitate coagulation of protein-
based formulas and actually
increase the number of tube occlu-
sions. Flushes with warm water
alone have been successful in
unblocking some tube occlu-
sions.36,37 For persistent tube occlu-
sions, pancrelipase (Viokase) with
the pH increased to 7.9 with sodium
bicarbonate has been successful
both in unblocking feeding tubes41
and in prolonging time to occlusion
when used prophylactically.37
Development of Enteral
Feeding Orders and Guidelines
Evidence-based protocols can
not only enhance delivery of nutri-
tion but also result in improved clin-
ical outcomes in critically ill
patients.3,33 Although no random-
ized trials have been done to assess
the use of enteral feeding protocols,
use of a protocol that includes pro-
kinetics and higher gastric residual
volumes (250 mL) has been associ-
ated with decreased time to reach
feeding goals (eg, desired rate of for-
mula administration and percentage
of nutritional requirements
received).42
Because of perceived barriers to
enteral nutrition, we assembled a
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 Table 1 Summary of enteral nutrition practice
Variable Practice/intervention/comments

Time to start enteral nutrition
Formula
Avoidance of bacterial contamination
Continuous vs intermittent enteral nutrition
Gastric vs small-bowel placement of feeding
tube
Confirmation of tube placement
Body positioning
Rate of administration of formula
Gastric residual volume
Prokinetic agents
Prevention of tube occlusions
Treatment of tube occlusions
Interruptions in feeding
a Expert opinion.
Start feeding within the first 24-48 hours of admission2-5
Start feeding when patient is fully resuscitated and in stable hemodynamic condition2-4,15
Bowel sounds are not required for starting enteral nutritiona20,21
Give formula full strength, undiluted7
Wipe top of formula cans with alcohol7
Routinely change bedside formula container every 24 hours7
Replace formula every 4 hours in open feeding systems7
Continuous feeding may offer additional prophylaxis for peptic ulcers6
Placement in small bowel reduces regurgitation and microaspiration29
Placement in small bowel is recommended for patients with impaired gastric motility or
high risk of aspiration30
Radiography is primary method for confirmation16,17
Use ink marking on feeding tube for secondary confirmation16
Elevate the head of the bed 30-45°6,15,31
Begin at 25 mL/ha
Increase rate by 25 mL/h every 4 hours if tolerateda
Assess patient for indications of intolerance to enteral nutrition if gastric residual
volume more than 200-250 mL3,23,24
Consider prokinetic agent and/or small-bowel feeding if gastric residual volume
remains higha30
Avoid stopping enteral nutrition because of a single elevated gastric residual volume6
Give metoclopramide if gastric residual volume remains high27
Routinely flush tube with water38-40
Flush tube with 30 mL every 4 hoursa
If flushing with warm water is ineffective, use pancreatic enzyme solution41
Minimize interruptionsa
Stop enteral nutrition immediately before minor procedures and restart within 1 hour
after procedurea11
Avoid stopping enteral nutrition for more than 4 hours before major proceduresa11,12

multidisciplinary group from 3
campuses of Saint Joseph Regional
Medical Center to examine the
evidence and develop a plan to
improve enteral nutrition in acute
care adult patients. The assembled
group consisted of dietitians, a
gastroenterologist, clinical nurse
specialists, a pharmacist, and staff
nurses. We planned to optimize
enteral nutrition in acutely ill
patients by using an evidence-based,
standardized approach to feeding.
During a 1-year period, we devel-
oped and implemented guidelines
for enteral nutrition in adults
(Table 1). The materials developed
included a preprinted physician
order form (Figure 1), which con-
tained an algorithm and instructions
for tube flushes and management of
tube occlusions on the reverse side
(Figure 2). Physicians also have the
option to delegate authority to the
registered dietitian to complete the
orders and begin enteral feeding.
Extensive revisions were also made
to the nursing enteral nutrition pol-
icy and procedure. When possible,
we used research evidence to
develop our guidelines. If no evi-
dence was available, we used expert
opinion and practice guidelines
from other institutions.
Highlights of the Enteral
Nutrition Guidelines
Administration Rate
Full-strength formula is started
at a rate of 25 mL/h, and the head
of the bed is elevated to a minimum
of 30º. Although our guidelines sug-
gest increasing the rate of enteral
feeding every 4 hours, no research
evidence was available to support this
frequency. However, every 4 hours
was common practice in other insti-
tutional protocols and the literature.

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  Physician authorizes dietitian to initiate, advance and monitor TF in consultation with physician.
1.
 Physician to select feeding schedule as ordered below.
2. TUBE FEEDING TYPE:
 NG  Peg Tube  J-Tube  Oral Gastric
3. TUBE FEEDING FORMULA: Please choose one of the following
 Standard with Fiber (1-1.2cal/ml)  Elemental (1-1.2cal/ml)  Renal (2cal/ml)
 Diabetic (1-1.2cal/ml)  High Calorie/High Protein (2 cal/ml)  Other:
TUBE FEEDING SCHEDULE: (HOB elevated to greater than or equal to 30º at all times unless contraindicated.)
4.
Please choose one of the following:
 CONTINUOUS TUBE FEEDING (Rate = total volume divided by 24 hours) Start TF full strength 25 ml/hr, increase ___ ml every
4 hours until goal of 75 ml / hr x 24 hrs is reached. Dietitian to assess patient and order final TF rate to meet needs.
 If TF is interrupted for test/procedures, Nursing to adjust TF rate of 1 to 1.2 cal/ml formulas as needed to meet patient’s 24 hr
volume goal ordered, and not to exceed maximum TF rate of  150 ml/hr or  _____ ml / hr rate
 CONTINUOUS CYCLIC (10-12 hrs per day/night) Max rate recommended = 150 ml / hr
Start TF full strength at 25 ml/hr, increase ___ ml every 4 hours until goal of ___ ml / hr is reached.
(Time of day _______ to ______ )
 INTERMITTENT BOLUS (by gravity). Max rate recommended = 500 ml / bolus.
Start full strength bolus at 120 ml / bolus. Advance by _____ ml every 4 hours until goal (see below) is reached.
Bolus goal volume = _____ ml / bolus, (frequency) _____ X (time)  24 hrs /  from _____ to _____
5. TUBE FEEDING FLUSHES:
 Standard flush following Water Flush Guidelines (see page 2)
 _____ ml additional water every _____ hours or  BID /  TID /  QID /  Daily
6. TUBE OCCLUSION TX:
 Viokase-8 tablet and sodium bicarbonate 325 mg per Tube Occlusion Guideline (see page 2).
7. CHECK GASTRIC RESIDUAL (See Enteral Feeding Guidelines pg 2.) No residual check with small bowel tube placement.
Gastric Residual greater than 200ml more than 2 consecutive hrs → replace 200 ml, discard the remainder, continue to hold TF
and Notify physician:  anytime day or night;  only between these hours: ___________________________________
8. BOWEL MANAGEMENT
 Senna 187 mg NG/FT every evening PRN
 Docusate Sodium 100 mg NG/FT BID PRN
 Milk of Magnesia 30 ml NG/FT daily PRN  Bisacodyl Suppository 10 mg daily PRN  Other:
9. LAB ORDERS:
 Comprehensive Metabolic Panel,  Phosphorus,  Magnesium,  Prealbumin now and repeat weekly.
 Repeat above labs (other frequency): __________________________________________________________________
10. Other:

Physician Signature: ___________________________

Date: __________________ Time: _______________

Figure 1 Orders for enteral feeding in adults.

Abbreviations: BID, twice a day; FT, feeding tube; HOB, head of the bed; NG, nasogastric; PRN, as needed; QID, 4 times a day; TF, tube feeding; TID, 3 times a day; TX,
treatment.

Reprinted with permission of Saint Joseph Regional Medical Center, South Bend, Indiana.

22 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 http://ccn.aacnjournals.org

Downloaded from ccn.aacnjournals.org by on November 3, 2010

Measure gastric residual volumes every 4 hours
or
before intermittent feedings
Gastric residual volume
≤200 mL
Replace residual
Flush tube with 30 mL of water
Maintain rate if feeding goal has been
attained or if this was second hour
cumulative residual check
Increase feeding rate every 4 hours as
ordered
Figure 2 Algorithm for checking gastric residual volumes.
Reprinted with permission of Saint Joseph Regional Medical Center, South Bend, Indiana.
Tube Flushes
Our protocol calls for flushes with
30 mL of tap water every 4 hours,
before and after intermittent feed-
ing, before and after administration
of medications, and after gastric
aspiration procedures. Patients with
fluid restrictions are reassessed on
an individual basis. The frequency
of routine water flushes has not been
previously studied, but every 4 hours
is common practice.40 Water flushes
are also used when a feeding tube
becomes occluded. If water flushes
do not restore tube patency, the tube
can be flushed with a dose of pancre-
atic enzyme solution: pancrelipase-8
tablet mixed with 325 mg sodium
bicarbonate (crushed) and 5 mL of
warm water. An attempt should be
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Gastric residual >200 mL
Replace 200 mL and discard the
remainder (document as output)
Flush tube with 30 mL of water
Stop feeding for 1 hour
Recheck gastric residual volume in 1 hour
Gastric residual volume >200 mL (second
hour)
Replace 200 mL and discard the remainder
(document as output)
Stop feeding
Notify physician (refer to order for call
preference)
Consider motility agent metoclopropamide
10 mg intravenously every 6 hours
(physician to adjust for renal function)
made to aspirate the contents of the
feeding tube before the enzyme solu-
tion is administered. This procedure
enables the enzyme solution to have
direct contact with the obstruction.
The feeding tube is clamped for 5
minutes after administration of the
enzyme solution and then flushed
with water until the tube is no longer
obstructed.
Assessment of Gastric
Residual Volume
Gastric residual volumes are
checked only in patients who have
tubes placed in the stomach (ie, not
in the small bowel). The stomach is
a reservoir that collects formula,
whereas the small bowel continually
propels contents forward.14,24 Imple-
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 25
mentation of evidence-based prac-
tice is not always straightforward. In
one study,43 nurses were reluctant to
change their practice despite the
presence of research data.
Although experts generally
define high gastric residual volumes
for critically ill patients as 200 to
250 mL, we chose to use 200 mL,
because using this volume as a cut-
off was a major practice change
within our institutions. Previously,
volumes less than 200 mL were con-
sidered an indication of high gastric
residual volume. We will consider
increasing the volume defined as
high at a later date, once the com-
fort level of physicians and nurses
has increased and outcomes remain
favorable. Along with checking gas-
tric residual volumes, nurses rein-
still aspirated gastric contents into
the feeding tube, up to a total of 200
mL. Any discarded gastric contents
are documented as output in the
fluid-balance record.
Although use of prokinetic agents
is suggested for patients who have
high gastric residual volumes, the
literature has few recommendations
on whether to stop feeding or to
maintain or reduce the rate of admin-
istration of formula when gastric
residual volumes are high. We opted
to stop administering formula for
1 hour and then reassess gastric
residual volume, because this
practice was common in other
ICUs. In addition, patients are
assessed for indications of intoler-
ance to enteral feeding.
Because the process associated
with checking gastric residual vol-
ume is the most complex part of our
guideline, an algorithm was devel-
oped to help nurses comply with the
process. This algorithm is printed
on the reverse side of the order
sheet (Figure 2).
Interruption of Feeding
Because a high proportion of
feeding interruptions were related
to feeding being stopped for proce-
dures, we attempted to address
these interruptions in our guide-
lines. In order to avoid unnecessary
cessation of feeding during patients’
repositioning, bathing, or linen
changes, nurses are encouraged to
place patients in the reverse Tren-
delenburg position if necessary. If
feedings are stopped for procedures,
an option on the physicians’ order
set allows nurses to make up lost
feeding volumes during the remain-
der of the 24-hour period. This
makeup is limited to formulas of 1
to 1.2 cal/mL and is not to exceed
the maximum tube feeding rate of
150 mL/h.44 Our policy suggests
that feeding be stopped for 2 hours
before procedures or as otherwise
ordered. We hope that this policy
will discourage the practice of stop-
ping feedings overnight for minor
bedside procedures.
Our enteral feeding guidelines
also provide prompts to incorporate
interventions such as administration
of additional water, bowel regimens,
and laboratory tests. If a patient’s
gastric residual volume is high
(>200 mL) for 2 consecutive checks,
the algorithm suggests that an order
for the promotility agent metoclo-
pramide should be obtained.
Miscellaneous Practice Issues
The revised policy and procedure
document also provides prompts for
nurses to notify a physician or dieti-
tian of any complications, such as
diarrhea, nausea/vomiting, feeding
26 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
Downloaded from ccn.aacnjournals.org by on November 3, 2010
tube occlusions that persist despite 1 month before the new guidelines
use of a pancreatic enzyme solution, were implemented. In order to
or presence of dry mouth or dry skin assess baseline knowledge related to
turgor. The occurrence of these enteral feeding practice, a test was
problems may indicate feeding administered before the nurses
intolerance or other complications began the educational program. The
that may increase the risk of tube test focused on topics (Table 2)
malposition, aspiration, or inadequate associated with practices that were
delivery of nutrition. being altered with the new evi-
dence-based guidelines and con-
Influence of Nursing Knowledge sisted of randomly assigned
on Enteral Nutrition Practice multiple-choice and true-false ques-
Nursing Education tions. The educational component
Several enteral nutrition practices consisted of a series of evidence-
are directly influenced by nurses, based, referenced slides. After com-
including timing of prompting physi- pleting the educational module, the
cians to implement feeding, timeliness nurses took another test, which con-
of increasing the rate of administra- sisted of the same 10 questions as
tion of formula to reach the desired the first test.
nutritional goals, interruptions in
feeding, elevation of the head of the Evaluation of Nurses’ Knowledge
bed, and preventing occlusions of The test questions were answered
feeding tubes. The number of such by nurses in 5 critical care units at 2
interventions suggests that nurses’ campuses. The critical care units
knowledge related to enteral nutri- consisted of an ICU, a stroke unit, a
tion is essential to achieve optimal progressive care unit, a mixed pro-
outcomes for patients. Available gressive care/ICU, and a cardiac
13,45,46
research supports the premise recovery unit. Test results were ana-
that nurses’ knowledge can directly lyzed for a total of 55 nurses, 52%
influence the success of a nutri- of the total number of critical care
tional support program. nurses (Figure 3). Although 65% of
EduCode soft-
ware (MC Strate-
Table 2 Topics covered by tests given before and after com-
gies, Inc; Atlanta, pletion of an educational module on enteral feeding practice
Georgia) was
1. Methods of verifying placement of feeding tubes
used at 2 of our
2. Presence of bowel sounds before feeding is started
campuses to
3. Minimum level for the head of the bed during feeding
develop Internet-
based educational 4. Volume of gastric residual contents necessitating
interruption or cessation of feeding
materials and
5. Feeding practice during bathing and bed making
tests on enteral
6. Length of time feeding stopped for procedures
nutritional sup-
7. Frequency and timing of routine water flushes of feeding tubes
port. This educa-
tional program 8. Causes of tube occlusions
was assigned to 9. Methods used to unblock tube occlusions
the nursing staff 10. Rate calculation for making up lost feeding time
at the 2 campuses
http://ccn.aacnjournals.org
the nurses had completed both tests
at the end of the 4-week period, we 100
excluded the results of tests com- 90
pleted after a presentation on enteral
80

Mean percentage of correct answers

nutrition at our institution’s annual
critical care conference to avoid 70
skewing the data. The mean score 60
for the 5 critical care units before
50
completion of the educational
module was 45%. After the educa- 40
tional program, the mean score 30
increased to 84%, a total increase of
20
39% in nurses’ knowledge among
the sample population. 10
Although the EduCode program 0
provided detailed test analysis, the A B C D E
answers to a given question on the Critical care unit
tests taken before completion of the Before module After module
educational module could not be
separated from the answers to the Figure 3 Mean percentage of correct answers, by critical care unit (n = 55 nurses),
before and after completion of an educational module on enteral nutrition.
same question on the tests taken
after completion of the module. Of
interest, 30% of the answers suggested
that enteral feeding could not be 100

started in patients who did not have 90

bowel sounds. In addition, 31% of
80
the answers indicated that feeding
should be stopped during bathing 70
Percentage of answers

and changes in bed linen. Answers 60

about gastric residual volumes varied,
50
but 41% of the test answers indicated
that enteral feeding should be stopped 40
when gastric residual volumes were 30
less than 200 mL (Figure 4). Again,
20
it was not possible to separate answers
to individual questions on the basis 10
of the time the tests were taken (ie, 0
before or after the educational mod- 50 100 150 200

ule). Plausibly, the majority of incor- Options, mL

rect answers were associated with
the tests taken before completion of
the module.
One unexpected finding was the
amount of discussion generated
among the nursing staff after the
educational program. Several staff
nurses were surprised by some of
Figure 4 Percentage of answers for each option to the test question: Enteral feeding
should be held when gastric residual volumes are greater than _____. Options were
50 mL, 100 mL. 150 mL, and 200 mL.
the research findings on enteral practice. Many were also surprised
nutrition; the nurses remarked that at the disparity between the research
they had been feeding patients for evidence and their knowledge base
years and thought they knew this prior to the educational program. In

http://ccn.aacnjournals.org CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 27

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addition to the educational module,
informal discussion has further
added to nurses’ awareness of enteral
feeding practice at our institutions.
Implementation
Nurses, radiology technicians,
physicians, and dietitians were
involved with the practice changes
related to enteral nutrition. On each
unit, nurses were solicited to
become “change champions” to help
promote the use of the new guide-
lines. Change champions are skilled
nurses who become expert in the
evidence-based guidelines and
model the practice change.47 Our
nurse champions are the informal
“go to” people on the topic of
enteral nutrition. In addition to the
formal educational program, prac-
tice changes were communicated in
a number of formats, including
newsletters for nurses, physicians,
and other hospital personnel; staff
meetings; and informal reminders.
Other measures being monitored
with our new guidelines include the
process of marking the feeding tube
to verify placement, gastric residual
volume used as an indicator to stop
feeding, and the length of time feed-
ings are stopped before procedures.
Outcome measures being evaluated
include the time elapsed between
the writing of an order for feeding
and the start of feeding, elapsed
time between the writing of an order
and assessment by a dietitian, elapsed
time to reach desired rate of admin-
istration of formula, and percentage
of desired nutritional requirement
received within 24 hours of initiating
enteral feeding. We plan to assess
these outcomes and make any nec-
essary adjustments to our protocol
at a later time.
28 CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007
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Conclusion
Although use of enteral feeding
protocols increases nutritional intake
in critically ill patients, our new
guidelines were implemented only
recently. These evidence-based
guidelines will be used with all acute
care adult patients, not just those in
critical care. We recognize that the
development of evidence-based
guidelines is only one step toward
changing practice. Educating nurses
and physicians about the guidelines
must be ongoing, both to promote
use of the guidelines and to prevent
unnecessary interruption of feeding.
Although we had predicted an
increase in nurses’ knowledge after
the educational program, the scores
on the tests taken before the program
were lower than we had anticipated.
Our test questions focused on local
practice changes, but much of the
literature to support these practice
changes had been published 4 years
earlier or more. This finding further
supports the theory that although
research is performed and published,
barriers such as lack of access, time,
knowledge, and other resources
often prevent research from being
implemented in the clinical setting.48
If you do not have an enteral
nutrition protocol in your ICU, we
challenge you to evaluate your cur-
rent practice. If nutritional goals are
not being met within a timely man-
ner, consider adopting consistent
evidence-based standards of enteral
nutrition for your patients. Addi-
tional guidelines, analysis of research
findings, and tools for implement-
ing evidence-based nutrition into
clinical practice are available at
www.criticalcarenutrition.com.
Did your own knowledge related
to enteral nutrition increase as you
read this article? If the answer is yes,
most likely others could also benefit
from this information. Consider
becoming a champion for enteral
nutrition on your unit. Talk to your
nursing leaders, dietitians, and physi-
cians to find out how you can help
implement evidence-based practice
within your institution and contribute
to positive outcomes for patients.
Acknowledgments
Special thanks to Chris Senff, Dawna Summers, Bridget
Dudash, and Kirsten Galasso for their contributions in
the development of the adult enteral nutrition guidelines.
Financial Disclosures
None reported.
References
1. Gramlich L, Kichian K, Pinilla J, Rodych NJ,
Dhaliwal R, Heyland DK. Does enteral
nutrition compared to parenteral nutrition
result in better outcomes in critically ill
adult patients? a systematic review of the
literature. Nutrition. 2004;20(10):843-848.
2. DiSario JA. Future considerations in aspira-
tion pneumonia in the critically ill patient:
what is not known, areas for future research,
and experimental methods. JPEN J Parenter
Enteral Nutr. 2002;26(6 suppl):S75-S79.
3. Heyland DK, Dhaliwal R, Day A, Jain M,
Drover J. Validation of the Canadian clinical
practice guidelines for nutrition support in
mechanically ventilated, critically ill adult
patients: results of a prospective observa-
tional study. Crit Care Med.
2004;32(11):2260-2266.
4. Critical Care Nutrition. Early vs delayed
nutrient intake. http://ccn.cissec.com/cpg
/2.0_early_07.pdf. Published January 8,
2007. Accessed May 8, 2007.
5. Artinian V, Krayem H, DiGiovine B. Effects
of early enteral feeding on the outcome of
critically ill mechanically ventilated medical
patients. Chest. 2006;129(4):960-967.
6. American Gastroenterological Association
technical review on tube feeding for enteral
nutrition. Gastroenterology. 1995;108(4):
1282-1301.
7. US Food and Drug Administration, Center
for Food Safety and Applied Nutrition.
Hazard analysis and critical control point.
http://www.cfsan.fda.gov/~lrd/haccp.html.
Accessed May 2, 2007.
8. Elpern EH, Stutz L, Peterson S, Gurka DP,
Skipper A. Outcomes associated with enteral
tube feedings in a medical intensive care
unit. Am J Crit Care. 2004;13(3):221-227.
9. O’Leary-Kelley CM, Puntillo KA, Barr J,
Stotts N, Douglas MK. Nutritional ade-
quacy in patients receiving mechanical ven-
tilation who are fed enterally. Am J Crit
Care. 2005;14(3):222-231.
10. McClave SA, Sexton LK, Spain DA, et al.
Enteral tube feeding in the intensive care
unit: factors impeding adequate delivery.
Crit Care Med. 1999;27(7):1252-1256.
11. Greenwood J. Enteral nutrition (EN) in the
critically ill adult: practice guidelines. Critical
http://ccn.aacnjournals.org
 Care Nutrition. http://ccn.cissec.com
/tools/EN%20practice%20guidelines.pdf.
Published July 21, 2003. Accessed May 2,
2007.
12. American Society of Anesthesiologists.
Practice guidelines for preoperative fasting
and the use of pharmacologic agents to
reduce the risk of pulmonary aspiration:
application to healthy patients undergoing
elective procedures. A report by the Ameri-
can Society of Anesthesiologist Task Force
on Preoperative Fasting. Anesthesiology.
1999;90(3):896-905.
13. Roberts SR, Kennerly DA, Keane D, George
C. Nutrition support in the intensive care
unit: adequacy, timeliness, and outcomes.
Crit Care Nurse. 2003;23(6):49-57.
14. Metheny NA, Titler MG. Assessing place-
ment of feeding tubes. Am J Nurs. 2001;
101(5):36-45.
15. McClave SA, DeMeo MT, DeLegge MH, et
al. North American Summit on Aspiration
in the Critically Ill Patient: consensus state-
ment. JPEN J Parenter Enteral Nutr. 2002;
26(6 suppl):S80-S85.
16. American Association of Critical Care
Nurses. Practice alert: verification of feed-
ing tube placement. http://www.aacn.org
/AACN/practiceAlert.nsf/Files/VOFTP/$file
/Verification%20of%20Feeding%20Tube%20
Placement%2005-2005.pdf. Published May
2005. Accessed May 2, 2007.
17. Metheny N, McSweeney M, Wehrle MA,
Wiersema L. Effectiveness of the ausculta-
tory method in predicting feeding tube
location. Nurs Res. 1990;39(5):262-267.
18. Rassias AJ, Ball PA, Corwin HL. A prospec-
tive study of tracheopulmonary complica-
tions associated with the placement of
narrow-bore enteral feeding tubes. Crit
Care. 1998;2(1):25-28.
19. Metheny NA, Schallom MF, Edwards SJ.
Effect of gastrointestinal motility and feed-
ing tube site on aspiration risk in critically
ill patients: a review. Heart Lung. 2004;
33(3):131-145.
20. Heyland DK, Cook DJ, Winder B, Guyatt
GH. Do critically ill patients tolerate early
intragastric nutrition? Clin Intensive Care.
1996;7(2):68-73.
21. Spain DA. When is the seriously ill patient
ready to be fed? JPEN J Parenter Enteral
Nutr. 2002;26(6 suppl):S62-S68.
22. US Food and Drug Administration, Center
for Food Safety and Applied Nutrition. FDA
public health advisory: reports of blue dis-
coloration and death in patients receiving
enteral feedings tinted with the dye, FD&C
blue no. 1. http://www.cfsan.fda.gov
/~dms/col-ltr2.html. Published September
29, 2003. Accessed May 2, 2007.
23. McClave SA, Snider HL. Clinical use of gas-
tric residual volumes as a monitor for
patients on enteral tube feeding. JPEN J
Parenter Enteral Nutr. 2002;26(6 suppl):
S43-S50.
24. Heyland DK, Dhaliwal R, Drover JW, Gram-
lich L, Dodek P; Canadian Critical Care
Clinical Practice Guidelines Committee.
Canadian clinical practice guidelines for
nutrition support in mechanically venti-
lated, critically ill adult patients. JPEN J
Parenter Enteral Nutr. 2003;27(5):355-373.
25. Lin HC, Van Citters GW. Stopping enteral
feeding for arbitrary gastric residual vol-
ume may not be physiologically sound:
results of a computer simulation model.
http://ccn.aacnjournals.org
Downloaded from ccn.aacnjournals.org by on November 3, 2010
JPEN J Parenter Enteral Nutr. 1997;21(5): in critically ill patients: a prospective, ran-
286-289. domized controlled trial. JPEN J Parenter
26. Booker KJ, Niedringhaus L, Eden B, Arnold Enteral Nutr. 2001;25(2):81-86.
JS. Comparison of 2 methods of managing 43. Spain DA, McClave SA, Sexton LK, et al.
gastric residual volumes from feeding Infusion protocol improves delivery of
tubes. Am J Crit Care. 2000;9(5):318-324. enteral tube feeding in the critical care unit.
27. Booth CM, Heyland DK, Paterson WG. JPEN J Parenter Enteral Nutr. 1999;23(5):
Gastrointestinal promotility drugs in the 288-292.
critical care setting: a systematic review of 44. McClave S. Protocols for enteral feeding in
the evidence. Crit Care Med. 2002;30(7): ICU: what should they contain and should
1429-1435. they make a difference. Paper presented at:
28. Berne JD, Norwood SH, McAuley CE, et al. Indiana Society for Parenteral and Enteral
Erythromycin reduces delayed gastric emp- Nutrition (ISPEN) Fall Conference; Septem-
tying in critically ill trauma patients: a ran- ber 16, 2005; Plainfield, IN.
domized, controlled trial. J Trauma. 2002; 45. Marshall AP, West SH. Enteral feeding in
53(3):422-425. the critically ill: are nursing practices con-
29. Heyland DK, Drover JW, MacDonald S, tributing to hypocaloric feeding? Intensive
Novak F, Lam M. Effect of postpyloric feed- Crit Care Nurs. 2006;22(2):95-105.
ing on gastroesophageal regurgitation and 46. Wentzel Persenius M, Larsson BW, Hall-
pulmonary microaspiration: results of a Lord ML. Enteral nutrition in intensive
randomized controlled trial. Crit Care Med. care: nurses’ perceptions and bedside
2001;29(8):1495-1501. observations. Intensive Crit Care Nurs.
30. Heyland DK, Drover JW, Dhaliwal R, 2006;22(2):82-94.
Greenwood J. Optimizing the benefits and 47. Titler MG, Everett LQ. Translating research
minimizing the risks of enteral nutrition in into practice: considerations for critical
the critically ill: role of small bowel feeding. care investigators. Crit Care Nurs Clin North
JPEN J Parenter Enteral Nutr. 2002;26(6 Am. 2001;13(4):587-604.
suppl):S51-S57. 48. Haynes B, Haines A. Barriers and bridges to
31. Drakulovic MB, Torres A, Bauer TT, Nicolas evidence based clinical practice. BMJ.
JM, Nogue S, Ferrer M. Supine body posi- 1998;317(7153):273-276.
tion as a risk factor for nosocomial pneu-
monia in mechanically ventilated patients:
a randomised trial. Lancet. 1999;354(9193):
1851-1858.
32. Van der Voort PH, Zandstra DF. Enteral
feeding in the critically ill. Comparison
between the supine and prone positions: a
prospective crossover study in mechanically
ventilated patients. Crit Care. 2001;5(4):
216-220.
33. Martin CM, Doig GS, Heyland DK, Morrison
T, Sibbald WJ; Southwestern Ontario Critical
Care Research Network. Multicentre, clus-
ter-randomized clinical trial of algorithms
for critical-care enteral and parenteral ther-
apy (ACCEPT). CMAJ. 2004;170(2);197-204.
34. Marcuard SP, Perkins AM. Clogging of
feeding tubes. JPEN J Parenter Enteral Nutr.
1988;12(4):403-405.
35. Powell KS, Marcuard SP, Farrior ES, Gallagher
ML. Aspirating gastric residuals causes
occlusion of small-bore feeding tubes. JPEN
J Parenter Enteral Nutr. 1993;17(3):243-246.
36. Marcuard SP, Stegall KS. Unclogging feed-
ing tubes with pancreatic enzyme. JPEN J
Parenter Enteral Nutr. 1990;14(2):198-200.
37. Bourgault AM, Heyland DK, Drover JW,
Keefe L, Newman P, Day AG. Prophylactic
pancreatic enzymes to reduce feeding tube
occlusions. Nutr Clin Pract. 2003;18(5):
398-401.
38. Metheny N, Eisenberg P, McSweeney M.
Effect of feeding tube properties and three
irrigants on clogging rates. Nurs Res. 1988;
37(3):165-169.
39. Scanlan M, Frisch S. Nasoduodenal feeding
tubes: prevention of occlusion. J Neurosci
Nurs. 1992;24(5):256-259.
40. Reising DL, Neal RS. Enteral tube flushing:
what you think are the best practices may
not be. Am J Nurs. 2005;105(3):58-63.
41. Marcuard SP, Stegall KL, Trogdon S. Clear-
ing obstructed feeding tubes. JPEN J Par-
enter Enteral Nutr. 1989;13(1):81-83.
42. Pinilla JC, Samphire J, Arnold C, Liu L,
Thiessen B. Comparison of gastrointestinal
tolerance to two enteral feeding protocols
CRITICALCARENURSE Vol 27, No. 4, AUGUST 2007 29
CE Test Test ID C074: Development of Evidence-Based Guidelines and Critical Care Nurses’ Knowledge of Enteral Nutrition
Learning objectives: 1. Identify issues related to the administration of enteral feeding 2. Describe 2 methods to confirm placement of enteral tubes
3. Discuss 3 nursing interventions to prevent complications of enteral feeding

1. A reduction in hospital mortality occurred when enteral nutrition was 7. Which one of the following gastric residual volumes is
initiated within how many hours of the start of mechanical ventilation? considered high in critically ill patients with an artificial airway?
a. 12 hours a. Greater than 50 mL
b. 24 hours b. Greater than 100 mL
c. 36 hours c. Greater than 150 mL
d. 48 hours d. Greater than 200 mL

2. Which of the following formulas should be used for all enteral feeding? 8. Which one of the following should be performed
a. Quarter strength for a gastric residual volume of 150 mL?
b. Third strength a. Maintain or increase feeding rate as ordered
c. Half strength b. Discard gastric residual volume
d. Full strength c. Decrease tube feeding rate by 25 mL/h
d. Discontinue enteral feeding
3. Which one of the following practice issues is responsible for
the majority of interruptions in enteral feeding? 9. Which one of the following is the minimum head of bed elevation to
a. Changes in body position reduce the risk of microaspiration and ventilator-associated pneumonia?
b. High gastric residual volumes a. 15°
c. Preparation for tests b. 30°
d. Hemodynamic instability c. 45°
d. 60°
4. Unless contraindicated, enteral nutrition should be restarted
within how many hours following a diagnostic procedure? 10. Which one of the following should be used to reduce
a. 1 hour bacterial contamination of the gastrointestinal tract?
b. 2 hours a. Cleaning the top of formula cans with water
c. 3 hours b. Replacing open system formula every 12 hours
d. 4 hours c. Changing the bedside formula container every 24 hours
d. Flushing feeding tubes with sterile saline
5. Which one of the following is the only reliable method for
determining accurate placement of orogastric and nasogastric tubes? 11. Which one of the following should be used to prevent
a. Capnography feeding tube occlusions?
b. Auscultation a. Water flushes
c. pH testing b. Saline flushes
d. Radiography c. Pancrelipase (Viokase)
d. Sodium bicarbonate
6. Which one of the following is a secondary method to confirm
placement of feeding tubes? 12. Which one of the following should be used as the initial
a. Volume of aspirate rate for tube feedings?
b. pH testing a. 10 mL/h
c. Marking tube exit site b. 25 mL/h
d. Color of aspirate c. 40 mL/h
d. 55 mL/h
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
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Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb Kb
Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc Kc
Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd Kd
Test ID: C074 Form expires: August 1, 2009 Contact hours: 1.0 Fee: $0 AACN members; $10 nonmembers Passing score: 9 correct (75%) Category: A, Synergy CERP A
Test writer: John P. Harper, RN, MSN, BC
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