Reducing Nutritional Supplement Related Diarrhea in ICU Patients

Janet Popp, MSN, RN, CCRN, Laura Roberson, BSN, RN, CCRN, Patricia Funk, MS, RD, CNSC, LDN, David Mozingo, MD

BACKGROUND• Patients with burn injuries and major wounds have high protein and

calorie needs for wound healing that often require the use of enteral tube feeding and nutritional supplements (e.g. protein, glutamine, Juven, fiber…). The use of continuous enteral tube feeding and intermittent supplements often result in diarrhea that requires a bowel management system to minimize the risks of wound infection, skin breakdown, and urinary tract infection. However, use of a bowel management system for long periods of time places patients at risk for loss of rectal sphincter tone and diarrhea results in the loss of fluid, electrolytes, and nutrients.

• Burn ICU RNs noted that after the administration of an intermittent bolus of nutritional supplements via the feeding tube, patients often complained of abdominal cramping or experienced immediate diarrhea. RNs indicated that multiple packets of various reconstituted supplements (6-10 per day with recommended water volumes of 0-240mL each) were ordered, but were often administered together in a 60mL syringe 2-3 times/day to save nursing time. Unused supplement packets were often found at the patients’ bedsides, contributing to inadequate nutrition. RNs indicated that unused packets were attempts to avoid inducing diarrhea and that using the required volume of water per packet was too much to administer at one time. The unit dietician was consulted and attributed the diarrhea to varied water volumes and rates of administration.

CONCLUSIONS

PURPOSE• To increase Burn ICU RN compliance with nutritional supplement

administration and reduce the incidence of diarrhea in Burn ICU patients receiving enteral tube feeding.

BENCHMARKS

Summary/lessons learned • Other UF Health adult ICUs/IMCs claimed to experience a similar

phenomenon in their patient populations, so process shared.• Average 117 Flexiseals/month ($46,225/month) prior to sharing process• Average 68 Flexiseals/month ($26,977/month after process shared • Decrease of 586 Flexiseals/year for all ICU/IMCs• Cost Savings of $230,976/year for all ICU/IMCs

MEASURES

METHODS

• Usage of bowel management systems• Incidence of diarrhea• Compliance with administration of nutritional supplements• Incidence of bowel specific organisms in urine and blood. • Incidence of skin breakdown• Weight loss• Length of stay• Mortality rate

Preliminary Results in Burn ICU • Average 4 Flexiseals/month ($1617/month) prior to changing process • Average 2 Flexiseals/month ($788/month ) after changing process• Decrease of 25 Flexiseals/yr • Cost Savings $9,948/year

.• It was hypothesized that if all the supplements are combined, constituted with the appropriate volume of water, and administered at an hourly rate over twenty-four hours there will be better RN compliance with administration and the supplements will be better tolerated, resulting in decreased diarrhea, decreased usage of bowel management systems, decreased hospital acquired infections, decreased skin breakdown, decreased weight loss, increased pre-albumin levels, decreased length of stay, and decreased mortality.

• A continuous supplement mixture administered via the enteral feeding system flush bag was proposed to the Burn ICU Medical Director who was in agreement and a maximum rate of 50mL/hr was determined.

• A trial run of the a worst case scenario was performed using the maximum numbers of protein, glutamine, Juven, and fiber packets that a patient would receive.

• In February 2014, supplements began to be administered in recommended volumes of sterile water over a twenty-four hour period via the enteral flush bag hourly flush systems as opposed to bolusing supplements throughout the day at scheduled intervals. In April 2014, the successful process was shared with the other IMC/ICUs.

• Plan was to evaluate outcomes by reviewing medical records of Burn ICU patients who received enteral tube feeding and nutritional supplements.