19-Protocol-Driven Enteral Feeding for Patients on High-Flow Nasal Cannula Respiratory Support
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GI and Nutrition, Pulmonary, 2021
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The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Sara H. Soshnick

Introduction/Hypothesis: High Flow Nasal Cannula (HFNC) is a commonly used form of non-invasive support for patients in respiratory failure. Many pediatric hospitals have algorithms for managing patients on HFNC, yet no published clinical guidelines exist regarding a standardized way to initiate and maintain nutrition. We created a feeding algorithm for patients on HFNC and aimed to decrease the median time to initiation of enteral feeds from start of HFNC by 50% over 6 months.

Methods: Quality improvement project. We created a multidisciplinary team and completed Plan-Do-Study-Act (PDSA) cycles to achieve the project aim. We created an enteral nutrition algorithm for patients on HFNC admitted to the Children's Hospital at Montefiore pediatric intensive care unit and educated multidisciplinary staff through lectures, Powerpoints, and on rounds. Patients with contraindications to enteral nutrition were excluded. We conducted 3 PDSA cycles: 1. physician entered order for nurses to complete objective respiratory scores every 2 hours which guided safely starting and continuing feeds 2. implementation of our algorithm by nurses and physicians and 3. adding twice daily evaluation of patient eligibility to daily workflow and repeat nursing education. The primary outcome measure was time to initiation of enteral feeds once on HFNC and secondary outcome was time to full enteral feeds.

Results: 122 patients were analyzed; 40 from the baseline period (September 1-October 17, 2019) and 82 from the post-intervention period (October 18, 2019-Present). In our baseline period median time to enteral feeds initiation was 18 (IQR 5.5-41) hours and time to goal feeds was 21 (IQR 7.25-41) hours. Six months post-intervention, median time to initiation of feeds decreased to 6 (IQR 4-18.5) hours (p=0.001) and time to goal feeds decreased to 15 (IQR 4-22) hours (p=0.002). Post-intervention, 1 patient stopped feeds after initiation due to worsening respiratory status. One baseline patient and 2 patients post-intervention did not tolerate feeding by mouth due to coughing but tolerated nasogastric feeds. There were no episodes of aspiration or death.

Conclusions: A standardized algorithm for enteral feeding on HFNC significantly decreased time to initiation of enteral feeds and time to goal feeds with no significant increase in adverse events.


Meta Tag
Content Type Presentation
Knowledge Area Pulmonary
Knowledge Area GI and Nutrition
Knowledge Level Intermediate
Knowledge Level Advanced
Membership Level Select
Tag Enteral Nutrition
Tag Oxygenation
Year 2021
video presentation
quality improvement initiative
Children's Hospital at Montefiore
enteral nutrition
high-flow nasal cannula


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