SCCM Resource Library-19-Protocol-Driven Enteral Feeding for Patients on High-Flow Nasal Cannula Respiratory Support

Video Transcription

Good afternoon. My name is Sarah Sashnick, and I'm a Pediatric Critical Care Medicine Fellow at the Children's Hospital at Montefiore in the Bronx, New York.  I'll be presenting our quality improvement initiative entitled Protocol-Driven Entral Nutrition for Patients Receiving High-Flow Nasal Cannula Respiratory Support.  The authors have nothing to disclose. High-flow nasal cannula is a commonly used form of noninvasive support for patients in respiratory failure.  Clinical decisions for patients on noninvasive support include the appropriate time to initiate entral nutrition in the safest route out of administration.  Absence of published guidelines for initiation and maintenance of entral nutrition may contribute to delays in feeding such patients.  Few studies exist in the literature regarding feeding on high-flow nasal cannula and focus on neonatal patients or evaluating individual provider practice and identifying adverse  outcomes. These studies have reported children fed entrally on high-flow nasal cannula have rare adverse  events such as respiratory distress or emesis, have decreased length of stay, and decreased duration of high-flow nasal cannula.  They have also reported a lack of standardized guidance on how to feed these patients. Studies have reported that the use of an entral feeding algorithm in critically ill patients  is associated with decreased time to goal entral nutrition and decreased use of parenteral nutrition.  However, despite frequent development of hospital feeding pathways, high-flow nasal cannula  policies, and management algorithms for bronchiolitis and status asthmaticus, there is a lack of evidence on how to entrally feed these patients.  We describe the development of an entral nutrition pathway for patients receiving high-flow nasal  cannula respiratory support to reduce variability among provider practices and decrease time to entral nutrition for critically ill children in the PICU.  Our SMART aim was to decrease the median time to initiation of entral feeds from start of high-flow nasal cannula by 50% over six months utilizing a standardized feeding algorithm.  Accordingly, the primary outcome was time to initiation of entral feeds once on high-flow. The secondary outcome was time to full calorie entral nutrition.  An entral nutrition pathway for patients on high-flow nasal cannula in the CHAM PICU was created by a core team of physicians, nurses, and respiratory therapists.  At CHAM, nutrition is consulted for all patients receiving tube feeds, which included patients being fed per our pathway.  Our feeding pathway begins with an initial assessment for every patient on high-flow. Patients needed to be on high-flow nasal cannula at less than or equal to two liters per kilo  per minute of flow and stable or weaning over four hours to be considered to feed. Time zero was defined as time the patient was started on high-flow nasal cannula or  time the patient arrived to the PICU if on high-flow nasal cannula prior to admission.  At CHAM, respiratory scores adapted from Seattle Children's Hospital are used to wean and escalate  support for patients in respiratory failure and are incorporated into established bronchiolitis and status asthmaticus pathways.  Per these protocols, patients with respiratory scores less than or equal to four should have  therapy weaned, scores five to eight therapy should be maintained, and respiratory scores greater than or equal to nine support should be escalated.  To be consistent, patients with respiratory scores of less than nine who are stable or weaning support were eligible to feed.  To variability and provider comfort regarding the maximum level of high-flow nasal cannula support deemed safe to initiate oral feeds, the pathway initiates feeds by tube.  However, if the medical team determined a patient was safe to feed by mouth, they were able to do so.  The pathway also had the provider evaluate if the patient was at high risk for aspiration,  defined as prior history of aspiration, hypotonia, dysphagia, discoordination, or multiple chronic medical conditions.  These patients would be considered for nasal duodenal tube placement. To minimize risk to patients, inclusion and exclusion criteria were created to identify  appropriate patients to feed while on high-flow, which can be seen here. Those patients on high-flow nasal cannula who were clinically decompensating or at escalating  high-flow nasal cannula settings and respiratory scores were greater than or equal to nine were included, but they were not fed until their high-flow settings were stable with  a respiratory score less than or equal to eight, resulting in longer time to initiation of feeds for these patients.  As you can see here, a key driver diagram outlining leading factors contributing to feeding delay was created, which contributed to the development of our Plan-Do-Study-Acts,  or PDSA, cycles. Key drivers included variable comfort levels of physicians and nurses feeding on high-flow  nasal cannula, lack of standardized enteral feeding algorithm, poor compliance with respiratory scores, and lack of frequent follow-up by care teams for readiness to feed.  We used PDSA cycle methodology based on the key drivers recognized in the prior diagram. We conducted four PDSA cycles.  Cycle one, physician-entered order for nurses and respiratory therapists to perform respiratory scores every two hours, which guided feed initiation and maintenance.  Cycle two, implementation of our pathway. Cycle three, targeted evening shift nursing education. And cycle four, twice-daily evaluation of patient eligibility to daily workflow and  evaluation of readiness to feed twice-daily on rounds. 144 patients were analyzed, 32 from the baseline period and 112 from the intervention period.  The baseline group had significantly more patients aged 6 to 12 years, more patients with asthma, and fewer patients with bronchiolitis than the intervention group.  High-flow duration increased by 5.5 hours in the intervention group, but this was not significant.  We considered this a balancing measure, which could potentially be explained by data collection  in the intervention group occurring during the winter months when there are more patients in the PICU with respiratory failure from viral illnesses.  These patients may have had a more prolonged illness course than the baseline patients who required high-flow nasal cannula in the fall for other etiologies.  All patients were fed by tube, all patients fed by tube were fed nasogastrically or through pyrogastrostomy, and no patients were fed via nasal duodenal tube.  Patients' feeds started at time 0 if fed within 1 hour of high-flow nasal cannula start or if prior tube feeds were continued within 1 hour of high-flow nasal cannula initiation.  In the baseline period, median time to feed initiation was 21 hours and time to goal feeds was 22 hours, which decreased by 76% to 5 hours and by 73% to 6 hours respectively after  the fourth PDSA cycle. Data for each PDSA cycle individually is presented in the table.  Median time to initiation of feeds significantly decreased after initiation of each PDSA cycle.  This is our run chart, which illustrates the median time to enteral feed initiation for all included patients.  There was a shift in our data after PDSA cycle 1, allowing us to safely monitor starting and continuing feeds.  There were two trends in the data, weeks 15 through 19 and 26 through 30, where time to initiation of enteral feeds was within our goal of 10 hours, occurring after introduction  of our pathway and after adding evaluation of readiness to feed to our twice daily rounds. Week 20 represents a gap in our data as we had no patients in the PICU and high-flow  nasal cannula that met inclusion criteria. During this time, patients on high-flow were triaged to stay on the general wards and patients  on non-invasive positive pressure ventilation were managed in the ICU due to a high census. Observe adverse events were low.  One patient stopped feeds in the intervention group due to worsening respiratory failure. This patient was admitted on high-flow for status ismaticus, was initially fed by mouth,  but developed worsening bronchospasm requiring BIPAP while asleep, yet continued to tolerate high-flow nasal cannula while awake.  Since the patient only required increased support while asleep, it is hard to contribute this need to enteral feeding alone.  Two other patients did not tolerate feeding by mouth due to coughing fits, but tolerated NG feeds. There were no episodes of aspiration or death.  Differences in our baseline and intervention group characteristics are likely due to the  data collected in the baseline group was completed prior to the winter months when respiratory viruses are more prevalent and the hospital is more full.  Overall, our intervention was well-tolerated and successful in significantly decreased time to initiation of feeds.  The overall decrease in time to enteral feeds post-intervention was to be expected, yet time to full nutrition was much faster than if the pathway was being strictly followed.  Protocol implementation, education, reminders on rounds, and general increased awareness of the project aim all likely contributed to our success.  In conclusion, a standardized algorithm for enteral feeding on high flow was associated  with a significant decrease in time for initiation of enteral feeds and time to goal feeds with no significant increase in adverse events.  By using a multidisciplinary approach and having early involvement from physicians, nurses, and respiratory therapists, we were able to achieve our aim and make a culture  change in our unit. Further studies are needed in order to evaluate the safety and efficacy of enteral feeding on high flow nasal cannula for patients outside the ICU setting.  Thank you and I'll be happy to answer any questions.

Video Summary

In this video presentation, Sarah Sashnick discusses a quality improvement initiative at the Children's Hospital at Montefiore in New York. The initiative focuses on developing a protocol for enteral nutrition in patients receiving high-flow nasal cannula respiratory support. The lack of guidelines for feeding patients on high-flow nasal cannula can contribute to delays in feeding and a lack of standardized practices. The aim of the initiative was to decrease the time to initiation of enteral feeds by 50% using a standardized feeding algorithm. Through multiple cycles and interventions, the initiative successfully decreased the time to initiation of feeds with no significant adverse events. Further studies are needed to evaluate the safety and efficacy of enteral feeding on high-flow nasal cannula.

Asset Subtitle

GI and Nutrition, Pulmonary, 2021

Asset Caption

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

Keywords

video presentation

quality improvement initiative

Children's Hospital at Montefiore

enteral nutrition

high-flow nasal cannula

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