Asian Nursing Research 14 (2020) 17e23

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Asian Nursing Research

journal homepage: www.asian-nursingresearch.com

Research Article

Effect of a Clinical Nursing Practice Guideline of Enteral Nutrition Care

on the Duration of Mechanical Ventilator for Critically Ill Patients
Apinya Koontalay,1, * Amornrat Sangsaikaew,2 Arunee Khamrassame3
1
College of Nursing and Health, Suan Sunandha Rajabhat University, Bangkok, Thailand
2
Boromarajonani College of Nursing NakhonPhanom, Nakhon Phanom University, Nakhon Phanom, Thailand
3
Intensive Care Unit, Kuchinarai Crown Prince Hospital, Kalasin, Thailand

a r t i c l e i n f o a b s t r a c t

Article history: Purpose: Early enteral nutrition (EN) can improve clinical outcomes in critically ill patients. This study
Received 14 August 2019 aimed to evaluate the effects of this clinical nursing practice guideline (CNPG) of EN care on the duration
Received in revised form of mechanical ventilator in critically ill patients to investigate whether it was able to improve clinical
17 December 2019
outcomes.
Accepted 18 December 2019
Methods: This study compares a pretest-posttest design for the two groups, which was done before and
after to determine the effects of a CNPG of EN care on the duration of a mechanical ventilator in critically
Keywords:
ill patients. This study was performed on 44 critically ill patients admitted to the intensive care unit
critical illness
enteral nutrition
(ICU). The patients were divided into two groups according to EN. For the intervention group, CNPG
practice guideline started within the first 48 hours of admission to the ICU, and for the control group, they received
ventilators, mechanical standard nursing care.
Results: After the implementation, it showed significant associations between the duration of me-
chanical ventilator in ICU. The intervention group who received the CNPG had significantly shorter
starting time of EN and a reduced duration of mechanical ventilator than those in the control group
(p < .001).
Conclusion: A CNPG for EN care reduced the duration of mechanical ventilator. This could possibly
improve the delivery of target calories when compared with current standard practice and improve the
outcome of critically ill patients.
© 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction prolonged duration of mechanical ventilation, increase in cost,

duration of hospitalization, and higher mortality rates [4].
Critically ill patients are patients who have severe illnesses with Malnutrition in critically ill patients is a global public health
life threatening conditions that have serious consequences, including problem with a prevalence of 40% to 60% [3,5]. 50% of patients have
malnutrition [1]. They are typically associated with increased hy- malnutrition before hospitalization and from the pathology of a
permetabolic [2] and the presence of lean body mass reduction that critical illness [4], while 70% of patients have malnutrition during
leads to malnutrition [3]. Patients' respiratory and cardiovascular hospitalization [6,7]. Critically ill patients cannot resume an oral
systems are abnormal, leading to major organ failure in which they diet, or most commonly, there is an interruption to the delivery of
cannot function properly; respiratory insufficiency; impairment of feeding, which is a problem related to bedside procedure, gastro-
healing; and increase in infections [2]. In addition, consequences intestinal function as high gastric residual volume, the presence of
associated with malnutrition in critically ill patients may include a diarrhea, and aspirated [2]. The management of nutrition is delayed
in 60% of critically ill patients and causes an inadequate daily calorie
target in 42% of these patients [7]. These conditions affect body
Apinya Koontalay: https://orcid.org/0000-0001-8777-468X; Amornrat Sangsai- muscle, particularly the diaphragm, which is used for respiration
kaew: https://orcid.org/0000-0002-2467-956X; Arunee Khamrassame: https:// and may become weak and atrophic [8]. However, malnutrition
orcid.org/0000-0003-1926-5810 could decrease patients' ability for weaning mechanical ventilation,
* Correspondence to: Apinya Koontalay, MNS, RN, College of Nursing and Health,
increase the duration of mechanical ventilation [4], pressure sores
Suan SunandhaRajabhat University, Bangkok, 10110, Thailand.
E-mail address: [email protected] [8], infections [6], and mortality rate [3,4]. Nutritional support is an

https://doi.org/10.1016/j.anr.2019.12.001
p1976-1317 e2093-7482/© 2020 Korean Society of Nursing Science. Published by Elsevier BV. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
18 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23

important role in critically ill patients, The American Society of starting and managing enteral feeding or parenteral nutritional,
Parenteral and Enteral Nutrition (ASPEN) recommended that and monitoring patients for potential complication. Thus, a CNPG of
nutrition support therapy from early EN should start within 24- EN care in critically ill patients is an integral part of evidence-based
48 hours after ICU admission, or when there is stable hemodynamic research and practice combined with clinical expertise of practi-
condition after resuscitation [8], the functional integrity of the gut tioners to make decisions for effective nursing care and the best
by maintaining the structural integrity and may help to maintain performance with the patient that is suitable for the context. This
the systemic immune functions. Moreover, critically ill patients study applies the scope used in the development of nursing prac-
that received target calorie requirement during the first 7 days of tices by the Australian NHMRC [13]. The recommendations
hospitalization [7,8] and their respiratory muscle function included are based on the ASPEN [4]. This guideline for clinical
improved, which would increase the ability to wean mechanical practice development comprises of seven steps: (1) determining
ventilation [5,6]. the need for and the scope of the guidelines, (2) convening a
Previous studies have been shown in only a few studies, multidisciplinary panel to oversee the development of the guide-
standardized enteral feeding guideline. Lack of such guideline lines, (3) defining the purpose of and target audience for the
leads to delayed enteral feeding for critical patients more than guidelines, (4) reviewing the scientific evidence and categorized
24 hours after being admitted to the critical care unit [9], levels of research, (5) proposing the validated evidence to the
resulting in inadequate energy intake and complications, such as guideline development team, (6) formulating a dissemination and
nausea, flatulence, dyspepsia, gastrointestinal hemorrhage, implementation strategy, and (7) implementing a CNPG and
diarrhea, and hyperglycemia [10,11]. Nurse is the closest care revising it. Furthermore, the researcher develops CNPG of EN care
provider and has a crucial role in nutritional care, such as in critically ill patients with clinical expertise to make decisions in
nutrition assessment, assessment of energy and nutritional re- providing nursing care to maximize benefits for patients.
quirements, prefeeding readiness assessment, and the execution From a published literature review on nutritional promotion
of enteral feeding [8]. The guideline that has been developed and EN care in critically ill patients during 2008-2016, the pro-
systematically based on reliable empirical evidence would assist cess of EN care in critically ill patients consisted of the time to
practitioners to make decision on treatment. Implementation of start feeding, which should be within 24-48 hours [4]. Other
clinical practices would lead to changes in overall practice, assessment included the readiness for EN, gastric residual vol-
reduction in cost, and improvement in treatment quality [12]. ume, an assessment of calories target requirements, and the
These guidelines aim to standardize and automate the provision monitoring of feeding complications [9]. There were 16 from 30
of EN, enabling bedside nurses to initiate, monitor, and alter the research articles which matched the research objectives. The
administration of feeding without direct orders from the researchers categorized levels of research credibility according to
attending physician. The guidelines create variances in nursing the criteria of the Royal College of Physicians of Thailand [14].
practice and have not been updated with evidence-based clinical There were 11 quasi-experimental papers of research (level A)
practice guidelines from the actual problems. A clinical nursing and five operational papers (level B). It could be summarized
practice guideline (CNPG) developed from evidence-based that the guidelines helped the patients receive EN within
practice is suitable for the problem, is beneficial to the patient, 24 hours. Starting EN as soon as possible without contraindica-
and helps improve enteral feeding service quality. With such tion after resuscitation or with stable circulation [15] helped
practice, complications from enteral feeding can be avoided and provide targeted calories to the patients [4,7]. It was also
managed. Development of a comprehensive, standardized prac- beneficial for the restoration of organs to function normally in
tice also provides clear roles for the interdisciplinary team [13]. critically ill patients who had EN within 6 hours after admission
The researcher, therefore, has an awareness and interest in by improving intestinal absorption and preventing intestinal
using empirical evidence to develop a CNPG for enteral feeding atrophy [6]. The patients received target calorie requirement
in critically ill patients, applying the Australian National Health during the first 7 days of hospitalization [7,8], and their respi-
and Medical Research Council (NHMRC) [13], NHMRC supports ratory muscle function improved, which would increase the
the development and approval of high quality guidelines for ability to wean mechanical ventilation [5,6]. The content of the
critical practice. This systematic and standardized development synthesis practice from systematic literature review based on
of nursing practice development would allow feeding for critical empirical evidence, the best researches on the content of five
patients within suitable time as well as obtain participation of activity categories: (1) Assessment for readiness of the critically
practitioners, which foster a sense of responsibility and will- ill patients before EN, (2) assessment of targeted calories
ingness to follow the guideline [4]. A guide to the development requirement, (3) EN procedure, (4) prevention of EN complica-
by NHRMC, implementation, and evaluation of CNPG may lead to tion, and (5) outcome evaluation after EN. In this regard, a CNPG
adaptation of strategies suitable for local conditions and devel- for EN care by using demonstration methods together with the
oped in concert with local clinicians in Thailand. In addition, promotion of practice guidelines. There is a common goal of the
there should be CNPG for EN specific to critically ill patients. This interdisciplinary team, share information, and opinions in
could provide patients with energy and protein requirements nursing together to follow the guidelines developed. The sug-
and nutrients, prevent feeding complications, reduce variety in gested summarizing content is shown in Table 1.
practice, and develop more effective services [9]. This study was
to evaluate the effects of this CNPG of EN care on the duration of Methods
mechanical ventilation in critically ill patients. The result of this
study showed a reduced duration of mechanical ventilation. A Study design
clinical practice guideline may have resulted in an improvement
in the delivery of EN to critically ill patients. This study used a quasi-experimental, pretest-posttest design
Nurses are the primary care provider for critically ill patients. with a comparison group, which was done before and after to
For nutritional support, a nurse has an important role in identifying determine the effects of a CNPG of EN care on the duration of a
nutritional risk screening, assessing the adequacy calories target, mechanical ventilator in critically ill patients.
 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23 19

Table 1 Summary of Clinical Nursing Practice Guideline of Enteral Nutrition Care in Critically Ill Patients.

Issue Information available in clinical nursing practice guideline

Assessment for readiness Before enteral nutrition, critically ill patients must be corrected for the shock of the blood circulatory system until the
before enteral nutrition and time to start circulation is stable for at least 6 hours. With the doctor's order and no contraindication, the enteral nutrition is started. The
enteral nutrition [3,6,15,19] (Grade B) assessment criteria consist of the followings
a. Heart rate less than 120 bpm
b. Average arterial pressure is 65 mmHg and over
c. Inotropic drug of less than 5 microgram/kg/min is received
d. No direct vasopressor drug
e. Base excess is more than
2.5 mEq/liter or blood lactate is less than 2.5 mEq/liter
In the case of patients with risks of abdominal compartment syndrome, they must be monitored for intraabdominal pressure
to be less than 15 mmHg. The risks of abdominal compartment syndrome include abdominal organ injury, receiving more
than 6 units of blood or blood components in the first 12 hours after injury, abdominal distension, and signs of increased
intraabdominal pressure which are oliguria, hypotension, hypoxia, and increased intracranial pressure. The enteral nutrition
is started when the patients pass all assessments for readiness, and the doctor is consulted if there is an abnormal condition.
Assessment of energy and protein The daily calories target requirement is 25 kcal/kg/d as HarriseBenedict equation x 1.0-1.3 and 1.0-2.0 gm/kg/body weight
requirement [3,6,15,16,19] (Grade B) (BW) and EN was recorded within 7 days.
The current or ideal BW was used in the patients whose body mass index (BMI) ¼ 18-30 kg/m2. Ideal BW in
males ¼ 50.0 þ 0.91 kg (height ¼ 152.4 cm) and in females ¼ 45.5 þ 0.91 kg (height ¼ 152.4 cm). For obese patients (BMI >
30), an adjusted body weight is used instead of their current weight. The adjusted BW ¼ 0.5 (current weight þ ideal weight)
Tube insertion techniques and Identifying the location of the feeding tube as the followings:
placement confirmation [3,16] (Grade A) a. Identifying the location of the feeding tube before feeding every 4 hours incontinuous feeding and before next feeding in
intermittent feeding.
b. Identifying the location of the feeding tube by;
 Length of the feeding tube from the nose or mouth angle without folding in the mouth.
 Characteristics of the aspirated gastric contents which should be clear or grassy-green and mixed with the remaining
food. If the gastric contents could not be aspirated or no certain location of the feeding tube, it could be tested by
pumping 10-20 ml of air into the feeding tube and listening to the air sound at epigastrium with stethoscope. This must
be confirmed by two nurses. If the feeding tube is not in the right location, the doctor will be consulted to reinsert the
feeding tube.
Selecting enteral nutrition pattern and adjusting diet amount. Continuous feeding should be started in critically ill patients
for 24 hours with the rate of 20 ml/hr. If the patients are well tolerated (gastric residues less than 200 ml in 4 hours and no
enteral nutrition complication), the feeding amount of 20 ml/hr is added every 8 hour until the targeted calories is met.
Selection of diet for critically ill patients: a. Standard concentration of enteral nutrition for critically ill patients is 1 kcal/ml. b.
Other choices of specialized diet depend on the doctor's consideration.
Preparing enteral nutrition and diet sets for the patients [3,16]
a. Preparing bottled liquid diet with sterile water and a sterile technique.
b. The liquid diet prepared at the ICU is recommended to be fed within 24 hrs.
c. The bottled liquid diet is prepared by the nutritional unit and should be stored in the refrigerator for not more than
24 hours and should be put at room temperature before feeding within 4 hours with the any leftover discarded.
d. Washing hands before holding food supplies and when feeding the patients.
e. Wearing clean gloves to wash feeding equipment.
f. All equipment for enteral and medicine feeding should be washed and dried before the next feeding:
 the feeding syringe should be washed with clean water, left to dry before the next use and changed to a new set every
shift
 the continuous feeding set (kangaroo pump set) should be washed with hot water after feeding for 4 hours, dried
before the next use and changed to a new set every 7 day
 the intermittent feeding set should be changed to a new set for each feeding
 the medicine cup and diet preparing equipment should be washed with dish washing soap and clean water and dried
before the next use.
Prevention of enteral nutrition Enteral nutrition should be temporarily stopped if there vital signs change to a state of shock which needs an increasing dose
complications [3,6,13,16,19] (Grade B) of cardiac drugs that cause blood vessel constriction. The enteral nutrition can be started with the same rate after the
patients' circulatory systems become stable.
Prevention of aspiration with the following procedures [16]:
a. Positioning the patients' beds to a 30 elevated head tilt during enteral nutrition (if no contraindication) and spending the
least time in a recumbent position or less than a 30 head tilt.
b. If there is contraindication of the elevated head tilt position, such as a spinal cord injury, the patients' bed should be in a
reverse Trendelenburg position.
c. If the patient needs to lower the head tilt or recumbent position for a longer period of treatment, the enteral nutrition
should be temporarily stopped until their conditions allow an elevated head tilt position.
d. The gastric residual volume (GRV) should be evaluated every 4 hours in continuous enteral nutrition and before each
feeding in intermittent feeding.
e. When there is regurgitation, vomiting, or choking, the enteral nutrition must be temporarily stopped, and the cause
should be investigated and solved before the next feeding.
f. The patients' oral care with sputum suction should be provided every shift. The enteral nutrition should be temporarily
stopped during sputum suction to prevent choking and movement of the feeding tube. The feeding can be restarted
promptly after sputum suction.
g. The endotracheal tube cuff pressure should be checked for a peripheral leak to obtain peak inflation pressure. The
endotracheal tube cuff pressure should not be over 24-30 cm H2O and should not be totally deflated to prevent
choking food into the trachea during using a ventilator.
Management of gastric residues by the followings [3,16]:
a. If the GRV is 200-300 ml, the rate of feeding should remain the same, and all residues should be put back. If the patients
have nausea, vomiting, choking, abdominal distension, and severe abdominal pain, the enteral nutrition should be
temporarily stopped, and 500 ml of GRV can be put back.
b. If the GRV is more than 500 ml, the enteral nutrition should be temporarily stopped and 500 ml of GRV put back and the
rest discarded. The GRV is reevaluated every 2 hours.
(continued on next page)
20 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23

Table 1 (continued )

Issue Information available in clinical nursing practice guideline

c. If the GRV twice is more than 500 ml, the causes should be investigated and corrected. The probable causes are body
condition, gastrointestinal tract abnormality, blood glucose, and sedatives. A prokinetic drug such as metoclopramide
should be prescribed by the doctor. Additionally, if the gastric residues remain, the enteral nutrition should not be
stopped for a longer period, but the feeding volume should be reduced instead.
d. For patients with a severe head injury who cannot tolerate enteral nutrition within 48 hours after injury, the location of
the feeding tube should be moved to the small intestine under the doctor's order for more food tolerance and safety from
choking.
e. An occlusion of the feeding tube can be prevented by washing the tube with 20 ml of drinking water every 4 hours in
continuous feeding and washing after intermittent feeding, after checking gastric residues, before and after giving
medicines via feeding tube and when stopping the enteral nutrition.
Managing abdominal distension by evaluating the symptoms from inquiry and physical examination. Abdominal distension
should be managed as follows:
a. Less abdominal distensiondkeep the same feeding rate and monitor the symptoms with a record every 4 hours. If the
symptoms remain the same, the feeding volume can be increased as normal practice.
b. Moderate abdominal distension or the patients complains of more distensiondthe feeding rate and volume should be
reduced to half. The causes should be investigated including the monitoring GRV and intraabdominal pressure. The
doctors should be consulted to prescribe a prokinetic drug and to adjust the feeding rate and volume. The symptoms
should be monitored and recorded every 4 hours.
c. Severe abdominal distension or the patients complain of severe abdominal distension, become nervous, have a rapid
pulse rate and rapid respirationdthe enteral nutrition must be temporarily stopped, and the causes should be
investigated. The doctor should be consulted to treat or order more investigations such as abdomen X-ray. The symptom
should be followed and recorded every 4 hours.
Managing diarrhea as the followings:
a. Diarrhea 3-4 times or 400-600 ml/daydThe feeding rate and volume should remain the same. If diarrhea persists for
more than 48 hours, the doctor should be consulted to investigate the causes such as side-effects of a prokinetic drug
and a drug that contains sorbitol, magnesium, or phosphorus.
b. Diarrhea for more than 4 times/day or more than 600 ml/daydthe feeding rate and volume should be reduced to half. The
doctor should be consulted to investigate the causes from intestinal infection and treat the patients.
c. If the patients have risks of wound or central venous line contamination from stool, the doctor should be consulted to
treat and prevent infection.
Outcome evaluation after enteral Record of feeding diet in every mealdtype of diet, feeding rate, volume, and gastric residues.
nutrition as follows [13] (Grade B) Evaluation of enteral nutrition complications every 4 hoursdabdominal distension, vomiting, choking, diarrhea, and change
in vital signs. The complications are recorded and corrected.

Setting and sample Ethical consideration

The participants were 44 critical ill patients at the Tertiary This study was approved by the Research Ethical Committee of
Hospital in Thailand from October 2018 to February 2019 in the the Public Health Office Research Ethics Committee (Approval no.
intensive care unit (ICU), who understood the purpose and pro- KLS.REC096/2561) belonging to the researcher to protect the hu-
cedures of this study and voluntarily consented to the research that man rights of the research participants. Before starting data
participated in this study. The inclusion criteria of participants collection, the participants and guardians were given a full expla-
were (1) being conciseness; (2) aged 18 years or over; (3) vital signs nation of the purpose and procedure of the study to potential
stable; (4) Acute Physiology and Chronic Health Assessment II participants and that they could withdraw from the study at any
(APACHE II)  15; (5) received the EN; and (6) willing to participate. time. All participants willing to participate voluntarily were asked
Patients were deemed ineligible if they had other metabolic dis- to sign the informed consent. Guardians replied for patients for
eases (e.g., uncontrolled diabetes mellitus, thyroid disease, cancer, whom a response was too difficult because of cognitive functioning
liver disease, or end of life) or were in a critical condition needing problems that developed during the study period.
complete bed rest. Patients who were determined EN or noninva-
sive ventilator support were excluded from this study. Measurement
To calculate the number of participants, the effected size of
intervention applied to CNPG for EN care in hospitalized in a pre- Questionnaires and measurements
vious study [15] was used. In this study, the effected size of the The participants' completed a demographic and clinical data
experimental group was .50. In applying alpha ¼ .05, power ¼ .80 sheet, included age, gender, diagnosis, disease severity (APACHE II),
on G*Power 3.1 software, a total of 44 critically ill patients were start EN (hours), daily calories target, and the duration of me-
initially included in the study (22 in the intervention group and 22 chanical ventilator (hours) interviews by the researchers.
in the control group). The participants included in the study were
matched according to their age, diagnosis, and disease severity Disease severity assessment form
(APACHE II) to provide homogeneity in groups. The researchers used the APACHE II which was developed by
In addition, all patients received first time invasive a mechanical Knaus et al. [16]. The APACHE II is a universal tool and widely used
ventilator in the ICU for more than 6 hours during the period and for assessment of disease severity and forecast the mortality risk of
hemodynamic stable before or after implementation of the CNPG the patients. The scores of disease severity were assessed by
with the permission from attending physicians were included in abnormal clinical signs during illness. The 12 variables were body
the study. Patients were divided into two groups based on the temperature, mean arterial pressure, heart rate, respiration rate,
physician's judgment for EN onset; the first group included patients blood pH, serum HCO3, hematocrit, white blood cell count, serum
who received CNPG for EN care within 24 hours after being creatinine, serum BUN, serum sodium, and serum potassium. The
admitted into ICU and the control group received standard nursing. highest abnormal scores within 24 hours of admission in ICU were
 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23 21

combined with Glasgow Coma Scores and were determined with included daily calories target requirements, and the duration of
chronic diseases, age, underlying diseases, white blood cell count, mechanical ventilator (hours) was assessed by a researcher.
and type of surgery. The combined scores would determine the Once data collection in the control group was finished, the
disease severity and forecast the risk of mortality in critically ill intervention group was recruited, and those phases of the study
patients who were admitted in ICU; score ranged from 0-71 with began. The intervention group's baseline data were collected
the higher scores determined more severity and higher mortality. through the medical records within 24 hours of hospitalization. A
The APACHE II scores of 25 and over indicated more than 50% risk of CNPG started within the first 48 hours of admission to the ICU, and
mortality. In this study, this instrument was tested with 10 critical the time to first enteral feeding prescription was recorded. We
ill patents and The Cronbach a coefficients for the present study included patients' age ≥ 18 years or over on mechanical ventilator
were .84 and for this study was .81. 6 hours, and they received EN. To calculate the daily calories
target requirement using the HarriseBenedict equation x 1.0-1.3
The daily calories target requirement and 1.0-2.0 gm/kg body weight, and EN was recorded within 7 days.
The calories target was calculated based on 25 kcal per kg of The participants in the intervention and control groups were
body weight for patients in a catabolic phase and 30 kcal per kg of monitored for the duration of the mechanical ventilator from the
body weight for patients in an anabolic phase as per the Har- first day of invasive mechanical ventilator and after hemodynamic
riseBenedict equation x 1.0-1.3 and 1.0-2.0 gm/kg body weight [4], stable within 6 hours.
and EN was recorded within 7 days. For the intervention group, the
assessment contained records of the daily calories target from the Data analysis
first hour that the patients had EN until they met the 7 days of daily
calories target requirements. In this study, this instrument was The data were analyzed using SPSS, version 22.0, statistical
tested with 10 critical ill patents, and the Cronbach a coefficients for program (IBM Corp., Armonk, NY, USA). Descriptive statistics, such
the present study was .93, and for this study was .95. as number, percentage, mean, and standard deviation, were used to
analyze the participants' demographics. Chi-square test and t test
The clinical nursing practice guideline of enteral nutrition care were used to compare baseline variables between the intervention
The CNPGs for EN care. The researchers adapted a conceptual and control groups. The significance test was used to examine
framework of clinical practice development from the NHMRC. The differences in quantitative variables between the groups. Contin-
CNPG and the content of the synthesis practice from systematic uous variables were compared using the independent sample t test.
literature review based on empirical evidence of which the best An independent sample t test was used to compare the differences
research on the content of five activity categories was (1) assess- between pretest and posttest scores of the participants' in the
ment for readiness of the critically ill patients before EN, (2) intervention and control groups. A paired sample t test was used to
assessment of the daily calories target, (3) EN procedure, (4) pre- compare the differences between pretest and posttest scores of the
vention of EN complications, and (5) outcome evaluation after EN. participants' at each group. For all analyses, p < .05 was accepted as
In this regard, CNPG was used by demonstrating methods together the level of significance.
with the promotion of practice guidelines. There is a common goal
of the interdisciplinary team to share information and opinions in Results
nursing together and to follow the guidelines developed. The
control group used standard nursing who were informed about the Comparison of demographic characteristics between two groups
project on the first day, and their information was recorded. The
developed practice guidelines were examined by three experts for There was no statistically significant difference in demographic
content validity; they were corrected as the experts' advice. The characteristics (age, diagnosis, and disease severity) between the
practice guidelines were tested with 10 critically ill patients to intervention and control groups. The mean age of the participants
assess feasibility for implementation. The instruments were was 47.11 years, ranging from 31-70 years, 39.4% were female, 54.5%
examined by three experts and were revised based on their sug- were diagnosed with septicemia, and 60.7% were mild severity of
gestions. The test and retest reliability yielded .90 for the patients' APACHE II score. No statistically significant difference were found
version with 10 critically ill patients, and the Cronbach a co- between the intervention and control groups regarding age, diag-
efficients for the present study was .89. nosis, and disease severity (APACHE II). (Table 2).

Data collection Starting time of enteral nutrition and daily calorie target

The data collection period was from October 2018 to February, The compared mean scores for the starting time of EN and daily
2019, in an ICU at the Tertiary Hospital in Thailand were recruited calorie target requirement in the first 7 days before and after
by purposive sampling. The purpose of this study was explained to implementation were analyzed by t test. The EN start was within
evaluate the effects of this CNPG of EN care on the duration of 8.78 hours (min-max ¼ 5-42 hours, mean ¼ 8.63, SD ¼ 6.15), and
mechanical ventilator in critically ill patients to investigate the daily calorie target requirement in 7 days was 4590.91 kcal/kg/
whether it was able to improve clinical outcomes. The patients day (min-max ¼ 1,400-19,600 kcal/kg/day, mean ¼ 6,700,
were divided into two groups according to EN. The data collection SD ¼ 4575.50). The results showed that mean scores on starting
in the control group was conducted first to prevent contamination time of EN and the daily calorie target requirement after using
of the care. The researcher reviewed patients' medical records to CNPG were different from the scores before using the practice
identify those who met inclusion criteria for the control group. guidelines with a statistical significance (p < .001). (Table 3).
Demographic data and history of illness were recorded from the
medical records, and the interview was conducted to respondents Duration of mechanical ventilator
or guardians at the time of enrollment. Disease severity and the
daily calories target requirement were assessed within 7 days. The The comparison of the mean scores for the duration of me-
control group received treatment and usual nursing care as chanical ventilation before and after implementation were
following the standard of care for EN care. Patient outcome analyzed by t test. The duration of mechanical ventilation was
22 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23

Table 2 Demographic Characteristics of Critical Ill Patients (N ¼ 44).

Demographic characteristics Intervention group (n ¼ 22) Control group (n ¼ 22) t or c2 p

Age (yrs) (M ± SD) 47.18 ± 10.32 47.05 ± 10.96 .04a .966

APACHE II (M ± SD) 20.16 ± 3.96 21.09 ± 5.49 -.44a .662

n (%) n (%)

Sex .54 .766

Men 10 (22.7) 8 (18.2)
Women 12 (27.3) 14 (31.8)
Diagnosis .77 .540
Septic shock 18 (40.9) 18 (40.9)
Pneumonia 2 (4.5) 1 (2.3)
Heart disease 2 (4.5) 3 (6.8)

Note. APACHE II ¼ Acute Physiology and Chronic Health Assessment II; SD ¼ standard deviation; yrs ¼ years.
a
Independent samples t test.

Table 3 Comparison of Mean Scores for the Starting Time of EN, Energy Protein Requirements in the First 7 Days, and Duration of Mechanical Ventilation Between the Intervention and
Control Groups (N ¼ 44).

Variables Intervention group (n ¼ 22) Control group (n ¼ 22) t p

M ± SD M ± SD

Starting time of enteral nutrition (hours) 8.63 ± 6.15 24.00 ± 10.49 6.19 <.001
Daily calorie target requirement in the first 7 days (kcal/day) 6700.00 ± 4575.50 2481.82 ± 1216.80
3.95 <.001
Duration of mechanical ventilation (hours) 33.90 ± 11.25 78.45 ± 41.50 4.86 <.001

Note. SD ¼ standard deviation.

33.64 hours (min-max ¼ 24-192 hours, mean ¼ 56.18,SD ¼ 37.55) patients receive nutrition as soon as possible if there is no
after using CNPG, and the intervention group had a shorter of contraindication. After implementing CNPG, the intervention
duration of mechanical ventilation than the control group, with a group had different durations of time on the mechanical ventila-
statistical significance (p < .001). Table 3. tion from the control group with a statistical significance
(p < .001). There was a study which found that after using practice
guidelines for EN within 24 hours and achieving the target calorie
Discussion daily requirement in the first 7 days [18], the duration of me-
chanical ventilation use would decrease. The patients with a
The results of this study showed that early EN in critically ill ventilator need a higher target calorie daily requirement than
patients before and after implementation of CNPG was analyzed. other patients [3,19]. This was consistent with the study of
The initial EN started within 48 hours after the patient was McClave et al. [4], which found that having critically ill patients in
admitted and stabilized of hemodynamic. For all patients in this the medical ward receive EN within 48 hours, and an adequate
study, an invasive mechanical ventilator was initialed on the first target calorie daily requirement as soon as possible was related to
day admission as well. To investigate the implementation of CNPG the duration of mechanical ventilation use with a statistical sig-
improvement of early EN, the target calorie daily requirements in nificance [6]. However, there were other factors besides nutrition
day 7 and the reduced duration of the mechanical ventilator were that affected the duration of a ventilator, such as age, disease
compared. The implementation of EN guidelines led to the severity, and underlying diseases [8].
achievement of the initialed early EN reach within 8.67 hours, In recently developed clinical practice guidelines for EN, it states
significantly after the implementation. that is a benefit for the potential risks and complications of that
The study showed that the intervention group had a reduced experiment [20], promotes early EN, and minimizing interruptions
time of duration of mechanical ventilator than the control group in feeding should be encouraged to be used. Nurses may be able to
with a statistical significance (p < .001). It could be explained that eliminate delay feeding and consultation with the multidisciplinary
after implementation, the intervention group received EN within team, confirmation of timing to initial EN [8]. Also, ensuring a
24 hours. They were evaluated for readiness and an adequate target timely resumption of enteral feeding when interruptions are no
calorie daily requirement after being admitted in the ICU as longer necessary may be beneficial [2]. Furthermore, evidence
A.S.P.E.N recommended [4,9]. Dhaliwal et al. [17] studied factors suggested that a clinical practice guideline recommendation into
that could affect EN. They found that having practice guidelines nurse-initial to start enteral feeding is an effective strategy to
could help patients to receive EN in 24 hours, who benefited from improve the delivery of nutritional feeding. The clinical practice
organ restoration to its normal function [4]. EN care for critically ill guideline for EN care is the potential role of critical care nurse in
patients within 6 hours after being admitted into ICU showed improving nutrition practice; critical nurses play an important role
improved intestinal absorption and prevention of intestinal atro- ensuring that patients meet nutritional target goals and an
phy [17]. They also received an adequate target calorie requirement adequate prescription and delivery of nutrition therapy [2,3,5,8].
which promoted respiratory muscle function [3].
EN in patients admitted to ICU is often delayed because of
reasons including procedures, gastrointestinal dysfunction, and Study limitation
nurses having a lack of knowledge. Nurses have an important role
in the nursing care, nursing plan, preventing and managing com- The approach of our study had a relatively small number of
plications, and coordinating the multidisciplinary team to have the patients who enrolled in our study and applied in one ICU hospital.
 A. Koontalay et al. / Asian Nursing Research 14 (2020) 17e23 23

Indeed, the participants of this study were recruited at a single support therapy in the adult critically ill patient. J Parenter Enteral Nutr.
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The findings of this study indicate that the integration of the 2014;371(18):1673e84. https://doi.org/10.1056/NEJMoa1409860
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Med. 2014;15(3-4):205e9.
tion in critically ill patients. It is recommended to start feeding as 8. Marshall A, Cahill NE, Gramlich L, MacDonald G, Alberda C, Heyland DK.
soon as possible within 24 hours so to receive the adequate target Optimizing nutrition in intensive care units: empowering critical care nurses to
calorie daily requirement in the first 7 days. Therefore, this program be effective agents of change. Am J Crit Care. 2012;21(3):186e94.
https://doi.org/10.4037/ajcc2012697
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tients treated with vasopressors and mechanical ventilation. Am J Crit Care.
2010;19(3):261e8. https://doi.org/10.4037/ajcc2010197
The authors declared no conflicts of interest. 12. Arbeloa CS, Elson MZ, Monzon LL, Bonet TM. Enteral nutrition in critical care.
J Clin Med Res. 2013;5(1):1e11. https://doi.org/10.4021/jocmr1210w
13. National Health and Medical Research Council [NHMRC]. A guide to the
Acknowledgment development, implementation and evaluation of clinical practice guidelines
[Internet]. Canberra, Australia: NHMRC. 1998 [cited 2009 Jan 15]. Available
The authors would like to express sincere thanks to the critical from: https://www.health.qld.gov.au/__data/assets/pdf_file/0029/143696/
nhmrc_clinprgde.pdf
ill patients for their participants in this study. The authors also wish
14. The royal College of physicians of Thailand. Evidence-based medicine &clinical
to thank the staff of the intensive care unit who allowed them to practice guidelines committee. R Coll Bull. Clin Prac Guide. 2001;18(6):36e47.
recruit patients from their department. The researchers thank all Thai.
the experts who examined the research tools, the research assis- 15. Roberts SR, Kennerly DA, Keane D, George C. Nutrition support in the intensive
care: unit adequacy, timliness, and outcomes. Crit Care Nurse. 2003;23(6):
tants. The researcher are also grateful to the National Research 49e57.
Council of Thailand for granting research funding for the study. 16. Knaus WA, Draper EA, Wangner DP, Zimmerman JE. Apache II: a severity of
disease classification system. Crit Care Med. 1985;13(10):818e29.
17. Dhaliwal R, Cahill N, Lemieux M, Heyland DK. The Canadian critical care
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