Effects of implementation of a computerized nutritional protocol in mechanically ventilated critically ill patients: A single-centre before and after study.

INTRODUCTION: Optimal nutrition, defined as adequate intake of energy, macronutrients -especially proteins- and micronutrients impacts on outcome of patients admitted to the Intensive Care Unit (ICU). However, both nutrition below and over target have been associated with increased morbidity and mortality. Computerized nutrition protocols may help to improve nutrition adequacy. In July 2014 a computerized nutritional protocol was implemented in our ICU. We designed a study to address the effects of this protocol implementation on energy and protein adequacy and outcome.

METHODS: A retrospective pre-post analysis of nutrition adequacy in adult mechanically ventilated critically ill patients before and after the implementation of an electronic nutritional protocol to initiate feeding and with hourly feedback. Primary outcome was adequacy of total caloric intake from day 2-7, secondary outcomes were adequacy of protein intake, clinical outcome results (length of ICU and hospital stay, ICU and hospital mortality, duration of tube feeding, duration of mechanical ventilation, number of patients with parenteral nutrition), and glucose and electrolyte abnormalities.

RESULTS: In total 146 patients were included (73 patients before and 73 patients after implementation). Before implementation we encountered more patients who were fed above target (actual caloric intake >110% of target) than after implementation (during day 2-7: 12% vs. 3%, P = 0.029) without significant reduction of protein intake (daily means during day 2-7: 1.18 g/kg vs. 1.08 g/kg, P = 0.09). Only on day 6, significantly more patients were fed on target after implementation (80-110%; 47% vs. 67%, P = 0.028). No differences in numbers of patients who were fed below target (<80%) were found. Numbers of patients with hypokalaemia after implementation (59% vs. 38%, P = 0.013) were lower. The incidence of electrolyte abnormalities (hypernatraemia, hyponatraemia and hypokalaemia) was lower after implementation, however hypomagnesaemia incidence increased. No statistical significant differences in clinical outcome were observed.

CONCLUSIONS: The implementation of an electronic nutritional protocol to initiate feeding with hourly feedback in our ICU reduced the rate of mechanically ventilated patients fed above target without reducing protein intake or increasing the rates of feeding below target, while reducing the incidence of electrolyte abnormalities. No statistical significant differences in other clinical outcomes were observed.