Nursing Staff Adherence to National and International Guidelines on Nutritional Management for Critically Ill Patients With Cancer: A Service Evaluation, 2019

Aim and objectives: Critically ill patients with cancer are at high risk of developing malnutrition, negatively affecting their outcome. This service evaluation aims to critically analyse nursing staff's adherence to nutrition management guidelines for critically unwell patients with cancer and identify barriers which prevent this. Two areas of nutrition management were evaluated: early initiation of enteral nutrition (<48hrs from admission) (EN); and continuation of EN without interruption.
Methods: A retrospective data analysis was performed in 2019 on mechanically ventilated adult patients admitted to a single cancer centre ITU between February 2017 to December 2018. Data from patient records concerning these three areas of nutrition management was collected. Healthcare professionals' (HCP) documentation was analysed, and a nursing staff focus group was undertaken.
Results: Sixty-four patient records were included. Early EN was not administered in 67% (n=43) of cases. The reasons for the three longest interruptions to EN feed were as follows: delays in enteric feeding tube insertion, gastric residual volumes <500ml/6 hours and patient intubation. Four main themes relating to barriers in practice were identified from the focus group data analysis: HCPs' approach towards nutrition management, patient's physiological condition and stability, multi-disciplinary team communication and guidance on nutrition management and practical issues with patient care.
Conclusions: Barriers in practice include inaccurate opinions and inadequate awareness on the importance of nutrition, multi-disciplinary communication difficulties and lack of clear recommendations set out by guidelines. Nursing education on the importance of optimal nutrition management is fundamental for this to improve. Results from this service evaluation can be used to improve practice in this unit. A further study with a greater number of cases incorporating views from the wider range of MDT members would be beneficial to determine the validity of these findings.<p>Aim and objectives: Critically ill patients with cancer are at high risk of developing malnutrition, negatively affecting their outcome. This service evaluation aims to critically analyse nursing staff's adherence to nutrition management guidelines for critically unwell patients with cancer and identify barriers which prevent this. Two areas of nutrition management were evaluated: early initiation of enteral nutrition (<48hrs from admission) (EN); and continuation of EN without interruption.

Methods: A retrospective data analysis was performed in 2019 on mechanically ventilated adult patients admitted to a single cancer centre ITU between February 2017 to December 2018. Data from patient records concerning these three areas of nutrition management was collected. Healthcare professionals' (HCP) documentation was analysed, and a nursing staff focus group was undertaken.

Results: Sixty-four patient records were included. Early EN was not administered in 67% (n=43) of cases. The reasons for the three longest interruptions to EN feed were as follows: delays in enteric feeding tube insertion, gastric residual volumes <500ml/6 hours and patient intubation. Four main themes relating to barriers in practice were identified from the focus group data analysis: HCPs' approach towards nutrition management, patient's physiological condition and stability, multi-disciplinary team communication and guidance on nutrition management and practical issues with patient care.

Conclusions: Barriers in practice include inaccurate opinions and inadequate awareness on the importance of nutrition, multi-disciplinary communication difficulties and lack of clear recommendations set out by guidelines. Nursing education on the importance of optimal nutrition management is fundamental for this to improve. Results from this service evaluation can be used to improve practice in this unit. A further study with a greater number of cases incorporating views from the wider range of MDT members would be beneficial to determine the validity of these findings.</p>

研究目的与目标：罹患癌症的重症患者发生营养不良的风险极高，且会对其预后产生不良影响。本服务评估旨在批判性分析护理人员对癌症重症患者营养管理指南的依从性，并识别阻碍依从性的相关障碍因素。本次评估涵盖两项营养管理内容：早期肠内营养（enteral nutrition, EN）启动（入院后48小时内），以及肠内营养的不间断持续实施。

研究方法：本研究于2019年开展回顾性数据分析，研究对象为2017年2月至2018年12月期间，收治于某单一癌症中心重症监护病房（intensive care unit, ITU）的机械通气成年患者。研究人员收集了患者病历中与上述三项营养管理内容相关的数据，分析了医疗保健专业人员（healthcare professionals, HCP）的相关文书记录，并开展了护理人员焦点小组访谈。

研究结果：本研究共纳入64份患者病历。其中67%（n=43）的病例未实施早期肠内营养。导致肠内营养输注三次最长中断的原因分别为：肠内营养管置入延迟、胃残余量<500ml/6小时，以及患者需进行气管插管。通过对焦点小组数据的分析，共提炼出四项与临床实践障碍相关的核心主题：医疗保健专业人员对营养管理的认知态度、患者的生理状态与稳定性、多学科团队（multi-disciplinary team, MDT）沟通情况，以及营养管理指导规范与患者护理实操问题。

研究结论：临床实践中的障碍包括对营养重要性的认知偏差与认知不足、多学科团队沟通障碍，以及指南未明确给出相关推荐意见。针对优化营养管理重要性的护理教育培训，是改善当前现状的核心基础。本次服务评估的结果可用于优化该重症监护病房的临床实践。未来可开展纳入更多病例样本、且涵盖更广范围多学科团队成员意见的后续研究，以验证本研究发现的有效性。