Opportunities to improve nutrition delivery in hospital after discharge from an intensive care unit: A mixed methods analysis.

Background and AimsThough adequate nutrition following critical illness is fundamental to rehabilitation, it is poorly provided. To inform interventions to improve nutrition support for patients discharged from an intensive care unit (ICU), we aimed to document remediable problems in nutrition management on general hospital wards, and the context for these problems. MethodsThis work forms part of a larger mixed methods study: REcovery FoLlowing intensivE Care Treatment (REFLECT). From three NHS hospitals, chosen to represent different hospital settings, we conducted in-depth reviews of 20 cases where in-hospital death after ICU discharge was judged probably avoidable and 20 cases where patients survived to hospital discharge. We interviewed 55 patients, family members and staff about their experiences of post-ICU ward care. From these primary data we extracted information related to nutrition provision to develop a process map of how enteral feeding is delivered to patients on hospital wards after ICU discharge. ResultsProblems with nutrition delivery were common (81 problems in 20/40 cases), mostly (70/81) in patients whose death was judged "probably avoidable". Common issues included failure to monitor nutritional intake, delays in dietician/nutritional support referrals, removal of enteral feeding tubes before oral intake was established, and poor management of enteral nutrition delivery. Staff identified workload related to the high care needs of post-ICU patients as contributing to these problems in nutrition delivery. The process map of enteral feeding delivery demonstrated that local policy for tube placement confirmation risked prolonged system-related delays to administering naso-gastric feed, significantly affecting the volume of feed delivered to patients. ConclusionsUsing a novel mixed methods approach, we identified problems throughout the process of delivering nutritional support, which had profound consequences for post-ICU patients. We demonstrated the importance of multi-professional collaboration in delivering enteral nutrition. Improving collaborative working processes within the ward system may ensure timely confirmation of correct nasogastric tube placement, and support safe feeding. Addressing the common problems in post-ICU nutritional support we identified may support improved nutritional delivery and potentially enhance recovery from critical illness. Study registrationISRCTN:14658054