Nutrition Support in the Critically Ill: A Physician SurveyFrom the 1 Department of Internal Medicine,2 Section of Gastroenterology and Nutrition,3 Department of Food and Nutrition,4 Department of General Surgery, and5 Section of Pulmonary and Critical Care Medicine, Rush University Medical Center, Chicago, Illinois. Address correspondence to: Srinadh Komanduri, MD, MS, Rush University Medical Center, Section of Gastroenterology and Nutrition, 1725 West Harrison Street, #206, Chicago, IL 60612; e-mail: sri_komanduri{at}yahoo.com.
Background: Current clinical practice guidelines delineate optimal nutrition management in the intensive care unit (ICU) patient. In light of these existing data, the authors identify current physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding in the ICU patient. Methods: The authors electronically distributed a 12-question survey to attending physicians, fellows, and residents who routinely admit patients to medical and surgical ICUs. Results: On a scale ranging from 1 to 5 (1 = low, 5 = high), the attending physician's mean rating for importance of nutrition in the ICU was 4.60, the rating for comfort level with the nutrition support at the authors' institution was 3.70, and the rating for the physician's own understanding of nutrition support in critically ill patients was 3.33. Attending physicians, fellows, and residents reported waiting an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in an ICU patient. Fifty-two percent of attending physicians chose parenteral nutrition as the preferred route of nutrition support in a patient with necrotizing pancreatitis. If a patient experiences enteral feeding intolerance, physicians most commonly would stop tube feeds. There was no significant difference in responses to any of the survey questions between attending physicians, fellows, and residents. Conclusions: This study demonstrates a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, indicating an urgent need for nutrition-related education at all levels of training.
Key Words: physician survey • early enteral nutrition • intensive care unit • critical care • necrotizing pancreatitis • parenteral nutrition Nutrition support is an important element in the care of a critically ill patient. As many as 40% of adult patients are seriously malnourished at the time of their hospital admission, and two-thirds of all patients experience deterioration of nutrition status during their hospital stay.1 Critical illness can worsen a patient's nutrition status by leading to hypermetabolism and ensuing malnutrition.2,3 Artificial nutrition support is considered to be the standard of care in critically ill patients as it reduces complication rates4 and has important improvements in the wound-healing response.5 Furthermore, enteral nutrition (EN) has been shown to improve important clinical outcomes such as mortality and mean hospital length of stay.6 Three sets of clinical practice guidelines published in the past several years have similar recommendations for optimal nutrition support in intensive care unit (ICU) patients.7-9 All 3 guidelines recommend early EN using a nasogastric tube in preference to parenteral nutrition (PN) in patients with no major gut dysfunction, and the use of promotility drugs if EN is not tolerated.7-9 In addition, the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) published practice guidelines for critical illness in 2002.10 These guidelines state that patients with critical illness are at nutrition risk and should undergo nutrition screening to identify patients requiring formal nutrition assessment. Specialized nutrition support (SNS) should be initiated when it is anticipated that critically ill patients will be unable to meet their nutrient needs orally for a period of 5-10 days. EN is the preferred route of feeding in critically ill patients requiring SNS, and PN should be reserved for those patients requiring SNS in whom EN is not possible.10 Despite existing data, there remains a wide variation in management of nutrition support. Understanding current physician practice would allow us to identify discordance in knowledge to facilitate physician education. Once areas of weakness are identified, they can be used in the development of a nutrition algorithm to optimize nutrition management in the critically ill. The primary objective of the present survey was to assess current physician perceptions and practice patterns regarding initiation and management of nutrition in the ICU patient.
The survey was electronically distributed to 150 attending physicians, 147 fellows, and 509 resident physicians at Rush University Medical Center. Attending physicians included surgeons, intensivists, gastroenterologists, and hospitalists. Each of these physicians routinely admits patients to the medical or surgical ICU. The medical ICU at our institution consists of critically ill patients with a wide variety of underlying medical conditions. The surgical ICU at our institution conducts routine postoperative surgical care. No trauma or closed head injury is cared for in this unit. Three standardized electronic mailings were produced between October and November 2006: the initial survey was followed by 2 duplicate surveys every 2 weeks after the original survey was mailed. The mailing included an introductory statement stating the goals of the survey. This research was approved with exempt status from the Institutional Review Board at our institution (ORA 06102301). The survey was composed of 12 questions constructed to identify physician perceptions of nutrition in critical illness, preferences relating to initiation of feeding, and management practices specific to nutrition after initiation of feeding (see the appendix). The survey was developed from a combination of the following: (1) a consensus of important nutrition issues identified by the nutrition management service at our institution, composed of an attending critical care physician, gastroenterologist, surgeon, and clinical dietitians; (2) data from the 3 sets of clinical practice guidelines that have been published regarding nutrition management in ICU patients7-9; and (3) standardized survey procedures.11 The number of questions per section corresponds to areas of importance identified by our institution's nutrition management service. Perceived importance of nutrition was assessed using a numerical score on a 5-point Likert-type scale, which ranged from 1 (not important) to 5 (very important). A similar 5-point evaluation scale was used to assess comfort level among physicians with the current level of nutrition support at our institution, and for physicians to rate their own understanding of the role of nutrition support in the critically ill. Questions relating to management practices were in both multiple-choice and open-ended response formats. Noninfected necrotizing pancreatitis was chosen as a representative disease state for the focus of 2 survey questions, as we see a large volume of this condition at our institution and as we have previously demonstrated a lack of understanding in the management of this disease. The term ileus is defined as small bowel ileus, and NPO is defined as no nutrition support.
Each completed survey was entered into a password-protected database for
analysis (SPSS software, version 13.0, Chicago, IL). The password was known
only to the primary investigator and the clinical research coordinator.
Descriptive statistics were used to compare differences in survey responses
based on the physician's level of training. The significance of difference in
training level was analyzed in relationship to responses by using
The survey achieved a total response rate of 22.6% (182 of 806). The response rate among attending physicians was 26.7% (40 of 150), among fellows was 16.3% (24 of 147), and among residents was 23.2% (118 of 509). As the response rate was lower among fellows, there was a significant difference in response rates between the 3 groups (P = .0004).
Perceptions of Nutrition
Initiation of Feeding The next section of the survey assessed physician preferences with regard to initiation of feeding. Attending physicians, fellows, and residents preferred waiting until a patient is NPO an average of 2.43, 1.79, and 2.63 days, respectively, before addressing nutrition status in a critically ill patient (P = .147). When asked what their preferred route of nutrition support is in the ICU, 100% of attending physicians, 96% of fellows, and 94% of residents chose EN over a parenteral route of feeding (P = .286). When questioned about initiation of feeding in a patient with noninfected necrotizing pancreatitis, 52% of attending physicians, 42% of fellows, and 47% of residents chose PN (P = .425; Figure 1). A slightly higher percentage of fellows (46%) chose EN over PN in a patient with noninfected necrotizing pancreatitis. Physicians were then asked about their preferences in placement of feeding tubes. Postpyloric feeding was favored in the critically ill patient (P = .525; Figure 2), while the location of choice in a patient with pancreatitis was beyond the Ligament of Treitz (LOT; P = .513; Figure 3). When asked if the presence of an ileus is an absolute contraindication to enteral feeding, 37% of attending physicians and 30% of both fellows and residents answered yes (P = .705).
Management Practices After Initiation of Feeding The final section of the survey focused on specific nutrition-related management practices after initiation of feeding. There was a wide variation in responses when physicians were asked to quantify (open-ended) acceptable gastric residual volumes (GRVs) in a tube-fed patient. Attending physicians responded with a mean GRV of 150 mL (standard deviation [SD] = 139.44 mL), fellows reported a mean GRV of 130 mL (SD = 104.83 mL), and residents reported a mean GRV of 118.44 mL (SD = 100.56 mL; P = .099). Finally, physicians were asked to list what they would do if a patient experienced nausea and vomiting with initial enteral feeding (Table 1). This question was in an open-ended format, and respondents had the option of listing multiple interventions. Attending physicians listed a mean of 1.53 interventions (range, 1-3), fellows listed a mean of 1.80 interventions (range, 1-3), and residents listed a mean of 2.02 interventions (range, 1-5). Most of the physicians preferred stopping the feeding over the addition of a promotility agent.
This study describes discordance in the nutrition-related perceptions and everyday practice patterns of physicians who care for ICU patients in a large tertiary care medical center. We surveyed a group that included attending physicians, fellows, and residents to determine if responses differed based on level of experience. We found no significant difference in responses to any of the survey questions between attending physicians, fellows, and resident physicians. There was no constant similarity between the responses of fellows to the responses of either residents or attending physicians, indicating that this group did not consistently behave like either of the other 2 groups. When asked about time to addressing nutrition issues and route of nutrition support in necrotizing pancreatitis, the responses of fellows did trend more toward evidence-based guidelines than the responses of the other 2 groups. However, the response rate among fellows was lower than the response rate among attending physicians and residents, and therefore, this group is underrepresented in the survey results. The actual 22.5% overall response rate was consistent with other Internet-based physician surveys.13,14 An Internet survey–based approach was used to facilitate response time and decrease cost. However, a mixed-mode distribution (including both postal and e-mail survey distribution)13 a shorter questionnaire,15 and a monetary incentive could have increased our response rate.15 A limitation of our survey-based study design is the reliance on self-reported rating, which can lead to systematic positive or negative response tendencies. Furthermore, our study did not revaluate baseline physician demographics or prior nutrition-related education. Medical ICU vs surgical ICU was not specified in the survey questions.
Providing adequate nutrition to the critically ill patient is considered a standard of care.10,16,17 The general goals of nutrition support are to provide nutrition support consistent with the patient's medical condition and nutrition status, to prevent or treat nutrient deficiencies, to avoid complications related to technique of dietary delivery, and to improve patient outcomes.17 Our findings indicated that while physicians at all levels of training did believe that nutrition is important in the ICU, they did not feel confident in their knowledge of the role of nutrition support in the critically ill. Several factors may contribute to this lack of confidence, including (1) a deficiency in awareness and familiarity with current guidelines,18 (2) availability of only poorly controlled, mostly retrospective data and expert opinion,19 and (3) difficulty integrating previous dogma19 with recent clinical practice guidelines.20 In addition, given the long-standing exclusion of nutrition in the clinical management of patients, there may now be a lack of outcome expectancy (that if one performs the requested behavior, it will actually make a difference).18 The current nutrition support practice at our institution includes a multidisciplinary nutrition support team composed of an attending critical care physician, an attending gastroenterologist, an attending surgeon, and clinical dietitians. These clinical dietitians round with attending and house staff physicians on a daily basis in the ICU. The nutrition support team is available for consultation to anyone in the institution who has nutrition-related management issues. Despite this level of assistance, our survey demonstrated that physicians felt only an average level of comfort with both the availability of the nutrition support team and the strength of the team's recommendations at our institution. This appears to be predominantly due to a lack of physician education regarding the available nutrition-related resources at our institution, and lack of awareness of whom this team is composed. This question referred to the comfort level with the availability and recommendations of the nutrition support team and could have been misinterpreted by the physicians surveyed to mean comfort with preparation of the actual nutrition support by the pharmacy or comfort with the proper administration of the nutrition support by nursing. Questions related to initiation of feeding and specific nutrition-related management practices after initiation of feeding identified discrepancies between physician responses and published guidelines. Attending physicians and residents reported waiting an average of 2.43 and 2.63 days, respectively, prior to assessing nutrition status in an ICU patient. Fellows waited an average of 1.79 days, which was less than both attending physicians and residents. The fellows' response time was also within the recommended time period. There is general consensus from all 3 evidence-based guideline recommendations that EN should be started within 1-2 days of ICU admission.7-9 Early EN (feeds initiated within 36 hours) vs delayed feeding (initiated after 36 hours) have shown a significant reduction in infectious complications.7,21,22 Furthermore, in a systematic review of 12 studies, early EN was associated with a shortened hospital length of stay by an average of 2.2 days.21 The physicians we surveyed agreed with published guidelines that EN is the preferred route of nutrition support in the ICU.7-9 However, most attending physicians and residents chose PN as the preferred route of nutrition support in a patient with necrotizing pancreatitis, while a slightly greater majority of fellows chose EN (46%) over PN (42%) in this condition. This is alarming in light of 5 prospective randomized controlled trials of EN vs PN in acute pancreatitis randomized within 48 hours.23-27 In these 5 studies, EN was associated with decreased infectious morbidity,23,25,26 shorter hospital length of stay,27 fewer overall complications,23 reduced duration of the disease process and length of nutrition therapy,26,27 and faster resolution of systemic inflammatory response syndrome.24 In patients with ileus, EN is encouraged by accessing the small bowel, decompressing the stomach, and initiating feeds to stimulate promotility agents.19 Many of our respondents indicated that ileus is an absolute contraindication to enteral feeding. Our survey results indicated that the preferred feeding tube location in the critically ill was postpyloric and in pancreatitis was beyond the LOT, indicating that physicians consider underlying disease state when determining tube location. Three meta-analyses of studies comparing small bowel and gastric feeding have found varying results, with small bowel feeding having reduced the risk of pneumonia in one study,7 having been associated with a trend toward increased energy delivery in another,21 and having no obviously beneficial effect in the third.28 The consistent recommendation from various guidelines is that small bowel feeding be used when EN intolerance occurs.29 When compared with the placement of nasogastric tubes, nasojejunal tubes are more time-consuming, less successful, and require more attempts to achieve adequate position.30 Therefore, deep jejunal access often requires fluoroscopy or endoscopy, both of which offer good success rates31,32 but are not always practical in the ICU. Furthermore, time to initiation of enteral feeding has been found to be significantly shorter in those patients receiving gastric feeds.33 Assessing and promoting tolerance may be the most important aspect of monitoring the patient on EN.19 There was a large standard deviation in responses regarding an acceptable GRV in a tube-fed patient, indicating discordance in this area. Although GRVs have poor validity as a marker for risk of aspiration in critically ill patients,34 they continue to be used in nutrition algorithms and are likely to be the practice of many ICUs.35 The North American Summit on Aspiration in the Critically Ill Patient developed a consensus statement in 2002 stating that GRVs >500 mL indicate the need to withhold feeds and reassess tolerance.36 Residual volumes in the range of 200-500 mL should prompt careful bedside evaluation and initiation of an algorithmic approach to reduce risk.36 All 3 physician groups surveyed reported lower acceptable values than 500 mL, indicating that they would inappropriately deem patients intolerant of feeds in most cases. The most commonly listed approach to a patient who experiences nausea and vomiting with tube feeds was simply cessation of feeding. In the critically ill population, both metoclopramide37 and erythromycin38 improve gastric emptying. Erythromycin appears to be superior as it improves short-term tolerance in patients with upper Gl tract enteral nutrition intolerance.39,40 Only 19% of attending physician responses and 17% of house staff responses included the administration of a promotility agent for nausea and vomiting with enteral nutrition. Furthermore, small bowel contractility may be assessed by examination for abdominal distension, bowel sounds, and air fluid levels on abdominal radiograph.19 A very small percentage of responses included checking an abdominal radiograph or even performing a physical examination (Table 1).
Our study demonstrated a substantial discordance in physician perceptions and practice patterns regarding initiation and management of nutrition in ICU patients, an alarming finding considering the importance of nutrition status in ICU patients. Despite this overall discordance, there appears to be a trend toward management based on accepted guidelines. Our results were consistent among attending physicians, fellows, and residents, indicating an urgent need for nutrition-related education at all levels of training. The results of this survey have aided physician education by the implementation of an evidence-based nutrition algorithm in our ICU.
Financial disclosure: none declared. Received for publication July 12, 2007. Accepted for publication November 12, 2007.
Journal of Parenteral and Enteral Nutrition, Vol. 32, No. 2,
113-119 (2008)
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Materials and Methods
Results
2 statistical methods and ANOVA. Statistical significance is
defined as P < .05. Reported P values refer to the
comparison between attending physician, fellow, and resident responses to
survey questions. 
