Results from an Epidemiological Follow-Up Survey on Home Artificial Nutrition in Switzerland from 2010 to 2015.

BACKGROUND: Home artificial nutrition (HAN) is an established treatment for malnourished patients. Since July 2012, the costs for oral nutrition supplements (ONS) are covered by the compulsory health insurance providers in Switzerland if the patient has a medical indication based on the Swiss Society for Clinical Nutrition guidelines. Therefore, the purpose of our study was to analyse the development of HAN, including ONS, before and after July 2012. METHODS: We obtained the retrospective and anonymized data from the Swiss association for joint tasks of health insurers (SVK), who registered patients on HAN. Since not all health insurers are working with SVK, this retrospective study recorded nearly 65% of all new patients on HAN in Switzerland from January 1, 2010, to December 31, 2015. RESULTS: A total of 33,410 patients (49.1% men and 50.9% women) with a mean BMI of 21.3 ± 4.5 kg/m2 and mean age of 68.9 ± 17.8 years were recorded. The number of patient cases on ONS increased from 808 cases in 2010 to 18,538 cases in 2015, while patient cases on home enteral nutrition (HEN) and home parenteral nutrition (HPN) remained approximately the same. The relative distribution of type of HAN changed from 26.2% cases on ONS, 68.7% cases on HEN and 5.1% cases on HPN in 2010 to 86.1% cases on ONS, 12.8% cases on HEN, and 1.1% cases on HPN in 2015. Treatment duration decreased for ONS from 698 ± 637 days to 171 ± 274 days, for HEN from 416 ± 553 days to 262 ± 459 days, and for HPN from 96 ± 206 days to 72 ± 123 days. Mean costs per patient decreased for ONS from 1,330 CHF in 2010 to 606 CHF in 2015. Total costs for HAN increased from 16,895,373 CHF in 2010 to 32,868,361 CHF in 2015. CONCLUSION: Our epidemiological follow-up study showed an immense increase in number of patients on HAN in Switzerland after July 2012. Due to shorter therapy duration and reduced mean costs per patient, total costs were only doubled while the number of patients increased 7-fold.

A comparative analysis of treatment costs for home-based care and hospital-based care in enteral nutrition patients: A retrospective analysis of claims data.

OBJECTIVE: To explore the differences in mean treatment costs between home-based care and hospital-based care in enteral nutrition patients in Japan. METHODS: Using claims data from September 2013 to August 2014, we analyzed patients with recorded reimbursements for enteral nutrition at home or in a hospital. Treatment costs were compared using a panel data analysis with an individual fixed effects model that adjusted for the number of comorbidities and fiscal year. Costs were compared for all patients, as well as for specific diseases (pneumonia, sequelae of cerebrovascular disease, and dementia). RESULTS: The study sample comprised 7,783 patients with a cumulative total of 33,751 person-months of data. The mean patient age was 84.4 years for home-based care, 83.7 years for hospital-based care. The panel data analysis found that the cost estimates for hospital-based care were consistently higher than those for home-based care; the difference in adjusted treatment costs were $4,894 for all patients, $5,315 for pneumonia patients, $4,481 for sequelae of cerebrovascular disease patients, and $4,519 for dementia patients (all P < 0.001). Hospital-based care was still more expensive even when long-term care services were included in home-based care treatment cost estimates. CONCLUSION: Home-based care was consistently and substantially cheaper than hospital-based care in enteral nutrition patients in Japan.

Economic analysis of costs with enteral and parenteral nutritional therapy according to disease and outcome.

OBJECTIVE: To conduct an economic analysis of enteral and parenteral diet costs according to the type of disease and outcome (survivors versus deaths). METHODS: It is a cross-sectional, observational, retrospective study with a qualitative and quantitative design, based on analysis of hospital accounts from a healthcare insurance provider in the Southern region of Brazil. RESULTS: We analyzed 301 hospital accounts of individuals who used enteral and parenteral diets. The total cost of the diet was 35.4% of hospital account total costs. The enteral modality accounted for 59.8% of total dietary costs. The major costs with diets were observed in hospitalizations related to infections, cancers and cerebro-cardiovascular diseases. The major costs with parenteral diet were with admissions related by cancers (64.52%) and dementia syndromes (46.17%). The highest ratio between total diet costs with the total of hospital account costs was in dementia syndromes (46.32%) and in cancers (41.2%). The individuals who died spent 51.26% of total of hospital account costs, being 32.81% in diet (47.45% of total diet value and 58.81% in parenteral modality). CONCLUSION: Enteral and parenteral nutritional therapies account for a significant part of the costs with hospitalized individuals, especially in cases of cancers and dementia syndromes. The costs of parenteral diets were higher in the group of patients who died. OBJETIVO: Realizar uma análise econômica de custos da terapia nutricional enteral e parenteral, conforme o tipo de doença e o desfecho (sobreviventes versus óbitos). MÉTODOS: Estudo transversal, observacional, retrospectivo, com estratégia qualitativa e quantitativa, a partir da análise de contas hospitalares de uma operadora de saúde da Região Sul do Brasil. RESULTADOS: Foram analisadas 301 contas hospitalares de usuários que utilizaram dieta enteral e parenteral. O custo total com dieta foi de 35,4% do custo total das contas hospitalares. A modalidade enteral representou 59,8% do custo total em dieta. Os maiores custos com dieta foram observados em internações relacionadas a infecções, cânceres e doenças cérebro-cardiovasculares. Os maiores custos com dieta parenteral foram observados nas internações relacionadas aos cânceres (64,52%) e às síndromes demenciais (46,17%). A maior relação entre o custo total com dieta e o custo total da conta foi na síndrome demencial (46,32%) e no câncer (41,2%). Os usuários que foram a óbito consumiram 51,26% dos custos totais das contas, sendo 32,81% com dieta (47,45% do valor total com dieta e 58,81% do custo na modalidade parenteral). CONCLUSÃO: As terapias nutricionais enteral e parenteral representaram uma parte importante dos custos no tratamento de indivíduos hospitalizados, principalmente nos casos dos cânceres e nas síndromes demenciais. O custo com dieta parenteral foi maior no grupo de usuários que foram a óbito.

Economic analysis of costs with enteral and parenteral nutritional therapy according to disease and outcome / Análise econômica dos custos com terapia nutricional enteral e parenteral conforme doença e desfecho

ABSTRACT Objective To conduct an economic analysis of enteral and parenteral diet costs according to the type of disease and outcome (survivors versus deaths). Methods It is a cross-sectional, observational, retrospective study with a qualitative and quantitative design, based on analysis of hospital accounts from a healthcare insurance provider in the Southern region of Brazil. Results We analyzed 301 hospital accounts of individuals who used enteral and parenteral diets. The total cost of the diet was 35.4% of hospital account total costs. The enteral modality accounted for 59.8% of total dietary costs. The major costs with diets were observed in hospitalizations related to infections, cancers and cerebro-cardiovascular diseases. The major costs with parenteral diet were with admissions related by cancers (64.52%) and dementia syndromes (46.17%). The highest ratio between total diet costs with the total of hospital account costs was in dementia syndromes (46.32%) and in cancers (41.2%). The individuals who died spent 51.26% of total of hospital account costs, being 32.81% in diet (47.45% of total diet value and 58.81% in parenteral modality). Conclusion Enteral and parenteral nutritional therapies account for a significant part of the costs with hospitalized individuals, especially in cases of cancers and dementia syndromes. The costs of parenteral diets were higher in the group of patients who died.

RESUMO Objetivo Realizar uma análise econômica de custos da terapia nutricional enteral e parenteral, conforme o tipo de doença e o desfecho (sobreviventes versus óbitos). Métodos Estudo transversal, observacional, retrospectivo, com estratégia qualitativa e quantitativa, a partir da análise de contas hospitalares de uma operadora de saúde da Região Sul do Brasil. Resultados Foram analisadas 301 contas hospitalares de usuários que utilizaram dieta enteral e parenteral. O custo total com dieta foi de 35,4% do custo total das contas hospitalares. A modalidade enteral representou 59,8% do custo total em dieta. Os maiores custos com dieta foram observados em internações relacionadas a infecções, cânceres e doenças cérebro-cardiovasculares. Os maiores custos com dieta parenteral foram observados nas internações relacionadas aos cânceres (64,52%) e às síndromes demenciais (46,17%). A maior relação entre o custo total com dieta e o custo total da conta foi na síndrome demencial (46,32%) e no câncer (41,2%). Os usuários que foram a óbito consumiram 51,26% dos custos totais das contas, sendo 32,81% com dieta (47,45% do valor total com dieta e 58,81% do custo na modalidade parenteral). Conclusão As terapias nutricionais enteral e parenteral representaram uma parte importante dos custos no tratamento de indivíduos hospitalizados, principalmente nos casos dos cânceres e nas síndromes demenciais. O custo com dieta parenteral foi maior no grupo de usuários que foram a óbito.

Strategies for High-Quality Nutrition Therapy in Brazil.

Strategies for improving nutrition therapy (NT) are of utmost importance in any healthcare system. The identification and treatment of malnourished patients improves clinical outcome and reduces the length of hospital length of stay and the associated costs. In particular, federal policy regulating the use of NT in Brazil and reimbursement of enteral nutrition (EN) treatment were 2 powerful mechanisms that stimulated the development of nutrition care. Basic and clinical research have also contributed to best practices in NT, thereby highlighting the need for nutrition therapy teams, quality indicators, and nutrition education for the delivery of high-quality NT. It is clear that the availability of training and continuing education programs in clinical nutrition is key to improving nutrition awareness and care, as well as patient outcome. On the basis of our experience, we recommend the Brazilian model as a strategy for improving nutrition care, with appropriate and necessary adaptations made to accommodate different settings.

Toward enteral nutrition for the treatment of pediatric Crohn disease in Canada: a workshop to identify barriers and enablers.

The treatment armamentarium in pediatric Crohn disease (CD) is very similar to adult-onset CD with the notable exception of the use of exclusive enteral nutrition (EEN [the administration of a liquid formula diet while excluding normal diet]), which is used more frequently by pediatric gastroenterologists to induce remission. In pediatric CD, EEN is now recommended by the pediatric committee of the European Crohn's and Colitis Organisation and the European Society for Paediatric Gastroenterology Hepatology and Nutrition as a first-choice agent to induce remission, with remission rates in pediatric studies consistently >75%. To chart and address enablers and barriers of use of EEN in Canada, a workshop was held in September 2014 in Toronto (Ontario), inviting pediatric gastroenterologists, nurses and dietitians from most Canadian pediatric IBD centres as well as international faculty from the United States and Europe with particular research and clinical expertise in the dietary management of pediatric CD. Workshop participants ranked the exclusivity of enteral nutrition; the health care resources; and cost implications as the top three barriers to its use. Conversely, key enablers mentioned included: standardization and sharing of protocols for use of enteral nutrition; ensuring sufficient dietetic resources; and reducing the cost of EEN to the family (including advocacy for reimbursement by provincial ministries of health and private insurance companies). Herein, the authors report on the discussions during this workshop and list strategies to enhance the use of EEN as a treatment option in the treatment of pediatric CD in Canada.

Differences in resource utilization between patients with diabetes receiving glycemia-targeted specialized nutrition vs standard nutrition formulas in U.S. hospitals.

OBJECTIVES: The purpose of the study was to compare patient outcomes and costs for patients with diabetes mellitus (DM) receiving glycemia-targeted specialized nutrition (GTSN) with similar patients receiving standard nutrition (STDN) formulas during acute care hospitalizations. RESEARCH DESIGN AND METHODS: The study was designed as a retrospective analysis over a 10-year period (2000-2009) of clinical and cost data from 125,000 hospital inpatient episodes in the Premier Research Database. Patients received either GTSN or STDN, by tube or orally, as a component of comprehensive care for hyperglycemia in patients with DM. To adjust for potential cohort imbalances, GTSN patients were matched with STDN patients on the basis of propensity scores, adjusting for many characteristics, including age, sex, race, All Patient Refined Diagnosis-Related Group (APR-DRG) illness severity, APR-DRG mortality risk, and comorbidities. RESULTS: Tube-fed patients with DM who were provided GTSN had a 0.88-day (95% confidence interval [CI], 0.73-1.02) shorter length of hospital stay (LOS) on average compared with those patients provided STDN. Orally fed patients with DM who were provided GTSN had a 0.17-day (95% CI, 0.14-0.21) shorter LOS than did those patients provided STDN. The shorter LOS associated with GTSN contributed to a cost savings of $2586 for tube-fed patients and $1356 for orally fed patients. CONCLUSIONS: The use of GTSN feeding formulas for patients with DM in acute care hospital settings was associated with reduced LOS and inpatient hospital episode cost in comparison to STDN.

[Oral nutritional supplements are effective, purposeful and economic]. / Der Einsatz von Trinknahrung ist wirksam, zweckmäßig und wirtschaftlich.

Numerous studies have shown that medically indicated sip feeding is an effective and cost-saving mean to combat malnutrition. Particularly, acutely ill, elderly, polymorbid internal and surgical patients benefit from sip feeding. In Switzerland, the reimbursement of medically indicated sip feeding at home by the compulsory health insurance is critically important for the good of the patient and cost optimization. This is particularly true in the longer-term considering the demographic trends in Switzerland with an important increase of the elderly population. Therefore, the reimbursement of sip feeding was requested from the Federal Department of Home Affairs - with success. Since July 2012, medically indicated sip feeding at home is covered by the compulsory health insurance provided that a medical diagnosis according to the strict and well-defined guidelines from the Society for Clinical Nutrition Switzerland (SSCN) is given.

The economic value of enteral medical nutrition in the management of disease-related malnutrition: a systematic review.

Economic evaluations for medical nutrition, such as oral nutritional supplements (ONS), are relatively uncommon compared with other health technologies, and represent an area that has not been reviewed so far. In this systematic review, economic evaluations of enteral medical nutrition in the management of disease-related malnutrition (DRM) were reviewed and qualified to estimate the economic value. Initially, 481 studies were found, of which 37 full-text articles were assessed for eligibility and were rated on their quality using the Quality of Health Economic Studies (QHES) instrument. The final review focused on the high QHES quality economic evaluation studies. As both the studied medical nutrition intervention and the form of the economic evaluation varied, a quantitative synthesis (meta-analysis) was not attempted but a critical analysis and comparison of the individual study results were performed. ONS was the most studied intervention, covering several patient populations and different health care settings. Outcomes included cost savings (n = 3), no significant extra costs per unit of clinical and/or functional improvement (n = 1), or significantly higher costs per unit of clinical and/or functional improvement but still cost-effective for the used threshold (n = 4). This review shows that the use of enteral medical nutrition in the management of DRM can be efficient from a health economic perspective.

[A comparative study of induction of remission and cost-effectiveness of enteral nutrition versus infliximab in moderate-to-severe Crohn's disease].

OBJECTIVE: To compare the induction of remission and cost-effectiveness of enteral nutrition (EN) and infliximab (IFX) in moderate-to-severe active Crohn's disease(CD). METHODS: Moderate-to-severe active CD patients were divided into IFX group and EN group. Remission rate, time to remission and treatment cost were compared between the two groups. Clinical remission was defined as Crohn's disease activity index (CDAI) < 150. The quality of life was evaluated by inflammatory bowel disease questionnaire of quality of life (IBDQ). RESULTS: A total of 100 patients were analyzed, including 48 patients in IFX group and 52 patients in EN group. IFX group had higher remission rate [87.5% (42/48) vs 67.3% (35/52) , P = 0.017] and shorter time to remission [(11.00 ± 8.35) days vs (33.94 ± 14.60) days, P < 0.001] than EN group. Treatment costs before remission were similar in two groups (P = 0.351) . The increase of IBDQ scores before and after treatment in IFX group was much higher than that of EN group (42.74 ± 27.50 vs 7.57 ± 22.77, P < 0.001) . Similarly, patients in EN group had greater increase of body mass index (BMI) than that of IFX group [(1.32 ± 0.29)kg/m(2) vs (0.51 ± 0.07) kg/m(2), P < 0.001]. For patients with CDAI < 280, remission rate was not significantly different [85.7% (24/28) vs 81.8% (18/22) , P = 0.718] between the two groups, while treatment cost in EN group was less than that of IFX group [(16.1 ± 5.9)×10(3) RMB vs (22.9 ± 11.9)×10(3) RMB, P = 0.021]. CONCLUSIONS: For patients with severe CD (CDAI ≥ 280), IFX has higher remission rate, shorter time to remission and comparable treatment cost than EN. But for patients with CDAI < 280, EN group has comparable remission rate to IFX group with lower cost.

Immunonutrition for patients undergoing elective surgery for gastrointestinal cancer: impact on hospital costs.

BACKGROUND: Oral or enteral dietary supplementation with arginine, omega 3 fatty acids and nucleotides (known as immunonutrition) significantly improve outcomes in patients undergoing elective surgery. The objective of the study was to determine the impact on hospital costs of immunonutrition formulas used in patients undergoing elective surgery for gastrointestinal cancer. METHODS: US hospital costs of stay with and without surgical infectious complications, and average cost per day in the hospital for patients undergoing elective surgery for gastrointestinal cancer were estimated using data from the Healthcare Cost and Utilization Project's 2008 Nationwide Inpatient Sample. These costs were then used to estimate the impact of perioperative immunonutrition on hospital costs using estimates of reduction in infectious complications or length of stay from a meta-analysis of clinical trials in patients undergoing elective surgery for gastrointestinal cancer. Sensitivity of the results to changes in baseline complication rates or length of stay was tested. RESULTS: From the meta-analysis estimates, use of immunonutrition resulted in savings per patient of $3,300 with costs based on reduction in infectious complication rates or $6,000 with costs based on length of hospital stay. Cost savings per patient were present for baseline complication rates above 3.5% or when baseline length of stay and infectious complication rates were reduced to reflect recent US data for those with upper and lower GI elective cancer surgery (range, $1,200 to $6,300). CONCLUSIONS: Use of immunonutrition for patients undergoing elective surgery for gastrointestinal cancer is an effective and cost-saving intervention.

Nutrição enteral artesanal, semiartesanal e industrializada em unidades hospitalares do Rio Grande do Sul: inquérito telefônico / Hospital-prepared, semi-industrialized and industrialized enteral nutrition in hospitals in Rio Grande do Sul: telephone survey

Introdução: estimativas apontam frequente utilização de formulações de nutrição enteral (NE) produzidas nas próprias unidades hospitalares (UHs) brasileiras por razões econômicas, culturais e logísticas. Objetivo: caracterizar o tipo de formulação de nutrição enteral utilizado, estabelecendo associações com o cadastramento das UHs para terapia nutricional enteral e com a equipe multidisciplinar de terapia nutricional. Métodos: foi realizado estudo transversal com UHs do Rio Grande do Sul (RS). Participaram do estudo UHs que utilizam terapia nutricional enteral para adultos internados, inseridas no Cadastro Nacional de Estabelecimentos de Saúde do Ministério da Saúde, como hospitais gerais, especializados, unidades mistas, pronto socorro geral, especializado e hospitais dia.Resultados: de um universo de 419 UHs do RS, foram incluídas 375 neste estudo. Considerando as perdas, recusas e a exclusão das UHs que não faziam uso de nutrição enteral, foram obtidos dados de 278 UHs de 220 municípios, por meio de entrevista telefônica com o profissional responsável pela terapia nutricional enteral. Das instituições participantes, 29,5% (82) relataram possuir equipes multidisciplinares de terapia nutricional enteral, sendo que, destas, 74,4% (61) possuíam equipe completa, 61,2% (170) utilizavam sistema aberto de infusão e 65,7% (182) usavam fórmula industrializada. Foi observada associação entre UHs cadastradas com o uso de fórmulas industrializadas, equipe multidisciplinar de terapia nutricional enteral completa, bomba de infusão (qui-quadrado; p < 0,001) e sistema fechado (qui-quadrado; p < 0,002), em contraposição às UHs não cadastradas. Conclusão: UHs cadastradas apresentam maiores conformidades quanto às recomendações do Ministério da Saúde.

Background: estimates indicate an increasing use of enteral formulas prepared in hospital kitchens in Brazil for economic, cultural and logistical reasons. Aim: to characterize the type of enteral nutrition used in hospitals, establishing an association with the hospital’s license for enteral nutrition therapy (ENT) and the multidisciplinary team of nutrition therapy (MTNT). Methods: this cross-sectional study was conducted in hospital units (HUs) located in the State of Rio Grande Sul, Brazil. HUs that used ENT for adult inpatients and were registered in the National Registry of Health Care Institutions of the Brazilian Ministry of Health, such as general and specialized hospitals, mixed units, general and specialized emergency departments, and day hospitals, participated in the study. Results: of a total of 419 HUs selected in the state, 375 were included in the study. Considering loss, refusal and exclusion of HUs that did not use enteral diets, we collected data from 278 HUs of 220 municipalities by telephone interview with the professional responsible for ENT. Of the participating institutions, 29.5% (82) reported having MTNTs, and of these, 74.4% (61) had a full team, 61.2% (170) used an open infusion system, and 65.7% (182) used industrially manufactured formulas. There was an association of registered HUs with use of industrially manufactured formulas, full MTNT, infusion pump (chi-square; p < 0.001), and closed systems (chi-square; p < 0.002), in contrast to non-registered HUs. Conclusion: Registered HUs show higher compliance with the recommendations of the Brazilian Ministry of Health.Conclusion: Further studies should be performed to confirm these findings.

Nutritional therapy for the treatment of pediatric Crohn's disease.

Crohn's disease and ulcerative colitis are lifelong conditions with particular effects upon nutrition, especially in children and adolescents. Various therapies are available for these conditions but there remains no cure. Over the last decades, exclusive enteral nutrition (EEN) has been demonstrated to have efficacy in the induction of remission, along with numerous other nutritional and inflammatory benefits. This article reviews the benefits and outcomes associated with EEN in Crohn's disease. The potential mechanisms of this therapy are highlighted, along with factors that are barriers to the wider use of EEN.

Usefulness of the daily defined dose method to estimate trends in the consumption, costs and prevalence of the use of home enteral nutrition.

BACKGROUND & AIMS: To analyse the trends in consumption and costs of home enteral nutrition (HEN) products in Andalusia (Spain) and estimate the prevalence of HEN from 2000 to 2007. METHODS: Using the defined daily dose (DDD) method, we assigned a DDD to each type of diet, grouped as whole diets, supplements, modules and thickeners. The number of cases/10(6) inhabitants/day (CID) was calculated. RESULTS: The number of persons receiving HEN rose notably, from 66.4 CID in 2000 to 1315.4 in 2007. The number of persons with home enteral tube feeding has remained stable since 2003, at around 220 CID. HEN with oral nutritional supplements (ONS) increased exponentially, with a prevalence of 910 CID in 2007. The prevalence of HEN in 2007 was similar to that of other European countries. The costs associated with HEN rose from 1.3 million euros in 2000 to over 37 million euros in 2007, due to the progressive increase in the number of persons being prescribed HEN, especially ONS, and the incorporation of more expensive organ-specific formulas. CONCLUSIONS: DDD is useful to indirectly estimate the prevalence of HEN and evaluate long-term trends in the prescription and costs of various HEN products.

Physicians' attitudes about artificial feeding in older patients with severe cognitive impairment in Japan: a qualitative study.

BACKGROUND: The question of whether to withhold artificial nutrition and hydration (ANH) from severely cognitively impaired older adults has remained nearly unexplored in Japan, where provision of ANH is considered standard care. The objective of this study was to identify and analyze factors related to the decision to provide ANH through percutaneous endoscopic gastrostomy (PEG) in older Japanese adults with severe cognitive impairment. METHODS: Retrospective, in-depth interviews with thirty physicians experienced in the care of older, bed-ridden, non-communicative patients with severe cognitive impairment. Interview content included questions about factors influencing the decision to provide or withhold ANH, concerns and dilemmas concerning ANH and the choice of PEG feeding as an ANH method. The process of data collection and analysis followed the Grounded Theory approach. RESULTS: Data analysis identified five factors that influence Japanese physicians' decision to provide ANH through PEG tubes: (1) the national health insurance system that allows elderly patients to become long-term hospital in-patients; (2) legal barriers with regard to limiting treatment, including the risk of prosecution; (3) emotional barriers, especially abhorrence of death by 'starvation'; (4) cultural values that promote family-oriented end-of-life decision making; and (5) reimbursement-related factors involved in the choice of PEG. However, a small number of physicians did offer patients' families the option of withholding ANH. These physicians shared certain characteristics, such as a different perception of ANH and repeated communication with families concerning end-of-life care. These qualities were found to reduce some of the effects of the factors that favor provision of ANH. CONCLUSION: The framework of Japan's medical-legal system unintentionally provides many physicians an incentive to routinely offer ANH for this patient group through PEG tubes. It seems apparent that end-of-life education should be provided to medical providers in Japan to change the automatic assumption that ANH must be provided.

Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients.

The objective of this study was to evaluate the evidence behind specific but common patient care decisions in support of enteral feedings for patients admitted to intensive care units. Six specific questions were developed and refined to address clinical outcomes specific to clinical practice decisions pertinent to enteral feeding of critically ill patients. The data sources consisted of an intensive literature review from five databases, using standardized search terms. Randomized controlled clinical trials, meta-analyses, consensus statements, reviews, US Food and Drug Administration alerts, and case reports were selected for study. Research reports were abstracted in detail and evaluated for research quality using the criteria developed by the American Dietetic Association. Consensus statements regarding the influence of specific enteral feeding methods on key clinical outcomes (ie, infectious complications, cost, length of hospital stay, and mortality) were developed and graded based on the quality of the available evidence. The data support the use of enteral over parenteral nutrition to reduce infectious complications and cost, and the initiation of enteral feedings within 24 to 48 hours of injury or admission to an intensive care unit to reduce infectious complications and length of hospital stay in head injury and trauma patients. Postpyloric tube placement is associated with reduced gastric residual volume and reflux, but adequately powered trials are not available to support prevention of aspiration pneumonia. Acceptance of gastric residual volumes of up to 250 mL may increase volume of formula delivered. Promotility agents are associated with reduced gastric residual volume. Feeding patients in the semirecumbent rather than supine position is associated with reduced aspiration pneumonia and pharyngoesophageal formula reflux. Actual delivery of 14 to 18 kcal/kg/day or 60% to 70% of goal is associated with improved outcomes, whereas greater intake may not be in some populations. Blue food coloring should not be used with enteral feedings due to its limited sensitivity for aspiration and some risk of mortality. Well-designed, adequately powered, randomized controlled clinical trials are needed to evaluate any benefit of tube tip position on aspiration pneumonia or mortality, and of early enteral feedings on mortality.