Quality of Nutritional Care Assessment among Critically-ill Patients in a Tertiary Government Hospital

Abstract

Background and Objectives. Malnutrition is prevalent both at baseline admission and because of hospitalization. It is aggravated by adverse hospital practices and results in poor outcomes, reduced quality of life, and higher treatment costs. Improving quality of care involves nutritional intervention as a low-risk, cost-effective strategy which guides providers in improving practices systems-wise. This study aims to assess the quality of nutritional care and the nutritional status of critically- ill patients admitted in a low-resource setting.

Materials and Methods. This is a mixed methods study among adults admitted in intensive care units (ICUs) of a tertiary government hospital. Anthropometric and biochemical indicators were obtained through chart review. The degree of malnutrition was assessed using the Subjective Global Assessment. Quality indicators under Donabedian domains were assessed and compared to current standards. The length of ICU stay and mortality rate were recorded. Dietary prescription and provision practices of healthcare providers were supplemented by a focus group discussion (FGD). Factors causing provision interruptions were also identified.

Results and Discussion. Sixty-four ICU admissions were included. Staff-to-patient ratio was not ideal. Under process-related factors, out of 49% with actual anthropometric documentations (rest were estimates), 24% had normal body mass indices (BMI), 17% were underweight, and the rest were either overweight or obese. The baseline ICU malnutrition rate was 69%. Malnutrition screening, and assessment of risk and biochemical indicators were not done routinely. Majority (92%) had baseline dietary prescription but only 69% had specific energy and macronutrient breakdown, all done through predictive weight-based equations. Nutritional supplies arrived within 8 hours in 65% of patients. Feeding was initiated within 24–28 hours in 94% of patients. Commercial formula was the preferred type of enteral nutrition (EN). Total duration on nothing-by-mouth (NPO) (hours) throughout ICU stay was significant. Supportive measures to improve gastro-intestinal (GI) tolerance were not standardized. Common factors in delaying feeding initiation were hemodynamic instability, fasting for procedures and GI bleeding. Throughout the ICU stay, fasting for procedures, hemodynamic instability and mechanical ventilation (MV)-related factors were common. ICU mortality rate was 19% and average length of ICU stay was 5 days.

Conclusion. Malnutrition is still prevalent in our ICUs and is affected by suboptimal healthcare practices. Staff - to-patient ratios, malnutrition risk screening and assessment, dietary referrals, documentation and minimizing interruptions in nutritional care provision needs improvement. A system review and establishment of a nutrition team is imperative.