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Nursing practice of checking gastric residual volumes based on old dogmas: opportunity to improve patient care while decreasing health care costs.

INTRODUCTION

Enteral feeding is a preferred and accepted route of nutritional support, rather than parenteral nutrition, in patients unable to feed themselves. Nursing care of patients with enteral feeding tubes has the potential to play a major role in affecting patient outcomes. Traditionally, monitoring of the gastric residual volume (GRV) in tube-fed patients is performed to assess feeding tolerance and to prevent aspiration pneumonia. (1) However, nursing practice of GRV checks varies due to individualized practices, unit tradition, or expert advice. Unfortunately, like many other procedures in medicine, GRV checks have never been validated. (2,3) Recommendations about the normal limit of GRV in critically ill patients vary widely. (4-7) Although aspiration is the most feared potential risk for enteral tube feeding, there is no guarantee that low residual volumes (RV) are without risk for aspiration, and high RVs do not necessarily predict aspiration. (3,8) On the other hand frequent holding of the enteral feeds may compromise the nutritional requirements of the patient. (9) Persenius et al (10) have focused on the nursing practices of the GRV checks in the intensive care unit (ICU) emphasizing the need for more knowledge and awareness among the nursing staff along with a systematic documentation for optimal care of the tube-fed patients.

We wished to examine the nursing practice of checking GRVs and their management in a single hospital setting. Specifically, we were interested in the nurses' perceptions and actions and physician involvement in this important nutritional intervention.

METHODS

Our study was part of a systems improvement project and consisted of a random survey of nurses. This study was approved by our institutional review board. Nurses in various hospital wards, as well as the intensive care unit, in our hospital were approached by members of the dietetics team at random over a two-day period. The nurses were offered a questionnaire, and their participation in the survey was voluntary and anonymous.

The self-administered questionnaire included questions about their practice of GRV checks, such as frequency, time spent, documentation, adherence to physician orders, and their perception of high GRV (Table). The nurses' perception of the time spent on gastric residual checks includes time involved in checking and withholding, in calling the doctor if the volume is high, and then in waiting for the call back followed by carrying out the orders, etc. All data were treated with confidentiality. There was no patient participation, and there were no patient identifiers involved.

RESULTS

Nurses (n=19) working in our hospital during the day shift were randomly approached during the study period, and all of them agreed to fill out the questionnaire. While all the nurses answered that they managed patients with tube feeds and checked GRV in all their patients, surprisingly, their responses on other critical questions varied widely.

There appeared to be wide variability in physicians' writing orders pertaining to checking GRVs. Twenty-one percent of the nurses replied that physicians wrote orders to check GRV only 25% of the time. On the other hand, only a small minority (10%) of the nurses responded that physicians wrote orders to check GRV 100% of the time.

Since, according to the nurses, orders for GRV checks were not there most of the time, not surprisingly there was a wide variation of nurses' perception of "high GRV" ranging from 100 mL to 200 mL. Similarly their actions in response to "high GRV" varied widely. Nurses would stop feeding at these "high" levels regardless of the symptoms. Interestingly, while the nurses held the tube feeds for "high GRV" and reinstituted feedings once repeat checks of GRV went below the threshold, only 68% of the nurses reported "high GRVs" to the physician.

There were also significant differences in the method of documentation. While 90% of nurses documented on the paper, 25% answered they documented in the patient's computerized electronic chart, and 15% documented in both places. Our hospital utilized electronic medical records at the time of the study.

Different nurses used intervals ranging from every four to 12 hours for checking GRVs (Figure 1). Perhaps as a consequence of that, the wide variation in nurses' responses to the fraction of total work time consumed in checking GRVs, calling physicians, etc, were even more surprising (Figure 2).

DISCUSSION

Enteral feeding is being increasingly used for nutritional support. The use of GRV as a tool for assessing the tolerance of enteral feeds has been included in many nutritional support algorithms in critical care units. (11,12) Several evidence-based protocols for nutritional support have been proposed previously especially in ICUs. (6,8,13-15) Nurses play an important role in the management of enteral nutritional support. In addition, suboptimal physicians' and nurses' knowledge regarding enteral feeds has been reported previously. (10,13,16) Results of our study showing wide variation in GRV practices is consistent with the literature.

Frequency of Checking GRV

Mentec et al (17) reported that too frequent GRV checks may lead to frequent holding of the feeds causing decrease in the volume of diet absorbed. On the other hand, not checking the GRVs in asymptomatic patients may pose a risk for aspiration pneumonia. Our study shows that while 74% of the nurses checked GRV every four hours, 10% recorded it only every 12 hours. This wide variation in patient care and lack of standardized practice in the hospital setting may have been related to the lack of evidence-based literature showing that frequent checking of GRV prevents aspiration pneumonia.

Documentation of GRV Checks

While nursing and physician documentation is predominantly done as part of electronic records in our hospital, both paper and computer documentation facilities are available. The paper records are eventually scanned into the computer in different files creating two classes of records. The latter system is labor intensive, is prone to error, and records are sometimes difficult to find even if they have been scanned and entered. While all the study participants documented the details of GRV checks in some form, the majority of the nurses in our study preferred paper documentation. Previously nursing documentation has been studied only in ICU settings. (10)

Nurses' Perception of "High GRV" and Physician Orders

Our results indicate that majority of the nurses use 200 mL as the threshold value for "high" GRV, although some used a threshold as low as 100 mL to withhold the feeding. Montejo et al (18) conducted a multicenter randomized study, the REGANE study, that for the first time compared two limits for GRV in mechanically ventilated tube-fed patients in the ICU. Similar to other studies, (19, 20) they concluded that increasing the limit for normal GRV to 500 mL as compared to 200 mL is associated with an increase in nutrient absorption with no associated diarrhea, regurgitation, or abdominal distension. (18) This also agrees with the findings of McClave et al (8) and of Lin and Van Citters (21) that residual volumes as a marker of risk for aspiration has a low predictive value and that stopping the enteral feeds at arbitrarily low selected volumes may not be clinically or physiologically sound.

Time Consumed for GRV Checks and Subsequent Actions

The nurses in our study had divergent responses when asked about the percentage of time they see orders written by physicians for checking GRV. While 42% of the nurses felt that physicians write orders to check GRV 75% of the time, only 11% of the nurses felt that physician orders are written all the time. Surprisingly, although 94% of the nurses held the tube feeds due to "high GRVs," only 68% of them reported it to the physician. The responses and reactions of the physicians to this practice was not evaluated. This reinforces the need to educate both the clinicians and nursing staff not to withhold tube feeds for low values of GRV in the absence of signs of intolerance and to have a uniform step-wise approach to manage tube-fed patients. Although an observational study by Mentec et al (17) showed an increased incidence of aspiration pneumonia with upper digestive intolerance to enteral feeding, a randomized controlled trial by McClave et al (8) documented the poor predictive value for GRVs as a risk factor for aspiration pneumonia. Results of a prospective study by Metheny et al (22) involving 206 critically ill patients also found no consistent relationship between gastric volume and aspiration pneumonia.

Nurses' Work Time

Specifically, this included time involved in checking GRV and the subsequent actions like calling physicians and call backs for high residuals with resulting changes in management. The perception of time consumed varied from less than 5% to as high as 25%. These differences may be a function of the type of the patients they take care of and the physicians that they encounter in these dealings. It is difficult to draw any significant conclusions from this data because of the small sample size. There are no comparative studies in the literature examining the nurses' perspective of work burden in the care of tube-fed patients.

[FIGURE 2 OMITTED]

[FIGURE 3 OMITTED]

CONCLUSIONS

We observed a wide variation in the checking and the management of GRVs in a single hospital setting. Periodic education for both physicians and nursing staff is needed to achieve optimal nutritional management for tube-fed patients. This calls for the implementation of a standardized evidence-based feeding protocol. Figure 3 presents the protocol recently estalished at our hospital. Thus far, we have seen no adverse events related to the implementation of this protocol. Further research studying management of enteral feeds from nursing and physician perspectives would be of benefit.

REFERENCES

(1.) Edward SJ, Metheny NA. Measurement of gastric residual volume: state of the science. Medsurg Nurs 2000;9:125-128.

(2.) Juve-Udina ME, Valls-Miro C, Carreno-Granero A, et al. To return or to discard? Randomized trial on gastric residual volume management. Intensive Crit Care Nurs 2009;25:258-267.

(3.) Zaloga GP. The myth of the gastric residual volume. Crit Care Med 2005;33:449-450.

(4.) Metheny NA, Schallom ME, Edwards SJ. Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review. Heart Lung 2004;33:131-145.

(5.) McClave SA, Demeo MT, Delegge MH, et al. North American Summit on aspiration in the critically ill patient: consensus statement 2002. JPEN J Parenter Enteral Nutr 2002;26:S80-85.

(6.) Kattelmann KK, Hise M, Russell M, et al. Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patient. J Am Diet Assoc 2006;106:1226-1241.

(7.) Marshall AP, West SH. Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding? Intensive Crit Care Nurs 2006;22:95-105.

(8.) McClave SA, Lukan JK, Stefater JA, et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005;33:324-330.

(9.) Dvir D, Cohen J, Singer P. Computerized energy balance and complications in critically ill patients: an observational study. Clin Nutr 2006;25:37-44.

(10.) Persenius MW, Larsson BW, Hall-Lord ML. Enteral nutrition in intensive care nurses' perceptions and bedside observations. Intensive Crit Care Nurs 2006;22, 82-94.

(11.) W0ien H, Bjork IT. Nutrition of the critically ill patient and effects of implementing a nutritional support algorithm in ICU. J Clin Nurs 2006;15:168-177.

(12.) Desachy A, Clavel M, Vuagnat A, et al. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med 2008; 34:1054-1059.

(13.) Bourgault AM, Ipe L, Weaver J, et al. Development of evidence based guidelines and critical care nurses knowledge of enteral feeding. Crit Care Nurse 2007;27:17-29.

(14.) Martin CM, Doig GS, Heyland DK, et al. Multicenter, cluster randomized clinical trial of algorithms for critical care enteral and parenteral therapy (ACCEPT). Can Med Assoc J 2004;170:197-204.

(15.) Heyland DK, Dhaliwal R, Drover JW, et al. Canadian critical care guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enter Nutr 2003;27:355373.

(16.) Marshall AP, West SH. Enteral feeding in the critically ill: are nursing practices contributing to hypocaloric feeding? Intensive Crit Care Nurs 2006;22:95-105.

(17.) Mentec H, Dupont H, Bocchetti M, et al. Upper digestive intolerance during enteral nutrition in critically patients: frequency, risk factors, and complications. Crit Care Med 2001;29:1955-1961.

(18.) Montejo JC, Minambres E, Bordeje L, et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med 2010;36:1386-1393.

(19.) Taylor SJ, Fettes SB, Jewkes C, et al. Prospective randomized controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999;27:2525-2531.

(20.) Pinilla JC, Samphire J, Arnold C, et al. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective randomized controlled trial. JPEN J Parenter Enteral Nutr 2001;25:81-86.

(21.) Lin HC, Van Citters GW. Stopping enteral feeding for arbitrary gastric residual volume may not be physiologically sound: Results of a computer simulation model. JPEN J Parenter Enteral Nutr 1997;21:286-289.

(22.) Metheny NA, Schallom L, Oliver DA, et al. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care 2008;17:512-519.

Deepthi Bollineni, MD; and Anil Minocha, MD, FACG, FACP, AGAF

Drs. Bollineni and Minocha are affiliated with medical service at the Overton Brooks Veterans Affairs Medical Center and with the Department of Medicine at Louisiana State University Health Sciences Center in Shreveport.
Table. Questionnaire to the nursing staff during the survey of
nursing practices of checking gastric residual volumes (GRVs).

Question             Response Options

1. Do you manage     Yes   No
patients with tube
feedings?

2. Do you check      Yes   No
GRVs in such
patients?

3. How often do      Every 4 hours   Every 6 hours
you check GRVs?      Every 12 hours   Daily   Never check

4. If you check      Yes   No
GRVs, do you check
every day?

5. Where do you      Paper   Computer   Never   write
write GRV results?

6. How often do      25%   50%   75%   100%
physicians write
orders for
checking GRVs?

7. What do you do    Check   Never check
if physicians do
not write orders
for GRV checks?

8. At what GRV do    100mL   150 mL   200mL   300mL   400mL
you withhold feeds
and call the
physician?

9. Do you call the   Yes   No
physician with a
"high GRV" if
patient is
asymptomatic?

10. What do you do   Hold tube feeds   Continue tube feeds
about tube feeds
if GRV is high and
if patient is
asymptomatic?

11. What percent     <5%   5%-10%   10%-20%   25% Other
of your time is
consumed by GRV
checks and calling
physicians?

Figure 1. Nurses' practice of checking gastric
residual volumes in tube-fed patients.

Q4hr    74.00%
Q6hr    16.00%
Q12hr   10.00%

Note: Table made from bar graph.
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Article Details
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Author:Bollineni, Deepthi; Minocha, Anil
Publication:The Journal of the Louisiana State Medical Society
Article Type:Report
Geographic Code:1USA
Date:Jul 1, 2011
Words:2466
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