Marjon Borgert

93 Potential risk factors in the delivery of enteral nutrition INTRODUCTION Malnutrition is a serious problem in critically ill patients. It is associated with increased morbidity and mortality and leads to higher costs of the healthcare system. 1,2 Due to the hypermetabolic response in critically ill patients the energy expenditure is increased. 3 But, feeding critically ill patients can be challenging since patients su er from gastrointestinal intolerance, due to impaired gastrointestinal motility, digestion or absorption in more than 60%. 3,4 This, in combination with an increased energy expenditure leads to malnutrition. 3 Around 30 to 50% of critically ill patients admitted to intensive cares (ICUs) do not receive their daily protein and energy intake. 5,6 An important therapy to prevent malnutrition in critically ill patients is Enteral Nutrition (EN). 7 This is usually administered through a nasogastric tube. An early start of EN within 24-48 hours following ICU admission has been advocated to enhance an adequate EN intake. 7 EN has several physiological bene ts in the preservations of gut integrity and prevents the increase in intestinal permeability. 7,8 Adequate delivery of EN has positive e ects on relevant clinical outcomes, such as the ICU and hospital length of stay, ventilator-free days, wound healing and nosocomial infections. 9,10 Despite thepositivee ects of adequateEN, discrepancies exist between theactual intake and optimal EN intake. 2,3,6 Guidelines have been developed to enhance the adequate delivery of EN in critically ill patients. However, poor adherence to the EN guideline still exists. 11 Cahill et al. showed that only 60% of the patients were adequately fed during their ICU admission. 6 Multiple factors negatively a ecting the delivery of EN in critically ill patients could be determined. For instance, delayed placement of feeding tubes and subsequent delayed administration of EN, interruptions in EN due to patient transports for advanced diagnostics and procedures outside the ICU. Another contributing factor is the existence of nutrition intolerance, causing for instance abdominal distension, vomiting, constipating or diarrhea. 2,5,12,13 The delivery of care, such as the delivery of EN, consists of a complex series of interactions between physicians, nurses, patients and medical interventions. 14 Monitoring and systematically analyzing these interactions can be helpful in identifying those areas where optimal care is potentially at risk. The identi cation of those potential risks is important in nding opportunities in improving the quality of care. 14 We do not exactly know to what extent patients are at risk in receiving adequate EN therapy, nor which patient categories or areas might even be at higher risk. If we could determine if patients are at risk for malnutrition, quality improvement strategies could be used to enhance the EN intake. In this study we aim to assess to what extent patients receive their daily