Optimizing Nutrition Therapy in the Intensive Care Unit Through the Evaluation of Barriers to Enterally Feeding Critically Ill Patients
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The purpose of this thesis was to determine the feasibility of implementing an intervention tailored to overcome barriers to adherence to recommendations of critical care nutrition guidelines in the Intensive Care Unit (ICU). The thesis is comprised of four manuscripts. The first manuscript described the development of a 26 item questionnaire rating the importance of potential barriers as impediments to the provision of enteral nutrition (EN) in the ICU. Preliminary evaluation demonstrated acceptable face and content validity and internal reliability, but the test retest reliability and within group reliability were poor for some items. The second manuscript provided evidence to support the construct validity of the developed questionnaire by reporting the results of a multilevel multivariate regression analysis of cross-sectional data from 55 ICUs that demonstrated that a 10 point increase in the overall barrier score was associated with a statistically significant 3.5% (Standard Error (SE) 1.3) decrease in prescribed calories received from EN. The third manuscript provided data to inform whether the intervention should be tailored to site specific barriers by describing the barriers to enterally feeding critically ill patients identified by 138 nurses, and evaluating whether these barriers differed across the 5 participating sites. Statistically significant differences were found among ICUs for 4 out of the 22 potential barriers. The fourth manuscript described the results of a pretest posttest study involving 5 ICUs in North America and determined that all participating sites successfully developed the tailored intervention. A statistically significant 10% (Site range -4.3 to -26.0%) decrease in overall barriers score, and a non-significant 6% (Site range -1.5 to17.9%) change in prescribed calories received was observed following the intervention. However, there was variability in the degree of implementation achieved by each site. Taken together, the results of this thesis demonstrated that adopting a tailored approach to improving nutrition practice is feasible. However, the findings also resulted in revisions to the barriers questionnaire and modifications to the design of the tailored intervention. Thus, the next step is to formally test the hypothesis that a tailored intervention designed to address barriers to feeding critically ill patients will improve nutrition performance.