To the Editor: Although providing early nutritional support of patients in the intensive care unit (ICU) is a strategy that may significantly reduce mortality, its implementation is far from complete. In their randomized controlled trial, Dr Doig and colleagues1 successfully developed and implemented a complex evidence-based nutrition guideline promoting early feeding, using a multifaceted practice change strategy. All hospitals implemented the nutrition guideline, resulting in a significant increase in the number of patients who received nutritional support during ICU stay and who were fed early (within 24 hours of ICU admission).
However, whether practice will continue to remain good after the initial guideline implementation remains uncertain. This question was not tested in the study by Doig et al, since the cluster randomized trial did not assess nutritional support beyond the 20-week study period. During the recruitment phase, dietitian site investigators may have been especially successful in motivating their colleagues to comply with the protocol. Adherence to the nutrition guideline might not continue after cessation of control-chart graphs to evaluate site performances. The study showed that a multifaceted approach has the potential to improve cumbersome nutrition practice; what is not known is whether such an approach results in a sustained improvement.
We are uncertain how to interpret measures of nutritional support guideline uptake, in particular the mean energy delivered per patient. Although it was reported that mean energy delivered (among all patients) was not different between patients in guideline vs control hospitals, and also that energy delivered (among fed patients) was not different over time, it is not stated whether there was any difference between patients over time in guideline vs control hospitals (ie, per day from days 1 to 7).
It is important to understand how measures of nutritional support guideline uptake were collected. It is not clear if data were presented as delivered volumes. Disappointingly large differences between prescribed and delivered volumes of enteral feeding in patients fed by gastric and duodenal feeding tubes have been described.2 These differences are believed to be due to delays in change of nutrition bottles or bags or inappropriate reasons for stopping the nutritional intake. In addition, technical factors may be responsible for clinically relevant discrepancies between prescribed and delivered volumes of enteral nutrition in ICU patients.3
Financial Disclosures: None reported.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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