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 Online  Journal  of  Parenteral  and  Enteral  Nutrition   9  
(Article  2|  Issue  Jan  2010  –  Jan  2012:  9-­‐16  
Submitted:  September  5,  2011  
Posted:  January  7,  2012  

TITLE:  Nutrition  team  supervision  on  nutrient  intake  in  critical  care  patients:  report  of  a  ten-­‐
year  experience  in  the  Philippines  (years  2000  to  2011)  

Luisito  O.  Llido,  MD  (1),  Mariana  S.  Sioson,  MD  (1,2),  Jesus  Fernando  Inciong,  MD  
(1),  Grace  Manuales,  MD  (1)


1.   Clinical  Nutrition  Service,  St.  Luke’s  Medical  Center,  Quezon  City,  Metro-­‐Manila,  
2.   Nutrition  Management  Service,  The  Medical  City,  Pasig  City,  Metro-­‐Manila,  Philippines  


Clinical  Nutrition  Service,  St.  Luke’s  Medical  Center,  279  E.  Rodriguez  Sr.  Ave.,  Quezon  City,  
Metro  Manila,  Philippines  1102    
Email:  (Corresponding  author:  Dr.  Luisito  Llido)    


OBJECTIVE:   To   determine   the   value   of   a   nutrition   team   in   the   management   of   critically   ill   ICU  
patients  through  adequacy  of  energy  intake    

METHODOLOGY:   Energy   requirements   with   actual   intake   records   of   ICU   patients   referred   to   the  
nutrition  team  were  gathered  for  a  ten  year  period  which  was  separated  to  four  stages:  Period  1  
(year  2000  to  2001),  Period  2  (year  2002  to  2003),  Period  3  (year  2005  to  2007),  and  Period  4  
(year  2010  to  2011).  Only  patients  with  7-­‐day  stay  in  the  ICU  were  included.  Calorie  intake  on  
days  1,  3,  5  and  7  were  reported  and  the  percent  adequacy  was  determined  on  these  specific  
days,   which   were   then   compared   per   time   period.   Differences   in   percent   intake   per   ICU   day  
were  analyzed  using  T-­‐Test  for  normal  distributed  data  and  Wilcoxon  or  Mann  Whitney  U  Test  
for  non-­‐normal  distributed  data.  

RESULTS:   Day   one   intake   on   period   1   was   the   lowest   (29%)   compared   to   the   same   days   on  
periods  2,  3  and  4.  This  improved  on  day  3  but  was  still  inadequate  (63%).  Adequate  levels  on  
days  5  and  7  were  achieved  in  all  time  periods.  Analysis  of  intake  in  the  fourth  period  (year  2010  
to   2011)   showed   better   intake   in   calories   and   protein   when   the   patient   was   referred   to   the  
nutrition  team.  

CONCLUSION:   A   nutrition   team   is   able   to   achieve   adequate   energy   intake   for   ICU   patients   on  
day  3  of  ICU  stay  and  there  is  an  increasing  degree  of  adequacy  for  most  ICU  days  as  the  practice  
progresses  through  time.  
PhilSPEN  Online  Journal  of  Parenteral  and  Enteral  Nutrition   10  
(Article  2|  Issue  Jan  2010  –  Jan  2012:  9-­‐16  
KEYWORDS:  Nutrition  team,  energy,  calorie,  protein,  adequate  intake  


Adequate   nutrient   intake   of   critical   care   patients   in   the   intensive   care   unit   (ICU)   makes   a   big  
difference  in  morbidity  and  mortality  outcomes.  The  ACCEPT  trial  in  2004  showed  a  reduction  of  
hospital   stay   and   “trend   towards   reduced   mortality”   in   ICU   patients   in   Canada   [1]   while   another  
study   done   in   the   same   critical   care   system   (2008)   later   showed   reduction   of   mortality   when   an  
increase  of  1,000  kcal  was  delivered  to  the  ICU  patients  [2].  Achieving  adequate  intake  in  critical  
care  patients  is  thus  considered  a  practice  standard,  but  it  is  also  a  challenge  [3].  Reports  from  
critical   care   units   in   Canada   [2],   Switzerland   [4],   Belgium   [5]   and   France   [6]   have   stressed   the  
problem   of   inadequate   intake   in   the   ICU   [7,8]   and   its   impact   on   clinical   outcomes   of   organ  
function   recovery,   infectious   complications   and   hospital   stay.   Our   own   experience   in   ICU  
nutrition   (Philippines)   also   showed   inadequate   intake   in   critical   care   geriatric   patients,   which  
persisted  even  on  the  third  day  of  ICU  stay  [9].  

Since   delivery   of   nutrition   to   the   critical   care   patient   is   a   complex   process   a   multidisciplinary  
nutrition  team  is  believed  to  be  the  best  solution  to  achieve  this  goal  of  adequate  intake  in  the  
ICU  patients  [10-­‐14].  This  is  the  report  of  the  ten-­‐year  experience  of  a  nutrition  team  from  the  
Philippines  in  working  at  achieving  this  goal.  


The   nutrition   team:   The   team   of   St.   Luke’s   Medical   Center   (a   private   tertiary   care   hospital   in  
Manila,  Philippines)  was  organized  based  on  ASPEN  guidelines  [15]  and  became  formally  active  
in  1998.  It  is  composed  of  a  physician,  dietitian,  nurse,  and  pharmacist.  The  ability  of  the  team  
to  follow  up  and  track  the  nutrient  intake  of  patients  was  enhanced  by  the  computerization  of  
the   nutrition   management   process   in   2000.   [16,17]   The   development   of   a   training   program   in  
clinical  nutrition  practice  was  also  started  in  2000  and  it  was  instrumental  in  providing  personnel  
(clinical  nutrition  physician  specialists)  who  run  the  daily  activities  of  the  team.  Initially  the  team  
was   called   Nutrition   Support   Team   (NST)   but   due   to   its   expanding   role   in   patient   care   it   was  
renamed  Clinical  Nutrition  Service.  [18]


Mechanics   of   team   function:   Nutrition   screening   on   all   patients   was   done   by   the   nurses   on  
admission   and   when   the   patient   is   classified   as   “nutritionally   at   risk”   nutritional   assessment   was  
done   by   the   Clinical   Nutrition   Service   personnel.   All   ICU   patients   are   classified   as   “high   risk”   will  
have  the  following  services:  a)  nutrition  care  plan,  b)  formulation  and  delivery  of  the  designed  
nutrition  regimen  (whether  oral,  enteral  or  parenteral),  and  c)  monitoring  of  the  nutrition  care  
delivery  including  nutrient  intake.

Adequate   intake:   The   cut-­‐off   value   for   declaring   adequacy   of   intake   is   75%   of   the   computed  
calorie  and  protein  requirement  of  the  patient.  This  is  used  as  the  main  indicator  of  the  nutrition  
team   performance.   Adequate   intake   data   of   ICU   patients   during   the   following   major   time  
periods  are  determined  as  follows:  a)  Period  1  (years  2000-­‐2001):  representing  initial  experience  
PhilSPEN  Online  Journal  of  Parenteral  and  Enteral  Nutrition   11  
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of   the   team,   b)   Period   2   (years   2002-­‐2003):   to   show   if   progress   was   made   in   the   goal   of  
adequate   intake,   c)   Period   3   (years   2005-­‐2006):   to   show   the   long   term   effects   of   nutrition   team  
activity,  and  d)  Period  4  (years  2010-­‐2011):  to  show  current  outcomes.  To  show  if  the  team  is  
still  effective  comparisons  with  non-­‐referrals  to  the  team  are  made  for  Period  4.  

Measured   parameters:  These  are  the  records  of  oral,  enteral  and  parenteral  nutrition  and  the  
number  of  patients  who  achieved  adequacy  levels.  The  sources  of  these  records  were  retrieved  
from  the  Clinical  Nutrition  Service  computer  database  archives.   Inclusion  criteria  are:  a)  patients  
who  stayed  in  the  ICU  for  at  least  seven  (7)  days,  b)  complete  records  from  days  1,2,3,5  and  7,  
and   c)   these   patients   were   admitted   in   the   four   different   time   period   analysis.   The   statistical    
analysis  used  T-­‐Test  for  independent  groups  of  normally  distributed  data  and  Wilcoxon  test  for  
non-­‐normal  distributed  data.  Significance  is  set  at  P  <  0.05.  


Profile  of  patients  (Table  1  and  3):  Mean  age  is  from  57y  to  71y;  more  than  60%  are  above  60  
yrs   old   and   8%   to   20%   were   above   80   yrs   old;   55%   to   71%   are   males.   By   Subjective   Global  
Assessment  (SGA)  all  are  at  “high  risk  of  developing  nutrition  related  complications”.  The  organs  
involved   were   documented   during   the   fourth   period   (year   2010   to   2011,   Table   3):   one   organ  
was  involved  in  18%  of  all  cases  (=pulmonary)  while  two  to  three  organs  were  involved  in  70%  of  
cases  (cardiac,  pulmonary,  renal,  or  gastrointestinal).  

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Calorie  counts  for  the  four  time  periods  (Figure  1):  Day  one  had  the  lowest  percent  intake  for  
all  the  periods  –  not  able  to  reach  adequate  levels  of  75%.  On  the  initial  year  of  implementation  
(2000-­‐2001)  day  one  had  the  lowest  intake  compared  to  the  rest  of  the  periods  (periods  2  to  4).  
Day   two   intake   adequacy   was   also   not   reached   on   period   1,   but   for   the   rest   of   the   periods  
(periods  2  to  4)  adequate  intake  was  achieved,  meaning  improvement  in  the  goals  on  period  2  
up  to  4  was  achieved.  On  Day  3  onwards  –  all  periods  showed  adequate  levels  of  intake.  
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Median  Total  Calorie  Requirement  (TCR)   (Table  2)  and  actual  intake  in  patients  referred  versus  
not   referred   to   the   nutrition   team   (Figure   2):   The   computed   median   TCR   was   1500   to   1700  
kcal/day  while  the  median  intake  for  all  periods  was  1100  to  1400  kcal/day.  The  overall  intake  
was  84%  for  the  four  periods  with  the  lowest  percentage  occurring  in  the  fourth  period  (=74%;  
year  2010  to  2011).  The  comparison  of  intake  in  referred  versus  not-­‐referred  patients  showed  
better  intake  in  Days  1  and  7  in  patients  supervised  by  a  nutrition  team.  

Distribution  of  intake   (Table   2):   Almost   90%   of   nutrient   delivery   was   through   the   enteral   route;  
9%   to   35%   were   through   the   parenteral   route;   while   the   utilization   of   mixed   enteral   nutrition  
(EN)  and  parenteral  nutrition  (PN)  was  only  8%.  

Nutrition   team   outcomes:  (a)  The  team  was  able  to  reach  goals,  i.e.  adequate  intake,  within  the  
first   three   days   of   ICU   stay   and   the   trend   was   improving   through   the   years   of   practice   of   clinical  
nutrition  (Figure  1  and  2),  (b)  Adherence  to  guidelines  are  evident  through  the  utilization  of  the  
gastrointestinal  tract  as  access  point  in  feeding  in  most  cases  (71%,  Table  2),  (c)  Computerization  
of  intake  data  –  vital  to  the  success  of  the  delivery  process  [16],  and  (d)  More  consistent  intake  
of  patients  with  team  supervision  compared  to  non-­‐referrals  (Figure  2).  
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ICU  patients  achieved  adequate  intake  within  24  to  48  hours  of  admission  when  nutrition  was  
managed  by  a  nutrition  team.  Although  this  goal  was  not  immediately  achieved  at  the  start  of  
the   program   (Period   1:   year   2000   to   2001),   the   consistent   presence   of   the   nutrition   team  
gradually   made   it   a   reality   when   this   program   was   sustained   up   to   the   current   study   period  
(from  2003  to  2011).  This  finding  reflects  what  was  reported  on  the  positive  effects  of  nutrition  
teams:   better   delivery   of   nutrition   with   corresponding   improvement   in   the   nutrition   process  
through  the  presence  of  the  nutrition  team  and  its  implementation  of  protocols  and  guidelines.  
[16,17,18]  The  population  shows  the  predominance  of  the  geriatric  age  group  (>  60yr  old:  61%  
to  85%  and  >  80yr  old:  8%  to  35%)  with  more  than  one  organ  dysfunction  involved  (Table  3)  all  
of   which   increased   the   complexity   of   the   care   process.   A   study   done   in   this   institution   [4]  
showed   the   reality   of   this   problem   of   actual   nutrient   intake   –   geriatric   patients   reached   only  
70%  of  computed  requirement  even  on  day  3  of  ICU  stay.  Only  a  nutrition  team  can  achieve  this  
goal   rationally   and   competently   and   this   study   shows   it   achieved   this   goal.   De   Jonghe   asked   this  
question   –   are   ICU   patients   receiving   the   intended   prescription?   [6]   Their   study   showed  
physicians  needed  to  focus  on  achieving  adequate  intake.  This  study  shows  that  the  presence  of  
a  nutrition  team  will  help  achieve  this  purpose  of  achieving  adequacy  of  intake  in  both  calorie  
and   protein   although   in   the   last   period   (Period   4:   year   2010   to   2011)   the   presence   of   more   than  
one   organ   dysfunction   where   the   gastrointestinal   tract   is   involved   has   lowered   the   adequacy  
level  (74%).  But  it  is  also  in  this  period  that  the  comparison  of  intake  between  referred  and  non-­‐  
referred   patients   showed   better   nutrition   delivery   by   the   nutrition   team   again   underscoring   the  
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value  of  a  nutrition  program  and  team  in  achieving  this  purpose  (Figure  2).  

Nutrition   delivery   showed   adherence   to   the   guideline   and   principle,   “if   the   gut   works,   use   it”,  
through  a  high  enteral  nutrition  usage  (48%  to  90%,  Table  2)  and  use  of  parenteral  nutrition  as  a  
supplement   (9%   to   34%,   Table   2).   This   indicates   the   adoption   and   utilization   of   enteral   and  
parenteral   nutrition   guidelines   from   ESPEN   and   ASPEN   on   critically   ill   patients.   [19,20,21]   This   is  
another  proof  to  the  observation  that  a  structured  system  of  nutrition  management  will  achieve  
the  seemingly  impossible  goal  of  achieving  consistent  adequate  intake  in  the  ICU.  [1]


Outcome   variables   were   not   included   in   this   study,   but   two   studies   done   in   other   centers  
showed   that   adequate   and   consistent   nutrient   intake   in   the   ICU   improves   outcomes   like  
reduction   of   infectious   complications   [4]   and   mortality   [2]   which   also   translated   to   reduced  
costs   [22,23].   Future   follow   up   of   these   patients   will   come   up   with   definite   outcomes   like  
morbidity  and  mortality  in  this  institution.  


A  nutrition  team  with  implementation  of  nutrition  care  protocols  and  guidelines  achieved  
consistent  adequate  intake  in  critical  care  patients  in  the  long  term.  


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