New Abstract and Commentary

Effectiveness of an Aspiration Risk-Reduction Protocol (Authors’ Abstract)

BACKGROUND: Aspiration of gastric contents is a serious problem in critically ill, mechanically ventilated patients receiving tube feedings.
OBJECTIVES: The purpose of this study was to evaluate the effectiveness of a three-pronged intervention to reduce aspiration risk in a group of critically ill, mechanically ventilated patients receiving tube feedings.
METHODS: A two-group quasi-experimental design was used to compare outcomes of a usual care group (December 2002-September 2004) with those of an Aspiration Risk-Reduction Protocol (ARRP) group (January 2007-April 2008). The incidence of aspiration and pneumonia was compared between the usual care group (n = 329) and the ARRP group (n = 145). The ARRP had three components: maintaining head-of-bed elevation at 30 degrees or higher, unless contraindicated; inserting feeding tubes into distal small bowel, when indicated; and using an algorithmic approach for high gastric residual volumes.
RESULTS: Two of the three ARRP components were implemented successfully. Almost 90% of the ARRP group had mean head-of-bed elevations of 30 degrees or higher as compared to 38% in the usual care group. Almost three fourths of the ARRP group had feeding tubes placed in the small bowel as compared with less than 50% in the usual care group. Only three patients met the criteria for the high gastric residual volume algorithm. Aspiration was much lower in the ARRP group than that in the usual care group (39% vs. 88%, respectively). Similarly, pneumonia was much lower in the ARRP group than that in the usual care group (19% vs. 48%, respectively).
DISCUSSION: Findings from this study suggest that a combination of a head-of-bed position elevated to at least 30 degrees and use of a small-bowel feeding site can reduce the incidence of aspiration and aspiration-related pneumonia dramatically in critically ill, tube-fed patients.
Metheny, N. A., Davis-Jackson, J., & Stewart, B. J. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59, 18-25.

Commentary by Dana N. Rutledge, RN, PhD, Nursing Research Facilitator

This fascinating study exemplifies excellent translational research. Translational research involves moving research findings into practice with a rigorous and systematic evaluation of adherence to the new practice and patient outcomes.
Description of elements in the care bundle being “tested” follow along with the rationale for the use of each practice.
1. Keeping patients who receive tube feedings in an elevated head-of-bed position (at least 30°); this practice has been found to decrease pneumonias caused by aspiration of tube feedings. The likelihood that patients are kept in the elevated positions has been found to increase when physician orders include this practice.
2. Feeding patients in the distal small bowel; this practice reduces the likelihood of gastroesophageal reflux, and the risk of microaspiration. Small bore feedings tubes can be placed in the distal small bowel by trained nurses.
3. Using an algorithmic approach to dealing with high gastric residual volumens (> 500 ml); this practice involves feeding disruptions, and can involve prokinetic drugs.
As can be seen from the results of the study, adherence to the bundle was good for elevated positioning and tube placement. Only 3 patients qualified for use of the algorithm for high residual volume; none received care based upon the algorithm. Thus, the findings show significantly improved patient outcomes given use of 2 of the 3 bundle elements. Nurses caring for critically ill, mechanically ventilated patients who receive tube feedings may want to consider use of the 2-factor bundle (HOB ↑ 30°; feeding tube placement in distal small bowel).