# Opportunities to Improve Nutrition for Patients in Hospital After Discharge From an Intensive Care Unit: A Human Factors Analysis

## TL;DR

This study identifies how poor teamwork and process delays in hospitals can lead to inadequate nutrition for patients recovering from critical illness after ICU discharge.

## Contribution

The paper maps the enteral nutrition delivery process using FRAM and highlights multi-professional collaboration as key to improving outcomes.

## Key findings

- Enteral nutrition delivery is non-linear and prone to delays due to poor multi-professional teamwork.
- Confirming nasogastric tube placement is a critical point where system delays occur.
- Improving collaboration among healthcare professionals could enhance nutritional support and recovery.

## Abstract

Nutrition during hospitalisation following critical illness is fundamental to rehabilitation, but provision is often poor.

To analyse the process of delivering nutrition to post‐ICU patients on the ward.

This work forms part of a mixed methods study. In three representative UK hospitals, we conducted: a structured judgement review (SJR) of 300 patients who died following discharge from ICU; in‐depth reviews of 20 survivors and 20 deaths judged to be ‘probably avoidable’ in the SJR; and interviews with 55 patients, family members and staff about their experiences of post‐ICU ward care. We extracted nutrition provision information from the primary data. Using these data and the Functional Resonance Analysis Method (FRAM), we worked with stakeholders to map the process of delivering enteral feed to patients discharged from ICU to hospital wards.

The stakeholder meeting included a dietitian and a medical registrar from two of the three primary data collection sites, two researchers with knowledge of the primary data (with nursing and physiotherapy backgrounds) and a human factors facilitator. The FRAM revealed that providing enteral feeding on the ward is not a linear process, with three clusters of functions delivering distinct steps within the wider process: establishing the need for nasogastric feeding, the nasogastric placement cycle and nasogastric feed delivery. There are multiple points in these processes where failures in multi‐professional teamwork result in the absence of the required steps to move through the processes in a timely manner. In particular, the process for confirming nasogastric tube placement risked system‐related delays to feed administration, significantly affecting the volume of feed delivered to patients.

The FRAM identified multiple process problems affecting nutritional support that may have led to profound consequences for post‐ICU patients, with multi‐professional collaboration a key factor for effective delivery of timely enteral nutrition.

Improving collaborative working processes and addressing common nutritional support problems after ICU discharge could improve nutritional delivery and expedite recovery from critical illness.

ISRCTN14658054

What is known about the topic
○Nutrition during hospitalisation following critical illness is fundamental to rehabilitation and recovery.○Previous studies have identified that nutrition provision following critical illness is poor on hospital wards.○In our previous retrospective case record review, we identified nutrition delivery as a significant contributory factor to probably avoidable deaths, with absence of a clear nutritional plan on ICU discharge common.
What this paper adds
○Mapping of the process of delivering enteral nutrition to patients on the ward following critical illness using the Functional Resonance Analysis Method (FRAM).○The FRAM identified multiple points where delays can be incurred in the process of delivering enteral nutrition.○Addressing such problems requires collaborative multi‐professional working to ensure patients receive the nutrition required to maximise their recovery from critical illness.

What is known about the topic
○Nutrition during hospitalisation following critical illness is fundamental to rehabilitation and recovery.○Previous studies have identified that nutrition provision following critical illness is poor on hospital wards.○In our previous retrospective case record review, we identified nutrition delivery as a significant contributory factor to probably avoidable deaths, with absence of a clear nutritional plan on ICU discharge common.

Nutrition during hospitalisation following critical illness is fundamental to rehabilitation and recovery.

Previous studies have identified that nutrition provision following critical illness is poor on hospital wards.

In our previous retrospective case record review, we identified nutrition delivery as a significant contributory factor to probably avoidable deaths, with absence of a clear nutritional plan on ICU discharge common.

What this paper adds
○Mapping of the process of delivering enteral nutrition to patients on the ward following critical illness using the Functional Resonance Analysis Method (FRAM).○The FRAM identified multiple points where delays can be incurred in the process of delivering enteral nutrition.○Addressing such problems requires collaborative multi‐professional working to ensure patients receive the nutrition required to maximise their recovery from critical illness.

Mapping of the process of delivering enteral nutrition to patients on the ward following critical illness using the Functional Resonance Analysis Method (FRAM).

The FRAM identified multiple points where delays can be incurred in the process of delivering enteral nutrition.

Addressing such problems requires collaborative multi‐professional working to ensure patients receive the nutrition required to maximise their recovery from critical illness.