# Real-world implementation of a standardized ICU protocol for daytime-restricted enteral nutrition in critically ill adults: A retrospective quality improvement study

## TL;DR

A new ICU protocol for daytime-only feeding showed better nutrition delivery and fewer interruptions compared to 24-hour feeding in a small study.

## Contribution

A novel standardized protocol for daytime-restricted enteral nutrition was implemented and evaluated in a real-world ICU setting.

## Key findings

- Daytime-restricted feeding achieved higher infusion rates and fewer interruptions compared to continuous feeding.
- Patients receiving daytime-restricted feeding met a greater percentage of their prescribed nutritional volume.
- Vomiting was more common in the daytime group, while constipation was more frequent in the continuous group, though not statistically significant.

## Abstract

Enteral nutrition (EN) delivery is often interrupted in the intensive care unit (ICU), and while continuous 24-hour feeding is standard practice, emerging evidence from circadian biology and pilot trials suggests that daytime-restricted EN may enhance nutritional adequacy and patient outcomes by aligning feeding with biological rhythms.

This quality improvement study describes a novel, standardized daytime-restricted EN protocol in a community hospital ICU and retrospectively evaluate its real-world implementation. The protocol involved a stepwise transition in EN delivery, beginning with continuous trophic feeding (acute/initial phase), followed by daytime-restricted 12-hour cyclic feeding (anabolic recovery phase), and advancing to intermittent daytime-restricted feeding (chronic recovery phase). A convenience sample of 22 adult ICU patients (12 received continuous 24-hour EN; 10 with the daytime-restricted EN protocol) was analyzed. Clinical data were extracted from electronic medical records, including EN infusion rates, duration, and interruptions.

Patients in the daytime-restricted group received EN at higher infusion rates (median 87.5 vs. 40.0 mL/hr), over fewer hours per day (11.0 vs. 14.5 hours), experienced fewer interruptions (1.0 vs. 9.5 hours/day), and received a greater percentage of their prescribed nutritional volume (90.0% vs. 57.5%) compared to the continuous group (all P value < 0.05). Vomiting was more frequently reported in the daytime-restricted group, while constipation was more common in the continuous group, though these differences were not statistically significant.

This preliminary evaluation supports the feasibility of implementing a daytime-restricted EN protocol in an adult ICU and suggests potential advantages in delivery consistency and nutritional adequacy. To support broader implementation, larger prospective studies across broader ICU populations are necessary.