Exploration of the factors that influence nutritional recovery following critical illness : a mixed methods study
Merriweather, Judith Lorna
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Survivors of critical illness suffer from a range of problems affecting physical, psychological and social well-being (Needham et al 2011). Weakness, fatigue and malnutrition are highly prevalent during the months following a critical illness. Few studies have systematically and comprehensively explored the factors that influence nutritional recovery or ways to overcome them. The aim of this study was to provide a comprehensive understanding of the factors influencing nutritional recovery, and the relationship between them, in post intensive care (ICU) patients. A model of care was then developed to improve current management of nutrition for patients recovering from critical illness. Grounded theory methodology was used with a mixed method research design. Nutritional status and intake were assessed on discharge from ICU and at three months post ICU discharge. The process of nutritional recovery during the first three months post ICU discharge was explored from a patient perspective and at the level of ward organisation of care, through observation of practice and interviewing patients and staff. Seventeen patients, who had required greater than 48 hours ventilation, were recruited on discharge from the ICU. On transfer to the ward 9 of the 17 patients were assessed as well-nourished and 8 were malnourished using Subjective Global Assessment. At three months post ICU discharge 14 patients were followed up (1 lost to follow up, 1 incapacitated following illness and 1 went overseas). Seven of these were classified as well-nourished and the other 7 were malnourished. Patients universally failed to meet their nutritional targets during their ward stay and although intakes had improved by three months post ICU discharge, the majority of patients were still not achieving their nutritional requirements. Qualitative data revealed that patients' nutritional intake was influenced by interrelated system breakdowns during the recovery process; this emerged as the overarching core theme. Three sub-themes were ‘experiencing a dysfunctional body’, ‘experiencing socio-cultural changes in relation to eating and ‘encountering organisational nutritional care delivery failures’. This study identified connections and interrelations between these concepts and provided new insights into the factors that influence the nutritional care of post ICU patients. In order to optimise nutritional rehabilitation in this patient group a model of care has been developed which addresses the identified organisational and patient related factors that were shown to influence the nutritional recovery of patients after critical illness. This nutritional strategy will need to be evaluated in clinical trials or quality improvement programmes.