Implementation of a Standard Re-feeding Education Program to Improve Nursing Staff Competence in Proper Re-feeding Technique

By U Flavia, SRD (UK), BSc (Nut & Diet) , MSc (Endo), Senior dietitian, Dietetic Unit


The purpose of the study is to investigate the current nursing practices and beliefs on re-feeding technique in the Intensive Care Unit (ICU). With the use of evidence based practice, a standardized re-feeding protocol is developed and introduced to the nursing staff to empower their practices. The aim of the study is to measure the staff competence in proper re-feeding technique.


Enteral feeding is considered to be the preferred method of nutritional support for critically ill patients. Large gastric residual volumes (GRV) can increase potential for regurgitation and vomiting and can also delay the achievement of nutritional goals due to under delivery of feeds.

It was observed that there are a variety of practices for nutrition support/enteral feeding in ICU. This includes practice differences with staff either discarding or re-feeding GRV and threshold for GRV.


1)    A questionnaire (attachment 1) was developed to collect data on current practices in Enteral Feeding. It consisted of six questions including the frequency of monitoring GRV, threshold for withhold feeding, re-feed or discard gastric content, and when to reintroduce feeding. Registered Nurses on duty in ICU were given the questionnaire during the 7-day study period for data collection. A total of 22 questionnaires were distributed with a response rate of 95.2% (21 questionnaires completed).

2)    Re-feeding protocol (Figure 1) was developed with consensus obtained from different stakeholders including the ICU director, gastrointestinal specialists, nursing administration, ICU coordinator, and dietitians.

3)    It was recommended that the frequency of GRV checks should be every 4 hours or before each feeding. The maximum GRV was set at 200ml and the aspirated content should be re-fed. The monitoring after the aspiration should be every 2-4 hours.

4)    A total of four sessions of education programs to introduce the re-feeding protocol were conducted in ICU and participants were required to fill out the same questionnaire. There were 16 registered nurses attended the education sessions in the 2 days and the response rate was 100%.

5)    The data collected through the questionnaires were analyzed.


The response rate for pre- and post-intervention data was 95.2% and 100% respectively. The re-feeding protocol was well accepted by the nursing staff in ICU and the competence on proper re-feeding technique in nursing staff has greatly improved. All nurses measure the GRVs every 4 hours in continuous feeding (Q1a) and the percentage of GRVs measurement has increased from 66.7 to 81.3% before each feed in bolus feeding (Q1b). Only 26.6% of nurses held feeding when the GRVs reach 200ml (Q2) and the competency has improved to 75% after the education program. Regarding to reefed (Q3), it is recommended that the aspirated content should be re-fed to patients. Before the introduction of protocol, only 23.8% of nurses chose to re-feed the aspirated content, the competency has improved to 75% after the education program. For resume feeding (Q6), the competency has improved from 23.8% to 74.9%, it is recommended that the monitoring and resume of feeding should occur 2-4 hours.



The competence in proper re-feeding technique has greatly improved after the intervention. The nursing staff agree that a re-feeding protocol helps to standardize nursing practices. During the education program, it was shown that the ICU staff are primarily concerned with regards to continuous feeding monitoring and the content of GRV on whether to re-feed or discard aspirated content.

Lessons learned

It is important to involve all stakeholders and obtain their consensus when developing a protocol. As a private hospital, decisions are made by chief doctors and they certainly have alternative standards regarding GRV and monitoring. Therefore, the ICU coordinator is planning to introduce the proper re-feeding protocol to all visiting doctors in ICU and to further collect their preferences and practices.

Next Steps

The re-feeding protocol should also be introduced to other wards to empower the nursing staff on enteral feeding practices. Also, there should be further liaison with HKSH nursing school in developing guidelines on enteral feeding.