The validation of a questionnaire to assess barriers to enteral feeding in critically ill patients: a multicenter international survey

Background: A growing body of literature supports the need to identify and address barriers to knowledge use as a strategy to improve care delivery. To this end, we developed a questionnaire to assess barriers to enterally feeding critically ill adult patients, and sought to gain evidence to support the construct validity of this instrument by testing the hypothesis that barriers identified by the questionnaire are inversely associated with nutrition performance. Methods: We conducted a multilevel multivariable regression analysis of data from an observational study in 55 Intensive Care Units (ICUs) from 5 geographic regions. Data on nutrition practices were abstracted from 1153 patient charts, and 1439 critical care nurses completed the 'Barriers to Enterally Feeding critically Ill Patients' questionnaire. Our primary outcome was adequacy of calories from enteral nutrition (proportion of prescribed calories received enterally) and our primary predictor of interest was a barrier score derived from ratings of importance of items in the questionnaire. Results: The mean adequacy of calories from enteral nutrition was 48 (Standard Deviation (SD) 17)%. Evaluation for confounding identified patient type, proportion of nurse respondents working in the ICU greater than 5 years, and geographic region as important covariates. In a regression model adjusting for these covariates plus evaluable nutrition days and APACHE II score, we observed that a 10 point increase in overall barrier score is associated with a 3.5 (Standard Error (SE)1.3)% decrease in enteral nutrition adequacy (p-values <0.01). Conclusion: Our results provide evidence to support our a priori hypothesis that barriers negatively impact the provision of nutrition in ICUs, suggesting that our recently developed questionnaire may be a promising tool to identify these important factors, and guide the selection of interventions to optimize nutrition practice. Further research is required to illuminate if and how the type of barrier, profession of the provider, and geographic location of the hospital may influence this association.