Abstract
INTRODUCTION: The post-ICU hospitalization period in critical care survivors has become a focus for nutrition rehabilitation. Longitudinal data on the nutritional status of ICU survivors over time are very limited in world literature and no data are available from Indian ICUs. OBJECTIVES: We aimed to evaluate the factors affecting nutrition status, barriers to adequate home nutrition, and the effect of an educational mHealth app-supported intervention to assist nutrition support in chronically ill tracheostomized patients at home after ICU care as a part of the AIIMS ICU rehabilitation (AIR) project. METHODS: This was a prospective observational mixed methods study embedded in the implementation of the AIR project. In Part 1 of the intervention family carers of chronically ill, bed-bound tracheostomized adults were educated in the ICU about the importance of nutrition, preparing nasogastric feeds, and feeding via nasogastric tube. Leaflets and videos with instructions for feeding, how to prepare cost-effective food with calorie and protein targets, and screening nutrition status by PGSGA tool were handed out as hardcopy and on the m health application. In part 2, reinforcement, troubleshooting, and feedback were achieved with a home visit on day 7, and a close follow-up with android based interactive app, video, and phone calls. Quantitative data were collected for nutrition intake by the 24-hour recall on days 7 and 21, and qualitative data for barriers to providing nutrition were collected by semi-structured interviews of patient carers. Undernutrition was defined as energy administration below 70% of the defined target. RESULTS: Of the 197 tracheostomized patients discharged home from the ICU or ward, the mean age of patients and carers was 47.9 ± 15.71 yrs. and 33.33 ± 10.9 yrs. respectively, with 59.2 % males. More than 90% of patients had neurologic causes of ICU admission (neurotrauma, stroke, post-brain surgery, post-arrest) with 58% low-income families (<120USD /month) and 40% unemployed carers. Most carers (96.6%) were satisfied with the training received. Post-discharge calorie intake on day 7 (n=174) was 1286.8 ± 380.7 Kcal with 60% underfed. By Day 21, this had significantly improved to 1695.53±419.1 Kcal (p<0.001) with 18% being underfed (p<0.0001). Low income was significantly associated with malnutrition (p= 0.03 univariate analysis) and p=0.05 when corrected for QOL at discharge. Lack of fear for NG feeding (93 %) was a consistent facilitator whereas non-affordability and lack of basic amenities such as a grinder and refrigerator emerged as barriers from carer interviews. DISCUSSIONS: Underfeeding is common in the post-ICU period and may be improved with education in the ICU. However, reinforcement with patient-faced interventions that include follow-up via telephone, mobile apps, and home visits is more effective. Income and lack of amenities appear to be hindrances in adequate nutrition provision at home in our cohort of patients.