Factors influencing the implementation and adherence to volume-based enteral feeding protocols in the critical care setting: A scoping review

Objective: Delivery of enteral nutrition is an essential component of care for patients in the intensive care unit (ICU); however, patients only receive approximately 60% of prescribed enteral nutrition. Volumebased feeding (VBF) has been demonstrated as a safe and effective strategy to catch up for missed delivery of enteral nutrition. The aim of this review was to investigate factors influencing the adherence and implementation of VBF in the adult critical care and high-dependency unit settings to inform future implementation of VBF protocols in the ICU. Methods: Systematic searches of databases (MEDLINE, EMBASE, and Emcare) and grey literature repositories (TROVE, TRIP, CPG Infobase, WorldCat, and Google) were conducted to identify original research studies including adults admitted to the ICU, where VBF or catch-up feeding protocols were in place. Studies reporting on barriers, enablers, and acceptability or adherence to VBF protocols were included. Results: A total of 28 studies involving 7057 participants were eligible for inclusion, of which 19 were conducted in the USA, seven in Canada, one in the UK, and one in Australia. Factors enabling the implementation of VBF included management support, multidisciplinary team engagement, a project team, multimodal education, and communication strategies. Embedding the protocol into current work systems increased success. Barriers included a culture of deprioritising nutrition, safety concerns, staff turnover, and failure to embed the changes into work systems including the electronic medical record. VBF was considered acceptable to ICU staff; however, adherence to VBF protocols was variable (between 32.1% and 90%). Conclusion: Successful implementation of a VBF protocol is enabled by strong project leadership, staff education, team engagement, and embedding VBF into current work processes. VBF is acceptable to staff; however, continuous education is recommended to sustain change in practice. Implementation of VBF should be considered as part of an "enhanced" feeding strategy in the ICU setting. Registration: The protocol was developed and registered a priori on Open Science Framework on 8th August 2023 (https://doi.org/10.17605/OSF.IO/8DJKY). (c) 2025 The Author(s). Published by Elsevier Ltd on behalf of Australian College of Critical Care Nurses Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).