Neurology · Medical Literature
Impact of a Staged Enteral Nutrition Nursing Pathway Based on Dynamic Assessment of Tolerance and Aspiration Risk vs Usual Care on Feeding Intolerance in Older Adult Patients With Acute Ischemic Stroke and Dysphagia: A Single-Center Randomized Controlled Trial.
Abstract
BACKGROUND Older adult patients with acute ischemic stroke have dysphagia and require early post-pyloric enteral nutrition, yet feeding intolerance and unstable energy delivery remain common, and practical pathways that integrate tolerance and aspiration risk are lacking. This trial evaluated whether a dual-axis staged nursing pathway, compared with usual care, was associated with lower feeding intolerance and better nutritional delivery. MATERIAL AND METHODS This single-center, parallel, 1: 1 randomized controlled trial enrolled older adult patients with acute ischemic stroke and dysphagia with post-pyloric nasoenteric tubes placed. The intervention group received a staged nursing pathway, and the control group received usual care. The primary outcome was 7-day feeding intolerance; secondary outcomes were time to ≥80% of target, target-achieving days, aspiration-related pneumonia, and safety. Analyses were intention-to-treat. RESULTS Compared with control, the intervention group had a lower 7-day risk of feeding intolerance (adjusted RR 0.61, 95% CI, 0.47-0.81; P=0.003); faster attainment of at least 80% of energy target (adjusted HR 1.65, log-rank P 0.05). Subgroup/sensitivity analyses were consistent. CONCLUSIONS A staged nursing pathway driven by dynamic dual-axis assessment was associated with lower feeding intolerance and earlier, more stable nutritional delivery in the context of post-pyloric feeding, without increasing short-term safety events.
Clinical relevance
Older adult patients with acute ischemic stroke and dysphagia represent a high-risk nutritional population in whom post-pyloric enteral nutrition is standard, yet feeding intolerance and failure to achieve energy targets remain prevalent and clinically consequential. No validated, practical nursing pathway that simultaneously integrates real-time gastrointestinal tolerance monitoring and aspiration risk stratification had previously been evaluated in a randomized trial for this specific cohort. This trial is clinically urgent because suboptimal early nutritional delivery in this population is directly linked to increased infection risk, impaired neurological recovery, and prolonged hospitalization.
Key findings
1. The staged dual-axis nursing pathway significantly reduced the 7-day risk of feeding intolerance compared with usual care (adjusted RR 0.61, 95% CI 0.47–0.81; P=0.003), representing a 39% relative risk reduction. 2. Patients in the intervention group achieved ≥80% of their prescribed energy target faster than controls, as demonstrated by a statistically superior time-to-target analysis (adjusted HR 1.65, log-rank P 0.05), confirming the safety of the intervention. Subgroup and sensitivity analyses were consistent with the primary intention-to-treat results.
Practice implications
Neurological and critical care nursing teams should consider adopting a formalized, dynamic dual-axis (gastrointestinal tolerance plus aspiration risk) staged pathway for managing post-pyloric nasoenteric feeds in older adults with acute ischemic stroke and dysphagia, as this approach demonstrably reduces feeding intolerance and aspiration-related pneumonia without increasing safety events. Pathway implementation should incorporate prospective, recurring reassessment of both tolerance markers and aspiration risk to guide stepwise advancement of feeding rates toward the ≥80% energy target threshold. Given the single-center design, institutions seeking to adopt this pathway should conduct local protocol adaptation and feasibility evaluation prior to broad implementation, and multicenter validation is needed before universal guideline incorporation.