Analysis of Commercial Enteral Formula (CEF) and Hospital Enteral Formula (HEF) usage on cost budget and patient food acceptance

• Tri Putri Putri
• Mitra Mitra
• Liza Srikusuma Devi

Vol. 6 No. 1: 2025 | Pages: 9-16

DOI: 10.47679/makein.2025221   Reader: 1153 times PDF Download: 490 times

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Abstract

INTRODUCTION

One of the healthcare services provided by hospitals is nutrition services. Hospital nutrition services are tailored to the condition of patients based on clinical status, nutritional status, and metabolic status. These services include outpatient and inpatient nutrition services, food provision, as well as research and development in nutrition (Kemenkes, 2013). The high prevalence of malnutrition in hospitals has increased the focus on nutrition management. Improved nutrition management has been shown to reduce malnutrition rates to 38% in 1988. However, progress has been slow, with research in 1995 indicating that 50% of hospitalized patients experienced varying degrees of malnutrition, and 25-30% of patients faced worsening malnutrition during their treatment (Purnomo et al., 2007). For critically ill patients who are unable to meet their nutritional requirements through oral intake, enteral nutrition should be prioritized when the gastrointestinal tract can be safely used, while parenteral nutrition may be considered when enteral feeding is contraindicated, not feasible, or insufficient to meet nutritional requirements (Singer et al., 2023).

Food plays a fundamental role in religious, cultural, and ethical traditions. We often prioritize medication or other medical interventions while neglecting nutritional therapy (Hartono, 2006). Nutrition is a critical determinant in improving human quality of life (Harjatmo, 2018). The provision of nutritional therapy in hospital services often encounters challenges, one of which is the acceptance of dietary meals. Diets may not be effectively implemented due to additional foods brought by patients' families, which are not part of the hospital-prescribed diet, often citing patient preference as the reason (Uyami et al., 2014). This factor influences the success of nutrition services, where patient acceptance of ≥80% means food waste should not exceed ≤20%, in accordance with Ministry of Health Decree No. 129/Menkes/SK/II/2008 concerning Minimum Hospital Service Standards, which states that uneaten food should not exceed 20% (Sari & Balgis, 2017).

Based on the recommended dietary allowances, the nutritional and energy requirements decrease with age (Kemenkes RI, 2019). When determining the type of diet to be provided to hospitalized patients, it is essential to assess the patients’ physical condition, which includes blood pressure, respiration, pulse, and temperature (Ibrahim et al., 2022). Consequently, food provision varies in form and type. Enteral nutrition can be administered either as a bolus or via infusion using an enteral pump (Harti, 2023).

Enteral nutrition can be provided using commercially manufactured formulas or appropriately prepared hospital-based formulas. Commercial enteral formulas offer advantages in terms of standardization, food safety, ease of preparation, and shelf life; however, their relatively higher cost may increase expenditure on long-term or repeated enteral feeding. Hospital-prepared enteral formulas may provide a more economical alternative when their nutritional composition, microbiological safety, physical characteristics, preparation procedures, and storage conditions are appropriately standardized (Lestari et al., 2019; Mezzomo et al., 2021).

Studies evaluating non-commercial enteral formulations have demonstrated their potential economic advantages. Lestari et al. (2019) reported that a modified hospital-prepared enteral formula had acceptable macronutrient composition and microbiological quality, favorable organoleptic acceptance, and lower ingredient costs than commercial enteral formulas. Similarly, Mezzomo et al. (2021) found that home-prepared and blended enteral formulas were less expensive than commercial formulas, although careful nutritional formulation remains necessary to ensure adequate micronutrient content. These findings support the development of cost-efficient hospital enteral formulas while emphasizing that lower cost should not compromise nutritional adequacy and food safety.

Budget efficiency is particularly relevant within Indonesia's National Health Insurance (Jaminan Kesehatan Nasional [JKN]) system. As of June 2024, JKN coverage had reached approximately 273.5 million people, representing 96.8% of the Indonesian population (BPJS Kesehatan, 2024). The extensive coverage of the program highlights the importance of efficient resource utilization at the hospital level while maintaining the quality and safety of healthcare services. Within hospital nutrition services, the repeated use of commercial enteral formulas (CEF), particularly among patients requiring multiple daily feedings, may represent a substantial component of nutritional care expenditure. Therefore, hospitals need to consider clinically appropriate strategies that optimize nutritional care while using available resources efficiently.

Evidence from enteral nutrition research suggests that non-commercial or locally prepared enteral formulas may offer economic advantages compared with commercial products. Mezzomo et al. (2021) found that home-prepared and blended enteral formulations were less costly than commercial enteral formulas. However, some non-commercial preparations showed limitations in micronutrient adequacy, emphasizing that lower cost alone should not determine formula selection. Nutritional adequacy, hygienic preparation, microbiological safety, viscosity, storage conditions, and individual patient requirements must also be considered. Therefore, hospital enteral formulas (HEF) developed from locally available ingredients may represent a cost-conscious alternative to CEF when their recipes, preparation procedures, nutrient composition, and safety are appropriately standardized and monitored (Lestari et al., 2019; Mezzomo et al., 2021).

This consideration is particularly relevant to RSUD Muhammad Sani Karimun, where the cost of CEF and the need to optimize hospital food-service expenditure have encouraged the development of HEF using locally available ingredients. Previous Indonesian studies have demonstrated the feasibility of modifying enteral formulas using local food ingredients while maintaining acceptable nutritional and organoleptic characteristics (Ariani et al., 2013; Lestari et al., 2019; Putriningtyas et al., 2023). Nevertheless, economic advantages should be evaluated together with nutritional adequacy, food safety, patient acceptance, and operational feasibility. Accordingly, the present study aims to analyze the cost efficiency and patient acceptance of HEF compared with CEF and to formulate practical recommendations for optimizing enteral nutrition services at RSUD Muhammad Sani Karimun.

Research by Putriningtyas et al. (2023) showed that 18 respondents (75%) liked the product's color, 13 respondents (54.2%) liked the taste, 21 respondents (87.5%) liked the aroma, and 16 respondents (66.7%) liked the texture of the developed enteral formula. Research by Lestari et al. (2019) indicated that the nutritional content aligns with Indonesia's general composition standards, the microbiological tests and shelf life are within safe limits according to SNI, and over 80% of sensory panelists favored powdered HEF based on organoleptic tests. Additionally, the material cost was cheaper than commercial enteral formulas (Lestari et al., 2019). Ariani et al. (2013) explained that using local food ingredients in HEF can improve and enhance body weight, but selecting and using local food ingredients must align with the nutritional content required in hospital enteral formulas (Ariani et al., 2013). Hawa and Murbawani (2015) illustrated that certain local food ingredients in enteral formulas can positively impact specific disease diagnoses, as evidenced by clinical and biochemical examinations (Hawa & Murbawani, 2015).

The importance of efficient nutrition management, in terms of cost and patient acceptance, must be emphasized in nutrition services. Commercial enteral formulas (CEF) offer convenience and hygiene advantages but are expensive, particularly for patients relying on BPJS coverage. On the other hand, hospital enteral formulas (HEF) provide a more cost-effective solution without compromising nutritional quality. This study aims to analyze the cost efficiency and patient acceptance of HEF compared to CEF as an innovative effort in nutrition services at RSUD Muhammad Sani Karimun.

METHOD

Research design

This study employs a qualitative approach with a case study design to compare the cost efficiency and patient acceptance of commercial enteral formulas (CEF) and hospital enteral formulas (HEF) at RSUD Muhammad Sani Karimun in 2024. The research follows an observational case study approach, allowing for an in-depth exploration of this phenomenon within a real-world hospital setting. This design provides comprehensive insights into contextual factors, including hospital policies, patient experiences, and the perspectives of nutrition staff.

Research Location and Participants/Informan

The research was conducted at RSUD Muhammad Sani Karimun, Karimun Regency, Riau Islands Province. Informants were selected purposively based on their direct experience with the provision, preparation, administration, or receipt of enteral formulas. The key informants included six inpatients receiving enteral nutrition and nutrition kitchen staff, while the Head of the Non-Medical Support Division served as a supporting informant because of their involvement in budgeting and the management of enteral formula services.

The adequacy of the number of informants was considered in relation to data saturation, that is, the point at which additional data collection no longer generated substantively new information relevant to the research questions. Saturation is commonly used to assess the adequacy of qualitative interview samples, particularly in studies involving relatively focused research questions and relatively homogeneous informant groups (Guest et al., 2006).

The selection of informants was based on inclusion and exclusion criteria. The inclusion criteria were: (1) inpatients at Muhammad Sani Hospital who received enteral formulas (CEF or HEF) during the study period, (2) nutrition kitchen staff directly involved in enteral formula provision, and (3) the Head of Non-Medical Support Division, who played a role in budgeting and managing enteral formula operations. The exclusion criteria included (1) patients unwilling to participate in interviews or observations, (2) nutrition kitchen staff who were not on duty during the study period, and (3) informants unable to provide information relevant to the study’s focus.

Data Collection

Primary data were obtained through direct observation and in-depth interviews with key and supporting informants. Secondary data were collected from hospital documents, including procurement and budget reports, hospital profiles, and nutrition unit records. The combination of interviews, observations, and document analysis enabled the researchers to examine both the experiential and operational dimensions of CEF and HEF utilization.

Data Validity

The credibility of the findings was strengthened through source and method triangulation. Source triangulation was conducted by comparing information obtained from patients, nutrition personnel, and hospital management, whereas method triangulation involved comparing evidence obtained through interviews, direct observations, and document analysis. The use of multiple data sources and methods can provide a more comprehensive understanding of a phenomenon and enable cross-validation of qualitative findings (Carter et al., 2014).

Data analysis

Qualitative data obtained from interviews, observations, and documents were analyzed thematically to identify recurring patterns related to cost efficiency, patient acceptance, operational barriers, and factors affecting HEF implementation. Thematic analysis provides a systematic and flexible approach for identifying, organizing, and interpreting meaningful patterns within qualitative data (Braun & Clarke, 2006).

Potential causes underlying the suboptimal utilization of HEF were subsequently organized using a cause-and-effect or fishbone diagram. The fishbone diagram is a quality-improvement tool used to systematically organize multiple factors that may contribute to a defined problem and to facilitate identification of potential root causes (Kumah et al., 2024).

After potential causes were identified, the problems were prioritized using the Urgency, Seriousness, and Growth (USG) approach. This method uses a scoring process to determine which identified problems require priority attention based on their urgency, seriousness, and potential to worsen if they remain unresolved (Apriani et al., 2024). The prioritized findings were then used as the basis for formulating practical interventions and the Plan of Action (POA).

RESULTS OF STUDY

This study was conducted at RSUD Muhammad Sani Karimun, a type-C hospital offering various specialized services, including inpatient nutrition services. These services encompass meal provision and the administration of enteral formulas for patients with specific needs (PLIP RSUD Muhammad Sani, 2023). RSUD Muhammad Sani Karimun offers a nutrition program that includes the use of commercial enteral formulas (CEF) and hospital enteral formulas (HEF). While CEF provides convenience in preparation and sanitation, it is costly. In contrast, HEF has been developed as a more economical alternative, utilizing local ingredients and modifications tailored to patient needs.

Based on observations and interviews with the Head of the Non-Medical Support Division, the Head of Support Services, the Procurement Officer, the Technical Activity Officer, and nutrition staff, some aspects of hospital nutrition services remain suboptimal. These include the patient food service system and nutritional care delivery. Interviews with the Head of the Non-Medical Support Division and the Head of Support Services revealed:

"Several service indicators still need to be evaluated and improved in hospital nutrition services, particularly regarding the high expenditure on commercial enteral formulas. ”

Further interviews with the Procurement Officer and the Technical Activity Officer highlighted:

"There is a need for budget efficiency in food procurement, particularly for milk or commercial enteral formulas. ”

Since early 2024, the Head of the Nutrition Installation has introduced modifications to liquid meals/enteral formulas by preparing and producing them internally in the hospital's nutrition kitchen. This initiative was motivated by the high budget allocation for commercial enteral formulas and aims to enhance the nutrition installation’s capacity to deliver nutrition services. It also seeks to improve the competency of nutrition staff in processing modified meals without compromising the nutritional content required by patients, using local food ingredients.

Despite the efforts, challenges remain in the implementation of HEF in dietary therapy. Observations and interviews revealed that the primary challenges are related to the routine procurement of HEF rather than patient acceptance. Routine procurement has been hindered by inconsistencies among nutrition staff in administering HEF for dietary therapy. There is still a preference for CEF over HEF in some cases. Additionally, nutrition staff have not fully adhered to HEF usage guidelines, which stipulate that HEF must be provided to patients on liquid diets between 5:30 AM and 7:00 PM. Observations showed instances where nutrition staff discreetly administered CEF outside permitted hours, as CEF is only allowed after 7:00 PM.

The combination of HEF and CEF usage is influenced by the fact that nutrition staff work in only two shifts per day, with the last shift ending at 7:00 PM. Moreover, the hospital lacks proper food storage equipment to maintain the temperature stability of HEF in inpatient pantries or patient rooms for those requiring dietary therapy after 7:00 PM.

Regarding HEF acceptance, observations and interviews found no complaints from patients or their families. The taste of HEF was generally well-received. Patient families expressed strong support for HEF, stating:

"If patients need enteral formula therapy at home post-discharge, the cost can be significant. Patients might require up to six servings daily, with each serving consuming one sachet of milk/CEF. Thus, hospital-provided information about preparing HEF at home serves as a cost-saving alternative."

Patients receiving enteral diet therapy who could orally sample the formulas compared CEF and HEF, stating:

"CEF tastes sweeter, but HEF is also palatable, resembling milk. However, the color differs slightly — HEF has a white-to-baby-pink hue, whereas CEF is pure white. CEF smells like commercial milk, while HEF has a sweet porridge or milkshake aroma. The texture is similar for both."

Based on the explanation above, it can be concluded that issues still persist regarding the suboptimal use of hospital enteral formulas for patients on liquid diet therapy and those with NGT (nasogastric tube) in the inpatient ward of RSUD Muhammad Sani. Challenges in Utilisation of Hospital Enteral Formula (HEF) at Muhammad Sani Hospital are presented in Table 1.

Table 1. Challenges in the Utilization of Hospital Enteral Formulas (FERS) at RSUD Muhammad Sani

Challenges	Issue	Description
Logistical Issues	Availability and Storage	FERS requires specialized storage to maintain temperature stability, especially for patients needing enteral formulas after 7:00 PM. Currently, adequate storage facilities are unavailable.
	Routine Procurement	Procurement of HEF lacks continuity due to reliance on local raw materials and some staff preferences for commercial enteral formulas (CEF).
	Limited Operational Hours	Nutrition staff work only two shifts, up to 7:00 PM, making it difficult to provide liquid diets beyond these hours.
Staff Preferences	Policy Compliance	Some nutrition staff provide CEF at unauthorized times due to convenience.
	Competence and Knowledge	There is insufficient training and understanding of HEF benefits among nutrition staff. Some staff prefer CEF as it is simpler to prepare.
Culture and Policy	Established Habits	The work culture favors quick methods without considering cost efficiency, leading to a preference for CEF
	Lack of Formal Policies	Hospital management has no binding policy to ensure consistent use of HEF in patient diet therapy.
Patient and Family Challenges	Cost Efficiency	While HEF is more economical, patients and families require education on its preparation and benefits to ensure therapy continuity at home.
	Acceptance	Patients and families generally accept HEF but often compare its taste to CEF, which is perceived as more palatable.

Fishbone Analysis

The challenges in the Nutrition Installation’s services were analyzed using the Fishbone Analysis method to identify the root causes of these problems. The diagram in Figure 1 illustrates the primary issues and contributing factors.

Figure 1. Fishbone Analysis of the Suboptimal Use of Hospital Enteral Formula

From the fishbone analysis diagram, the causes and alternative solutions for the use of hospital enteral formula (HEF) for patients on liquid diet therapy and those with NGT in the inpatient unit of RSUD Muhammad Sani can be identified (Table 2).

Table 2. Alternative Solutions

No	Component	Causes	Solution
1.	Man	· Lack of knowledge and training on the benefits of HEF.	· Enhance knowledge of CEF and HEF among healthcare providers (HCP) and improve nutrition staff competence in HEF preparation.
		· Patients and families complain about the high cost of CEF for home therapy.	· Modify enteral formulas using HEF and educate patients and families on recipes and preparation methods for home use.
2.	Method	No established policy or regulation regarding the use of CEF and HEF.	Develop management policies (Director-level) on HEF usage for inpatient dietary therapy at RSUD Muhammad Sani.
3.	Money	The cost of CEF is higher than HEF produced in-house	Implement HEF usage to reduce the procurement cost of CEF in patient food supply
4.	Material	Limited availability of CEF or frequent stock shortages	Combine the use of CEF with HEF
5.	Machine	Lack of adequate equipment for enteral formula implementation	Provide HEF storage equipment to maintain temperature stability for evening use (when nutrition staff are off duty), ensuring HEF can be used during all patient feeding times
6.	Environment	Excessive waste from CEF packaging and a hospital culture inclined toward quick methods without cost consideration.	Reduce CEF usage and raise awareness of the importance of HEF for the hospital, the environment, and overall staff outcomes.

Table 3. Plan of Action (POA) for Optimizing the Use of HEF for Patients on Liquid Diet Therapy and Patients with NGT in the Inpatient Unit of RSUD Muhammad Sani Karimun

NO	Components	Activities	Goals	Target	Time	Funding	Location	Implementers	Method	Indicators
1.	MAN	· Provide specialized training on enteral formulas (CEF and HEF) to nutrition staff and PPA. · Educate patients and families on the recipes and preparation of HEF at home.	· To enhance the knowledge of PPA and improve the competency of nutrition staff in preparing HEF. · To increase patients' and families' understanding of HEF preparation so they can continue HEF therapy at home.	· Nutrition Staff, Dietitians, and other PPA. · Patients and families.	Adjusted Adjusted	BLUD RSUD Muhammad Sani -	RSUD M.Sani RSUD M.Sani	Head of Nutrition Installation Ward Dietitians	Lectures, Discussions, Q&A, Practice Lectures and Q&A	Availability of competent and skilled nutrition staff Patients and families able to continue HEF therapy at home for those requiring ongoing HEF therapy
2.	METHOD	Proposal of a policy brief to management (Director).	To establish binding policies or regulations for all PPA and nutrition units in administering diet therapy using HEF.	Director	Adjusted	-	RSUD M.Sani	Head of Nutrition Installation	Discussions and document submissions	Issuance of Policy Letter or Regulation for the use of HEF at RSUD M. Sani.
3.	MONEY	Proposing budget allocations and reporting on cost comparisons for the procurement of liquid food using CEF and HEF.	To optimize budget efficiency for patient meal expenses (especially for CEF).	Director	Adjusted	BLUD RSUD Muhammad Sani	RSUD M.Sani	Head of Nutrition Installation	Discussions and document submissions	Availability of funds for patient meal provisions
4.	MATERIAL	Procuring HEF as a combination in the administration of liquid diet therapy for patients	To modify patient diets by utilizing local food resources, reducing costs effectively.	PPBJ, Warehouse Supervisor, and Nutrition Staff	Adjusted	BLUD RSUD Muhammad Sani	RSUD M.Sani	Head of Nutrition Installation	Submission of recipe formularies and SOPs	Availability of HEF in nutritional therapy
5.	ENVIRONMENT	Disseminating policies on the use of HEF for diet therapy	Ensure all PPA and nutrition unit staff adhere to policies or regulations on the use of HEF.	PPA and Nutrition Unit.	Adjusted	BLUD RSUD Muhammad Sani	RSUD M.Sani	Head of Nutrition Installation	Discussions and Q&A	Implementation of HEF use in accordance with policies and SOPs
6.	MACHINE	Procuring storage and processing equipment for HEF implementation	To apply HEF during all patient meal times as per the predetermined diet therapy	Management, PPBJ, and PPTK	Adjusted	BLUD RSUD Muhammad Sani	RSUD M.Sani	Head of Nutrition Installation	Submission of equipment request documents	Availability of equipment to support HEF procurement

DISCUSSION

The findings indicate that HEF has a potential economic advantage over CEF within the specific operational context of RSUD Muhammad Sani Karimun. Based on procurement data from 2022–2024, the use of HEF was associated with an estimated budget reduction of approximately 51.64%–52.64% compared with CEF. Rather than attributing this finding to a general “resource efficiency theory,” the result should be interpreted as context-specific evidence that locally prepared enteral formulas may reduce procurement expenditure when suitable ingredients, facilities, and preparation procedures are available.

This finding is consistent with previous evidence indicating that home-prepared or blended enteral formulas can be less expensive than commercially manufactured products (Mezzomo et al., 2021). However, economic efficiency should not be interpreted solely in terms of lower ingredient costs. Mezzomo et al. (2021) also demonstrated that some non-commercial enteral preparations may have limitations in micronutrient adequacy. Similarly, the economic advantages identified in the present study should therefore be considered together with nutritional composition, hygienic preparation, microbiological safety, recipe standardization, storage requirements, and patient-specific nutritional needs.

The findings of the present study also support previous Indonesian research. Lestari et al. (2019) reported that modified hospital enteral formulas could provide an economically favorable alternative while maintaining acceptable nutritional, microbiological, and organoleptic characteristics. Putriningtyas et al. (2023) likewise demonstrated favorable sensory acceptance of modified enteral formulas, particularly in terms of color, aroma, taste, and texture. Taken together, these findings suggest that the potential value of HEF lies not only in reducing expenditure but also in balancing affordability, nutritional adequacy, safety, and patient acceptance.

The effect of local ingredients in enteral formulas, as studied by Ariani et al. (2013), demonstrated that local food ingredients in enteral food could increase hemoglobin and iron levels in malnourished rats. Meanwhile, Hawa and Murbawani (2015) showed that pumpkin was an antidiabetic ingredient for diabetic rats, although it did not significantly lower postprandial blood glucose levels (Hawa & Murbawani, 2015). Therefore, it can be concluded that modifying enteral formulas with local ingredients can improve nutritional value, reduce costs, and provide health benefits under certain conditions.

The fishbone analysis identified multiple interacting factors contributing to the suboptimal implementation of HEF, including staff knowledge and competence, the absence of formal institutional policies, limited storage facilities, working-hour restrictions, procurement continuity, and staff preferences. The use of a cause-and-effect diagram is appropriate for this type of service problem because it facilitates the systematic organization of multiple contributing factors rather than attributing an operational problem to a single cause (Kumah et al., 2024).

The subsequent USG prioritization provides an operational basis for determining which problems require more immediate intervention. In healthcare management settings, USG scoring can assist in ranking identified problems according to their urgency, seriousness, and potential for further development or deterioration (Apriani et al., 2024). In the present study, this prioritization supports the formulation of targeted interventions involving staff training, management policies, procurement arrangements, storage facilities, and patient and family education.

This study identifies practical implications of the findings for hospital policy as follows: The lack of institutional policies is a major obstacle; hospitals need to establish policies mandating the implementation of HEF, accompanied by strict oversight to ensure adherence to standardized recipes. Training for nutrition staff and healthcare professionals on the procedures and benefits of HEF is essential to enhance their knowledge and skills. The more efficient waste management of HEF compared to CEF supports environmentally friendly policies and reduces waste disposal costs. Additionally, providing adequate storage and management equipment in inpatient pantries is crucial to ensure the sustainability of HEF implementation.

Recommendations for future research on HEF implementation include investigating the long-term effects of HEF, optimizing HEF recipes, and conducting broader-scale comparisons, such as comparative studies involving a larger sample of hospitals, including private hospitals and remote areas, to evaluate the feasibility of FERS implementation in various contexts. Additionally, cost-environmental analyses of HEF implementation should be explored.

CONCLUSIONS AND RECOMMENDATION

Based on the findings of this study, HEF represents a potentially more economical alternative to CEF within the nutritional service system of RSUD Muhammad Sani Karimun. The estimated cost savings associated with HEF ranged from approximately 51.64% to 52.64%, while patient acceptance was generally favorable in terms of taste, aroma, and texture. HEF also offers flexibility in the selection and modification of ingredients according to patient requirements. However, its routine implementation depends on standardized recipes, nutritional adequacy, hygienic preparation, appropriate storage facilities, trained nutrition personnel, consistent procurement, and institutional policy support.

The present study did not directly evaluate changes in nutritional status, clinical complications, duration of hospitalization, recovery time, readmission, or mortality. Therefore, clinical benefits in these outcomes should not be directly attributed to HEF on the basis of the present findings. Nevertheless, evidence from hospitalized patients with malnutrition indicates that appropriately targeted nutritional interventions can contribute to shorter hospital stays, demonstrating the broader clinical importance of adequate nutritional care (Cano-Torres et al., 2017). Future studies should therefore evaluate not only the cost and acceptability of HEF but also its nutritional adequacy, microbiological safety, tolerance, and clinical outcomes using larger samples and comparative or prospective study designs.

Based on these findings, RSUD Muhammad Sani Karimun is encouraged to develop institutional policies and standard operating procedures governing the preparation and administration of HEF. Standardized recipes should be developed and periodically evaluated for energy, macronutrient, and micronutrient adequacy. Training should be provided to dietitians, nutrition kitchen personnel, nurses, and other healthcare professionals involved in enteral nutrition. Adequate processing and storage equipment should also be provided to ensure that HEF can be safely administered throughout the required feeding schedule. In addition, patients and family caregivers should receive practical education regarding the appropriate preparation and use of enteral formulas when nutritional therapy needs to be continued after discharge.

DECLARATIONS

Ethics approval and consent to participate

This study involved human participants, including hospitalized patients receiving enteral nutrition and hospital personnel who participated in interviews and observations. All participants were informed about the objectives, procedures, voluntary nature of participation, confidentiality, and their right to withdraw from the study at any time without consequences. Written informed consent was obtained from all participants prior to data collection. Participant anonymity and confidentiality were maintained throughout data collection, analysis, and reporting.

Consent for publication

Not applicable. The manuscript does not contain identifiable personal information, images, or other individual-level data that could reveal the identity of the participants. Any quotations from interviews were presented anonymously and without identifying information.

Availability of data and materials

The data supporting the findings of this study include interview data, observational records, and relevant hospital documents. Due to participant confidentiality and the institutional nature of some hospital data, these materials are not publicly available. Anonymized data may be made available by the corresponding author upon reasonable request.

Conflicts of interest

The authors declare that they have no conflicts of interest or competing interests that could have influenced the conduct, analysis, interpretation, or reporting of this study.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Artificial Intelligence-Assisted Technology

Generative artificial intelligence-assisted technology (ChatGPT, OpenAI) was used solely to support language refinement, improve clarity and readability, and assist with the consistency and formatting of references during manuscript preparation. AI-assisted technology was not used for research design, participant recruitment, data collection, data analysis, or the generation or interpretation of the study findings. All AI-assisted outputs were critically reviewed, verified, and revised by the authors. The authors take full responsibility for the accuracy, integrity, originality, and final content of the manuscript.

Authors’ contributions

Tri Putri (TP) contributed to the conceptualization of the study, methodology, investigation, data collection, data curation, formal analysis, interpretation of the findings, and preparation of the original manuscript draft. Mitra (M) contributed to the study conceptualization, methodology, supervision, validation of the analysis, interpretation of the findings, and critical review and editing of the manuscript. Liza Srikusuma Devi (LSD) contributed to the coordination of data collection at RSUD Muhammad Sani Karimun, access to relevant institutional data, investigation, validation of the findings, interpretation of the hospital nutrition service context, and critical review of the manuscript. All authors reviewed and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.

Copyright and Licenses

Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under an Attribution-ShareAlike 4.0 International (CC BY-SA 4.0) that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.

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