ASPEN Safe Practices for Enteral Nutrition Therapy symposium... · ASPEN Safe Practices for Enteral Nutrition Therapy Ainsley Malone, MS, RDN, ... Metheny NA, Crit Care Med 2006 ...

ASPEN Safe Practices for Enteral Nutrition Therapy

Ainsley Malone, MS, RDN, CNSC, FAND, FASPEN

Nutrition Support Dietitian Mt. Carmel West Hospital

ASPEN Clinical Practice Specialist

Disclosure

I have nothing to disclose

6/6/2017 2

Objectives

List key recommendations and rationale for safe EN prescribing

Outline the essential parameters to monitor in enterally fed patients to minimize and/or prevent complications

Describe processes for procuring, selecting and preparing enteral formulas including closed system, powdered and blenderized formulas

3

Development Timeline

2009 Enteral Nutrition Practice Recommendations

Revision task force appointed 2014

First draft completed in mid 2016

Reviewed and revised Published late 2016 in

JPEN

4

The Enteral Nutrition Use Process

EN used in 250,000 neonates to adults in hospital1

Inherent risk of complications with EN • Gastrointestinal • Metabolic

Errors can occur at each step • Administration • Connections

1 Agency for Healthcare Research and Quality, 2013

Key Questions Identified

Grouped into relevant sections

Section Leaders led literature

review

Drafted practice recommendations

Included rationale with

specific citations

Methodology

What Water to Use?

Used for enteral access device flushing, formula dilution, and medication delivery

Sterile water recommended for immunocompromised patient

Scenario

Your hospital doesn’t have a standard order set for enteral feedings and would like to develop one for transition to a new electronic health record.

What are the critical (required) elements for a complete EN order? What are the supplementary (auxiliary) elements to the EN order that may improve patient safety?

Critical Elements of the EN Order

Patient information • Name, age, medical record number • Height/length, dosing weight • Allergies

EN formula name • Generic terms desired with trade name

Delivery route and enteral access device (EAD) Administration method and rate

• Specific administration method • Define volume and rate • Can include advancement schedule

Supplementary Orders

Design and implement policies/procedures addressing supplementary orders

Specific product for modular therapies • Prescribed amount and administration schedule

Establish proper EAD flushing Address re-assessment of the head of bed

elevation Ongoing monitoring

• Laboratory orders • Clinical parameters

Scenario

Your ICU leadership team is reviewing its feeding tube insertion policies

The nursing council is evaluating whether to utilize capnography as a reliable method to confirm feeding tubes are not placed in the lung.

12

What is the best way to confirm accurate

EAD placement in adult patients?

Confirming Accurate EAD Placement

Obtain radiographic confirmation to confirm proper position • Blindly placed EAD • Prior to its initial use for EN and

medications

Capnography • Measures presence of CO2 • Is reliable to determine

pulmonary placement • Unreliable to distinguish proper

gastric or small bowel placement

*Sorokin R. JPEN 2006;30:440-445.

Confirming Accurate EAD Placement

Cannot rely on auscultation • Study in 2006 - 1.3% - 2.4% misplacement rate*

Bedside tests useful as precursor for radiology

pH and appearance of aspirates may be helpful • Lung aspirate color is pale yellow or serous with

a pH of ≥7 • Gastric aspirate color ranges from clear to green

or brown – pH ≤5

*Sorokin R. JPEN 2006;30:440-445.

What About Pediatrics and Neonates?

Use multiple variables for confirming accurate EAD placement • EAD insertion length • Gastric pH • Visualization of gastric aspirate

Abdominal radiology is the gold standard • Endorsed by the Child Health Safety

Organization in it’s 2012 safety alert

Multiple repeated radiographs may result in high cumulative radiation • Radiology not practical in home, ambulatory

and long term care settings

Scenario

You begin consulting for a new long term care facility and have identified patients having their long term EAD replaced every three months. This requires transfer to an outpatient GI lab which is costly and disruptive to the resident.

How often should you replace long-term EADs?

Replacement of Long Term EAD’s

Develop institutional protocols for replacing percutaneous EAD’s • Routine removal/replacement may not be

necessary • Replace per manufacturer’s guidelines

Consider tube replacement • Deterioration or dysfunction of the EAD • A ruptured internal balloon • Stomal tract disruption • Peristomal infection that persists • Non-healing ulcer • Fistula

Scenario

Your hospital has decided to add blenderized feedings to your home enteral feeding program for those patients who prefer not to use commercial formulas.

What are the safety issues when using blenderized

tube feedings and how can risk of complications be

reduced?

Blenderized Feedings (BTF)

Usage of BTF increasing • Adult home EN program-Mayo Clinic 2016

– Reported 50% of patients were using BTF’s

• Oley Foundation survey – 2016 – 58% pediatric; 42% adults – 89% of pediatric respondents using BTF

• ≥71% of their daily enteral intake

– 66% of adult respondents using BTF • ≥56% of their daily enteral intake

– Respondents more active and involved; more likely to see out BTF’s

Various options of BTF’s

Practice Recommendations with BTF’s

Limit hang time to 2 hours or less • Higher risk for cross contamination and

potential for food borne illness • Best for bolus administration

Sanitize blenders after each use Use a 14 French or greater feeding tube

• Viscosity increases clogging • Concern with new EnFit connectors

Involve a RDN or nutrition support clinician in development of a BTF • Ensure adequate nutrient delivery

Scenario

Your hospital is preparing to upgrade its electronic health record and is working with a consulting group to assist with the upgrade.

In working with your nutrition leaders, the consultant notifys you that the only information needed on the EN label is patient name and age; everything else can be verified by the bedside RN.

Enteral Nutrition Label

Include all critical elements of the EN order on the EN label • Patient identifiers • Formula type • EN delivery site • Administration method and type

What are the critical elements of the EN

order that need to appear on the patient-

specific label?

Components of the EN Label

Adult and Pediatric Labels

Scenario

Your ICU Nursing Council has been charged with evaluating EN administration policies and procedures to address an increase in ventilator associated pneumonia. It has been 5 years since the last review of EN policies and procedures. You are being asked to provide input.

25

What are the essential steps in EN administration to prevent aspiration?

Aspiration Prevention

Related to oral/pharyngeal secretions • Also esophageal/gastric reflux

Maintain head of bed at least 30◦ or upright in a chair • Aspiration Risk Reduction Protocol – Metheny et

al • Combined HOB, small bowel tube and GRV

assessment • Aspiration decreased 88% vs 39% (p<0.001) • Pneumonia decreased 48% vs 19% (p<0.001)

Nurs Research, 2010;59:18-25

Aspiration Prevention

Monitor patients at least every 4 hours for positioning

Minimize use of sedatives Monitor patient status for tolerance

• Abdominal distention or firmness • High volume gastric residual volumes (GRV’s) • Bloating or nausea

Monitor tube position at least every 4 hours • Metheny, 2006 – 201 ICU patients • 25 patients with malpositioned tubes after 3

days – Significantly higher incidence of pneumonia

Metheny NA, Crit Care Med 2006;34:1007-1015.

Aspiration Prevention

Monitor visible length of tubing or marking at tube exit site

Investigate placement when a deviation is noted

Optimal tube placement may help reduce potential EN reflux • Metheny , 2011 – evaluated 428 ICU patients

– Aspiration decreased (compared to gastric) (p<0.001) • Tube in first portion of duodenum – 11.6% • Second/third portion of duodenum – 13.2% • Fourth portion of duodenum – 18%

Metheny NA.JPEN 2011;35:346-355.

Aspiration Prevention

Recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (M/H)

McClave S. JPEN2016;40:159-211

Owens C. Gastrointest Endosc Clin N Am

2007;17:687-702

Sajid MS. Eur J Clin Nutr 2014;68:424-432

ASPEN/SCCM Critical Care Guidelines

Gastric vs Small Bowel Feeding

Small bowel feeding: improvement in pneumonia No difference in mortality or length of stay

McClave S. JPEN 2016;40:159-211

American Assoc Crit Care Nurses

Maintain HOB 30◦-45◦ unless contraindicated

Use sedatives sparingly Assess feeding tube placement q

4 hours Observe for change in external

tube Assess GI tolerance q 4 hours

• Assess GRV’s and abdominal status

Avoid bolus feedings for those at high aspiration risk

Scenario

Your hospital participated in the ICU International Nutrition Survey in 2015.

Your results for the “amount of prescribed energy” and “prescribed protein” received: • 55% and 45%

The primary reason for this suboptimal performance was related to feeding interruptions

Under what circumstances (if any) should EN be held to improve patient safety (prior to transportation, prior to procedures, surgery, or extubation)?

Practice Recommendations

Avoid interruptions or holding EN for routine interventions • Extubation • Procedures where short periods of HOB

lowering are needed • Perform assessment for retention of

oropharyngeal secretions and gastric reflux

Withholding feeding based solely on tradition is not advisable • Evidence based decision making imperative

Enteral Interruptions

Peev, 2015 – JPEN Observational study

to characterize EN interruptions • Surgical ICU

26% of interruptions were considered “avoidable”.

Those w/ at least 1 interruption - 3 X more likely to be underfed • Longer hospital LOS

Enteral Interruptions

Standard practice of NPO after midnight has been challenged

Study in jejunal versus gastric feedings • Moncure, 1999 in trauma patients

– Jejunal feeding just prior to OR – Jejunal feedings held for 8 hrs prior to OR – No differences in aspiration

• Pousman, 2009 in trauma patients – Old protocol: gastric feedings discontinued 8 hr prior

to OR – New protocol: Gastric feedings discontinued 45 min

prior to surgery or jejunal feedings continued until time of OR Moncure M. JPEN 1999;23:356-359; Pousman RM. JPEN 2009;33:176-180

Enteral Interruptions

Pousman – procedures No difference in complications between two

groups • Ventilator associated pneumonia • Infectious complications

Pousman RM. JPEN 2009;33:176-180.

Enteral Interruptions

Follow the American Society of Anesthesiologists pre-operative fasting recommendations

Anesthesiology 2011;114:495-511

Scenario

You are working with a patient who has a feeding jejunostomy and will be going home with his EN. The attending surgeon instructs the patient to use a carbonated beverage to flush the tube if it becomes clogged.

What is the best way to open a clogged feeding tube? What are the best practices to maintain tube patency and prevent tube clogging?

How To Resolve an EAD Clog

Prevention is the best strategy Instill warm water into the EAD using a 30-

60 mL syringe Use an uncoated pancreatic enzyme

solution • With sodium bicarbonate

Use an enzyme containing declogging kit or mechanical declogging device

Success depends on the cause of the clog Begin process when tube becomes sluggish

Declogging EAD’s

Pancreatic enzyme solutions effective with clogs due to enteral formulas • More effective when

compared with cola

Mechanical devices available • ClogZapper • Bard Brush • TubeClear

Prevention of EAD Clogs – Best Practices

Use the largest diameter feeding tube feasible • Jejunal tubes more likely to clog

Utilize EAD flushing protocols Limit gastric residual checks

• Gastric contents may lead to formula precipitate

• Flush following GRV checks

Flushing following EN “holds” Consider use of an automatic flushing pump

Scenario

You are a new clinical nutrition manager and are evaluating your enteral feeding management policy for RDN evaluation and reassessment.

What are the minimum monitoring parameters and timeframes for reassessment to allow for safe management of the patient receiving EN?

Monitoring and Reassessment of EN

Reassessment time frames depend on the practice setting • EN intolerance in ICU

likely to occur 1-3 days following initiation

• In longterm care at least monthly

• In home care setting at least quarterly

Blaser AR. Clin Nutr 2015;34:956-961; Gungabissoon U. JPEN 2015;39:441-448.

Monitoring Parameters

Future Research

Multiple research recommendations for all topic areas

Electronic health record decision support Use of technology for EN volume

documentation Error documentation Non-radiologic EAD confirmation Human milk and fortification Gastric vs small bowel feeding and

outcomes with prone positioning Aspiration and bolus feedings

Take Home Messages

The EN process includes multiple steps involving multiple disciplines.

Multiple opportunities to introduce best practices for the safe use of enteral nutrition therapy.

Practice recommendations beneficial for incorporation into institutional policies/procedures and protocols.

Thank You!!