ASPEN Safe Practices for Enteral Nutrition Therapy

Transcription

1 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

2 Disclosure I have nothing to disclose 6/6/2017 2

3 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

4 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

5 The Enteral Nutrition Use Process EN used in 250,000 neonates to adults in hospital 1 Inherent risk of complications with EN Gastrointestinal Metabolic Errors can occur at each step Administration Connections 1 Agency for Healthcare Research and Quality, 2013

6 Methodology Key Questions Identified Grouped into relevant sections Section Leaders led literature review Drafted practice recommendations Included rationale with specific citations

7 What Water to Use? Used for enteral access device flushing, formula dilution, and medication delivery Sterile water recommended for immunocompromised patient

8 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?

9 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

10 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

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12 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. What is the best way to confirm accurate EAD placement in adult patients? 12

13 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:

14 *Sorokin R. JPEN 2006;30: Confirming Accurate EAD Placement Cannot rely on auscultation Study in % - 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

15 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

16 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?

17 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

18 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?

19 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 % 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

20 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

21 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.

22 Enteral Nutrition Label What are the critical elements of the EN order that need to appear on the patientspecific label? Include all critical elements of the EN order on the EN label Patient identifiers Formula type EN delivery site Administration method and type

23 Components of the EN Label

24 Adult and Pediatric Labels

25 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. What are the essential steps in EN administration to prevent aspiration? 25

26 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

27 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, ICU patients 25 patients with malpositioned tubes after 3 days Significantly higher incidence of pneumonia Metheny NA, Crit Care Med 2006;34:

28 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:

29 Aspiration Prevention ASPEN/SCCM Critical Care Guidelines 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: Owens C. Gastrointest Endosc Clin N Am 2007;17: Sajid MS. Eur J Clin Nutr 2014;68:

30 Gastric vs Small Bowel Feeding Small bowel feeding: improvement in pneumonia No difference in mortality or length of stay McClave S. JPEN 2016;40:

31 American Assoc Crit Care Nurses Maintain HOB 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

32 Scenario Your hospital participated in the ICU International Nutrition Survey in 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)?

33 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

34 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

35 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: ; Pousman RM. JPEN 2009;33:

36 Enteral Interruptions Pousman procedures No difference in complications between two groups Ventilator associated pneumonia Infectious complications Pousman RM. JPEN 2009;33:

37 Anesthesiology 2011;114: Enteral Interruptions Follow the American Society of Anesthesiologists pre-operative fasting recommendations

38 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?

39 How To Resolve an EAD Clog Prevention is the best strategy Instill warm water into the EAD using a 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

40 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

41 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

42 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?

43 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 Monitoring Parameters Blaser AR. Clin Nutr 2015;34: ; Gungabissoon U. JPEN 2015;39:

44 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

45 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.

46 Thank You!!