The role of clinical pharmacist to improve medication administration through enteral feeding tubes by nurses

Effect of Virtual Education on Knowledge and Practice of Critical Care Nurses Regarding the Administration of Drugs Through Enteral Feeding Tubes: A Prospective Randomized Pre-Post Intervention Study

A study was conducted to evaluate the effect of virtual education on knowledge and practice of nurses regarding administration of drugs through enteral feeding tubes (EFTs). Sixty nurses working in 4 intensive care units were enrolled. A questionnaire evaluating knowledge and practice of nurses regarding drug administration through EFTs was used. At the pre-intervention stage, all nurses responded to the questionnaire. Then an educational videoclip was provided to the intervention group. One month later, post-intervention stage, both groups answered to the questionnaire again. At the end of the study, the scores of all items in the knowledge domain including medication preparation (mean difference [MD] [95% CI]: 1.11 [0.57; 1.66]), tube flushing (MD [95% CI]: 2.15 [1.59; 2.79]), recognizing drug-drug/drug-feed interactions (MD [95% CI]: 0.57 [0.05; 1.09]), and recognizing dosage forms (MD [95% CI]: 1.51 [0.94; 2.10]) and practice domain including medication preparation (MD [95% CI]: 1.63 [1.04; 2.21]), tube flushing (MD [95% CI]: 1.19 [0.64; 1.74]), and recognizing drug-drug/drug-feed interactions [MD (95% CI): 2.16 (1.53; 2.80)] in the intervention group were significantly higher than those in the control group (P < .05). Education of proper technics of preparation and administration of drugs through EFTs improved knowledge and practice of the participants.

Assessment of Good Practice Guidelines for Administration of Drugs via Feeding Tubes by a Clinical Pharmacist in the Intensive Care Unit

Background

In intensive care units, patients are frequently unable to take oral drugs because of orotracheal intubation or sedation.

Local Problem

Adverse events occurred during the administration of drugs by feeding tube. This study assessed the impact of implementing good practice guidelines by a clinical pharmacist on the prescription and administration of drugs through feeding tubes.

Methods

Nonconformity of drug prescription and administration in patients with feeding tubes was assessed before and after implementation of good practice guidelines in the intensive care unit of a large teaching hospital. Data were collected from medical records and interviews with physicians and nurses using a standardized form. Assessment of prescription nonconformity included compatibility of a drug’s absorption site with the administration route. Assessment of administration nonconformity included the preparation method.

Results

The analysis included 288 prescriptions and 80 administrations before implementation and 385 prescriptions and 211 administrations after implementation. Prescriptions in which the drug’s absorption site was not compatible with the administration route decreased significantly after implementation (19.8% vs 7.5%, P &lt; .01). Administration nonconformity decreased significantly in regard to crushing tablets and opening capsules (51.2% vs 4.3%, P &lt; .01) and the solvent used (67.1% vs 3.5%, P &lt; .01). Simultaneous mixing of drugs in the same syringe did not decrease significantly (71.2% vs 62.9%, P = .17).

Conclusion

Implementation of good practice guidelines by a multidisciplinary team in the intensive care unit significantly improved practices for administering crushed, opened, and dissolved oral forms of drugs by feeding tube.

A systematic approach for assessing the suitability of enteral feeding tubes for the administration of controlled-release pellet formulations

Enteral nutrition plays an important role for patients who are unable to properly swallow food. In such patients, enteral feeding tubes are often used, through which food, but often also oral medications, are administered. However, this can pose the risk of tube clogging. Compared to the administration of crushed tablets, multiparticulate dosage forms are often considered easier to administer and furthermore have the advantage of enabling the administration of even controlled-release preparations. The objective of this systematic study was to identify tube- and formulation-related factors that contribute to successful administration of coated pellet formulations via a variety of commercially available feeding tube devices. The suitability of enteral feeding tubes for the administration of controlled-release pellet formulations that differed in size and type of starter core and functional coating was investigated in a stepwise approach using a novel in vitro setup. Results of the study indicate that pellet diameter and inner diameter of the feeding tube are by no means reliable parameters for estimating the tube's suitability for pellet administration, but that many other tube and formulation-related factors and combinations thereof must be considered to ensure safe and effective drug administration via enteral feeding tubes.

Solid oral medications' suitability for use in enteral feeding tubes

BACKGROUND

There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable.

AIMS AND OBJECTIVES

To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes.

DESIGN

This was a descriptive retrospective document analysis study.

METHODS

During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders.

RESULTS

In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer-provided information.

CONCLUSION

This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors.

RELEVANCE TO CLINICAL PRACTICE

This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines.

Oral medications administration through enteral feeding tube: Clinical pharmacist-led educational intervention to improve knowledge of Intensive care units' nurses at Jordan University Hospital

Introduction

Medication administration through enteral feeding tubes is a practice that is commonly encountered in hospital settings, particularly in critically ill patients. This study aims to evaluate the knowledge of intensive care unit nurses regarding enteral medication administration and evaluate the effect of an educational intervention led by a clinical pharmacist that would improve nurses’ knowledge regarding the subject.

Methods

A pre/post interventional study was conducted. Improvement in nurses’ knowledge regarding medication administration through an enteral feeding tube was assessed using a validated questionnaire.

Results

Data were coded, entered, and analyzed using the Statistical Package for Social Sciences (IBM SPSS statistics 22). Independent samples t-test and paired t-test were used to detect any statistically significant differences in the mean total knowledge scores both between and within each group respectively. A P-value of <0.05 was considered statistically significant. The mean total knowledge score for nurses in the intervention and control group at the pre-interventional phase of the study was inadequate. There was a statistically significant improvement in the mean total knowledge score for the interventional group at the post-interventional phase of the study, while that of the control group remained inadequate (Intervention group total mean knowledge score at baseline 12.11 ± 3.75, post-intervention 21.50 ± 2.36, p-value <0.001; Control group total mean knowledge score at baseline 12.05 ± 3.12, post-intervention 12.60 ± 3.76, p-value 0.96).

Conclusion

Incorrect drug preparation and administration for patients with feeding tubes can affect patients. The knowledge of nurses regarding the subject can be improved significantly via an educational intervention. The activation of clinical pharmacists’ role and collaboration between pharmacists, physicians, and nurses is highly recommended in this clinical setting.

Enteral tube administration of oral chemotherapy drugs

Objective

Patients receiving oral chemotherapies face treatment interruptions if they require placement of an enteral tube for nutrition, potentially leading to adverse outcomes in cancer treatment. Enteral tube medication administration can provide a suitable alternative. The purpose of this review is to compile available data that describe enteral tube administration of oral chemotherapy agents. Data sources: A systematic evaluation of all Food and Drug Administration-approved oral chemotherapy agents through 31 July 2019 was conducted. Information on crushing or opening of the tablet or capsule, enteral tube administration, and extemporaneous formulations was compiled from the prescribing information, tertiary resources, and primary literature. Drug manufacturers were contacted for additional information. Data summary: A total of 87 oral chemotherapy agents were evaluated. Of the 87 drugs, 33 agents (37.9%) had information regarding enteral tube administration with only four drugs with nasogastric or gastric tube administration instructions in their prescribing information. The strength of evidence varied from non-peer reviewed data to complete evaluations of efficacy and safety. The majority of chemotherapies (62%) had no available data on enteral tube administration.

Conclusions

The results of this review suggest that there is limited data surrounding enteral tube administration of most oral chemotherapies, demonstrating the need for more studies to be conducted to provide more guidance to healthcare providers when administration via an enteral tube is needed in their patients.

Improving knowledge, attitudes, and practice of nurses in medication administration through enteral feeding tubes by clinical pharmacists: a case-control study

PURPOSE

Administering drugs and food to patients with swallowing disabilities via enteral tubes requires special skills. This task is a nursing duty and vital to ensure that they do this safely. An integrated program training nurses by a clinical pharmacist is likely to result in improved quality of oral drug administration via enteral feeding tubes. This quantitative study was undertaken to determine the efficacy of a clinical pharmacist educational program for improving nurses' knowledge, attitudes, and practice (KAP) concerning administrating medication via feeding tubes.

METHODS

This case-control study was performed to evaluate KAP of intensive-care nurses with regard to drug delivery through enteral feeding tubes before and after their training program. A questionnaire focusing on nurses' KAP was prepared by a clinical pharmacist and reviewed by 18 nurses for its reliability. Then, an educational program was designed for the case group. Two months later, nurses' KAP in the case and control groups were reevaluated. Nurses' practice regarding drug administration through feeding tube was observed three times.

RESULTS

This study was carried out with 82 nurses working in six intensive-care units in two major training hospitals in Shiraz, Iran. The overall knowledge of nurses increased significantly after the training program in the case group, with adequate awareness regarding solid dosage-form crushing increasing from 14% to 63.2% (P˂0.001), tube flushing and drug dilution from 32.6% to 81.6% (P˂0.001), and knowledge about mixing crushed drugs through a feeding tube from 23.3% to 55.3% (P˂0.001). On the contrary, there was no change in the control group. After intervention, nurses' attitudes in the case group had changed significantly, and 50% of them consulted with pharmacists regarding drug administration.

CONCLUSION

An in-service education program by clinical pharmacists can lead to substantial improvements in administration of drugs via enteral feeding tubes.

Clinical and economic impacts of clinical pharmacists' interventions in Iran: a systematic review

OBJECTIVES

There are many studies about Iranian clinical pharmacists' interventions and their impacts on medication safety and cost. The aim of this study is to collect data and critically evaluate the clinical and economic effects of Iranian clinical pharmacist interventions and activities. To our best of knowledge, this research is the first review of publications about Iranian clinical pharmacists' interventions and activities.

EVIDENCE ACQUISITION

Six online databases, including PubMed, Scopus, Medline, Cochrane Central Register of Controlled Trials, Cochrane Database of Systemic Reviews, and Google Scholar were searched using the terms '"Iranian", "clinical pharmacist", 'adverse drug reactions", "medication errors", "drug interaction", "drug utilization evaluation", "cost", and "interventions" for English studies conducted in Iran and described clinical pharmacist-initiated interventions, published before December 2018. The search and extraction process followed PRISMA guidelines. Observational or retrospective studies, clinical trials, congress abstracts, and case reports or case series were excluded. The search strategy after full-text review identified 39 articles matching the eligibility criteria.

RESULTS

Thirty-nine articles were recruited. They included establishing pharmaceutical care in out-patient clinics and drug information centers (n = 4); prevention, detection, and management of adverse drug reactions(n = 4), designing protocols and improving drug utilization pattern(n = 16), prevention, detection, and management of medication errors (n = 11), and all clinical pharmacist services(n = 4). Most clinical pharmacist interventions and activities were regarding designing protocols, improving drug utilization pattern, as well as detection, prevention, and management of medication errors. About three-fourth (74.35%) of included studies were from either ambulatory care or in-patient settings in Tehran. The median (interquartile range) duration of intervention as well as follow-up phases was 9 (5) months.

CONCLUSION

Data of our review support the beneficial role of clinical pharmacists in the improvement of quality, safety, and efficiency of patients' pharmaceutical care in Iran. Graphical abstract Clinical pharmacists' interventions in Iran.

Knowledge and practice of healthcare professionals relating to oral medicine use in swallowing-impaired patients: a scoping review

Objectives

Swallowing impairment is a growing problem that affects 16% of the overall population and can significantly affect medicine-taking. However, little is known about the knowledge and practice of healthcare professionals (HCPs) relating to swallowing-impaired (SI) patients. The aim of this scoping review was to investigate the knowledge and practice of HCPs in supporting SI patients with their medicine-taking, to identify their reference sources, and to describe their training and information needs.

Method

Databases searched included Scopus, Web of Science, Medline and Google Scholar from inception to August 2017. Qualitative and quantitative studies describing knowledge and practice of HCPs relating to medicine use in SI patients were included.

Key findings

The nine included studies, from an initial 142, involved nurses (nine studies), pharmacists (one study) and doctors (two studies) in hospitals or aged-care facilities. A knowledge deficit linked to lack of training was revealed, particularly with identification of modified-release dosage forms, medication that can/cannot be crushed, vehicle for safe dispersion, consequences of inappropriate modification, drug stability and legal aspects. Written information sources were named, but not used in practice. Pharmacists were the primary experts for consultation, and were involved in nurse education, and were members of multidisciplinary teams.

Conclusions

Knowledge in nurses was inadequate, with practice indicating potentially serious medication-related errors. Additional training, either undergraduate or as continuing professional development, is recommended. Information to guide safe medicine modification practice should be accessible to all practitioners. Pharmacists could take the lead role in offering training to nurses.

Medication Errors in Patients with Enteral Feeding Tubes in the Intensive Care Unit

Objective:

Most patients admitted to Intensive Care Units (ICU) have problems in using oral medication or ingesting solid forms of drugs. Selecting the most suitable dosage form in such patients is a challenge. The current study was conducted to assess the frequency and types of errors of oral medication administration in patients with enteral feeding tubes or suffering swallowing problems.

Methods:

A cross-sectional study was performed in the ICU of Shahid Sadoughi Hospital, Yazd, Iran. Patients were assessed for the incidence and types of medication errors occurring in the process of preparation and administration of oral medicines.

Findings:

Ninety-four patients were involved in this study and 10,250 administrations were observed. Totally, 4753 errors occurred among the studied patients. The most commonly used drugs were pantoprazole tablet, piracetam syrup, and losartan tablet. A total of 128 different types of drugs and nine different oral pharmaceutical preparations were prescribed for the patients. Forty-one (35.34%) out of 116 different solid drugs (except effervescent tablets and powders) could be substituted by liquid or injectable forms. The most common error was the wrong time of administration. Errors of wrong dose preparation and administration accounted for 24.04% and 25.31% of all errors, respectively.

Conclusion:

In this study, at least three-fourth of the patients experienced medication errors. The occurrence of these errors can greatly impair the quality of the patients’ pharmacotherapy, and more attention should be paid to this issue.

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

Knowledge of staff members of residential care facilities for individuals with intellectual disability on medication administration via enteral feeding tube

BACKGROUND

Guidelines for the safe administration of drugs through enteral feeding tube (EFT) are an important tool to minimise the risk of errors. This study aimed to investigate knowledge of these guidelines among staff of residential care facilities (RCF) for people with ID.

METHOD

Knowledge was assessed using a 13-item self-administered questionnaire. Questions reflected key aspects of guidelines on medication administration via EFT. All staff members that administer medication through EFT in Belgian RCFs were invited to participate (n = 553).

RESULTS

Nine out of 10 RCFs participated, and 356 questionnaires were collected. Almost all participants were women (96%), and most (82%) had a non-nursing educational background. Mean self-perceived knowledge of medication administration via EFT was 6.7 (on a 0-10 scale). On average, 5.7 (SD 1.9) out of 13 questions were answered correctly. A nursing degree and previous education on medication administration via EFT were associated with significantly higher scores. Guideline recommendations regarding rinsing of used medicine cups (90% correct answers) and preparation of hard gelatin capsules (89%) were known best. Those regarding the use of protective equipment when crushing toxic substances (4% correct answers), crushing of sustained release and enteric-coated dosage forms (6%), elevation of the patient's backrest (14%) and flushing of the EFT (15%) were known the least.

CONCLUSION

This study identified a substantial lack of knowledge of guidelines for drug administration through EFT among staff of RCFs for people with ID. Our findings call for tailored educational programmes in order to increase knowledge on this subject.

Exploring clinical pharmacists' perception of their impact on healthcare in Khartoum State, Sudan

Objective:

The principal aim of this study was to explore the self-perception of clinical pharmacists of their impact on healthcare in Khartoum State, Sudan, how they think doctors perceive their impact, exploring the obstacles that clinical pharmacists are facing, and identifying what clinical pharmacists recommend for a better clinical pharmacy practice in Sudan.

Methods:

This was an exploratory cross-sectional study that employed a qualitative method. Individual, in-depth interviews were conducted with a convenient sample of 26 clinical pharmacists working in 14 governmental hospitals in Khartoum State, Sudan, in March 2016. Each interview was recorded, transcribed, and coded into themes. Thematic analysis was carried out.

Findings:

The study revealed different themes regarding clinical pharmacists' perception of their impact on healthcare. The majority believed that they made an improvement in healthcare but not to the level they aspire to. Participants expressed that junior doctors and nurses had a better acceptance of clinical pharmacists' interventions compared to senior doctors. The main obstacles that clinical pharmacists were facing were their limited number, lack of support from health authorities, lack of training and educational program, lack of job descriptions, lack of specific area in patient files for clinical pharmacist intervention, and low salaries. Most participants showed dissatisfaction with the syllabus of the master of clinical pharmacy they studied.

Conclusion:

The study revealed that clinical pharmacists were looking for a better contribution in healthcare in Sudan. This can be achieved by solving the problems identified in this study.