Medication administration via enteral tubes: a survey of nurses' practices

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

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.

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.

Clinical nurses' nasogastric feeding practices in adults: a multicenter cross-sectional survey in China

OBJECTIVE

We aimed to investigate practices of nasogastric tube (NGT) intubation and feeding for adults by clinical nurses in China.

METHODS

A self-designed and validated questionnaire comprising 30 questions was distributed to 560 clinical nurses in three comprehensive hospitals of Xiamen, China. The questionnaire covered participants' demographic characteristics, NGT placement, administration of enteral nutrition (EN), and monitoring or management of feeding intolerance.

RESULTS

A total 464 (82.9%) questionnaires were completed; 36.2% of nurses used nose-ear-xiphoid and 79.5% forehead-xiphoid measurement to define the internal length of the NGT. Many participants still used traditional methods to confirm NGT placement (auscultation of injected air 50.2%, bubble test 34.7% and observing feeding tube aspirate 34.3%). Bolus feeding was the most commonly used technique to administer EN. A total 97.0% of all nurses used syringes to measure gastric residual volume (GRV), and 62.7% measured GRV every 4-8 hours. The most frequently used GRV threshold values were 200 mL (44.6%) and 150 mL (25.2%). Most nurses stopped feeding immediately when encountering high GRV (84.3%) or diarrhea (45.0%). The nasogastric feeding practices of many clinical nurses were not consistent with international guidelines.

CONCLUSIONS

Our study can provide an impetus for nursing administrators to revise their nasogastric feeding procedures, to promote compliance with evidence-based guidelines.

Safety and feasibility of crushing sevelamer tablets for enteral feeding tube administration

WHAT IS KNOWN AND OBJECTIVE

Sevelamer is an insoluble polymer indicated for the management of hyperphosphatemia in patients with chronic kidney disease (CKD). The package inserts for both tablet formulations recommend the tablets be administered whole. Due to whole tablets being sometimes inadvertently crushed and the significantly increased cost of sevelamer packets, we evaluated the safety and feasibility of crushed sevelamer tablets for enteral feeding tube administration.

METHODS

A single-centre retrospective chart review was performed. All adult ICU patients prescribed sevelamer carbonate between 1 January 2015 and 31 July 2019 were included if they received at least one dose of a sevelamer tablet or packet, whereas they had an enteral feeding tube in place. The primary outcome was the incidence of an obstructed enteral feeding tube or need for replacement, as defined as the number of occurrences over the total numbers of doses administered. The secondary outcome was the change in phosphorus levels from time of sevelamer initiation to discontinuation or patient discharge.

RESULTS

A total of 14 obstructions were reported, four in the tablet arm and ten in the packet arm (0.4% tablet arm, 0.5% packet arm; P = .5931). Of these, four (29%) required tube replacement and were followed by sevelamer discontinuation. Two (14%) were documented to be due to increased tube feeds and esomeprazole. Six (43%) cases required tube replacement, but no issues arose upon continuation. Only one of the obstructions resulted in a recurrent tube occlusion.

WHAT IS NEW AND CONCLUSION

Sevelamer tablets may be crushed and administered via enteral feeding tubes, provided clear instruction on tablet preparation is included. Oral administration in dysphagic patients requires further evaluation with clear protocols for preparation and administration.

Survey of nurses' knowledge and practice regarding medication administration using enteral tubes

AIM AND OBJECTIVES

To identify the practice variation of the individual practitioners in medications' formulation modification for patients using enteral feeding tubing and to support health practitioners involved in this process.

BACKGROUND

Blockage of enteral tubes is a common problem that can sometimes be resolved but may require replacement of the tube. Medications are a common culprit.

DESIGN

A survey of 73 registered nurses' practices around medication administration via enteral feeding tubes.

METHODS

A questionnaire study was undertaken within a district general hospital across a broad variety of wards to explore nurses' experiences of medication administration via enteral tubes. The study is reported in accordance with the squire 2.0 guidelines from the EQUATOR network.

RESULTS

Seventy-three nurses responded. Twenty-six per cent reported never checking about drug modification for administration via a tube, 12% check every time and 61% when unsure about a new drug. The volume of fluid flushes administered after medication ranged from 7.5-150 ml. Seventy-one per cent of participants reported stopping feed when medications are required, varying from 1-60 min. Sixty per cent had experienced a blocked tube and 52% the tube being removed for these reasons. The clinical nurse specialist was the commonest first point of call to help. Staff named 15 medications as the most problematic to administer, lactulose and omeprazole were the top two.

CONCLUSIONS

Practice varies significantly amongst nurses around medication administration. Theoretically, this may contribute to blocked tubes and excessive fluid administration to some patients. Barriers to medication administration were thematically grouped into: time, difficulty modifying medication, medication interactions and knowledge. Areas identified to support staff include training, devices to crush medications, medication suitability, multidisciplinary approach to streamline care and quick reference guides.

RELEVANCE TO CLINICAL PRACTICE

Health professionals may use these results to reduce and ultimately avoid problems with administering medications through feeding tubes. Organisations may use these results to develop their local practice pathways for prescribing, dispensing and training around administration of medications through enteral tubes. In a community setting, this paper may improve the awareness of patients, caregivers and prescribers of the possible implications of tubing blockages.

Registered Nurses' medication administration skills: a systematic review

AIMS

The aim of this review was to identify methods for measuring Registered Nurses' medication administration skills and to describe these skills.

DESIGN

A systematic literature review.

DATA SOURCES

The CINAHL, PubMed, Scopus, Cochrane, PsycInfo and Medic databases were searched for articles from the period 2007-2018.

REVIEW METHODS

Two researchers independently selected the articles and evaluated their quality using the National Heart, Lung and Blood Institute study quality assessment tools. The data were analysed using content analysis.

RESULTS

A total of 727 studies were identified of which 22 studies were included in this review. A total of six different measurement methods were identified: questionnaire or survey, observation, knowledge test or exam, focus group interviews, chart reviews and voluntarily reported errors. Different methods provided different information on medication administration skills. Medication administration skills were classified under nine areas: (1) safe ordering, handling, storing and discarding of medications, (2) preparing of medications, (3) the administration of medications to patients, (4) documentation, (5) evaluation and assessment of medication-related issues, (6) drug calculation skills, (7) cooperation with other professionals and (8) with the patients and (9) reporting of medication information. The results demonstrated that there are many areas that need to be improved to increase medication safety.

CONCLUSIONS

Medication administration includes many different phases, as a result of which nurses need to have many various skills to cope with medication administration as required by their profession. This review shows that nurses' medication administration skills need to be developed, and special attention should be paid to the preparation and administration phases. It is important to regularly utilise different teaching strategies and verify nurses' medication competence. As each research method has different limitations, it is vital that further studies combine different methods to form a comprehensive picture of nurses' medication administration skills.

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.

Intensive care unit nurses' knowledge of medication administration via enteral tubes

BACKGROUND

Medication administration via enteral tubes is a complex and key application for which nurses in intensive care units are responsible.

AIM

The aim of this study was to evaluate drug administrations via enteral tubes by nurses in intensive care units.

METHODS

This research was conducted using a descriptive and cross-sectional research design. The study was conducted with 289 nurses at intensive care units in hospitals in İzmir, Turkey. The data of the study were collected with the 'Sociodemographic Information Form' and the 'Enteral Medication Administrations Questionnaire', which was designed in accordance with the literature and consists of questions on interventions before, during and following medication administrations via enteral tubes.

RESULTS

It was found that more than half the nurses (62.3%) use nasogastric tubes for medication administrations and that all of them use the enteral way for the administration of medications in the form of tablets, while 58.8% use this method to administer the medications in the form of enteric-coated tablets. It was determined that approximately half the nurses (52.6%) apply more than one medication separately, and a majority (84.1%) use tap water to wash the enteral tube.

CONCLUSIONS

Enteral medication administration practices are inconsistent. Some nurses use unsafe practices and may therefore compromise patient care.

RELEVANCE TO CLINICAL PRACTICE

Conduction of education programmes on medication administration via enteral tubes for intensive care unit nurses is important in improving nurses' knowledge.

[Antiepileptic drugs administration by nasogastric tube in comatose patients]

AIM

To evaluate the modalities of administration of antiepileptic drugs (AED) with nasogastric tube (NGT) by nurses and to draw up recommendations.

METHODS

Our study consisted on investigating the modalities of administration of AED's with NGT by nurses during four months. We prepared 10 questions including demographic information. Participation was voluntary and anonymous. The questionnaire was distributed in seven intensive care departments after authorization of each head of the department. Thus, 45 nurses were included.

RESULTS

Nurses sex ratio was 1.5 and mean age was 31 years (25 to 37 years). Among the nurses, 60% mentioned that the NGT were silicone made and 4% that they were PVC made. The mean duration before replacing the NGT was thought to be 5±3 days. Among the nurses, 91% affirmed to clear the NGT after each use. All the nurses had agreed that the solid form is the most commonly used pharmaceutical form in the NGT. AED were associated with the enteral feeding solution in 56%. The AED should be crushed before administration for 98% of the nurses even in case of polymedication. Among them, 62% recommended to crush all of the associated drugs together. Before introducing the AED into the NGT, 93% of the nurses reported mixing with tap water. We have noticed that 62% of nurses felt the need to improve their knowledge AED administration with NGT.

CONCLUSION

To optimize AED therapy, modalities of administration by NGT in epileptic comatose patients should be enhanced.

Manipulating tablets and capsules given to hospitalised children in Norway is common practice

AIM

This study provided an overview of manipulating oral medicines given to hospitalised children and evaluated this practice in two hospitals. It focused on the type of manipulation and the dosage forms that were manipulated.

METHOD

This was a cross-sectional, prospective study, carried out on the paediatric wards at two Norwegian hospitals for four weeks in 2013. A medicine was said to have been manipulated if it was not administered as described in the Norwegian summary of product characteristics.

RESULTS

This study showed that 17% of the 3070 administrations of oral medicines to the hospitalised children involved manipulation. Tablets, including modified release preparations, were the most frequently manipulated medicines. In approximately half of these cases, only a segment of the unit dose was administered. No manipulation of oral liquids was seen. The bioavailability of as much as 44% of the most frequent given substances may be sensitive to such manipulations due to limited aqueous solubility. Various routines for splitting and handling the unit doses were observed.

CONCLUSION

Manipulation of oral medication was regularly performed on paediatric wards. There is an urgent need for age-appropriate medicines, documented and standardised processes for manipulating medicines and staff training on the consequences of manipulation.

Methods used by critical care nurses to verify feeding tube placement in clinical practice

BACKGROUND

The American Association of Critical-Care Nurses practice alert on verification of feeding tube placement makes evidence-based practice recommendations to guide nursing management of adult patients with blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improper positioning of a feeding tube within the gastrointestinal tract, thereby increasing aspiration risk.

OBJECTIVES

To determine how the expected practices from the American Association of Critical-Care Nurses practice alert were implemented by critical care nurses.

METHODS

This study was part of a larger national, online survey that was completed by 370 critical care nurses. Descriptive statistics were used to analyze the data.

RESULTS

Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes, although 14% were unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy of auscultation methods, only 12% of nurses avoided this practice all of the time.

CONCLUSIONS

Implementation of expected clinical practices from this guideline varied. Nurses are encouraged to implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient harm.

Crushing oral solid drugs: Assessment of nursing practices in health-care facilities in Auvergne, France

Iatrogenic harm from crushing oral drugs, a common but hazardous practice, can be largely avoided by following recommendations for good practice. The aims of this study were to evaluate the frequency of tablet crushing and opening capsules in hospitals and to compare the nursing practices with national recommendations. From 46 health facilities in Auvergne, 1110 nurses answered an anonymous self-completed questionnaire between September and November 2014 regarding general medication issues, prescription, preparation and administration of crushed medications. Crushing tablets or opening capsules was reported as a daily practice for 28% (increasing to 67% in geriatric units). While most best practice recommendations were followed by most nurses, scope for improvement remained: pharmacists were rarely contacted, rationales for change of medication formulation were seldom recorded in patients' files and medications were often crushed and administered together, risking drug interactions. Study data were used to inform recommendations for practice improvement. As findings bear similarities to those from other countries, this may be a widespread issue and study recommendations may be widely relevant. Practice will be reviewed again once practice improvement has been completed.