Benefits of Postpyloric Enteral Access Placement by a Nutrition Support Dietitian

Role of registered dietitians in nasoenteric feeding tube placement

Provision of enteral nutrition (EN) in hospitalized patients is an integral part of clinical care. For various reasons, including but not limited to delayed enteral access placement and EN initiation, it is becoming more prevalent for registered dietitians (RDs) to place feeding tubes in various clinical settings. Although numerous RDs have expanded their practice by learning this skill, many remain hesitant about adding feeding tube placement to their scope of responsibilities. Feeding tube placement is within RDs' scope of practice. The recently updated Accreditation Council for Education in Nutrition and Dietetics (ACEND) standards is requiring dietetic interns to learn the process and assist in placing feeding tubes. This will help promote the inclusion of this practice and open doors for future advancement in the scope of practice for RDs. This review will provide an overview of feeding tube placement methods, evidence-based techniques, training, competencies, and barriers to accepting this practice in dietetics.

Extending the scope of dietetic practice in a regional setting: Dietitians credentialed to insert and manage nasogastric tubes

BACKGROUND & AIMS

To describe the process of credentialing and implementing dietitian insertion of nasogastric tubes (NGTs) in a regional setting in Australia, and report on patient outcomes, timeliness and safety of insertion, and staff acceptance.

METHODS

An observational, mixed-methods study of service and patient outcomes was undertaken during the 2 years (2018-2020) following the implementation of dietitian credentialling for the insertion and management of NGTs. Data relating to the insertion of NGTs by credentialled dietitians were collected prospectively. A staff survey was circulated during and after the data collection period. Data has been reported descriptively.

RESULTS

The model of care was successfully implemented with two dietitians credentialed to insert NGTs. There were 38 unique occasions of NGT insertions for 31 individual patients. Eighty-seven percent (n = 33) of cases were inpatients. NGT insertion was successfully performed by the dietitian 82% of the time (n = 31). No medical complications relating to NGT insertion were reported following a dietitian inserted NGT, with the exception of one incidence of mild epistaxis. The average insertion time was 25.5 min (14.1), the average number of insertion attempts by a dietitian was 1.7 (1.27) and on one occasion more than one x-ray was required.

CONCLUSION

This study supports the recommendations of Dietitians Australia that this model of care is viable as an extended scope of practice model of care for dietetic departments across Australia. This evaluation adds to the evidence base for extended scope of practice and informs future directions for the service and training of dietitians.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Post-pyloric feeding tube placement in critically ill patients: Extending the scope of practice for Australian dietitians

AIM

To determine whether the placement of a post-pyloric feeding tube (PPFT) can be taught safely and effectively to a critical care dietitian.

METHODS

This is a prospective observational study conducted in an adult intensive care unit (ICU). The intervention consisted of 19 attempts at post-pyloric intubation by the dietitian. The 10 'learning' attempts were performed by the dietitian under the direction of an experienced (having completed in excess of 50 successful tube placements) user. A subsequent nine 'consolidation' attempts were performed under the responsibility of the intensive care consultant on duty. The primary outcome measures were success (i.e. tip of the PPFT being visible in or distal to the duodenum on X-ray) and time (minutes) to PPFT placement. Patients were observed for adverse events per standard clinical practice.

RESULTS

A total of 19 post-pyloric tube placements were attempted in 18 patients (52 (23-70) years, ICU admission diagnoses: trauma n = 4; respiratory failure n = 3; and burns, pancreatitis and renal failure n = 2 each). No adverse events occurred. Most (75%) patients were sedated, and mechanically ventilated. Prokinetics were used to assist tube placement in 11% (2/19) of attempts, both of which were successful. Placement of PPFT was successful in 58% (11/19) of attempts. Whilst training, the success rate was 40% (4/10) compared with 78% (7/9) once training was consolidated (P = 0.17). In the successful attempts, the mean time to placement was 11.0 minutes (3.9-27.1 minutes).

CONCLUSIONS

A dietitian can be trained to safely and successfully place PPFT in critically ill patients.

The activities of a dietitian-led gastroenterology clinic using extended scope of practice

Background

Extending the scope of practice of allied health professionals has been a strategy adopted in the United Kingdom to address issues within the health system.

Australia’s health system is currently undermined by similar issues, heightening government interest in adopting the extended scope health care model. The aim of the current study was to describe the activities and outcomes of a dietitian-led gastroenterology clinic which operated under an extended scope of practice model in an outpatient gastroenterology department at a tertiary hospital in regional Queensland, Australia, and to assess patient satisfaction with the initiative.

Methods

A descriptive, cross-sectional case series undertaken over 50 clinics involving 82 category 2 and 3 patients with suspected/confirmed coeliac disease or inflammatory bowel disease; low haemoglobin; gastroesophageal reflux disease, or; malnutrition. Data was analysed using Microsoft Excel 2010, and presented as descriptive statistics.

Results

Sixty out of 82 selected patients (median age 51 years) attended an initial appointment with the dietitian. Twenty-four review appointments were attended. Average waiting period for an initial appointment was 148 days (range 31–308 days). A total of 149 management strategies were provided, and 94 (63 %) of these involved the dietitian utilising extended scope of practice. The dietitian managed 47 (78 %) patients without need for gastroenterologist referral, and 25 (42 %) were discharged after dietetic management.

Patients reported high levels of satisfaction with the clinic.

Conclusions

Seventy-eight percent of category 2 and 3 patients referred to the gastroenterologist could be managed exclusively in the dietitian-led clinic. This extended scope model of care could potentially benefit the efficiency and acceptability of Australia’s public health system.

Cost-analysis of nutrition support in patients with severe acute pancreatitis

PURPOSE

The purpose of this research was to assess the preferred route of nutrition support (enteral versus parenteral) for treatment of severe acute pancreatitis in the acute care setting. Further, in cases when enteral nutrition is the preferred route, is nasal-bridling a lower-morbidity and cost-effective method?

DESIGN/METHODOLOGY/APPROACH

A retrospective review of pre-existing data from an 870-bed hospital system. Medical records were reviewed via an online database system (n = 25 patients) with severe acute pancreatitis. Length of stay and cost were analyzed.

FINDINGS

More patients received TPN versus the nasal-jejunal (post-pyloric) tube feeds group. No significant relationship was found between total cost and number of co-morbidities or between either of the two treatment groups. However, a medium to large effect size was shown which could indicate a significant relationship in a larger sample size.

ORIGINALITY/VALUE

The findings of this research add to the literature already available and will be of interest to those who specialize in this area.

Enteral nutrition without the use of an endoscope in patients with severe acute pancreatitis

One of the main elements of acute pancreatitis therapy is nutritional treatment, which should ensure the implementation of the patients' energetic needs, limit the exocrine activity of the pancreas, and maintain the gastrointestinal passage. The most important argument in favor of the above-mentioned is the fact that enteral nutrition in case of severe acute pancreatitis prevents infectious complications. The most effective method is enteral nutrition. The unavailability of bedside endoscopy, and thus the need to transport the patient in order to obtain access, considerably complicates the procedure. Literature data described various bedside techniques consisting in the blind introduction of the feeding tube, which are rarely used, despite the fact that they are cheaper and as effective as endoscopy.

Dietitians and small bowel feeding tube placement

Some advanced practice nutrition support dietitians have added small bowel feeding tube placement to their scope of responsibility. This is due, in part, to the challenges of gaining early enteral access in patients with functioning GI tracts. Emerging literature supports the practice of skilled practitioners placing feeding tubes at bedside. A variety of methods can be used to place tubes at the bedside. The nutrition support dietitian must understand licensure and liability considerations to perform this invasive procedure. This article will review literature reports of dietitians placing feeding tubes and provide information on the methods used, training and competencies required, and legal issues involved.

Bedside electromagnetic-guided feeding tube placement: an improvement over traditional placement technique?

BACKGROUND

Registered dietitian/registered nurse (RD/RN) teams were created to place small bowel feeding tubes (SBFT) at the bedside in intensive care unit (ICU) patients using an electromagnetic tube placement device (ETPD). The primary objective of this study was to evaluate the safety of placing feeding tubes at the ICU bedside using an ETPD. Secondary outcomes included success rate, cost, and timeliness of feeding initiation.

METHODS

Data were collected prospectively on 20 SBFT blind placements in ICU patients (control group). After implementing a protocol for RD/RN teams to place SBFTs with an ETPD, 81 SBFTs were placed (study group). Complications, success rate, number of x-rays after tube placement, x-ray cost, and time from physician order to initiation of feedings were compared between the groups.

RESULTS

No adverse events occurred in either group. Successful SBFT placement was 63% (12/19) in the control group and 78% (63/81) in the study group (not significant, NS). The median time between physician order for tube placement and feeding initiation decreased from 22.3 hours (control group) to 7.8 hours (study group, p = .003). The median number of x-rays to confirm correct placement was 1 in the study group compared with 2 in the control group (p = .0001), resulting in a 50% decrease in the mean cost for x-rays.

CONCLUSIONS

No adverse events occurred with the implementation of bedside feeding tube placement using an ETPD. In addition, SBFT placement with an ETPD by designated ICU RD/RN teams resulted in lower x-ray costs and more timely initiation of enteral feedings compared with blind placement.

Nutrition support and the chronic critical illness syndrome

Critical illness can be viewed as consisting of 4 distinct stages: (1) acute critical illness (ACI), (2) prolonged acute critical illness, (3) chronic critical illness, and (4) recovery. ACI represents the evolutionarily programmed response to a stressor. In ACI, substrate is shunted away from anabolism and toward vital organ support and inflammatory proteins. Nutrition support in this stage is unproven and may ultimately prove detrimental. As critical illness progresses, there is no evolutionary precedent, and man owes his life to modern critical care medicine. It is at this point that nutrition and metabolic support become integral to the care of the patient. This paper (1) delineates and develops the 4 stages of critical illness using current evidence, clinical experience, and new hypotheses; (2) defines the chronic critical illness syndrome (CCIS); and (3) details an approach to the metabolic and nutrition support of the chronically critically ill patient using the metabolic model of critical illness as a guide. It is our hope that this clinical model can generate testable hypotheses that can improve the outcome of this unique population of patients.

Ventilator associated pneumonia and infection control

Ventilator associated pneumonia (VAP) is the leading cause of morbidity and mortality in intensive care units. The incidence of VAP varies from 7% to 70% in different studies and the mortality rates are 20-75% according to the study population. Aspiration of colonized pathogenic microorganisms on the oropharynx and gastrointestinal tract is the main route for the development of VAP. On the other hand, the major risk factor for VAP is intubation and the duration of mechanical ventilation. Diagnosis remains difficult, and studies showed the importance of early initiation of appropriate antibiotic for prognosis. VAP causes extra length of stay in hospital and intensive care units and increases hospital cost. Consequently, infection control policies are more rational and will save money.