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.

Nutrition support teams: Institution, evolution, and innovation

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

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.

Efficacy and safety of a modified method for blind bedside placement of post-pyloric feeding tube: a prospective preliminary clinical trial

Objective

To compare the efficacy and safety of a new modified method of bedside post-pyloric feeding tube catheterization with the Corpak protocol versus electromagnetic-guided catheterization.

Materials and Methods

We conducted a single-center, single-blinded, prospective clinical trial. Sixty-three patients were treated with a non-gravity type gastrointestinal feeding tube using different procedures: modified bedside post-pyloric feeding tube placement (M group), the conventional Corpak protocol (C group), and standard electromagnetic-guided tube placement (EM group).

Results

The success rate in the M group, C group, and EM group was 82.9% (34/41), 70.7% (29/41), and 88.2% (15/17), respectively, with significant differences among the groups. The time required to pass the pylorus was significantly shorter in the M group (26.9 minutes) than in the C group (31.9 minutes) and EM group (42.1 minutes). The proportion of pylorus-passing operations completed within 30 minutes was significantly higher in the M group than in the C group and EM group. No severe complications occurred.

Conclusion

This modified method of bedside post-pyloric feeding tube catheterization significantly shortened the time required to pass the pylorus with no severe adverse reactions. This method is effective and safe for enteral nutrition catheterization of patients with dysphagia and a high risk of aspiration pneumonia.

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.

Devices and Techniques for Bedside Enteral Feeding Tube Placement

Enteral feedings are an integral part of care for many hospitalized patients. Accessing the gastrointestinal (GI) tract safely and in a timely manner can be challenging. Various techniques and devices to enhance the safety of bedside feeding tube placement are available for clinicians. Three specific devices are highlighted, including the colorimetric CO(2) detector (CCD), a magnetically guided feeding tube (MGFT), and the electromagnetic tube placement device (ETPD). The CO(2) detector is applied to detect the presence or absence of CO(2), thus assisting in correct placement of the feeding tube tip into the GI tract vs the lung. The MGFT uses a magnetic device to manipulate the feeding tube through the GI tract into the small intestine. The ETPD provides real-time visualization of the feeding tube as it progresses into the small intestine. Training and repetition are essential for safe and successful feeding tube placement, and the highlighted devices can contribute to both of these goals.

The Efficacy of an Enteral Access Protocol for Feeding Trauma Patients

BACKGROUND

Proper enteral access to deliver specialized nutrition support in critically injured patients can be difficult, time consuming, and costly. We designed a protocol with interdisciplinary input to facilitate early enteral access in our trauma patients. Our primary objective was to determine if the protocol improved our ability to obtain small-bowel access in patients within 48 hours of their admission to the surgical intensive care unit (SICU). Secondary objectives were to examine the efficacy of the protocol by evaluating parenteral nutrition (PN) use, adequacy of enteral caloric delivery, and clinical outcomes including pneumonia and sepsis rates, SICU length of stay (LOS), hospital LOS, and mortality before and after its implementation.

METHODS

The medical records of 51 trauma patients admitted to the SICU, who met inclusion criteria, were reviewed retrospectively and divided into 2 groups. Patients in group 1 were admitted before protocol implementation (1997-1998, n = 17). Patients in group 2 were admitted after protocol implementation (1998-2000, n = 34).

RESULTS

Small-bowel access was achieved earlier in group 2 compared with group 1 [2.2 +/- 2 days vs 5.4 +/- 8 days, respectively (p = .04)]. PN was used less frequently in group 2 at 41.2% (14/34) as opposed to 64.7% (11/17) in group 1 (p = .05). There was a reduction in the number of days to reach caloric goal from 4.9 days in group 1 to 3.9 days in group 2 (n.s.). Clinical outcomes were similar in both groups.

CONCLUSIONS

The use of a protocol was effective in the achievement of prompt small bowel access. The number of days to reach caloric goal decreased after protocol implementation, but not to a statistically significant degree. However, we were able to detect a significant reduction in the use of PN.

Benefits of Postpyloric Enteral Access Placement by a Nutrition Support Dietitian

BACKGROUND

Although enteral nutrition is considered the preferred strategy for nutrition support, it is often precluded by nasogastric feeding intolerance or the inability to place feeding access into the postpyloric position. In an effort to improve enteral nutrition (EN) outcomes at our institution, the nutrition support dietitian (NSD) began placing postpyloric feeding tubes (PPFT) in intensive care unit patients.

METHODS

Intensive care unit patients who received blind, bedside PPFT placements by the NSD (n = 18) were compared with a concurrent age- and diagnosis-matched control group that received standard nutritional care without NSD intervention (n = 18). Interruption of EN infusion, appropriateness of parenteral nutrition (PN) prescription (based on American Society of Parenteral and Enteral Nutrition guidelines), and incidence of ventilator-associated pneumonia (VAP), as defined by the American College of Chest Physicians practice guidelines, were determined in each group.

RESULTS

The NSD was successful in positioning the PPFT at or distal to the third portion of the duodenum in 83% of attempts. The PPFT group demonstrated no interruption of enteral feeding compared with 56% in the control group (p < .01) and required 1 (6%) PN initiation in contrast to 8 (44%) in the control group (p < .01). There was a trend toward reduced VAP in the PPFT group (6% vs 28%, p = .07). Of the PN initiations in the control group, 88% were deemed to be potentially avoidable; 6 of 8 PNs were initiated because of gastric residuals.

CONCLUSIONS

Enteral nutrition facilitated by NSD placement of postpyloric feeding access is associated with improved tube feeding tolerance and reduced PN use. Further studies are needed to evaluate a possible effect of postpyloric feeding on the incidence of VAP.

The History of Nonsurgical Enteral Tube Feeding Access

Specialized nutrition support, particularly enteral feeding, has been used for centuries. Technologic advancements have affected the provision of enteral feeding. Feeding solutions and devices, as well as the techniques to place the feeding devices, have evolved. This article reviews the history of bedside placement methods for short-term enteral access devices.

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.

Gastric Versus Small Bowel Feeding in Critically Ill Adults

Critically ill patients often require enteral feedings as a primary supply of nutrition. Whether enteral nutrition (EN) should be delivered as a gastric versus small bowel feeding in the critically ill patient population remains a contentious topic. The Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN), the European Society for Parenteral and Enteral Nutrition (ESPEN), and the Canadian Clinical Practice Guidelines (CCPG) are not in consensus on this topic. No research to date demonstrates a significant difference between the two feeding routes in terms of patient mortality, ventilator days, or length of stay in the intensive care unit (ICU); however, studies provide some evidence that there may be other benefits to using a small bowel feeding route in critically ill patients. The purpose of this paper is to examine both sides of this debate and review advantages and disadvantages of both small bowel and gastric routes of EN. Practical issues and challenges to small bowel feeding tube placement are also addressed. Finally, recommendations are provided to help guide the clinician when selecting a feeding route, and suggestions are made for future research.

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.

Feeding the injured intestine: enteral nutrition in the critically ill patient

PURPOSE OF REVIEW

The utilization of enteral nutrition in critically ill patients is frequently suboptimal. This may be due, in part, to ongoing controversies regarding appropriate use of enteral support, but there are also perceived barriers to its use even when there is good evidence that it can be given. This review was undertaken to outline some of these controversies and barriers to use of enteral nutrition in the ICU.

RECENT FINDINGS

Although the advantages of enteral nutrition may have been overstated, it remains preferable to parenteral nutrition for support of critically ill patients. Early initiation of enteral support is a reasonable approach. Many patients with perceived contraindications to enteral therapy are actually good candidates for its use. Frequent interruptions in enteral nutrition lead to suboptimal nutrient delivery, but might be overcome by use of specific protocols emphasizing safe and effective utilization of enteral support.

SUMMARY

Use of enteral nutritional support is recommended for critically ill patients requiring specialized nutritional support. Barriers to its use could be overcome by better educating providers about indications for use and by developing methods to avoid undue interruption of therapy.

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 for neurologically impaired children: a clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition

Undernutrition, growth failure, overweight, micronutrient deficiencies, and osteopenia are nutritional comorbidities that affect the neurologically impaired child. Monitoring neurologically impaired children for nutritional comorbidities is an integral part of their care. Early involvement by a multidisciplinary team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional status. Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-related morbidity and mortality.

Preventing Respiratory Complications of Tube Feedings: Evidence-Based Practice

The most dreaded complication of tube feedings is tracheobronchial aspiration of gastric contents. Strong evidence indicates that most critically ill tube-fed patients receiving mechanical ventilation aspirate gastric contents at least once during their early days of tube feeding. Those who aspirate frequently are about 4 times more likely to have pneumonia develop than are those who aspirate infrequently. Although a patient’s illness might not be modifiable, some risk factors for aspiration can be controlled; among these are malpositioned feeding tubes, improper feeding site, large gastric volume, and supine position. A review of current research-based information to support modification of these risk factors is provided.

Evaluation of a technique for blind placement of post-pyloric feeding tubes in intensive care: application in patients with gastric ileus

OBJECTIVE

To evaluate a blind 'active' technique for the bedside placement of post-pyloric enteral feeding tubes in a critically ill population with proven gastric ileus.

DESIGN AND SETTING

An open study to evaluate the success rate and duration of the technique in cardiothoracic and general intensive care units of a tertiary referral hospital.

PATIENTS

20 consecutive, ventilated patients requiring enteral nutrition, where feeding had failed via the gastric route.

INTERVENTIONS

Previously described insertion technique-the Corpak 10-10-10 protocol-for post-pyloric enteral feeding tube placement, modified after 20 min if placement had not been achieved, by insufflation of air into the stomach to promote pyloric opening.

MEASUREMENTS AND RESULTS

A standard protocol and a set method to identify final tube position were used in each case. In 90% (18/20) of cases tubes were placed on the first attempt, with an additional tube being successfully placed on the second attempt. The median time for tube placement was 18 min (range 3-55 min). In 20% (4/20) insufflation of air was required to aid trans-pyloric passage.

CONCLUSIONS

The previously described technique, modified by insufflation of air into the stomach in prolonged attempts to achieve trans-pyloric passage, proved to be an effective and cost efficient method to place post-pyloric enteral feeding tubes. This technique, even in the presence of gastric ileus, could be incorporated by all critical care facilities, without the need for any additional equipment or costs. This approach avoids the costs of additional equipment, time-delays and necessity to transfer the patient from the ICU for the more traditional techniques of endoscopy and radiographic screening.

Effect of gastrointestinal motility and feeding tube site on aspiration risk in critically ill patients: a review

OBJECTIVE

The purpose of this literature review is to examine the effect of the interaction between gastrointestinal motility and feeding site on the aspiration risk in critically ill, tube-fed patients.

METHODS AND RESULTS

A single answer to the question of the preferred feeding site is not likely to be found because the degree of aspiration risk varies significantly according to individual variations in gastrointestinal motility and multiple pre-existing and treatment-related risk factors. However, regardless of the feeding site, it is ultimately regurgitated gastric contents that are aspirated into the lungs. For this reason, the clinical assessment of greatest interest is the evaluation of gastric emptying, usually monitored clinically by measuring gastric residual volumes.

CONCLUSION

Current recommendations for monitoring residual volumes and preventing aspiration are provided.

Bedside placement of small bowel feeding tubes in hospitalized patients:

OBJECTIVE

The benefits of enteral nutrition when compared with parenteral nutrition are well established. However, provision of enteral nutrition may not occur for several reasons, including lack of optimal feeding access. Gastric feeding is easier to initiate, but many hospitalized patients are intolerant to gastric feeding, although they can tolerate small bowel feeding. Many institutions rely on costly methods for placing small bowel feeding tubes. Our goal was to evaluate the effectiveness of a hospital-developed protocol for bedside-blind placement of postpyloric feeding tubes.

METHODS

The Surgical Nutrition Service established a protocol for bedside placement of small bowel feeding tubes. The protocol uses a 10- or 12-French, 110-cm stylet containing the feeding tube; 10 mg of intravenous metoclopramide; gradual tube advancement followed by air injection and auscultation; and an abdominal radiograph for tube position confirmation. In a prospective manner, consults received by the surgical nutrition dietitian for feeding tube placements were followed consecutively for a 10-mo period. The registered dietitian recorded the number of radiograph examinations, the final tube position, and the time it took to achieve tube placement.

RESULTS

Because all consults were included, feeding tube placements occurred in surgical and medical patients in the intensive care unit and on the ward. Of the 135 tube placements performed, 129 (95%) were successfully placed postpylorically, with 84% (114 of 135) placed at or beyond D3. Average time for tube placement was 28 min (10 to 90 min). One radiograph was required for 92% of the placements; eight of 135 (6%) required two radiographs. No acute complications were associated with the tube placements.

CONCLUSIONS

Hospitalized patients can receive timely enteral feeding with a cost-effective feeding tube placement protocol. The protocol is easy to implement and can be taught to appropriate medical team members through proper training and certification.