Get it inKeep it in

Keep it running

Adventures in bedside feeding tube placement and other hands-on feeding tube

related activities by registered dietitians.Utah Academy of Nutrition and

DieteticsAnnual Meeting, March 20, 2014

Objectives• Describe the experience of one clinical nutrition

team developing a program for hands-on feeding tube placement and care.

• Discuss benefits in terms of patient care of dietitian involvement in feeding tube placement and care, including cost savings.

• Discuss pros and cons for dietitians of taking on the role of feeding tube placement and care.

Participation Activity

What Get it in

Bedside feeding tube placementKeep it in

FT bridle placementKeep it running

FT clog clearing

By Dietitians

Why?

Why • Altruistim (patient care)• Self interest (job satisfaction)• Practical reasons (cost containment)

Patient Care

Job Satisfaction• Avoid burn out• New marketable skill• Increased recognition

Cost Containment

Getting It Done

Data collection Training

EquipmentSupport

Idea

Desire

Inspiration

Idea

Support• Direct manager• Fellow staff• Nursing • Physicians• Administration• Approving committees• Outside sources

Equipment

Feeding tube bridle

Dobhoff feeding tube

OUCH!

Frederick-Miller feeding tube

Cortrak

Other tubes

Other tubes

Personal Protective Equipment:

a fashion must

Personal Protective Equipment:

a fashion must

Stethescope

TubeClear

Training: bridle placement

• MD champion• Watch one – Do one• Competency check list provided by

manufacturer

Bridle placement method

• Insert probes• Feel & listen for click• Remove stylet• Pull tape through• Clip onto feeding tube• Knot and clip ends

Training: bedside feeding tube placement

• Outside advice• Create training competency• One on one training with multiple RNs• Trained RDs pass off other RDs

FT placement method• Position patient• Measure• Advance to stomach• Assess

o Pull back with syringeo Watch for “pop”o Observe contents for amount, texture, coloro Listen over abdomen middle and side

• Advance using “puff and twist”• Assess again, look for changes• Secure• Confirm placement (abdominal film)• Document

Training: TubeClear• In-house training by manufacturer• Artificial feeding tube clogs provided• Competency checklist provided

Dietitian Pros & Cons• Better understanding of patient experience • Increased empathy• Ability to trouble shoot feeding tube problems• Recognition from RNs and other staff• Improved relationship with caregiver team

Dietitian Pros & Cons• Exposure to mucous and vomit• Inflict pain or discomfort• Difficult or agitated patients• Increased responsibility/liability • Greater commitment

Data collection• Checklist items• Adverse events• RD time spent• Time from order to insertion•Gastric vs SB placement•Who placed the tube

Reduced total fluoro placement

• Bedside placement by RNs and RDs• Avoid unnecessary replacement

o Bridleso Clearing clogso Avoiding clogs

• Feed stomach when appropriate• Educating MDs on appropriate uses for fluoro• Intraoperative placement

• Feeding tubes placed in fluoro

o 2012: 124 o 2013: 88

• Cost reduced by 29%

Reduced total fluoro placement

ReferencesMcClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adjult Critically Ill Patient. JPEN, 2009, 33 (3),:277-316.

Faisy et al. Impact of energy deficit calculated by a predictive method on outcome in medical patients requiring prolonged acute mechanical ventilation. Fr J Nutr. 2009;101:1079-1087.

Bartlett et al. Measurement of metabolism in multiple organ failure. Surgery. 1982;92:771-779.

Villet et al. Negative impact of hypocaloric feeding an denergy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24:502-509.