Get it in Keep 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 Dietetics Annual 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 placement Keep it in FT bridle placement Keep 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 Equipment Support 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

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 syringe o Watch for pop o Observe contents for amount, texture, color o 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 Bridles o Clearing clogs o 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

References McClave et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adjult Critically Ill Patient. JPEN, 2009, 33 (3),: 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: Bartlett et al. Measurement of metabolism in multiple organ failure. Surgery. 1982;92: Villet et al. Negative impact of hypocaloric feeding an denergy balance on clinical outcome in ICU patients. Clin Nutr. 2005;24: