1. 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

2. 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.

3. Participation Activity

4. What Get it in Bedside feeding tube placement Keep it in FT bridle placement Keep it running FT clog clearing By Dietitians

5. Why?

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

7. Patient Care

8. Job Satisfaction Avoid burn out New marketable skill Increased recognition

9. Cost Containment

10. Getting It Done Data collection Training Equipment Support Idea

11. Desire Inspiration Idea

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

13. Equipment

14. Feeding tube bridle

15. Dobhoff feeding tube OUCH!

16. Frederick-Miller feeding tube

17. Cortrak

18. Other tubes

20. Personal Protective Equipment: a fashion must

22. Stethescope

23. TubeClear

24. Training: bridle placement MD champion Watch one – Do one Competency check list provided by manufacturer

25. Bridle placement method Insert probes Feel & listen for click Remove stylet Pull tape through Clip onto feeding tube Knot and clip ends

26. Training: bedside feeding tube placement Outside advice Create training competency One on one training with multiple RNs Trained RDs pass off other RDs

27. 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

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

29. 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

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

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

32. 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

33. Feeding tubes placed in fluoro o 2012: 124 o 2013: 88 Cost reduced by 29% Reduced total fluoro placement

34. References McClave 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.