1. TITLE & CONTENT Objectives Understand at least 3 steps to consider when implementing a change to dietitian’s practices in the hospital setting. 1

2. TITLE & CONTENT ASPEN/SCCM Guidelines A2. Nutrition support therapy in the form of enteral nutrition (EN) should be initiated in the critically ill patient who is unable to maintain volitional intake. (Grade: C) 2 JPEN 2009; 33:277-316

3. TITLE & CONTENT ASPEN/SCCM Guidelines A3. EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy. (Grade: B) 3 JPEN 2009; 33:277-316

4. TITLE & CONTENT ASPEN/SCCM Guidelines A4. Enteral feeding should be started early within the first 24-48 hours following admission. (Grade: C) The feedings should be advanced toward goal over the next 48-72 hours. (Grade: E) 4 JPEN 2009; 33:277-316

5. TITLE & CONTENT Timing: Window of Opportunity Early feeding in critically ill patients Early defined as <36 hours from admission to ICU or post-op Early EN group outcomes:  Lower incidence of infection (p=0.0006)  Reduced LOS by 2.2 days (p=0.004)  Decreased mortality (not significant) 5 Marik P et al. CCM 2001; 29: 2264

6. TITLE & CONTENT Timing: Window of Opportunity Compared early EN vs NPO in GI surgery pts Early defined as <24 hours post-op GI surgery Early fed (EN or PO) group outcomes:  Reduced risk of anastomotic dehiscence (p=0.08)  Reduced infections (p=0.036)  Reduced LOS by 0.8 days (p=0.001)  Reduced mortality (p=0.15) 6 Lewis SJ et al. BJM 2001; 323:1-5

7. TITLE & CONTENT ASPEN/SCCM Guidelines A7. Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. (Grade: C) Withholding of enteral feeding for repeated high gastric residual volumes alone may be sufficient reason to switch to small bowel feeding (the definition for high gastric residual volume is likely to vary from one hospital to the next, as determined by individual institutional protocol). (Grade: E) 7 JPEN 2009; 33:277-316

8. TITLE & CONTENT Process Before Using Electromagnetic Technology 8

9. TITLE & CONTENT Time Delays with C-arm Placement 5 month data collection of feeding tube placements in the ICU showed 13.4% (n=29) placement delays Reasons for delays included:  6.9% other procedures on pt caused FT to be postponed  34.5% order entered incorrectly in EHR  58.6% scheduling issues/prioritizes within radiology 9

10. TITLE & CONTENT Radiation Exposure 2010 FDA Press Release “The U.S. Food and Drug Administration have announced an initiative to reduce unnecessary radiation exposure from three types of medical procedures: computed tomography (CT), nuclear medicine studies, and fluoroscopy.” FDA working with CMS to incorporate the initiative into regulations and guidelines 10 http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm200085.htm

11. TITLE & CONTENT Radiation Exposure Average placement time with fluoro is 3.7 minutes Random sample of 1 month showed 20% exceeded 5 minutes Average dose is120 mrem 300 mrem is the average annual dose in Minnesota A chest film is 2 mrem Rooms in ICU are not leaded, scatter field near patient is 4.5 mrem/min 11

12. TITLE & CONTENT Process of Implementation Gather data  Time delays  Radiation exposure  Patient Safety/Transport  Staffing time/costs  Scope of practice considerations 12

13. TITLE & CONTENT Dietitian Standards of Practice Academy  Standard 3: Nutrition Intervention  RDs identify and implement appropriate, purposefully planned actions designed with the intent of changing a nutrition-related behavior, risk factor, environmental condition, or aspect of health status for an individual, target group or the community at large. Dietitians in Nutrition Support  3.10 Carries out the plan for nutrition support therapy  3.10D With specialized training, demonstrated competency, and delineated clinical privileges may place nasoenteric access devices 13 JADA 2008:108 (10);1538-1542 NCP 2007:22;558-586

14. TITLE & CONTENT Dietitian Scope of Practice State Board  Subd. 10. Nutrition care services. "Nutrition care services" means: (1) assessment of the nutritional needs of individuals or groups; (2) establishment of priorities, goals, and objectives to meet nutritional needs; (3) provision of nutrition counseling for both normal and therapeutic needs; (4) development, implementation, and management of nutrition care services; or (5) evaluation, adjustment, and maintenance of appropriate standards of quality in nutrition care. 14 www.dieteticsnutritionboard.state.mn.us/

15. TITLE & CONTENT Academy Decision Analysis Tool Part A: General Review  Describe the activity or service to be performed  Review the practice expectations (job description, policies and procedures) and core competencies for your level (DTR, RD, or RD Specialty/Advanced Practice) to determine whether the service or act is permitted.  Review the Code of Ethics, Standards of Practice in Nutrition Care, and Standards of Professional Performance for your practice level to determine whether the service or act is permitted.  Review any licensure laws to determine whether the activity is allowed or not explicitly restricted. 15

16. TITLE & CONTENT Academy Decision Analysis Tool Part B: Education, Credentialing, Privileging Part C: Existing Documentation Part D: Advisory Opinions Part E: Obtaining an Advisory Opinion Part F: Performing the Service or Activity 16

17. TITLE & CONTENT Process of Implementation PEC TAC Med Exec Critical Care Nursing Leaders Risk HR 17

18. TITLE & CONTENT Training Policies – Feeding Tube Placement, Bridle Observe 3 FT placements with fluoro Review training video 10 successful placements with a radiologist Annual competency 18

19. TITLE & CONTENT Learnings and Re-implementation Communication  TEAM STEPPS Order set for providers to ensure correct equipment used Indications for when to stop 19

20. TITLE & CONTENT Historical Data 2008 – 579 placed via fluoro (324 bedside or SPR) 2009 – 656 placed via fluoro (401 bedside or SPR) 2010 – ~680 placed via fluoro (~416 bedside or SPR) 2011 – ~688 placed via fluoro ( ~330 bedside or SPR), 91 placed by dietitians Jan - March 2012 – 454 placed via fluoro, 414 placed by dietitians 20

21. TITLE & CONTENT Current Process with Cortrak Feeding Tube Team consists of 3 dietitians Additional 4 dietitians in process of training Schedule of 1 week coverage rotation (FT, Obs, Relief) Scrubs worn during FT coverage No RNs placing tubes at this time No standardized weekend coverage with Cortrak 21

22. TITLE & CONTENT 2012 Feeding Tube Placement Data 22

23. TITLE & CONTENT 2012 Feeding Tube Placement Data 23

24. TITLE & CONTENT 2012 Feeding Tube Placement Data 24

25. TITLE & CONTENT 2012 Feeding Tube Placement Data 25

26. TITLE & CONTENT 2012 Feeding Tube Placement Data 26

27. TITLE & CONTENT 2012 Feeding Tube Placement Data 27

28. TITLE & CONTENT 2012 Feeding Tube Placement Data 28

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32. TITLE & CONTENT Benefits At Fairview Using Electromagnetic Technology Reduced radiation exposure Improved time to placement Reduced need for replacements due to “kinks” 32