06_PEN673053.indd

Journal of Parenteral and Enteral

Nutrition

Volume 41 Number 1

January 2017 15 –103

for Parenteral and Enteral Nutrition

DOI: 10.1177/0148607116673053

jpen.sagepub.com

Consensus Recommendation

ASPEN Safe Practices for Enteral Nutrition Therapy

Joseph I. Boullata, PharmD, RPh, BCNSP, FASPEN, FACN

;

Amy Long Carrera, MS, RD, CNSC, CWCMS

;

Lillian Harvey, MD, FACS, CNSC

; Arlene A. Escuro, MS, RD, LD, CNSC

;

Lauren Hudson, MS, RD, LDN

; Andrew Mays, PharmD

;

Carol McGinnis, DNP, RN, CNS, CNSC

;

Jacqueline J. Wessel, MEd, RDN, CNSC, CSP, CLE

;

Sarita Bajpai, PhD, RD, CD, CNSC

; Mara Lee Beebe, RD, LD, CNSC

;

Tamara J. Kinn, MS, RD, LDN, CNSC

;

Mark G. Klang, MS, RPh, BCNSP, PhD

; Linda Lord, NP, ACNP-BC, CNSC

;

Karen Martin, MA, RDN, LD, FAND

;

Cecelia Pompeii-Wolfe, RD, LDN, CNSC

; Jackie Sullivan, MS, RDN, CD

;

Abby Wood, RD, LD, CNSC

; Ainsley Malone, MS, RD, CNSC, FASPEN

; and

Peggi Guenter, PhD, RN, FAAN

; ASPEN Safe Practices for Enteral Nutrition

Therapy Task Force, American Society for Parenteral and Enteral Nutrition

Abstract

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome

benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors.

The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration.

To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes

open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations

based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring

for patients receiving EN. (JPEN J Parenter Enteral Nutr. 2017;41:15-103)

Keywords

enteral nutrition; enteral access; enteral formulas; nutrition; safety

Table of Contents

Introduction 15

Assessment and Recommendations 18

Prescribing and Communicating the

Enteral Nutrition Order 22

Review of the Enteral Nutrition Order 31

Enteral Access 36

Procure, Select/Prepare, Label, and Dispense EN 48

Administration: General 59

Administration: EAD Patency 74

Medication Delivery via Enteral Access Devices 77

Complication Avoidance and Error Reporting 85

Monitoring and Reassessment 92

Transition of Care 95

Documentation and Quality Review Issues 100

Common Terms and Abbreviations Used

Throughout the Document

Blenderized tube feeding (BTF)

Computerized prescriber order entry (CPOE)

Electronic health record (EHR)

Enteral access device (EAD)

Enteral nutrition (EN)

Gastric residual volume (GRV)

Gastrointestinal (GI)

Head of bed (HOB)

Human breast milk (HBM)

Intensive care unit (ICU)

Parenteral nutrition (PN)

Introduction

Enteral nutrition (EN) refers to the system of providing nutri-

tion directly into the gastrointestinal (GI) tract bypassing the

oral cavity.

Each year in the United States, this nutrition sup-

port modality is used in 250,000 hospitalized patients annually

from infants to older adults.

EN is also widely used in sub-

acute, rehabilitation, long-term care, and home settings. For

the purposes of this document, EN will include those nutrient

formulas and human breast milk (HBM) delivered through an

enteral access device (EAD).

16 Journal of Parenteral and Enteral Nutrition 41(1)

The EN process (Figure 1) is the system within which EN is

used. This involves a number of major steps: the initial patient

assessment, the recommendations for an EN regimen, the

selection of the EAD, the EN prescription, the review of the

EN order, the product selection or preparation, the product

labeling and dispensing, the administration of the EN to the

patient, and the patient monitoring and reassessment, with doc-

umentation at each step as required. This process requires a

multidisciplinary team of competent clinicians working in con-

cert to provide safe nutrition care.

Although clinician competence is assumed in the EN Use

Process, an inherent risk of clinical complications is related to

EN and the formulas used, as well as potential errors at each

step in the process. Serious adverse events, including fatalities,

can occur when lapses allow for errors.

1,4

These types of

adverse events include the following:

 Clinical complications of using EN such as GI compli-

cations, refeeding syndrome, or gut ischemia

 Process-related errors, including those associated with

process steps, such as administration errors and

misconnections

Optimal communication and standardization across all

steps of the EN Use Process is a risk management strategy.

reduce the risk of adverse events and improve patient safety,

effective communication among all members of the multidis-

ciplinary team is necessary throughout the process.

Collectively, team members must also develop and adhere to

policies and standardized procedures for daily practice and

decision making related to patient care. Standardization does

not refer to, and should not lead to, a one-size-fits-all strategy

for patient care. Instead, it refers to the development and

implementation of technical and practice standards into a pro-

cess so that all healthcare providers deliver the same level of

safe care.

Opportunities exist for standardization across the

EN process (eg, EN order templates). Process standardization

may include independent double-checks and automation with

forcing functions to help improve EN safety. Policies include

the organization’s mechanisms to maintain competency of

individual clinicians involved in EN.

Methodology

This document focuses on safe practices for EN therapy. The

objective is to provide recommendations based on either evi-

dence (when available) or expert consensus that supports safe

practices by clinicians who recommend, prescribe, review, pre-

pare, administer, and/or monitor patients receiving EN therapy

and by their supporting organizational structures. Indications

for EN and the ethics surrounding the use of EN are outside of

the scope of this document.

To develop this document, an interdisciplinary group of

American Society for Parenteral and Enteral Nutrition

(ASPEN) experts identified key questions related to EN

Figure 1. The Enteral Nutrition (EN) Use Process.

From

Clinical Nutrition Support Services, Hospital of the University of Pennsylvania and Department of Nutrition, Drexel University, Philadelphia,

Pennsylvania, USA;

Shield Healthcare, Valencia, California, USA;

Northshore University Hospital, Manhasset, New York, and Hofstra University

NorthWell School of Medicine, Garden City, New York, USA;

Digestive Disease Institute Cleveland Clinic Cleveland, Ohio, USA;

Hospital of the

University of Pennsylvania, Philadelphia, Pennsylvania, USA;

Baptist Health Systems and University of Mississippi School of Pharmacy, Jackson,

Mississippi, USA;

Sanford University of South Dakota Medical Center, Sioux Falls, South Dakota, USA;

Cincinnati Children’s Hospital Medical

Center, Cincinnati, Ohio, USA;

Indiana University Health, Indianapolis, Indiana, USA;

Mount Carmel West Hospital, Columbus, Ohio, USA;

Loyola University Medical Center, Maywood, Illinois, USA;

Memorial Sloan Kettering Cancer Center, New York, New York, USA;

University

of Rochester Medical Center, Rochester, New York, USA;

University of Texas Center for Health Sciences at San Antonio, San Antonio, Texas, USA;

University of Chicago, Medicine Comer Children’s Hospital, Chicago, Illinois, USA;

Aurora Lakeland Medical Center, Elkhorn, Wisconsin, USA;

Baylor University Medical Center, Dallas, Texas, USA; and

American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA.

Financial disclosure: None declared.

Conflicts of interest: L. Harvey and J. J. Wessel are members of the Abbott Nutrition Speakers Bureau. M. L. Beebe is a member of the Nutricia

Speakers Bureau. L. Lord is a member of Nestlé Nutrition and Bard. All other authors have no conflicts of interest to report.

Received for publication June 14, 2016; accepted for publication September 14, 2016.

This article originally appeared online on November 10, 2016.

Corresponding Author:

Peggi Guenter, PhD, RN, FAAN, ASPEN, 8630 Fenton St, Suite 412, Silver Spring, MD 20910, USA.

Email: [email protected]

Boullata et al 17

practice issues with safety implications. These questions were

then grouped into relevant sections, including patient assess-

ment, EN prescribing, order review, EN access, product han-

dling, administration, monitoring and reassessment, and

transition of care. The term order is used throughout the docu-

ment to refer to an EN prescription or the act of prescribing

EN. Administration was further divided to focus on tube

patency, medications, and complications, as well as general

approaches. A number of topics crossed sections. These are

addressed in depth in only one section and cross-referenced

elsewhere. Redundancy was built in purposefully as users will

likely go to a specific section for guidance.

The experts contributed to the sections with which they

had the most familiarity and experience. Under the direction

of a section leader, the authors performed an English-language

literature search using multiple terms relevant to the section

and questions posed. The experts then reviewed the available

literature and weighed risks against benefits to come to a set

of best practice recommendations for each question. Each set

of practice recommendations is followed by the rationale,

which cites relevant references. The sections that comprise

this document were reviewed in their entirety by task force

members. Discussions and consensus took place to arrive at

the final recommendations. This document has undergone

internal and external review, including approval by the ASPEN

Board of Directors.

The recommendations within this document are intended

for discussion and adoption over time by organizations

involved in the delivery of EN. These recommendations are

not intended to supersede the judgment of the healthcare pro-

fessional or employing institution based on the circumstances

of the individual patient.

References

1. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recom-

mendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

2. Agency for Healthcare Research and Quality. All listed ICD-9CM pro-

cedure code for enteral nutrition infusion 2013. Healthcare Utilization

Project (HCUP) National Inpatient Survey. www.hcupnet.ahrq.gov.

Accessed January 2016.

3. Hudson LM, Boullata JI. A quality improvement case report: an institu-

tion’s experience in pursuing excellence in parenteral nutrition safety.

JPEN J Parenter Enteral Nutr. 2014;38(3):378-384.

4. Malone AM, Seres DS, Lord L. Challenges and complications with enteral

nutrition. In: Mueller CM, ed. The Science and Practice of Nutrition

Support: A Case Based Curriculum. 3rd ed. Silver Spring, MD: American

Society for Enteral and Parenteral Nutrition; 2012:218-233.

5. Boullata JI. Safe practices for enteral and parenteral nutrition. In: Seres

DS, Van Way CW, eds. Nutrition Support for the Critically Ill. Cham,

Switzerland: Springer International Publishing; 2016:229-241.

Appendix 1. Water

Due to the repeated use of water throughout the enteral use

process, this appendix will delineate the terms and defini-

tions for the appropriate use of water terms. Reports in the

lay press about water contamination are giving clinicians

and patients a reason to pay closer attention to the source of

their water. For the patient receiving EN, there are multiple

points of interface with water and therefore will be discussed

here briefly. Water is used to hydrate the patient, flush the

EAD, and dilute medication and powdered formula.

Clinicians should be familiar with the terms used when

describing water (Table A1).

Regulations for drinking water

(Environmental Protection Agency) and bottled water (Food

and Drug Administration) are limited in the number of con-

taminants regulated and threshold concentrations allowed.

2,3

So although most drinking water may be considered safe for

healthy individuals, the types and concentrations of contami-

nants may pose risks to patients requiring EN. Contaminants

may be chemical or biologic; pathogenic microorganisms are

included in the latter. Water contaminated with pathogens

has been associated with colonization and infection with out-

breaks attributed to the water supply.

4–10

A source of sterile

water (eg, sterile water for irrigation) is considered best

practice for the immunocompromised patient and for recon-

stituting powdered enteral formula. The same water could be

used for preparing (diluting, reconstituting, compounding)

medication because it is an example of purified water (ie,

contaminant free), even though the sterility is not required.

The same water (ie, sterile water for irrigation) could even

be used for flushing the EAD and hydrating the patient when

the degree of chemical contamination of the drinking water

is unknown or excessive.

References

1. Boullata JI. Enteral nutrition practice: the water issue. Support Line.

2010;32(3):10-17.

2. United States Environmental Protection Agency.

3. United States Food and Drug Administration.

4. Venezia RA, Agresta MD, Hanley EM, et al. Nosocomial legio-

nellosis associated with aspiration of nasogastric feedings

diluted in tap water. Infect Control Hosp Epidemiol. 1994;15:

529-533.

5. Bert F, Maubec E, Bruneau B, et al. Multi-resistant Pseudomonas

aeruginosa outbreak associated with contaminated tap water

in a neurosurgery intensive care unit. J Hosp Infect. 1998;39:

53-62.

6. Anaissie EJ, Penzak SR, Dignani MC. The hospital water supply as a

source of nosocomial infections: a plea for action. Arch Intern Med.

2002;162: 1483-1492.

7. Vonberg RP, Eckmanns T, Bruderek J, et al. Use of terminal tap water

filter systems for prevention of nosocomial legionellosis. J Hosp

Infect. 2005;60: 159-162.

8. Johansson RJH, Andersson K, Wiebe T, et al. Nosocomial transmis-

sion of Legionella pneumophila to a child from a hospital’s cold-

water supply. Scan J Infect Dis. 2006;38:1023-1027.

9. Rogues AM, Boulestreau H, Lasheras A, et al. Contribution of tap

water to patient colonization with Pseudomonas aeruginosa

in a medical intensive care unit. J Hosp Infect. 2007;67:

72-78.

10. Garvey MI, Bradley CW, Tracey J, Oppenheim B. Continued trans-

mission of Pseudomonas aeruginosa from a wash hand basin tap in a

critical care unit. J Hosp Infect. 2016;94:8-12.

18 Journal of Parenteral and Enteral Nutrition 41(1)

Section 1. Assessment and

Recommendations

Background

EN is a complex therapy that may be associated with adverse

events. Therefore, before making any recommendations about

its use, a qualified nutrition clinician must evaluate indications

and weigh risks and benefits for each patient who may be a

candidate for this therapy. Nutrition assessment is a compre-

hensive approach to collecting and analyzing data from the

patient (history, physical exam, anthropometrics, laboratory,

and other tests) to diagnose any nutrition-related problem for

which nutrition intervention may be appropriate. In both the

adult and pediatric population, diagnosing malnutrition is

essential to promote improved outcomes.

1,2

A documented care

plan with consistent recommendations will follow the assess-

ment. The first goal is to evaluate the indication for EN.

Additional objectives of the assessment are to estimate macro-

nutrient, fluid, and micronutrient needs; determine the most

appropriate formula and route of administration; identify barri-

ers to tolerance; and prevent or ameliorate potential adverse

events, including GI intolerance, and metabolic and/or fluid

disturbances. Meeting these objectives requires a thorough

understanding of the patient’s overall condition. By making the

process of organizing and evaluating data as efficient as pos-

sible, institutions allow all members of the patient care team to

access the relevant information about EN recommendations;

thus, the electronic health record (EHR) may facilitate essen-

tial documentation and communication processes.

Question 1.1. What factors need to be included in the

overall nutrition assessment to determine the safety

and appropriateness of EN?

Practice Recommendations

1. Collect and organize relevant data on patient history,

physical exam, anthropometrics, laboratory values,

and other tests.

a. Patient history includes clinical diagnoses, past and

current medical and surgical interventions,

medications, dietary supplements, nutrition history,

social history, religious background, potential

ethical dilemmas, and mental status challenges.

b. Physical exam includes GI function assessment

and existing access devices as well as nutrition-

focused physical findings.

c. Anthropometrics includes height, weight, body

mass index (BMI), growth chart z scores, and any

available objective measures of body composition

or changes in any of these parameters.

d. Laboratory values and other test findings include

all relevant blood (eg, comprehensive metabolic

panel) and urinary tests regardless of whether the

findings are normal or abnormal, functional tests,

radiologic findings, or predictive scores such as

the Nutritional Risk Index.

2. Evaluate patient data to determine nutrition status, any

nutrition-related problem (real or potential), indication

for nutrition interventions via the enteral route, and

estimated energy, protein, fluid, and micronutrient

needs based on the patient’s status or accepted standards.

Rationale

Each of the recommended types of nutrition assessment data

provides essential information about whether EN is indicated

and can be administered safely. Nutrition status, including

presence or risk of malnutrition, also influences the effective-

ness and safety of implementing EN administration.

Patient history. The success of EN therapy depends on the

patient’s clinical state and disease process. A review of clinical

diagnoses and surgical/medical history will capture information

that has bearing on the patient’s ability to tolerate EN (Table 1).

3–8

A thorough social and nutrition history can determine if the

patient is at risk for refeeding syndrome due to recent anorexia or

food insecurity. This part of the assessment can also identify

nutrient intolerance or allergy, which could result in an adverse

Table A1. Water and Enteral Nutrition (EN) Use.

Term Definition Use in Patient Receiving EN

Source water Nonsaline, freshwater found on the surface (eg, lakes) or in the ground

(eg, aquifers)

Distribution water Water flowing from site of storage (eg, municipal treatment facility,

storage tank, or well) to point of use (ie, “tap” water)

Yes, for water flushes depending

on the degree of contaminants

Drinking water Distribution water and bottled water Yes, for water flushes depending

on the degree of contaminants

Purified water Contaminant free after treatment steps (eg, distillation, ultrafiltration,

UV light)

Yes, for medication preparation

Sterile water Purified water free of microorganisms and pyrogens Yes, for reconstituting powdered

formula

UV, ultraviolet.

Boullata et al 19

reaction to an EN product. The clinician evaluates GI symptoms

that may affect EN tolerance, such as nausea, bloating, diarrhea,

excessive ostomy output, constipation, abdominal discomfort or

pain, and reflux. Constipation is associated with early satiety and

feeding intolerance in addition to difficulty weaning from the

ventilator, related to an increase in intra-abdominal pressure.

Fecal impaction, obstruction, and ileus identified radiologically

will also affect EN tolerance. The nutrition clinician should also

note the presence of existing access devices or plans for EAD

placement and the appropriateness of these plans.

Prescribed medications that may affect safety and tolerance

of EN should be considered. For example, liquid medications

containing sorbitol may cause loose stools and abdominal dis-

comfort, leading to cessation of the feeding. Enteral feeding

administration should be rate adjusted and held with provision

of medications known to interact with formula or clog the

EAD. Medications should be scheduled for administration in

conjunction with the feeding regimen. At all times, a flushing

protocol should be in place to prevent formula-drug interaction

and device clogging. Hemodynamic instability and the need

for vasopressors increase the risk of gut ischemia, and the use

of EN should be considered cautiously in these patients.

Laboratory values and other test data. Closer review of perti-

nent laboratory values is an important component of the nutri-

tion assessment. Attention to hydration status, using available

markers such as urea nitrogen and urine sodium as well as fluid

intake and output, helps identify appropriate formula selection

and free water needs. Visceral proteins, including prealbumin,

in the presence of inflammatory biomarkers (eg, C-reactive

protein) may be useful as markers of inflammation and disease

severity as well as predictors of morbidity and mortality for

some populations.

10,11

However, these protein levels are not

indicative of nutrition status.

Anthropometry. Anthropometry, including weight and weight

history, is assessed to identify an adequate and appropriate feed-

ing regimen and to determine the presence or risk of malnutri-

tion. Unintentional weight loss is well established as an indicator

of malnutrition.

Malnutrition is associated with increased risk

of pneumonia, Clostridium difficile infection, pressure ulcers,

and postoperative complications.

In pediatrics, anthropometry

includes weight for age, length for age, and head circumference

for age and weight for length until 36 months. From age 2–20

years, weight for age, standing height for age, and BMI are

assessed. Plotting children on the appropriate growth chart is

important. For premature infants, the Fenton or Olsen growth

curves are used.

For term infants, the World Health Organiza-

tion (WHO) growth curve is used until age 2, and then the Cen-

ters for Disease Control and Prevention (CDC) growth curve is

used.

16,17

Traditionally, these curves were used with percentiles.

To be more accurate in assessment, it is now recommended that

z scores be used. A z score is a statistical measure of how far a

point is from the mean. Using percentiles, the only way to

describe a very low-weight child was to state that he or she was

below the third percentile. This could either describe a child just

barely below the third or a child severely below the third percen-

tile. With z scores, these points are given numeric values and

they can be compared from one measurement to the next.

18,19

Another useful measurement in the assessment of pediatric

malnutrition is mid–upper arm circumference (MUAC).

2,20–22

The WHO has MUAC standards from 6–59 months,

and

other references are available for older children and adults.

MUAC has been shown to correlate with BMI in children.

More information on assessment of pediatric malnutrition is

available elsewhere.

Physical exam. Along with weight status, nutrition-focused

physical exam findings should include assessment of skin

Table 1. Selected Clinical Conditions Relevant to a Patient’s Ability to Tolerate EN.

3–8

 Prematurity in the neonate results in immature GI motility and risk of developing necrotizing enterocolitis.

 Trauma and critically ill patients may have altered metabolism and varying needs during the different phases of illness.

 Critically ill patients with traumatic brain injury have a higher frequency of GI disorders, such as gastroparesis and subsequent

feeding intolerance.

 Diabetes and certain neurological conditions place patients at risk for gastroparesis and poor EN tolerance.

 Chronic obstructive pulmonary disease predisposes patients to muscle atrophy and weight loss related to chronic inflammation,

increased metabolism, and other physiologic derangements.

 Ventilator-dependent respiratory failure may affect decision of formula selection and concentration.

 Altered GI anatomy resulting from small bowel resection, bariatric surgery, other GI surgery, or fistula affects decision making

about feeding route and formula selection.

 Altered GI anatomy also poses a risk of anastomotic leak, malabsorption leading to diarrhea, and subsequent loss of nutrients, which

may result in metabolic derangements.

 Renal failure affects the patient’s ability to tolerate fluid volume and electrolytes.

 Hemodynamic instability may preclude the safe initiation of EN in the critical care patient.

 Cancer and ongoing treatments such as high-dose radiation to the head/neck may result in inflammation of the esophagus with dysphagia.

 Dysmotility conditions associated with gastroschisis or scleroderma may impact ability to tolerate EN.

 Neuromuscular diseases such amyotrophic lateral sclerosis can result in dysphagia

EN, enteral nutrition; GI, gastrointestinal.

20 Journal of Parenteral and Enteral Nutrition 41(1)

integrity, fluid accumulation or deficit, muscle and fat loss, and

functional status. Handgrip strength is a predictive indicator of

postoperative complications, hospital length of stay and read-

mission, and physical status. Physical therapists may offer a

valuable assessment of physical function. Muscle function cor-

relates well and reacts quickly to changes in nutrition status. In

pediatric patients, developmental status and risk of aspiration

with oral intake should be evaluated.

23,24

Assessment of malnutrition and nutrition needs. Malnutrition

is also associated with longer hospital length of stay, higher

cost of hospitalization, increased risk for readmission, and

increased mortality.

Indeed, it is the third most common rea-

son for 30-day readmission among selected surgical patients.

With up to 50% of hospitalized patients reported to be mal-

nourished, it is a critical factor to consider during nutrition

assessment.

13,26

In the neonatal population, data show that

improvement in growth and neurodevelopment outcomes are

correlated with better nutrition intake.

Although there is no universally accepted approach to the

diagnosis and documentation of malnutrition, standardized

protocols should be put in place to assess each patient’s anthro-

pometric and laboratory data, previous and current food/nutri-

ent/fluid intake, and functional recommendations from the

Academy of Nutrition and Dietetics and the American Society

for Parenteral and Enteral Nutrition.

The use of a standardized

approach to identify and treat malnutrition can lead to cost-

effective patient-centered nutrition support therapy.

Question 1.2. What are the required elements of the EN

therapy recommendation and where are they to be

documented?

Practice Recommendations

1. Include these required elements in the EN therapy

recommendations as listed below. These data will be

consistent with the elements of the subsequent EN

prescription.

a. Indication for EN therapy and rationale

b. Enteral formula name, concentration if appropriate

(such as kcal/oz in pediatrics), and modular

component names as appropriate

c. Enteral access device, including tip placement

d. Volume per feeding or total volume per day

e. Initial rate, goal rate, and advancement schedule

f. Rationale for recommending a specialized enteral

formula or suggesting a change (as applicable)

g. The specific method of feeding (such as

continuous, intermittent gravity, or bolus) is

specified, as well as the feeding route and access

device

h. Schedule and amount of routine water flushes, if

applicable

i. The daily nutrients to be provided at goal,

including total daily volume of formula, calories,

protein, and free water. Grams of carbohydrate

may be useful in patients with diabetes. Record

nutrients per kilogram of body weight such as

grams of protein and kcal per kilogram.

j. Monitoring required to identify adverse events,

such as refeeding syndrome, GI intolerance, or

tube malposition, as early as possible

2. Recommend modular products, such as additional

protein, fiber, and other supplements along with

administration schedule, as appropriate. Note final

kcal/oz for pediatric patients.

3. Include additional elements of feeding protocols, such

as keeping the head of the bed (HOB) elevated, oral

care/decontamination or holding the feeding for

abdominal distention, vomiting, new or worsening

hypotension, or other indications of intolerance.

4. Specify baseline or routine laboratory markers and

monitoring.

5. Document the recommendations of nutrition support

clinician in the EHR that allows access for all

healthcare providers.

Rationale

The success of EN relies on the expertise of nutrition support

clinicians. The most current Standards of Practice for nutrition

support clinicians outline the level of professional responsibil-

ity and clinical expertise required or expected of these health-

care professionals.

29–33

Important elements of the EN

recommendation made by the nutrition clinician address the

monitoring of biochemical data, anthropometrics, nutrient

needs, enteral access, EN tolerance, and other indicators.

Communication and implementation of the EN recommenda-

tions are essential for successful nutrition intervention and

may impact outcomes in terms of desired weight gain,

improved markers of nutrition status, and reduced hospital

length of stay.

34,35

Providing recommendations for use of feed-

ing protocols has resulted in increased number of days on EN,

more total EN volume and calories delivered, and improved

GI tolerance.

Documenting the nutrition assessment and recommenda-

tions in the EHR allows for quicker communication and imple-

mentation of the recommendations, as well as better

accessibility and legibility than other documentation methods,

such as paper charts.

A standardized uniform and complete

recommendation will allow the prescribers and the rest of the

healthcare team accessing the EHR to fully understand the

nutrition recommendations and rationale.

Question 1.3. What is the most effective way to

communicate the recommendation for EN therapy to

the licensed prescriber?

Boullata et al 21

Practice Recommendations

1. Communicate the recommendation in a standardized,

timely, and accurate manner.

2. Use the EHR system to communicate the nutrition

assessment and nutrition recommendations to the

licensed prescriber.

3. Consider a facility policy that allows registered

dietitians or other nutrition clinicians to order medical

nutrition therapy, per state regulations and institutional

privileges.

4. Program the EHR so the nutrition assessment and EN

recommendation flow directly into the order entry

section of the EHR for prescribers to review and accept.

5. Verbally communicate the recommendations to the

prescriber in addition to permanent documentation

through the EHR.

Rationale

Effective 2-way communication between nutrition support

clinicians, the prescriber, and the primary care team is critical

in order to implement nutrition support therapy recommenda-

tions in a timely manner. Where state regulation and facility

policy grant EN order-writing privileges for the registered

dietitian or other nutrition clinician, the plan may be reviewed

and implemented immediately.

34,35,37

In these cases, the plan is

always communicated with the healthcare provider, who has

ultimate responsibility for the patient’s care. This communica-

tion is safest and most direct when the nutrition plan is docu-

mented in a central location, such as the medical section of the

EHR.

Current methods of communication among healthcare pro-

viders regarding EN orders vary from one facility to the next.

Perhaps the most easily standardized method of communication

is the EHR. Communication via this method is more accessible,

legible, and immediate than other methods and therefore may

result in improved outcomes, including improved EN volume

and calorie provision.

36,38

Whenever possible, additional com-

munication between the recommending clinician and the pre-

scribing physician is encouraged. Open dialogue between 2 or

more people improves communication and information sharing

in the context of healthcare.

39–44

In-person discussion is consid-

ered more effective than other methods of communication

(such as telephone calls, e-mail, or text messaging) to reinforce

the assessment and recommendations provided in the EHR (or

paper chart if still in use). In the inpatient setting, in-person

communication can occur during interdisciplinary patient care

rounds, but follow-up written documentation is important.

39–44

Topics for Future Research

 Multidisciplinary use of nutrition-focused physical

examination indicators

 Integration of nutrition assessment parameters in the

EHR

 EHR support in calculating nutritional parameters, fluid

requirements, nutrition risk assessment tools, etc

 Methods of communicating nutrition assessment and

recommendations and outcomes

 National standardization of EHRs

 Nutrition informatics, translational research,

telemedicine

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Section 2. Prescribing and Communicating

the Enteral Nutrition Order

Background

In comparison with the greater risks associated with PN, the pre-

scription of EN may seem benign, but patient harm can occur

when EN practice recommendations are not followed. Adverse

events related to EN have been reported at each step of the EN

process. Examples of these events include enteral feeding tube

malposition or misconnection, EN formula contamination, and

bronchopulmonary aspiration.

Therefore, patient safety is a fun-

damental consideration in the EN prescribing process. Prescribers

of EN need in-depth knowledge of protein and energy require-

ments, electrolyte and fluid balance, acid-base homeostasis, and

GI anatomy and function. Prescribers of EN must also be knowl-

edgeable in proper indications and contraindications to EN,

proper care and selection of EADs intended for gastric or small

bowel placement, and potential complications related to EN.

2–5

Currently, EN orders may be inconsistently worded and

executed due to the individualized prescribing habits of clini-

cians, variance between institutions, and inadequate prescriber

education. Furthermore, many organizations still sanction pre-

scribing EN via telephone, verbal, or handwritten orders. The

use of standardized electronic EN orders can help address

problems of incomplete, ambiguous, or incorrect EN orders.

This section will provide guidance for healthcare organizations

when developing policies and procedures to safely prescribe

and communicate the EN order.

Question 2.1. How can the approach to prescribing EN

be standardized to reduce EN-related errors?

Practice Recommendations

1. Use a standardized approach for prescribing EN to

minimize complications associated with incomplete or

ambiguous EN orders.

2. Develop and implement policies and procedures that

address all aspects of the EN order process and

competency assessments for healthcare professionals

involved in the prescription of EN.

Boullata et al 23

3. Apply a standardized model of prescribing for safe EN

practice, with each organization using the insight of

their prescribers to determine how best to apply the

model. Consider including EN prescribing in ongoing

professional practice evaluation (OPPE) and focused

professional practice evaluation (FPPE).

4. Incorporate interdisciplinary teams as available within

the organization, allowing each member to address

relevant issues as it relates to the EN process.

5. Develop and implement a process for the primary

healthcare team to assess, document, and communicate

the therapeutic goals and monitoring of EN therapy.

Following the process, the primary healthcare team can:

a. Evaluate the patient to assess that EN

administration is safe and indicated.

b. Confirm that the patient has an appropriately

placed EAD that is appropriate in regards to

current clinical status.

c. Review the nutrition assessment and nutrition

recommendations as documented by nutrition

support clinicians (see Section 1).

6. Describe specific methods of communication to be used

among physicians, advanced practice providers, dietitians,

pharmacists, and nurses involved with the prescription,

order review, administration, and monitoring of EN.

7. Involve clinicians specializing in nutrition support in

the design of a standardized EN order process that will

meet the needs of the organization’s specific patient

population.

a. Prescribe EN for all patients using standardized

electronic EN orders (eg, computerized provider

order entry [CPOE] systems).

b. When CPOE systems are unavailable, prescribe

EN with a standardized order template using an

editable electronic document, saved as a PDF,

which will remain part of the EHR.

c. Avoid handwritten, telephone, and verbal EN orders

because of the potential for transcription errors.

d. Design electronic EN order sets with clear

instructions that are easily understood by all

healthcare professionals involved in the

prescription of EN.

8. Design a transitional EN order template that assists

with the transition from acute care to long-term care or

home care settings (see Section 11). Using a well-

designed standardized template will facilitate

communication of the following:

a. Patient identifiers, previous EN formula and water

flushes, delivery site and access device, and

administration method and rate

b. Previously trended laboratory values and clinical

assessments relevant to EN tolerance

c. Contingency plans for transition to oral feedings

or PN as circumstances may dictate

Rationale

Organizations need proper, accurate documentation of nutrition

interventions that is available to all members of the healthcare

team. This documentation can promote effective 2-way commu-

nication between prescribers of EN and those reviewing EN

orders and subsequently monitoring the patient regarding appro-

priate energy and protein delivery, changes in therapy, medica-

tion interactions, EN tolerance, and other pertinent information.

The implementation of a standardized EN ordering process

that includes an electronic order template can eliminate the

possibility for inappropriate EN orders due to omissions, tran-

scription errors, or illegible documentation. When all elements

of the EN order are included during electronic prescription, the

risk for errors related to verbal order clarification and tran-

scription can be lessened. Standardized EN orders can also

guide all EN prescribers within an institution to use the same

terminology when referencing EN.

6,7

Other advantages of stan-

dardized orders can include preventing incomplete orders and

improving efficiency for the prescriber and enhancing patient

safety. When all elements of the EN order are included during

electronic prescription, there is a reduced risk for errors.

The adoption of EHRs can give nutrition support profes-

sionals an opportunity to implement standardized EN order

processes. In a recent national survey of hospital pharmacy

directors by the American Society of Health-System

Pharmacists, 80.9% of hospitals that responded were using

CPOEs for general medication orders.

However, the degree of

customization within electronic systems is low. Nutrition sup-

port clinicians will need to work closely with information tech-

nology personnel (who can in turn reach out to vendor and

application architects as needed) to request adequate decision

support capability and proper documentation for those pre-

scribing EN. In a survey of the American Society for Parenteral

and Enteral Nutrition’s membership regarding the safety and

efficacy of nutrition documentation and nutrition-related

ordering processes, Vanek

found that nutrition support practi-

tioners do not highly rate their institutions’ EHR systems and

concluded that the growing adoption of EHRs and CPOE sys-

tems offers nutrition support practitioners the opportunity to

ensure that nutrition and nutrition support content within their

system is adequate and safe. Ammenwerth et al

conducted a

systematic review to determine the effect of CPOE systems on

general medication error and adverse drug events. Within the

systematic review, 25 out of 27 studies addressed medication

errors. Of those 25, 23 studies showed a relative risk reduction

for medication errors of 13% to 99% after implementation of

CPOE. Ammenwerth and colleagues also concluded that a

transparent culture of safety within healthcare systems can

increase proper reporting of medication errors, which will pro-

vide better data for future research.

Documentation of nutrition interventions should be avail-

able to all members of the healthcare team. Proper documenta-

tion allows prescribers of EN to communicate EN tolerance,

24 Journal of Parenteral and Enteral Nutrition 41(1)

EAD status, changes in therapy, and any other pertinent infor-

mation to the rest of the healthcare team. This documentation

should allow for communication between prescribers of EN and

those reviewing EN orders for appropriate energy, protein, and

fluid delivery; medication interactions; and EN tolerance.

Malone et al

reported a case of a 65-year-old woman who

was supposed to receive EN through a gastrostomy tube and

fluid and electrolyte replacement via central venous catheter.

However, she inadvertently received 160 mL of EN through her

central line when it was mistaken for the gastrostomy tube. She

subsequently required hydration, diuretic therapy, and prophy-

lactic antibiotics, after which she recovered and was discharged

from the acute care setting 8 days later. This case is an example

of errors among healthcare providers in a patient with multiple

access devices. Electronic EN orders can specifically indicate

proper EN administration directions and may help eliminate

errors related to orders that could expose patients to harm.

The use of a complete EN order specifically designed to pre-

scribe EN for home or transitional use will promote the continu-

ity of a patient’s care. The EN regimen can be optimized while

the patient is in an inpatient setting, and the nutrition support

clinician can reassess nutrition needs before discharge. A com-

plete EN transition order will also allow the primary outpatient

clinician to take over patient care and determine the appropriate

frequency of laboratory monitoring, reassessment of nutrition

needs, and confirmation of tube placement. EN transition orders

can also assist with self-management of home enteral feedings

in those who do not receive skilled nursing services. A complete

order for discharge can allow for adequate education to be pro-

vided to patients being discharged to home with EN.

Overall, a standardized approach to the EN prescription

process that is administratively supported by the organization

can ensure patient safety, assist the entire healthcare team, and

help provide cost-effective nutrition therapy. Nutrition support

clinicians must be engaged and held accountable for the devel-

opment and implementation of policies and procedures related

to the EN prescription process.

Questions 2.2 and 2.3. What are the critical (required)

elements for a complete EN order? What are the

supplementary (auxiliary) elements to the EN order

that may improve patient safety?

Practice Recommendations

1. Include the following critical elements in the standardized

electronic EN order template (Figures 2 and 3):

a. Patient information

i. Identify patients by the following: patient

name, date of birth/age, and medical record

number.

ii. Transmit patient-specific information

relevant to the electronic EN order such as

height/length and dosing weight and allergies

(eg, food, medication).

b. EN formula name

i. Describe EN primarily via descriptive

generic names (eg, “standard,” “high

protein”) to minimize confusion for

prescribers. The product trade name could

also be included along with the

organizationally defined generic term. For

pediatric patients, add final kcal/oz.

c. Delivery site (route) and EAD

i. Include the administration route in the EN

order based on the enteral tube’s distal tip

position (gastric or small bowel).

ii. The specific EAD to be used (eg, nasogastric

[NG], orogastric, gastrostomy, nasojejunal,

orojejunal, jejunostomy, or gastro-

jejunostomy).

d. Administration method and rate

i. Include the specific method of administration

in the EN order (eg, continuous, bolus,

intermittent feedings).

ii. Define the volume and rate of administration

of EN for each method of administration.

iii. Order sets that include advancement can be

populated with the standard advancement

and held, to be released each day after the

clinician examines the patient and reviews

orders with the team.

2. Develop nurse-driven EN protocols for volume-based

feeding as per institutional policy.

a. Include the volume and frequency of water

flushes.

b. Provide suggested methods to advance the volume

and/or rate toward goal.

3. Create and implement policies and procedures that

promote all elements of the EN order to be completed

whenever the EN order is modified or reordered.

4. Design electronic order sets with elements that promote

patient safety.

a. Use required fields within the EN order to prevent

submission of the order until it is complete.

b. Use menus to facilitate standardization of EN

prescribing.

5. When EN is reordered, require that prescribers take

accountability for the proper monitoring of the

patient’s clinical condition, EN tolerance, and

metabolic status.

a. Monitor patients with newly initiated EN, newly

placed permanent EADs, critically ill patients,

patients at risk for refeeding syndrome, patients

with poor glycemic control, or patients recovering

from recent surgery as they will require more

frequent monitoring.

6. Design and implement policies and procedures that

address supplementary EN orders within the CPOE.

See Figure 4.

Boullata et al 25

a. Confirm that the initial enteral feeding tube

position is correct via proper radiographic imaging

that visualizes the entire enteral feeding tube. The

exception to this may be in pediatric and neonatal

patients who require multiple tube placements due

to the x-ray exposure (see Section 4).

b. Establish proper EAD flushing in supplementary

orders (see Section 7). Develop protocols that call

for proper flushing before and after medication

administration, during continuous feedings,

before and after intermittent feedings, and before

and after gastric residual volume (GRV)

measurements.

c. Address reassessment of the appropriateness of

HOB elevation and ongoing monitoring for EN

tolerance in policies and procedures.

d. Integrate EAD care and assessment into policies

and procedures to assist with infection prevention

INPATIENT ENTERAL NUTRITION ORDER

Patient Name: ____________

Room Number:___________

Medical Record Number: _____________ Dosing Weight (kg): ______________________

Date of Birth: __________

Allergies: ______________

Total Energy kcal/day

_____________

Total Protein g/day

____________

Total Carbohydrate g/day

______________

Total Fat g/day_______________

Total Fluid mL/day___________

ENTERAL NUTRITION FORMULA

□ Standard

□ Standard High protein

□ Standard High Calorie

□ Fiber Containing

□ Carbohydrate controlled

□ Elemental include peptide-based

□ Immune modulating

□ Renal – low electrolytes

DELIVERY SITE (ROUTE AND ACCESS)

Route:

□ Gastric

□ Small bowel

Access:

□ Nasogastric

□ Nasoduodenal

□ Nasojejunal

□ Orogastric

□ Oroduodenal

□ Orojejunal

□ Gastrostomy

□ Jejunostomy

□ Transgastric G/J tube

ADMINISTRATION (Method and Rate)

Method:

□ Continuous

□ Intermittent

□ Bolus

Rate:

□ Initial ____________________________ mL/h

□ Advance by _________ mL/h every _________ h to goal of __________ mL/h

□ Initial ________ mL feeding over ________ min _________ times daily

□ Advance by _________ mL each day to goal of _________ mL feeding

over __________ min _________ times daily

□ Initial ________ mL bolus over _________ min _________ times daily

□ Advance by _________ mL each day to goal of ___________ mL bolus

over __________ min __________ times daily

OTHER

□ Flush feeding tube with _____________ mL of water every __________ hours (minimum of 30 mL per flush)

□ Elevate head of bed 30–45 degrees

Figure 2. Enteral nutrition order template (specific content can be customized per institution). G/J, gastrojejunostomy.

26 Journal of Parenteral and Enteral Nutrition 41(1)

and allow for proper intervention if a complication

occurs.

e. Ongoing monitoring includes laboratory

monitoring, measurement of intake and output,

weight measurements, physical assessment, and

GI tolerance.

f. Identify the specific product for modular therapies

along with the proper prescribed amounts and

administration schedule.

g. State specific amounts of additional macronutrients

per day with orders for modular nutrition therapies

(eg, 12 g protein powder per day) along with

directions for proper reconstitution and

administration.

7. Make consultation to the nutrition support team or

clinical nutrition service available for prescribers.

8. Determine the duration (time limits) of the EN order

before it has to be renewed.

Rationale

The development of clearly defined policies and procedures

regarding the required elements of the EN order helps the facil-

ity ensure that the orders are complete throughout the EN pro-

cess and that the right patient receives the right product, in the

right amount, via the right route at the right time. It is recom-

mended that the essential elements of the EN order are made

available for viewing by all healthcare professionals via proper

electronic documentation in the EHR. Critical elements for a

complete EN order must be addressed through a CPOE order or

editable electronic document before supplementary elements

can be acknowledged.

In a prospective study, Armada et al

evaluated the effect of the implementation of the CPOE system

on the incidence of prescription errors and found that prescrip-

tion errors decreased significantly from the error rate for hand-

written of 44.8% to an error rate of 0.8% after CPOE

implementation (P < .001). This prospective study demonstrates

□ Start feedings of Human Breast Milk (HBM) at 1 mL q3h via NG tube (15 mL/kg/day, @ 10 kcal/kg).

□ Continue for 3 days for trophic feedings.

□ Increase feedings by 1 mL q3h per day on day 4, 5, and 6 of the feeding protocol until feeds on day 7 are at 75 mL/kg (5 mL q3h).

□ On day 8 continue same feeding volume and begin fortification of feeds to 24 kcal/oz using human milk fortifier, 1 packet to 25 mL of

human milk.

□ On day 8 and thereafter the advancement continues at 1 mL q3h until the total volume is 160 mL/kg or 11 mL q3h on day 14. This will

provide 160 mL/kg, @128 kcal/kg, @ 4.5 g/kg protein.

□ Do not routinely check gastric residuals.

□ Do not routinely flush NG tube.

□ Continue daily weights.

□ Obtain length measurements using (length board) and head circumference measurements (taking the average of three measurements) weekly.

□ After reaching full-volume feedings, add vitamin D (400 International Units) and evaluate the baby for the need for additional elemental iron.

Figure 3. Example of neonatal enteral nutrition feeding protocol. NG, nasogastric.

SUPPLEMENTARY ORDERS

Auxiliary Orders:

□ Assess gastric residual volume (GRV) every 6 hours or before each bolus/intermittent feeding

If GRV > 500 mL hold feeding for 2 hours and recheck GRV. If GRV recheck < 500 mL, restart feeding

□ May give appropriate medications via enteral feeding tube, follow each medication by at least 15 mL water flush before and after medication as

volume allowed (do not mix medications together or with EN formula)

□ Consult Nutrition Support Team or Nutrition Support Clinician

Monitoring:

□ Observe for signs of EN intolerance (include signs and symptoms of intolerance) every ____________ hours

□ Enteral feeding tube site care and assessment every ____________ hours

□ Obtain body weight every day, or every ______________ days

□ Strict fluid volume Ins/Outs

□ Capillary blood glucose: per institutional protocol

Laboratory Orders:

□ Comprehensive Metabolic Panel every day or every ________ days

□ Serum Magnesium every day or every _________ days

□ Serum Phosphorus every day or every _________ days

Figure 4. Suggested enteral nutrition (EN) supplementary orders (specific content can be customized per institution).

Boullata et al 27

the impact that healthcare technology can have on patient safety,

and it helps nutrition support professionals justify the impor-

tance of nutrition-based software integration.

It is important

when developing electronic EN ordering documents that institu-

tion specific and patient population customization is permitted

(Figures 2 and 3).

The appropriate initiation and advancement of an EN regi-

men depend on the patient condition as well as the administra-

tion method and EAD type. Continuous EN administration via

enteral feeding pump with small-volume, frequent water flushes

is preferred in the critically ill, those at risk for intolerance, and

for small bowel feedings. Directions for continuous EN admin-

istration identify the proper initial administration rate and can

contain supplementary orders addressing timing of rate

advancement to goal infusion volume. Bolus and intermittent

methods of EN administration via syringe, regulated drip

enteral feeding bag, or enteral feeding pump are preferred in

patients who have proven tolerance with continuous EN admin-

istration and those who will transition out of the acute care set-

ting with EN. Directions for bolus and intermittent EN

administration document the proper number of feedings per day

along with initial proper volume of EN administration rate and

volume and frequency of water flushes. Bolus and intermittent

feeding orders can also contain supplementary orders that give

directions for volume advancement and goal EN volume.

The implementation of enteral feeding protocols may

improve energy, protein, and fluid delivery to ICU patients who

experience interruptions in EN delivery due to unavoidable pro-

cedures (reintubation/extubation, bedside procedures involving

the GI tract or airway, and imaging studies).

16,17

The administra-

tion of large volumes of EN to compensate for EN that was

missed during procedures can place patients at risk for intoler-

ance of EN.

18–21

If enteral feeding protocols are going to be

implemented, healthcare organizations should utilize multidisci-

plinary teams to determine if these protocols are beneficial for

that institution’s patient population and how to build this into the

order entry process. See Figure 3 for an infant EN protocol.

Supplementary orders (see Figure 4) assist with adequate

energy and protein delivery, maintain patient safety, and assist

clinical staff with therapeutic monitoring of EN therapy.

Although supplementary orders are not essential, they comple-

ment the EN order with additional guidance to better communi-

cate and standardize EN for a patient. Supplemental orders will

be based on institutional policies that advocate for the proper

care of the enterally fed patient within the practice variations at

each organization. These orders can also permit prescribers to

consult an institution’s nutrition support service to assist with

management of EN. Supplementary orders address the use of

adjunct modular therapies, which can allow clinicians to

enhance macronutrient contents of an EN prescription.

Critical and supplementary elements of the EN order facili-

tate proper and safe EN prescription and administration.

Nutrition support clinicians can help institutions determine and

develop any supplementary orders that would benefit their

patient population. Continued review of institutional policies

and procedures along with national clinical guidelines and

practice recommendations will allow institutions to continue to

improve the EN process.

Question 2.4. What is the safest way to describe EN

formulas?

Practice Recommendations

1. Set policies and procedures on how EN formulas will

be described throughout the healthcare organization,

including in electronic order sets, patient-specific EN

labels, and all other references to EN (eg, for product

inventory, purchasing, healthcare provider

documentation).

2. Describe EN primarily via descriptive generic names

(eg, “standard,” “high protein”) to minimize confusion

for prescribers. The product trade name could also be

included along with the organizationally defined

generic term.

3. Develop a patient-specific EN label template to reflect

all the critical elements of the EN order.

Rationale

The EN prescription should be a patient-specific therapy that is

prescribed, reviewed, prepared, and administered, with a pro-

cess optimized for patient safety. The use of CPOE has been

shown to reduce the opportunity for medication errors due to

illegible orders, transcription errors, and prescriber error.

The

use of electronic order sets in CPOE can positively assist pre-

scribers when obtaining patient-specific and EN formula infor-

mation. However, with constantly evolving medication trade

names and EN formula brand names and product labeling, there

is opportunity for transcription error when acting on an EN

order, especially if it is handwritten. EN formula-specific infor-

mation should be easily accessible to prescribers to allow for

the delivery of adequate protein and energy, electrolytes, and

fluid and to ensure proper EN formula prescription. Disease-

specific formulas should be selected using clinical judgment

with knowledgeable clinicians weighing efficacy, tolerance,

cost, and clinical evidence (from randomized clinical trials).

Determine descriptive generic names to be used to describe

EN formulas throughout the entire healthcare system. The use

of generic names to describe EN is encouraged because health-

care organizations often change EN formularies and because

EN formularies will vary among the acute, chronic, and home

care settings. Brand names for EN can be confused when other

formula or medications have similar names. When institutions

change EN formularies, it is important that clinicians have easy

access to formulary changes and a “formulary card” or “con-

version chart” with new EN formulas, old EN formulas, and

modular products available. For example, an EN formula that

28 Journal of Parenteral and Enteral Nutrition 41(1)

contains nonhydrolyzed macronutrients that is intended for

those with normal digestive function can be generically identi-

fied as “standard.” An EN formula that contains hydrolyzed

macronutrients, which could be used for those with malabsorp-

tive disorders, can be generically identified as “peptide-based”

or “elemental.” An EN formula that contains a higher percent-

age of calories from fat along with a higher fiber content to

assist with glycemic control can be generically identified as

“carbohydrate controlled.”

Develop policies and procedures regarding patient-specific

EN formula labels that can be affixed to EN formula adminis-

tration containers. Develop patient-specific EN formula labels

that contain all of the elements in the same sequence as the

original EN order. Determine if patient-specific EN formula

labels present all nutrients or only macronutrients and select

micronutrients.

Question 2.5. How often should the EN order be

reviewed for renewal in the acute care, chronic care,

and home care settings?

Practice Recommendations

1. Determine an institution-specific or organization-

specific policy for the frequency of EN order review

and renewal based on the level of care provided by the

institution (acute care vs subacute care vs long-term

care vs home care).

2. Complete all elements of the EN order when the EN

order is modified or reordered.

3. Review orders daily in conjunction with monitoring

daily in unstable patients (eg, critically ill patients,

postsurgical patients, patients with poor glycemic

control, patients with unstable fluid and electrolyte

status, and patients at risk for refeeding syndrome).

4. Review orders daily for neonatology and critical

pediatric patients. Stable pediatric patients may need

less frequent review.

5. Reduce monitoring of EN orders to every 2–7 days (1–3

times per week) in stable adult hospitalized patients.

6. Monitor patients in the long-term care or home setting

who have demonstrated to be stable on an EN

prescription with no signs of intolerance every 1–4

weeks. Less frequent review and reordering may be

appropriate in select patients on long-term EN in

keeping with regulatory requirements.

Rationale

Even though EN may seem to be a benign therapy, there are

complications and adverse events related to the EN process.

Policies and procedures addressing the timeframe for the

renewal of the EN order will help facilities have the best EN

order system based on the patient’s current condition.

By monitoring the patient and reviewing the EN orders at

appropriate frequencies, clinicians can provide nutrition sup-

port that is safe, able to detect any clinical or metabolic compli-

cations, and assess the extent to which nutrition goals have been

reached. Unlike PN, which may require frequent adjustments,

the EN regimen may not require therapeutic interventions as

frequently. Often, the EN order is best reviewed and renewed

when a patient changes levels of care or when the patient on EN

is discharged to home or a long-term care facility.

Existing literature does not address the ideal frequency for

reviewing EN orders. Therefore, practitioners must rely on

expert clinical experience and consensus opinion to provide

clinical practice guidelines. The ideal timeframe for EN order

review and renewal may vary based on the healthcare setting

and the acuity of the patient population. Patients newly initiated

on EN will need more frequent monitoring than those whose

tolerance of EN has been established. Special attention is also

given to high-risk patients, such as those who are clinically

unstable (eg, patients with preexisting metabolic abnormalities,

critically ill patients, or postoperative patients) and those at risk

for refeeding syndrome. The frequency of order review usually

decreases as patients stabilize and transition to lower levels of

care. In long-term care settings, time intervals between order

renewals may be subject to regulatory standards.

Each healthcare organization can establish its own policy

regarding the frequency of the EN order review and renewal.

Clinicians with expertise in the area of nutrition support, pref-

erably from multiple disciplines, are key players to engage in

policy development. To ensure patient safety and assess the

effectiveness of nutrition interventions, organizations will

want to monitor compliance with policies.

Question 2.6. What educational programs and

systematic changes can be implemented to prescribers

of EN to improve EN ordering and reduce errors?

Practice Recommendations

1. Provide education regarding safe practices for EN

prescribing and monitoring to all clinicians that

prescribe EN.

2. Provide ongoing rigorous education about safe EN

prescribing practices to improve communication and

monitoring. Educational initiatives can include

healthcare team in-services, pocket cards, and regular

audits with reporting results at institutional quality

improvement meetings.

3. Integrate education regarding safety in EN into the

core curriculum for healthcare students and trainees. A

multidisciplinary team of clinicians with expertise in

the area of nutrition support can conduct this education.

4. Provide in-depth and rigorous educational content on

safety issues to all clinicians who will care for patients

receiving EN in the acute, chronic, and home care

Boullata et al 29

settings and those who are training to specialize in

nutrition support care.

5. Evaluate or design a physical environment for EN

prescribing by assessing needs that may affect the

performance of EN prescribers to safely communicate

the EN order for transcription, interpretation, and

review in the following 5 factors outlined by the United

States Pharmacopeial Convention, USP General

Chapter <1066>:

a. Characteristics of the individual prescriber can

vary in responses to physical environment.

Therefore, adaptation to the physical environment

to meet individual needs will optimize accuracy

of all prescribers of EN.

b. Tasks performed and workloads: Prescribers

presented with large workloads often find

workarounds and overrides that could place

patient safety at risk.

c. Tools and technology used to perform tasks: With

the constant evolution of technology within

healthcare, the tools and technologies implemented

in healthcare systems must be user-friendly, easily

accessible, and optimized to each institution’s needs.

d. Compliance of the physical environment in

relation to USP General Chapter <1066>: Sensory

interference from noise, light, interruptions, or

poorly constructed work environments can

adversely impact the ability of clinicians to safely

prescribe EN.

e. Organizational support: Offer support that helps

address new and ongoing concerns related to the

safe communication and transcription of the EN

order.

6. Avoid verbal and telephone prescriptions except for

communication between prescriber and nutrition

support clinician to clarify the EN order that may result

in order revision.

Rationale

Research is limited regarding whether educational programs

about safe EN prescribing practices affect patient outcomes.

However, studies have shown that patient care with multidisci-

plinary teams increases communication among healthcare pro-

fessionals, which in turn contributes to higher rates of patient

safety,

and this finding suggests that educational techniques

that improve communication among members of the EN team

may be warranted. Further research on the impact of the educa-

tion of EN prescribers on the incidence of EN-related errors

and inappropriate prescribing is needed.

The implementation of education programs has been asso-

ciated with safer practices for prescribing medication.

Elements of safe EN prescribing are appropriate topics for the

core didactic curricula in professional programs (medical,

pharmacy, advanced practice nursing, nutrition, and physician

assistants). Safe practices for prescribing EN can also be inte-

grated into the clinical training for professional programs, resi-

dencies, and specialty/fellowship programs for those who may

be involved in the prescribing of EN.

The process of prescribing EN requires an environment that

is productive for each prescriber of EN and an environment

that is designed with consideration of the following: prescriber

characteristics, workload of prescribers and those implement-

ing orders, technology available, and organizational support.

The October 2010 bulletin by the USP, titled “Physical

Environments That Promote Safe Medication Use,” establishes

work environment standards to reduce the risk of medication

errors. This bulletin gives nutrition support professionals a

resource to incorporate safe EN prescribing practices into poli-

cies and procedures for clinical practice.

Question 2.7. What are the essential elements of safe

communication and transcription of the EN order?

Practice Recommendations

1. Create policies and procedures that minimize the need

for order transcription, therefore limiting transcription

errors and increasing safe communication within the

EN order process.

2. Use EHR communication technology to avoid

transcription during the EN order process.

3. Institute and follow policies and procedures to

encourage that transcribed orders are independently

double-checked for completeness and accuracy before

EN review and preparation.

a. Whenever possible, avoid multiple transcriptions

of EN order data.

b. If manual data transcription is completely

unavoidable, document any transcribed data that

undergoes a double-check process and make it

available for quality improvement audits.

4. Review and compare EN orders to the most current

recommendations when reassessing patients. Whenever

there are unexplained discrepancies between the order

and the recommendations, communicate with the

healthcare team according to institutional policies to

ensure that recommendations were understood.

5. Develop protocols/algorithms to serve as com-

munication tools and guides to safe EN practice for the

healthcare organization. These may include guidance

about the following:

a. Initiation of EN prior to completion of nutrition

assessment by the dietitian or other nutrition

support clinician

b. Approach to feeding through various EADs

c. Water-flushing protocols, especially if using

automated systems

30 Journal of Parenteral and Enteral Nutrition 41(1)

d. Medications that can be given via EADs and if

tube feedings need to be held (see Section 8)

Rationale

An incomplete order, missing data, required transcription

step, or inadequate verbal communication between prescrib-

ers and those ultimately implementing the EN order increases

the risk for errors that can adversely affect patient care. The

use of technology can assist with the provision of safe EN

therapy. The development of standardized EN order forms

can facilitate consistent prescription of complete EN orders

without the need for interpretation or transcription. As EN

prescribers adopt the use of standardized orders, the process

of standardized independent double-checks with stepwise

checklists becomes easier as orders are prescribed and com-

municated to other staff in a consistent manner. To have an

effective process, 2 clinicians must independently review the

EN order prior to preparation and labeling. The use of inde-

pendent double-checks should not be overused as to cause

fatigue for healthcare providers, but they should assist with

addressing potential breakdowns found in the EN process.

Independent double-checks must be used in conjunction

with other safety measures, and education should be pro-

vided to reiterate the importance of independent double-

checks to healthcare staff.

Multidisciplinary teams can assist with the facilitation of

open communication between members of the healthcare dis-

ciplines. Teamwork between disciplines can also improve rela-

tionships between departments within the healthcare system,

and this communication can lead disciplines to better under-

stand the demand on other disciplines. This open communica-

tion can improve the EN process by increasing team members’

knowledge and facilitate learning about problems. The rela-

tionships built with the use of multidisciplinary teams can also

ease the communication between providers when clarifying or

optimizing an EN regimen. Communication between teams

can also lead to identification of a problem, finding the root

cause of the problem, and development of a team-based multi-

disciplinary action plan.

Evidence-based EN protocols/algorithms developed by

nutrition support professionals serve as a guide for safe, stan-

dardized EN practice and communication. Their use has been

shown to minimize the use of inappropriate EN, increase EN

days, increase the percentage of prescribed calories delivered,

and reduce hospital stays and mortality. In order for protocols/

algorithms to be used in practice, ongoing and rigorous educa-

tion and monitoring are needed.

Topics for Future Research

 Documentation of errors related to EN prescribing

 The impact of electronic EN orders on the accuracy,

monitoring, and safety of EN therapy

 The effect of standardized orders on adequate protein

and energy delivery

 Error rates related to incomplete, ambiguous, or

incorrect EN orders

 Error rates associated with use of standardized EN

orders vs error rates with the use of telephone, verbal, or

handwritten EN orders

 Outcomes research regarding how the frequency of

monitoring of EN orders affects the achievement of

patient safety and nutrition goals

 The impact of education programs and annual

competency assessment on errors related to EN ordering

and patient safety measures

 The use of a standardized EN home transition order

form in the continuity of care for patients discharged

home with EN

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Section 3. Review of the Enteral Nutrition

Order

Background

A dedicated review of the EN order by a nutrition support pro-

fessional ensures that the order contains all the critical elements

for a complete EN order and that it meets the specific patient’s

energy, protein, micronutrient, and fluid needs. This review is

conducted independently from the EN recommendation and the

EN prescription. Safety issues in the EN order review can

involve the correct patient identification; the appropriateness of

the prescribed EN formula for the patient; dosing, administra-

tion, and monitoring instructions; free water flushes; the EAD;

concurrent medications and potential drug-nutrient interactions;

the EN infusion site; and the effect of EN on the patient’s elec-

trolyte, acid-base, and fluid balances. Healthcare organizations

must have policies and procedures that address the EN review

process for nutrition support professionals and determine how

interventions will be communicated to the primary team.

Question 3.1. What are the best mechanisms and

practices for independent EN order review for safe

and optimal EN preparation and delivery?

Practice Recommendations

1. Develop and implement policies and procedures

at the healthcare organizational level that address

the independent review of the EN order by a

knowledgeable healthcare provider and the documen-

tation of the review process for safety and clinical

audits.

2. Prescribe EN using standardized electronic order

templates (ie, CPOE system) that transmit the complete

EN order.

a. In the absence of a CPOE system with standardized

templates, prescribe EN with a standardized order

template that is maintained as an editable

electronic document with each patient-specific

order saved as a pdf in the EHR, and implement

best practices to avoid transcription errors from

handwritten or telephone orders.

b. Enter EN order data in a standardized format,

and transmit any supplemental orders in standard

units. Include order instructions that are clear to

those reviewing or administering EN.

c. Make nutrition assessment and nutrition

recommendations available in the EHR.

3. Include the EN order in the patient’s electronic

medication profile to allow a pharmacist to review the

EN order and patient medication profile. The

pharmacist will assess:

a. The appropriateness of the medication route of

administration

b. The compatibility of medication with enteral

formulas

c. Methods to optimize the medication regimen

4. Evaluate the following elements as part of the

clinician’s independent review of the EN order:

a. Patient allergies

b. Proper dosing weight

c. Current clinical status and nutrition needs

d. Indication for therapy

e. Appropriate energy, protein, micronutrient, and

fluid delivery

5. Develop clear policies and procedures for the

healthcare organization to address the clarification of

EN orders if any of the following occur:

a. Order elements are missing.

b. Clinical dosing does not meet recommendations.

c. Administration is inconsistent with guidelines or

may be associated with incompatibilities.

6. Document any order clarification or change to the EN

order within the facilities’ EHR or, in the absence of

32 Journal of Parenteral and Enteral Nutrition 41(1)

EHR, document any clarification to the EN order in the

permanent record.

7. Do not use abbreviations, symbols, or dose designations

that appear on The Joint Commission’s Official “Do

Not Use List” or on the Institute for Safe Medication

Practices list of Error-Prone Abbreviations, Symbols,

and Dose Designations.

8. Review the EN prescription independently whenever

there are transitions in patient care (eg, admission to a

facility, discharge from a facility, or any change in the

level of care within a facility).

9. Develop criteria at the healthcare organization level to

annually evaluate the competency of nutrition support

clinicians and pharmacists to review EN orders and to

assess associated patient laboratories, medications, and

clinical monitoring.

Rationale

The standardization of the EN order process can increase

compliance with independent double-checks and improve

patient safety at all points of the healthcare model.

Use of

CPOE systems along with clinical decision support software

can facilitate the review of each element critical to a complete

EN order. Ideally, a nutrition support clinician or other

knowledgeable healthcare provider (“reviewer”) will review

EN orders in an environment with minimal distractions,

appropriate lighting, and access to electronic patient and EN

formula information. For optimal review, the electronic EN

order will contain the critical elements required for a com-

plete order (eg, patient identifiers, EN formula, free water

flushes, delivery site and EAD, and administration method

and rate) as well as any supplementary orders that meet insti-

tution-specific needs related to the safe prescription of EN

and the adequate delivery of protein, calories, and fluid. If the

reviewer concludes that a critical element is omitted or a ther-

apeutic intervention would be beneficial, this reviewer must

communicate with the prescriber to reconcile missing ele-

ments or recommend clinical interventions. Any communica-

tion with the EN prescriber should be electronically

documented in the EHR.

When a patient on EN requires medications, it is advisable

to consult a pharmacist to determine whether a medication can

be safely prepared and administered via the EAD. The pharma-

cist can also review medication profiles for medications that

could cause adverse effects when administered via either a gas-

tric or small bowel EAD. Schier et al

reported a case of a

38-year-old woman who received crushed extended-release

antihypertensive medications via a nasogastric tube. The

instant release of medication that was intended to release over

a 24-hour period led to the patient’s death secondary to brady-

cardia and severe hypotension. This case shows how important

the review process can be to ensure proper administration of

medication via enteral feeding tube.

The inclusion of the EN order in the electronic medication

profile and the medication administration record (MAR)

enables the pharmacist to review the EN order along with med-

ications to be administered to the patient. When CPOE systems

are appropriately configured, prescribers enter orders for medi-

cations that specify the specific administration method (eg,

nasogastric feeding tube, orogastric feeding tube, small bowel

feeding tube, gastrostomy tube, jejunostomy tube, or desig-

nated port of gastrojejunostomy tube). The pharmacist can then

review the record to assess the compatibility of any medica-

tions that are to be concomitantly administered with EN and

determine the most optimal formulation of the medication to

be administered through the EAD. The pharmacist will indi-

cate whether EN is to be held for a period of time before or

after medication administration (see Section 8).

Handwritten orders can increase the risk of transcription

errors or incomplete EN orders. Bobb and colleagues

reviewed

prescribing errors within a 700-bed academic medical center,

and they used their findings to assist with CPOE implementa-

tion in their institution. Out of a total of 17,808 inpatient and

emergency department orders that were processed during the

week of the study, 1111 orders (6.2%) contained a prescribing

error. The most common error types identified were wrong

dose, wrong nomenclature, and wrong frequency. This group

determined that CPOE systems can improve practitioner pre-

scribing habits, and that the use of CPOE systems with clinical

decision support software in conjunction with clinical staff

involvement can mitigate most prescribing errors. The use of

detailed standardized electronic order sets can limit the number

of possible transcription errors and can promote safety by

eliminating the option to choose incorrect elements of the EN

order (eg, if jejunostomy feeding is selected, only continuous

administration options would be available for selection).

4,5

The Institute for Safe Medication Practices List of Error-

Prone Abbreviations, Symbols, and Dose Designations and The

Joint Commission’s “Do Not Use” list are important consider-

ations for healthcare organizations building electronic EN order

forms. The Joint Commission’s “Do Not Use” list currently

does not apply to EHRs including CPOE systems. However,

healthcare organizations will want to eliminate the use of these

abbreviations, symbols, or dose designations from their EHR

software so that they do not appear in standardized EN orders.

6,7

Independent reviews and procedures to double-check EN

orders require time and resources. If these requirements seem

disruptive or burdensome to practitioners, the risk of noncom-

pliance can increase. Organizations will need to allow resources

to fulfill this critical step in the EN process.

As the patient’s level of care changes, proper reconciliation

and communication of the EN order is vital to patient safety

and continuity of nutrition care. The World Health Organization

reports that up to 46% of errors occur when new orders are

written at patient admission or discharge.

As patients transi-

tion to different levels of care, the risk of errors related to the

EN order grows. For example, if transfer orders need to be

Boullata et al 33

printed and reconciled before a change in therapy is made, the

patient may not receive the new therapy promptly after the

transition in level of care.

Question 3.2. What are the critical elements of the EN

order that need to be transmitted to optimize a

complete review?

Practice Recommendations

1. Prescribe EN using a standardized electronic EN order

template (ie, CPOE system). In the absence of a CPOE

system, prescribe EN with a standardized order

template (can use an editable electronic document)

format (eg, using an Excel spreadsheet, with each

unique order saved as a pdf).

2. A complete EN order contains all of the following

critical elements:

a. Patient information: Include the following patient

identifiers: patient name, date of birth/age, and

medical record number.

b. Describe EN primarily via descriptive generic

names (eg, “standard,” “high protein”) to

minimize confusion for prescribers. The product

trade name could also be included along with the

organizationally defined generic term.

c. Delivery site (route) and access device

i. Identify the delivery site by the enteral

feeding tube tip position (gastric or small

bowel).

ii. Identify the specific EAD (nasogastric

feeding tube, orogastric feeding tube, small

bowel feeding tube, gastrostomy tube,

jejunostomy tube, designated port of

gastrojejunostomy tube).

d. Administration method and rate

i. Document the method of administration

(continuous, bolus, intermittent feedings).

ii. Clearly define the volume and/or rate of EN

administration for each method of

administration.

iii. Include any suggested methods to advance

the volume and/or rate toward goal.

iv. Guidelines for volume based feeding if

applicable.

v. Address the advancement of EN to

established goal along with transitions from

PN to EN, EN to diet, or hospital to home/

alternative care sites.

vi. Document instructions for water flushes,

including the solution to be used (eg, purified

water), volume, frequency, and timing, as

well as the volume to be administered in

24-hour period.

3. Use supplementary orders to assist with the care of the

EN patient and help ensure patient safety.

Supplementary orders can include:

a. Confirmation of tube position

b. Evaluation of skin

c. Assessment of tolerance

d. Specific laboratory monitoring

e. Recommendations for modular products

f. Instructions for EN preparation, including

directions for reconstitution of powder (if

indicated), shaking contents of can/container,

wiping off can with alcohol prep

g. Nutrition support consult

h. Head of bed elevation

i. Oral care/decontamination

j. GRV checks

4. If EN orders are modified, reordered, or ordered upon

hospital discharge/transfer, verify that all elements of

the EN order are completed and independently

reviewed by a nutrition support professional.

Rationale

A complete EN order will maintain patient safety while ensur-

ing adequate EN formula delivery and proper EN administra-

tion. The EN order should contain the following critical

elements: (1) patient identifiers, (2) EN formula type, (3)

delivery site and access device with identification of correct

port for infusion, and (4) administration method, EN infusion

rate or volume of EN to be infused at stated intervals, and vol-

ume of water flushes at stated intervals. The EN order should

be transmitted for review via CPOE or by an electronic edit-

able document if CPOE is not available at a healthcare institu-

tion. These electronic orders can assist with the appropriate

prescription of EN by decreasing improper EN prescription

and eliminating order transcription.

Patient information. Patient identifiers, including the patient’s

name, date of birth, and medical record number (MRN), help

ensure that the right patient receives the correct EN order. The

use of standardized electronic EN orders could eliminate the

possibility of the wrong patient receiving the EN order by

requiring the use of adequate multiple patient identifers.

EN formula name. The EN formula can be clearly identified in

the electronic order by a descriptive generic name and/or trade

name that is identified on the can, container, or package. For

example, an EN formula that contains nonhydrolyzed macronu-

trients that is intended for those with normal digestive function

can be generically identified as “standard.” An EN formula that

contains hydrolyzed macronutrients, which could be used for

those with malabsorptive disorders, can be generically identi-

fied as “peptide based” or “elemental.” An EN formula that

contains a higher percentage of calories from fat along with a

34 Journal of Parenteral and Enteral Nutrition 41(1)

higher fiber content to assist with glycemic control can be

generically identified as “carbohydrate controlled.”

EN delivery site, route, and access device. The EN delivery

site with correct route (gastric or small bowel) and EAD is a

critical element of the EN order. The proper identification of

delivery site and device can decrease the possibility of enteral

feeding tube misconnections. Route of administration identi-

fies gastric or small bowel tube feedings, whereas enteral

access identifies short-term devices, including nasogastric or

orogastric feeding tubes (NGT, OGT), or percutaneous devices,

including gastrostomy (G), jejunostomy (J), or gastrojejunos-

tomy (G/J) tubes. The identification of site for EN administra-

tion and medication administration can decrease the possibility

of EN administration via the wrong access when more than 1

port or access device is present.

Administration method and rate. The EN order includes the

proper method of administration and EN infusion rate. The

administration method identifies whether EN is to be adminis-

tered via pump, gravity, or bolus methods. The infusion sched-

ule lists the infusion times and initial rate or volume to be

infused per feeding. It should also include an advancement

rate/volume along with the total volume to be infused within a

24-hour period. The infusion schedule also identifies the vol-

ume and frequency for water flushes, which may change as

the EN infusion and volume change in the absence of IV flu-

ids. The EN schedule identifies whether EN is administered

via a continuous drip, intermittent drip, cyclic drip, or bolus

delivery.

Organizations can implement standardized electronic order

sets that prevent prescribers from ordering improper adminis-

tration methods for specific EADs. For example, electronic

orders for jejunostomy feedings could only allow prescribers

to order continuous feeding administration. The specificity of

choices in essential and supplementary orders can make the

EN order review process more efficient.

Supplementary orders. Supplementary orders can be devel-

oped according to each institution’s identified needs and

patient population. They can be used to assist with the advance-

ment of EN, as well as transitions from PN to EN, EN to oral

diet, or one facility to another facility/home. The care of enter-

ally fed patients is also appropriately addressed in supplemen-

tary orders. For example, HOB elevation, enteral feeding tube

care, GRV checks, and monitoring and laboratory parameters

are to be addressed by supplementary orders.

Prescribers of EN refer to available information about EN

formulas when they order EN. The use of electronic order

sets can help prescribers determine whether a base EN for-

mula will provide adequate macronutrient content for a

24-hour period or if a supplementary prescription of modular

macronutrients can help meet the patient’s needs. Patients

with fluid tolerance limits (eg, pediatric patients; patients

with renal failure or heart failure) may need augmentation of

base EN formulas with a modular macronutrient to increase

calories without additional fluid. Populations with high pro-

tein needs may need additional protein modulars, whereas

those who require protein restriction may benefit from carbo-

hydrate or fat modulars. Institutions can decide whether to

provide micronutrient, electrolyte, and water content of EN

formulas to prescribers via information boxes within the

CPOE system. The inclusion of micronutrient and electrolyte

data in the ordering system can help prescribers select EN

products for patients who have electrolyte imbalances or con-

ditions where micronutrients are either not eliminated prop-

erly or are depleted with high-volume fluid losses.

Question 3.3. What steps can be taken to evaluate EN

access, administration timing, fluid requirements,

and other critical elements related to the enterally

fed patient?

Practice Recommendations

1. Develop and institute policies and procedures at the

healthcare organizational level that define the roles and

responsibilities of each individual involved in the EN

therapy process.

2. Support a multidisciplinary committee that reviews the

healthcare organization’s policies and procedures and

analyzes errors related to the EN therapy process.

a. Develop protocols for EAD assessment and care.

b. Develop protocols regarding EN hang time and

proper labeling of the beyond use date and time

for EN formulas.

c. Develop surveillance programs to monitor and

review cases of EN formula contamination.

d. Develop protocols for proper administration of

medications through an EAD, as well as

appropriate water flushes and EAD declogging

procedures.

3. Optimize the EN prescription, administration, and

order review process with methods, technology, and

procedures that improve patient safety and decrease

opportunities for lapses in clinician adherence to

institutional policies.

4. Standardize the EN process at the healthcare

organizational level to assist with the consistent

delivery of patient care.

5. Develop EHR systems that can address the nutrition

support clinician’s concerns related to an institution’s

patient-specific population.

6. Institute policies and procedures regarding the

documentation of the assessment of EN patients and

independent double-check processes.

7. Develop protocols that incorporate checklists for each

individual in the EN therapy process.

Boullata et al 35

Rationale

The proper evaluation of the enterally fed patient can optimize

patient safety while monitoring the provision of energy, pro-

tein, fluid, and medications. Patients receiving EN may have

electrolyte abnormalities, acid-base disorders, and fluid imbal-

ances that can be potentiated with administration of calories.

Patient monitoring of the patient’s metabolic status, feeding

tolerance, and EAD placement are all essential in the delivery

of EN. When monitoring also includes surveillance of high-

risk steps within the EN process, healthcare organizations can

improve the EN process as a whole.

Enteral access device placement and maintenance. The pri-

mary healthcare team should choose an EAD after evaluating

current anatomy, clinical status, and estimated course of ther-

apy. After the EAD is selected and its initial placement is con-

firmed via radiograph, the EAD placement must be continually

reassessed. Patient movement, coughing, suctioning, emesis,

or movement of the tube within the tube securement tape/

device can cause the distal tip of a feeding tube to migrate dis-

tal or proximal to the intended site. A malpositioned EAD

could lead to gagging/emesis of EN formula aspiration and

sepsis. A malpositioned long-term EAD can lead to site leak-

age, blockage of the pylorus, and buried bumper syndrome. To

confirm that the position of the EAD has not changed, the doc-

umented EAD length of the numerical marking at the exit site

of the tube is assessed every 4 hours or before being accessed.

Continue to confirm proper placement by comparing docu-

mented length or the numerical marking at the exit site of the

EAD every 4 hours or prior to being accessed. If patient assess-

ment leads a clinician to think that the EAD has migrated or is

malpositioned, confirm the EAD placement by radiograph in

adults

(see Section 4 for EAD placement).

Healthcare organizations also need protocols that address

the care and maintenance of EAD sites. One protocol can out-

line the procedure for notifying the medical team if the patient

has new or increasing pain, excess leakage, redness, swelling,

induration, or bleeding from the enteral feeding tube site. Some

incisional pain is expected after an initial percutaneous EAD

insertion, but it should lessen over time. Protocols can also

address the notification of the medical team if the patient has

pain, nausea, feelings of fullness, or emesis during EN infu-

sions as these signs could indicate a malpositioned EAD.

Clinicians must follow institutional guidelines regarding dress-

ing changes and wound care. In 2010, the National Patient

Safety Agency reported the case of a patient who underwent

percutaneous endoscopic gastrostomy (PEG) placement and

had postprocedure pain and leakage from the gastrostomy site.

This patient was discharged and then readmitted 4 days later

with internal leakage. The patient died 3 weeks later secondary

to sepsis from the PEG site.

This case reinforces that EAD

site maintenance is important to patient care and appropriate

observation can decrease the risk of adverse events.

Question 3.4. What systems need to be in place to make

order clarifications and interventions to improve the

safety and delivery of EN?

Practice Recommendations

1. Create policies and procedures that address the proper

methods for order clarifications and clinical

interventions for EN orders.

2. Document each order clarification or clinical

intervention within the patient’s EHR.

3. Conduct regular systematic reviews of all documented

order clarifications and clinical interventions with a

multidisciplinary team and create action plans to

address any shortcomings identified within the EN

process.

4. Independently review each EN order by a clinician

whose competencies are assessed by the healthcare

organization.

Rationale

The continual systematic review of oversight in the EN process

helps identify gaps in the EN process. Many organizations

review incident/event reporting and near misses, but problems

can be substantially underreported if employees fear repercus-

sions from error reporting. Healthcare organizations that create

a culture of transparency allow employees to report errors

without fear of repercussions.

Healthcare organizations need cost-efficient methods to

identify and review medical errors. Meyer-Massetti and col-

leagues

performed a systematic review of 28 studies to assess

the accuracy, efficiency, and efficacy of 4 medication safety

assessment methods: incident report review, direct observa-

tion, chart review, and trigger tool. They found that each

method of identifying drug safety–related problems has dis-

tinctive advantages and disadvantages and the various methods

identify different types of safety issues. Therefore, they recom-

mend that healthcare organizations select the methods that best

fit the context and the nature of the suspected problems.

Accurate documentation of clinical interventions can pro-

vide objective data to justify clinical staffing and evaluate clini-

cal staff performance. This documentation can also demonstrate

that clinical staff takes accountability for patient care and avoids

unnecessary costs. However, the interpretation of the quality of

clinical interventions can be limited when quality improvement

measures are lacking. Rector and colleagues

described the

implementation of an education project to improve documenta-

tion of clinical interventions by pharmacists. They found that a

pharmacist education initiative led to increased clinical inter-

vention documentation with increased documentation of costs

avoided. This initiative led the quality improvement project to

stratify clinical intervention by their appropriateness and rein-

force a new culture for pharmacy trainers.

36 Journal of Parenteral and Enteral Nutrition 41(1)

Optimization of the independent double-check process

ensures that practitioners think critically while conducting

checks as designed. However, independent double-checks can

be overused in the healthcare industry, and the improper use of

such checks can lead to safety concerns, especially if checks

are inconsistent or if clinicians become noncompliant.

Standardization of the independent double-check process using

checklists can reduce inconsistencies in the process, and a

review of the process can help identify reasons for noncompli-

ance or other problems. When coupled with other error reduc-

tion strategies, the use of properly implemented double-check

processes can prevent errors from reaching patients.

Topics for Future Research

 The effect of EN ordering via CPOE or editable

electronic document on EN-related error rates

 Comparison of errors associated with the use of

standardized EN order sets vs errors related to the

transcription of handwritten orders

 The patient safety impact of pharmacists reviewing the

EN order with a patient’s medication profile to identify

medication interventions

 Documentation of EN errors related to transitions in

level of care

 Documentation of errors related to the misconnection

of EADs

 The error-related consequences of standardizing the EN

order process

 The use of systematic reviews to identify gaps in the

EN process

References

1. Institute for Safe Medication Practices. Independent double checks:

undervalued and misused. ISMP Medication Safety Alert! June 12, 2013.

https://www.ismp.org/newsletters/acutecare/showarticle.aspx?id=51.

Accessed August 8, 2015.

2. Schier JG, Howland MA, Hoffman RS, Nelson LS. Fatality from admin-

istration of labetalol and crushed extended-release nifedipine. Ann

Phamacother. 2003;37:1420-1423.

3. Bobb A, Gleason K, Husch M, et al. The epidemiology of prescribing

errors: the potential impact of computerized prescriber order entry. Arch

Intern Med. 2001;164(7):785-792.

4. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recom-

mendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

5. Institute for Safe Medication Practices. 1,000-Fold overdoses can occur,

particularly in neonates, by transposing mcg and mg. ISMP Medication

Safety Alert! September 6, 2007. https://www.ismp.org/newsletters/

acutecare/articles/20070906.asp. Accessed August 8, 2015.

6. Institute for Safe Medication Practices. ISMP’s List of Error-Prone

Abbreviations, Symbols, and Dose Designations. 2013. https://www.

ismp.org/tools/errorproneabbreviations.pdf. Accessed August 10, 2015.

7. The Joint Commission. Official “Do Not Use” List. March 2009. http://www.

jointcommission.org/assets/1/18/dnu_list.pdf. Accessed August 10, 2015.

8. WHO Collaborating Centre for Patient Safety Solutions. Assuring medi-

cation accuracy at transitions in care. Patient Safety Solutions. May 2007.

http://www.who.int/patientsafety/solutions/patientsafety/PS-Solution6.

pdf. Accessed August 8, 2015.

9. Institute for Safe Medication Practices. Oops, sorry, wrong patient! A

patient verification process is needed everywhere, not just at the bedside.

ISMP Medication Safety Alert! March 10, 2011. https://www.ismp.org/

newsletters/acutecare/articles/20110310.asp. Accessed November 20,

2015.

10. Simons SR, Abdallah LM. Bedside assessment of enteral tube placement:

aligning practice with evidence. Am J Nurs. 2012;112(2):40-46.

11. Malhi H, Thompson R. PEG tubes: dealing with complications. Nursing

Times. 2014;110(45):18-21.

12. Meyer-Massetti C, Cheng CM, Schwapach DL, et al. Systematic review

of medication safety assessment methods. Am J Health Syst Pharm.

2011;68(3):227-240.

13. Rector KB, Veverka A, Evans SK. Improving pharmacist documentation

of clinical interventions through focused education. Am J Health Syst

Pharm. 2014;71(15):1303-1310.

Section 4. Enteral Access

Background

The selection of the EAD can greatly affect the success of EN.

The optimal device and location (gastric vs small bowel) must

be determined as placement of any enteral access device

entails associated risks. If patients with an EAD are trans-

ferred to a facility without complete documentation, the

receiving facility, whether acute care, long-term care, or home

care agency, will need to confirm the type and placement of

that feeding tube prior to initiating EN. The practice recom-

mendations in this section help guide that facility or agency to

confirm the EAD type and placement prior to starting feedings

and avoid feeding through an EAD that may no longer be at

the appropriate distal site.

Complications following EAD placement can include

misplacement, which is when the tip of the EAD is placed in

an anatomical position not intended for the proper adminis-

tration of EN. EAD displacement is when the device tip

later migrates or is inadvertently moved to an anatomic posi-

tion not intended for the proper position of the device. Proper

EAD placement and maintenance help prevent aspiration of

EN, dumping syndrome, and other adverse outcomes.

Although risk of complications cannot be completely elimi-

nated, minimizing placement errors reduces the complica-

tion rate and improves patient outcomes.

Question 4.1. What are the critical components to

consider when selecting an EAD for a patient?

Practice Recommendations

1. Select an EAD based on patient-specific factors (eg, GI

anatomy, GI function, expected duration of EN).

2. Place a short-term nasoenteric or oroenteric EAD in

patients who require EN for up to approximately 4–6

weeks in duration.

3. Place a long-term EAD in patients who require EN for

longer than 4–6 weeks.

Boullata et al 37

Rationale

The selection of an EAD requires an evaluation of the patient’s

disease state, GI anatomy (taking into account past surgeries),

gastric and intestinal motility and function, and the estimated

length of therapy. The healthcare team decides whether to

place the distal tip of the EAD in the stomach or in the small

bowel. In general, gastric access is appropriate for patients

with a functional stomach free of delayed gastric emptying,

obstruction, or fistula. Small bowel feedings are most appro-

priate for patients with gastric outlet obstruction, severe gas-

troparesis, and in those with known reflux and aspiration of

gastric contents. Patients who need simultaneous gastric

decompression with small bowel feedings can be best accom-

modated by a dual-lumen gastrojejunal EAD.

EADs inserted via nasal and oral routes. EADs inserted via

the nasal and oral routes are usually intended for short-term use

(no more than 4–6 weeks) in the hospitalized patient. However,

there may be situations when use of a nasogastric access in the

outpatient setting is appropriate. Some patients, particularly

pediatric patients in the home, are able to self-place a nasogas-

tric tube as part of their own care.

EADs for long-term access. The decision concerning place-

ment of EADs for long-term EN depends on the estimated

length of therapy, the long-term goals, the patient’s disposi-

tion, and the special needs of the patient and caregivers. The

use of gastrostomy tubes (balloon and nonballoon tubes) has

become routine practice worldwide and is currently the

method of choice for medium-term and long-term enteral

feeding.

Two studies of adult patients with persistent dyspha-

gia due to neurological disease randomly assigned patients to

feedings via NG or PEG tube placement.

2,3

These studies

found that the patients with PEG tubes had gained more

weight and missed fewer feedings. The patients fed by NG

tube received significantly less because of tube difficulties

compared with the PEG patients, who had no such difficul-

ties.

2,3

One of the studies allowed patients with an NG tube to

cross over to a PEG tube if they had repeated tube difficulties

(usually displacement), and, consequently, only 1 of 19

patients had an NG tube in place for 4 weeks.

At the end of

the study, the last patient with an NG tube opted for a PEG

tube, stating that the NG tube was cosmetically unacceptable.

Concerns for pediatric patients. In the pediatric literature,

commonly accepted criteria for EN intervention depend on the

clinical condition of the patient.

4–6

EN support is considered

after other aggressive oral interventions have been tried. Pedi-

atric patients who meet the criteria for EN include:

 Children with insufficient oral intake, particularly

children older than 1 year who are unable to meet

60%–80% of individual requirements for 5 days and

children younger than 1 year who are unable to meet

60%–80% of individual requirements for 3 days

 Children who meet the criteria for failure to thrive,

wasting, and stunting

EN is also appropriate in a disabled child whose total feeding

time is more than 4–6 hours per day. EN can also be an option

when diet modification is used as a treatment of a disease (eg,

Crohn’s disease), food intolerance, and metabolic disorders.

Specific indications for feeding tubes in pediatric patients

include cystic fibrosis, neurological impairment, oral/head

and neck tumors, chronic liver disease, trauma, and extensive

burns.

Contraindications to EAD placement. The choice of EAD

needs to take into account contraindications to the placement

of the device. These can be divided into systemic and mechani-

cal reasons and may be relative or absolute. Systemic contrain-

dications are those where the overall condition of the patient

precludes feeding tube placement. Mechanical ones are those

where specific local conditions such as hepatomegaly or previ-

ous abdominal surgery preclude safe placement of the EAD. In

some cases, the condition may be corrected. Absolute contrain-

dications include mechanical obstruction of the GI tract (unless

the procedure is indicated solely for decompression), active

peritonitis, uncorrectable coagulopathy, or bowel ischemia.

Traumatic injuries to the head, face, and neck region as well as

recent transphenoidal surgery may preclude a nasally placed

EAD. A number of other conditions represent relative contrain-

dications to enteral access, such as recent GI bleeding, hemo-

dynamic instability, ascites, respiratory compromise, and

certain anatomic alterations.

Question 4.2. What steps are recommended to confirm

placement of a preexisting EAD prior to initiating EN?

Practice Recommendations

1. Develop a policy at the healthcare organizational level

to confirm the EAD type and placement prior to EN

initiation.

2. Assess the patient and caregiver knowledge about the

tube, such as agency or facility where the tube was

placed, insertion date, where the patient was transferred

from, and what type of tube and previous care and

feeding orders were provided to the patient or caregiver.

3. Communicate with staff from the transferring

institution, facility, or agency to obtain as much

information as possible on the EAD type, tip position,

and need for ongoing replacement and documentation.

4. Confirm type of EAD and tube placement via the

accepted methods of tube verification (see Section 4,

question 4 for methods used in adult patient and

question 5 on pediatric patients).

38 Journal of Parenteral and Enteral Nutrition 41(1)

5. Document the confirmation process and findings in the

patient’s health record.

6. Encourage transferring agencies to communicate the

full information about EAD type, insertion date, and

placement upon transfer.

Rationale

Adequate and timely transfer of information between care set-

tings during transitions in care is imperative for the safe care of

patients.

A percutaneously positioned tube in a GI tract that

has not fully matured may be displaced prior to or during trans-

fer, particularly if the tube is inadequately secured. If the dis-

placement is not identified, this complication may lead to

intraperitoneal administration of EN. Incomplete or incorrect

communication of the EN tube type and placement during

patient transfer may delay the administration of adequate and

appropriate nutrition. Poor communication during transitions

of care may also lead to hospital readmissions and emergency

department visits that may have been preventable.

The EAD type, placement, and requirements for ongoing

replacement need to be communicated in the available medi-

cal record and clinical information. Clear descriptions in

plain language without ambiguous abbreviations will mini-

mize misinterpretation and error. Ideally, this documentation

is provided by the transferring agency to the new facility

prior to discharge,

10,11

and the enteral prescription and regi-

men are transferred to the accepting care team via standard

electronic information systems that are accessible to all

healthcare providers and suppliers associated with the

patient.

Use of these systems may improve communication;

however, they may not be universally available or accessible.

If this information must be communicated by telephone, the

nutrition support provider at the new facility should repeat it

back to ensure that it is received and interpreted correctly.

Feeding tube information, such as brand, type, tube tip posi-

tion, need for ongoing replacement, French size, and length

(if applicable), is also verified at this time.

Question 4.3. What steps can be taken to enhance the

safety of bedside nasoenteric tube placement?

Practice Recommendations

1. Develop organizational policies to outline who is qualified

to place a nasoenteric tube, under what circumstances,

and with what supervision or competencies.

2. Assess patients prior to tube placement for potential

contraindications, identification of high-risk patients

for misplacement, or if bedside placement is medically

appropriate.

3. Actively assess patient tolerance during tube placement.

4. Educate and assess competencies for all clinicians

involved in tube placement.

Rationale

Addressing safety measures designed to enhance the safety of

bedside blind insertion of feeding tubes before and during

tube insertion is critical as this this is where the most serious,

potentially life-threatening adverse events occur.

13,14

This is

especially needed when considering that numerous disci-

plines, with varying degrees of training, commonly place

these tubes today. The importance of training and competency

assessment of all clinicians involved in tube insertion should

be clearly delineated.

13–16

Patient assessment prior to tube insertion is essential to

preventing placement-related injury. This could include iden-

tification of patients at high risk for pulmonary misplace-

ment; recognizing contraindications to nasal passage of tubes,

including recent history of transphenoidal surgery or basilar

skull fracture (ethmoid, sphenoid, or occipital bones); evalu-

ation of bleeding risk, including coagulation values and safe

limit cutoffs; recent bleeding from esophageal varices; time

since banding; and so on. The presence of anatomical factors

that can lead to perforation should also be part of the assess-

ment: hiatal hernia or Zenker’s diverticulum and previous

bariatric surgery. Not all patients are candidates for bedside

insertion, and fluoroscopic or endoscopic placement may

provide a safer choice for tube placement.

Alternate bedside methods of placement are available

and include electromagnetic placement device (EMPD), use

of carbon dioxide (CO

) sensing, and direct visualization

using a tube with a camera. These techniques are described

below.

13–16

Development of institutional policies and proce-

dures for placement and ongoing competency assessment is

crucial. One institution temporarily stopped placement of

tubes by untrained personnel until a quality improvement

program could be put into place.

It is important to docu-

ment the size and manufacturer/model of the tube once it is

placed. The diameter plays an important role in types of for-

mula and medications that can be infused, and internal

diameter can change depending on the device material and

model.

Question 4.4. What is the best way to confirm accurate

EAD placement in ADULT PATIENTS?

Practice Recommendations

1. Obtain radiographic confirmation for any blindly

placed short-term EAD to demonstrate that it is

properly positioned in the GI tract prior to its initial

use for administering feedings and medications in

adult patients.

2. When attempting to insert a short-term feeding tube,

obtain a tube aspirate for appearance and pH

measurement. The appearance and pH are likely

dependent on location.

Boullata et al 39

3. Do not rely on the auscultatory method alone to

differentiate between gastric and respiratory placement

or between gastric and small bowel placement.

4. Mark the exit site of a feeding tube at the time of the

initial placement and document either the incremental

marking on the tube or the external length of the tube

in the medical record.

5. Evaluate whether the incremental marking or external

tube length changes, and, if a change is observed, use

other bedside tests such as visualization and pH testing

of tube aspirate to help determine if the tube has

become dislocated. If in doubt, obtain a radiograph to

determine tube location.

6. For long-term feeding tubes, document tube type, tip

location, and external markings in the medical record

and in follow-up examinations.

7. Avoid use of catheters or tubes not intended for use as

EADs, such as urinary or GI drainage tubes, which

usually are without an external anchoring device. Use

of such tubes may lead to enteral misconnection as

well as tube inward migration, which can potentially

cause obstruction of the gastric pylorus or small bowel.

8. Avoid administration of feedings, fluids, or medications

through the EAD until correct position has been

confirmed.

Rationale

The patency and placement of an EAD should be confirmed

before using it for feeding or medication administration. Proper

radiographic imaging is recommended to confirm the position

of any blindly placed enteral feeding tube. Healthcare profes-

sionals cannot rely on auscultatory methods to differentiate

between gastric and bronchopulmonary tube placement

because auscultatory methods cannot distinguish tubes improp-

erly placed in the lung or coiled in the esophagus from properly

positioned tubes.

Nasal or oral insertion of a short-term EAD is often per-

formed at the bedside. Nasojejunal tubes may be placed blindly

or with the assistance of endoscopy, fluoroscopy, electromag-

netic, carbon dioxide sensing (capnography), or direct camera

visualization devices. Studies have demonstrated that errors in

blindly placed NG tubes are not uncommon.

14,18–20

Sorokin and

Gottlieb

reported a 1.3%–2.4% incidence of misplacement of

a tube in 2000 NG tube insertions into adults. Of the misplaced

devices, 28% resulted in pulmonary complications, with 2 of

these misplacements culminating in death.

Confirmation that the newly inserted EAD is correctly posi-

tioned is mandatory before feedings or medications are admin-

istered. A variety of bedside tests to determine tube placement

are used with varying degrees of accuracy. Usually bedside

detection methods serve as precursors to radiographic confir-

mation, as they may serve to decrease the number of radio-

graphs needed to a single one.

For a blindly inserted EAD, the

gold standard for confirming correct placement is a properly

obtained and interpreted radiograph that visualizes the entire

course of the tube.

14,21–23

Confirmation is usually provided through imaging, which

can add significant cost and time to EAD placement. Recent

adjuncts have been developed, including the use of carbon

dioxide or pH sensors to confirm intubation of the stomach

rather than the pulmonary tree.

Sensitivity and specificity of

those 2 methods have been reported in one trial as high as 86%

and 99%, respectively.

Newer technology provides the clini-

cian with multiple options in confirming tube location prior to

the initiation of enteral feeding. A multicenter study compared

the use of an electromagnetic placement device (EMPD) for

placement and tube tip confirmation to standard x-ray. Of the

194 patients in this study, only 1 had data showing discrepan-

cies between the original EMPD verification and the final

abdominal radiograph interpretation, providing a 99.5% agree-

ment.

Other recent studies and a literature review demon-

strated similar conclusions,

27,28

while 2 more recent papers

point out the potential risk of eliminating x-ray confirmation

with inexperienced operators.

29,30

A more recent innovation is a disposable feeding tube with

an integrated real-time imaging system to visually aid in the

placement of small-bore feeding tubes. This technology

method features a 3-mm camera integrated within a small-bore

feeding tube to allow clinicians to identify anatomical markers

during the placement of a tube.

Although observing for respiratory symptoms is warranted

during EAD insertion, malpositioning may occur without any

apparent symptoms.

32,33

The appearance and pH of aspirates

from a feeding tube may provide clues to an EAD location but

has not been shown to be reliable as a single marker for tube tip

location. Fluid withdrawn from a tube that has perforated into

the pleural space typically has a pale yellow serous appearance

and a pH of 7 or higher, whereas fasting gastric fluid typically

is clear and colorless or grassy green or brown with a pH of 5

or less.

34–38

Several studies demonstrating the use of pH testing

indicate a pH of 5.5 from tube aspirate is adequate to check

the position of the tube in the stomach.

The auscultatory method of tube tip confirmation is unreli-

able.

17,39

Multiple case reports clearly indicate that clinicians

cannot differentiate between respiratory and gastric placement

by the auscultatory method.

32,40,41

Several studies have indi-

cated that capnography can be helpful in determining when a

tube has taken the wrong course into the trachea during the

insertion process.

42,43

However, it is important to point out that

this method cannot distinguish between EAD placement in the

esophagus and the stomach. Thus, even though capnography

may indicate nonbronchotracheal placement of a newly

inserted tube, a radiograph is still required to ensure proper

placement in the stomach.

A tube is malpositioned if it is located in the stomach of a

patient receiving small bowel feedings. One study found that

experienced nurses could not distinguish between gastric and

40 Journal of Parenteral and Enteral Nutrition 41(1)

small bowel placement by the auscultatory method.

higher level of accurate placement has been reported when

clinicians observe the appearance and pH of the feeding tube

aspirate.

Small bowel aspirates are typically bile stained,

while fasting gastric fluid is typically clear and colorless or

green or brown.

Gastric fluid usually has a lower pH than

that of small bowel secretions. For example, Griffith et al

found that most gastric pH readings were 5, with or without

the use of gastric acid suppression therapy.

It should be

noted that when gastric pH is 6, the pH method is of no

benefit in predicting tube location in the GI tract (or in ruling

out tracheopulmonary placement).

After feedings have been started, it is necessary to check

that the tube remains in the desired location (either the stomach

or small bowel). Securing tube with a bridle may be helpful for

preventing accidental dislocation (see below for more detail on

securement). Unfortunately, a small bowel tube may dislocate

upward into the stomach or a gastric tube may migrate down-

ward into the small bowel; a worse scenario is when a tube’s

tip dislocates upward into the esophagus.

Obviously, an x-ray

cannot be obtained several times a day to confirm tube loca-

tion; thus, clinicians rely on a variety of bedside methods for

this purpose. Use of the above-mentioned bedside placement

technology (electromagnetic, direct visualization, pH measure-

ment, or CO

sensing) can help clinicians to verify tube tip

position. A sharp increase in gastric residual volume may indi-

cate displacement of a small bowel tube into the stomach.

47,48

For long-term EADs, incorrect feeding technique and compli-

cations in tube replacement and removal can result from failure

to recognize the type of tube inserted (gastric vs small bowel),

the insertion technique, and the location of the distal catheter

tip. Follow-up of a long-term percutaneous EAD is indicated to

ensure that the enteral retention device is properly approxi-

mated to the abdominal wall, there is no tube migration, and

excessive tension to the exterior portion of the tube is avoided,

as well as to assess the condition of the surrounding skin.

Question 4.5. What is the best way to confirm accurate

EAD placement and evaluate risk versus benefit of

radiation exposure especially in PEDIATRIC/

NEONATAL patients?

Practice Recommendations

1. Use accurate measurement of enteral tube insertion

length, gastric pH testing, and visual observation of

gastric aspirate as acceptable nonradiologic methods

for assessing tube placement when radiographic

verification is not available.

2. Obtain an abdominal radiograph when other

nonradiographic methods for validation of tube

location are not confirmatory.

3. Avoid using auscultation alone as verification for

nasogastric feeding tube placement.

Rationale

Although placement of a nasogastric tube is a common pro-

cedure, it is not without risk of significant harm or death.

Great care must be taken when placing tubes and confirming

their correct placement. In 2012, the Child Health Patient

Safety Organization issued a safety alert to recommend

immediate discontinuation of the auscultation method for the

assessment and verification of NG tube placement.

A study

cited in the alert reported that 1.3%–2.4% of NG tubes in

more than 2000 insertions were located outside the GI tract.

Moreover, more than 20% of the misplaced NG tubes led to

pulmonary complications.

14,49

This alert acknowledges an

abdominal radiograph as the current gold standard when

other nonradiographic methods for validation of tube loca-

tion are not confirmatory.

When abdominal radiography is not readily available or

advisable, the Child Health Patient Safety Organization safety

alert identifies accurate measurement of EAD insertion length,

gastric pH testing, and visual observation of gastric aspirate are

acceptable nonradiologic methods for assessing tube place-

ment listed in the alert.

In addition, the alert specifies chil-

dren who are considered at high risk for misplaced or dislodged

gastric enteral tubes: neonates, children with neurological

impairment, children in an obtunded neurological state, and

children who are encephalopathic, have a decreased gag reflex,

or are sedated or critically ill. For these children, the alert rec-

ommends abdominal radiography as the best practice for veri-

fying location of a gastric enteral tube.

In addition to the above-mentioned alert, the American

Association of Critical-Care Nurses issued a practice alert

and the American Society for Parenteral and Enteral Nutrition

(ASPEN) published practice recommendations

to address the

risks and potential complications associated with misplaced

NG tubes.

50,51

Placement of a gastric EAD potentially poses

risks to patient safety, and device dislodgement poses similar

risks.

In a retrospective study of children, Ellett et al

demon-

strated by radiographic documentation a prevalence of 21% for

misplaced or dislodged NG, orogastric, and transpyloric tubes.

In a follow-up prospective study, Ellett and Beckstrand

used

abdominal radiography to evaluate device placement and

reported a prevalence between 22% and 44% in NG tube place-

ment error in children in their institution, a rate that exceeds the

range found in adult studies. Although alternative methods

exist, abdominal radiographic imaging is the “gold standard”

for verifying NG tube placement.

18,51,54–56

However, even with

radiographs, there may be variation in the interpretation of

device location. This variation is due to a lack of consensus on

identification of specific anatomical landmarks used to verify

the NG tube position within the gastric lumen.

In addition,

the lack of a relevant clinical history explaining the need for a

radiograph along with omission of a specific request for device

and device tip location in the radiology requisition can

Boullata et al 41

influence the radiology report.

56,57

Despite these limitations,

radiographic determination is the standard by which all other

methods of verifying NG tube location are measured. An

abdominal or chest radiograph that includes an abdominal

view is considered the most reliable method to document the

course of the tube and its tip location at the time the radiograph

is obtained.

Although the radiation exposure associated with a single

abdominal radiograph may be low, repeated exposures for mul-

tiple placement verifications may, over time, result in high

cumulative radiation doses. Both cohort and case-control stud-

ies have associated increased radiation doses with various types

of cancer, including childhood leukemia.

58,59

Moreover, obtain-

ing abdominal radiographs for home care patients and those in

ambulatory and long-term care centers is not practical.

The patency and placement of an EAD must be confirmed

before any new EAD is accessed for feeding or medication

administration. Healthcare professionals cannot solely rely on

auscultatory methods to differentiate between gastric and bron-

chopulmonary tube placement because these methods cannot

differentiate between properly placed tubes and tubes improp-

erly placed in the lung or coiled in the esophagus.

In pediat-

rics, 2 methods are suggested for tube confirmation. X-ray

confirmation is only valid for that moment in time, as an infant

or child can dislodge the tube quickly. Due to the many times a

pediatric or neonatal tube may be inserted, it may not be rea-

sonable to have x-ray confirmation of each tube placement. In

these situations, when ongoing x-rays are not possible, 2 meth-

ods of tube verification, such as tube length measurement and

pH testing, are recommended.

Question 4.6. What are the safe and effective methods to

secure EADs to prevent their displacement?

Practice Recommendations

1. Provide practical education on EAD securement to

clinical staff and assess clinical competencies on a

regular basis.

2. Securement of enterally placed feeding tubes and

prevention of dislodgement are the responsibility of all

clinical staff.

3. Routinely assess patients with EADs to check tube

securement in addition to appropriate tube position.

Early detection of displacement reduces the risk of

adverse events.

4. Consider bridling of nasally placed feeding tubes,

which may help reduce displacement of tubes at risk

for displacement. Understand, however, that there are

insufficient data to recommend this technique on a

routine basis.

5. Include routine assessment in patient monitoring for

signs of tissue pressure, patient discomfort, and

inadequate securement.

a. Pressure on internal tissue related to technique has

not been adequately explored and means to reduce

pressure as well as monitoring for adverse effects

on internal as well as external tissue should be

routine.

6. Use trained staff to periodically assess the appropriate

fit of percutaneous EAD external bolsters and skin

integrity in order to help prevent tissue damage,

leakage, and other issues.

7. Avoid maintaining a bridle for longer than 4 weeks.

Rationale

Nasal tubes. Once the nasally inserted tube has been safely

placed and tip location verified, the challenge is to keep the

tube in place. Nasal feeding tubes are frequently dislodged in

hospitalized patients. In a study of 49 intensive care units by

Mion et al,

22.1 episodes of tube dislodgement occurred per

1000 patient days, for a rate of 28.9% for nasogastric tubes.

Not surprisingly, EAD removal has been associated in several

studies with patient agitation, disorientation, and restlessness;

nosocomial infection; and a score of 9 or less on the Glasgow

Coma Scale, as well as medication use.

61,62

Aspiration is among the risks associated with dislodgment

of nasal feeding tubes. The potential for aspiration may be

greatest in patients whose tubes become only partially dis-

placed so that feeding is infused into the pharynx or upper

esophagus, especially if the displacement remains undetected

for a period of time.

Nasal tubes are sometimes taped to the nose, with a type of

wrap around the tube using adhesive tape, partially split ban-

dage, or other material, which then may be pinned to a patient

gown or clothing. The tube typically hangs from the nose,

where it could be a patient distraction, and gown misplace-

ment or change can tug on the tube secured to it. When a nasal

tube is taped to the nose, the taping must be done in a manner

to prevent pressure against surrounding tissue as pressure

sores may develop. Monitoring for pressure on related tissue

must be routine.

Another method of securing the nasal feeding tube uses a

semipermeable transparent dressing from the tube exit at the

naris and across the cheek, as is often noted in pictures of tube

securement for children. Taping the tube to the neck (pinching it

around the tube) provides additional securement in a stable area.

This method may work well for smaller flexible tubes, although

resecurement may be needed as facial hair grows. Skin cleansing

and an adherent agent such as tincture of benzoin may be helpful

in securing the dressing to oily skin. This method is more out of

sight and discreet for the patient than a tube secured to the nose.

If the patient has a visual deficit in one eye, placement of the

tube in the naris and securement on the affected side of the face

may reduce the patient’s temptation to pull at the tube.

Manufactured fixation devices are also sometimes used for

nasal tube securement. These devices may include adhesive

42 Journal of Parenteral and Enteral Nutrition 41(1)

strips or a clip for attachment of the feeding tube, which has

been shown to reduce nasal pressure ulcers. In a study of 205

patients, Ambutas et al

reported use of a commercial NG tube

holder was associated with fewer nasal pressure ulcers than use

of typical adhesive tape to secure 14 and 16 French sump

tubes. The results for in this study did not reach statistical sig-

nificance, but the findings were deemed to be clinically mean-

ingful, suggesting that the method of securement may impact

pressure on surrounding tissue.

Nasal tubes may be sutured to the naris in some situations to

reduce inadvertent displacement such as after head and neck

surgery; however, tubes can become displaced partially or com-

pletely through the sutures. The suture disrupts skin integrity,

which carries a risk of infection. Additionally, the patient may

experience discomfort at the suture site, especially if there is

tension on the tube, such as from being snagged or tugged on.

The nasal tube retention device, also known as a “bridle” or

“bridle loop” provides additional securement for patients at

high risk for nasal feeding and occasionally nasogastric suction

tube displacement. Various techniques and materials for bri-

dling tubes have been described. In general, small-bore tubing

or umbilical or twill-type tape wraps around the nasal septum

with each end exiting a naris and the feeding tube is secured to

the bridle tubing or twill tape. It is recommended that staff who

bridle tubes be trained in the technique, demonstrate compe-

tency, and maintain skill through frequency of use.

One method of bridling a feeding tube involves the use of a

manufactured device. This method uses a magnetic retrieval

system to facilitate bridle placement. Another method is con-

structed with materials and supplies available in many nursing

areas. This method involves retrieval of 5 French feeding tubes

that have been inserted through each naris from the oral cavity

and pulling one aspect back through a naris to create a loop

around the posterior aspect of the nasopharynx, which is then

secured to the feeding tube with skin securement strips and

secured to the side of the face.

Bridling is associated with low rates of morbidity and com-

plications, the most common being failure to prevent feeding

tube displacement. Even with the bridle in place, patients with

fine motor skills can catch a small loop of the feeding tube

between the naris and bridle and dislodge the tube. Patients

with gross motor skills might tug on the bridled tube, espe-

cially if they do not associate the discomfort they experience

with the tugging. When the small-bore feeding tube is used as

a bridle, it may break and release if it is tugged on firmly,

which may be viewed as a benefit in reducing or preventing

tissue trauma. It is advisable to evaluate the patient for internal

nasoseptal damage if any bridled tube is tugged on signifi-

cantly. Nasal ulceration is another potential complication if

securement is too tight. Ideally, the bridle material does not

cause pressure on internal and/or external tissue or make the

patient uncomfortable by being secured too tightly; however,

the bridle must be secure enough to prevent tube dislodgement.

To prevent undue pressure on the septum from the bridle loop,

the feeding tube might be secured to the patient’s face. Other

potential complications of bridling include sinusitis, bleeding,

patient discomfort, and septal erosion or trauma. In a study of

80 patients randomly assigned to nasal bridle or adhesive

device, bridled tubes were less likely to be dislodged than

unbridled tubes; however, 5 cases of mild epistaxis and 4 cases

of superficial nasal ulceration were associated with the bridle.

Two patients presented with retained system insertion stylets

as nasal foreign bodies.

It has been suggested that the use of

nasal bridles for greater than 4–8 weeks can result in nasal ero-

sion, although longer term use of the bridle has been reported

with no adverse effects.

In a study of burn patients, Parks and colleagues

reported

that 17 patients with bridled tubes had significantly fewer tube

insertions than the prebridle control group of 33 patients with

taped tubes. The investigators concluded that the use of a nasal

bridle to secure tubes in burn patients had clinical advantages

over traditional adhesive tape securement. A systematic review

by Brugnolli et al

of published and unpublished reports of

nasogastric tube securement in any language found 5 studies, 2

of which were randomized controlled trials. Four studies in

that review compared bridled tubes with unbridled (taped)

tubes and found a favorable advantage for bridled tubes. Three

studies in that review measured time until failure, with 2 com-

paring bridle vs tape methods and the other study comparing

types of tape. Of those 2 studies, one did not find a significant

difference between groups and one demonstrated a longer time

until securement failure in bridled tubes. Three studies com-

paring adverse events in bridled vs nonbridled tubes had con-

tradictory findings. The authors of these studies concluded that

despite the large number of patients receiving this intervention,

“there is insufficient evidence to suggest one securing tech-

nique over another” and “there is little or no statistically sig-

nificant evidence regarding bridling of nasogastric tubes but

more research is needed.” Patient discomfort was not measured

in the studies in this report.

A meta-analysis by Bechtold and

colleagues,

reviewing patients with nasal bridles, showed

similar results, finding limited data regarding secondary out-

comes such as pain, nasal septal erosion, and epistaxis. Proper

care and technique are suggested to avoid skin irritation, break-

down, and ulceration, and it is important to limit pressure and

remove the bridle once removal is clinically indicated. Bridling

for those at high risk for tube dislodgement may be an effective

strategy for access securement. Consideration of the benefits

of placement of a nasal bridle in the severely agitated patient

must be weighed against the potential for internal septal

trauma. As with any healthcare decision, the clinician and

patient/family must consider the safety, potential benefits, and

potential risks to bridling a nasally placed tube.

Contraindications to the use of the bridle include nasal

trauma or malformation, mechanical obstruction, craniofacial

or basilar skull fractures, and propensity for epistaxis by his-

tory or related to coagulation status. Removal of the bridled

tube is done by cutting one (and only one) aspect of the bridle.

Boullata et al 43

The bridle can then be pulled through the naris along with the

nasally placed tube. This information should be sent with a

patient who has a bridled feeding tube when he or she transfers

to another care facility.

Inability to maintain the nasoenteral route for feedings due

to dislodgement may precipitate a decision point in therapy to

answer the following questions. Will this patient continue on

enteral feeds? Is oral nutrition now possible and will oral intake

adequacy be obtained if EN is stopped? Or, have the goals of

therapy changed? If ongoing EN is still indicated, the place-

ment of a percutaneous EAD (ie, gastrostomy, jejunostomy,

gastrojejunostomy tube) may be necessary to maintain enteral

access. A percutaneous tube placement may be preferred in

patients who are expected to need EN for more than 4–6 weeks

and a more reliable feeding delivery system with a reduction of

tube dysfunctions. However, patients who have repeatedly dis-

lodged nasally placed tubes may also be at risk for dislodging

a percutaneously placed tube, which can have dire clinical con-

sequences, especially soon after placement and prior to tract

maturation. Therefore, a strategy to avoid tube displacement

must be included in the patient plan of care.

Percutaneous tubes. General categories of percutaneous

EAD include gastrostomy, jejunostomy, and gastrojejunos-

tomy tubes. Securement of these tubes is necessary to not

only prevent dislodgment but also to prevent internal migra-

tion related to peristalsis that can result in feeding intolerance

and in gastrostomy tubes; blockage can occur at the pylorus

by the internal fixation device (eg, balloon, rubber bumper or

pigtail loop). Percutaneous EADs typically have external bol-

sters (known as “bumpers” or “disks”) to prevent this inward

migration and are recommended for use as opposed to cathe-

ters not designed for enteral feeding, which may not have

external bolsters (such as urinary catheters). External bolsters

must fit appropriately to prevent both internal and external

pressure (such as buried bumper). Fit should allow for easy

rotation of the tube (gastrostomy tube only; jejunostomy and

gastrojejunal tubes should not be rotated) and permit cleaning

under the bolster (suturing of the bolster to the skin may pro-

hibit cleaning and contribute to irritation; other means to

reduce displacement may be preferable). A slim layer of light

breathable gauze can be inserted under the disc, if indicated.

An external disc that is too loose, permitting internal and

external movement of the tube (positioning), may let gastric

contents leak through the gastrostomy opening, which then

may lead to skin excoriation and other complications. Appro-

priate fit of gastric (and jejunal) tubes and the integrity of

surrounding tissue are key to successful tube usage as well as

patient comfort.

Gastrostomy tubes placed endoscopically typically have an

internal bolster as opposed to a balloon to keep them from

being pulled out. Some types of these tubes may be more chal-

lenging to remove, but other tubes are called “traction remov-

able,” meaning that clinicians can intentionally remove them

with moderate traction for replacement or discontinuation.

However, they can also be inadvertently removed by patients

as well. As a result, means of securement are as important for

these tubes as they are for other tubes. In a study of PEG tubes

placed by one surgeon during a 3-year period, Rosenberger and

colleagues

reported a 30-day mortality rate of 7.8%, a 7-day

early dislodgement rate of 4.1%, and a lifetime early accidental

dislodgement rate of 12.8% (72 of the 563 PEG tubes).

Internal balloons can secure gastrostomy or gastrojejunos-

tomy tubes that are placed using fluoroscopy or open or lapa-

roscopic surgical procedures. Tubes can potentially be pulled

out with the balloon intact; additionally, balloons may rupture

or slowly loose ability to hold fluid, resulting in tube loose-

ness and dislodgement. Michaud et al

evaluated 165 gastros-

tomy tubes for 84 children and reported that the mean

longevity of the balloon-type low-profile gastrostomy tube

was 5 months (range, 14 days to 14 months). In that study,

balloon failure was not correlated with underlying disease,

age of the patient, or the use of antisecretory drugs. Some

companies highlight the strength of the balloon, including

low-profile tubes. However, literature on outcomes of specific

internal fixation methods is sparse, and clinicians should fol-

low manufacturer’s guidelines for frequency of tube changes.

Another internal fixation method uses a pigtail-type catheter

where the internal end becomes looped when pulled on by an

external string. One brand of gastrostomy tube has a right

angle feature, which results in a lower profile and may have

the advantage of being more discreet.

Low-profile, skin-level, or button-type tubes are used fre-

quently, especially in children, although many adults also

appreciate these types of EAD. They are less bulky to pull on

(especially when not accessed by an adaptor for feeding), are

less visible under clothing, contain antireflux valves, and do

not require tape to secure them to the abdomen. However, they

may cost more than other standard gastrostomy tubes. Use of a

low-profile device requires periodic resizing in growing chil-

dren to prevent compression injuries of the gastric mucosa or

epidermis.

Accidental removal of gastrostomy tubes within 2–4 weeks

of placement before the tract has matured may result in perito-

nitis and even death if gastric content leaks into the perito-

neum.

72–74

Excessive traction on the tube in this period may also

cause peritonitis if the bolster gets pulled through the gastric/

jejunal wall.

Techniques such as gastropexy using temporary

sutures or T-fasteners to secure the stomach to the abdominal

wall until it affixes to the abdominal wall can help reduce

potential for leakage into the peritoneum and aid in easier and

safer tube replacement when needed.

76–79

These devices must

be monitored to be sure they are not causing pressure on the

skin.

Jejunostomy tubes might have low-volume (eg, 3–4 mL)

balloons to prevent tube displacement. However, balloons

can be dislodged in the tract. Fit of the bolster and care of

surrounding tissue are paramount to successful use of these

44 Journal of Parenteral and Enteral Nutrition 41(1)

tubes. To reduce pressure and tugging on the tube, it is impor-

tant to adequately secure the tube to the abdomen with an

appropriate tape (fixing tape around the tube, then to the skin)

or another method of securement. Some jejunal tubes have a

Dacron cuff that becomes embedded in the subcutaneous tis-

sue and can help prevent displacement and serve as success-

ful jejunal access for years. Secure these tubes low to the skin

to allow the cuff to embed (as opposed to padding under the

tube itself) and also to the abdomen, at least until the cuff is

well embedded.

Other tubes (eg, red rubber catheters) may not have an

internal means of fixation. If these tubes are not well secured,

external migration resulting in dislodgement can occur more

easily than with other types of tubes. In addition, if this type

of tube irritates and reddens patient skin, securing the tube to

the irritated skin may be difficult. External fixation devices

are not always necessary or fail-proof. If they are used, the

skin under them must be carefully monitored for moisture

retention, which can lead to microbial growth and tissue

breakdown.

Strategies to prevent tube dislodgement. Patients can cause

serious harm to themselves by removing tubes essential for

breathing or feeding. In the past, the use of medications or

physical restraints, including wrist restraints or mittens, was

suggested for high-risk patients. However, the use of physical

restraints may actually increase a state of delirium and/or agi-

tation and in turn contribute to tube removal by the patient.

The use of physical or chemical restraints is rightfully dis-

couraged in today’s healthcare environment. Alternative

methods of securing tubes are advisable whenever and wher-

ever their use is possible. Healthcare providers can also reduce

risk of dislodgement by talking to patients and orienting them

in a calm, person-centered manner, as people are generally

more cooperative when they are well informed.

Healthcare organizations may choose to employ staff to

prevent self-harm by patients without use of restraints. This

approach may be effective, but it is an added expense. Family

members who are visiting or caring for the patient are some-

times asked to monitor for patient safety. The range of effective

alternatives to restraints may expand as patient cognition

improves.

The acronym MARK can be used to guide steps for moni-

toring tube securement. M is for marking the tube at the exit

with an indelible marker to help identify displacement at a

glance. It is also important to record the external length at the

time of placement by using the number on the tube at the exit

site, which is often denoted in centimeters; this number can be

used to monitor for feeding tube migration. A is for anchoring

the tube (as previously discussed). R is for reassessment of the

tube placement. Frequent reassessment is advisable, especially

in patients at risk for displacement as well as during procedures

that increase risk of dislodgement, such as patient positioning

and transfers. K has 2 meanings. It stands for keeping pressure

off of skin or the septum, and it refers to the knowledge needed

to ensure safe practice in policy, procedure, and clinical prac-

tice (Lorraine Linford, personal communication).

Other recommendations for preventing displacement of

long-term tubes include using an abdominal binder for those

at risk for pulling at tubes, using a gastrostomy tube that has

an internal bolster that “cannot” be removed with traction

(requires endoscopic removal), and changing to a low-profile

tube.

Tubes can be hidden inside of a tucked-in shirt and

other creative strategies can be used to secure the tube and

keep it “out of sight and out of mind,” reducing patient focus

on the tube. If a tube securement device is used, the potential

exists for moisture to be trapped under the coverage area until

the device is replaced, which may be days, due to cost or pro-

tocol. Moisture retention can promote microbial growth and

potential skin breakdown. Therefore, careful assessment and

monitoring are recommended when tube securement devices

are used. Feedings can be scheduled so that the patient receives

needed feeding over shorter periods, such as gravity bolus

feeding for gastric tubes, when more staff are available for

monitoring, or jejunal delivery of feedings can be scheduled at

night or day to reduce periods when the tube is accessed.

Additionally, follow-up by trained personnel is key to pre-

venting tube displacement, other issues (such as buried bum-

per due to tightness of securement), and minimizing problems

if a tube should become displaced.

75,81

Key strategies to reduce or prevent tube displacement

include education of staff at inpatient and transfer facilities,

education of patients and their families, and monitoring of prac-

tice and performance improvement projects. To ensure safety

and efficacy while maintaining dignity and comfort for the

patient as possible, the clinician is advised to use researched as

well as innovative noninvasive methods to secure enteral tubes.

Question 4.7. How soon after placement of a long-term

percutaneous endoscopic gastrostomy (PEG) can

feedings begin?

Practice Recommendations

1. Use a PEG tube for feedings within several hours of

placement. Current literature supports 4 hours in

adults and children.

2. Educate providers on the appropriate timing of use of

the PEG tube postprocedure.

3. Review procedural documentation for time of PEG

insertion.

Rationale

Traditionally, tube feedings have been delayed after percuta-

neous placement of gastrostomy tubes to the next day and up

to 24 hours after the procedure. No consensus exists regarding

feeding initiation after placement. In 2011, a national survey

Boullata et al 45

of practicing gastroenterologists found variation in the timing

of feeding.

The response rate for the questionnaire was 28%

(n = 1474), and 41% of the respondents were aware of the cur-

rent literature on post-PEG feeding times. Those aware of the

current literature were more likely to initiate early feeding.

Eight percent of the respondents initiated feedings in general

ward patients within the first 3 hours, and 32.5% initiated

feedings 4–6 hours post-PEG in the same patient population.

Bechtold and colleagues

pooled the results of 6 randomized

controlled trials that compared early (range, 1–4 hours) vs

delayed feeding after PEG placement and found no statisti-

cally significant differences in complications or death in the

first 72 hours after PEG placement.

A meta-analysis of 5 randomized controlled trials compared

early feeding after PEG placement (3 hours) with delayed or

next-day feeding and found no significant differences in com-

plications, deaths in the first 72 hours, or number of significant

gastric residual volumes at day 1.

A retrospective study

examined the safety and outcomes of early feedings (4 hours)

during a 5-year period at a tertiary care center where the major-

ity of PEG procedures were performed on inpatients by gastro-

enterologists.

The mean time of feeding was 3.2 hours for the

early group (4 hours) vs the delayed (>4 hours) feedings for

either overall mortality within 30 days or overall complications

such as wound infection, melena, vomiting, leakage, stomati-

tis, and aspiration pneumonia.

Kim and associates

evalu-

ated the feasibility and safety of implementation of an early

tube use protocol compared with the institution’s policy on

4-hour post-PEG tube placement checks. The early tube use

protocol involves immediate tube assessment by the gastroen-

terology fellow after return of the patient’s preprocedure level

of consciousness (within 1 hour of procedure completion).

This study showed that an immediate-use protocol with a

prompt assessment following recovery from sedation seems

safe and effective. The difference in the rates of complication

between the 4-hour placement group and the immediate-use

group was not significant.

In pediatric patients, the earliest reported time of feeding ini-

tiation after PEG tube placement had been 6 hours. Corkins

et al

randomly assigned pediatric patients to use a PEG tube for

feedings at 3 hours and 6 hours after placement. The researchers

documented the change in abdominal girth from before the ini-

tial feeding to 1 hour after, any vomiting, and the gastric residual

volume before the next feeding. The initial feeding was limited

to Pedialyte (Abbott Nutrition, Columbus, OH) at a volume of

60 mL bolus feeding. The authors concluded that feedings after

PEG tube placement can be started as soon as 3 hours with no

increase in complications.

A recent prospective randomized

controlled study compared early (4th hour) and late (12th hour)

feeding after a PEG procedure in 69 children.

This study

showed that initiation of feedings at the 4th hour was safe and

well tolerated by patients and shortened the duration of the hos-

pital stay.

In a retrospective chart review of 70 pediatric

patients, the early initiation of feedings (6 hours post-PEG) also

led to a shortened length of hospital stay with no increase in

adverse events or reported pain.

Question 4.8. How often should you replace long-term

EADs?

Practice Recommendations

1. Develop institutional protocols for replacing

percutaneous EADs that reflect manufacturers’

guidelines:

a. Routine removal and replacement of a well-

maintained percutaneous EAD may not be

necessary.

b. Replace per manufacturer guidelines.

2. Consider tube replacement sooner than indicated in

manufacturer guidelines if any of the following are

identified:

a. Deterioration and dysfunction of the EAD

b. A ruptured internal balloon

c. Stomal tract disruption

d. Peristomal infection that persists despite

appropriate antimicrobial treatment

e. Skin excoriation

f. Nonhealing ulcer formation that will not heal

despite good wound care technique

g. Colocutaneous fistula or gastrocolic fistulas

3. Replace the percutaneous tube only after the stoma

tract has fully matured (30–90 days from initial

insertion) or per institutional protocols.

4. Consider routine replacement of the percutaneous tube

after the stoma tract has matured (>30 days from initial

insertion) or per institutional protocols.

Rationale

Eventually, tubes will require replacement. The most common

indications for replacement include tube deterioration over

time, inadvertent removal, device-related complications (leak-

ing, unrestorable tube patency), fistula disruption, peristomal

infection, skin excoriation, ulcer formation, colocutaneous or

gastrocolic fistulas, or the device is being changed to a low-

profile gastrostomy tube.

8,90,91

In patients with a PEG tube, most major complications have

been reported to occur within the first few days of initial tube

placement when the tube tract is not yet mature. The tract

begins to mature approximately 7–10 days after PEG place-

ment, and it takes a few weeks for fusion to take place between

the stomach and peritoneum. In malnourished or immunocom-

promised patients, this process can take longer.

Patients who

are discharged home with a newly inserted PEG tube must be

closely monitored to prevent inadvertent dislodgement. If the

gastrostomy tube dislodges in the first 7–10 days after inser-

tion, the inserting provider needs to be contacted as soon as

46 Journal of Parenteral and Enteral Nutrition 41(1)

possible for further intervention. A dislodged PEG tube can

become a medical emergency, as stomach contents are likely to

leak into the peritoneum. The tube should not be reinserted

blindly at this stage because it may be repositioned into the

peritoneum. Possible approaches to management include

immediate reinsertion under radiographic or endoscopic guid-

ance, laparotomy, or conservative management (cessation of

oral intake, nasogastric suction, and antibiotics) followed by

reinsertion in 7–10 days.

21,80

If displacement occurs after the

tract is mature (>30 days), prompt replacement with a percuta-

neously balloon gastrostomy tube is recommended.

DiBaise and associates

evaluated the rate of tract disrup-

tion in adults requiring long-term EN and found that tract dis-

ruption occurs infrequently during replacement of gastrostomy

tubes. Tract disruption seems to be an issue primarily during

the initial tube exchange using a skin-level device. The mini-

mum duration to wait before there is sufficient tract maturity to

allow for safe gastrostomy replacement remains unknown, and

the authors recommend waiting at least 2 or 3 months for safe

tube replacement.

Most gastrostomy tubes with internal bolsters (ie, PEG

tubes) use soft, deformable internal bolsters, allowing transcu-

taneous replacement to be performed without endoscopy. A

credentialled provider can remove the device from the skin by

traction. In this procedure, the bolster is extended linearly so

that it passes through the gastrocutaneous stomal tract. A new

percutaneous EAD is then inserted through the gastrocutane-

ous stoma. The new EAD may be either a balloon gastrostomy

tube that is followed by balloon inflation or a nonballoon bol-

ster that is stretched taut by using an obturator and then

released. With optimal care, most bolster-type gastrostomy

tubes may remain in place for up to 1–2 years.

Manufacturers

often do not recommend such a long duration because internal

bolsters can wear off and potentially obstruct the GI tract. In

accordance with the manufacturers’ recommendations, some

institutions routinely replace EADs at 6-month intervals,

before the deformability of the bolster decreases.

Preventive

maintenance of balloon gastrostomy tubes, which includes

elective change at a fixed time interval (such as every 3–6

months), is the standard of practice in some facilities because

of the potential for balloon failure.

Topics for Future Research

 Comparison of nonradiographic methods of confirming

tube position to abdominal x-ray

 Communication about EN during the transition of care

and confirmation of EAD placement and EN orders

after transition of care

 Obstacles and/or barriers in standardizing post-PEG

feeding practices

 Optimal timing for initiation of feeding for other types

of percutaneous gastrostomy tubes (eg, balloon G-tubes,

gastrojejunostomy tubes, and jejunostomy tubes)

 The frequency of malposition and peritonitis after PEG

and balloon gastrostomy tube replacement

 The optimal protocol for PEG and balloon tube

replacement

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Section 5. Procure, Select/Prepare, Label,

and Dispense EN

Background

With a wide variety of available EN products on the market,

each organization makes clinical and fiscal decisions to estab-

lish an EN formulary. Each EN product, including human

breast milk (HBM), procured and stocked within a facility,

needs to be uniquely recognized by clinicians involved in EN

therapy. Selection errors can occur when products have similar

names or product labels. Whether dispensed from a central

location or stocked on a patient care unit, EN products must be

labeled to identify the intended patient, date of feeding, and

duration of feeding. Some patients receive EN products that

require preparation from powdered form, which increases the

complexity and safety risk of EN use.

Question 5.1. How is a clinically appropriate and cost-

effective formulary developed, and which experts

should be involved in its development?

Question 5.2. How are EN product shortages and

substitutions managed?

Practice Recommendations

1. Establish a formulary of available EN formulas specific

to the needs of the institution’s patient population.

a. Base the size of the enteral formulary on the

specific needs of the facility, but limit the size to

avoid product duplication, decrease inventory

management, and lower costs.

b. Prioritize formulas that meet the estimated

nutrient needs of patients rather than the patient’s

diagnosis. Use evidence-based research to

evaluate the inclusion of specialty formulas on

the formulary.

Boullata et al 49

c. Consider whether competitive bidding, group

purchasing organizations, or the selection of all

products from the same manufacturer can be cost-

effective. If the facility participates in a corporate

buying group, optimize the contractual agreement

to allow for the purchase of a formula outside of

the formulary if it better meets patients’ nutrition

needs.

2. Develop a multidisciplinary formulary selection

committee of clinicians and administrators, including

dietitians, nurses, pharmacists, and physicians.

3. Generate a substitution list for each EN formula during

the development or restructuring of the EN formulary,

which can be implemented in the case of product

shortages.

4. Allow enough flexibility in the EN process to respond

to manufacturer revisions to their product lines, as well

as product shortages or outages.

Rationale

Over 200 different commercially prepared EN formulas are

available for neonatal, pediatric, and adult use. Beyond stan-

dard formulas, a myriad of specialty formulas are marketed

for specific disorders and disease states. As it is not practical

or cost-effective to provide all available formulas, healthcare

facilities create enteral formularies to control inventory and

cost. In one study published in 1989, more than 75% of the

hospitals had developed EN formularies. The documented

reasons were cost containment, decreased product duplica-

tion, staff education, and inventory management.

Another

method to control costs is participation in a group purchasing

organization. Group purchasing may allow healthcare facili-

ties to control costs while providing the best patient care.

Typically, an established commitment level is set for institu-

tional compliance and results in benefits for the purchase of

products and services at lower costs.

2,3

Organizations can

request a clause in the contract to allow for the purchase of a

noncompeting product without penalty if it better meets the

patients’ needs.

The multidisciplinary formulary selection committee will

represent the perspectives of dietitians, nurses, pharmacists,

physicians, and administrators. The committee evaluates the

institution’s patient population and its specific nutrition needs

to identify the enteral formula categories needed.

When

available formulas in each category are evaluated, formulas

that will meet the estimated nutrition needs of the patient are

usually preferred to those tailored to specific diagnoses.

Evidence-based research can inform the selection of products

and is especially helpful when considering specialty and dis-

ease-specific formulas.

Specialty formulas are considerably

more expensive than standard formulas, and research to sup-

port the increased cost may be lacking. Evidence-based guide-

lines from the American Society for Parenteral and Enteral

Nutrition and the Evidence Analysis Library from the

Academy of Nutrition and Dietetics can be utilized to identify

indications and appropriate use for disease-specific formulas.

Although shortages of enteral formulas have not been as

common as recent PN shortages, certain EN formulas may

sometimes be unavailable due to demand, manufacturing

issues, or disaster. By identifying which products have similar

nutrient profiles and indications, the formulary selection com-

mittee can develop a substitutions list to systematically iden-

tify appropriate alternative formulas to use if a shortage

occurs. This can then be implemented and communicated in a

timely manner when needed. The substitutions list can also be

used to select products for patients whose home formula is not

available on the institution’s current formulary.

Question 5.3. How should human breast milk (HBM) be

managed as an enteral formula?

Practice Recommendations

1. Use HBM for infant feeding whenever possible and

when there are no medical contraindications.

2. If maternal human milk is not available, use

pasteurized donor human milk for premature infants.

3. Donor milk should come from an accredited (Human

Milk Banking Association of North America

[HMBANA]) milk bank or commercial company that

uses HMBANA or more stringent guidelines. Do not

purchase HBM from individuals or through the Internet.

4. Develop at the healthcare organizational level policies

for the collection, receiving, storage, labeling, and

feeding of HBM. Storage recommendations are

described in Table 2.

5. The recommended length of time that milk can be

frozen at –20C (–4F) should be shortened to 3 months.

6. HBM should not be preheated for feeding to a

temperature greater than 40C (104F).

7. Use fortified HBM for premature infants.

8. Use sterile products to fortify HBM, whenever possible.

9. Fortify HBM in a milk lab under sterile conditions.

The optimal timing between human milk fortification

and feeding is not known.

10. Educate all mothers expressing HBM regarding

lactation science, as well as human milk collection

and storage, including cleaning of the breast pump.

Rationale

Human milk is the feeding of choice for infants.

Use of HBM

offers many benefits to mothers and infants, including prema-

ture infants.

8,9

However, the nutrient profile of unfortified

HBM is not adequate to support the growth of premature

infants; therefore, HBM for premature infants must be

fortified.

8–11

50 Journal of Parenteral and Enteral Nutrition 41(1)

Guidelines for use of HBM from mothers who abuse

drugs. The Academy of Breastfeeding Medicine and the

American Academy of Pediatrics have guidelines regarding

the use of HBM from mothers who admit to abusing drugs.

Milk from adequately nourished mothers who are HIV nega-

tive, who have had consistent prenatal care, and who are par-

ticipating in a treatment program can be used.

Use of donor human milk. If maternal HBM is unavailable,

the use of donor HBM is recommended for premature infants

by the American Academy of Pediatrics and the European

Society for Pediatric Gastroenterology, Hepatology, and

Nutrition.

7,13

Because the protein content of donor HBM

depends on the stage of lactation, various fortification strate-

gies may be needed to ensure the protein content of all donor

HBM is sufficient.

14,15

Organizations can acquire donor milk

from an accredited Human Milk Banking Association of

North America (HMBANA) human milk bank or a commer-

cial company that uses similar stringent donor selection and

HBM preparation guidelines. Buying HBM from the Internet

is not safe.

The U.S. Food and Drug Administration recom-

mends against feeding infants HBM acquired directly from

individuals or through the Internet.

Fortification of human milk. Powdered products can never

be completely sterile. Therefore, it is recommended that liquid

sterile products be used to fortify HBM whenever possible.

It is best to fortify HBM away from the bedside, in a sterile

milk lab. The optimal time between HBM fortification and

feeding is not known. It is suggested that this time be as short

as feasible to limit the breakdown of nutrients in HBM. Arti-

cles using prior renditions of the current human milk fortifiers

reported an increase in osmolarity over time.

18,19

Human milk storage and handling. The Academy of Nutri-

tion and Dietetics published recommendations for HBM stor-

age for hospitalized infants in 2011.

More recent literature

raises concerns about long-term freezing of unpasteurized

HBM at –20C (–4F).

The dornic activity is a measure of

the acidity of HBM and is used as an indirect method of

assessing milk quality and bacterial contamination.

Lipopro-

tein lipase maintains its activity at this temperature, and this

activity increases when HBM is frozen for more than 3

months, which is thought to result in a breakdown of triglyc-

erides to free fatty acids that could damage the intestinal epi-

thelial cells.

Slutzah and colleagues

have recommended that fresh

HBM can be refrigerated for up to 96 hours; however, their

study was not conducted in a real-time environment with

multiple entries of HBM into the same bottle. According to

the Academy of Nutrition and Dietetics recommendations,

refrigeration for 96 hours is acceptable with unit-dosed,

single-entry access.

In a unit with multiple entries, it

seems reasonable to be more conservative about refrigera-

tion storage times, limiting refrigerated storage to 72 hours.

In 2015, Bransburg-Zachary and colleagues

raised concern

about the heating of HBM for infant feeding. HMBANA advo-

cates for the warming of human milk for premature infants to

body temperature.

Term infants may have milk directly from

the refrigerator or at room or body temperature.

At tempera-

tures greater than 40C (104F), the nutritional and immuno-

logical properties of HBM begin to deteriorate. The amount of

time that HBM is kept warm is also important; at 38C

(100.4F), lipolysis is rapid with a 440% increase in free fatty

acids in an hour.

Published reports of infants becoming ill as a result of HBM

contamination are few; however, contamination can be a prob-

lem. HBM expressed using breast pumps has a higher rate of

contamination than HBM expressed by manual expression.

Educational intervention may decrease the prevalence of

contamination.

Question 5.4. What are the best ways to determine

clinical advantages/disadvantages of the closed EN

system?

Table 2. Recommendations for Human Breast Milk Storage for Hospitalized Infants.

Storage Method and Temperature Recommended Storage Time

Freezer (home combined with refrigerator) 3 months; new evidence would suggest shortening this time

Freezer (–20°C, –4°F) 6–12 months; new evidence would suggest reducing this to 3 months

Freezer (–70°C, –94°F) >12 months

Refrigerator (4°C, 40°F), fresh milk New evidence would suggest lengthening this from 48 to 72 hours unit

dosed, single entry 96 hours

Refrigerator (4°C, 40°F), thawed milk 24 hours

Refrigerator (4°C, 40°F), fortified milk 24 hours

Refrigerator (4°C, 40°F), thawed pasteurized donor milk 48 hours

Cooler with ice packs (15°C, 59°F) fresh milk 24 hours

Room temperature (25°C, 77°F) <4 hours

Adapted with permission from Lessen R, Sapsford A. Expressed human milk. In: Robbins ST, Meyers R. Infant Feedings: Guidelines for Preparation of

Human Milk and Formula in Health Care Facilities. Chicago, IL: American Dietetic Association; 2011:47.

Boullata et al 51

Practice Recommendations

1. Select an open or closed system for EN delivery based

on the following factors of each system and the needs

of the institution:

a. Cost: The use of a closed system can potentially

save money because it requires fewer nursing

resources and lowers the risk of infections due to

bacterial contamination.

b. Safety: If an open system is used, facilities must

be willing and able to implement protocols and

diligently monitor compliance with all EN product

handling and administration procedures, including

hand hygiene, proper handling of enteral feedings

and sets, and hang-time limits.

Rationale

Over the years, many healthcare institutions have transitioned

from open enteral systems (in tetra-packs, bottles, or cans) to

closed enteral systems (in bags or rigid containers) in efforts

to reduce infection from contaminated enteral formulas and

to reduce nursing time. Commercially available liquid EN

products are sterilized before distribution but can become

contaminated when used at the facility. Contamination of

enteral formulas can cause abdominal distension,

diar-

rhea,

29–31

and bacteremia following administration.

Several

studies have shown that the risk of contamination is greater

with open systems because these systems increase physical

handling of EN.

33–37

Closed systems can decrease manipula-

tion and human contact with enteral formulas and feeding

administration sets, which in turn reduces the risk of contami-

nation.

38–43

However, some studies have shown that open sys-

tems can be safely used when staff practice good hygiene and

comply with proper handling procedures.

44–46

Multiple stud-

ies have demonstrated that using a closed system reduces

nursing time.

46–48

Closed systems can be costly because of formula packag-

ing and waste from unused formula (closed system products

come in 1000-mL or 1500-mL containers, whereas open-sys-

tem products come in 237-mL or 250-mL containers). Closed

containers have an increased hang time of up to 48 hours

(compared to 4–8 hours with open systems); however, most

closed containers are discarded after 24 hours due to current

manufacturer recommendations to change enteral feeding

sets every 24 hours and to spike each closed container only

once.

Nevertheless, studies have found that using closed

systems with increased hang times reduces waste and

costs.

49,50

A 2013 cost-analysis study showed that a closed

system was more expensive than an open system when

accounting for waste ($4.80 per patient day compared to

$4.21 per patient day).

However, when nursing time was

factored into the costs, the expense of the open system

increased to $9.83 per patient day.

Pediatric Open Systems

Open systems will likely need to continue to be utilized in the

pediatric population because many products are only available

in powdered form. Powdered infant formulas are not sterile upon

manufacture. In 2004, an infant died as a result of a Cronobacter,

formerly called Enterobacter sakazakii, infection that was found

in the infant’s reconstituted powdered infant formula.

The

organism was also found in unopened cans of the formula.

Ready-to-feed and concentrated liquids are sterile products, but

not all formulas come in this form as noted above. Therefore, it

is recommended that powdered formula not be used for immune-

compromised infants, if other options are available.

Over time, infant formula manufacturers have converted

many products, such as human milk fortifiers, from powder to

liquid forms. However, certain products are only available in

powder, such as products for infants with inborn errors of

metabolism, infant and pediatric elemental formulas, and a

specialty infant renal formula. Some formulas only come as

ready-to-feed or powder products and are not supplied in con-

centrated liquid form. If the clinician wants to use these formu-

las at a higher calorie density, nonsterile powder is commonly

added to ready-to-feed formula, which increases the risk of

contamination.

HBM is the preferred nutrition for infants. If mother’s own

milk is not available, donor human milk may be used. Donor

milk is pasteurized, which diminishes the immunoprotective

nutrients. Compared to fresh or frozen HBM, proliferation of

bacterial pathogens in pasteurized HBM was 1.8–4.6 times.

In 2011, the Academy of Nutrition and Dietetics issued

guidelines for hang times for infant feedings,

and these strin-

gent guidelines are recommended for neonates and immuno-

compromised infants until there is sufficient further evidence.

In a prospective, descriptive study of 30 pediatric patients,

Lyman et al

found that “decanted enteral formula adminis-

tered continuously over 12 hours in a pediatric hospital setting

has a lower than expected rate of bacterial growth when recom-

mended handling practices are followed.” This evidence might

influence the Academy of Nutrition and Dietetics to revise the

hang-time guidelines to 12 hours for pediatrics; however, there

is no evidence at this time that guidelines for immunocompro-

mised or neonatal patients should be altered.

Question 5.5. What are the critical elements of the EN

order that need to be transmitted to ensure safe

product preparation?

Practice Recommendations

1. Develop and design standardized EN orders (CPOE or

editable electronic templates, or paper as a last resort)

for adult and pediatric EN regimens to aid prescribers

in meeting each patient’s nutrition needs and to

improve order clarity.

52 Journal of Parenteral and Enteral Nutrition 41(1)

2. Include all critical elements in the EN orders: (1)

patient identifiers, (2) the formula name, (3) the EAD

site/device, (4) the administration method and rate,

plus (5) water flush type, volume, and frequency.

Incorporate the feeding advancement order, transitional

orders, and implementation of complementary orders

into protocols. All elements of the EN order must be

completed when EN is modified or reordered.

3. Avoid the use of unapproved abbreviations or

inappropriate numerical expressions.

4. Encourage the use of generic terms to describe EN

formulas. All elements of the EN order must be

completed when EN is modified or reordered.

5. Provide clear instructions related to modular products,

including product dose, administration method, rate,

and frequency.

6. Establish and enforce policies and procedures that clearly

describe the preparation of powdered EN products,

including who will evaluate compatibility, measure the

dose, reconstitute the product, what diluent and source

will be used, the location of preparation, labeling

including beyond use date and time, and storage.

Rationale

Many problems associated with EN orders often result in

inadequate delivery of formula to patients in critical care set-

tings. These problems are attributed to underordering, fre-

quent cessation of the enteral infusion, and slow advancement

of the EN to goal rate.

54,55

EN protocols,

54,56–58

algorithms,

and clinical practice guidelines

have been developed to

standardize enteral feeding practice, and many have resulted

in an improvement in the delivery of enteral feedings to

patients. One group developed a protocol that standardized

ordering, nursing procedures, and rate advancement and also

limited interruptions to EN administration. Use of the proto-

col improved delivery of goal volumes, although there was

physician resistance to using a standard order.

A Canadian

group improved delivery of the required formula volume

using a protocol.

Woien and Bjork

reported on a feeding

algorithm that was developed to increase the likelihood of

meeting nutrition requirements in intensive care. The algo-

rithm also resulted in an increased utilization of EN (rather

than PN) and in the number of patients who met EN adminis-

tration goals. Another study described a stepwise process to

develop and implement a tailored action plan that could be

adopted in ICUs with differing characteristic and used to help

identify barriers to adequate provision of EN in critically ill

patients (eg, EN formula and feeding pump availability on

units, use of a protocol to reduce interruptions, an algorithm

for managing diarrhea) and help those facilities tailor inter-

ventions to improve nutrition practice.

Patient-specific EN orders should include all critical ele-

ments: (1) patient demographics, (2) the formula name, (3)

delivery site and access device, and (4) administration method

and rate, plus water flush type, volume, and frequency. Orders

can be provided as a single order representing a specific pre-

scription, or they can be part of a larger protocol that directs

advancement of EN from initiation to a goal rate or volume

that represents a nutritionally adequate end point. Specific

preparation or administration instructions can also be included

in these protocols. Such instructions are especially important

for safe use of modular products or reconstituted powdered

products to meet patient requirements. The inclusion of transi-

tional orders will direct weaning from EN, and ancillary orders

may address various patient care issues. Orders may be com-

municated through a CPOE system or via editable templates in

electronic format, with paper forms clearly being a last resort

or for when electronic systems are down.

Patient identifiers: The order should clearly state the

patient’s name, date of birth, location, and medical record

number (MRN).

Formula: The formula should be clearly identified in the

order by a generic name as well as by the specific product brand

depending on institutional policy. For example: A formula that

contains 1 calorie per mL can be generically identified as “iso-

tonic” or “standard”; formula that contains 2 calories per mL

can be generically identified as “calorie dense”; a partially

hydrolyzed formula can be generically identified as “semi-ele-

mental” or “peptide based.” Formula orders may also include

the administration of modular products used to enhance the pro-

tein, carbohydrate, fat, or fiber content of the enteral regimen.

In the adult population, these products are usually administered

directly to the patient via the EAD in prescribed amounts and

frequency with specific administration guidelines but are most

often not added to the enteral formula. In the neonatal and pedi-

atric population, fluid tolerance limits are a greater concern;

therefore, the base formula is often augmented with a modular

macronutrient as compatibility allows. When this type of

manipulation to infant formula is prescribed, the base formula,

the modular product, and the base and final concentration of

formula per 100 calories are all considered.

62,63

If this is done in

the home, it is important to teach the parents or caregivers the

proper method to prepare a formula with additives.

Delivery site/device: The route of delivery as well as the

access device for EN formula administration should be clearly

identified in the order to prevent wrong-site administration.

Enteral misconnections have been reported in the literature.

Identification of the infusion site (eg, jejunal port of gastrojeju-

nostomy tube) also decreases the chance of inadvertent use of

the wrong feeding port for enteral infusion.

Administration method and rate: Bolus, gravity, or continu-

ous method (rate based or volume based): volume or rate of

administration and timing of formula delivery within a speci-

fied period of time (24 hours or cyclic) should be clearly set

forth in an EN order.

Supplementary orders: Orders that differ from the standard

formula rate, route, and volume prescriptions. These can include:

Boullata et al 53

Advancement orders: These orders direct the progression of

an EN regimen from initiation through to an end point or goal

formula volume infused over a specified time period. Increases

in formula volume or rate of administration to achieve a goal

should be clearly written. Protocols should visibly illustrate

feeding adjustments when volume based feeds are utilized.

Advancement orders also need to be coordinated with decreases

in PN.

Transitional orders: The incremental decreases in formula

volume over a period of time to accommodate for an increase

in oral intake.

Ancillary orders: Routine or ancillary orders will depend

on both the population and setting. These orders are based

on institutional policies for care of the enterally fed patient,

such as orders for HOB elevation, tube occlusion treat-

ment, bowel management,

and monitoring laboratory

parameters.

EN orders contain all the elements that should be part of

an EN order plus suggestions for ancillary and transitional

orders. Many institutional settings already utilize CPOE

systems, and these systems should be designed with detailed

order sets that promote safety by using EHR drop-down

menus within each element of an EN order, including

required fields. Such menus may facilitate standardized

advancement of initial administrations to goal volumes, uni-

form enteral access device flushing volumes and methods,

and population-specific ancillary orders. Orders for moni-

toring, flushing, and transitioning from tube feeding can

also be included.

Question 5.6. What are the minimum requirements for

the safe preparation of EN formulas that need to be

decanted from small commercial containers or

reconstituted from dry powder?

Practice Recommendations

1. Use competent personnel trained to follow strict

aseptic technique for formula preparation.

2. Immediately refrigerate formulas reconstituted in

advance. Discard unused reconstituted and refrigerated

formulas within 24 hours of preparation.

3. Expose reconstituted formulas to room temperature for

no longer than 4 hours. Discard unused formula after

this time.

4. Use a sterile water source for formula reconstitution.

5. Use formula decanted from a screw cap instead of a

flip top.

Rationale

Between 0% and 57% of enteral formulas prepared in the hos-

pital and over 80% of those prepared in the home have been

found to be contaminated with bacteria.

39,67–69

EN preparation

may include the mixing, reconstitution, or dilution of modular

products and formula with sterile water, and/or pouring the

formula into an administration container. The sterility of the

commercially available liquid EN products, as well as that of

the sterile bags and administration sets, is disrupted by any

manipulation, which increases the risk for contamination.

Commercially available EN products manufactured in dry

powder form are not required to be sterile and may be con-

taminated by the end of the production process prior to reach-

ing the market. A study of powdered infant formulas across

several European countries revealed Enterobacter species

contamination in 53% of 141 samples.

Although these bacte-

ria were found in amounts within the accepted maximal limits,

the organism would be expected to multiply rapidly once

these products are reconstituted with water, especially if at

room temperature.

A more recent study of EN powder for-

mulas in the care of adults identified considerable contamina-

tion. Out of 28 samples of reconstituted powdered formulas,

27 (96%) had total viable bacterial counts greater than 10

colony-forming units (CFU)/g.

The CDC recommends that

if a powder EN product is selected to meet a patient’s needs,

trained personnel should prepare it following strict aseptic

technique.

Reconstituted formula exposed to room tempera-

ture for more than 4 hours should be discarded. In addition,

the reconstituted formula that is not immediately used must be

promptly refrigerated, and any formula that remains 24 hours

after preparation must be discarded. In the absence of a for-

mula preparation room, the pharmacy can support reconstitu-

tion of powdered formula in a laminar airflow environment.

The water supply may be a source of potential contamina-

tion if purified water is not used. All water supplied for feeding

preparation must at least meet federal standards for drinking

water and not contain contaminants. For reconstitution of pedi-

atric and neonatal formulas, the water needs to be sterile.

53,72

This should also be considered for reconstituting formulas

intended for adults. Weenk et al

compared various feeding

systems and found a sterile glass bottle containing enteral for-

mula to be associated with the lowest level of microbial growth

from touch contamination. They also found that decanted for-

mula poured from a container with a screw cap into a feeding

bag was associated with lower levels of microbial growth than

formula poured from a container with a flip top (similar to the

type of top found on a soda can).

Question 5.7. What are the safety issues when using

blenderized tube feedings and how can the risk of

complications be reduced?

Practice Recommendations

1. Prepare blenderized tube feedings (BTF) using safe

food-handling techniques, and store it at refrigerator

temperature immediately after preparation. Discard

any unused portion after 24 hours.

54 Journal of Parenteral and Enteral Nutrition 41(1)

2. Limit the hang time of blenderized tube feedings

(BTF) to 2 hours or less.

3. Give BTF only via a gastrostomy tube that is 14 Fr in

size or greater.

4. Do not use BTF in patients who do not have a proven

tolerance to bolus feeds, those who are medically

unstable, or those who lack a mature gastrostomy site

that is free of infection.

5. Involve a registered dietitian or nutrition support

clinician in the development of the BTF formula to

ensure adequate nutrient delivery.

6. Sanitize mechanical devices (eg, blenders) used to

prepare BTF after each use with an established protocol.

Rationale

An alternative to commercial enteral formulas, BTFs use foods

that are blended to a consistency that allows for ease of use

with a feeding tube.

BTFs can be provided exclusively or in

conjunction with a commercial formula. In addition, commer-

cially prepared, ready-to-use, real-food blenderized formulas

are available for those patients who do not want to make their

own homemade formulas.

There is limited research on the safety and efficacy of BTF

in home-fed patients. Several studies demonstrate some benefit

with this technique in, for example, postfundoplication

patients. However, more research is needed to demonstrate the

benefit in additional patient populations generally maintained

on partial or complete home nutrition support.

74,75

Home-prepared BTFs have a higher risk of cross-contami-

nation and potential for foodborne illness than commercial EN

products.

76–78

High risk of contamination was a major reason

why institutions moved away from using BTF in the hospital

setting when commercial enteral formulas became available. In

the home environment, care should be taken to prepare BTFs

using safe food-handling techniques to prevent cross-contami-

nation. Once prepared, the BTF should be immediately used or

immediately refrigerated at appropriate temperatures.

73,79

Access to adequate refrigeration, clean water, and electricity is

imperative before considering a change to BTF.

Given the

potential for infection associated with foodborne illness, use of

BTF may not be appropriate among medically unstable patients,

immunocompromised patients, or those without a mature feed-

ing tube site.

73,81

BTF should not be held at room temperature

for more than 2 hours due to concerns about food safety and

bacterial contamination; therefore, a bolus regimen instead of a

continuous infusion is recommended.

73,76

Patients with volume

limitations or known intolerance to bolus feeds are not good

candidates for BTFs. Refrigerated BTF formula that is not used

within 24 hours of formulation should be discarded.

There may be an increased risk of tube occlusion with BTFs

given their high viscosity. Therefore, BTFs are not recom-

mended for patients with a feeding tube smaller than 14 French

as smaller tubes are more likely to occlude.

A recent study was

conducted to determine the flow rate of BTFs through the new

enteral (ENFit) connector system compared to various other

available feeding tube components. In this study, ENFit and

Cath-tip syringes flow and pressure requirements were essen-

tially equivalent. If BTFs can go through the Cath-tip syringe,

they should also be able to go through the ENFit connector.

Another study by Mundi et al

observed a need for increased

force with the ENFit connector to administer blenderized for-

mulas compared to traditional connectors, but this study was

conducted with device prototypes and not with FDA-approved

products. Currently, the FDA and other independent labs are

conducting flow and pressure studies with a variety of tubes and

a variety of formulas, including blenderized diets.

Several studies have demonstrated that the macronutrient and

micronutrient content of BTFs is highly variable and the energy

content is often overestimated.

76,78,83–85

Registered dietitians

should be involved in development of the BTF composition to

ensure adequate nutrient delivery in the home environment and

help maintain consistency of the regimen to prevent

underfeeding.

74,76,86

Questions 5.8–5.10. Does a standardized approach to

labeling EN reduce errors and what are the critical

elements of the EN order that need to appear on the

patient-specific label? What elements on a commer-

cial container must be present to meet the critical

elements of the EN order/patient identification?

How does one best avoid errors associated with

sound-alike, look-alike product names and labels?

Practice Recommendations

1. Include all the critical elements of the EN order on the

EN label: patient identifiers, formula type, enteral

delivery site (route and access), administration method

and type, and volume and frequency of water flushes.

2. Standardize the labels for all EN formula containers,

bags, or syringes to include who prepared the formula,

date/time it was prepared, and date and time it was

started.

3. Express clearly and accurately on all EN labels in any

healthcare environment what the patient was ordered.

Given changes to administration rates/volumes,

consider patient-specific labels that state:

a. “Rate not to exceed ______”

b. “Volume not to exceed _______”

4. Include on the label of HBM stored in the hospital:

contents in container, infant’s name, infant’s medical

record number, date and time of milk expressed, maternal

medications, fortifiers added, and energy density.

5. State on the HBM label whether the milk is fresh or

frozen, date and time the milk was thawed, and the

appropriate expiration date. Bar codes, special colors,

or symbols may be used to further identify the HBM.

Boullata et al 55

6. Label commercial enteral containers “Not for IV Use”

to help decrease the risk for an enteral misconnection.

7. Carefully check commercial enteral container labeling

against the prescriber’s order. Be aware of sound-alike

or look-alike product names that may be mixed up on

the order or during selection of the product.

Rationale

In any healthcare environment, patient-specific, standardized

labels for EN express clearly and accurately what the patient is

receiving at any time. Having standardized components on a

label decreases potential confusion when a patient is trans-

ferred to a different unit within a facility or when a new staff

member takes over a patient’s care.

Clear labeling that the

container is “Not for IV Use” helps decrease the risk for an

enteral misconnection. Proper labeling also allows for a final

check of that enteral formula against the prescriber’s order.

Standardized labels can be affixed to all EN formula admin-

istration containers (bags, bottles, syringes used in syringe

pump). Each label lists the 4 critical elements of the EN order:

patient identifiers, formula type, enteral delivery site (route and

access), and administration method (see Table 3). It also identi-

fies the individuals responsible for preparing and hanging the

formula as well as the time and date the formula is prepared and

hung.

88,89

See Figures 5 through 8 for examples of labels, which

may also include nutrient information if the label is computer

generated. Care should be taken in developing a label that is

clear and concise and of a size that fits neatly on the container.

Special considerations regarding the labeling of HBM. Clear

and concise labeling of HBM is essential to prevent errors in the

delivery of HBM to the infant. The label of milk stored in the

hospital should include the following information: contents in

container (HBM), the infant’s name, the infant’s medical record

number, the date and time when milk was expressed, maternal

medications, fortifiers added to the HBM, and the energy den-

sity of the HBM.

Additionally, the label should state whether

the milk is fresh or frozen, date and time the milk was thawed,

and expiration date based on whether milk is fresh or frozen.

If the mother is separating fore and hind milk, this designation

should appear on the label. Unique identifiers may be used to

describe other factors such as colostrum, transitional, and

mature milk. Bar codes, special colors, or symbols may be used

to further identify the HBM. Hospitals may use computer-gen-

erated or, at last resort, handwritten labels (see Figures 7 and 8).

Topics for Future Research

 Efficacy of methods and objectives for developing EN

formularies

 Best practice for formulary decision-making process

 The cost-effectiveness of including specialty formulas

in formularies

 The optimal size of formularies

 The costs and benefits of participating in corporate-

buying organizations

 Safe storage and hang times for all categories of human

milk, including the concern for the dornic activity of

unpasteurized human milk during freezing

 The optimal feeding temperature for HBM for

premature infants to promote digestion without altering

the beneficial properties in human milk and the length

of time HBM can safely remain at this temperature

 The optimal time between preparation and feeding the

infant using the newer HBM fortifiers and modular

additives

Table 3. Components of the Formula Label.

Labeling of Enteral Formula Labeling of Incoming Human Breast Milk

 Patient’s name

 Medical record ID number

 Formula name and strength of formula, if diluted

 Date and time formula prepared

 Date and time formula hung

 Administration route

 Rate of administration expressed as mL/h over 24 hours if

continuous administration or “Rate not to exceed ______”

or “Volume not to exceed _______”

 Administration duration and rates are to be expressed on the

label if the EN is cycled or intermittent

 Initials of who prepared, hung, and checked the EN against

the order.

 Appropriate hang time (expiration date and time)

 Dosing weight if appropriate

 “Not for IV Use”

 Infant’s name

 Medical record ID number

 Dosing weight

 Date and time that milk expressed

 Medication or supplements being taken by the mother

 Specify whether milk is fresh or frozen

 Contents in syringe/container (expressed breast milk)

 If frozen, date and time milk thawed

 Expiration date (based on whether the milk was fresh or frozen)

 “Not for IV Use”

 Fortified human breast milk also includes:

{{

Name of fortifier

{{

Final concentration

{{

Date and time formula prepared

{{

Initials of who prepared, hung, and checked the EN against

the order

EN, enteral nutrition; ID, identification; IV intravenous.

Date-time formula prepared and date-time formula hung may be different, so note both.

56 Journal of Parenteral and Enteral Nutrition 41(1)

Figure 5. Standard enteral nutrition (EN) label template (adult patient). ID, identification; IV, intravenous. Adapted from Bankhead R,

Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

Figure 6. Standard enteral nutrition label template (neonatal or pediatric patient). ID, identification; IV, intravenous. Adapted from

Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.

Boullata et al 57

 Ideal fortification for mother’s and donor human milk

for the premature infant in and outside the hospital

 Methods to analyze and fortify human milk

 Best method of fortification for the infant who requires

surgery or the infant with short bowel syndrome

 The safety and cost-effectiveness of the closed system

on patient and nursing satisfaction

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Section 6. Administration: General

Background

The administration of EN therapy is a step in the process with

significant potential for error. Errors can stem from incom-

plete evaluation of a patient’s tolerance for enteral feeding

that increases the risk for aspiration or GI complications.

Enteral misconnections, poor positioning, pump misadven-

tures, and contamination can all lead to less than optimal

patient outcomes.

Question 6.1. What system-based measures can be

implemented to enhance the safety of EN administration?

Practice Recommendations

1. Develop policy and procedure documents for evidence-

based practices to standardize the approach to and the

administration of EN in all patient populations.

2. Maintain competency as defined within the

organization to maximize safety of the patient for all

caregivers involved in the administration of EN.

3. Develop and use enteral feeding and related protocols

with order sets and checklists to optimize nutrition

delivery and promote safe and effective practice, from

patient evaluation to pump programming.

4. Initiate and update protocols periodically based on

best evidence, including national guidelines and

recommendations to meet the needs of the specific

patient populations.

60 Journal of Parenteral and Enteral Nutrition 41(1)

5. Monitor performance of EN delivery and related care

and have in-place systems to enhance practice in

terms of efficacy and safety as indicated.

6. Encourage change champions, such as nutrition

support team members, to guide EN practice.

7. Include knowledgeable nurses in decision making for

selection and purchase of EN administration sets,

feeding pumps, and access devices.

8. Commit to adequately staffing patient care units on

which many patients receive EN with nurses having

documented competency in EN administration.

9. Support both the physical and cognitive efforts of

nurses and other caregivers involved in maintaining

safe practices around EN administration. For example:

a. CPOE for EN orders with the full order available

on the nursing medication administration record

b. Bar coding on EN containers and patient-specific

labels

c. Prompts for documentation of essential steps in

administration of EN as well as the care and

monitoring related to feeding tube and EN use

10. Develop and implement interdisciplinary quality

improvement programs, including systematic review

and analysis of administration-related EN errors, then

implement subsequent safeguards to address any

identified errors in the process.

Rationale

A transparent and collaborative approach using guidelines, pro-

tocols, and standardized practice based on best evidence

enhances patient care within the EN process. Guidelines are

published periodically to provide recommendations for practice

based on best available current evidence.

1–3

Although the prac-

tice of EN administration varies widely, protocols can standard-

ize and guide practice toward safety. The benefit of using

protocols to enhance clinical practice has been articulated.

4–8

Heyland et al

demonstrated that protocols can significantly

improve nutrition practices. Racco

discussed development of

a protocol to help overcome barriers to achieving goal rate and

guide staff in areas such as holding feeding for gastric residual

volume (GRV). Protocol order set included starting EN rate,

energy, protein, and fluid goals as set by the nutrition support

clinician, bowel management program, prokinetic agent use as

indicated, and education of this order set. Data collection

revealed that 23 protocol patients achieved goal rate in one-

third the time of 13 patients who received EN in the usual man-

ner. Patients with elevated GRV reached goal 16 hours sooner

when the protocol was used, and those with elevated GRVs

started on prokinetic agents after 3 elevated GRVs 75% of the

time. In an evidence-based implementation project with pretest-

posttest measures, Kenny and Goodman

showed that EN

protocols in a military hospital improved practices, such as

keeping the head of the bed up, medication administration, and

tube-unclogging practices, and also increased provision of fam-

ily education. Institutional protocols can guide practice in areas

such as tube placement verification, hang time and feeding set

changes, monitoring tolerance of EN, and adequacy of EN. A

nurse-driven protocol to assess stool for Clostridium difficile as

appropriate can also be helpful. Protocols may be institution

specific. It is advisable to periodically review protocols and

update them as warranted by new evidence.

Order sets can guide appropriate EN product selection, ini-

tiation rate and progression to goal, delivery route, and admin-

istration method. Additionally, they can prompt safety features

in EN care and monitoring. For example, routine monitoring of

laboratory values could be especially helpful for those at risk

for issues such as refeeding syndrome or hyperglycemia. Order

sets can prompt additional fluid administration and offer guid-

ance for staff in areas such as HOB elevation, residual volume

check, and abdominal assessment. Safety practices and proto-

cols can be embedded in the order set to populate the EHR to

schedule and remind staff of necessary clinical tasks. Elements

of EN ordering that should also be included in the order set

include demographics such as patient identifiers, and body

weight might also be included or readily accessible.

Accountability is optimized when the system process iden-

tifies who is responsible for what. Organizations can standard-

ize safety practices for EN, such as those related to decreasing

risk for enteral misconnections

 Tracing tubings and lines with reconnections at

handoffs

 Training nonclinical staff to ask a qualified clinician

to reconnect lines instead of attempting reconnection

themselves

 Discouraging the modification or adaptation of IVs

or EADs even if the availability of adaptors and

connectors is reduced

 Labeling of tubes and connectors

 Identification and confirmation of solutions label and

labeling of bags with bold statements in terms of

contents

 Identification and minimization of conditions and

practices that contribute to healthcare worker fatigue

and mitigate risk

 Purchasing of appropriate, safe equipment that meets

standards and guidelines such as those from American

National Standards Institute/Association for the

Advancement of Medical Instrumentation (ANSI/

AAMI)

 Careful evaluation of purchasing decisions by an

interdisciplinary task force

 Following manufacturers’ guidelines to promote safe

connections

Assessing barriers to guideline adherence is key to effective and

consistent use of guidelines and protocols. The 2013 update to

Boullata et al 61

the Canadian Critical Care Nutrition Guidelines discusses key

strategies to promote their previous guidelines and explores 5

thematic domains in analyzing barriers as well as offering sys-

tem-level quality improvement interventions.

This guidelines

update promotes evaluating and monitoring practice via perfor-

mance improvement strategies to enhance nutrition care and

improve patient outcomes. As noted earlier, Kenny and

Goodman

have described the development and implementa-

tion of an evidence-based practice protocol for care of patients

with EN tubes; after these performance improvement interven-

tions, HOB elevation was achieved 100% of the time. Lyerla

and colleagues

used a modified interrupted time-series design

to collect data on 43 patients and 33 nurses in a 12-bed critical

care unit. They found that a nursing clinical decision support

system integrated into the electronic flow sheet increased adher-

ence to guidelines. Change champions have been shown to

facilitate change processes to improve care.

11,16

This is a role

that can be played by appropriate staff who take an active inter-

est in and accountability for enhancing practice.

Question 6.2. What are the essential components for

EN administration to include in nursing policies,

procedures, and practices?

Practice Recommendations

1. Define the quality control process for receipt,

distribution, storage, preparation, handling, and

administration of EN products.

2. Use sterile liquid EN formulations in preference to

powdered, reconstituted, or blenderized preparations,

whenever possible.

3. Administer EN by, or under the direct supervision of,

competent personnel as defined by the organization.

The personnel who administer EN will:

a. Either accept the delivery of the EN container

identified with the patient-specific label or select

the product from the unit-based inventory and

places the patient-specific label (depending on the

organizational model).

b. Visually inspect the product or preparation for

damage to the container, altered formula

characteristics, and expiration date limits.

c. Confirm that the EN container with the patient-

specific label reflects what has been ordered by

the prescriber. Verify patient identifiers, product

name, and route (and rate) of administration.

d. Perform proper handwashing prior to entering the

patient care area as well as prior to working with

the feeding administration. Don clean gloves prior

to working with the feeding tube and adminis-

tration set.

e. Use aseptic technique in setting up and connecting the

feeding administration set and related equipment.

For example, use a small clean towel under the

patient feeding tube connection to facilitate a clean

area prior to working with the tube.

f. Verify patient identifiers at the bedside matching

those on the EN label, per institutional protocol,

and verify appropriate patient positioning for

feeding.

g. Trace tubing from point of the enteral access device

that was described in the EN order and confirm that

there has been no dislocation of that device.

h. Position the EN container appropriately for the

patient and set up the administration set, priming

it as indicated.

i. Flush EAD and attach administration set using

aseptic technique. The EN container and

administration set make up the EN “delivery

device” and are attached together until discarded.

j. Cover the end with a clean cap for any

disconnection, such as when the feeding is stopped

and the distal end of the delivery device is

disconnected as for nocturnal or gravity bolus

feeding. If a pump is being used as for continuous

feeding, program it based on the EN order.

k. Base any change to the administration rate on

documented EN orders (including prescribed rates

for advancement or weaning).

l. Do not interrupt feeding administration for routine

care unless specifically ordered (as for medication

administration). If the feeding must be interrupted,

flush the tube to reduce the residue in the tube and

decrease potential for clogging.

m. Ensure that administration of enteral medication

via the EAD is reviewed and approved with

documentation as indicated by a knowledgeable

pharmacist.

n. Document EN processes in the patient’s EHR,

with a second entry for any independent double-

check performed. This includes documentation of

tolerance and administration volumes, including

hourly rates as well as amount of intake, and water

flushes.

Rationale

The purpose of policies and procedures is to ensure that staff

follow a consistent standard of care and quality at all lev-

els.

Policy statements guide practice by indicating what is

to be done and by whom. They are often based on institu-

tional protocol. Procedures describe the specific methods for

following policies in practice. When staff understand the

rationale for policy and procedures, they may be more likely

to adhere to protocol and use critical thinking. Issues to

address in policies and procedures related to EN delivery are

listed in Table 4.

62 Journal of Parenteral and Enteral Nutrition 41(1)

Organizations can use a systematic plan to promote the

periodic review of policies and procedures and the updating of

policies and procedures based on relevant and current evidence

as well as best practice for patients in the particular care

setting or organization. By conducting quality or performance

improvement, healthcare organizations can monitor practice

and identify areas for improvement and then implement appro-

priate measures to address the findings. For example, Guenter

has discussed areas for potential human error related to EN and

suggested the need for nursing oversight to minimize compli-

cations and enhance practice. Kenny and Goodman

describe

the use of change champions to increase nursing knowledge of

procedures and issues related to the environment of care.

Policies and procedures for the ongoing care and routine

assessment of EADs can help with early identification of com-

plications and proper interventions. Policies regarding EAD

care and assessment can cover correct tube placement, muco-

sal and skin surfaces assessment, and infection prevention.

Question 6.3. What are the essential steps in EN

administration to prevent aspiration?

Practice Recommendations

1. Maintain elevation of the HOB to at least 30 or upright

in a chair, unless contraindicated, and then consider

reverse Trendelenberg position.

2. Monitor the patient at least every 4 hours for appropriate

positioning. In pediatrics, it is recommended that

infants under 1 year of age sleep on their back and not

have the head of the bed elevated.

3. Minimize the use of sedatives because airway clearance

is reduced in sedated patients.

4. In patients who have difficulty clearing secretions,

follow instructions from appropriate staff regarding how

to clear secretions (eg, by oral suctioning), especially

prior to lowering of the head of the bed and prior to

extubation.

5. Understand that the method of administration (bolus,

intermittent, continuous) and optimal site (gastric,

small bowel) of EN feeding will depend on the patient

needs, medical conditions, tolerance and goals (eg, if

home use is anticipated), and resources available.

6. Monitor patient status for tolerance using measures

such as assessment for abdominal distention, firmness,

and large gastric residual volume (GRV), feeling of

fullness, or nausea that might lead to gastric reflux.

7. Monitor patients for appropriate feeding tube

placement at least every 4 hours or per institutional

protocol. Monitor visible length of tubing or marking

at tube exit site (naris or stoma) and investigate

placement when a deviation is noted.

8. Monitor tube placement and abdominal distention,

firmness for stable patients with longstanding EN therapy.

9. Place infants under 1 year of age on their back for sleep

and do not have the HOB elevated.

Rationale

Aspiration may be related to oral pharyngeal secretions and/

or reflux of esophageal and gastric content, including EN.

Critically ill patients and patients with impaired swallowing

Table 4. Issues to Cover in Policies and Procedures for EN Delivery.

 How feeding tubes are to be inserted

 How verification of EAD placement is to occur and how EAD placement is monitored

 Care for enteral feeding tubes

 How to prevent or handle practice challenges such as tube dislodgement

 Elements necessary in a provider order for EN

 Administration of EN in terms of formula attainment and verification, labeling, administration route, and method (eg, pump use or

gravity bolus feeding method)

 Rate or frequency of feedings

 Type, volume, and frequency of water flushes

 Hang times and equipment handling (eg, in terms of administration set changes)

 Medication delivery issues that involve or relate to EN or the enteral tube

 Issues related to safety in administration such as recommendations from The Joint Commission Sentinel Event Alert 53 and other

safety issues such as head of bed elevation

 How to optimize that the appropriate volumes of feeding product and fluid are actually delivered

 Methods to monitor for adequacy of EN as well as potential adverse effects, and identify who is responsible for overall and specific

aspects of monitoring as well as patient/family education, especially when transition to the home setting when continued feeding is

anticipated

 Frequency of residual assessment, what tubes are to be assessed, how assessment should be performed, and the rationale for the

assessment (the rationale helps staff identify the need for abdominal and more global patient assessment as a guide for tolerance to

EN instead of relying solely on gastric residual assessment)

EAD, enteral access device; EN, enteral nutrition.

Boullata et al 63

may have difficulty protecting their airways. Frequent, good

oral care and oropharyngeal suctioning, especially prior to

lowering the HOB as for positioning, can reduce adverse

events related to aspiration of oropharyngeal secretions.

20,21

Metheny and colleagues

compared usual care with an aspi-

ration risk reduction protocol (ARRP), which included HOB

30 or higher unless contraindicated; distal small bowel feed-

ing tube placement, when indicated; and use of an algorith-

mic approach for high GRVs. With usual care, 88% of patients

aspirated compared to 39% with the ARRP protocol. In the

usual care group, 48% of patients developed pneumonia vs

19% in the ARRP group. The authors concluded that combin-

ing HOB at least 30 and use of small bowel feeding site can

reduce aspiration and aspiration-related pneumonia dramati-

cally in critically ill, tube-fed patients. In an earlier article

(2006), Metheny

reported that 25 of 201 critically ill

patients had malpositioned enteral feeding tubes and signifi-

cantly higher risk for aspiration than those with tubes appro-

priately positioned. Risk for aspiration may be increased with

enteral tube ports in the esophagus, especially if there are

other risk factors for regurgitation. Some standard NG tubes

(when used to deliver EN for short-term use) have end holes

spaced 3 inches apart, and the standard tube placement mea-

surement of nose to ear lobe to tip of xiphoid (NEX) may be

suboptimal in guiding gastric tube tip placement. A nose to

earlobe to mid-umbilicus (NEMU) method to estimate appro-

priate nasogastric tube placement has been recommended to

promote placement of the tube end holes in or closer to the

gastric fluid pool.

24–26

Appropriate location of the enteral

tube’s distal end must be ascertained prior to instillation of

fluid or medication. It is recommended in infants aged 1 year

or less that they sleep on their back and not have the HOB

elevated. These recommendations are part of the American

Academy of Pediatrics Safe Sleep Initiative, to reduce sudden

infant death syndrome.

It is important to obtain, ascertain, and maintain optimal

enteral tube placement to help reduce potential reflux of EN.

Metheny et al

performed a retrospective analysis of 428

critically ill, mechanically ventilated patients and found that

the percentage of aspiration was 11.6% lower when feeding

tubes were in the first portion of the duodenum, 13.2% lower

in the second/third portion, and 18% lower in the fourth por-

tion of the duodenum or lower (P < .001). In a randomized

controlled trial of 33 ventilated patients randomized to gastric

vs transpyloric feeding, Heyland et al

found that feeding

beyond the pylorus was associated with significant reduction

in gastroesophageal regurgitation and there was a trend

toward less micro-aspiration. In critically ill patients, small

bowel feeding may be associated with less pneumonia than

gastric feeding, but without differences in mortality or days

on a ventilator.

The American Association of Critical-Care Nurses recom-

mend the following to reduce the risk for aspiration: maintain

the HOB 30–45 unless contraindicated; use sedatives as

sparingly as possible; assess feeding tube placement at 4-hour

intervals; observe for change in amount of external length of

the tube; assess for gastrointestinal intolerance at 4-hour inter-

vals; assess residual volume, patient, and abdominal status and

advance the tube if indicated; avoid bolus feeding for those at

high risk for aspiration; assess swallow before oral feedings

are started for recently extubated patients after prolonged intu-

bation; maintain endotracheal tube cuff pressure at an appro-

priate level; and ensure that secretions are cleared from above

the cuff before it is deflated.

Question 6.4. Can EN be administered safely in patients

who require prone positioning?

Practice Recommendations

1. Assist the patient in clearing secretions as indicated

and promote good oral hygiene.

2. Assess abdominal status every 4 hours and as indicated

and monitor bowel status as a guide for GI motility

status.

3. Consider short-term use of prokinetic agents if

indicated clinically.

4. Consider transpyloric tube placement for patients who

are at increased risk for aspiration or have persistently

elevated GRVs.

Rationale

Evidence is limited, demonstrating the safety and tolerability

of EN in the prone position, although the minimal available

evidence does not suggest a substantial increase in complica-

tions compared to EN administered in a supine position.

Strategies to increase enteral feeding tolerance in the supine

position such as HOB elevation, small bowel feeding, and use

of prokinetic agents may increase EN tolerance for patients in

the prone position. When the patient’s clinical situation

favors positioning other than HOB elevation at 30 or greater,

as in proned patients, the use of small bowel feeding and pro-

kinetic agents with 25 HOB elevation has been shown to

increase volume tolerance and progress toward feeding

goals.

Linn et al

reviewed the literature related to administration

of EN in adult patients in the prone position. Only 2 of the 4

studies that they found that met their inclusion criteria were

designed to compare outcomes associated with EN adminis-

tered in the prone vs supine position. The conclusions of these

2 studies were that GRVs of patients in the prone position were

similar to those noted in patients in the supine position; also,

EN delivered to prone-positioned patients did not appear to

increase risk of vomiting or pneumonia in the 2 studies where

this risk was specifically explored. The limited evidence in this

area is highlighted by these authors. Fineman and colleagues

compared 51 prone and 51 supine pediatric patients with acute

64 Journal of Parenteral and Enteral Nutrition 41(1)

lung injury in terms of mechanical ventilation, airway manage-

ment, and pain and sedation management, as well as EN. These

authors determined that there was no difference in feeding

complications between the supine and prone positions. They

also noted that patients who were fed via the jejunal route

reached feeding goal earlier than those fed via the gastric route;

however, the study design monitored adverse effects as

opposed to actively looking at outcomes.

Prokinetic agents (eg, erythromycin) and HOB elevation

of 25 were specifically employed in prone patients who

exhibited volume intolerance.

Delayed gastric emptying is

reported in 50%–60% of critical care patients, and multiple

factors, including use of vasopressors, and endogenous and

exogenous catecholamines, can contribute to the delay. The

efficacy of erythromycin as a prokinetic agent exceeds that of

metoclopramide, although the effectiveness of erythromycin

diminishes over time. Both agents may have a synergistic

effect when combined. When the use of small bowel feeding

tubes is feasible, it also may increase EN tolerance in prone

patients.

The National Pressure Ulcer Advisory Panel (NPUAP)

recommends limiting HOB elevation to 30 for an individual

on bedrest, unless contraindicated by the patient’s medical

condition or feeding and digestive considerations. NPUAP also

recommends that an individual not be positioned directly on a

pressure ulcer.

Schallom and colleagues

have compared

research to prevent aspiration and pressure ulcers in critically

ill patients and suggest that the optimal elevation to balance the

risks for both of these issues is unknown. They recommend

that until more evidence is available, caregivers should make

HOB elevation decisions in the context of the patient’s overall

condition. They recommend HOB elevation of 45 for patients

receiving EN who require mechanical ventilation or are heav-

ily sedated, but lowering the head to 30 might be done peri-

odically for patient comfort. They also stated that for critically

ill at less risk for aspiration (eg, non–mechanically ventilated

patients), it is recommended to maintain HOB at 30 and take

pressure-relieving measures.

Questions 6.5 and 6.6. Is elevated HOB required for

patients without significant aspiration risk? Are

there modes of ventilator support that can increase

the risk of aspiration (eg, high-volume flows, BIPAP,

APRV)?

Practice Recommendations

1. Maintain elevation of HOB at 30 or more for gastric

feeding. However, pump feeding interruption for short

periods of time to lower the HOB may not be necessary

or recommended unless contraindicated.

2. Consider carefully the indication for EN in the patient

receiving high-flow modes of ventilation, especially if

that patient is concomitantly receiving any sedation.

Rationale

When evaluating the research related to EN and aspiration risk,

it is important to note that much of this research has been con-

ducted in patients with critical care status, a factor that may

already increase aspiration risk. However, non–critically ill

patients may also be at risk for aspiration related to EN.

Patients requiring EN may not be able to protect their air-

way due to difficulty swallowing or other reasons, and aspira-

tion from oropharyngeal secretions may occur more readily in

the supine position. Patients in the supine position may be at

greater risk of aspiration due to gastric reflux than those whose

heads are elevated either in a bed or chair, while stopping a

slow-drip feeding for a brief period to reposition the patient in

bed may not be necessary and may even be counterproductive.

Assessment of the patient’s abdominal and bowel status to

check adequate gastrointestinal motility is an ongoing priority

in caring for the patient receiving EN. Returning the patient’s

HOB quickly to at least 30 is imperative.

High-flow ventilators and bag-valve-mask ventilations

increase likelihood of aspiration. However, these therapies are

essential in some situations because irreversible hypoxic brain

injury trumps the risk of potential aspiration. High-flow vol-

umes by noninvasive ventilation (NIV), noninvasive positive

pressure ventilation (NIPPV), or other means can increase the

risk of aspiration, and the risk is further increased in the sedated

patient.

EN is not always indicated in patients on high-flow

volume NIV as some patients have learned to eat with high-

flow volume NIV without incidence of pneumonia, including

patients with neuromuscular diseases such as amyotrophic lat-

eral sclerosis. Guidance from a speech and language patholo-

gist may help determine risk of aspiration, although eating may

be a quality-of-life issue for the patient who exercises self-

determination and elects to eat and drink while aware of the

risk of aspiration.

Meeting EN volume targets for patients with gastrostomy

tubes who are receiving respiratory therapies, especially with

high-pressure settings, is challenging. Patients who are receiv-

ing high-pressure respiratory support via NIV may experience

gastric insufflation. A patient with normal muscular function

may belch (eructate) to relieve the abdominal distention and

then be able to eat or take EN. However, a patient with a weak

diaphragm may be unable to belch and may experience gastric

bloating and fullness due to aerophagia. This phenomenon

happens when pressures to support respiration and the work of

breathing force air into the stomach. Early satiety and gastric

bloating may cause the patient to be unable to meet EN goals

due to feeling sated, sometimes despite feeling hungry. Venting

the gastric tube may relieve this condition and increase feeding

tolerance toward goals. Some medical centers have developed

aerodigestive clinics devoted to serving this client base. When

aggressive manual venting (eg, via open syringe) is not ade-

quate, a gastric decompression valve bag may provide addi-

tional relief and allow feeding toward volume goals.

Boullata et al 65

Carron and colleagues

reviewed optimal head position

and use of a nasogastric tube to ameliorate gastric distension,

although this review was unrelated to EN use. They detail the

sequelae whereby gastric distention compresses the lungs and

decreases compliance, which in turn demands higher airway

ventilation pressure. They suggest that airway pressures higher

than 20–25 cm H

O should be avoided. Moreover, considering

recent evidence of the efficacy of high-pressure NIV in severe

chronic hypercapnic COPD, this therapy should be carried out

in an almost sitting position approximately half an hour after a

meal or EN and with routine gastric decompression care.

37,38

Question 6.7. What factors determine the best duration

or rate of the feeding to improve the likelihood that

the full prescribed dose is received?

Practice Recommendations

1. Minimize interruptions to EN as much as possible to

help ensure optimal nutrition delivery.

2. Evaluate brief “NPO” status (eg, for procedures) for

need and minimize those interruptions as much as

possible. For example, the amount of time that a jejunal

feeding must be stopped for a procedure may be

different from the duration required for gastric feeding.

3. Accommodate interruptions to feeding delivery when

they are anticipated, and plan the feeding schedule to

maximize delivery of the daily feeding volume. A

volume-based feeding protocol may provide the nurse

with latitude in modifying EN administration to meet

the patient’s goal safely.

4. Consider patient condition factors and tolerance,

lifestyle, goals and convenience, and placement of the

distal end of the tube in formulating the feeding

regimen to meet patient nutrition and fluid needs.

Rationale

Various scheduling techniques for EN may be used in clinical

practice. Volume-based feeding protocols have been recom-

mended to ensure that patients receive adequate nutrition in a

given 24-hour period. In a pilot study, Heyland et al

demon-

strated improvement in nutrition delivery using volume-

based enteral feedings or the delivery of a daily feeding

volume target over a 24-hour period that prompts makeup of

missed feeding within set guidelines. McClave et al

evalu-

ated a volume-based feeding (VBF) protocol designed to

adjust for delivery interruptions in a prospective randomized

controlled trial compared to rate-based feeding (RBF) in

which the physician determined a constant hourly rate. On

days where feeding was interrupted, VBF patients received a

mean of 76.6% of goal calories vs the RBF group, which

received a mean of 61% of goal calories (P = .001); further-

more, VBF was not associated with vomiting, regurgitation,

or feeding intolerance. These investigators concluded that

VBF is safe and improves EN delivery compared to RBF.

In a prospective controlled trial where 164 critically ill

patients were randomly assigned to intermittent feeding (one-

sixth of the feeding goal was administered every 4 hours) vs

continuous feeding, both groups reached the feeding goal by

day 7, but the participants in the intermittently fed group

reached the goal faster and had a higher probability of being at

goal than those fed continuously.

Lichtenberg et al

found

that 158 patients scheduled for a 20-hour rate to compensate

for interruptions had a significantly reduced caloric deficit

(and a higher level of overfeeding) compared to 110 patients

fed for a 24-hour rate. Van den Broek and colleagues

observed

that administered feeding amounts were significantly lower

than prescribed in a 4-month study of 55 patients who received

continuous pump feeding, portion drip, or combined feeding

schedules. A mean energy deficit 1089 kJ/d (range, –7955 to

+795 kJ/d) was noted largely due to interruptions for proce-

dures. The delivered feeding was in goal range only in critical

care. They suggest adapting EN schedules to accommodate

periods when patients are off feedings as well as the use of

formulations with higher energy density.

Outcomes of these EN administration protocols may be dif-

ficult to demonstrate. de Araujo et al

studied 41 critically ill

patients who received continuous vs intermittent (per pump)

feeding and found no statistically significant difference in

terms of calories received per day, bowel distention, or emesis

for patients who had 6 hours off at night vs those fed for 24

hours per day. It has been suggested that feedings held for a

6-hour period might result in reduced gastric microbial growth

due to increased gastric acidity during the off period.

Patient convenience, lifestyle, and preferences are factors to

consider when creating the EN schedule, especially when EN

is likely to continue postdischarge. A 24-hour feeding schedule

is seldom needed, and periods without being connected to

feeding may enhance patient lifestyle. It may therefore be

advisable to individually assess the feeding schedule of each

patient, including those in long-term care settings.

Although jejunal feeding may be better tolerated as periodic

continuous feeding (eg, nocturnal feeding), the delivery sched-

ule options are limited compared to gastric feeding. Nocturnal

feeding may be used to encourage daytime oral intake; how-

ever, the patient’s appetite may still be dampened, and it may

be challenging to determine the adequacy of meals and modify

the EN volume accordingly. If oral intake is encouraged and a

gastric tube is being used, postmeal gravity bolus feeding can

be infused immediately after each meal to promote the patient’s

appetite for the next meal, and the amount of feeding can be

adjusted according to the adequacy of intake of each meal (eg,

use half of the EN volume after half of the meal is eaten).

When oral intake is discouraged (eg, because of marked dys-

phagia) but a patient is in an environment involving food, EN

can be administered prior to encounters with people eating to

dampen the patient’s appetite and reduce the desire to eat.

66 Journal of Parenteral and Enteral Nutrition 41(1)

When continuation of EN into the home setting is anticipated,

clinicians can implement the home schedule (such as gravity

bolus meal-like feedings) in the acute care setting before dis-

charge. This approach allows the acute care team to not only

work toward the feeding goal and assess patient tolerance but

also provide the patient or family as much assistance and train-

ing as possible before discharge.

Question 6.8. What practices maintain safety throughout

EN administration in regard to pump issues?

Practice Recommendations

1. Purchase best-performing pumps and follow

manufacturer recommendations for pump use and

maintenance.

2. Ensure that institutional biomedical engineering

departments periodically test, according to manufacturer

recommendations, whether pumps continue to meet the

accuracy rates and whether alarms function.

3. Consider a volume-based ordering system as opposed

to a rate-based delivery when appropriate to optimize

delivery of the total volume in a set time period.

4. Compare time of container initiation with completion

of infusion of container in terms of expected delivery

amounts as a double-check of accuracy of delivered

volume.

5. Zero the volume delivery amount on the feeding pump

at the beginning of a time period, such as usual intake

and output assessment period. This can serve as a check

of amount delivered, especially when that volume is the

same as the expected delivery volume. When the

volume delivered varies from expectations, additional

investigation regarding the variance is in order.

6. Use lightweight, portable, user-friendly, and accurate

pumps. For patients who may require continued pump

use in the home setting, consider the simplicity of use

and reliability of the pump. If possible, begin use of the

pump to be used in the home care setting before the

patient is discharged from acute care.

Rationale

Enteral feeding pumps are used to ensure accurate, consistent

feeding delivery with an alarm designed to signal interruption or

alteration to this delivery. Patients and caregivers who rely on

and are responsible to account for this consistent delivery expect

that an alarm will sound for any deviation from what is pre-

scribed in terms of delivery and that the volume-delivered fea-

ture represents actual volume delivered in a specific time period.

However, pumps have been shown to deliver rates and volumes

that vary from the prescribed settings.

Accuracy in delivery is

important for all who rely on enteral feeding pumps because

even small variances over time can have a significant impact on

the patient’s nutrition status. Particularly in vulnerable neonates

and young children, small differences in the rate and volume of

feeding can lead to major consequences.

White and King

discuss 4 areas for safety regarding the

use of enteral feeding pumps: (1) the consistent and accurate

delivery of formula, (2) the minimization of errors regarding

tube misconnection, (3) the impact of feed delivery itself, and

(4) the potentially toxic chemical composition of the casing

used in pump manufacture, although sets free of di(2-ethyl-

hexyl)phthalate (DEHP) are now marketed. They assert that

accuracy, safety, and consistency are important for patient con-

fidence and acceptance of feeding pumps.

The potential unreliability of pumps can be a source of

stress not only for staff and caregivers but also for patients,

including those in home settings, who may be concerned when

fluid remains in delivery containers at the end of a programmed

pump delivery period or, to the contrary, if feeding infuses

more quickly than expected. In 1 study of home EN in 34 pedi-

atric patients with inherited metabolic disorders, 75% of fami-

lies of children surveyed reported sleep disturbances related to

alarms, and 50% of home patients experienced faulty pumps

that affected accuracy and, in 1 critical incident, led to under-

feeding.

These authors published the review of enteral

pumps, suggesting that formula delivery is accurate to within

10% of what is programmed. Some pediatric and adult sys-

tems report adhering to deviance rates of only 5%.

Pump inaccuracy has been identified as a primary contribut-

ing factor in both underdelivery and overdelivery of feedings.

Tepaske et al

looked at 13 commercially available pumps

tested in a laboratory setting in 12 sessions with different tubes

and formulas. Formula delivery differed from preset to actual

delivery over a 24-hour period, with deficits ranging from

0.5%–13.5%, and differences of +66 mL to –271 mL per 24

hours. Decreased accuracy was attributed to the feeding pump

vs formula viscosity or resistance in delivery; however, only 1

pump of each type was tested in this study, and EADs varied

between 6 and 16 Fr in diameter. Spronk et al,

who tested 14

feeding pumps (6 Kangaroo 324 pumps and 8 Kangaroo 224

pumps), noted that discrepancies of up to 24 mL/h below the

preset volume occurred despite frequent calibrations by techni-

cal service using weight volume analysis. They discuss that dif-

ferences in delivered volumes could be due to viscosities of

formula or bending or twisting as the patient moves. They rec-

ommend monitoring pump function in various settings and con-

ditions, suggesting that technical service, age, and depreciation

of pumps influence their accuracy. For one brand of enteral

feeding pump, a 2011 report was issued to warn that users who

incorrectly pressed a certain key sequence might conclude that

an inoperable pump was infusing and consequently be at risk of

hypoglycemia due to lack of feeding.

Additionally, incorrect

key presses may cause a particular type of pump to appear to be

infusing even though an occlusion exists.

Older reports of

inaccuracies exist from 2003 and prior, but these findings may

not be generalizable to newer pumps.

Boullata et al 67

Manufacturers establish accuracy rates for their specific

pumps and generally fall within the accuracy rates as described

above.

Low-flow rates combined with high-dose settings

may exceed the life of the disposable set and should be replaced

every 24 hours to maintain delivery accuracy, allow proper air

and occlusion sensing, and prevent growth of bacteria.

Therefore, avoid programming a rate and dose combination

that exceeds a 24-hour feeding regimen. Pumps should be used

exclusively for enteral formulas or human milk and not inter-

changeably for medications and EN. When using HBM in

infants, syringe pumps are used to minimize the loss of HBM

in a feeding bag.

Question 6.9. Can the EN feeding system be a source for

contamination and infection and how can

contamination in the EN feeding system be best

prevented?

Practice Recommendations

1. Use a closed EN delivery systems when possible.

2. Follow the manufacturer’s recommendations for

duration of infusion through an intact delivery device

(container and administration set).

3. Do not reuse the enteral delivery device for open or

closed systems (container and administration set in

excess of what is recommended by the manufacturer).

4. If open systems are used, follow recommended hang

times and avoid topping off remaining formula, which

may result in a continuous culture for exponential

microbial growth.

a. Limit infusion time for open EN feeding systems

to 4–8 hours maximum (12 hours in the home

setting).

b. Limit infusion time for a reconstituted powder

product or modular to 4 hours maximum.

c. Change the delivery device (container and

administration set) according to the manufacturer’s

recommendations for open systems.

5. Be aware that the addition of modular units to an open

feeding system may result in an unacceptable risk of

contamination in hyperthermal environments.

6. To limit the risk of microbial growth and biofilm

formation, avoid unnecessary additions to the EN

administration set. If additional equipment, such as

3-way stopcocks, are used, follow manufacturer

recommendations or facility protocol for change and

cleaning practices.

7. Establish and follow protocols for preparation,

handling, and storage of commercial and handmade

EN.

a. Educate those who prepare and administer EN

about hand hygiene (a critical point) and safe

handling of EN preparation and administration;

extend education to patients and family members/

care givers who will continue this practice into

the home setting.

b. Use effective hand hygiene in all aspects of EN

preparation and administration. When gloves are

used, they must be clean gloves, not having been

involved in other nonrelated tasks. The importance

of hand washing in minimizing transference of

microbial growth and preventing hospital-

acquired infections cannot be overstressed.

c. Give preference to selecting systems that require

minimal handling.

d. Use a clean work surface for EN preparation.

e. Use equipment dedicated for EN use only.

f. Store EN formula according to the manufacturer’s

instructions. Store prepared or opened ready-to-

feed solutions in an appropriate refrigerator,

discarding any used solutions within 24 hours of

preparation or opening.

8. Periodically survey and regularly monitor adherence

to the above-listed protocols. Document findings and

take appropriate actions if protocols are not followed.

9. Reduce potential for touch contamination of

EN-related equipment as well as risk of exposure to

body fluids by reducing interruptions to the system,

providing a clean work surface (eg, small clean towel

under tube/administration connection) and when

interruptions are necessary, and using only washed

hands and gloves.

10. Keep all equipment, including syringes and containers

for flush and medication administration, as clean and

dry as possible. Store clean equipment away from

potential sources of contamination.

11. Consider whether microbial growth related to EN

might be implicated as part of the diagnosis when

patients have adverse conditions such as diarrhea.

Rationale

Although microbial growth has been associated with EN in a

variety of studies and in a variety of ways, contamination

related to EN is an often overlooked source of bacterial infec-

tion.

1,51

In discussing microbial growth, questions arise such as

which types and what amount of microorganisms are harmful,

what are the associated adverse effects of harmful microbial

growth, and what areas related to EN are most strongly corre-

lated with harmful microorganisms.

Patients who require EN

may be immunocompromised, at least until their nutrition sta-

tus is improved, and they rely on healthcare professionals to

minimize risk related to EN delivery.

Hospital-prepared EN poses the risk for foodborne illness

or nosocomial infection.

38,53,54

Blenders used in reconstituting

formulas have been cited as a primary source of contamina-

tion.

Diluting formula hung for a period of time is no longer

68 Journal of Parenteral and Enteral Nutrition 41(1)

recommended because additions to the EN system increase

risk of microbial growth.

Water that is hung as a separate infusion to the EN delivery

device may also serve as a source for exponential microbial

growth, especially when the water is hung for extended periods

(eg, >8–24 hours); however, reporting of well-designed research

in this area is lacking.

In a prospective, descriptive study, cultures were taken

from 30 pediatric patients every 4 hours as they were adminis-

tered continuous feeding of decanted formula over a minimum

hang time of 12 hours with formula added per “current prac-

tice.” Out of 111 usable cultures, 100 had no growth, 6 had

growth below the FDA threshold for contamination, and 5 cul-

tures in 2 patients grew coliforms with no evidence of bacterial

gastroenteritis over the 48-hour data collection period.

In this

study, decanted formula used for pediatric patients had a lower

growth rate over a 12-hour period than anticipated when rec-

ommended handling procedures were followed.

Perry and colleagues

compared closed EN systems with

open systems and open systems with modular additives in a criti-

cal care burn unit. No microbial growth was found in closed and

open systems in the thermoneutral and hyperthermal critical care,

nonpatient environment, although humidity was not reported.

Microbial growth was noted in both temperature environments in

the open system with modular additives. Significant growth in

the open system with modular additives was noted in the hyper-

thermal environment, where 30% of samples exceeded FDA

standards by 4 hours and CFUs were too numerous to count by 8

hours. These investigators concluded that the addition of modular

units to an open feeding system may result in an unacceptable

risk of contamination in hyperthermal environments.

A wide variety of organisms was recovered from neonatal

feeding tubes in studies by Juma and Forsythe

and Hurrell

et al.

In Juma and Forsythe’s study, some of the organisms

were encoded for antibiotic resistance.

Hurrell and colleagues

reported that a multitude of organisms, including antibiotic-

resistant ones, was identified in 129 feeding tubes collected

from 2 neonatal intensive care units (NICUs), and Klebsiella

pneumoniae and Serratia marcescens caused infections in the

2 NICUs.

The significance of biofilm formation in enteral

feeding tubes, which constitutes a risk factor for susceptible

neonates, is highlighted in another report by this group of

investigators.

Biofilm growth on 3-way stopcock valves used

within the feeding delivery system can cause nosocomial

infections; Pseudomonas aeruginosa was found to develop a

bacterial biofilm in these valves within 3 days.

These valves

may be used with no routine change time or care practices and

may be exposed to many interruptions and manipulations.

System design has been suggested to play an important role

in reducing bacterial contamination. Retrograde spread of the

patient’s own flora has been identified as a source of contami-

nation in EN administration sets, and system design improve-

ments (such as recessed spikes on administration sets) have

been recommended to reduce potential touch contamination.

Mathus-Vliegen et al

reported that the large amount of

potentially pathogenic bacteria found in delivery sets was

likely related to the endogenous vs exogenous route, poten-

tially due to retrograde microbial growth.

In a study of EN-related equipment, clean, dry feeding

equipment had less microbial growth than feeding equipment

that retained moisture, feeding formula, and other media for

microbial growth. Syringes stored for up to 5 days in a clean,

dry fashion as 2 pieces (ie, piston being removed from the bar-

rel of the syringe prior to storage) had less microbial growth

than more newly obtained syringes (eg, 12 hours) that housed

moisture where cultures exceeded standards for both type and

amount of microbial growth. Also noted, feeding tubing

administration caps taped upright to IV poles had significantly

more adverse microbial growth cultured from them than caps

that were stored in a manner to prevent moisture retention.

Ho and colleagues

found a strong correlation between cul-

tures taken from staff hands and contamination of tube hubs,

enteral feeding, and nasopharynx and gastric fluid, and the

investigators noted a significant reduction in contamination in

the group that received an infection control program (ICP).

Hand contamination with methicillin-resistant Staphylococcus

aureus (MRSA) was highly correlated with contamination of the

EN system, and these authors recommend ICPs in long-term

care settings. The effect of touch contamination has been dem-

onstrated in syringes,

and healthcare professionals must take

measures to avoid the transfer of microbial growth from hands to

patient care items and areas, such as the inner aspect of a feeding

tube. The importance of appropriate hand hygiene and clean

glove use as indicated cannot be overstressed. Additionally, a

clean surface (eg, a clean small towel under tubing prior to dis-

connections or manipulation) may reduce inadvertent touch con-

tamination from less clean areas. Changing delivery systems at

once is less risky than topping off the volume of formula.

Reuse of feeding bags for the home setting is sometimes

considered a cost-saving measure. Oie and Kamiya

found that

washing feeding bags with water and then 0.1% sodium hypo-

chlorite (ie, bleach) solution significantly reduced microbial

growth (P < .01) compared with washing with water alone.

Rinsing of continuous EN sets used for 24 hours with tap water

was not determined to decrease contamination when cultured at

8 and 16 hours in a 2-group comparison (rinse vs nonrinse).

Williams and colleagues

conducted a randomized controlled

trial and concluded that aspirating GRVs less frequently in critical

care was not correlated with increased patient risk of complica-

tions from EN but could potentially reduce the risk of contamina-

tion of the feeding circuit and the risk of exposure to body fluid. In

another study, Williams et al

identified other strategies to reduce

interruptions to enteral feeding that might increase risks of con-

tamination and negatively affect nutrition outcomes.

Adverse events related to microbial growth in EN have

been addressed, but additional research in this area may

prove to be of benefit. Clostridium difficile and associated

diarrhea in hospitalized tube-fed patients have been corre-

lated with EN, especially in those receiving postpyloric

feeding.

68,69

With the steady increase in this very serious

Boullata et al 69

malady, every potential correlation must be considered,

including medications, underlying disease, and prior status,

but bacterial contamination must also be considered.

There

are many potential causes of frequent and/or loose stools,

including medications, underlying disease, and prior status,

but bacterial contamination must be considered.

In an

observational, retrospective study of EN use in 175 hospital-

ized poststroke patients compared 24-hour hang time vs

72- or 96-hour hang time, the 24-hour hang time was inde-

pendently associated with a lower risk of diarrhea and longer

diarrhea-free survival.

Jack et al

reported a 78% inci-

dence of diarrhea in 55 patients using EN, and the frequency

increased with longer periods of enteral feeding. They rec-

ommended that organizations use a diarrhea risk manage-

ment algorithm. Hurt et al

suggested that incorporation of

EN as a base strategy for stress ulcer prophylaxis to reduce

the need for acid-suppressive therapy may reduce C difficile

pseudomembranous colitis. Others have recommended

allowing stopping EN for periods of time (eg, 6-hour break)

to allow gastric pH to return to its more normal acidic pH to

help reduce gastric microbial growth.

Healthcare organizations that follow national standards

practice recommendations (eg, Hazard Analysis and Critical

Control Point [HACCP] and National Institute for Health and

Clinical Excellence [NICE] 2012) in training and monitoring

staff who work with EN can reduce and contain microbial

growth.

74,75

For example, Oliveira et al

reported that a hospital

reduced bacterial count from 10

CFU/mL to 10

CFU/mL by

following HACCP guidelines for preparation, storage, and

delivery of enteral feeds and using a flowchart and monitoring

critical control points defined using a decision tree based on

HACCP guidelines. If using a threshold of 10

CFU/mL, then

EN delivery sets should be used within 24 hours.

See Figure 9

for hang times for EN and Figure 10 for an overview of poten-

tial contamination points in EN.

Question 6.10. Under what circumstances (if any) should

EN be held to improve patient safety (prior to

transportation, prior to procedures, surgery, or

extubation)?

Practice Recommendations

1. Avoid interruptions or holding EN for routine

interventions, including endotracheal extubation and

procedures where short periods of HOB lowering are

needed.

a. Perform a thorough assessment for oropharyngeal

secretion retention and potential for reflux of

gastric fluid by a qualified professional.

b. Disconnection of EN equipment not only

decreases nutrition delivery and increases

potential microbial growth of related equipment

but also increases the risk for tubing misconnection.

2. Consider risk vs benefit regarding disconnection of EN

on an individual basis as it reduces needed nutrient

delivery and may increase safety risk.

3. Follow the American Society of Anesthesiologists

preoperative fasting recommendations

a. Human milk—4 hours

b. Infant formula—6 hours

c. Nonhuman milk—6 hours

Figure 9. Hang times for enteral nutrition. HBM, human breast milk; IC, immunocompromised; PDM, pasteurized donor milk.

70 Journal of Parenteral and Enteral Nutrition 41(1)

Rationale

Safety can be built into all aspects of patient care, and ownership

for safety integration must be an expectation of all healthcare

professionals. When EN is held for tests and procedures, patients

are deprived of nutrition and fluid unless lost volume is effec-

tively made up during the other hours of the 24-hour period.

Peev et al

compared avoidable and unavoidable interruptions

in EN and equated interruptions in EN delivery to undesirable

outcomes such as underfeeding and prolonged length of hospi-

talization. Withholding feeding can be done as necessary, but

decisions based solely on tradition are not advisable. Instead,

clinicians are encouraged to use evidence and critical thinking to

decide whether to interrupt feedings. Williams and colleagues

have reviewed means to reduce avoidable interruptions.

Transporting patients between departments, areas, facilities, or

care settings increases the potential for disconnection and miscon-

nection of the enteral feeding system, delay of feeding resump-

tion, and potential tube clogging, as well as deviation from usual

preventive practices, such as maintaining HOB elevation.

Intrahospital transportation has been identified as a risk factor for

pneumonia. In a cohort-matched design study of critically ill ven-

tilated patients, 118 patients were transported (primarily for radio-

logic procedures) and 118 were not. Of those who were transported,

26% developed ventilator-associated pneumonia (VAP), as

opposed to 10% of those who were not transported.

Three inde-

pendent risk factors for VAP were identified in this study: the need

for reintubation, EN, and intrahospital transport. It was not clear

whether alteration in HOB positioning was a factor in these

outcomes. During transport, appropriate hand-off between quali-

fied personnel is essential. Documentation of line tracing and

ready access provide resources if concerns or questions arise.

Depending on the context, turning continuous EN off for

lowering the HOB for a brief time may be unnecessary and even

counterproductive in terms of reduced feeding volume, risk of

forgetting to turn the feeding back on, and increased potential for

tube clogging. If the HOB must be lowered, it should be quickly

reelevated to 30°, or preferably 45°, unless contraindicated.

28,34

Another possible option is to reposition the patient in reverse

Trendelenburg while feedings infuse. The patient clinical condi-

tion may be a more influential risk factor for reflux and aspira-

tion than the small per-minute volume of feeding delivery.

Oropharyngeal suctioning and assessment of patient condition,

including abdominal assessment, may be more helpful in tem-

pering aspiration risk than stopping small-volume feeding infu-

sion for a short period for lowering the HOB.

The standard practice of NPO after midnight prior to proce-

dures and surgery has been challenged and warrants patient-

specific consideration regarding its appropriateness and risks

and benefits.

For example, jejunal feeding may not need to be

held for the same time period as gastric feeding, especially

when gastric decompression may be an option prior to a proce-

dure. In a study by Moncure and colleagues,

46 patients with

jejunal tube feeding that infused until they were transported to

the operating room were compared to 36 patients who had jeju-

nal feeding held for 8 hours prior to surgery. No aspiration was

noted in either group, and the investigators concluded that jeju-

nal feeding may safely continue until the time of surgery.

Figure 10. Contamination points in formula preparation. EAD, enteral access device; EN, enteral nutrition; HBM, human breast milk;

PDM, pasteurized donor milk.

Boullata et al 71

In a prospective, observational cohort study, critically ill,

mechanically ventilated patients were fed via gastric tube until

45 minutes prior to selected operative and nonoperative proce-

dures or via duodenal tube until the procedure started. Pousman

and colleagues

found a trend in the intervention group toward

increased nutrition administration and faster attainment of target

goals, with no statistically significant difference between the usual

practice group and the patients with the reduced fasting protocol.

The American Society of Anesthesiologists have published

practice guidelines for preoperative fasting timeframes for elec-

tive procedures. These include discontinuing various liquids

prior to an elective surgical procedure. Those liquids pertinent

to the patient receiving EN include human milk, infant formula,

and nonhuman milk. A 2-hour fasting time period for those

receiving human milk is recommended, a 4-hour time period is

recommended for infant formula, and a 6-hour time fasting

period is recommended for those receiving nonhuman milk.

The practice of holding EN for patient conditions also war-

rants critical appraisal. For example, McClave and Chang

have

concluded that “evidence of gastrointestinal bleeding is not an

automatic contraindication” to EN; rather, EN may protect the

gut mucosa and further reduce bleeding, increase the risk for

rebleeding, or “serve as a moot point with no relation to further

bleeding.” They discuss reasons to consider continuing or hold-

ing feeding for a period of time, depending on etiology of the

bleeding. Other decisions about interrupting EN, such as whether

to hold feeding for a period prior to endotracheal extubation or

for medication administration, will also depend on the specific

situation and the best evidence available to the clinician.

Question 6.11. What is the most accurate method to

measure the amount of formula infused (ie, recorded

I/O, marking the bottle or bag)? Who is responsible

for monitoring whether the amount recorded was

actually infused?

Practice Recommendations

1. Do not rely on pump rate and volume settings alone to

determining the amount of feeding infused. Calculate

the hourly rate multiplied by the hours infused, allotting

for any downtime and use other methods to double

check and ensure accuracy of volume infused. Compare

that volume to the pump history of volume infused for

an accurate measure of intake.

2. Document the volume of EN and other fluid

administered and investigate when suboptimal nutrition

and fluid seems to have been delivered. Serve as patient

advocates to promote best nutrition and fluid delivery.

3. Monitor nutrition and fluid trends, including any gaps

in delivery, and pursue methods to enhance delivery as

indicated.

4. Implement methods to ensure that adequate nutrition is

being administered for patients who continue EN after

they transition from acute care to another setting.

5. Tailor ordering methods to help ensure that accurate

nutrition volumes are delivered:

a. Consider volume-based feeding schedules where

a specific volume is to be infused in a 24- hour

period.

b. Use an easily measurable volume, such as one or

two 1-liter containers/d or 2 cartons (cups) of

feeding per EN “meal,” in orders for EN in the

home care setting.

6. Institute systems to embed accountability and oversight

for accurate delivery of nutrition intake, including

methods of ordering and documenting actual intake.

Have policies and procedures to determine whether

systems are suboptimal or break down, and use system

improvement methods to address problems.

7. Encourage use of electronic connectivity between

enteral pump and the intake portion of the EHR to

document EN volume infused.

Rationale

Many stakeholders are involved in ensuring that adequate feed-

ing volumes are infused, including the patient/family, direct

care staff, and those who oversee specific aspects or the overall

management of the patient course, from recovery to healing and

maintenance. Daily care staff are responsible to account for EN

infusion volume over a specific period. If the infusion rate is

multiplied by the number of hours infused, there is a risk that

periods when feeding was held may be inadvertently omitted

from the intake record. Feeding pump infusion volume may

also be an unreliable measure. Volume-based ordering has been

recommended over rate-based ordering for more accurate EN

delivery.

39,48,83

Sometimes, staff or patients themselves question

why 100 mL of EN remains after an overnight infusion when

the total volume should have infused. However, when the less-

than-optimal infusion volume is not noticed, nutrition deficits

can accrue. Professionals who oversee the broad aspects of EN

delivery volume use records of daily feeding volumes to assess

the overall EN delivery trend and its effects. They may be

responsible for establishing and updating the nutrition plan

based on trends and outcomes. Delivery and calculation of EN

formula may be more accurate when volumes can be ordered in

specific amounts, such as 2 cartons/cans/cups of feeding 3

times per day or one 1000-mL container per night. Similarly, if

water intake is ordered in specific amounts and accountability

for it is built into the EHR, such as via the medication adminis-

tration record, delivery may be more reliable and accurate.

Also, when water is described in terms of household measure-

ments, such as a cup of water, the patient, family, and staff

might more easily equate feeding to meals.

Enteral feeding pump inaccuracy contributes to the dis-

crepancy between ordered and delivered formula volume.

Feeding pumps may either overdeliver or underdeliver pre-

scribed volume within the prescribed timeframe.

84–86

Deficits

of 0.5%–21% have been observed.

84,85

The set rate on the

72 Journal of Parenteral and Enteral Nutrition 41(1)

pump does not always correlate with the amount of formula

delivered, and this discrepancy may be responsible for up to

81% of cases where the patient does not receive the prescribed

amount of formula.

Advances in enteral feeding pump tech-

nology may improve accuracy.

Double-checks and assessments for accuracy of delivered

amounts such as comparing formula amount and time hung

with amount remaining at the end of a time period compared to

expected delivered amount can help detect inaccuracies of EN

delivery.

Topics for Future Research

 Comparison of gastric vs small bowel feedings on

clinical outcomes in patients requiring prone positioning

 The advantages and disadvantages of holding enteral

feedings for surgical procedures and for what duration

prior to the procedure

 Incidence of overt or microaspiration in patients fed via

the bolus method

 Jejunal feeding transition from continuous to

intermittent or bolus method for patient convenience

 Feasibility of transferring enteral volume data directly

from enteral feeding pump to the EHR

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Section 7. Administration: EAD Patency

Background

Feeding tubes (EADs) are prone to clogging for a variety of

reasons. The risk of clogging may result from feeding tube

properties (narrow tube diameter and the tube material), the

tube tip location (gastric vs small bowel), insufficient water

flushes, formula contact with acidic fluid, aspiration for

GRV, contaminated formula, and incorrect medication prep-

aration and administration.

1–3

The importance of maintaining

tube patency is well known. A clogged feeding tube can result

in decreased nutrient delivery or delay administration of medi-

cation, and, if not corrected, the patient may require additional

intervention to replace the tube. Replacement of the EAD can

increase cost and cause patient discomfort. Replacement costs

are higher for jejunal feeding tubes, as they must be replaced in

radiology and require fluoroscopic confirmation of tube

placement.

A common cause for an enteral feeding to fail is tube

occlusion, with an incidence as frequent as 23%–35%.

most cases, tube occlusion delays administration of nutri-

tion support and medications. Prompt restoration of tube

patency reduces the clinical impact and may save health-

care resources devoted to tube replacement. Research sup-

ports water as the best choice for initial declogging efforts.

Flushing a tube with water is an easy and often effective

step. The use of cranberry juice and carbonated beverages

may worsen occlusions because of the acidic pH of these

fluids. Acid can cause proteins in enteral formula to pre-

cipitate within the tube, making the clog worse or leading

to more clogging later on.

2–6

Papain, as a sole treatment

option, has produced varying results.

If water does not

work, a pancreatic enzyme solution, an enzymatic declog-

ging kit, or mechanical devices for clearing feeding tubes

are second-line options.

Question 7.1. What are the best practices to maintain

tube patency and prevent tube clogging?

Practice Recommendations

1. Use the largest diameter feeding tube feasible without

sacrificing patient comfort. This includes the largest

inner diameter for a jejunal extension tube through

PEG tubes.

2. Flush feeding tubes immediately before and after

feeding with intermittent feedings. With continuous

feedings, flush at standardized intervals.

3. Flush feeding tubes before and after medication

administration and follow appropriate medication

administration practices (see Section 8).

4. Limit gastric residual checks as acidic gastric contents

may cause protein in enteral formulas to precipitate

within the lumen of the tube.

5. Use aseptic technique when handling enteral formula,

administration sets, and feeding tubes.

6. Use an administration pump when slow rates of enteral

formula are required, such as in the neonatal population,

and respond promptly to pump alarms.

7. Use purified water for flushing the EAD in adult and

neonatal/pediatric population before and after

medication administration.

8. Use purified water for tube flushes in immuno-

compromised or critically ill patients, especially when

the safety of tap water cannot be reasonably assumed.

9. Consider use of an automatic flush pump to prevent

tube clogging and provide additional hydration.

Rationale

Small internal diameter and longer feeding tubes, such as naso-

gastric and nasojejunal tubes, have a higher risk of clogging

compared to shorter and large diameter tubes such as gastros-

tomy tubes.

1–3,7

The larger the diameter of the tube lumen, the

better the flow. Larger bore tubes are less likely to be occluded

by either medication or highly viscous formulas.

3,4,8

In a retrospective review of 560 long-term home EN

patients, Ao et al

compared complication rates requiring tube

replacement between jejunostomy tube and PEG tube patients.

The study found that, compared with PEG tubes, jejunostomy

tubes are associated with higher rates of complications that

require tube replacement, with dislodgement and obstruction

being the main causes for tube replacement. Polyurethane

tubes are preferable to silicone because polyurethane better

sustains patency.

However, in a laboratory study by Rucart

et al,

the impact of different unclogging agents (sterile water,

sodium bicarbonate, papain, digestive enzymes, cola, orange

juice, and pineapple juice) on silicone and polyurethane tubes

showed that silicone tubes seem to be less vulnerable to dam-

age. In this study, only bare tubes were put in contact with the

Boullata et al 75

unclogging agents, and the investigators concluded that occlu-

sion is partly influenced by interactions at the tube surface, and

damage would be aggravated during the administration of EN

and medications.

One study found that surface modifications

of polyurethane could reduce both the amount of material

absorbed into the surfaces as well as occlusion in the tubes.

The mechanism of clogging may involve denaturation and

precipitation of proteins in enteral formulas when formulas come

into contact with gastric acid from the stomach. Clogging may

also be caused by interactions of the coagulated formula with

feeding tube surfaces, especially during slow feeding infusion

rates.

3,5

It has been observed that feeding tubes positioned in the

highly acidic environment of the stomach may clog more readily

than those positioned in the more neutral pH environment of the

small bowel.

The technique of aspirating gastric juices into feed-

ing tubes for GRV checks can increase clogging.

The hubs of feeding tubes have been shown to harbor enteric

bacteria that appear to have migrated from GRV and tube patency

checks and further contaminated the extraluminal portion of

enteral delivery sets.

Formula contamination must be mini-

mized to prevent clog formation from formula coagulation. To

reduce risk of formula contamination, administer water as sepa-

rate flushes instead of adding it directly to the tube-feeding for-

mula; also, wipe down enteral formula containers with isopropyl

alcohol and allow them to air dry prior to use. Manufacturer rec-

ommended hang times must be followed to prevent bacterial

growth.

When handling enteral feeding administration sets, indi-

viduals must follow standard precautions.

Prevention is the preferred way to minimize the risk of

enteral feeding tube clogs. Consistent and scheduled flushing

of all types of tubes during feeding and medication administra-

tion is the best way to decrease the incidence of tube occlusion.

If formula infusion rates are slow, an enteral feeding pump

can be used. Pump occlusion alarms must receive prompt

attention.

Enteral feeding pumps with automatic flush systems

are designed to decrease clogged feeding tubes and provide

additional hydration.

Flushing the tube is an effective preventive measure. No solu-

tion has been found to be superior to water for its effectiveness,

accessibility, and cost.

Based on the available data, water is the

preferred fluid for flushing feeding tubes, reconstituting or dilut-

ing enteral feeding formulas, and diluting medications for enteral

administration. Water used for tube flushing could be drinking

water or sterile water.

There are variations in practice, such as

using purified water when the tap water is not proven safe from

microbial or chemical contaminants. In a survey of 823 nurses,

26% always use sterile water to flush tubes before or after medi-

cation administration and 70% always use tap water.

Use of

sterile water for tube feeding can minimize the risk of transmis-

sion of pathogens from water sources in high-risk patient areas.

In the home setting, either tap water or bottled water is generally

used for water flushes, if tap water is free of contaminants.

In neonatal nutrition, flushes are used sparingly because the

nutrient needs of neonates are so high and there is little room

for fluids that do not contain nutrients. When necessary, flushes

are used at a minimal volume (2 or 3 mL) to maintain the

patency of the feeding tube. In pediatrics, depending on the

size of the child, flushes are more commonly used to maintain

tube patency and to give more water volume.

Question 7.2. What factors determine optimal frequency

and amount of water flushes?

Practice Recommendations

1. In the adult patients, flush feeding tubes with a

minimum volume of 30 mL of water every 4 hours

during continuous feedings or before and after

intermittent feedings.

2. Flush the feeding tube with 30 mL of water after GRV

measurements in an adult patient.

3. In neonatal and pediatric patients, flush feeding tubes

with the lowest volume necessary to clear the tube.

Rationale

There are variations in clinical practice with regards to volume,

timing, and frequency of water flushes. However, consistent

flushing before and after medication administration, bolus feed-

ings, and periodically with continuous or cyclic feedings is very

important to prevent tube occlusion.

18–21

For inpatients receiving

continuous feedings, the amount of water recommended for

flushing ranged from 20–100 mL, and the suggested frequency

of flushing ranged from every 4 hours to every 8 hours. In

patients receiving intermittent or bolus feedings, the amount of

water recommended ranged from 15–100 mL, and sources rec-

ommended flushing both before and after feeding.

18,21

The larger

the flush volume, the more likely the tube is to remain patent;

however, the amount of water used in a flush must be deter-

mined by the patient’s fluid needs and restrictions.

In pediatrics, it is important to take the child’s age into

account when flushing an EAD with water. Routine water

flushes are not recommended after each bolus feeding or inter-

rupting continuous feeding for any tubes other than nasojejunal

tubes. For most NG and OG tubes, 3–5 mL of water will suffice

to flush a feeding tube.

1,22

In a recent survey conducted by

ASPEN, 62 clinicians who care for pediatric or neonatal patients

reported using water or air for flushing. The general flushing

volume consensus was to use 2–5 mL in pediatric patients and

1 mL or less of water or air in place of water in neonates.

Question 7.3. What is the best way to open a clogged

feeding tube?

Practice Recommendations

1. Provide proper training, credentialing, and privileging

at the healthcare organizational level to staff responsible

for unclogging tubes according to local practice acts

and institutional privileging.

76 Journal of Parenteral and Enteral Nutrition 41(1)

2. Instill warm water into the EAD using a 30- or 60-mL

syringe, and apply a gentle back-and-forth motion with

the plunger of the syringe.

3. If water flush does not resolve the clog, use an uncoated

pancreatic enzyme solution by crushing one uncoated

pancreatic enzyme tablet and one 325-mg sodium

bicarbonate tablet mixed in 5 mL of water. The solution

should be introduced to the clog and clamp the feeding

tube for at least 30 minutes. If the clog is not cleared

within 30 minutes, the solution should be removed

from the tube and replaced with a fresh mixture.

4. If water flush does not resolve the clog, use an enzyme

containing declogging kit or mechanical declogging

device.

Rationale

Prevention is the best strategy to manage risk of EAD occlu-

sion.

However, when EAD occlusion does occur, efforts to

clear the lumen may be appropriate before resorting to EAD

replacement. An approved institutional policy on declogging

enteral feeding tubes will expedite the process. Several

declogging methods are available. The success of the method

has much to do with the cause of obstruction and the knowl-

edge and skill of the provider. The declogging process may

begin when resistance is met when attempting a flush or when

an occlusion alarm sounds on an enteral feeding pump and the

tube is not kinked. However, it may be prudent to begin the

declogging process as soon as the tube becomes sluggish.

Warm water is often effective and should be first-line treat-

ment. A 30- or 60-mL syringe is attached initially to the tube

and the plunger pulled back to help dislodge the clog. The flush

syringe is then filled with warm water and reattached to the

tube to attempt a flush. If resistance is met, the plunger of the

syringe may be moved using a gentle back-and-forth motion to

help loosen the clog, then clamp the tube and soak for up to 20

minutes to allow the warm water to penetrate the clog.

3,18

resistance continues, a second-line approach is to use an acti-

vated pancreatic enzyme solution.

Pancreatic enzymes have been documented as effective agents

in clearing feeding obstructions caused by enteral formulas.

2,6,23

While enteric-coated and extended-release pancreatic enzyme

products are available, they are not as effective for dissolving

obstructions in feeding tubes.

23,24

Klang

evaluated the removal

of the enteric coating to release the pancreatic enzymes for the

purpose of unclogging feeding tubes. The findings show that pan-

creatic enzymes in enteric-coated products can be released and

that these pancreatic enzymes can disrupt clogs. If the clog is of

considerable size, warm water is still the first choice to allow for

the passage of fluid.

Another study evaluated the effectiveness

of alkalinized Creon delayed-release pancreatic enzyme protocol

to clear occluded feeding tubes. The protocol was administered to

83 patients, and tube patency was restored to approximately half

(48.2%) of occluded tubes.

A recent in vitro study evaluated the

efficacy of an uncoated pancreatic enzyme in comparison to

water or cola in dissolving an enteral formula clog that would

occur in feeding tubes.

When combined with sodium bicarbon-

ate, the uncoated pancreatic enzyme effectively dissolved an

enteral formula–associated occlusion, whereas water loosened

the clog but did not dissolve the obstruction, and cola did not

have an impact on the obstruction.

Well-designed in vivo studies

are needed to better evaluate all options.

Commercially available enzyme declogging kits contains a

syringe preloaded with a powder of food-grade papain, cellu-

lose, and amylase enzymes, which can break down protein,

fiber, and starch clogs. The powder is activated by pulling

water into the syringe. An elongated hollow catheter is

attached to the syringe so that the declogging solution is deliv-

ered closer in proximity to the clog and left clamped for 30–60

minutes. After that period of time, the tube is unclamped and

a water flush is attempted. If the tube is still clogged, the

declogging process may be repeated with the remaining solu-

tion in the syringe. In one study, 15 of 17 tubes were success-

fully declogged on the first attempt, and the remaining 2 were

declogged on the second try, preventing the need for any tube

reinsertions.

Other commercially available mechanical

devices are designed to mechanically dismantle clogs and can

be used for formula or medication-related occlusions.

2,18,24

the clog is not resolved by these methods, feeding tube

replacement is indicated.

Topics for Future Research

 Identifying incidence rates of EAD obstructions by

unit, institution, and health systems to better understand

the problem

 Understand the differences in maintaining tube patency

between recommended guidelines and actual clinical

practice

 The safety and efficacy of currently available methods

to unclog enteral feeding tubes

 The safety and efficacy of commercially available

agents marketed for resolving occlusions related to

enteral formula or medications

 Maximum volume for flushing small bowel feeding

tubes

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19. Schrag SP, Sharma R, Jaik NP, et al. Complications related to percuta-

neous endoscopic gastrostomy (PEG) tubes: a comprehensive clinical

review. J Gastrointest Liver Dis. 2007;16(4):407-418.

20. Blumenstein I, Shastri YM, Stein J. Gastroenteric tube feeding: techniques,

problems and solutions. World J Gastroenterol. 2014;20(26):8505-8524.

21. Reising DL, Neal RS. Enteral tube flushing. Am J Nurs. 2005;105(3):58-63.

22. Lyman BL, Shah SR. Nutrition access. In: Corkins MR, ed. The A.S.P.E.N.

Pediatric Nutrition Support Core Curriculum. 2nd ed. Silver Spring, MD:

American Society for Parenteral and Enteral Nutrition; 2015:567-582.

23. Arriola TAD, Hatashima A, Klang M. Evaluation of extended-release pan-

creatic enzyme to dissolve a clog. Nutr Clin Pract. 2010;25(5):563-564.

24. Bommarito AA, Heinzelmann MJ, Boysen DA. A new approach to

the management of obstructed enteral feeding tubes. Nutr Clin Pract.

1989;4(3):111-114.

25. Lazar J. Treatment of feeding tube occlusions [abstract]. A.S.P.E.N.

Clinical Nutrition Week. Nutr Clin Pract. 2011;26(1):E13.

Section 8. Medication Delivery via Enteral

Access Devices

Background

Medication administration through an EAD can be much more

complex than it would seem. The vast majority of medications are

not formulated to be administered through a feeding tube. In fact,

not all drugs are safe or appropriate for this route of administra-

tion. Careful consideration must be given to each individual medi-

cation prescribed and the goals of therapy. Administration of

many oral medications via enteral feeding tube can be an effective

method of medication administration, but a number of medica-

tions carry complex drug-nutrient or drug-drug interactions that

can impact drug efficacy and drug toxicity. When institutions

create policies regarding medication administration via enteral

feeding tube, they can determine what supplementary order

accompanies the EN order to facilitate proper medication admin-

istration. To prevent untoward consequences, including fatalities,

it may be advisable to have a pharmacist review medication orders

and the preparation of medications for administration via EAD.

It is essential that a necessary medication is appropriately

prepared and administered through a feeding tube without

increasing the risk for complications in the patient. Com-

plications include impairing the patency of the feeding tube,

reducing therapeutic effect of the medication, or increasing

drug toxicity. Additionally, some medications can pose a haz-

ard to the healthcare provider. Safety must be the focus of both

the preparation of the medication and administration of the

medication. Preparation refers to the retrieval of a medication

and any alteration to a dosage form to make it suitable for

delivery through a feeding tube. The alteration may be as sim-

ple as diluting a liquid medication or as complex as compound-

ing a new formulation from multiple components, including

the active pharmaceutical ingredient. The administration step

involves the timing of drug delivery to the patient’s GI tract

with respect to flushing protocols, other medications, and the

EN regimen. Practice recommendations have been available to

practitioners for a number of years.

The rationale for such rec-

ommendations has been further described.

2,3

Despite these

publications, recent surveys still identify that some preparation

methods and administration practices do not follow best prac-

tices, which may contribute to adverse risk.

Question 8.1. What factors should be evaluated to safely

prepare and administer medication through an

enteral access device?

Practice Recommendations

1. Evaluate factors related to the patient and to their

enteral feeding tube.

a. Identify the patient’s current enteral status (oral,

NPO, or NPO except for medications).

b. Identify whether the patient can take medication by

mouth or requires enteral medication administration.

c. Identify what, if any, anatomical or functional

abnormalities in the patient’s GI tract that may

preclude drug absorption.

d. Document or retrieve the documentation in the

EHR of the current feeding tube so that these data

are available for all healthcare providers. Describe

the device by its entry point and distal end (ie,

nasogastric, percutaneous jejunostomy) and its

diameter (eg, 12 French), rather than by the brand

name or color of the feeding tube.

e. Document or retrieve the documentation in the

EHR, verifying the placement of the distal end of

the feeding tube.

f. Document or retrieve the documentation in the

EHR regarding the feeding formulation and

78 Journal of Parenteral and Enteral Nutrition 41(1)

flushing regimen being administered through the

feeding tube.

g. Confirm tube patency.

2. Evaluate factors related to the medication and its

dosage form.

a. Identify the route (oral vs enteral) and the distal

site of drug administration as ordered (drug

administration should match current enteral status).

b. Develop real-time communications to inform the

pharmacy of any changes to the route or distal site

of medications being prepared and dispensed.

3. Confirm the following aspects of enteral medication

orders and resolve any inappropriate orders with the

prescriber and nurse.

a. The drug dosage form is appropriate for enteral

feeding tube administration (ie, immediate release).

i. Avoid any solid dosage form medications

that would result in a significant change in

the absorption of the active ingredient(s) if

opened (capsule) or crushed (tablet).

ii. Evaluate each medication for its inherent

solubility and release characteristics. If

crushing the medication alters its delivery

(eg, enteric coated, extended release, or novel

excipients for alternative delivery systems),

consider an alternative dosage form, drug, or

route of administration.

b. The drug and the formulation are both appropriate

based on the distal end of the feeding tube.

i. Avoid bypassing the primary site of drug

absorption.

ii. Avoid high-osmolality or highly viscous

preparations.

c. Any medication order that will require a

preparation step (eg, crushing, diluting, mixing)

prior to administration is identified.

i. Establish and follow organizational policies

and procedures to prepare medications for

enteral administration that will comply with

USP chapter <795>.

4. Document in the EHR any clarifications or interventions

related to the prescribing, reviewing, preparation, or

administration of medications for the patient receiving

EN.

5. Work with CPOE vendors and application architects to

design systems such that each medication is ordered by

the appropriately intended route of administration.

Rationale

The enteral route of drug administration is unique and differs

from the oral administration in several ways. The topic of enteral

medication administration is receiving more attention in the lit-

erature.

Organizations that develop and put into practice proto-

cols for enteral medication administration are much more likely

to prevent related medication errors than those that lack proto-

cols.

6,7

Best practices include an evaluation of both the EAD and

the medication profile in a systematic fashion. Although not

widely recognized or reported, medication errors related to the

enteral route of administration happen.

Inappropriate prepara-

tion and/or administration technique can lead to an occluded

tube, reduced drug effect, or increased drug toxicity. These poten-

tial adverse outcomes are not always captured in medication error

rates. Routine reporting of all enteral medication errors to the

medication safety committee or other appropriate institutional

committee is important so that systems improvements can be

made to address them. The responsibility for preventing enteral

medication errors should be shared by the prescriber, pharmacist,

and nurse. The nurse is in a difficult position if a prescriber enters

an inappropriate medication order and the pharmacist does not

clarify it. An interdisciplinary group of healthcare providers,

including knowledgeable prescribers, pharmacists, and nurses,

can work together to develop protocols for administering medi-

cations through enteral tubes within their organization.

Summary

documentation of clarifications or interventions related to medi-

cation use in the enterally fed patient can be reviewed on a regu-

lar basis. Unless a culture of safety already exists within an

organization to consider, document, and report all errors related

to EN and medication administration in patients receiving EN,

institutions may assume that there are no safety issues or errors.

Emami et al

reported a case of a 53-year-old man who was

in the ICU and subsequently intubated with a nasogastric tube

being used for nutrition support and medication administra-

tion. During his 30-day hospitalization, this patient improperly

received all of his scheduled oral medications via feeding tube,

including multiple sustained-release and extended-release

drugs, crushed and combined with each other in 40 mL of tap

water. A multidisciplinary team with a pharmacist reviewing

medications to be administered via enteral feeding tube could

have prevented these errors and intervened with proper recom-

mendations for medication administration.

Caregivers are typically confident that they prepare and/or

administer drugs appropriately, although surveys have suggested

otherwise.

1,4

Prospective observational studies suggest that these

types of medication errors may occur with about 60% of doses;

these finding highlight the need for pharmacists to be vigilant and

work closely with prescriber and nurse colleagues.

10,11

In a study

by Boullata and colleagues,

patients with “NPO” orders and

unable to take medication by mouth were still prescribed drugs

“PO” over 80% of the time. Of those, many orders were not cor-

rected by the pharmacist reviewing the orders, which therefore

placed the nurse in the precarious position of committing a wrong

route medication error. In this same study of drug administration

in enterally fed hospitalized patients, less than 20% of drugs

administered directly into the small bowel were considered

appropriate.

In these cases, therapeutic alternatives or a differ-

ent route of administration may need to be considered.

A number of medications, including modified-release dos-

age forms (eg, delayed release, sustained release), are inappro-

priate for the enteral route. A listing of the many oral dosage

Boullata et al 79

forms that should not be crushed or opened is readily avail-

able.

These dosage forms are implicated not only in potential

for interaction or excessive bolus drug doses but also for

exposing caregivers (including via inhalation) to allergenic,

cytotoxic, and teratogenic products.

Liquid medications, while offering the advantage of an easier

to administer dosage form for the feeding tube, rarely are the ideal

formulation for that route. Ingredients such as sugars, preserva-

tives, and thickening agents can cause significant side effects that

may be interpreted as intolerance to the EN formula. The undi-

luted administration of liquid medications with an osmolality

>500–600 mOsm/kg may be associated with significant GI distur-

bances, especially in vulnerable patients.

14–16

The healthy stomach

is able to tolerate hyperosmolar liquids much better than the small

intestine, although gastric emptying may be delayed. Gastric

administration reflects the intended site of drug disintegration

when administered orally, but postpyloric administration may

alter bioavailability and affect the risk of GI complaints and mal-

absorption. The highest physiologic osmolality expected in the

small bowel is ~600 mOsm/kg in the fed jejunum.

Crushing an immediate-release solid dosage form and giving

the medication with adequate dilution is often the safest course of

action. For a medication administered enterally to be absorbed, it

must first be dissolved in solution. Preparing a liquid dosage form

is fraught with complexities, and an appropriate reference should

be consulted before assuming stability.

17–21

Even simple opera-

tions such as crushing an immediate-release tablet and mixing it

with water must be examined because the safety and efficacy of

the medication may be affected by the quality of the water (tap vs

purified), degree of crushing (particle size), and time of exposure

(as the drug may degrade in a liquid form). In the absence of drug-

specific data, pharmaceutical principles should be used to make

recommendations. Many newer drugs have poor water solubility.

They are formulated with coprecipitates, solubilizers, and surfac-

tants that should remain in close proximity to the active pharma-

ceutical ingredient (API) to ensure dissolution at the targeted time.

Mixing these formulations in a separate vessel and then transfer-

ring the contents to the enteral feeding system may allow the sepa-

ration of ingredients, precipitation of the API, and failure to

absorb. Suggestions for drug products containing a poorly soluble

API have included placing the product in the barrel of a syringe

and adding a diluent to allow a slurry to form before administra-

tion. This methodology requires a larger EAD (14 Fr).

By addressing issues with drug administration in the patient

with an EAD, the pharmacist plays a critical role in supporting the

prescriber and the nurse.

When evaluating an enteral drug order

in a patient receiving EN, the pharmacist needs to be aware of the

patient’s GI status, the EN regimen, and the location of the EAD

to identify inappropriate administration routes, any potential inter-

actions, or other administration route issues. The pharmacist must

resolve conflicts when a prescriber orders a drug to be adminis-

tered PO in the patient with NPO orders. If the drug is intended for

administration through the EAD, the order must indicate this

route; if it does not, the nurse who administers the medication by

the “wrong route” seems to commit a medication error. More

important, the pharmacist needs to decide whether the drug and its

formulation are appropriate for EAD administration. Given the

risks for physicochemical incompatibility and instability, drugs

are not to be admixed together. Potential drug-nutrient interactions

that result from a physical, chemical, physiologic, or pathophysi-

ologic relationship between a drug and EN also need to be consid-

ered.

An interaction is considered clinically significant when it

influences therapeutic response (or compromises nutrition status)

with clinical consequences related to altered drug (or nutrient) dis-

position. For example, EN can alter drug bioavailability. The bio-

availability of some drugs may benefit from administration in

close proximity to EN, whereas the bioavailability of others may

be significantly reduced in the same circumstances. In the latter

case, administration of drug should be temporally separated from

EN. Lists of drugs to be administered with, or separated from, EN

are best used in conjunction with other considerations for drug

administration via EAD (eg, flushing protocol, appropriate drug

dilution, location of EAD distal tip).

Question 8.2. What steps offer the safest method to

deliver medication through an enteral feeding tube?

Practice Recommendations

1. Develop policies and procedures to ensure safe

practices by staff across all departments involved with

enteral medication preparation and administration.

2. Identify drug, dose, dosage form, route (ie, enteral),

and access device (eg, nasoduodenal tube) in the

prescriber’s order.

3. Review by a pharmacist of each medication order to

determine whether the enterally administered medi-

cation will be safe, stable, and compatible as ordered.

4. Institute and follow nursing policies and procedures to

prepare and administer each medication safely.

5. Provide nonsterile compounding pharmacy services

to support medication preparation.

6. Use best practices as per USP <795> for any enteral

drug preparations compounded in advance (ie, not for

immediate use) and these should be based on:

a. Published stability data and clearly described

with citations in the organization’s Master

Formulation Records

b. Documenting in a permanent Compounding Record

c. Providing a beyond-use date

d. Storage in a container consistent with the

stability/compatibility literature and USP <795>

7. Do not add medication directly to an enteral feeding

formula.

8. Administer each medication separately through an

appropriate access.

9. Avoid mixing together different medications intended

for administration through the feeding tube given the

risks for physical and chemical incompatibilities, tube

obstruction, and altered therapeutic drug responses.

80 Journal of Parenteral and Enteral Nutrition 41(1)

10. Use available liquid dosage forms only if they are

appropriate for enteral administration. If liquid dosage

forms are inappropriate or unavailable, substitute only

immediate-release solid dosage forms.

11. Prepare approved immediate-release solid dosage forms

of medication for enteral administration according to

pharmacist instructions. Techniques may include:

a. Crush simple compressed tablets to a fine powder

and mix with purified water.

b. Open hard gelatin capsules and mix powder

containing the immediate-release medication

with purified water.

12. Use only appropriate instruments to measure and

prepare enteral medication.

13. Use only clean enteral syringes (20 mL with ENFit

device) to administer medication through an EAD.

14. Provide appropriate tube irrigation around the timing

of drug administration:

a. Prior to administering medication, stop the feeding

and flush the tube with at least 15 mL water.

b. Administer the medication using a clean enteral

syringe.

c. Flush the tube again with at least 15 mL water,

taking into account the patient’s volume status.

d. Repeat with the next medication.

e. Flush the tube one final time with at least 15 mL

water.

15. Restart the feeding in a timely manner to avoid

compromising nutrition status. Hold the feeding by 30

minutes or more only if separation is indicated to

avoid altered drug bioavailability.

16. Consult with an adult or pediatric pharmacist for patients

who receive medications coadministered with EN.

Rationale

The most consistent delivery of medication through an EAD

comes from adequate drug dilution and flushing.

23–26

Medication that is in an appropriately powdered form, either

from pulverized tablets, capsule contents, or dry powder prod-

ucts intended for reconstitution, needs to be diluted to ensure

delivery through the EAD. Dilution may be necessary for the

enteral administration of liquid medications (ie, solutions, sus-

pensions) to reduce viscosity or osmolality. Reducing viscosity

allows the full drug dose to reach the distal end of the EAD,

especially for longer, small-bore tubes. Not diluting a suspen-

sion could result in a significant decrease in drug delivery and

bioavailability when administered through an EAD.

23,24

In a

crossover study in healthy volunteers, administration of an

undiluted drug suspension (posaconazole) through a 16 Fr

nasogastric tube resulted in a 23% lower bioavailability than

the oral administration.

In another study, compared to 1:1

(v:v) dilution, 11%–24% of undiluted drug suspension (carba-

mazepine) was lost, depending on the diluent, despite all 12 Fr

nasogastric tubes being flushed.

Again, the most consistent delivery through an EAD comes

from adequate drug dilution and flushing.

23,24

Water is the sim-

plest fluid for diluting powdered or liquid medication (see

Appendix 1). The U.S. Pharmacopeia requires that purified water

be used for preparation of drug dosage forms. Purified water

refers to water that is free of contaminants (chemical and biologi-

cal) following source water selection, distillation, and filtration.

Drinking water (tap, bottled, and well water) may contain

chemical contaminants. Therefore, the use of drinking water to

dilute medication prepared for enteral administration can increase

the risk for potential drug interactions, which may, in turn, alter

drug bioavailability.

26,27

For this reason, purified water is required.

Sterile water for irrigation is an example of a purified water prod-

uct, but there is no need for the diluent to be sterile.

However, the

potential for acute drug-drug, drug-chemical interactions when

contaminated waters are combined with medication has not been

quantified. More data regarding the appropriateness of medication

dilution and the potential for drug interactions are needed.

Dilution with 30–60 mL of water seems adequate for pow-

dered medication.

28–31

The volume required to dilute liquid med-

ication depends on the desired degree of viscosity and/or

osmolality. Diluting viscous suspensions in a volume of at least

1:1 seems to be adequate for some drugs.

24,32

High-osmolality

medication can result in localized adverse effects at the mucosa

or create an osmotic effect throughout portions of the bowel. The

higher the osmolality, the greater the volume of diluent required

to lower the osmolality.

The case has been made that it would

be more practical to crush an acetaminophen tablet to a fine

powder and disperse in a smaller volume of water than to use a

liquid formulation that requires significant volume dilution.

The time lapse between stopping the EN, administering the

drug, and restarting the EN will depend on any potential for

drug-nutrient interaction in the GI lumen.

1,33

When an immediate-release solid dosage form needs to be

prepared for EAD administration, there are several options

available. A study compared 3 preparation methods in terms of

crushing yield, microscopic observation, suspension stability,

and aerosolization.

The data suggest no significant difference

in efficiency of crushing between methods. However, the parti-

cle granularity differed by drug, indicating that crystal structure

and excipients are a factor in determining how fine a powder can

be produced, and this may predict interaction potential. Confined

crushing yielded smaller particles, but all particles suspended

similarly in water. Open crushing yielded significantly greater

amounts of particulate matter (>10

particles) in the cubic meter

of space directly above where the drug is prepared.

Although more time-consuming, separation of each medica-

tion administered through an EAD reduces the risk of tube

obstruction and interactions. Drug errors can additionally be

related to inappropriate use of dosing instruments as well as

health literacy.

The ideal medication delivery system for EN administration

would be to have the drug fully dissolved in a solution that has

a neutral pH, tolerable osmolarity, and low viscosity. This

delivery system does not exist. Most liquids are thick and

Boullata et al 81

contain sweeteners and insoluble excipients. The drugs that are

not available in liquid formulation have limited stability in that

state, making them poor candidates for enteral administration.

To optimize patient safety, it is important to evaluate each

medication for appropriateness of the specific enteral route.

Factors to assess include the formulation, solubility of the API,

and the use of excipients to deliver the medication. Each medi-

cation is unique, and global assumptions can lead to both inef-

fectiveness of the targeted medications or toxicity of enhanced

absorption.

One approach that is becoming popular

1. Open an appropriate oral or feeding tube syringe by

withdrawing the plunger.

2. Place the single medication dosage form in the syringe.

This could be a capsule or tablet.

3. Replace plunger.

4. Add 15–30 mL purified water at room temperature.

5. Wait 20 minutes for slurry to form.

6. Once all solids have disintegrated, use the syringe to

administer the medication through a flushed feeding tube.

7. Rinse the feeding tube with an additional 15–30 mL

purified water.

This method is especially useful when handling hazardous

medications ordered for administration through an EAD. It is also

beneficial in administering drugs formulated with cosolvents that

would precipitate if mixed in a separate container and transferred

to a syringe. Some capsules are slow to dissolve in water and will

form clogs in smaller bore feeding tubes (<12 Fr). In these cases,

a special compounded liquid formulation will be needed.

Extra caution is needed when using specialty pharmacies

that compound oral liquid formulations. Most formulations

contain high amounts of sorbitol, a potent cathartic, which is

added as a sweetening agent. There is no need for sweeteners

and flavoring agents for drugs to be administered through an

EAD. Ask the compounding pharmacist to use a low-osmolar-

ity suspending agent for compounding drugs that will be more

likely tolerated for feeding tube use.

Question 8.3. When prescribing medications to be

administered via an enteral route, what is the safest

and most effective way to name (communicate) the

route and site of administration?

Practice Recommendations

1. Develop policies, procedures, and practices across

departments for a uniform way of referring to short-

term and long-term EADs across departments.

2. Describe each device by its entry point (eg, naso-,

percutaneous) and its distal end (ie, gastric, jejunostomy),

its diameter (eg, 12 French). Avoid references to brand

names, shapes, or colors of the feeding tube.

3. Work with EHR vendors so that CPOE systems allow

for a specific route of administration when medications

are intended for feeding tube administration.

Rationale

The method used to prepare a drug for administration through

an EAD depends on the internal diameter, total internal sur-

face area, and distal site of drug delivery. The dimensions of

the feeding tube are crucial in determining the appropriate

selection of a formulation for the medication to be adminis-

tered. Tubes with an internal diameter equal to or greater than

10 Fr work best for administering crushed or dissolved solid

dosage medications. If the tube is less than 10 Fr, the medica-

tion must be in a liquid formulation with few, if any, residual

solids. Some feeding tubes have internal dual channels to

allow for the separation of stylus. Due to their small internal

diameters, these tubes are especially prone to clogging.

The proximal site or entry point provides a clue as to the

length of the tube and its overall surface area. Longer tubes are

more prone to complications related to the cumulative resistance

to flow as well as medication interaction with the tubing mate-

rial. The distal site, whether gastric, duodenal, or jejunal, will

determine the extent of dissolution that will be required in the

formulation selection. For a jejunal feeding tube, the API should

be fully dissolved and prepared in a vehicle with a final osmolar-

ity of approximately 285 mOsm/L. In some cases, acid is added

to the formulation to enhance API solubilization; in other cases,

sodium bicarbonate is added to remove the medication’s enteric

coating and allow dissolution. Liquid medications administered

into a feeding tube with the distal end placed in the stomach can

have a higher osmolarity of approximately 500 mOsm/L. Drugs

administered into the stomach can include slurries and suspen-

sions since dissolution should occur in the gastric fluid.

It is troubling how few CPOE systems allow for selecting

the specific feeding tube route as a designation when placing an

electronic medication order for that route. The practice of using

“PO” for the “allowed” route and then indicating special admin-

istration instructions in a free text field can contribute to error.

Question 8.4. What factors will determine whether the

pharmacy or the nurse will prepare medication for

enteral administration?

Practice Recommendations

1. Develop policies, procedures, and practices to

determine how the workload of drug preparation for

enteral administration will be distributed.

2. Only trained personnel can prepare hazardous

medications or drugs that contain known allergens.

Prepare these medications under conditions that protect

all personnel, in compliance with OSHA and NIOSH

publications as well as USP Chapter <800>.

3. Avoid environmental risks of cross-contamination

between medications.

4. If permitted by the organization, a nurse may prepare

nonhazardous and nonallergenic drugs with limited

stability in a clean area of the medication room.

a. Maintain practices and responsibilities consistent

with USP chapter <795>.

82 Journal of Parenteral and Enteral Nutrition 41(1)

b. Unless prepared for immediate use, label the final

container (eg, enteral syringe) according to all

applicable federal and state laws, and include a

beyond-use date.

5. Appropriately trained personnel in the pharmacy are

responsible for preparing drugs that require significant

manipulation and fall within the context of compounding.

a. Follow the organization’s policies and procedures

as well as USP chapter <795>.

b. Unless prepared for immediate use, label the final

container (eg, enteral syringe) according to all

applicable federal and state laws, and include a

beyond-use date.

Rationale

Ideally, all medications that must be compounded or mixed

are presented to the nurse in the final dosage formulation to be

administered. However, each organization will need to deter-

mine how best to approach this given its resources and admin-

istrative support structures.

The enteral administration of hazardous medications

poses additional risk. For oral chemotherapy agents, crushing

must be avoided. Ideally, a closed-system transfer device,

similar to those used for reconstitution of injectable chemo-

therapy, would be used in compounding of chemotherapy for

enteral administration. For more information on hazardous

medication handling, refer to OSHA and USP chapter <800>

guidance.

36,37

Several reports indicate that the optimal way to prepare

drugs is to place the drug inside a syringe, add water, and then

mix to dissolve the medication. This method can be safer than

crushing drugs because it limits the operator’s exposure to

some of the hazardous components of the tablet or capsule for-

mulation. Furthermore, putting the uncrushed drug in a syringe

and making a slurry keeps all components together and allows

delivery similar to oral intake of the medication. Many drugs

have poor water solubility and are formulated with excipients

to enhance dissolution. Crushing the drug and mixing in a sep-

arate container risks that the components will separate and

drug will precipitate.

Question 8.5. What is the optimal method for the

pharmacy to dispense medications to the patient

care unit for the nurse to administer via the feeding

tube?

Practice Recommendations

1. Develop policies and procedures that describe the

labeling and dispensing of enteral medications in a

manner consistent with federal and state laws as well

as USP chapter <795>.

2. Label the medication using:

a. Patient identifiers

b. Common (ie, generic) name of the drug using

TALLman lettering as indicated

c. Dose of the drug

d. Scheduled date/time of the dose

e. Manufacturer name and lot number

f. Beyond-use date

g. The organization’s Compounding Record number,

if compounding was required

3. Affix the label to the container being dispensed (eg, the

enteral syringe).

4. Dispense the medication in a manner consistent with

organizational staffing.

a. Dispense the commercial unit dose product for the

nurse to prepare.

b. Dispense unit doses prepared in the pharmacy in a

suitable container.

i. Dispense dry powder medication with

directions to dilute it with purified water.

ii. Dispense a stable slurry of the dry powder

medication in an appropriate diluent.

iii. Dispense a commercially available liquid or

extemporaneously compounded liquid

medication with directions to dilute it further

or administer it as is.

5. Dispense medication with appropriate directions for

preparation and administration.

Rationale

To optimize safety, all medication dispensed for enteral

administration must reflect practices related to stability and

be appropriately labeled. Each medication must be com-

pounded into a unique formulation appropriate for the spe-

cific type of EAD administration. Careful adherence to the

recommendations of USP <795> is essential to ensure the

medication reaches its intended target.

Even simple opera-

tions, such as crushing an immediate-release tablet and mix-

ing it with water, must be examined because outcomes may

be influenced by the quality of the water (tap or purified),

degree of crushing (larger particles are more likely to clog

EADs), or the time of exposure (the drug may degrade in a

liquid form).

Many newer drugs have poor water solubility. They are

formulated with coprecipitates, solubilizers, and surfactants

that should remain in close proximity to the API to ensure

dissolution at the targeted time. In some cases, mixing these

formulations in a separate vessel and then transferring the

contents to the syringe allows the ingredients to separate or

the API to precipitate, which decreases absorption of the API.

It is advisable to prepare all poorly soluble API drugs in a

syringe, adding the diluent and allowing a slurry to form

before administration. This methodology requires large-bore

feeding tubes (14 French) for adults.

Boullata et al 83

Question 8.6. What medications are of particular

concern for enteral delivery?

Practice Recommendations

1. Maintain at the healthcare organizational level a list of

medications that pose a concern for administration via

EAD.

2. Ensure that this list of medications complies with

NIOSH guidelines, OSHA regulations, and USP

chapter <800> and reflects the release characteristics

of the drug dosage form as well as data on interactions

with EN formula and/or enteral feeding tubes.

Rationale

Safe handling of hazardous medications is imperative.

According to USP chapter <800>, NIOSH guidelines, and

OSHA regulations, when a hazardous medication is assigned

for feeding tube administration and a liquid formulation is not

available, the dosage form must not be crushed outside the

confines of a biological safety cabinet.

36,37,39

An alternative to

crushing is to place the intact hazardous medication in a syringe

and add water to dissolve.

Another important safety issue is

the release character of the drug dosage form. For example, the

crushing of extended-release medications can cause the entire

dose to be released immediately. Significant adverse effects,

including fatality, can result from this bolus administration.

A significant number of drugs are not to be administered

through an EAD. These include hazardous drugs as well as

some nonhazardous drugs. The number of drugs considered

“hazardous” will vary with the practice setting, and the list will

be determined by the experts within each organization. The

characteristics of hazardous drugs include those that are carci-

nogenic, mutagenic, or teratogenic or that impair fertility, as

well as those causing serious toxicity at low doses in treated

patients.

36,37,39

For the purposes of enteral administration, non-

hazardous drugs that would nonetheless be inappropriate to be

manipulated and administered through an EAD are also impor-

tant to incorporate into the list and include the modified-release

versions of medication.

Lists of these substances can be read-

ily accessed through NIOSH (http://www.cdc.gov/niosh/

docs/2014-138/pdfs/2014-138_v3.pdf

) and ISMP (http://www.

ismp.org/Tools/DoNotCrush.pdf

) for review by each organiza-

tion in generating their own inventory.

13,39

The list should be

periodically reviewed and updated to reflect new data and mar-

keted drug products added to an organization’s formulary.

The administration of drugs via a feeding tube can clog the

tube, which may lead to serious complications for patient care.

Clogs also form as a reaction of protein with the acidity of the

gastric environment. The appropriate method for fixing the

clog may depend on what caused it. Many drugs are a weak

base and dissolve better in acidic fluid, whereas protein

clumps in acid and responds better to protease enzymes.

Flushing the tube with water has been shown to work well for

both forms of clogs.

Many drugs require the acid environment of the stomach to

properly dissolve. Once they are dissolved, they are absorbed

in the more basic milieu of the small bowel. Administration of

these drugs directly into the jejunum will result in altered

absorption and changes in efficacy.

Each medication admin-

istered through a feeding tube with the distal site past the pylo-

rus must be evaluated for changes in absorption by that

route.

43,44

Consideration must also be given to the action of

gastric acid–inhibiting treatments, such as proton pump inhibi-

tors, which may also alter absorption of medications.

The number of errors associated with the use of enteral-

based medications is cause for concern.

Once syringes with

enteral connectors, such as the ENFit design, are fully avail-

able, their use to dispense medications prepared for feeding

tube administration may improve safety.

The ENFit design

only allows for feeding tube administration and cannot to be

confused with any other type of therapeutic access in the patient.

The administration of medications with poor solubility is

another challenge in caring for patients on EN. These medica-

tions are specially formulated to allow dissolution under optimal

conditions.

If these drugs are mixed in a container and allowed

to sit, the excipients will separate from the active drug and pre-

cipitate out. Administering medication that has separated from

the excipients can possibly lead to therapeutic failure.

Therefore, drugs with poor water solubility should not be com-

pounded into a liquid formulation unless they are evaluated for

clinical efficacy as well as stability. In some cases, the drug can

be combined with water in an oral syringe and administered

immediately after forming a slurry.

Topics for Further Research

 Identify incidence rates of enteral medication

preparation and administration errors to better

understand the problem

 Preparation of specialized formulations for feeding tube

administration

 Design a suspension vehicle with a low osmolarity

(~285 mOsm/L) and neutral pH (~6.5–7.5)

 Stability of oral medications in low-osmolar suspending

agents and/or water

 Prospective description of enteral drug preparation and

administration systems such as type of water, degree of

crushing, time to decomposition, EAD French, or

surface area

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Boullata et al 85

Section 9. Complication Avoidance and

Error Reporting

Background

Complications associated with EN therapy are often prevent-

able with standardized monitoring protocols and vigilant

care. General complications of EN include GI, mechanical,

and metabolic consequences. For a complete review of over-

all enteral complications, refer to Section 4 on tube place-

ment as well as the ASPEN Adult and Pediatric Core

Curricula. Most complications are not of an immediate

safety concern and therefore will remain outside the scope of

this document. The safety-related complications to be dis-

cussed here include refeeding syndrome, pulmonary aspira-

tion, and enteral misconnections. An enteral misconnection

is an inadvertent connection between an enteral feeding sys-

tem and a nonenteral system, such as an intravascular cath-

eter, peritoneal dialysis catheter, tracheostomy, or medical

gas tubing.

Beginning in 2015, a new patient access connec-

tor called ENFit was made available on enteral administra-

tion sets, with enteral syringes and EADs to follow. These

connectors will not be interconnectable with other therapy

connectors such as those on intravenous, respiratory, neur-

axial, or limb-cuff pressure devices.

Question 9.1. How can EN-related refeeding syndrome

be prevented?

Practice Recommendations

1. Identify patients at risk for refeeding syndrome prior to

initiation of EN. Risk factors include:

a. Inadequate nutritional intake for >2 weeks

b. Poorly controlled diabetes

c. Cancer, both before and during treatment

d. Anorexia nervosa

e. Short bowel syndrome

f. Inflammatory bowel disease

g. Being an elderly patient living alone

h. Low birth weight and premature birth

i. Chronic infections (eg, HIV)

2. Monitor fluid balance, daily weight, and electrolyte

status (eg, potassium, magnesium, phosphorus), as

well as other metabolic parameters (eg, glucose) as

needed based on the patient’s presenting clinical

situation.

3. Evaluate metabolic and nutrition parameters, and

correct metabolic abnormalities or depleted

electrolyte concentrations prior to the initiation of

enteral feedings.

4. Initiate 25% of goal requirements on day 1 of EN.

5. Provide supplemental thiamin (IV or PO) with EN

initiation.

6. Monitor parameters (serum potassium, phosphorus,

magnesium, glucose) following EN initiation and

replace as needed.

Rationale

Refeeding syndrome is a condition that occurs when malnour-

ished patients are refed near their goal rate.

2–6

It is manifest by

rapid shifts in both intracellular and extracellular electrolytes,

which can cause life-threatening complications (Table 5).

Monitoring of these metabolic parameters prior to the initiation

of enteral feedings and periodically during EN therapy is based

on protocols and the patient’s underlying disease state and length

of therapy. Prevention of refeeding syndrome is of utmost impor-

tance. Patients at high risk for refeeding syndrome and other

metabolic complications must be identified and followed closely,

and depleted minerals and electrolytes should be replaced prior to

initiating nutrition support. Stanga et al

highlighted cases of

refeeding syndrome, and each case developed 1 or more features

of refeeding syndrome, including deficiencies and low plasma

concentrations of potassium, phosphate, magnesium, and thiamin

combined with sodium and water retention.

These patients

responded to specific interventions; however, in most cases, these

abnormalities could have been anticipated prior to feeding and

prevented.

Other cases have been described in the literature.

EN can be initiated at approximately 25% of the estimated

goal and advanced cautiously over 3–5 days toward the goal

rate. Serum electrolytes, volume status, clinical manifestations,

and vital signs are monitored carefully after EN is started.

Question 9.2. How can EN-related pulmo nary aspiration

be prevented?

Practice Recommendations

1. Routinely evaluate all enterally fed patients for risk of

aspiration.

2. Actively employ steps to reduce risk of aspiration.

3. Verify that the feeding tube is in the proper position

before initiating feedings.

4. Keep sedation level as minimal as possible.

5. Insert or advance the feeding tube with tip in the small

bowel for patients with high risk of aspiration.

6. Keep the HOB elevated at 30 to 45 at all times during

the administration of gastric enteral feedings.

7. Deliver EN continuously rather than intermittently in

patients with intolerance to gastric bolus feedings.

8. Consider a course of promotility agents (eg,

metoclopramide or erythromycin) where clinically

feasible in patients with high risk of aspiration.

86 Journal of Parenteral and Enteral Nutrition 41(1)

9. GRV measurements may not need to be used as part of

routine care to monitor ICU patients on EN. For those

patient care areas where GRVs are still utilized, holding

EN for GRVs <500 mL in the absence of other signs of

intolerance should be avoided. A gastric residual

volume of between 250 and 500 mL should lead to

implementation of measures to reduce risk of aspiration

as defined elsewhere in this document.

Rationale

In most patient populations, pulmonary aspiration can cause

chemical pneumonitis and lead to significant complications

such as hypoxia and bacterial pneumonia. Aspiration can be

defined as the inhalation of material into the airway. In the

critically ill patient, this material may include nasopharyngeal

secretions and bacteria as well as liquids, food, and gastric con-

tents.

The risk factors for aspiration include sedation, supine

patient positioning, the presence and size of a nasogastric tube,

malposition of the feeding tube, mechanical ventilation, vomit-

ing, bolus feeding delivery methods, the presence of a high-

risk disease or injury, poor oral health, nursing staffing level,

and advanced patient age and patient transfers for procedures

to other units and facilities.

Much of the research and many of

the recommendations presented here come from the critical

care literature and may not explicitly be extrapolated to all

patient populations; however, the principles generally apply.

EAD positioning. Proper positioning of the tip of the EAD is

of major importance in the prevention of aspiration. Migration

of the tube to an inappropriate position such as the esophagus

can be a factor in the regurgitation and aspiration of gastric

contents. The American Association of Critical-Care Nursing

prevention of aspiration practice alert recommends that the

position of feeding tubes be checked every 4 hours.

Radio-

graphs are the “gold standard” for placement verification, but

it is not practical to do frequent x-rays on most patients simply

to confirm the position of the tip of the tube. Other suggested

methods of checking EAD placement include marking the

point where the feeding tube enters the nares or penetrates the

abdominal wall (in the case of a gastrostomy or jejunostomy

tube) and then assessing whether the mark shifts, or measuring

and documenting the visible tube length. Although this tech-

nique can give some information, it does not verify the position

of the tip of the tube. Methods such as aspiration of GI con-

tents/tube feeds or insufflation and auscultation alone are unre-

liable in determining the position of the tube tip.

Endotracheal intubation impairs the swallowing reflex.

Modern, “soft-cuff” endotracheal tubes do not completely

occlude the tracheal lumen and allow for the passage of small

quantities of liquids into the pulmonary system. Also, the

presence of an object in the trachea allows for the partial

compression of the esophagus due to pressure of the object

across the membranous portion of the trachea. Therefore,

although endotracheal intubation may help prevent massive

aspiration from vomiting, it does not prevent aspiration of

small amounts and therefore cannot be considered protective

against aspiration.

Changing the level of infusion of EN from the stomach to

the small bowel has been shown to reduce the incidence of

regurgitation, aspiration, and pneumonia.

10,11

In 13 randomized

controlled trials, pneumonia was significantly lower in patients

with small bowel EN. Compared to patients on gastric EN, the

lower rates were significant even when studies were restricted

to those using evidence of ventilator-associated pneumonia.

However, there were no differences in mortality, ICU length of

stay, hospital length of stay, duration of mechanical ventilation,

or time to goal EN.

12–23

It may be necessary to feed the child at risk for aspiration

into the small bowel. Gastrojejunostomy tubes are recom-

mended for pediatric patients who require long-term EN and

have demonstrated intolerance to gastric feedings due to

delayed gastric emptying, gastroesophageal reflux, or risk of

aspiration.

Sedation. Other steps to decrease aspiration risk include reduc-

ing the level of sedation/analgesia when possible and minimiz-

ing transport for diagnostic tests and procedures.

25,26

Any

treatment that impairs the ability of the patient to clear contents

in the pharynx increases the risk of aspiration. Under normal

circumstances, the presence of any material in the pharynx

induces a swallowing or coughing reflex, which helps to pre-

vent aspiration. Sedation of a patient decreases or eliminates

this reflex and increases the risk of aspiration. Keeping patient

comfort and care in mind, it is advisable to keep sedation levels

as minimal as possible to minimize the suppression of the swal-

lowing/coughing reflexes.

Table 5. Nutrient Deficiencies and Potential Complications

Associated With Refeeding Syndrome.

Nutrient Deficiency Manifesting Complication

Phosphorus Cardiac arrhythmia and sudden death

Congestive heart failure

Respiratory failure

Renal failure from osmotic diuresis

Hemolysis

Altered mental status

Potassium Cardiac arrhythmia

Respiratory failure

Paresthesias, paralysis, seizures

Ileus

Rhabdomyolysis

Magnesium Cardiac arrhythmias, sudden death

Respiratory failure

Paresthesias

Paralysis

Seizures, tetany

Thiamin Korsakoff’s syndrome

Wernicke’s encephalopathy

Boullata et al 87

Positioning of patient. One study compared patients in supine

and semirecumbent positions. The investigators found that ele-

vating the head of the bed 30–45 reduced the incidence of

pneumonia from 23% to 5% (P = .018).

Infants and children

lying flat are at increased risk of reflux and aspirating formula. It

is important to position the infant or child to prevent aspiration

episodes, with the head of the child elevated at least 30° while

receiving a feeding.

28,29

It is generally recommended that infants

under 1 year of age be positioned on their back in a flat position.

However, the American Academy of Pediatrics guidelines make

exceptions for infants whose risk of death from complications of

gastroesophageal reflux is greater than the risk of sudden infant

death syndrome (SIDS), including those infants with anatomical

abnormalities, such as type 3 or 4 laryngeal clefts, who have not

had antireflux surgery. Otherwise, elevating the head of the bed

while the infant is supine is not recommended.

Chlorhexidine mouthwashes. In 2 studies, optimizing oral

health with chlorhexidine mouthwashes twice daily reduced

respiratory infection and nosocomial pneumonia in patients

undergoing heart surgery.

31,32

Studies where chlorhexidine oral

care was included in bundled interventions showed significant

reductions in nosocomial respiratory infections.

33,34

Bolus vs continuous infusions. The potential harm from aggres-

sive bolus infusion of EN leading to increased risk of aspiration

pneumonia was shown in 1 study.

A randomized controlled

trial showed a trend toward decreased mortality with continu-

ous EN (13.9% intermittent vs 7.4% continuous, P = .18).

Five small randomized controlled trials comparing bolus to

continuous infusion have shown greater volume with fewer

interruptions in delivery of EN with continuous EN, but there

was no significant difference between techniques with regard to

patient outcome.

37–41

Use of prokinetic agents. Oral or intravenous use of prokinetic

agents such as erythromycin or metoclopramide has been

shown to improve gastric emptying and tolerance of EN.

Erythromycin doses of 3–7 mg/kg/d have been used to treat

gastric enteral feeding intolerance. Likewise, metoclopramide

10 mg given 4 times a day has been shown to be efficacious for

elevated gastric residuals; however, dosage adjustments to

metoclopramide may be necessary in patients with declining

renal function. Use of prokinetic agents such as erythromycin

or metoclopramide has resulted in little change in clinical out-

come for ICU patients. A total of 8 randomized controlled trials

using metoclopramide and 1 trial combining erythromycin

with metoclopramide were reviewed by meta-analysis. The use

of prokinetic agents was not found to make a difference in

terms of mortality or infection.

42–49

Erythromycin has been

associated with undesirable effects, including cardiac toxicity,

tachyphylaxis, and bacterial resistance, and should be used

cautiously with monitoring. Metoclopramide also has associ-

ated adverse complications, including tardive dyskinesia, more

frequently in the elderly. Both agents have been associated

with QT prolongation, predisposing to cardiac arrhythmias.

50,51

Combination therapy with erythromycin and metoclopramide

demonstrated improved GRVs allowing for greater feeding

success; however, neither hospital length of stay (LOS) nor

mortality was improved. Furthermore, the incidence of watery

diarrhea was statistically higher in patients receiving combina-

tion therapy.

In pediatrics, the risks of the use of metoclo-

pramide should be very carefully considered.

Measurement of GRVs. Measurement of GRV has tradition-

ally been one technique used as an indicator for aspiration risk.

Research regarding the efficacy of this technique has provided

conflicting results. That is, no adequately powered studies

have, to date, demonstrated a relationship between aspiration

pneumonia and GRV.

In addition, no adequately powered

studies have demonstrated that elevated GRVs are reliable

markers for increased risk of aspiration pneumonia. Building a

protocol around risk for aspiration could include several fac-

tors to reduce risk but not be solely based on measurement of

G RV.

GRV cannot be correlated with pneumonia (after the

initiation of enteral feedings), ICU mortality, or hospital mor-

tality. Studies suggest that “the elevated residual volumes by

themselves have little clinical meaning and that only when

combined with vomiting, sepsis, sedation, or the need for vaso-

pressor agents does the correlation with worsening patient out-

come emerge.”

Elevated and increasing residual volumes

may be a symptom of another underlying problem manifesting

itself as delayed gastric emptying. If serial measurements

reveal a change in GRV, other potential causes must be investi-

gated rather than simply holding the enteral feedings.

Results

from 4 randomized controlled trials indicate that raising the

cutoff value for GRVs (leading to automatic cessation of EN)

from a lower number of 50–150 mL to a higher number of

250–500 mL does not increase the incidence of regurgitation,

aspiration, or pneumonia.

20,54–56

Decreasing the cutoff value

for GRVs does not protect the patient from these complica-

tions. Use of GRVs leads to increased EAD clogging, inappro-

priate cessation of EN, consumption of nursing time, and

allocation of healthcare resources and may adversely affect

outcome through reduced volume of EN delivered.

Note that

GRV measurement may be dependent on type of EAD as well

as patient position.

Three studies (2 randomized controlled trials and 1 pro-

spective before/after implementation trial) have shown that

eliminating the practice of measuring GRVs improves delivery

of EN without jeopardizing patient safety.

57–59

All 3 trials

showed no significant difference between groups with regard

to pneumonia.

57–59

Two of the trials found that elimination of

GRV measurement was associated with significantly greater

EN delivery, either by increased volume of EN infused or

greater reduction in energy deficit.

58,59

If the practice of GRVs is eliminated, a number of alterna-

tive strategies may be used to monitor critically ill patients

88 Journal of Parenteral and Enteral Nutrition 41(1)

receiving EN, including careful daily physical examinations,

review of available abdominal radiologic films, and evaluation

of clinical risk factors for aspiration. Those ICUs that are

reluctant to stop using GRVs are advised to take care in their

interpretation. GRVs in the range of 200–500 mL may raise

concern and lead to the implementation of measures to reduce

risk of aspiration, but it is not appropriate to stop EN for GRVs

<500 mL in the absence of other signs of intolerance.

19,25,54–56

Pediatric considerations. In neonatology, GRV measurement

was once thought to be part of a prevention strategy for necrotiz-

ing enterocolitis.

However, because checking gastric residuals

is associated with a high percentage of held feeds and failure to

meet enteral feeding goals without being a good marker of feed-

ing intolerance, some neonatal clinicians no longer check residu-

als.

Holding feeds in response to GRVs can be a major reason

why infants do not meet their feeding goals,

62,63

but the clinical

value of GRVs for assessing feeding tolerance in this population

is not established. GRV levels are not considered a marker of

feeding intolerance in premature infants due to their immature

motility. Higher residuals in premature infants are thought to be

related to position (with left lateral and supine positions being

associated with higher volumes), as well as the degree of prema-

turity and normal dysmotility of prematurity.

64–66

Also, by the

time an infant has residuals, he or she may already have necro-

tizing enterocolitis or an ileus from sepsis.

Question 9.3. What are the current methods to prevent

enteral misconnections?

Practice Recommendations

1. Utilize enteral devices (tubes, syringes, administration

and extension sets) with enteral connectors that comply

with ISO standard 80369-3 (ENFit).

2. Review currently used systems to assess practices that

include the potential for misconnection, including

nonstandard, rigged work-arounds (Luer adapters, etc).

3. Train nonclinical staff and visitors not to reconnect

lines but to seek clinical assistance instead. Only

clinicians or users knowledgeable about the use of any

device should make a reconnection.

4. Make connections under proper lighting.

5. Do not modify or adapt IV or feeding devices because

doing so may compromise the safety features

incorporated into their design.

6. When making a reconnection, routinely trace lines

back to their origins and then ensure that they are

secure.

7. When arriving at a new setting or as part of a hand-off

process, recheck connections and trace all tubes.

8. Identify and confirm the EN label. Note that a 3-in-1

PN admixture can appear similar to an EN formulation

bag.

Rationale

Reports of enteral misconnections date as far back as 1972,

when a case of an inadvertent intravenous (IV) administration

of breast milk was published.

In 1 literature review, over 115

cases of published enteral misconnections were reported.

The

published reports consistently substantiate the highest level of

severity for this type of error, which commonly results in the

death of the patient by embolus or sepsis,

but current reporting

may greatly underestimate the number of actual cases or near-

miss incidents involving feeding connectors.

In April 2006, The Joint Commission issued a Sentinel

Event Alert on tubing misconnections. It stated that multiple

reports to agencies such as The Joint Commission, ECRI

Institute, U.S. Food and Drug Administration, Institute for Safe

Medication Practices (ISMP), and USP indicated that these

misconnection errors were occurring with significant frequency

and, in a number of instances, had deadly consequences. The

alert also identified root causes and risk reduction strategies.

Despite many other healthcare alerts on medical misconnec-

tions from various safety and regulatory agencies, errors involv-

ing misconnections continued.

That Joint Commission alert in

2006 called for a connector design that prevents cross-connec-

tions between IV and enteral products and asserted that any

other remedies might decrease risk but would not eliminate it.

For example, color-coding enteral connectors (for which there

is no current authorized standard color) simply alerts the clini-

cian that the connector is not an IV connector, but a unique

color does not physically prevent the misconnection.

In 2008, the International Organization of Standardization

(ISO) convened a working group to develop standards for the

redesign of small-bore connectors. ISO standards are recog-

nized by many national governments, organizations, and other

entities as the resource to drive conformity. As such, ISO sets

voluntary global standards to which various governments, pur-

chasing organizations, manufacturers, and users subscribe.

The first step in this process was developing a master standard

for small-bore connectors that contained certain requirements

to which all small-bore connectors must adhere. That standard

is ISO 80369-1: Small Bore Connectors for Liquids and Gases

in Healthcare Applications—Part 1: General Requirements.

According to these general requirements, connectors must

 Not be connectable to others in the series

 Be made of rigid or semi-rigid material

 Pass a misconnection test

 Not be connectable with Luer or needleless connector

ports

This master standard set the stage for redesigned connectors to

be used in respiratory, enteral, noninvasive blood pressure

monitoring, neuraxial, urology, and intravascular systems.

The first ISO-compliant patient access enteral connector,

called ENFit, can be seen in Figure 11.

Boullata et al 89

This new connector is available on enteral administration

sets, enteral syringes, and enteral feeding tubes. These products

began to be introduced into the market in 2015. To transition

from the new connector to the current feeding tube, a transition

set is available to provide connectivity so that patients receive

their nutrition formula, hydration, and medications.

Communication about these changes is available from the

Global Enteral Device Supply Association (GEDSA), which

has launched a campaign for the introduction of new small-bore

connectors called StayConnected (www.StayConnected.org).

In August 2014, The Joint Commission issued a Sentinel

Event Alert titled Managing Risk During Transition to New ISO

Tubing Connector Standards which included the background on

the issue and a series of actions suggested by The Joint

Commission.

These suggested strategies included preparing for

the new standards, development of effective processes and proce-

dures, education and training of staff, effective communication,

and leadership and emphasis on a safety culture. The alert also

included a table of related Joint Commission requirements for

institutions and agencies regarding the use of tubing.

Question 9.4. What are the best practices to

systematically identify, document, and report errors

associated with EN within an organization and

externally to patient safety organizations?

Practice Recommendations

1. Develop and provide education within healthcare

organizations for clinicians responsible for the

prescription, dispensing, and administration of EN.

2. Coordinate education with ongoing competency

assessments and should be dynamic to each provider’s

practice setting, institution-specific errors, and changes

in EN guidelines and practice recommendations.

3. Develop and provide education regarding EN and

medical device safety for ancillary staff and healthcare

students (medical, nursing, allied professions).

4. Support mechanisms to systematically report any and

all errors associated with any step in the EN process,

including those related to enteral medication

administration.

5. Create a “culture of safety” within healthcare

organizations where healthcare clinicians will not be

reprimanded for reporting errors related to EN.

6. Develop interdisciplinary teams to evaluate and

analyze errors related to EN within an organization.

7. Provide outpatient EN services with processes for

evaluating patient and caregiver competency related to

EN.

8. Develop and implement policies and procedures to

systematically collect, document, and report errors

associated with EN to the Institute for Safe Medication

Practices (ISMP) Medication Errors Reporting Program.

9. Develop and implement policies and procedures to

systematically collect, document, and report errors

associated with EN infusion pumps and devices to the

U.S. Food and Drug Association (FDA).

Rationale

Safe practices for EN therapy involve a broad interplay of pro-

viders, departments, and administrative support structures

across the many steps of the EN process. Errors can occur from

patient assessment to prescribing, order review, and documen-

tation, although most recognized errors focus on product selec-

tion and administration. Maintaining a safety culture around

EN depends on continuous surveillance, recognition of poten-

tial risk at each step in the process, and systematic reporting of

all errors—including near misses. Monitoring and reporting

safety issues can allow for subsequent system improvements

upon review by an organization’s committee or a national

patient safety organization.

The improper administration of EN has led to patient harm

and even death. The use of resources such as patient safety

reporting databases and national patient safety organizations is

vital to identify issues associated with the delivery of EN. As

clinicians report events, national patient safety organizations

and local healthcare organizations can take the proper steps to

analyze events, determine their root causes or weaknesses in the

EN process, and establish changes and new recommendations

to prevent future errors.

Healthcare organizations can use published clinical guide-

lines to develop nursing policies and procedures for EN admin-

istration. Review of these policies and procedures by a

multidisciplinary team on at least an annual basis will identify

issues related to the EN process and can prevent future break-

downs in the process. Healthcare organizations in all settings

Figure 11. ENFit enteral connector. Reprinted with permission

from the Global Enteral Device Supply Association (GEDSA).

90 Journal of Parenteral and Enteral Nutrition 41(1)

can provide continuous education of healthcare providers,

patients, and caregivers for those administering EN.

Competency must be validated at critical times, such as the

following

 During orientation of new medical and ancillary staff

 Before a change in organizational policy or procedure

 Before a change in equipment, EN products, or

infusion sets

 When deficits in EN administration knowledge are

present

The reporting of EN-related errors or close calls is best viewed

as an opportunity to improve patient safety.

The underreport-

ing of adverse events related to EN hinders a healthcare orga-

nization’s ability to identify and address gaps in policies and

procedures. For example, few organizations systematically

report and review EAD occlusion rates. Healthcare organiza-

tions can create a culture of safety by reassuring workers that

they will not be punished for reporting safety events and fram-

ing these events as an opportunity for education.

The education of ancillary staff and student practitioners

within a healthcare organization is important to the safety of

patients receiving EN. Organizations also need to identify

ancillary staff who could possibly be responsible for the con-

nection, disconnection, or reconnection of devices attached to

patients and develop policies and procedures that outline

responsibilities for these staff members relating to the connec-

tion or disconnection of medical tubing.

EN infusion pumps are a necessity in some patients receiv-

ing EN in both the acute and home setting. These pumps are not

error free, and they can malfunction, leading to inappropriate

delivery of EN. Evans et al

looked at overnight EN safety

issues in children with metabolic disorders. In this study, 32%

of patients had faulty equipment (leaking EN bags or tubing

defects), and 50% of patients had total pump failure that affected

feeding accuracy, with 1 patient becoming hypoglycemic and

hospitalized. Policies and procedures related to the safe opera-

tion of EN infusion pumps can explain appropriate caregiver

roles regarding alarm silencing, adjusting pump settings, and

making the connection or disconnection from a patient.

Healthcare organizations are advised to develop policies

and procedures that address the collection, documentation,

and reporting of errors related to EN to the ISMP’s National

Medication Errors Reporting Program (MERP). After analysis

of adequately reported medication errors, the ISMP has

responded with nationwide hazard alerts to healthcare profes-

sionals with safety issues and error reduction recommenda-

tions. The ISMP has also been able to distribute press releases

regarding safety issues to both the lay and healthcare media.

These reports have led to individual practice and organiza-

tional system changes. Analysis of errors reported to the

MERP has led the ISMP to release guidelines regarding stan-

dardized order sets.

76–78

Organizational policies and procedures related to EN admin-

istration that address EN infusion pump errors or failure are valu-

able. Organizations can use the voluntary MedWatch Form FDA

3500 to report device malfunctions to the FDA. Adequate report-

ing of any medical device issues allows for the FDA to detect

potential device-related safety issues. Organizations are required

to report all device-related deaths or serious injuries to the FDA

and manufacturer within 10 working days of becoming aware of

the event using Form FDA 3500A. User facilities are required to

send an annual summary of deaths and serious injuries to the

FDA with Form FDA 3419 by January 1 for the preceding year.

Topics for Future Research

 Clinical outcomes from combination promotility

therapy as well as the associated risk of adverse effects

 The transition to new enteral connectors in the

marketplace, particularly in neonates and home care

 Adverse events reported by the FDA and ISMP as

measures of change effectiveness

 Cost-effectiveness of workflow processes to prepare

medications for EAD administration

 Identify existing error rates at each step in the EN

process

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www.accessdata.fda.gov/scripts/medwatch/index.cfm?action=reporting.

home

. Accessed July 15, 2015.

Section 10. Monitoring and Reassessment

Background

The goal of nutrition reassessment is to update the nutrition

care plan based on changes in clinical or nutrition status as

identified through ongoing monitoring and evaluation.

Monitoring the patient receiving EN can help prevent iatro-

genic malnutrition and other adverse events. The timeframe for

follow-up of enterally fed patients is often driven by an organi-

zation’s policy and procedures.

Making certain that the patient receives the amount of for-

mula recommended and ordered is important to optimize

nutrition status and prevent malnutrition. Volume delivered is

often not the amount ordered. In most cases, volume delivered

is less than what was ordered, with the most common reasons

being GI intolerance, such as nausea, vomiting, abdominal

distention, or diarrhea; tube obstruction or dislodgement; or

feeding interruptions for nursing or physician care, proce-

dures, or patient refusal. Measuring the volume the patient

received within a specified timeframe is important to deter-

mine whether nutrient needs are being met. Methods to track

volume delivered are not standardized and may include

recording intake and output, documenting number of hours

the feeding was held vs infusion hours ordered, marking the

bottle or bag, or logging the volume measured by the enteral

feeding pump, with the latter method possibly allowing the

least room for human error. Reassessment will also include

the transition from EN to oral nutrition as appropriate.

Question 10.1. What are the minimum monitoring

parameters and timeframes for reassessment to allow

for safe management of the patient receiving EN?

Practice Recommendations

1. Monitor and evaluate the patient receiving EN to

identify all changes in physical examination findings,

laboratory values, anthropometric data, and outcomes.

2. Include a thorough review of changes in clinical status,

new medications and therapies, EN intake and

tolerance, biochemical indices, anthropometric

Boullata et al 93

changes (eg, physical examination and weight), and

malnutrition risk.

3. Assess nutrition risk of the patient receiving EN

throughout the patient’s therapy.

a. Determine frequency of assessment by considering

patient acuity and progression of clinical care.

b. Provide regular documentation of patient

reassessment—typically, daily and/or weekly.

Monitoring of nutrition status may be more

frequent than documentation of reassessment.

4. Reassess the tube-fed patient in institutionalized long-

term care at least monthly.

5. Reassess the home tube-fed patient at least quarterly.

Rationale

Reassessment timeframes will depend on the practice setting.

EN intolerance will likely be noted within the first 3 days of

initiation, if at all.

Monitoring parameters focus on changes in

clinical status that will likely affect tolerance of the enteral pre-

scription. Tolerance is measured using various methodologies,

which are discussed elsewhere in this document. It is important

to monitor the adverse effects of medications or particular

forms of medications that can affect the safety of EN. For

example, liquid medications with high sorbitol content may

contribute to loose stools, dehydration, and perceived intoler-

ance of the enteral formula. Interruptions to EN, including

those due to intolerance of EN, are monitored because they can

contribute to undernutrition.

Energy deficit is associated with

increased clinical complications, especially infections.

It is

important to monitor that medications are administered sepa-

rately and diluted appropriately to prevent clogging of the tube

and missed nutrition.

Routine laboratory monitoring will assist the clinician in

determining overall tolerance of the nutrition treatment plan.

The nutrition assessment and recommendations section found

earlier in this document addresses this factor in more detail.

Unintentional weight loss is a risk factor on validated malnu-

trition screening tools and therefore must be monitored

closely in all patients on EN. Last, organizations need proto-

cols to monitor and prevent potential adverse effects associ-

ated with EN, such as aspiration. The clinician can monitor

oral hygiene and the use of other precautions, such as elevat-

ing the HOB to at least 30 to 45 during and after tube

feeding.

Question 10.2. How is EN tolerance best determined?

Practice Recommendations

1. Assess tolerance to EN using a combination of

parameters appropriate to the individual patient.

2. Evaluate patient subjective complaints, objective

findings of GI function (eg, GRV, vomiting, diarrhea),

and physical examination findings (eg, abdominal

distension).

Rationale

Patients in all settings and age groups must be monitored while

undergoing EN support. Monitoring EN tolerance is essential in

the delivery of EN because patients who experience EN intoler-

ance frequently fail to achieve EN goals.

Monitoring for EN

intolerance often includes multiple parameters such as GRV

and assessment of GI function.

In a recent observational study,

Wang and colleagues

reported that 32% of patients receiving

EN in a large tertiary hospital experienced enteral feeding intol-

erance. Of those patients, approximately two-thirds demon-

strated a single high GRV, whereas one-third experienced a

combination or 2 or more of the following symptoms: high

GRV, nausea/vomiting, and abdominal distention. Blaser and

colleagues

recently evaluated EN intolerance in ICU patients

with the objective to identify a definition most strongly associ-

ated with ICU mortality. They concluded the “best” definition

of EN intolerance is based on “a complex assessment of GI

symptoms” rather than a single measurement.

GRV monitoring and interventions to improve EN tolerance

based on this assessment are covered elsewhere in this docu-

ment. The American Society for Parenteral and Enteral

Nutrition/Society of Critical Care Medicine nutrition guide-

lines, recommendation D1 states that “patients should be moni-

tored daily for tolerance of EN (determined by physical exam,

passage of flatus or stool, radiologic evaluations and absence of

patient complaints such as pain or abdominal distention).”

Inappropriate cessation of EN should be avoided.

Question 10.3. What is the best way to transition from

EN to oral feeding?

Practice Recommendations

1. Identify a safe oral feeding regimen through discussion

with interdisciplinary team members, including speech

and language specialists who evaluate swallowing and

aspiration risk with various food consistencies. Provide

an individualized diet with necessary modifications in

the initial stages of oral intake.

2. Transition continuous EN to an intermittent

schedule when clinically appropriate. Provision of

either partial or full EN via this intermittent regimen

will depend on the nutrition needs and status of the

patient.

3. Coordinate oral feedings with times when EN is off

to help stimulate appetite. Consider intermittent EN

feedings that are administered as a supplement after

a meal is consumed and/or continuous feedings at

night.

4. Establish a consistent meal routine.

94 Journal of Parenteral and Enteral Nutrition 41(1)

5. Document the percentage of food consumed at each

meal or snack. Ideally, the type and amount of food

are also recorded.

6. Document any identified issues with oral consumption.

7. Involve the patient and/or family members in food

and oral supplement preferences regarding oral diet

advancement.

8. Monitor swallowing performance, nutrition and

hydration status, and respiratory complications with

adjustment of EN as appropriate.

9. Consider a trial of eliminating the EN regimen when

the patient is able to meet the majority of energy needs

with oral intake.

10. Obtain weights at least weekly to ensure adequate

caloric intake to meet weight goals.

Rationale

Transitional orders from EN to oral feeding have been defined

as incremental decreases in EN volume over a period of time

to accommodate for increasing oral intake. Minimal research

or guidelines exist regarding transition from enteral feeding to

oral feeding. Crary and Groher

recommends that at mini-

mum, tube-fed patients with dysphagia must demonstrate a

safe and efficient swallow on a consistent basis to be consid-

ered candidates to return to oral feeding. Additionally, patients

must be able to consume adequate food or liquid to support

nutrition requirements before they can be fully transitioned

from EN to oral feeding.

Buchholz

developed a clinical algorithm specific to

patients with acquired brain injury or stroke that provides sug-

gestions for transitioning tube-fed patients to oral feeding. The

initial transition phase is termed the preparatory phase and

focuses on the patient’s physiologic readiness for oral nutri-

tion. This first phase incorporates medical and nutrition stabil-

ity, intermittent tube-feeding implementation, and swallowing

assessment. The second phase is termed weaning and includes

a graduated increase in oral feeding, with corresponding

decreases in tube feeding. In this algorithm, once a patient is

consuming 75% or more of his or her nutrition requirements

consistently by mouth for 3 days, all tube feedings are discon-

tinued. Another proposed option is nighttime cycling of EN

once patients are meeting more than 60% of target calories by

the oral route.

Clinical reality dictates that both patients and healthcare

professionals will vary in terms of their readiness to discon-

tinue enteral feeding. The process of transition should be

thoroughly discussed with the patients, assuming that they

are clinically able to communicate, and outline a plan of

action. Simple and patient-specific goals are often helpful.

Oral ingestion is best attempted at times when the stomach is

not full, taking full advantage of the hunger drive. Continuous

feedings can be modified to an intermittent schedule to stim-

ulate normal hunger cycles, and ideally, intermittent

feedings are tolerated before an oral diet is attempted. When

patients attempt oral feedings, it is important that they are

fully upright and alert. For patients with fluctuating mental

status, try feeding when their pattern of alertness is maximal.

Therefore, for these patients, return to oral intake may only

involve attempts at 1 or 2 meals per day. If patients have

swallowing difficulties, a speech-language pathologist can

recommend appropriate types and textures of food to put on

trays.

During the transition process, it is important to remember

that the total time to wean from tube feeding to oral feeding is

patient dependent. Also, weaning from tube to oral nutrition is

not a goal shared by all patients.

Abrupt discontinuation of

nutrition therapy predisposes the patient to hypoglycemia if an

insulin regimen is not adjusted. A reduction in the nutrition

support infusion rate without an adjustment in insulin therapy

was the second most common cause for hypoglycemia in 1 ret-

rospective study.

Close monitoring of glycemic control in

patients transitioning from enteral to oral diet is critical to pre-

vent sentinel events.

Topics for Future Research

 Optimal frequency of nutrition screening/reassessment

based on outcomes

 Optimal protocol to transition EN to order feeding

 Updated data on pump accuracy studies using pumps

currently in use in the United States

References

1. Gungabissoon U, Hacquoil K, Baines C, et al. Prevalence, risk factors,

clinical consequences, and treatment of enteral feed intolerance during

critical illness. JPEN J Parenter Enteral Nutr. 2015;39(4):441-448.

2. Elpern EH, Stutz L, Peterson S, Gurka DP, Skipper A. Outcomes associ-

ated with enteral tube feedings in a medical intensive care unit. Am J Crit

Care. 2004;13(3):221-227.

3. Villet S, Chiolero RL, Bollmann MD, et al. Negative impact of hypocalo-

ric feeding and energy balance on clinical outcome in ICU patients. Clin

Nutr. 2005;24(4):502-509.

4. Mueller CM, Compher C, Druyan ME. A.S.P.E.N. clinical guidelines:

nutrition screening, assessment, and intervention in adults. JPEN J

Parenter Enteral Nutr. 2011;35(1):16-24.

5. Blaser AR, Starkopf L, Deane AM, Poeze M, Starkopf J. Comparison of

different definitions of feeding intolerance: a retrospective observational

study. Clin Nutr. 2015;34(5):956-961.

6. Malone AM, Seres DS, Lord L. Challenges and complications with

enteral nutrition. In: Mueller CM, ed. The Science and Practice of

Nutrition Support: A Case Based Curriculum. 3rd ed. Silver Spring,

MD: American Society for Enteral and Parenteral Nutrition; 2012:218-

233.

7. Wang K, McIiroy K, Plank LD, et al. Prevalence, outcomes and man-

agement of enteral tube feeding intolerance: a retrospect cohort study in

a tertiary center [published online February 5, 2016]. JPEN J Parenter

Enter Nutr.

8. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the provi-

sion and assessment of nutrition support therapy in the adult critically ill

patient: Society of Critical Care Medicine (SCCM) and American Society

for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter

Enteral Nutr. 2016;40:159-211.

Boullata et al 95

9. Crary MA, Groher ME. Reinstituting oral feeding in tube-fed patients with

dysphagia. Nutr Clin Pract. 2006;21(6):576-586.

10. Buchholz AC. Weaning patients with dysphagia from tube feeding to oral

nutrition: a proposed algorithm. Can J Diet Pract Res. 1998;59:208-214.

11. Collier BR, Cherry-Bukowiec JR, Mills ME. Trauma, surgery, and

burns. In: Mueller CM, ed. The A.S.P.E.N. Adult Nutrition Support Core

Curriculum. 2nd ed. Silver Spring, MD: ASPEN:392-411.

12. Corrigan ML, Escuro AA, Celestin J, Kirby DF. Nutrition in the stroke

patient. Nutr Clin Pract. 2011;26(3):242-252.

13. Dickerson RN, Maish GO, Minard G, Brown RO. Nutrition support team-

led glycemic control program for critically ill patients. Nutr Clin Pract.

2014;29(4):534-541.

Section 11. Transition of Care

Background

A major goal of transitioning the EN patient to home or an alter-

nate care site is to prevent readmission to the acute facility.

Therefore, many factors need to be considered to ensure that

patients have everything for the safe and successful admission of

EN at home or in another setting. Institutions play a critical role

in ensuring the safe transition and adequate education of patients

and caregivers to home EN therapy. Optimal transition to home

EN requires a collaborative approach among all disciplines and

professions involved in the care of the patient.

1,2

Disciplines

involved in the transition of home EN patients can use guide-

lines, policies, and procedures to best serve the interests and

safety of these patients. It is advisable to commence the educa-

tion of the patient and caregiver as early as possible so potential

problems and concerns can be identified.

Question 11.1. What are the criteria and factors to

consider to safely transition a patient on EN from the

hospital to home or an alternate care site?

Practice Recommendations

1. Establish tolerance to EN at the goal regimen prior to

discharge.

2. Provide written and verbal instruction to the patient

and/or caregivers well before discharge.

3. Ascertain that the patient/caregiver demonstrates

competence in all components of the EN therapy.

4. Assess safety of the home environment by including

home care provider and case manager in the process.

5. Utilize competent nutrition clinicians to monitor home

EN therapy.

6. Prior to discharge, educate the patient/caregiver on

how to obtain necessary supplies.

Rationale

To ensure a safe transition of the EN patient from the hospital

to home setting, multiple conditions must be met. Most impor-

tant, the patient must tolerate the EN therapy (formula, rate,

and volume) to be continued in the home or alternate care set-

ting. Patients experiencing EN intolerance are at much greater

risk of developing complications that may require hospital

readmission, including tube blockage, GI issues, and underhy-

dration or overhydration. The patient/caregivers will need edu-

cation about the EN therapy to be used in the new setting.

Written and verbal instruction can begin well before discharge

and will include the following: all elements of the EN prescrip-

tion, including water-flushing regimen and treatment plan;

care of the feeding tube; troubleshooting of common complica-

tions; and who to contact for help at any time. Instruction to

specifically address water requirements and flushing is impor-

tant. In a study of older adults receiving EN at home, 73% of

patients reported decreased urination and 63% reported consti-

pation.

As part of the instruction process, educators must eval-

uate the patient/caregiver’s ability to demonstrate competence

in the fundamental aspects of EN therapy.

Prior to discharge, the home environment must be screened

for safety. A clean water supply, refrigeration and electricity, a

sanitary environment, sufficient space to administer feedings and

store supplies, and telephone access are required to safely admin-

ister EN at home.

In addition, the home must have resources

available for use during emergencies. For alternate site care, the

care team at the hospital thoroughly discusses the patient’s plan

of care with the receiving facility’s nutrition support expert.

The lack of professional nutrition services in the home setting

may increase the risk of preventable complications. In 1 report,

one-third of older adult patients receiving EN at home reported

tube clogs or leaks, problems that increase the risk for underfeed-

ing, dehydration, or stoma complication. Almost one-third of

patients using an EN pump reported pump malfunction, which

increases the risk of underhydration and underfeeding.

The need

for tube changes is another common complication of EN.

These

patients need to be managed and monitored by healthcare profes-

sionals who are competent in nutrition support and are available

to respond to complications. In addition, collaboration and com-

munication between these professionals are essential.

2,4

Patients receiving EN at home often feel isolated as a result

of their therapy.

To help prevent such isolation, clinicians

involved in preparing patients for EN at home can refer them

to a support organization, such as the Oley Foundation or the

Feeding Tube Awareness Foundation, which can help patients

when the need for EN at home is established and prior to hos-

pital discharge.

When preparing patients for home, the care

team can also establish an initial and ongoing process for

obtaining all necessary supplies, including initial review and

verification of insurance and/or third-party coverage prior to

discharge. In addition, the home medical supply company or

alternate site must be able to supply formula, equipment, and

supplies prior to or upon discharge. It is certainly advanta-

geous to the patient’s safety and comfort if the home supply

company provides competent nutrition clinicians to address

education needs, tolerance, complications, and nutrition ade-

quacy of EN at home.

96 Journal of Parenteral and Enteral Nutrition 41(1)

Questions 11.2–11.4. What components of EN education

are important to promoting efficacy, safety, and

quality of life for the caregiver/patient? What are the

most effective methods of caregiver/patient EN

education/instruction considering literacy and

safety? When should education/instruction for

patients receiving EN at home be performed?

Practice Recommendations

1. Begin the referral process once the decision for EN

therapy is made.

2. Begin education for the patient receiving EN at home

prior to placement of the EAD.

3. Provide patient and caregiver education that is

comprehensive, includes education materials related to

EN therapy, and uses a standard checklist.

4. Provide the patient and caregiver with verbal and

written education that covers the following topics:

a. Reason for EN and short-term and long-term

nutrition goals (ie, weight goal)

b. Feeding device, route and method, formula, and

feeding regimen

c. Identify necessary supplies needed to administer

enteral tube feedings at home

d. Use and cleaning of equipment, including

administration/feeding set, infusion pump, and

syringe

e. Care of the feeding tube and access site such as

securing, flushing, and unclogging the tube and

stoma care

f. Nutrition and hydration guidelines: feeding plan/

regimen, water flushes, hydration monitoring

g. Weight schedule, lab work recommendations

h. Safe preparation and administration of formula

i. Safe preparation and administration of medications

j. Proper position during and after feedings

k. Recognition and management of complications

(mechanical, gastrointestinal, and metabolic)

l. Available resources, emergency care plan, and

healthcare contacts

5. Use demonstration and teach-back method of patient

education to assess comprehension.

6. Use various methods of education for EN to take into

account various learning styles.

7. Implement an EN education checklist to assist with the

discharge coordination process.

Rationale

Effective patient and caregiver education is an integral part of

discharge for patients going home on EN and can start soon

after the decision is made to transition a patient. Inadequate ini-

tial EN education and follow-up have been reported as

challenges associated with EN at home.

A study of parents of

children receiving EN at home reported that most parents indi-

cated a need for improved EN services. Parents wanted a more

structured follow-up and would have preferred that 1 healthcare

professional coordinate EN education and discharge.

Institutions need guidelines, protocols, and policies for the

safe provision of EN to adult and pediatric patients as well as

procedures for ensuring a safe discharge to home on EN. Home

care and supply companies should continue this process after

discharge. When possible, it is advisable to provide training for

more than 1 person on all aspects of tube care and feeding

management. Essential components of the education process

include training on feeding tube and access site care, prepara-

tion and administration of formula, medication administration,

enteral pump operation, monitoring and troubleshooting com-

plications, and emergency care plan and contact informa-

tion.

6,8–12

Thompson et al

have emphasized the need for

clinicians to evaluate the effectiveness of their EN education

process, provide comprehensive EN education and patient

resources, proceed over more than 1 educational session, and

prepare patients and caregivers to resolve foreseeable prob-

lems, such as tube occlusion and dislodgement, skin care

issues, and psychosocial challenges.

Patients receiving EN at home may cope more effectively

and comply more successfully with the EN plan when clinicians

actively seek their input regarding the feeding plan and craft a

plan that is as flexible as possible to conform with the family’s

lifestyle. Flexibility within feeding regimens may alleviate some

of the stress that patients have and has the potential to improve

the impact of EN on quality of life. Simplifying the EN regimen,

minimizing the infusion time, and providing an ambulatory

pump or feeding tube that best fits the patient’s physical and life-

style needs may help reduce EN-associated life disruptions.

For some patients with gastrostomy tubes, transition to home

may be made easier by employing the syringe/bolus feeding

method. Feedings are ideally scheduled to fit as conveniently as

possible with the patient’s home and/or work routine. In addi-

tion, the clinician can help the patient/caregiver understand why

changes to the enteral or medication regimen could result in

adverse outcomes.

Another opportunity to help patients cope

with the day-to-day living on home nutrition support is to refer

the patient to a support group or organization specific to the dis-

ease or therapy the patient is experiencing.

Various methods may be used to deliver education for the

patient receiving EN at home. The most effective methods for

a given patient or caregiver will take into account the individ-

ual’s specific learning styles and provide visual demonstration

and reinforcement with graphics, video, online tutorials, nutri-

tion education handouts, or other approaches that best suit the

learner. Language and health literacy are factors to consider in

the instruction process. Clayton

authored an invited review to

aid selection of effective patient nutrition education materials

and has identified some key features of the healthcare delivery

system that may detract from the effectiveness of EN education

Boullata et al 97

and negatively affect the patient’s ability to safely administer EN

at home, including decreased patient-provider contact time,

length of hospital stay, and increased patient responsibility for

self-care. When selecting education materials, it is important to

evaluate them for content, literacy level, graphics, layout, and

typography. The motivating principles, cultural relevance and

primary language, feasibility (cost, equipment needs), and

accessibility are other factors to consider in patient education.

When online sources are used, educators need to evaluate the

references’ credibility and help patients find reliable Internet

resources. For example, websites can be reviewed for potential

conflicts of interest, disclaimers, and disclosures, and the ease of

navigation and interactivity can also be evaluated.

An EN discharge checklist helps the educator and patient/

caregiver document and track stepwise instruction. Use of a

discharge checklist has been shown to enhance patient care

and help streamline the discharge coordination process.

The

Agency for Clinical Innovation and the Gastroenterological

Nurses College of Australia clinician’s guide provides an

example of an EN checklist.

Items detailed in this example

include tube/device and site care, the nutrition and hydration

plan, regimen details and preparation instructions, proce-

dures for supply procurement and refills, monitoring, follow-

up care, and contact details. The checklist can also document

the date(s) that instruction was given and whether the patient

and/or caregiver can demonstrate the instructions, as indi-

cated by patient/caregiver and educator signatures.

Optimal EN education begins before the EAD is placed.

Preoperative education may increase the patient’s comfort

level, allay anxiety, reduce the hospital length of stay, and

improve patient satisfaction. Whenever possible, the patient

and family must be made aware before the procedure of poten-

tial complications and scope of care of the feeding tube, as well

as what costs of care will be reimbursed.

Identifying con-

cerns early can help alleviate some of the patient’s fears and

potential misconceptions about having a feeding tube. Early

educational interventions also provide opportunities to assess

the ability of the patient to care or obtain care for the tube and

administer feedings.

Question 11.5. What is the best method to communicate

enteral prescriptions and care instructions during

patient transfer or discharge home or alternate care

site?

Practice Recommendations

1. Determine the safest and most effective mechanism for

communicating the EN care plan. See Figure 12.

2. Involve representatives of the discharging site

(nutrition support clinician, case manager, or

prescriber) and the accepting site or home care team

(nutrition support clinician, home supply company,

home health agency) in planning the care transition.

3. Transfer the EN prescription and regimen to the

accepting home care team (nutrition support clinician/

home supply company/home health agency) via

standard electronic information systems accessible to

all healthcare providers and suppliers associated with

the patient prior to discharge.

4. Communicate the EN regimen to the home care team

caring for the patient.

Rationale

Adequate and timely transfer of information between inpatient

and community settings is imperative for safe care of EN

patients.

Incomplete or incorrect communication of the EN pre-

scription and regimen during patient transfer may delay the

administration of adequate and appropriate nutrition. It may also

lead to hospital readmissions and emergency department visits

that may have been preventable.

See Figure 12 for a template of

information that should be available for safe transitions. Ideally,

the enteral prescription and regimen are transferred to the accept-

ing home care team via standard electronic information systems

that are accessible to all healthcare providers and suppliers associ-

ated with the patient.

Use of these systems may improve com-

munication; however, they may not be universally available or

accessible due to technical limitations or institutional policies. The

EN prescription and regimen are best communicated in the avail-

able medical record. Effective communication of the EN plan is

written in plain language, includes all essential elements, and does

not use abbreviations that might lead to misinterpretation and

error. Ideally, the EN plan is provided to the home health agency

or medical supply company prior to discharge.

1,19

If a change or

clarification of the EN prescription must be communicated by

phone, the person receiving the new information should repeat it

back to ensure that it is received and interpreted correctly.

Clear and complete communication of the EN prescription will

cover the feeding method, the name of the formula and any modu-

lar additives, the calorie concentration, the rate in milliliters per

hour if pump fed, and the volume of formula per feeding or per

day, as well as the duration of the feeding—for example, [full

name of specific formula product, including concentration] at 75

mL/h times 22 hours to provide 1650 mL daily. Clear and com-

plete instructions about water flushes are also part of the EN pre-

scription and regimen communicated to the patient or caregiver

and the home care team.

An example of these instructions would

be as follows: 250 mL of water 4 times daily plus 50 mL water

before, with, and after each medication. If feeding tubes are

included in the EN prescription, instructions about the brand, type,

French size, and length, if applicable, are also communicated.

Communication of the home EN regimen, including guidance on

tube replacement and medication administration, is relevant to all

healthcare providers and suppliers involved in the patient’s care.

An interdisciplinary team consisting of the case manager, pre-

scriber, nurse, dietitian, and homecare provider can facilitate the

effective communication of the nutrition prescription.

20,21

98 Journal of Parenteral and Enteral Nutrition 41(1)

CURRENT EN ORDER

Patient Name: ______________________ Medical Record Number: ________________

Date of Birth: _______________ Current Dosing Weight: __________ kg Height _____________ cm

Anticipated Discharge/Transfer Date: __________________ To: _______________________________

EN FORMULA

Energy _____________ kcal/d Protein ________________ g/d Carbohydrate _________________ g/d Fat _____________ g/d

[] Standard [] Fiber Containing [] Elemental or Peptide-based

[] Standard, High Protein [] Carbohydrate Controlled [] Immune-modulating

[] Standard, High Calorie [] Renal, Low Electrolyte

DELIVERY SITE

(Route and Access)

ROUTE: ACCESS:

[] Gastric [] Nasogastric [] Orogastric [] Gastrostomy

[] Small Bowel [] Nasoduodenal [] Oroduodenal [] Jejunostomy

[] Nasojejunal [] Orojeujunal [] Transgastric G/J tube

ADMINISTRATION

(Method and Rate)

Method: Rate:

[] Continuous [] Currently at ______ mL/h with goal of _____ mL/h

[] Intermittent [] Currently ______ mL feeding over _____ mins _____ times daily

With goal of ______ mL feeding over _____ mins _____ times daily

[] Bolus [] Currently ______ mL bolus over _____ mins _____ times daily

With goal of ______ mL bolus over _____ mins _____ times daily

Water Flush _______ mL every _____ hours (minimum volume _____ mL)

CURRENT CLINICAL DATA

Current Nutrition Assessment:

History …

Vitals including anthropometrics …

Pertinent findings

 Nutritionally focused physical exam

 EN tolerance

 Tests

 Recent lab data

Anticipated Nutrition Care Plan:

Maintain … with goal of ….

Transition to oral diet …

Transition to PN …

Figure 12. Enteral nutrition transition template. EN, enteral nutrition; G/J, gastrojejunostomy; PN, parenteral nutrition.

Boullata et al 99

Question 11.6. If the patient is going home on a different

formula (or different feeding method) than the one used

in the hospital, is it advisable to try it first in the hospital?

Practice Recommendations

1. Use the type of formula that will be administered at

home for a trial period prior to discharge.

2. Use the feeding method that will be administered at

home for a trial period prior to discharge.

3. Avoid making last-minute changes to either the

formula or method just prior to discharge.

Rationale

The hospital provides a safe setting in which patients are

closely monitored for tolerance to EN. However, the patient

may go home on a different enteral formula or feeding method

due to patient preference, lifestyle or ability, insurance cover-

age, or product availability through the home health agency or

the supply company. In this case, the new formula or feeding

method should be used in the hospital setting for a trial period

to avoid potential complications related to intolerance.

A trial

may be more important when the patient is to transition from a

more specialized formula to a standard or less-specialized

product or to bolus or gravity feeding from continuous pump

feeding. For example, a patient transitioning from a peptide-

based to a standard formula may be at risk for intolerance and

GI complications that may be more safely handled in the hos-

pital setting. GI complications are common with EN at home

and have the effect of reducing the amount of nutrition deliv-

ered to the patient, increasing the risk of malnutrition.

Adequate instruction of the patient or caregiver on the feed-

ing method and formula to be used at home can optimize safety

and adherence to the treatment plan. Ideally, the method or

regimen chosen for home care is one that fits well with the

patient or family’s ability and lifestyle.

Planning for discharge

throughout the patient’s hospital stay can reduce the risk of

readmission.

Inpatient administration of the EN to be used at

home and education on the EN regimen for home are part of

the planning process.

Topics for Future Research

 Patient and caregiver ability, attitudes, and experiences

 Effect of insurance coverage for EN at home on

outcomes

 Evaluation of EN patients’ experience regarding the

discharge process at home

 Evaluate support systems and potential interventions

for caregivers of tube-fed children

 Appropriate mechanism for follow-up and monitoring

for patients receiving EN at home

 EN and EHRs

 Ideal feeding method and formula for EN at home

References

1. Silver HJ, Wellman NS, Arnold DJ, Livingstone AS, Byers PM. Older adults

receiving home enteral nutrition: enteral regimen, provider involvement, and

health care outcomes. JPEN J Parenter Enteral Nutr. 2004;28(2): 92-98.

2. Durfee SM, Adams SC, Arthur E, et al. A.S.P.E.N. standards for

nutrition support: home and alternate site care. Nutr Clin Pract.

2014;29(4):542-555.

3. Planas M, Lecha M, García Luna PP, et al. National registry of home

enteral nutrition in 2003. Nutr Hosp. 2006;21(1):71-74.

4. Klek S, Hermanowicz A, Dziwiszek G, et al. Home enteral nutrition

reduces complications, length of stay and health care costs: results from a

multicenter study. Am J Clin Nutr. 2014;100:609-615.

5. Chopy K, Winkler M, Schwartz-Barcott D, Melanson K, Greene G. A

qualitative study of the perceived value of membership in The Oley

Foundation by home parenteral and enteral nutrition consumers. JPEN J

Parenter Enteral Nutr. 2015;39(4):426-433.

6. Edwards S, Davis AM, Ernst L, et al. Caring for tube-fed children: a

review of management, tube weaning, and emotional considerations.

JPEN J Parenter Enteral Nutr. 2015;39(8):899-909.

7. Shortall C, Aherne M, Boland S, Sheane R, Ward F, Hensey O. Hospital

to home pediatric enteral nutrition—parents need support. Irish Med J.

2015;108(2):46-48.

8. Best C, Hitchings H. Enteral tube feeding—from hospital to home. Br J

Nurs. 2010;19(3):174-179.

9. Best C. Supporting home enteral tube feeding: some considerations.

Nutrition. 2012;17(suppl 7):S6-S10.

10. Best C, Hitchings H. Day case gastrostomy placement for patients in the

community. Br J Nurs. 2010;15(6):272-278.

11. DiBaise JK, Scolapio JS. Home parenteral and enteral nutrition.

Gastroenterol Clin North Am. 2007;36(1):123-144.

12. Majka AJ, Wang Z, Schmitz KR, et al. Care coordination to enhance man-

agement of long-term enteral tube feeding: a systematic review and meta-

analysis. JPEN J Parenter Enteral Nutr. 2014;38(1):40-52.

13. Thompson CW, Durrant L, Barusch A, Olson L. Fostering coping skills

and resilience in home enteral nutrition (HEN) consumers. Nutr Clin

Pract. 2006;21(6):557-565.

14. Clayton LH. Strategies for selecting effective patient nutrition education

materials. Nutr Clin Pract. 2010;25(5):436-442.

15. Arthur E, Greaves, J. The use of an enteral nutrition discharge checklist

to enhance patient care and help streamline the discharge coordination

process. Clinical Nutrition Week 2014. http://pen.sagepub.com/content/

suppl/2013/12/27/38.1.124.DC1/CNW14_All_Abstracts_file_1.

16. Agency for Clinical Innovation and the Gastroenterological Nurses College

of Australia. A Clinician’s Guide: Caring for People With Gastrostomy Tubes

and Devices. Chatswood, Australia: Agency for Clinical Innovation; 2014.

17. Centers for Medicare and Medicaid Services. National Coverage

Determination (NCD) for enteral and parenteral nutrition therapy (180.2).

Centers for Medicare and Medicaid Services website. https://www.cms.

gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=242&

ncdver=1&DocID=180.2&SearchType=Advanced&bc=IAAAABAAA

AAA&. Published July 11, 1984. Accessed October 3, 2016.

18. Bjuresäter K, Larsson M, Nordström G, Athlin E. Cooperation in the care

for patients with home enteral tube feeding throughout the care trajectory:

nurses’ perspectives. J Clin Nurs. 2008;17:3021-3029.

19. Hesselink G, Zegers M, Vernooij-Dassen M, et al. Improving patient dis-

charge and reducing hospital readmissions by using intervention mapping.

BMC Health Serv Res. 2014;14:389.

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tion in pediatric patients. Nutr Clin Pract. 2011;26(3):273-285.

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Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral

Nutrition. London, UK: National Collaborating Centre for Acute Care;

2006. NICE Clinical Guidelines No. 32.

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hospitalizations. Cleveland Clin J Med. 2014;81(5):312-320.

100 Journal of Parenteral and Enteral Nutrition 41(1)

Section 12. Documentation and Quality

Review Issues

Background

The EN process is highly complex, involving a multistep con-

tinuous process, including patient assessment and EN recom-

mendations, prescribing, order review, the selection/procurement

of enteral products, their preparation and labeling, and EN

administration and monitoring/reassessment. Documentation

throughout the EN process is important and provides a source for

process evaluation from which to identify gaps in process and

outcomes. For example, documentation of the nutrition assess-

ment is core to the process and has a direct impact on patient care.

Question 12.1. What documentation needs to occur at

each step in the EN process?

Practice Recommendations

1. Document nutrient requirements, including energy,

protein, and fluid, in the medical record within 48

hours of admission.

2. Document data used for nutrition assessment, including

nutrient/fluid intake, anthropometric data, weight

changes and goal weight, lab work, functional and

physical assessment, and any other assessment tools

employed. If any data are extrapolated from another

clinician’s note, such as the physical examination,

include from where the information was obtained.

3. Document the EN prescription and ancillary orders

using the EHR as appropriate.

4. Document how the recommended EN regimen meets the

estimated energy, protein, and fluid requirements initially

and any time a different EN regimen is recommended.

5. Provide an EN prescription review mechanism for all

clinicians involved.

6. Document the formula selection and preparation

through policies and procedures and specifically for

each patient in the EHR.

7. Develop and implement EN protocols to improve EN

administration in patients.

Rationale

The first step of documentation in the EN process is determina-

tion of energy requirements to guide the nutrition plan of care.

Wakeham and colleagues

performed a chart review in a cohort

of pediatric ICUs and found that patients with documented calo-

rie requirement were more likely to receive EN support than

those without on each of the first 4 days of admission. Patients

with documented calorie requirements had higher total daily

energy intake by the enteral route and by the enteral and paren-

teral route combined. The authors concluded that documentation

of calorie requirement in the medical record within 48 hours of

admission is significantly associated with higher total daily

energy intake and more frequent use of the enteral route for nutri-

tion. Importantly, in this study, the registered dietitian entered

almost all of the calorie requirements that were present early in

medical records. Documented protocols can also affect the qual-

ity of EN care. Kim and colleagues

performed a literature review

to identify major barriers to adequate EN intake in critically ill

adults. They found that interruption of EN is often due to avoid-

able causes such as routine nursing procedures and bedside care.

Also, after an interruption occurs, EN may be restarted at a low

rate. They suggest that standardized feeding protocols to prevent

unnecessary cessation of feedings and restart of EN after inter-

ruptions may maximize EN delivery in the ICU.

Question 12.2. What organizational systems/

administrative structures need to be in place to

support a safe EN process?

Practice Recommendations

1. Provide leadership and oversight at the healthcare

organizational level by competent clinicians

knowledgeable in the EN process.

2. Develop and implement policies and evidence-based

practice guidelines to support the individuals involved

in the assessment and care of patients receiving EN.

3. Develop and implement policies and guidelines

collaboratively among all disciplines involved in the

EN process, and align policies and procedures from

various disciplines, departments, and settings within

the organization.

4. Create a formal committee or structure that includes

expert clinicians from all disciplines to provide

oversight of the EN process.

Rationale

Documentation needs to be supported by a strong infrastruc-

ture of organizational systems and administrative oversight.

The EN process involves many disciplines and departments.

An EN process that minimizes risks requires interdisciplinary

collaboration, standardization through guidelines, and practice

alignment among professions, departments, and settings.

Evidence-based practice guidelines targeted at the clinical,

departmental, and organizational levels support a safe EN pro-

cess. Ideally, policies and guidelines addressing nutrition care,

nursing care, and physician prescribing are developed to target

each discipline’s role in the EN process. These guidelines need

to be aligned and complementary to avoid inconsistencies.

Recent literature supports the use of enteral feeding practice

guidelines and feeding algorithms to improve the safety and

efficacy of enteral feedings. Gentles and colleagues

found that

introduction of an enteral feeding practice guideline and par-

ticipation by a dietitian in multidisciplinary bedside rounds

Boullata et al 101

improved provision of nutrition support and overall energy

intake. Similarly, Geukers and colleagues

demonstrated that

the introduction of a nurse-driven, early EN algorithm and

implementation of a nutrition support team safely and effec-

tively increased the nutrition intake of critically ill children

during the first few days of an ICU stay.

Organizations can use a governing body or committee com-

posed of a multidisciplinary group of content experts, such as a

nutrition committee, to support safe EN practice. This group can

be charged with reviewing and approving guidelines and identi-

fying educational programs and strategies to disseminate evi-

dence-based guidelines and practices. This interdisciplinary

group can also evaluate and respond to changes in the EN pro-

cess, process failures, and data and outcome measures to con-

tinually improve the process to ensure safety and effectiveness.

Question 12.3. What is the role of clinical decision

support in the EN order and review process?

Practice Recommendations

1. Use clinical decision support tools in guiding safe EN

prescribing.

2. Develop and implement procedures for the EN order

review process.

Rationale

The EHR provides the opportunity to use computerized clini-

cal decision support (CDS) to guide accurate prescribing. CDS

involves the use of alerts, algorithms, and rule-based recom-

mendations to guide ordering. The impact of CDS is controver-

sial. Shojania and colleagues

conducted a review of studies

that evaluated the effect of computer reminders on processes or

outcomes of care. Their goal was to determine the degree to

which computer reminders changed provider behavior. They

found that computer reminders delivered to physicians during

routine electronic ordering achieved only small to modest

improvement in care, with a median improvement of 4.2%.

The authors concluded that these changes fall below thresholds

that would be considered clinically significant and “constitute

an expensive exercise in trial and error.” Schedlbauer et al

performed a systematic review of alerts and other reminders

and prompts to evaluate the impact on prescribing behavior.

They evaluated 27 different types of alerts and prompts and

found that 23 of 27 resulted in a significant improvement in

prescribing behavior and/or reduction in medication errors,

and many of the alerts and prompts were clinically relevant.

The authors concluded that most of the studies that evaluated

the impact of computerized CDS systems show positive and

significant effects. Although these studies specifically target

medication prescribing, the EN process parallels the medica-

tion management process and therefore the study findings are

relevant to EN.

Question 12.4. What organizational quality control

processes need to be implemented for EN safety?

Practice Recommendations

1. Develop and implement enteral feeding algorithms to

improve the provision of nutrition and possibly reduce

length of stay and mortality.

2. Develop organizational guidelines that address safe

enteral practices collaboratively by a multidisciplinary

team.

3. Disseminate the organizational guidelines by

interactive communication/education methods

utilizing individuals with nutrition expertise.

4. Monitor the EN process for safety and effectiveness.

5. Promote active involvement by members of the

nutrition service in the development of electronic EN

orders and clinical documentation to optimize safe and

effective electronic communication.

Rationale

In a multicenter, cluster-randomized trial, Martin and col-

leagues

demonstrated that the implementation of evidence-

based algorithms for nutrition support improved the provision

of nutrition support, reduced hospital length of stay, and may

decrease hospital mortality in critically ill patients in both

community and teaching hospitals. Along with initiation of

nutrition support algorithms, other strategies were used to

improve the effectiveness of nutrition support care, including

educational sessions, educational outreach, and audit with

feedback. Guidelines alone are not adequate; they must be sup-

ported by professional collaboration, education, and effective

communication strategies. In a review, Marshall and col-

leagues

identified factors that influence nursing nutrition

practice around EN and how these factors contribute to varia-

tions in practice. Evidence-based guidelines were found to be

important, but EN guidelines were often lacking strong recom-

mendations and evidence related to nursing-specific practice,

which limited their usefulness. To increase use of guidelines

and effectively apply these standards to clinical care, the

authors recommend that the implementation of guidelines be

combined with contributions from resource personnel who

have nutrition and clinical expertise. They emphasize that if

the intent is to use guidelines to standardize and improve prac-

tice, the information is best delivered using strong communica-

tion strategies that incorporate social interaction as a component

of this knowledge transfer. The authors also support an inter-

disciplinary, collaborative approach where professionals from

different disciplines (namely, dietitians, nurses, and physi-

cians) function in a supportive organizational environment that

includes integrated and cohesive care and symmetrical power.

This multidisciplinary team can collaborate in nutrition-related

practice, education, and research.

102 Journal of Parenteral and Enteral Nutrition 41(1)

Standardization of EN orders in the EHR is another avenue

for supporting a safe EN process. Since the passage of the

Health Information Technology for Economic and Clinical

Health (HITECH) Act in 2009, hospitals have been imple-

menting EHR at increasing rates. Successful implementation

of an EHR requires input from the clinicians who will use the

EHR to provide patient care regarding how the EHR can be

built and implemented to maximize patient care and avoid

harm to patients. The safety and efficacy of nutrition and nutri-

tion support content in EHR were the focus of a study that

surveyed members of ASPEN. This survey indicated that most

respondents (85.9%) were using an EHR, with the most com-

mon duration of use between 5 and 10 years. The results dem-

onstrated a significant need for improvement in the safety and

effectiveness of the nutrition and nutrition support content of

the EHRs, with an overall rating of fair for this content (ratings

ranged from unacceptable to excellent). The authors conclude

that nutrition support content needs improvement and that

nutrition support clinicians need to be actively involved in con-

tent development and optimization.

Question 12.5. What competencies need to be maintained

by clinicians involved in the EN process?

Practice Recommendations

1. Use discipline-specific standards and available

competencies from professional organizations to create

job descriptions for all clinicians involved in the EN

process.

2. Encourage nutrition support clinicians involved in the

EN process to be board certified by one of the

accredited certifying organizations.

3. Develop at the healthcare organizational level

competency evaluations that measure EN core

elements and knowledge for all clinicians involved in

the EN process.

Rationale

Given the complexity and scope of the EN process, each

organization needs an oversight structure, which may reside

within a standing committee. This group is uniquely qualified

to oversee the EN process. In addition, all clinicians involved

in the EN process must be competent and receive ongoing

education/training to ensure safe and effective care. Education

and competencies set by nutrition-related professional orga-

nizations are also important. For example, the standards of

practice (SOP) and standards of professional performance

(SOPP) for registered dietitian nutritionists (RDNs) in nutri-

tion support have been developed by the American Society

for Parenteral and Enteral Nutrition and the Academy of

Nutrition and Dietetics.

These standards outline the compe-

tencies needed for dietitians to provide nutrition support care,

including EN. Similar standards are available for other clini-

cians involved in the EN process.

11–13

Board certification in

nutrition support is highly desirable for those involved in the

EN process. For example, the National Board of Nutrition

Support Certification (NBNSC) certification examination

validates that clinicians (dietitians, nurses, pharmacists, phy-

sicians, and physician assistants) have attained the threshold

of skills and knowledge necessary to provide quality nutrition

support care. Additional board certification processes are

available for some of these healthcare professionals. Surveys

of nutrition support professionals indicate that board certifi-

cation is critical to providing safe and effective care to

patients.

Brody and colleagues

conducted a survey of

healthcare professionals affiliated with ASPEN and used a

case-based scenario based on established clinical guidelines

to evaluate knowledge of nutrition support practices. More

than half of the respondents were board certified by NBNSC,

and the results indicated that those holding the certification

were significantly more likely to choose correct answers

compared to those without the credential. Although a certifi-

cation examination cannot guarantee patient safety, it can

help ensure patient safety by identifying those individuals

who can demonstrate knowledge through a standardized vali-

dated board certification process.

Question 12.6. What essential EN administration and

monitoring components should be documented by

nursing staff and at what interval should EN clinical

documentation occur?

Practice Recommendations

1. Document interruptions to enteral feedings, including

reason and length of interruption; this is best done by

the nursing staff.

2. Document HOB elevation, date/time of administration

start and tubing changes, and residuals for gastric

feedings at each shift.

3. Document amount, type, frequency, and rate of

feeding; patient’s response to tube feeding; abdominal

assessment; patency of the tube; condition of the skin

at tube site if placed in abdominal wall; amount of any

additional water; flush volume, frequency, and rate;

and patient and family education.

4. Record intake and output, weights, and methods used

to verify placement of an EAD.

5. Complete the nursing documentation of EN at each

shift or with any change in condition or order.

Rationale

Documentation of nursing care related to EN administration

and monitoring is critical to a safe EN process and can be

supported by protocols and evidence-based guidelines.

Boullata et al 103

HOB elevation, the time/date of EN administration, and

residuals are common nursing documentation standards.

According to Mosby’s Nursing Skills,

the following docu-

mentation is also recommended: amount, type, frequency,

and rate of feeding; patient’s response to tube feeding;

abdominal assessment; patency of tube; condition of the skin

at tube site if placed in abdominal wall; amount of any addi-

tional water; flush volume, frequency, and rate; and patient

and family education.

Topics for Future Research

 How well does documentation at each step of the EN

process identify opportunities for safety improvement

 Data on clinical decision support systems and EN

prescribing and safety

References

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ing a difference: early medical record documentation of estimated

energy requirements in critically ill children is associated with higher

daily energy intake and with use of the enteral route. J Acad Nutr Diet.

2013;13(10):1311-1316.

2. Kim H, Stotts NA, Froelicher ES, Engler MM, Porter C. Why patients

in critical care do not receive adequate enteral nutrition? A review of the

literature. J Crit Care. 2012;27:702-713.

3. Gentles E, Mara J, Diamantidi K, et al. Delivery of enteral nutrition after the

introduction of practice guidelines and participation of dietitians in pediatric

critical care clinical teams. J Acad Nutr Diet. 2014;114(12):1974-1980.

4. Geukers V, Neef M, Dijsselhof M, Sauerwein H, Bos A. Effect of a nurse-

driven feeding algorithm and the institution of a nutritional support team

on energy and macronutrient intake in critically ill children. e-SPEN J.

2012;7(1):e35-e40.

5. Shojania KG, Jennings A, Mayhew A, Ramsay C, Eccles M, Grimshaw

J. Effect of point-of-care computer reminders on physician behavior: a

systematic review. CMAJ. 2010;182(5):216-225.

6. Schedlbauer A, Prasad V, Mulvaney C, et al. What evidence supports the

use of computerized alerts and prompts to improve clinicians’ prescribing

behavior? JAMA. 2009;16(4):531-538.

7. Martin C, Doig G, Heyland D, Morrison T, Sibbald W. Multicentre,

cluster-randomized clinical trial of algorithms for critical-care enteral and

parenteral therapy (ACCEPT). CMAJ. 2004;170(2):197-204.

8. Marshall AP, Cahill NE, Gramlich L, MacDonald G, Alberda C, Heyland

DK. Optimizing nutrition in intensive care units: empowering critical

care nurses to be effective agents of change. AJCC. 2012;21(3):186-194.

9. Vanek V. Providing nutrition support in the electronic health record era:

the good, the bad and the ugly. Nutr Clin Pract. 2012;27:718-737.

10. Brantley SL, Russell MK, Mogensen KM, et al. American Society for

Parenteral and Enteral Nutrition and Academy of Nutrition and Dietetics

revised 2014 standards of practice and standards of professional perfor-

mance for registered dietitian nutritionists (competent, proficient, and

expert) in nutrition support. Nutr Clin Pract. 2014;29:792-828.

11. Mascarenhas MR, August DA, DeLegge MH, et al. Standards of prac-

tice for nutrition support physicians. Nutr Clin Pract. 2012;27(2):

295-299.

12. Tucker A, Ybarra J, Bingham A, et al. A.S.P.E.N. standards of practice for

nutrition support pharmacists. Nutr Clin Pract. 2015;30:139-146.

13. DiMaria-Ghalili RA, Gilbert K, Lord L, et al. Standards of nutrition care

practice and professional performance for nutrition support and generalist

nurses. Nutr Clin Pract. 2016;31(4):527-547.

14. Materese LE, Chinn RN, Hertz NR, Callahan P, Harvey-Banchik L,

Strang B. Practice analysis of nutrition support professionals: evidence-

based multidisciplinary nutrition support certification examination. JPEN

J Parenter Enteral Nutr. 2012;36(6):663-670.

15. Brody R, Hise M, Fleisch Marcus A, Harvey-Banchik L, Matarese L.

Evaluating evidence-based nutrition support practice among healthcare

professionals with and without the certified nutrition support clinician cre-

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16. Mosby’s Skills. Enteral nutrition via nasoenteric, gastrostomy, or jejunos-

tomy tube. http://mns.elsevierperformancemanager.com/NursingSkills

Accessed June 1, 2015.

Conclusion

The EN process consists of numerous steps involving several

disciplines that perform a number of specific tasks at each

step. These daily responsibilities are critical to ensuring safe

care of the patient requiring EN therapy. Given the potential

risk for error in the systems within which EN is used, ongoing

systematic surveillance, critical process and outcome evalua-

tion, and quality improvements will support patient safety.

Organizations can incorporate into their system of care the

best practice recommendations within this document, to sup-

port a culture of safety, by applying an interdisciplinary

approach in an accommodating administrative structure.