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Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians. Utah Academy of Nutrition and Dietetics Annual Meeting, March 20, 2014

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Page 1: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Get it inKeep it in

Keep it running

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

related activities by registered dietitians.

Utah Academy of Nutrition and Dietetics

Annual Meeting, March 20, 2014

Page 2: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Objectives• Describe the experience of one clinical nutrition

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

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

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

Page 3: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Participation Activity

Page 4: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

What Get it in

Bedside feeding tube placementKeep it in

FT bridle placementKeep it running

FT clog clearing

By Dietitians

Page 6: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Why

• Altruistim (patient care)

• Self interest (job satisfaction)

• Practical reasons (cost containment)

Page 7: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Patient Care

Page 8: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Job Satisfaction

• Avoid burn out• New marketable skill• Increased recognition

Page 9: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Cost Containment

Page 10: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Getting It Done

Data collection Training

EquipmentSupport

Idea

Page 11: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Desire

Inspiration

Idea

Page 12: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Support

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

Page 13: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Equipment

Page 14: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Feeding tube bridle

Page 15: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Dobhoff feeding tube

OUCH!

Page 16: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Frederick-Miller feeding tube

Page 17: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Cortrak

Page 19: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Other tubes

Page 20: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Personal Protective Equipment:

a fashion must

Page 21: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Personal Protective Equipment:

a fashion must

Page 22: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Stethescope

Page 23: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

TubeClear

Page 24: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Training: bridle placement

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

manufacturer

Page 25: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Bridle placement method

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

Page 26: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Training: bedside feeding tube placement

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

Page 27: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

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

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

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

Page 28: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

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

Page 29: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

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

Page 30: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Dietitian Pros & Cons

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

Page 31: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

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

Page 32: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

Reduced total fluoro placement

• Bedside placement by RNs and RDs• Avoid unnecessary replacement

o Bridleso Clearing clogso Avoiding clogs

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

Page 33: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

• Feeding tubes placed in fluoro

o 2012: 124 o 2013: 88

• Cost reduced by 29%

Reduced total fluoro placement

Page 34: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians

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

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

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

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

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Page 36: Get it in Keep it in Keep it running Adventures in bedside feeding tube placement and other hands-on feeding tube related activities by registered dietitians