Achieving quality and patients safety in nutritional care

Quality indicators in enteral nutrition therapy

ESPEN Congress Barcelona 2012

M. Holst (Denmark)

Quality indicators in enteral nutrition therapy

Mette HolstHead of Clinical Nutrition Research, RN, MCN, Phd

Centre for Nutrition and Bowel DiseaseAalborg University Hospital, Denmark

Educational Session: Achieving quality and patients’ safety in nutritional care

Aim of lectureTo emphasize that:

1. Use of quality indicators in Enteral Nutrition Therapy (ENT) and audits, can improve quality of care including patient safety

2. Improving quality by use of quality indicators is demands leadership and implementation

3. Research is needed to improve guidelines and safe enteral nutrition practise

Quality goals for EN therapy

1. Patient meets requirements for energy and protein

2. Right feeding method for right patient3. Patient safety4. Improve outcome

Piece of cake, or??

Quality indicators: Tool for quality development

An indicator is an operational target for quality, a measurable variable which alone, or in conjunction with other indicators can illustrate if the quality is right (Danish Board of Health)

A statistical value that indicates the condition or directionof the performance of a process or achievement of an outcome over time (Joint commision International)

The indicators reflect either patient experienced, professional or organizational quality.

Nutrition Care Process- EN

RequirementsNutrition plan

Safety management

Action and monítoring

Follow upRevision of planCommunication

Screening &Assessment of

risk factorsAdmittance

Discharge

ESPEN Guidelines on adult enteral nutrition. Lochs et al. Clin Nutr. 2006

Patient needs Enteral Nutrition

RequirementsFeeding techniqueWhich product?Combi therapy?Placement control methodSafe daily management

Placement controlleAdministrationMonitoring of EN/ON/PNDocumentation

Requirements met?Adverse events?

Audit

What are quality indicators for enteral nutrition?

Can QI impact quality in EN practise?

Quality indicators for enteral nutrition(ICU)

Cartolano F, Caruso L, Soriano F; Rev Bras Ter Intensiva. 2009; 21(4)376-383

Patient safety risks

Misplacement / aspirationMisconnectionsEnteral Nutrition delivery errorsMedical administration errors

Misplacement

Misconnections..of 116 cases in 34 reports

Tubing misconnections: normalization of deviance. Simmons D. Nutr Clin Pract 2011 26:286

Enteral Nutrition delivery errorsCauses for not meeting requirements

”No programmed pause” 63%

Image diagnostic procedures 16%

Surgical procedures 9.6%

Gastrointestinal complications 7%

Exchange feeding tubes 6%

Respiratory tube procedures 2.6%

Haemodynamic instability 1.3%

In 658 patient cases, only 10% of calories prescribed were notadministered.

Enteral Nutrition delivery errors

Of 160 patients in 40 units80% aschieved on day 4, in 79%

Causes for not meeting requirements

OR

Logistics 64.5

Unknow causes 47.6

High gastric residue 29.2

Accidental loss of feeding tube 28.1

Unexpected delay in EN delivery 27.4

Patient refusal to treatment 24.1

Obstruction of feeding tube 20.3

External physician interference 17.3

Abdominal distension 10.2

Vomiting 8.0

Diarrhea 3.0

Poster ESPEN 2010

Meet requirements?

>20 kcal/kg/day > 1 g P/kg/day

52% 22%

Analysis of medical and nursing records, and nutritionnotes related to the volume infused of enteral feedingof 791 patients on enteral nutrition who were admitted

to two hospitals in Sao Paulo 2009-2010

Poster ESPEN 2011

Delivery or documentation?

Can improvement be made?

Cartolano F, Caruso L, Soriano F; Rev Bras Ter Intensiva. 2009; 21(4)376-383

Administered vs prescribed. 116 patient cases for a periode of four Years in ICU. Same QI

Quality indicators for enteral nutrition(ICU)

Cartolano F, Caruso L, Soriano F; Rev Bras Ter Intensiva. 2009; 21(4)376-383

Medical administration error

Kelly J, Wright D, Wood J; JAN 67 (12 ) 2011

In 2129 hospitalized patients.Error in 817 patients313 patients with dysphagia

Medical administration error In 56% of dysphagia patients with enteral tube

Bedside Assessment of Enteral Tube placement

Simons S R& Abdallah LM; AJN Feb 2012 Vol 112, no 228 New England Hospitals

102 published articles

Nasogastric tube safety in placement and management–do guidelines agree?

Indicator NICE NPSA ASPEN ESPENAssessment prior to Prescribing EN

√ √ √ √

Local protocols √ √ % %

Insertion skills √ √ √ %

X-ray after insertion √ √ √ %

Aspiration and PH before each use

√+Local protocol for when asp not possible

√ √ %

X-ray before use When nessesary When nessesary When nessesary %

Exit site centimeter markings and obs

% √ √ %

Auscultatatory method

% % Do not rely on %

Elevate HOB >30° %

Tjeck misconnections % % √ %

Documentation for all tube checks

% √ % %

Audit % √ % √

Nice guideline- Nutrition Support in adults; 2006National Patient Safety Agency (2011)

ASPEN: Gunther P: Crit Care Nurs Clin N AM 22(2010)ESPEN: Lochs H et al. Clin Nutr. 2006 Apr;25(2):180-6

Implementation of guidelines – does it work?

Tho PC, Mordiffi S, Ang E, Chen H; Int J Evid Based Healthc 2011; 9

Implementation of the evidence review on best practice for confirming the correct placement of nasogastric tube in patients in an acute care hospital

Conclusion1. Use of quality indicators in Enteral Nutrition Therapy

(ENT) and audits, can improve quality of care including patient safety√

2. Improving quality by use of quality indicators needs leadership and implementation√

3. Research is needed to improve and concretize guidelines and safe enteral nutrition practise-especially regarding control of tube before EN administration, and how to improve medication errors√

Perspectives

Need for improved implementationstrategies and continued audit of all safetyprocedures including Quality Indicators

Thank you for your attention

mette.holst@rn.dk