- Email: [email protected]
Dietitians place feeding tubes?
MEDICAL NUTRITION IN DIETETICS
Editor: Eva Shronts, MMSc, RD
Dietitians Place Feeding Tubes? Gail Cresci, MS, RD, CNSD, LD From the Department of Surgery, Medical College of Georgia, Augusta, Georgia, USA ver the past decade, most clinicians tend to agree that enteral nutrition is the preferred route of nutrient delivery for patients with adequately functional gastrointestinal tracts and whose oral nutrient intake is insufficient to meet estimated needs. There are multiple methods for gaining enteral access. The nasoenteric feeding tube is most commonly used due to its low complication rates, relatively low cost, and increased versatility because it can be placed into the stomach, duodenum, or the jejunum. Although many patients can be fed successfully into the stomach, there are those with increased aspiration risk and gastroparesis who require postpyloric feedings.1 Positioning a feeding tube into the small intestine is much more difficult than positioning a tube into the stomach. Several bedside “blind” methods using special placement techniques, weighted versus nonweighted tubes, pH sensor tubes, prokinetic agents, magnets, and bioelectrical detection devices have been reported, all with similar success rates (⬃80% to 85%).2–10 Due to lack of universal success in “blind” placement of nasoenteric tubes, fluoroscopic or endoscopic guidance is often sought when local expertise is available. If portable equipment is not available, both of these techniques require patient transport to the radiology or endoscopy suite, which may not be feasible for critically ill patients. Both methods carry an 85% to 95% success rate in obtaining postpyloric feeding tube placement.11 So, despite multiple methods available to gain enteral access, early enteral nutrition often is not used because of the lack of success in obtaining desired positioning of a nasoenteric feeding device. Registered dietitians play an integral role in providing patients with optimal nutrition support. They are typically part of a nutrition support team, if not the sole clinician intimately managing the patient’s nutritional care plan. Typically, a certified nutrition support dietitian is responsible for performing nutrition assessments, making recommendations for enteral and parenteral nutrition care plans, monitoring the patient’s response to the nutrition support reg-
O
Correspondence to: Gail Cresci, MS, RD, CNSD, LD, Medical College of Georgia, Department of Surgery, GI Section, Room 4072, 1120 15th Street, Augusta, GA 30912, USA. E-mail: [email protected]
imen, and making recommendations for changes in the nutrition regimen as needed. It is no wonder that dietitians are pursuing competency for placing postpyloric feeding tubes. This task carries an 80% to 90% success rate among the very best and dedicated clinicians, leaving marginal success to those with occasional experience. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently updated and revised their standards of practice for nutrition support dietitians (NSDs).12 Although the main purpose of the standards is to provide guidance for the NSD, they do not supersede the NSD’s professional judgment or health care institution’s policies and procedures in which the NSD practices. This past year, the American Dietetic Association (ADA), with the support of the Dietitians in Nutrition Support practice group, adopted the A.S.P.E.N. Standards of Practice (SOP) for NSDs.13 The SOP states that NSDs shall participate with implementation of a medical nutrition therapy care plan. The NSD’s involvement with implementation may occur at several levels depending on their job responsibilities, professional licensure, and institutional clinical privileges.12 Levels of involvement include recommending not only the placement and management of enteral access devices but also the actual placement and management of nasoenteric access devices after special training and certification.12 If an NSD is interested in placing nasoenteric access devices, there are several issues that require prior investigation. The first is to determine whether the state in which you practice has licensure for dietetics professionals. Only states with licensure, not those with certification acts, will have a scope of practice that affects boundaries of practice.14 Review your state’s scope of practice for possible limitations. Also recommended is to avoid violating another profession’s scope of practice, be certain skills performed would not be considered practicing medicine, and be sure to practice under the direction of the appropriate licensed professional as indicated by state regulations (e.g., physician, physician assistant, and nurse practitioner).14 The placement of nasoenteric access devices is considered an invasive procedure requiring special training, demonstrated competency, and delineated clinical privileges. NSDs should ensure that it is within the interests of the health care facility that
Nutrition 18:778 –779, 2002 ©Elsevier Science Inc., 2002. Printed in the United States. All rights reserved.
employs them to have them place nasoenteric access devices. The NSD should obtain proper training and periodic competency assessment. This training and assessment should be specified in appropriate policies and procedures and in the job description. Personnel files should contain records of training and assessments. In addition, facilities need to check with their insurance carrier to determine whether the insurer will cover an employee trained as a dietetics professional but performing duties across other disciplines.14 Secondary insurance for malpractice coverage may be necessary. Be certain to obtain a copy of your protection and limitations of coverage. For example, the ADA’s liability insurance program covers ADA active members in the provision of professional services as a trained dietetics professional functioning within the guidelines of their state and occupation.14 An activity considered a professional service is one that is expected to be provided based on the education and/or training of a dietetics professional, thus making upskilled duties potentially not covered under liability insurance policies.14 Another option for the NSD is to seek a licensed professional (e.g., physician) willing to carry the liability. Once the NSD has reviewed state and institution policies and restrictions and determines that it is feasible to place nasoenteric access devices, special training and certification must be obtained. The one question I receive most often is how to obtain this special training. First, check within your own institution or geographic location for professionals that already perform the skill and ask them how they were trained. It does not need to be, and most likely will not be, an NSD that trains you to place feeding devices. A registered nurse trained me in my facility. Other avenues for training include skills workshops, nursing or physician assistant training programs, or exchange/liaison programs arranged with other experienced, credentialed individuals. The ADA has a list of allied organizations that may be helpful. This can be obtained by e-mail at [email protected]. Allied organizations and links to allied web sites are posted on ADA’s web site http://www.eatright.org/healthorg.html. Although placing nasoenteric access devices can add to the burden of daily workload, this route of upskilling has many potential benefits. One very important benefit I have found is more timely delivery of en0899-9007/02/$22.00 PII S0899-9007(02)00820-1
Nutrition Volume 18, Number 9, 2002 teral nutrition to patients. As NSDs, we have a vested interest in gaining enteral feeding access and often will take more time and care in ensuring it is accomplished. For example, through the past several years of placing enteral access devices, I have achieved an almost 95% success rate of gaining small bowel access in approximately 30 min. This also leads to cost savings to the health care institution because reduced assets are used (e.g., radiographs, medications, and feeding devices) to obtain access. More timely access also can lead to a reduction in parenteral nutrition usage, leading to further cost savings and patient benefits. In addition, there are many personal benefits that accompany placing nasoenteric access devices such as increased job satisfaction, job flexibility and retention, increased self-esteem, and increased compensation in certain situations. As the health care environment continues to change, with shrinking budgets and downsizing, the practice of dietetics continues to evolve. This evolution brings the opportunity, and often the necessity, for NSD upskilling. NSDs should view this as an opportunity to become a more integral part of the health care team. The actual
Dietitians Place Feeding Tubes? placement of nasoenteric access devices may not be feasible or desired for all NSDs. However, at the very minimum, the NSD should understand the various routes for obtaining enteral access including their risks and benefits. The NSD can then use this knowledge and participate in an interdisciplinary process and recommend the placement and management of enteral access devices.12
7.
8.
9.
REFERENCES 1. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients. A multicenter study. Crit Care Med 1999;27:1447 2. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. Chest 1991; 100:1643 3. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. JPEN 1986;10: 104 4. Grabriel SA, Ackermann RJ, Castresana MR. A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med 1997;25:641 5. Davis TJ, Sun D, Dalton ML. A modified technique for bedside placement of nasoduodenal feeding tubes. J Am Coll Surg 1994;178:407 6. Salasidis R, Fleiszer, Johnston R. Air insufflation
10.
11. 12.
13.
14.
779
technique of enteral tube insertion: a randomized, controlled trial. Crit Care Med 1998;26:1036 Cresci G, Grace M, Park M, et al. Accurate and timely blind bedside placement of post-pyloric feeding tubes using an electromagnetic navigation device (abstract). Nutr Clin Pract 1999;14:101 Lord LM, Weiser-Maimone A, Pulhamus M, Sax H. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN 1993;17:271 Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled double-blind study. JPEN 1987; 11:33 Taylor B, Schallom L. Bedside small bowel feeding tube placement in critically ill patients utilizing a dietitian/nurse team approach. Nutr Clin Pract 2001; 16:258 Minard G. Enteral access. Nutr Clin Pract 1994;9: 172 A.S.P.E.N. Board of Directors. Standards of practice for nutrition support dietitians. Nutr Clin Pract 2000; 15:53 Fuhrman M, Winkler M, Biesemeier C. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) standards of practice for nutrition support dietitians. J Am Diet Assoc 2001;101:825 American Dietetics Association. Frequently asked upskilling questions and responses. Available from: http://www.eatright.org/upskilling.html. Accessed January 29, 2002
Editor: Eva Shronts, MMSc, RD
Dietitians Place Feeding Tubes? Gail Cresci, MS, RD, CNSD, LD From the Department of Surgery, Medical College of Georgia, Augusta, Georgia, USA ver the past decade, most clinicians tend to agree that enteral nutrition is the preferred route of nutrient delivery for patients with adequately functional gastrointestinal tracts and whose oral nutrient intake is insufficient to meet estimated needs. There are multiple methods for gaining enteral access. The nasoenteric feeding tube is most commonly used due to its low complication rates, relatively low cost, and increased versatility because it can be placed into the stomach, duodenum, or the jejunum. Although many patients can be fed successfully into the stomach, there are those with increased aspiration risk and gastroparesis who require postpyloric feedings.1 Positioning a feeding tube into the small intestine is much more difficult than positioning a tube into the stomach. Several bedside “blind” methods using special placement techniques, weighted versus nonweighted tubes, pH sensor tubes, prokinetic agents, magnets, and bioelectrical detection devices have been reported, all with similar success rates (⬃80% to 85%).2–10 Due to lack of universal success in “blind” placement of nasoenteric tubes, fluoroscopic or endoscopic guidance is often sought when local expertise is available. If portable equipment is not available, both of these techniques require patient transport to the radiology or endoscopy suite, which may not be feasible for critically ill patients. Both methods carry an 85% to 95% success rate in obtaining postpyloric feeding tube placement.11 So, despite multiple methods available to gain enteral access, early enteral nutrition often is not used because of the lack of success in obtaining desired positioning of a nasoenteric feeding device. Registered dietitians play an integral role in providing patients with optimal nutrition support. They are typically part of a nutrition support team, if not the sole clinician intimately managing the patient’s nutritional care plan. Typically, a certified nutrition support dietitian is responsible for performing nutrition assessments, making recommendations for enteral and parenteral nutrition care plans, monitoring the patient’s response to the nutrition support reg-
O
Correspondence to: Gail Cresci, MS, RD, CNSD, LD, Medical College of Georgia, Department of Surgery, GI Section, Room 4072, 1120 15th Street, Augusta, GA 30912, USA. E-mail: [email protected]
imen, and making recommendations for changes in the nutrition regimen as needed. It is no wonder that dietitians are pursuing competency for placing postpyloric feeding tubes. This task carries an 80% to 90% success rate among the very best and dedicated clinicians, leaving marginal success to those with occasional experience. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) recently updated and revised their standards of practice for nutrition support dietitians (NSDs).12 Although the main purpose of the standards is to provide guidance for the NSD, they do not supersede the NSD’s professional judgment or health care institution’s policies and procedures in which the NSD practices. This past year, the American Dietetic Association (ADA), with the support of the Dietitians in Nutrition Support practice group, adopted the A.S.P.E.N. Standards of Practice (SOP) for NSDs.13 The SOP states that NSDs shall participate with implementation of a medical nutrition therapy care plan. The NSD’s involvement with implementation may occur at several levels depending on their job responsibilities, professional licensure, and institutional clinical privileges.12 Levels of involvement include recommending not only the placement and management of enteral access devices but also the actual placement and management of nasoenteric access devices after special training and certification.12 If an NSD is interested in placing nasoenteric access devices, there are several issues that require prior investigation. The first is to determine whether the state in which you practice has licensure for dietetics professionals. Only states with licensure, not those with certification acts, will have a scope of practice that affects boundaries of practice.14 Review your state’s scope of practice for possible limitations. Also recommended is to avoid violating another profession’s scope of practice, be certain skills performed would not be considered practicing medicine, and be sure to practice under the direction of the appropriate licensed professional as indicated by state regulations (e.g., physician, physician assistant, and nurse practitioner).14 The placement of nasoenteric access devices is considered an invasive procedure requiring special training, demonstrated competency, and delineated clinical privileges. NSDs should ensure that it is within the interests of the health care facility that
Nutrition 18:778 –779, 2002 ©Elsevier Science Inc., 2002. Printed in the United States. All rights reserved.
employs them to have them place nasoenteric access devices. The NSD should obtain proper training and periodic competency assessment. This training and assessment should be specified in appropriate policies and procedures and in the job description. Personnel files should contain records of training and assessments. In addition, facilities need to check with their insurance carrier to determine whether the insurer will cover an employee trained as a dietetics professional but performing duties across other disciplines.14 Secondary insurance for malpractice coverage may be necessary. Be certain to obtain a copy of your protection and limitations of coverage. For example, the ADA’s liability insurance program covers ADA active members in the provision of professional services as a trained dietetics professional functioning within the guidelines of their state and occupation.14 An activity considered a professional service is one that is expected to be provided based on the education and/or training of a dietetics professional, thus making upskilled duties potentially not covered under liability insurance policies.14 Another option for the NSD is to seek a licensed professional (e.g., physician) willing to carry the liability. Once the NSD has reviewed state and institution policies and restrictions and determines that it is feasible to place nasoenteric access devices, special training and certification must be obtained. The one question I receive most often is how to obtain this special training. First, check within your own institution or geographic location for professionals that already perform the skill and ask them how they were trained. It does not need to be, and most likely will not be, an NSD that trains you to place feeding devices. A registered nurse trained me in my facility. Other avenues for training include skills workshops, nursing or physician assistant training programs, or exchange/liaison programs arranged with other experienced, credentialed individuals. The ADA has a list of allied organizations that may be helpful. This can be obtained by e-mail at [email protected]. Allied organizations and links to allied web sites are posted on ADA’s web site http://www.eatright.org/healthorg.html. Although placing nasoenteric access devices can add to the burden of daily workload, this route of upskilling has many potential benefits. One very important benefit I have found is more timely delivery of en0899-9007/02/$22.00 PII S0899-9007(02)00820-1
Nutrition Volume 18, Number 9, 2002 teral nutrition to patients. As NSDs, we have a vested interest in gaining enteral feeding access and often will take more time and care in ensuring it is accomplished. For example, through the past several years of placing enteral access devices, I have achieved an almost 95% success rate of gaining small bowel access in approximately 30 min. This also leads to cost savings to the health care institution because reduced assets are used (e.g., radiographs, medications, and feeding devices) to obtain access. More timely access also can lead to a reduction in parenteral nutrition usage, leading to further cost savings and patient benefits. In addition, there are many personal benefits that accompany placing nasoenteric access devices such as increased job satisfaction, job flexibility and retention, increased self-esteem, and increased compensation in certain situations. As the health care environment continues to change, with shrinking budgets and downsizing, the practice of dietetics continues to evolve. This evolution brings the opportunity, and often the necessity, for NSD upskilling. NSDs should view this as an opportunity to become a more integral part of the health care team. The actual
Dietitians Place Feeding Tubes? placement of nasoenteric access devices may not be feasible or desired for all NSDs. However, at the very minimum, the NSD should understand the various routes for obtaining enteral access including their risks and benefits. The NSD can then use this knowledge and participate in an interdisciplinary process and recommend the placement and management of enteral access devices.12
7.
8.
9.
REFERENCES 1. Montejo JC. Enteral nutrition-related gastrointestinal complications in critically ill patients. A multicenter study. Crit Care Med 1999;27:1447 2. Zaloga GP. Bedside method for placing small bowel feeding tubes in critically ill patients. Chest 1991; 100:1643 3. Thurlow PM. Bedside enteral feeding tube placement into duodenum and jejunum. JPEN 1986;10: 104 4. Grabriel SA, Ackermann RJ, Castresana MR. A new technique for placement of nasoenteral feeding tubes using external magnetic guidance. Crit Care Med 1997;25:641 5. Davis TJ, Sun D, Dalton ML. A modified technique for bedside placement of nasoduodenal feeding tubes. J Am Coll Surg 1994;178:407 6. Salasidis R, Fleiszer, Johnston R. Air insufflation
10.
11. 12.
13.
14.
779
technique of enteral tube insertion: a randomized, controlled trial. Crit Care Med 1998;26:1036 Cresci G, Grace M, Park M, et al. Accurate and timely blind bedside placement of post-pyloric feeding tubes using an electromagnetic navigation device (abstract). Nutr Clin Pract 1999;14:101 Lord LM, Weiser-Maimone A, Pulhamus M, Sax H. Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation. JPEN 1993;17:271 Kittinger JW, Sandler RS, Heizer WD. Efficacy of metoclopramide as an adjunct to duodenal placement of small-bore feeding tubes: a randomized, placebo-controlled double-blind study. JPEN 1987; 11:33 Taylor B, Schallom L. Bedside small bowel feeding tube placement in critically ill patients utilizing a dietitian/nurse team approach. Nutr Clin Pract 2001; 16:258 Minard G. Enteral access. Nutr Clin Pract 1994;9: 172 A.S.P.E.N. Board of Directors. Standards of practice for nutrition support dietitians. Nutr Clin Pract 2000; 15:53 Fuhrman M, Winkler M, Biesemeier C. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) standards of practice for nutrition support dietitians. J Am Diet Assoc 2001;101:825 American Dietetics Association. Frequently asked upskilling questions and responses. Available from: http://www.eatright.org/upskilling.html. Accessed January 29, 2002