Objectives
• Understand at least 3 steps to consider when
implementing a change to dietitian’s practices in the
hospital setting.
1
ASPEN/SCCM Guidelines
A2. Nutrition support therapy in the form of enteral
nutrition (EN) should be initiated in the critically ill
patient who is unable to maintain volitional intake.
(Grade: C)
2
JPEN 2009; 33:277-316
ASPEN/SCCM Guidelines
A3. EN is the preferred route of feeding over parenteral
nutrition (PN) for the critically ill patient who requires
nutrition support therapy. (Grade: B)
JPEN 2009; 33:277-316
3
ASPEN/SCCM Guidelines
A4. Enteral feeding should be started early within the
first 24-48 hours following admission. (Grade: C) The
feedings should be advanced toward goal over the next
48-72 hours. (Grade: E)
JPEN 2009; 33:277-316
4
Timing: Window of Opportunity
• Early feeding in critically ill patients
• Early defined as <36 hours from admission to ICU or
post-op
• Early EN group outcomes:
 Lower incidence of infection (p=0.0006)
 Reduced LOS by 2.2 days (p=0.004)
 Decreased mortality (not significant)
5
Marik P et al. CCM 2001; 29: 2264
Timing: Window of Opportunity
• Compared early EN vs NPO in GI surgery pts
• Early defined as <24 hours post-op GI surgery
• Early fed (EN or PO) group outcomes:
 Reduced risk of anastomotic dehiscence (p=0.08)
 Reduced infections (p=0.036)
 Reduced LOS by 0.8 days (p=0.001)
 Reduced mortality (p=0.15)
6
Lewis SJ et al. BJM 2001; 323:1-5
ASPEN/SCCM Guidelines
A7. Either gastric or small bowel feeding is acceptable in the ICU
setting. Critically ill patients should be fed via an enteral access
tube placed in the small bowel if at high risk for aspiration or after
showing intolerance to gastric feeding. (Grade: C) Withholding of
enteral feeding for repeated high gastric residual volumes alone
may be sufficient reason to switch to small bowel feeding (the
definition for high gastric residual volume is likely to vary from
one hospital to the next, as determined by individual institutional
protocol). (Grade: E)
JPEN 2009; 33:277-316
7
Process Before Using Electromagnetic Technology
8
Time Delays with C-arm Placement
• 5 month data collection of feeding tube placements in the
ICU showed 13.4% (n=29) placement delays
• Reasons for delays included:
 6.9% other procedures on pt caused FT to be postponed
 34.5% order entered incorrectly in EHR
 58.6% scheduling issues/prioritizes within radiology
9
Radiation Exposure
• 2010 FDA Press Release
“The U.S. Food and Drug Administration have announced an
initiative to reduce unnecessary radiation exposure from
three types of medical procedures: computed tomography
(CT), nuclear medicine studies, and fluoroscopy.”
• FDA working with CMS to incorporate the initiative into
regulations and guidelines
10 http://www.fda.gov/newsevents/newsroom/pressannouncements/ucm200085.htm
Radiation Exposure
• Average placement time with fluoro is 3.7 minutes
• Random sample of 1 month showed 20% exceeded 5
minutes
• Average dose is120 mrem
• 300 mrem is the average annual dose in Minnesota
• A chest film is 2 mrem
• Rooms in ICU are not leaded, scatter field near patient is
4.5 mrem/min
11
Process of Implementation
• Gather data
 Time delays
 Radiation exposure
 Patient Safety/Transport
 Staffing time/costs
 Scope of practice considerations
12
Dietitian Standards of Practice
• Academy
 Standard 3: Nutrition Intervention
 RDs identify and implement appropriate, purposefully planned
actions designed with the intent of changing a nutrition-related
behavior, risk factor, environmental condition, or aspect of
health status for an individual, target group or the community at
large.
• Dietitians in Nutrition Support
 3.10 Carries out the plan for nutrition support therapy
 3.10D With specialized training, demonstrated competency, and
delineated clinical privileges may place nasoenteric access
devices
JADA 2008:108 (10);1538-1542
13
NCP 2007:22;558-586
Dietitian Scope of Practice
• State Board
 Subd. 10. Nutrition care services. "Nutrition care services"
means: (1) assessment of the nutritional needs of individuals
or groups; (2) establishment of priorities, goals, and
objectives to meet nutritional needs; (3) provision of nutrition
counseling for both normal and therapeutic needs; (4)
development, implementation, and management of nutrition
care services; or (5) evaluation, adjustment, and
maintenance of appropriate standards of quality in nutrition
care.
14
www.dieteticsnutritionboard.state.mn.us/
Academy Decision Analysis Tool
• Part A: General Review
 Describe the activity or service to be performed
 Review the practice expectations (job description, policies and
procedures) and core competencies for your level (DTR, RD, or
RD Specialty/Advanced Practice) to determine whether the service
or act is permitted.
 Review the Code of Ethics, Standards of Practice in Nutrition
Care, and Standards of Professional Performance for your practice
level to determine whether the service or act is permitted.
 Review any licensure laws to determine whether the activity is
allowed or not explicitly restricted.
15
Academy Decision Analysis Tool
• Part B: Education, Credentialing, Privileging
• Part C: Existing Documentation
• Part D: Advisory Opinions
• Part E: Obtaining an Advisory Opinion
• Part F: Performing the Service or Activity
16
Process of Implementation
• PEC
• TAC
• Med Exec
• Critical Care
• Nursing Leaders
• Risk
• HR
17
Training
• Policies – Feeding Tube Placement, Bridle
• Observe 3 FT placements with fluoro
• Review training video
• 10 successful placements with a radiologist
• Annual competency
18
Learnings and Re-implementation
• Communication
 TEAM STEPPS
• Order set for providers to ensure correct equipment used
• Indications for when to stop
19
Historical Data
• 2008 – 579 placed via fluoro (324 bedside or SPR)
• 2009 – 656 placed via fluoro (401 bedside or SPR)
• 2010 – ~680 placed via fluoro (~416 bedside or SPR)
• 2011 – ~688 placed via fluoro ( ~330 bedside or SPR), 91
placed by dietitians Jan - March
• 2012 – 454 placed via fluoro, 414 placed by dietitians
20
Current Process with Cortrak
• Feeding Tube Team consists of 3 dietitians
• Additional 4 dietitians in process of training
• Schedule of 1 week coverage rotation (FT, Obs, Relief)
• Scrubs worn during FT coverage
• No RNs placing tubes at this time
• No standardized weekend coverage with Cortrak
21
2012 Feeding Tube Placement Data
100
90
80
70
60
# tubes placed with fluoro all units
50
# tubes placed by dietitians ICU only
40
30
20
10
0
Jan
22
Feb
March
April
May
June
July
August Sept
Oct
Nov
Dec
2012 Feeding Tube Placement Data
18
16
14
12
10
8
6
4
2
0
Bridles
June
23
July
August
Sept
Oct
Nov
Dec
2012 Feeding Tube Placement Data
50
45
40
35
30
# tubes placed with fluoro in ICU
25
# tubes placed by dietitians in ICU
20
15
10
5
0
Oct
24
Nov
Dec
2012 Feeding Tube Placement Data
Tubes Placed per Unit in 2012
180
160
140
120
100
80
60
40
20
0
MICU
25
SICU
CVICU
2012 Feeding Tube Placement Data
100%
80%
% successful post pyloric radiology
60%
% successful post pyloric dietitians
40%
% successful total RD
placements(including gastric)
20%
0%
Jan
26
Feb
March
April
May
June
July August Sept
Oct
Nov
Dec
2012 Feeding Tube Placement Data
7
6
5
4
3
2
1
0
27
Time from CPOE to FT
Placement
2012 Feeding Tube Placement Data
60%
50%
40%
30%
Length of Time to Place
Tube
20%
10%
0%
15 min
28
30 min
45 min
60 min
29
30
31
Benefits At Fairview Using Electromagnetic
Technology
• Reduced radiation exposure
• Improved time to placement
• Reduced need for replacements due to “kinks”
32