FEEDING TUBE PLACEMENTS:

DIETITIAN TRAINING AND THE PROCEDURE

Lisa Molnar, RD, LD, CNSCHennepin County Medical Center

(HCMC)

OBJECTIVES After this presentation the attendee should

be able to Develop training for dietitians to place feeding

tubes at their facility Understand the procedure of feeding tube

placement at the bedside.

DIETITIAN FEEDING TUBE PLACEMENTS AT HCMC Started in June of 2011 Primary placer in the MICU, SICU, BURN, and PICU,

Monday – Friday 8am-4pm Each floor has own rules for nursing placement

Back up placer in all other areas of the hospital during same hours Float Pool RN is primary contact 24/7 on floors

After hours/weekend/holiday if available, but not staffed 5 Dietitians

2 Full Time 3 Part Time (0.6, 0.5, and 0.7)

Use the Cortrak® Monitor Avg. 50-60 patients/placements per month Currently, no change in staffing or work loads

FEEDING TUBE DATAAPRIL-DECEMBER 2012, N=489

Average length of time from order placement to response: 5 ½ hours Delayed 2/2 other procedures, weekend/night

orders, hemodynamic instability of patient Average Length of time of feeding tube

placement: 23 minutes Actual placement time (not including set

up/clean up) 85% Small Bowel placement 78% Nasal Bridle use Average number of X-rays per feeding tube

placement: 1.15 Reglan use: 38% of placements

FEEDING TUBE PLACEMENT COMPETENCY AT HCMC

Review Hospital Policies Feeding Tube Placement and Enteral Feeding

Review Readings Mosby’s Nursing Skills Guidelines for the Provision and Assessment of Nutrition Support Therapy in

the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) American Dietetic Association’s Evidenced Analysis Library, Critical Illness

topics: gastric vs small bowel feeding tube placement; Monitoring criteria in critical care: gastric residual volume, patient positioning, promotility agents

Nutrition Critical Care Clinical Practice Guidelines. Strategies to Optimize Delivery and Minimize Risk of EN.

View videos on feeding tube placement Corpak® Video Cortrak® Video

Observe feeding tube placement in Fluoroscopy x 1-2 Review directions for use of the Cortrak® device and observe RD/RN

place gastric and small bowel feeding tubes using Cortrak® until comfortable with the procedure

On the job training with trained RD/ICU RN with successful placement of at least 3 in small bowel

TRAINING WITH CORPAK® MEDSYSTEMS Cortrak® sent out a nurse to assist with

Training for 1 week after complete non-hands on portion of competency

Completed slide show education with the nurse from Cortrak®

Hands on training – placed as many feeding tubes as ordered during that week in SICU and MICU with observation of Cortrak® nurse Minimum for 3 successfully before deemed

“competent” After “competent”, must complete 1 feeding

tube placement successfully every 3 months to maintain competency

TRAINING NEW DIETITIANS Same competency form New dietitian will shadow competent dietitian

placing feeding tubes until comfortable to start placing on own

New dietitian will place at least 3 post pyloric feeding tubes successfully with observation until dietitian is comfortable.

CHECK LIST BEFORE STARTING Check physician order

Nasal vs Oral Placement Gastric vs post-pyloric

Communicate with primary RN Timing Sedation needed Pro-kinetic agent (ie Reglan)

Explain procedure to the patient/family

FEEDING TUBE PLACEMENT – SET UP Obtain Supplies

Feeding tube 10 Fr in adults (43 in or 55 in) 8 Fr in peds (36 in)

Cortrak® Monitor 10 mL saline flush 60 mL luer or eccentric tip syringe Lubrication Stethoscope Nasal Bridle or Tape

AMT Bridle® NGT tape Paper Tape, Silk Tape (to patient or ETT) Twill Tape

CORTRAK® MONITOR

Monitor

Place over Zyphoid Process

Feeding tube wire connects to monitor

USING THE CORTRAK® GRID

GETTING STARTED Place Cortrak® monitor device over Zyphoid

Process, the device should be level Enter via nare or mouth depending on order Once feeding tube advanced to 5-10 cm, turn

Cortrak® monitor on Watch monitor as advance feeding tube

Feeding tube should go straight down to cross section

If deviates left or right prior to cross section, possible lung placement

POSSIBLE LUNG PLACEMENTS- PULL BACK

PLACEMENT

GETTING TO THE STOMACH Most adults GE junction is at 50 cm, can

measure if peds or abnormal sized adult Auditory confirmation by pushing air through 60

mL syringe and listening with a stethoscope Advance feeding tube to desired final location Ok to push (give length) through the stomach. If having trouble

Pull NGT Fill stomach with air Pull out stylet a few inches and try to advance Turn the tube as advancing Go slower

GASTRIC PLACEMENT

GETTING POST PYLORIC The longest portion of the feeding tube

placement Do not advance in length, put pressure on

the tube only, small intestine will pull it in Tips to improve advancement

“Floppy tip” – pulling out the stylet Flush with saline or air Reglan use (IV 10 mg works in minutes) Turn the tube while putting on pressure Reposition the patient Pull back/out NGT

POST-PYLORIC PLACEMENT

EXAMPLE AT HCMC:LIGAMENT OF TREITZ

EXAMPLE AT HCMC: DUODENAL PLACEMENT

CORTRAK/FLUOROSCOPY COMPARISON

SECURE THE FEEDING TUBE

Nasal Bridle

NGT Tape

Twill Tape