Feeding Tube Placements: Dietitian training and the Procedure

1. Feeding Tube Placements:Dietitian training and the Procedure Lisa Molnar, RD, LD, CNSC Hennepin County Medical Center (HCMC)

2. 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.

3. 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

4. Feeding Tube Data April-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

5. 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

6. 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

7. 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.

8. 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 (ieReglan) • Explain procedure to the patient/family

9. 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 mLluer or eccentric tip syringe • Lubrication • Stethoscope • Nasal Bridle or Tape • AMT Bridle® • NGT tape • Paper Tape, Silk Tape (to patient or ETT) • Twill Tape

10. Cortrak® Monitor Feeding tube wire connects to monitor Monitor Place over Zyphoid Process

11. Using the Cortrak® Grid

12. 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

13. Possible lung placements - Pull back

14. Placement

15. 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

16. Gastric Placement

17. 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

18. Post-Pyloric Placement

19. Example at HCMC: Ligament of Treitz

20. Example at HCMC: Duodenal Placement

21. Cortrak/Fluoroscopy Comparison

22. Secure the feeding tube NGT Tape Nasal Bridle Twill Tape