Development and Implementation of a Nurse Led Enteral Feeding Protocol

Joanne Roddick

Clinical Dietitian RBWH

1

AH-TRIP

What is the clinical problem?

2

7th most commonly diagnosed cancer in

Australia1

Head and Neck Cancer

RBWH (ENT/MaxFacs/Plastics) Data

➢ 20% increase in # surgeries, no change to Dietetic FTE

➢ 40% (n=29) of patients did not commence enteral feeds

within 24 hours of surgery

➢ Delays in achieving goal feeding rates

Surgery is often first line of treatment → many

patients require enteral feeding post-op2

What is the evidence?

3

COSA: Head and neck cancer nutrition

guidelines (2015):

Post operative tube feeding should commence

within 24 hours (Grade A)3

SCCM + A.S.P.E.N: Guidelines for the provision

and assessment of nutrition support therapy in

the adult critically ill patient (2016):

We recommend that enteral feeding protocols be

designed and implemented to increase the overall

percentage of goal calories provided.

(Moderate to High)4

What is the evidence?

4

➢ Provision of nutrition support in

immediate post operative period

improves healing and reduces

complications5-8

➢ In critical care setting,

standardised protocols provide a

standard to care to guide practice

to result in the provision of timely

nutrition support9-12

Implementation

5

Knowledge to Action

Framework

1. Identify problem and

review knowledge. Data

audited over 9 month

period

2. Adapt knowledge to

context by consulting

nursing staff and surgeons

during protocol

development

3. Assess barriers through

focus groups and one-on-

one interactions

Addressing Barriers to Implementation

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1. Belief that initiation of enteral feeds is not part of nursing role.

➢ Nursing Champions identified to pilot and lead

implementation

➢ Education to address specific concerns raised in pre-

implementation discussions

2. Lack of knowledge around which enteral feed to use and

lack of clarity around enteral feed starting rates

➢ Revised enteral feed forms in line with protocol clearly

stating which enteral feed to use and starting rates made

easily available on ward

➢ Posters placed on ward for staff to refer to and increase

awareness

8

ROYAL BRISBANE AND WOMEN’S HOSPITAL DO NOT FILE IN MEDICAL NOTES

ENT/MaxFacs/Plastics

ENTERAL FEEDING REGIMEN

UR No: Surname: Given Name: Sex:

EN

TE

RA

L F

EE

DIN

G R

EG

IME

N

• ALLERGEN INFORMATION: This feed product contains milk protein and fish oil: it is not suitable for those with anaphylaxis to dairy or fish products. Please contact the dietitian for alternative options.

• Please record all feed and flushes delivered to the patient on the fluid balance chart.

• This order remains current until changed or ceased by the Dietitian or Medical Team.

Feeding method: Continuous Weight: ____________

Please select one feeding regimen only

Refer to “ENT/MaxFacs/Plastics Enteral Nutrition Pathway”

Standard Feeding Regimen (Non-Refeeding Risk)

START DATE

TIME OF FEED

FEED

DURATION

RATE (ml/hr)

COMMENTS

On commencement Nutrison Protein Plus

Multifibre

4/24 40ml/hr If tolerated increase to goal until 2200hrs

0600-2200 Nutrison Protein Plus

Multifibre

16/24 GOAL

____mL/hr

Refer to Dietitian

Refeeding Risk Regimen

On commencement Nutrison

Multifibre 16/24 40ml/hr Refer to Dietitian

FLUSHES: Continuous Feeds flush:

If on IV fluids: 60ml q4/24 If nil IV fluids: 120ml q4/24 Always give a water flush:

- whenever feeding is temporarily stopped (minimum of 40ml) or at least daily if not being used for feeds

- 30ml before medications, 5ml between each medication and 30ml after all medications given via tube

Total fluid volume = ________ml/ day (Feed = ________ml/ day ; Flush = ________ml/ day)

NOTE:

• Confirm tube placement before commencing feeds and document in medical chart using Enteral Nutrition insertion sticker

• Ensure the head of bed is elevated during gastric feeding and for at least 30 minutes after feeding

• Ready to hang bottles and giving sets can hang for no longer than 24 hours

• Record the time feeding was commenced on label on Ready to hang bottle

• If oral Phenytoin or Ciprofloxacin is administered, cease feeds 2 hours prior & recommence feeds 2 hours post administration and extend feeds for an extra 4hours and request dietitian review of feed times.

• Ensure the patient has a medication review by the ward pharmacist

• If there is pain on feeding or flushing of feeding tubes, stop feed/medication immediately and refer to the treating team.

Completed by _________________ Contact__________

Monitoring

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➢August 2017-August 2018

➢Comparison of time to

commencing enteral feeds and

time to goal rate to baseline data

➢Survey to be conducted with

MDT to determine gaps in

knowledge and awareness of

protocol.

Outcomes

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➢100% (n=9) of patients have had enteral feeds initiated within

24 hours and achieved goal rate within average of 2 days.

ANECDOTALLY:

➢ Reduced pressure on Dietetic

workload

➢Nurses report high levels of

autonomy

➢‘We love being able to start

patient feeds as soon as

possible’

➢‘Very easy to use protocol’

➢We love having our own

enteral feed protocol’

Looking Forward

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➢Development of Work Unit Guideline (WUG)

➢Enteral feeding form to be uploaded to intranet for easier

access by staff

➢Exploring how to embed protocol into standard practice for

sustainability

References

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1. Australian Institute of Health and Welfare. Head and neck cancers in Australia [Internet] 2014 [cited October 18th 2017]. Available

from http://www.aihw.gov.au/publication-detail/?id=60129547291

2. Australian Government Cancer Australia. Head and Neck Cancer. Treatment Options [Intenet] 2015 [cited October 18th 2017].

Available from

http://headandneckcancerguide.org/adults/cancer-diagnosis-treatments/surgery-and-rehabilitation/cancer-removal-surgeries/

3. Findlay, M., Bauer, J., & Brown, T. (2015). Evidence-based practice guidelines for the nutritional management of adult patients with

head and neck cancer-Cancer guidelines Wiki. Wikicancerorgau. 2015. wiki. cancer. org. au/australia/COSA:

Head_and_neck_cancer_nutrition_guidelines. Accessed, 20th June 2017

4. McClave, S. A., Martindale, R. G., Vanek, V. W., McCarthy, M., Roberts, P., Taylor, B., ... & American College of Critical Care

Medicine. (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of

Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN). Journal of Parenteral and Enteral

Nutrition, 33(3), 277-316.

5. Abunnaja, S., Cuviello, A., & Sanchez, J. A. (2013). Enteral and parenteral nutrition in the perioperative period: state of the art.

Nutrients, 5(2), 608-623.

6. Kratzing, C. (2011). Pre-operative nutrition and carbohydrate loading. Proceedings of the Nutrition Society, 70(3), 311-315.

7. Stoppe, C., Goetzenich, A., Whitman, G., Ohkuma, R., Brown, T., Hatzakorzian, R., ... & Yeh, D. (2017). Role of nutrition support in

adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery.

Critical Care, 21(1), 131.

8. Weimann, A., Braga, M., Carli, F., Higashiguchi, T., Hübner, M., Klek, S., ... & Waitzberg, D. L. (2017). ESPEN guideline: Clinical

nutrition in surgery. Clinical Nutrition, 36(3), 623-650.

9. Stewart, M. L. (2014). Interruptions in enteral nutrition delivery in critically ill patients and recommendations for clinical practice.

Critical care nurse, 34(4), 14-22.

10. Friesecke, S., Schwabe, A., Stecher, S. S., & Abel, P. (2014). Improvement of enteral nutrition in intensive care unit patients by a

nurse‐driven feeding protocol. Nursing in critical care, 19(4), 204-210.

11. Compton, F., Bojarski, C., Siegmund, B., & van der Giet, M. (2014). Use of a nutrition support protocol to increase enteral nutrition

delivery in critically ill patients. American Journal of Critical Care, 23(5), 396-403.

12. Mackenzie, S. L., Zygun, D. A., Whitmore, B. L., Doig, C. J., & Hameed, S. M. (2005). Implementation of a nutrition support protocol

increases the proportion of mechanically ventilated patients reaching enteral nutrition targets in the adult intensive care unit. Journal

of Parenteral and Enteral Nutrition, 29(2), 74-80.

13. Straus, S. E., Tetroe, J., & Graham, I. (2009). Defining knowledge translation. Canadian Medical Association Journal, 181(3-4), 165-

168.

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➢ Ward 8AN

➢ Claire Blake

➢ Adrienne Young

➢ Nutrition and Dietetics

Department RBWH

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Produced by Allied Health

Metro North and Metro South Hospital and Health Service

http://qheps.health.qld.gov.au/TRIP

State of Queensland (Metro North and Metro South Hospital and Health Service) 2018