1. F EEDING T UBE P LACEMENTS : D IETITIAN TRAINING AND THE P ROCEDURE Lisa Molnar, RD, LD, CNSC Hennepin County Medical Center (HCMC)

2. O BJECTIVES 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. D IETITIAN F EEDING T UBE 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. F EEDING T UBE D ATA A PRIL -D ECEMBER 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. F EEDING T UBE P LACEMENT C OMPETENCY A T 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. T RAINING WITH C ORPAK ® M EDSYSTEMS 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. T RAINING NEW D IETITIANS 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. C HECK L IST 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

9. F EEDING T UBE P LACEMENT – S ET 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

10. C ORTRAK ® M ONITOR Monitor Place over Zyphoid Process Feeding tube wire connects to monitor

11. U SING THE C ORTRAK ® G RID

12. G ETTING S TARTED 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. P OSSIBLE LUNG PLACEMENTS - P ULL BACK

14. P LACEMENT

15. G ETTING TO THE S TOMACH 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. G ASTRIC P LACEMENT

17. G ETTING 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. P OST -P YLORIC P LACEMENT

19. E XAMPLE AT HCMC: L IGAMENT OF T REITZ

20. E XAMPLE AT HCMC: D UODENAL P LACEMENT

21. C ORTRAK /F LUOROSCOPY C OMPARISON

22. S ECURE THE FEEDING TUBE Nasal Bridle NGT Tape Twill Tape