LAST SPRING, Nursing2013 conducted a survey in the journal and online in cooperation with the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) to explore nurses' knowledge of evidence-based guidelines for medication administration via enteral feeding tubes. This survey was specifically geared toward best practices for medication delivery through an enteral access device and addressed how to prevent complications such as tube clogging, drug-nutrient interactions, and inadequate medication delivery. This article reviews the results of the survey, discusses best practices, and provides evidence-based rationales.
Challenges and opportunities
Tube occlusion is a frequent problem (20% to 45% of tubes become occluded during the life of the tube) often requiring tube replacement.1–3 Risk factors for tube occlusion include increasing tube length, decreasing tube caliber, inadequate water flushing, frequent medication delivery, and use of the tube to measure residual volumes.3 Appreciating the complexity of drug administration through a feeding tube and maintaining appropriate techniques may prevent tube occlusion and decrease the risk of reduced drug efficacy or drug toxicity.
Medication administration in patients receiving enteral nutrition (EN) includes implementing administration techniques that assure bioavailability without further complicating the patient's overall care. Guidelines for administering medication via enteral feeding tubes are available,4–12 as are a number of surveys of enteral drug administration practices and techniques.13–19
Surveys suggest that practice differs significantly from guidelines, and several common practices could interfere with appropriate medication delivery.13–19 For example, previous surveys suggest that only 5% to 43% of practitioners flush tubes before or between medications, only 32% to 51% administer drugs separately from one another, only 44% to 64% dilute liquid medication, and only 75% to 85% avoid crushing modified-release dosage forms. Some of these practices may contribute to measurable adverse outcomes—tube occlusion, reduced drug efficacy, and increased drug toxicity in particular.20
These studies were completed before publication of A.S.P.E.N. Enteral Nutrition Practice Recommendations in 2009.21 This survey was conducted to determine whether nursing practice today is in line with current recommended guidelines.
What survey results reveal
Eight hundred and twenty-three nurses from across the country responded to our survey. For a snapshot of this convenience sample, see Respondent profile.
The following pages present responses to individual survey questions, correct answers, and evidence-based rationales. Correct answers are highlighted in red. The percent of responses for each answer is found at the end of the row. Numbers have been rounded. Percentages don't always add up to 100% because not every participant answered every question.
1. How often do you care for patients with an enteral feeding tube?
According to the latest available Nationwide Inpatient Sample (NIS) data, in 2011 over 269,000 patients received EN during a hospital stay.22 Approximately 5.8% of long-term-care facility residents in the United States receive EN; the prevalence is higher for residents with cognitive impairment (18% to 34%).23 Most patients with feeding tubes receive not only enteral formula, but also medications and additional hydration through the device.
2. How often do you add medications directly to the enteral nutrition formula?
3. If you add medications directly to the enteral nutrition formula, which of the following do you routinely add?
Guidelines for medication administration include the recommendation: “Do not add medication directly to an enteral feeding formula.”21 Although combining medication with an EN formula may be convenient, a couple of major concerns should be noted. Foremost, data that support compatibility and stability are required before considering combining drugs with each other or with EN. The physical and chemical interactions between a medication and EN may alter properties of the drug and the nutrients, leading to risk for feeding tube occlusion, altered drug bioavailability, and/or distorted gastrointestinal (GI) function.20
A number of drugs have been studied and reveal incompatibility and instability with mixing in EN.24–29 In fact, 96% of incompatible drug-EN mixtures result in tube occlusion with very few cleared by water flushes.26 Compatibility is influenced by factors related to the drug (pH, alcohol content, mineral content, viscosity, osmolality) and the EN formula (type and concentration of protein, fiber content, mineral content).11 The widely used closed enteral feeding systems would require a break in sterility to add a drug, which poses another serious concern.21
Although 72% of respondents say they “never” add medications to EN, 21% do so “frequently” or “occasionally.” This represents a significant proportion of nurses engaging in the risky procedure.
4. Do you hold (stop) feedings while administering medication through the same enteral tube?
5. Do you flush the enteral tube before administering medication through it?
Guidelines for medication administration include the recommendation: “Prior to administering medication, stop the feeding and flush the tube with at least 15 mL water.”21 A cleared feeding tube helps ensure delivery of the total dose of medication to the patient through this access device.
Residue from the EN formula and from previously administered drug products adhere to the lumen of the feeding tube. The amount will vary with the medication, EN formula, and feeding tube. Flushing of the tube has been shown to decrease the incidence of tube occlusion.30 Although most respondents (89%) know to flush the tube before administering a medication, 11% do not.
6. Do you flush the enteral tube after administering medication through it?
Guidelines for medication administration include the recommendation: “Flush the tube again with at least 15 mL water, taking into account patient's volume status. Repeat with the next medication (if appropriate). Flush the tube one final time with at least 15 mL water.”21 Flushing water through the feeding tube helps to ensure the delivery of the entire drug dose to the distal end of the tube and ultimately to the patient. Additionally, the flush reduces drug residue within the tube lumen so that the tube is again cleared before the EN feeding is restarted. The lowest necessary volume needed to clear the tube is recommended for neonates, pediatric patients, and fluid-restricted patients.21
In this survey only 2% of the respondents reported that they fail to flush after giving medications.
7. If you flush the enteral tube before and/or after drug administration, which of the following do you use?
The flush fluids respondents specified as “other” included filtered water, cranberry juice, or ginger ale.
Guidelines for medication administration include the recommendation: “Sterile water is recommended for use in adult and neonatal/pediatric patients before and after medication administration.”21 Purified or sterile water is the preferred fluid for flushing feeding tubes and diluting medications for enteral administration.31 This is based in large part on the fact that microbial contaminants and chemical contaminants are present in the drinking water supply.32,33 These may include endocrine-disrupting compounds (for example, bisphenol A and some pesticides that interfere with hormone systems), personal care products (such as sunscreen and insect repellant), and pharmaceuticals.
Sterile water is also recommended for flushing all enteral tubes in immunocompromised and critically ill patients, especially when the safety of tap water can't be assured.34 Water is as good as or better than other fluids (such as juice or soda) at maintaining tube patency.35,36
Although nurses are generally knowledgeable about the need to flush the tube before and after administering medications, most use tap water instead of sterile water. Only 26% ”always” use sterile water to flush before or after medication administration and 70% say they “always” use tap water. This is especially concerning for institutional practice.
8. When giving two or more medications via an enteral tube, do you give each medication separately or mix them together before administering?
Guidelines for medication administration include the recommendation: “Avoid mixing together medications intended for administration through an enteral feeding tube given the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses.”21 When more than one drug is scheduled for administration at the same time, they must be given separately.
This is analogous to avoiding mixing I.V. drugs together before administration without data on compatibility and stability, even though they end up together in the bloodstream. Drug-drug interactions from mixing liquid medications or especially from crushing two or more medications together has a high potential for changing molecular structure or resulting in altered physicochemical properties.37 This practice also has the potential to create a new drug entity with unknown characteristics. Predicting problems with stability when a drug is prepared for enteral feeding tube administration is difficult enough without complications iinvolving other drugs and excipients (the non-therapeutic ingredients required to formulate the product).
In this survey, 62% of respondents mixed medications at least some of the time, if not always.
9. When you give two or more medications via an enteral tube, do you flush the tube between medications?
Guidelines for medication administration include the recommendation: “Flush the tube again with at least 15 mL water taking into account patient's volume status. Repeat with the next medication (if appropriate).”21 The flush of water through the feeding tube after administering one drug helps to ensure the delivery of the entire dose and reduces drug residue within the tube lumen so that the tube is again cleared before the next medication is delivered, reducing the risk of tube occlusion.30 Purified or sterile water is the preferred fluid for flushing feeding tubes between medications, in part because of contaminants found in tap water.31–33
When giving two or more medications via an enteral tube, only 19% of survey respondents flush with sterile water between medications, and 55% flush with tap water. Nearly 25% never flush with any solution between medications, contributing to the risk of adverse outcomes.
10. Which type of oral tablets do you crush and administer via enteral tube? (Check all that apply.)
11. Which type of hard gelatin capsules do you open and administer via an enteral feeding tube? (Check all that apply.)
Guidelines for medication administration include the recommendation: “Liquid dosage forms should be used when available and if appropriate. Only immediate-release solid dosage forms may be substituted. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix powder with sterile water.”21
Drug dosage forms include solids (capsules, tablets) and liquids (solutions, suspensions). Most solids are immediate-release products (compressed tablets, hard gelatin capsules) that contain the active drug molecule mixed with inactive ingredients. Immediate-release products are designed to release the drug within minutes of reaching the stomach following oral administration. But more and more drugs have been introduced as modified-release products (enteric-coated, extended-release, sustained-release).
Drugs manufactured for oral administration are designed specifically for the healthy GI tract. Destroying the carefully designed delivery mechanisms by opening or crushing solid dosage forms will alter the drug's performance in the GI tract, influencing bioavailability. Least affected are the immediate-release solids, so this is the only solid dosage form recommended for feeding tube administration. Enteric-coated, extended-release, and sustained-release tablets and capsules should never be crushed or opened and therefore can't be administered by feeding tube.38
Besides altering drug properties, crushing enteric coatings increases the risk of tube occlusion because coating particles tend to clump together in water. When crushed, extended/sustained-release products rapidly release large amounts of drug at one time, resulting in erratic blood levels, potentially toxic levels, and even fatalities.39
12. Do you dilute crushed medications and powder from opened capsules before administering them?
13. Do you dilute liquid medications before administering them?
Guidelines for medication administration include the recommendation: “Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe (≥30 mL in size).”21 To be sure that the full dose of medication is delivered through the distal end of the feeding tube, the drug powder or viscous liquid needs to be diluted.24 Liquid drug products contain thickeners and sweeteners that increase their viscosity and osmolality. Dilution improves drug delivery.40–42
High osmolality medications contribute to GI intolerance and diarrhea. In some cases, these liquids may require dilution with 150 to 250 mL of water, making them less attractive dosage forms than solid immediate-release forms that are administered in 15 mL of water for feeding tube administration.
Sterile water or 0.9% sodium chloride (sterile saline) are preferred diluents for most drugs to meet United States Pharmacopeia standards.21,31 Tap water should be avoided in many cases because, as already noted, it may contain pathogenic microorganisms, pesticides, pharmaceuticals, and heavy metals that may interact with the administered drug.31
Nearly half of respondents don't dilute liquid medications at all before administering via enteral tube. Among those who dilute liquid medications, 38% dilute with tap water and only 13% dilute with sterile water.
14. Do you hold continuous enteral feeding for at least 1 hour around dosing of any of the following? (Check all that apply.)
Medications respondents specified as “other” included synthroid, famotidine, and ciprofloxacin.
Guidelines for medication administration include the recommendation: “Restart the feeding in a timely manner to avoid compromising nutrition status. Only hold the feeding by 30 minutes or more when separation is indicated to avoid altered drug bioavailability.”21
A small number of medications, such as some fluoro-quinolones and other antimicrobials, antiepileptic drugs, levothyroxine, and warfarin, are known to interact sufficiently with EN in the GI tract to reduce bioavailability. In these cases, a period of 30 to 120 minutes–depending on the drug–may be needed prior to restarting EN.20,21
Feedings should be held for at least 60 minutes for the drugs listed in the survey question.20,21 This is analogous to administering drugs orally on an empty stomach. Holding feeding for a sufficient amount of time is more of an issue for patients receiving continuous EN. Scheduling these drugs for administration during intermittent feeding regimens is much easier.
15. Does the pharmacy provide you with ready-to-administer enteral drug products already prepared in an oral syringe labeled for the patient?
Currently there is no “correct” answer to this question, as pharmacies dispense medications in various ways, even within the same institution and for the same patient. The ideal process would be for the pharmacy to always provide patient-specific, unit-dose, ready-to-administer enteral drug products in oral/enteral syringes.
If the pharmacy dispenses a liquid medication in a syringe, it should be in an oral or enteral syringe. It should be properly labeled with, at a minimum, patient identifiers, drug name and dosage, and expiration date.
Nurses must communicate with the pharmacist when a patient is to receive a drug through a feeding tube and again when the tube has been relocated or removed. Sentinel event medication errors have occurred when oral or GI medications have been drawn up in I.V. (rather than oral) syringes and then inadvertently given I.V.43
The 36% of respondents who report that they never have ready-to-administer medications are susceptible to increased risk of wrong-route medication errors. In addition, these nurses may spend inordinate time preparing medications, a task better left to the pharmacy.
16. What are your source(s) for information on medication administration? (Check all that apply.)
Nurses clearly draw their medication administration information from various printed, electronic, and staff sources. It's reassuring that 70% of respondents include pharmacists as an information source. In a 1997 survey of critical care nurses, respondents cited clinical experience (57%), coworkers (22%), and nursing school (13%) as their sources of medication administration knowledge.15 Long-term care nurse survey respondents reported using similar sources.18
Always consult with an adult or pediatric pharmacist for patients who receive medications coadministered with enteral nutrition. The pharmacist can help you determine whether a drug or its dosage form is appropriate for administration depending on the tube type and location of its distal end.20 For example, administrating a drug through a jejunostomy tube will bypass a major drug administration site, the duodenum.
17. Does your institution have a nursing policy and procedure for medication delivery through an enteral feeding tube?
A large majority of nurse respondents acknowledged that their institution has a nursing policy and procedure for medication delivery through an enteral feeding tube. In a nationwide survey published in 1997, only about one-third of nurse respondents were aware of printed guidelines and only about 5% used them as their primary source.15 In another survey, about 70% of nurses were aware of printed guidelines but just 17% cited them as their primary information source.18 It's encouraging that nurses today are more aware of institutional policies on this medication delivery process.
18. How often do you consult with a pharmacist when you're unsure about medication delivery?
In this survey, most (85%) respondents consult either often or always with a pharmacist when they're unsure about a medication. It's been demonstrated that fewer medication errors occur when pharmacists and nurses collaborate on medication delivery. In one study of an interdisciplinary approach, clinicians reduced the number of medication errors and tube occlusions by holding training sessions for nurses, promoting practice guidelines, establishing a database of oral-enteral dosage forms, and having pharmacists offer patient-specific recommendations.44
19. What nursing actions do you take when you encounter a clogged feeding tube? (Check all that apply.)
Clogged or occluded feeding tubes often result from protein-based formulas coming in contact with gastric acid and/or medications. Routine water flushes are vital to prevent tube occlusions. A completely occluded tube is an urgent problem preventing the patient from receiving essential nutrients, hydration, and medications.
The first thing the nurse should do is assess if the tube is kinked or compressed in any way. Attempt to draw back with a syringe and then attempt to flush the tube with warm water. If that doesn't work, follow institutional protocol for occluded feeding tubes.
Actions to mitigate the occlusion can include chemical or physical declogging regimens.45,46 If these are unsuccessful, the tube may need to be removed and replaced.
Over 50% of respondents stated that they flush with another fluid. Most reported using a carbonated beverage such as cola, ginger ale, or lemon-lime soda; some used cranberry juice. Investigators have shown the superiority of water over cranberry juice in flushing feeding tubes. No data shows that carbonated beverages are more effective than water as a flush solution or as a declogging solution.47 Some studies demonstrate that a sodium bicarbonate-pancreatic enzyme solution can be effective in opening occluded feeding tubes.48
Thirty-five percent of respondents also mentioned use of a declogging device. Several of these chemical or mechanical devices are on the market. It's important to have and follow an institutional nursing protocol for using these devices.
The key findings from this survey include the following, discussed in terms of major best practice recommendations.
* Never add medications to EN formula. Although 72% of respondents say they “never” add medications to EN, 21% still do so “frequently” or “occasionally.”
* Never mix medications before administering them. Medications should never be mixed together for administration, but only 38% “always” give meds separately and 47% think it depends on the patient.
* Flush the tube before and after medication administration, and also between drugs when giving two or more at the same time. Although most respondents (89%) know to flush the tube before administering a medication, 11% do not. When giving two or more meds via an enteral tube, only 19% flush with sterile water between drugs; 55% flush with tap water; and 24% don't flush at all.
* Use sterile water, not tap water, to flush the tube and dilute medications. Although nurses are generally knowledgeable about the need to flush the tube before and after administering medications, most use tap water instead of sterile water. Only 26% ”always” use sterile water to flush before or after medication administration; 70% say they “always” use tap water.
Nearly half of respondents don't dilute liquid medications at all before administering via tube. About 38% dilute with tap water; only 13% dilute with sterile water.
* Only immediate-release oral medications should be given via enteral tube. Most respondents know that only immediate-release oral capsules and tablets should be opened or crushed and given via enteral tube. But 25% say they open extended release or sustained release hard gelatin capsules and administer them via enteral tube.
* All medications, both liquid and solid, should be diluted before administration.
Nearly all respondents say they dilute crushed medications and powder from opened capsules before administration, but only 22% dilute them with sterile water, versus 72% with tap water. Nearly half (48%) don't dilute liquid medications before administration.
When compared to previous nursing surveys on medication administration, this survey shows that overall knowledge and translation to practice has improved in several areas but remains unchanged in others. Many more respondents now flush the tube before and between administration of medication (76% to 89% in this survey, versus 5% to 43% in the past). Unfortunately, however, most are still using tap water for flushing.
Many more nurses now include a pharmacist as a key source of information than in the past (70% to 85% in this survey versus 6% to 12% in past surveys). But many nurses are still mixing medications together (38% versus 32% to 51%), not diluting liquid medications as they should (51% versus 44% to 64%), and preparing modified-release medications for tube administration (25% versus 15% to 25%).
Best practices for medication administration
Documented procedures and guidelines for medication administration through an enteral feeding tube with clear step-by-step instructions can assist caregivers in optimizing therapeutic response to the medication and preventing complications such as tube occlusion. As discussed earlier, important concepts to consider include tube size and tube tip location. See Practice recommendations and procedures for giving drugs through an enteral access device for practical guidelines.
Optimizing medication safety and effectiveness in patients receiving EN requires administration techniques that assure bioavailability without further complicating the patient's care and condition. Follow the guidelines for administering medication via enteral feeding tubes discussed here to minimize adverse events and support optimal patient outcomes.
Here's a snapshot of the 823 nurses responding to this survey.
* RN diploma, 11%
* associate degree, 19%
* bachelor's degree, 40%
* master's degrees or higher, 15%
* LPN/LVN, 10%
* student, 2%
Years of nursing experience
* over 15 years, 51%
* 5 years or less, 33%
Primary clinical area
* medical-surgical, 35%
* geriatrics, 16%
* intensive care/critical care, 15%.
Most respondents (62%) worked in hospitals, followed by long-term care/subacute care (19%), and home healthcare (7%). Most respondents (68%) don't have a nursing specialty certification.
Practice recommendations and procedures for giving drugs through an enteral access device49
Use only oral/enteral syringes labeled “for oral use only” to measure and administer medication through an enteral feeding tube. Consult with an adult pharmacist or pediatric pharmacist for patients who receive medications coadministered with enteral nutrition. Never add medication directly to an enteral feeding formula. Also follow these additional guidelines to safely administer medication via an enteral feeding tube.
1. Verify tube tip placement by checking for stomach or small intestine contents, X-ray, or another accepted method. Auscultation alone isn't acceptable.
2. Turn off the enteral formula pump or administration bag.
3. Flush the tube with at least 15 mL sterile water to check tube for patency and to flush residual feeding formula through. (Modify flush volumes throughout as needed for infants, children, and patients with fluid restrictions.)
4. Don't mix together medications intended for administration through an enteral feeding tube because of the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses. Instead, administer each medication separately through an appropriate access. Liquid dosage forms should be used when available and if appropriate. Only immediate-release solid oral dosage forms may be substituted.
5. Immediate-release tablets should be ground to a fine powder and mixed with sterile water before administration. Hard gelatin capsules should be opened and the contents mixed with sterile water. Draw up liquid medication with an oral-enteral syringe.
6. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe (≥ 30 mL in size). Note: Dilution/flush should be less for pediatric doses (minimum 50:50 volume) and at least 5 mL when fluid is not restricted.
7. Connect the syringe to the side medication port on tube end if available.
8. Gently administer each medication individually through the tube, flushing it with 15 mL sterile water between each medication (taking into account the patient's volume status).
9. Flush the tube with at least 15 mL water following the last medication.
10. Reconnect and turn on the feeding formula unless contraindicated. Restart the feeding in a timely manner to avoid compromising nutrition status. Hold the feeding by 30 minutes or more only when a lengthy separation is indicated to avoid altering drug bioavailability.
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