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Department: INSPIRING CHANGE

A standardized approach to enteral medication administration

Nielsen, Carol MSN, RN, OCN, PCCN, CMSRN; Ward, Chan'Nel MSN, RN; Zamora, Zelne DNP, RN, CMSRN; Shuck-Conner, Camille BSN, RN

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doi: 10.1097/01.NURSE.0000827136.76706.5f
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Enteral feeding tubes are used to provide nutrition and medications to patients who are unable to consume these orally but have an intact gastrointestinal (GI) tract. A tube may be needed by patients after conditions such as stroke, head trauma, and head and neck surgeries. It is common practice for nurses to maintain the enteral tube's patency by flushing before and after each medication administration, every 4 hours during continuous feedings, or before and after intermittent feedings.

Research has shown that consistently flushing enteral tubes before and after medication administration helps maintain enteral tube patency.1 Obstructed tubes result in reduced nutrition delivery and delays in administering necessary medications.1

However, the volume of fluid for diluting medications and for flushes between medications vary. Many hospital policies use vague language for the amount of fluid used to dilute medication. Policies and procedures may not state specific volumes of diluent or flushes, leaving the fluid volume up to the discretion of the nurse.2 A nurse unfamiliar with enteral tubes or new to administering medications enterally can cause an increased risk of enteral feeding tube obstruction or volume overload.3 When enteral feeding tubes become clogged, additional time is spent to remove the obstruction, delaying both nutritional support and medication administration. If the tube is not cleared, it must be replaced, further causing additional stress and cost for the patient.1 During medication administration, excess fluid administration may lead to other complications, such as pulmonary edema, aspiration, weight gain, and abdominal fullness complaints.3 Standardizing the process and amount of fluid to be administered can help guide nursing practice and reduce complications. This article discusses a collaborative quality improvement (QI) project involving frontline nurses and pharmacists in a tertiary academic medical center that aimed to address fluid overload among at-risk patients by developing a new approach to enteral medication administration.

In corresponding inserts, manufacturers include information on how much fluid would be needed if the medication needs to be crushed. Most pills need only 5 to 15 mL of diluent.4 In this QI project, participants determined which medications have a commercially prepared liquid and which pills can be crushed, the volume needed to create a suspension from a crushed pill, and whether medications need to be administered individually.

Project background

The adult enteral medication administration policy is based on the American Society for Parenteral and Enteral Nutrition (ASPEN) 2017 guidelines, which indicate the use of sterile water (SW) when administering medications.4 Before administering medications through an enteral feeding tube, the tube feeding should be stopped and each medication must be prepared. If the medication was to be crushed, a minimum of 30 mL of SW was used to dissolve it. The enteral tube would then be flushed with SW, and each medication administered was followed by a 15 mL SW flush. After administering all medications, the enteral feeding tube was flushed with a final 30 mL of SW.

Bedside nurses at a tertiary academic medical center expressed concerns about the potential for fluid overload among at-risk patients when following the organization's policy on adult enteral medication administration. One reported case involved a patient with gastric residual volumes of 250 mL before morning drug administration. In observance of the policy, the nurse added 475 mL of drug/fluid volume to the patient's already full stomach. The patient complained of abdominal distension pain and refused further feedings for several hours until the fullness subsided. The head of the bed had to remain at a 45-degree angle to assist with gastric emptying. The patient was unable to rest and missed needed nutrition.

To improve the current practice and patient outcomes, an interdisciplinary healthcare team was formed at the medical center in 2018. The team consisted of nurses from three different medical-surgical units, the nursing research director, and the enteral medications pharmacist director.

Evaluating the current practice

The first step was to determine if the current practice resulted in the fluid volume excess expressed by frontline nurses. The acute care unit gathered baseline data on the number of drugs administered, administration time of day, the total time for administration, and total fluid volumes the patient received following the current policy. Patients included in the data were inpatients with more than five medications. Many had 10 or more medications prescribed in addition to p.r.n. (as needed). This extra fluid amount may contribute to complications related to fluid overload for adults with renal or cardiac disorders. The baseline assessment found that patients with five to six medications received 600 mL of additional fluid in 24 hours. In contrast, patients with 10 or more medications received 1,500 mL of extra fluid in 24 hours, solely from medication administration. The baseline data supported the nurse's concerns regarding fluid volumes.

Nurses reported missed bolus feedings because of high gastric residual volumes (greater than 300 mL). Patients complained of feeling overly full after medication administration and refused bolus feeding. Additionally, variances in nursing practice matched findings in other publications.5,6

Developing a new approach

The interdisciplinary team aimed to develop a protocol that standardized nursing processes in enteral medication administration while providing positive patient outcomes.

A literature search and review for evidence-based practice (EBP) was used to determine best practices.6 ASPEN's national standards guided medication administration; however, there were no directives for patients with fluid restrictions.4 Upon contact, ASPEN recommended that nurses should incorporate the use of pediatric administration guidelines as there were no other guidelines available. The ASPEN guideline provided evidence supporting the use of 30 mL of SW to flush the enteral tube before and after medication administration in adults.4 Assessment of pediatric drug administration showed much smaller volumes used for both diluent and flushes.7 In addition to the ASPEN guidelines, 19 articles and 3 other area hospital policies were reviewed using the Johns Hopkins EBP model, which employs user-friendly tools to evaluate the level and quality of evidence.8 A new nursing QI protocol was created upon reviewing the data, available literature, and outside hospital policies. The outcomes evaluated included the volume of fluid administered enterally, patient comfort, and loss of tube patency. The protocol also included educating nurses on excess fluid volume signs and symptoms such as changes in lung sounds, respiratory rate, depth, and effort; heart rate and heart sounds; edema; jugular vein distension; and residual gastric volume assessment every 4 hours or as prescribed.

Next, the proposed protocol was submitted to the organization's Pharmacy and Therapeutics Medication Safety Committee (PTMSC), which assessed the safety of administering one drug at a time and allowing the tube to clear with no flush between drugs. Pharmacists determined there was such a potentially small amount of drug left that the risk of drug-drug interaction would be minimal and inconsequential, thereby not warranting concern. After receiving approval from the PTMSC, it was submitted to the organization's Quality Improvement Committee, Clinical Practice Council, and Nursing Oversight Committee. Upon receiving the approval for the QI proposed protocol from all oversight committees, the new protocol was test-piloted on the adult acute care medical-surgical unit.

Testing the new protocol

In May 2019, the unit nurses were educated on the new protocol steps, test pilot questions, and data gathering requirements. Education included a list of already manufactured, prepared solutions to reduce the need to crush pills.9 In June and July 2019, the unit initiated the new protocol. The only medical criterion for pilot inclusion was if the patient had an enteric feeding tube with medications prescribed. No additional criteria were used to increase the sample size. No demographic variables were collected as this was a QI project. Unit nurses used the new protocol where each pill was crushed then dissolved in 5 mL of SW in separate medication cups; medications were not mixed. Before administration, the tube was flushed with 30 mL of SW to ensure patency. Each medication was administered one after another, allowing the tube to clear between drugs, with no flush in between. Finally, after all medications had been administered, the tube was flushed with 30 mL of SW.

FU1-16
Figure:
Fluid volume differences in 24 hours

The nurses completed an enteral medication questionnaire for each patient who had medications administered via a nasogastric, gastric, or jejunum tube. The medications given at 0900 and 2100 were the only medications surveyed on the questionnaire, as these were the times when the largest number of drugs were given at one time. The nurses documented the start and finish time of the medication pass, the volume of total fluids given in the electronic health record under Intake & Output, and if the patient was having any GI pain or discomfort. After the medications were given, patients were asked how their stomach felt compared with before medications were administered. There was a box to check if the patient could not respond verbally by shaking the head or squeezing the hand. The de-identified medical administration record (MAR) was printed and stapled to the form. The questionnaires, combined with the deidentified MAR, were gathered. The de-identified data were collated in a spreadsheet to determine the differences between the policy and the new protocol.

Findings

In the 20 de-identified patient data, there was a difference between the policy fluid volumes and reduced protocol fluid volumes. The patients reported no feelings of fullness, bloating, or distension pain. Nurses also reported no holding of tube feedings because of high gastric residual volumes and no signs or symptoms of edema, aspiration, or clogged tubes. A large decrease in the total fluid administered with SW flushes and medication diluents was evident in every patient's MAR. The changes in volume ranged from 315 mL for three medications per original process, to 145 mL given with the new method, to a high of 1,565 mL reduced to 624 mL using the new method in patients with 10 or more medications (see Fluid volume differences in 24 hours).

On the ENT Questionnaire, the potential outcome for increased abdominal discomfort was determined by the initial assessment question before medication administration: “Are you having any stomach/GI pain or discomfort?” The post medication administration follow-up question was, “Are you having more or less stomach/GI discomfort?” No patient indicated a change in abdominal discomfort.

Moreover, the patients expressed satisfaction with the new protocol; they like the new way nurses gave the medications and reported no pain. There was no evidence of drug interaction without flushing between drugs that match the pharmacist's assessments. There was no evidence of an increased potential for clogged enteral tubes.

After sharing the findings of the enteral medication administration trial with the new flush and medication diluent volumes with the organizational medication safety committee, the decision was made to update the current enteral medication administration policy. The update reflected the changes in SW flush volumes, elimination of in-between medication flushes, and the use of 30 mL SW flushes before and after medication administration. The SW medication diluent amounts were defined as 5-15 mL as needed to create a solution for crushed pills. As this project rolled out across the organization, education was developed using an in-service module uploaded to all nursing and pharmacy employees' compulsory education. The organization is currently using the new process and has not reported increases in medication intolerance or abdominal discomfort identified to date.

Conclusion

Nurses can implement safe and innovative methods to improve patient outcomes. Excess fluid volumes can lead to additional hospitalization costs, length of stay, and increased health issues. This QI project presents a new approach to enteral medication administration. The new protocol reduces fluid volume overload and decreased gastric residual volumes while maintaining feeding tube patency, nutrition, and needed medications.

This QI project shows that standardization of the nursing process and a cultural change concerning enteral tubes and medications are needed. Further investigation and research are required in the area of enteral medication administration.

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