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Ensuring safer enteral feeding

Lau, Mary Theresa APN, CNS, CNSN, CRNI; Girard, Joanne , RN, PTA, WCC

doi: 10.1097/01.NUMA.0000407579.93705.e9
Feature: 2012 Guide to Patient Safety Infection control

Enteral nutrition assists critically ill patients with fighting off disease.

Mary Theresa Lau is the nutrition support and venous access cinical nurse specialist at Edward Hines Jr. VA Hospital in Chicago, Ill. Joanne Girard is the assistant director of nursing at Morgan Health Center in Johnston, R.I.

The authors have disclosed that they have no financial relationships related to this article.

Enteral nutrition has been utilized as a medical necessity for centuries. Since ancient times, patients unable to consume adequate calories and protein from food were given liquids via glass and wooden tubes. These methods fell out of favor in the 19th century due to their cumbersome and dangerous nature. In the 1800s, absorption was thought to occur in the colon, so accessing the upper gastrointestinal tract was deemed unnecessary. As a result, enteral feedings were given via the rectum.

With the advent of parenteral nutrition in the late 1960s, enteral nutrition lost favor, which further delayed the advancement and administration of tube feedings. Studies started in 1990 showed improved patient outcomes with the use of enteral nutrition, helping this field develop into what it is today.1

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Feeding tube basics

Enteral nutrition maintains gut integrity and immune function. Bowel rest during illness leads to changes in the integrity of the gut mucosal lining. This has been found to lead to local and systemic effects such as translocation of bacteria through the thinned gut mucosa. Enteral nutrition has demonstrated “additional structural as well as functional benefits including the support of gut-associated lymphoid tissue (GALT) and mucosa-associated lymphoid tissue (MALT) which in turn are critical for maintaining the gut-associated immune function.”1

A systematic review of the research concluded that when enteral nutrition is used in critically ill patients, an important decrease in infectious complications and cost was apparent when compared with parenteral nutrition.2 The authors recommended that enteral nutrition should be the first choice for nourishing the critically ill.2

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Enteral complications

Enteral feeding obstacles can be divided into four categories: postinsertion mechanical complications, infectious complications, gastrointestinal problems, and metabolic barriers. The overall procedure complication rate post insertion is 10%. These difficulties include tube misplacement, aspiration, epistaxis, and respiratory or circulatory compromise. Once the tube is established, complications include tube migration, tube occlusion (due to medication and feeding coagulation), and tube malfunction. The latter two require tube removal.

Until the late 1990s and early 2000s, the only way to administer enteral feeding was in an open system in which the formula, either from a can or reconstituted powder, was poured into a bag. The risk of contact contamination was high—the nurse could touch the can or formula as it was being poured into the bag. Entry into the system was frequent, at least six times per day, thus increasing the threat of corruption. These bags had to be rinsed every 8 hours with water, increasing exposure to the system and creating a potential cesspool of bacteria.

Clinical studies confirm that open feeding systems can be a significant source of septicemias. Pathogens found within open systems that have been contaminated include: Acinetobacter baumannii; Enterobacter cloacae; Enterobacter agglomerans; and Klebsiella pneumoniae. These can cause aspiration pneumonia and diarrhea, two of the most common enteral feeding illnesses. In addition, there' s a risk of splash contamination of bloodborne pathogens as the nurse pours the formula into the bag. Methods to reduce the potential of infectious complications with open enteral systems include: (1) washing hands for 10 seconds before handling enteral feeding supplies, (2) cleaning the top of the can, (3) not using expired feeding formulas, (4) avoiding formulas that need to be diluted or mixed, (5) discarding dented and damaged cans, (6) handling the formula as little as possible, (7) never adding new formula to existing formula, (8) hanging only an 8-hour supply at a time, and (9) keeping the formula at room temperature.

Lastly, another potentially fatal risk of enteral feeding is misconnection, a serious patient safety issue. According to The Joint Commission, “an enteral misconnection is an inadvertent connection between an enteral feeding system and a nonenteral system such as an intravascular line, a peritoneal dialysis catheter, a tracheostomy tube cuff, and medical gas tubing. In each case, serious patient harm, including death, can occur if fluids, medications, or nutritional formulas intended for administration into the gastrointestinal tract are administered via the wrong route.”3

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Closed feeding systems

Closed enteral feeding systems have become the preferred feeding tube method because they reduce contamination considerably.4 Closed enteral feeding systems are a patient safety initiative. Many hospitals use the Hazard Analysis Critical Control Point guidelines for the preparation and administration of enteral feeding.5 The adoption of the closed feeding system has been shown to minimize enteral formula contamination because there's less risk of touch contamination.5

Table 1

Table 1

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Future modifications

Altering the enteral feeding components is underway. Through the efforts of the American Society for Parenteral and Enteral Nutrition, The Joint Commission, and the manufacturing industry, major changes are being implemented with significant modifications in feeding tube designs. These changes, along with the education of healthcare providers, will ensure the decrease of complications and contamination.

Interview with Joanne Girard, RN, PTA, WCC

Assistant Director of Nursing

Morgan Health Center

Johnston, R.I.

Q. Are clogged feeding tubes a problem at your facility? What prevention strategies have you used to prevent clogging? How has the closed connector helped in the prevention of clogged tubes?

In the past, tube clogging was a common problem in our facility. To clear it, you must either squeeze the tube along its length or use a tube declogger, which is very ineffective. As a long-term-care facility, we would often have to send the patient to the hospital for tube replacement. Since we've been using the closed connector, clogging is less of a problem. If a clog occurs, it happens at the connector and goes no further. To clear it, you just flush the line and replace the connector. It saves time and reduces the need to send the patient to the hospital for tube replacement.

Q. Can you describe your facility's experience with the closed connector with regard to flushing enteral feeding tubes? How easy is it to use with parenteral medication?

The connector has made a big difference in flushing and administering medications. (See Product evaluation: Closed-system connector.) You just open the valve, insert the syringe, flush the tube, close it off, and remove the syringe. Because it's a closed system, you can leave the syringe in the connector between administrations. When it's time to deliver medication, you just close the valve, administer the medication, turn the valve, add water, and let the medication go down. You never have to disconnect the syringe.

Q. Have you noticed a reduction in nursing time and workflow with the closed connector?

The connector saves a significant amount of nursing time and all the nurses love it because it's so easy to use. We very seldom get a connector that's clogged. As for time, we can do procedures in less than 5 minutes now.

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1. Gottschlich MM, ed. The A.S.P.E.N. Nutrition Support Core Curriculum: A Case-Based Approach—The Adult Patient. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2007:189,190,192,240.
2. Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition. 2004;20(10):843–848.
3. Guenter P, Hicks R, Simmons D, et al. Enteral feeding misconnections: a consortium position statement. Jt Comm J Qual Patient Saf. 2008;34(5):285–292.
4. Beattie TK, Anderton A. Decanting versus sterile prefilled nutrient containers-the microbial risks in enteral feeding. Int J Environ Health Res. 2001;11(1): 81–93.
5. Winkler, MF, Hedberg AM. Quality and performance improvement. In: Matarese LE, Gottschlich MM, eds. Contemporary Nutrition Support Practice, A Clinical Guide. 1st ed. Philadelphia, PA: Saunders; 1998:616–624.
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