From the 2019 HVPAA National Conference
Dr. Jessica Chan (University of Utah), Dr. Elizabeth Ryals (University of Utah), Dr. Elizabeth Joiner (University of Utah), Dr. Anne Kennedy (University of Utah), Mr. J. Bradley Wiggins (University of Utah), Dr. Yoshimi Anzai (University of Utah)
Background
Timely feeding of critically ill patients is essential for the safety and quality of patient care, as malnutrition leads to a higher risk of surgical site infection, decubitus ulcer, and readmission. Many critically ill patients are too ill to meet their nutritional demands through oral intake, and require enteral tube feeds. Historically at our institution, inpatient feeding tubes were placed at bedside by nurses without imaging guidance, and if unsuccessful, were placed under fluoroscopic guidance in the fluoroscopy suite by radiologists. However, as the volume and complexity of diagnostic imaging studies increased, radiologists were less available to place fluoroscopic-guided feeding tubes (FgFTP).
Objective
To reduce delays in feeding tube placement and improve resource utilization, we formed a feeding tube task force, comprising members of the nursing staff and radiology department.
Methods
Using a fishbone diagram, a root cause analysis was performed. The task force proposed to transition from FgFTP to electromagnetic-guided feeding tube placement (EMgFTP), for inpatients, which was supported by the Chief Value Officer Committee and hospital CMO. The EMgFTP system (Cortrak; Avanos Medical) is performed at the bedside using on-screen visualization of the feeding tube tip. Nine inpatient nurses were recruited and trained on the EMgFTP system using a simulator. For the first 6 months, a portable abdominal radiograph was obtained after EMgFTP to confirm the position of the feeding tube tip and correlate with the image on the Cortrak monitor. Following nearly perfect correlation of the feeding tube tip position on the Cortrak screen with the abdominal radiograph, routine confirmatory abdominal radiographs were no longer obtained, and FgFTP was reserved for inpatients in whom EMgFTP failed.
Results
The annual number of fluoroscopic-guided feeding tubes decreased from 182 in 2016 to 129 in 2017, corresponding to a 29% reduction after implementation of the EMgFTP system in December 2016. The number of electromagnetic-guided feeding tubes steadily increased after its introduction with 115 tubes placed in December 2016, 2,232 during 2017, and 1,284 during the first 6 months of 2018. The cost of feeding tube placement decreased with the introduction of the EMgFTP system, as the billed cost was $275.00 for EMgFTP and $1,185.57 for FgFTP (including the use of the fluoroscopic suite as well as radiological interpretation and supervision).
Conclusions
The transition from FgFTP to EMgFTP improved the quality of care received by inpatients requiring enteral tube feeds, by reducing the time, cost and radiation associated with feeding tube placement. Since its implementation, the EMgFTP service has grown, comprising 14 nurses available 9am-9pm daily.
Clinical Implications
The transition from FgFTP to EMgFTP improved internal resource allocation in the form of decreased cost and decreased strain on the radiology department, while improving patient care by decreasing time to feeding tube placement, radiation, and risk of fall or line malposition during transportation.
Figures
