From the 2024 HVPA National Conference
Melissa Victory Brodman MD (University of Texas Medical Branch), Layla Abdul Jabbar MD, Raakhi Menon DO, Erin Hommel MD
Background:
Timely initiation of enteral nutrition and medication (ENM) plays a critical role in healing for the hospitalized adult unsafe for oral intake. At our institution, residents expressed concern about delayed initiation of ENM overnight because of institutional policy. Preliminary investigation showed a significant delay between placement of an enteral tube order and clearance of the tube for use, corroborating the concern. We also identified significant practice variation regarding orders required to move from tube placement to ENM delivery.
Objective:
Improve ENM delivery among hospitalized adults by reducing practice variation among clinicians. We also aim to reduce the time between each step from tube placement to ENM delivery.
Methods:
We created a multidisciplinary team including resident and faculty physicians, nurses, dietitians, pharmacists, EPIC analysts, and clinical data specialists. The ENM process flowchart identified the following barriers: an institutional policy requiring faculty to confirm tube placement, cumbersome ENM order entry, and inconsistent physician practice to convert medications from oral to enteral.
The electronic health record was queried for all inpatients aged 18 or older where an enteral tube was placed. We collected time stamps and frequencies for the following: order for tube placement, documented time of placement, order for x-ray, x-ray result, order for tube clearance, and order for ENM.
Results:
Baseline data was collected January 2023 to April 2024. Interventions went live April 9, 2024. At baseline, there was significant variation in use of orders for the necessary process steps: 28% for tube placement, 43% for x-ray order to verify location of the tube, 38% for tube clearance order. Diet orders were found for only 28% of patients. At baseline, the average time between order for tube placement and for tube clearance was 9.74 hours. The average time between order for tube placement and for ENM was 18.46 hours. We revised the institutional policy to permit tube placement verification by a certified radiology resident, streamlined ENM order entry, and created a pharmacy consult to prompt conversion of medications to enteral. Post-intervention results will be available at the time of presentation.
Conclusions:
We identified significant variation in orders for enteral tube placement, clearance, and ENM among hospitalized adults at our institution. We also demonstrated significant delays in enteral tube clearance and ordering EN. We believe the institutional policy requiring faculty confirmation for enteral tube clearance contributed significantly to these delays. Clinicians also identified opportunities to simplify the process for ordering ENM. Our interventions should reduce the time to enteral tube clearance and ENM delivery. However, significant education will be necessary to reduce practice variation and assure compliance with each process step necessary for safe, efficient delivery of ENM. Next phases of the project will focus on measures of ENM delivery as the ultimate outcomes of interest.
Clinical implication:
ENM delivery is a frequent necessity among seriously ill hospitalized adults. It is easy to assume this process is hardwired and streamlined within a health system. However, in-depth analysis of enteral feeding practices could reveal critical deficiencies in patient care, necessitating a multidisciplinary approach to care improvement. Importantly, health system policies may be important contributors to care delays within a system, as we found here. Complex data analysis is often necessary to strike the balance between safety and efficiency when designing processes for patient care.