Hospitals are becoming concerned about nutrition as they try to reduce readmission rates. Nearly one-fifth of all Medicare beneficiaries discharged from a hospital return within 30 days according to the Medicare Payment Advisory Commission (MEDPAC). A study they did found weight loss to be one of six co-morbidities in data collected from more than 6,800 general medicine patients in university medical centers across the U.S.
A feeding tube may be prescribed to help with weight loss or malnutrition. Nasogastric (NG) or nasojejunal (NJ) are two types of feeding tubes commonly used postoperatively in a hospital setting. Inserted at a patient’s bedside or in the radiology department, these enteral feeding tubes can be used for primary feedings, medicine or to supplement with nutrition received orally. Although these devices and procedures are intended to help the patient, they do not come without risks.
A study conducted by MEDPAC in 2007 revealed that 37 U.S. children’s hospitals found a higher rate of readmissions associated with an increased use of assistive technology including a feeding tube.
To curtail readmission, a reduction program was established in 2012 by the U.S. Department of Health and Human Services to reduce Medicare payments to hospitals based on the frequency of Medicare readmissions. These incentive measures have been carried through to 2015 with the Hospital-Acquired Condition Reduction Program, which requires adjusted payments for the worst-performing hospitals according to the Centers for Medicare and Medicaid Services.
Guess and Check
A guess and check method may take multiple attempts and can take more time to arrive at the real answer. Clinicians working in an acute care hospital or ICU rely on this method daily when they blindly insert NG tubes into their patients.
After using several methods to predict the placement of the tube in the stomach, X-rays are taken to confirm the position of the tube into the stomach or beyond to the duodenum or jejunum. Costs increase with each X-ray ordered-sometimes taking three or four to successfully position the tube. Then additional chest or abdominal X-rays are taken to monitor placement of the tube over time according to standard of care guidelines published by the American Association of Critical-Care Nurses.
Besides an increase in cost, X-rays also expose patients to radiation, which is a known human carcinogen. An abdominal or chest X-ray emits a small amount of radiation at 0.1 mSv; however, exposure increases with CT scans and fluoroscopy at around 8 mSv or more depending on how long or how often the imaging tests are performed according to the American Cancer Society. Healthcare professionals are encouraged to take X-rays only when absolutely necessary, especially when treating children who are more sensitive to radiation than adults. Meanwhile, a number of additional risks come with transporting patients to radiology from acute or intensive care.
Blindly inserting a feeding tube also carries the risk of tube misplacement. In 2010, a 61-year-old man died after having a feeding tube blindly inserted into his lung instead of his stomach. According to the Chicago Daily Law Bulletin, Glenn Sutherland of Arkansas was in a work-related accident in June 2010 and admitted to a hospital. 1 Sedated in the trauma center, physicians ordered Sutherland a second NG feeding tube after the success of the first tube. After the second feeding tube was blindly inserted, a chest X-ray confirmed the feeding tube’s placement into the stomach. However, due to a mix-up among hospital staff, the X-ray confirmed the placement of the first NG feeding tube while the second NG tube unknowingly sat curled up in Sutherland’s right lung. After feedings began, his oxygen saturation started to decrease and he began aspirating through his tracheal air tube. The wrongful death suit was settled out of court for $3.8 million just this past year.
Although this mortality was caused in part by human error, misplacement itself through blind insertion is not that rare. In 2009, a 1-year cohort study was done of level IIIc neonates with a NG tube who were in a NICU 2. The research published in Advances in Neonatal Care revealed that, of the 326 radiographs reviewed, nearly half of the tubes were misplaced and substantial or excessive air was found in more than one-third of the cases.
GPS for NG Tubes
To mitigate these issues, an increasing number of hospitals are turning away from the blind insertion method in favor of new technology. The enteral access system is a real-time visual aid for the placement of a NG or NJ feeding tube at the bedside. The electromagnetic technology gives clinicians three perspectives including anterior, depth cross section and lateral view perspectives, which reduces the need for a confirmatory X-ray or eliminates them altogether.
“It could be thought of as a GPS for a feeding tube where the tip of the stylet inside the tube is the car and the receiver would be the satellite,” said Jill Lazar, senior product manager for CORPAK MedSystems. “It triangulates the signal that’s emitted at the tip of the stylet and that signal is fed back to the monitor and a representation of the path of the movement of that tip is displayed on the screen.”
A 2011 study published in the Journal of Parenteral and Enteral Nutrition involving over 600 patients found that this technology was 100% accurate in avoiding lung placement3. Lazar said the system also closes the gap between the time a feeding tube is ordered and when feedings can actually start, which supports adequate nutrition.
Since the first model of this new process entered the healthcare marketplace in 2006, other companies have begun working on systems to improve patient outcomes, in turn reducing hospital readmissions, by offering an alternative to feeding tubes by blind insertion.
References
1. Wood, L. Feeding Tube in lung nets $3.8 million deal. Chicago Daily Law Bulletin. http://www.chicagolawbulletin.com/Archives/2015/11/06/Wrongful-death-suit-11-6-15.aspx Updated November 6, 2015. Accessed December 11, 2015.
2. Boer, et al. Nasogastric Tube Position and Intragastric Air Collection in a Neonatal Intensive Care Population. Advances in Neonatal Care. 2009;9(6):293-98. doi:10.1097/ANC.0b013e3181c1fc2f
3. Rivera, R, et al. Small Bowel Feeding Tube Placement Using an Electromagnetic Tube Placement Device Accuracy of Tip Location. JPEN. 2011;35(5):636-42. doi:10.1177/0148607110386047
Chelsea Lacey-Mabe is a staff writer. Contact: [email protected].
