Decreasing our time doing redundant work

The dietitians at my hospital are generally consulted to start any enteral feeding. Our policies and protocols allow us to initiate and manage enteral feeds when we are consulted. This has led to many PCPs being unable to put in their own orders as they almost never do it. There is a lack of nutrition and enteral education in PCP curriculum and that is quite obvious when it comes to enteral feeds.

We found ourselves being brought back in on weekends, or staying late just to put tube feeding orders in. We decided to devise an order that any PCP or nurse could enter that would initiate feeding at that time and also consult the dietitians to manage and make changes as needed. It has worked beautifully.

First Things First

  1. What type of tube feeding can be used universally?
  2. What rate can be used to start all new feeds?
  3. What volume of flushes should be used in the beginning?
  4. What times should this go into effect?

These and more questions had to be answered before going forward. There were many meetings with IT, Physician groups, ICU protocol committees, etc. to make sure all were on board. We found our physician groups to be very supportive and even excited. Apparently, many of them would like to start their own enteral feeds, but they did not know how.

What We Decided

The formula we picked was Osmolite 1.5. We felt this would fit most patients needs and even if it isn’t perfect, at such a low dose it will not do any harm. We us it on the medical floors and for all icu patients. The rate we decided on was 15 ml/hour because our tube feeding pumps do not like to run at 10 ml/hour. The flushes were set at 50 ml every 4 hours because this is a standard flush for patients in our intensive care units. This tube feeding is the standard initial order for every patient that has tube feeding started. If it is regular hours, the dietitian can modify it quickly, usually within a few hours of it being ordered. We usually contact our food service to let them know we will be changing it and to not send it yet. If this order is placed after hours or on the weekend, this is the order that is used, and the dietitian will see the patient the next day for goal rate or change in formula.

Workflow

  1. PCP puts in an order for “Starter Tube feeding,”
  2. The RD is consulted for tube feeding management.
  3. Food service will send the product based on what the dietitian communicates to them or always sends if it is after regular hours or on the weekend.
  4. The dietitian will evaluate the patient either the day it is ordered or the next day, depending on when the PCP puts in the order.

What We Had to do to Get Here

As mentioned above, there were many meetings, dry runs and of course, the most important piece was nursing education. This was done through emails (which are not effective), bathroom notices with “how to” explanations and “one on one” review. One on one review is the most effective way of teaching. We would have to stop PCPs or nurses in the hallway and review the orders with them, which was met generally positive. The orders were made so nothing had to be chosen on the set, it just has to be signed. The only thing they needed to know was how to find the order in the search bar.

This is the order set

How it’s Going

I have to say, it is going well. Like with any new order, there are bumps in the road, but generally speaking, better than I thought it would! Our call back time on weekends and holidays has been cut down to almost nothing. The nurses feel good because they can start feeding the patients immediately instead of waiting for us. The PCPs also know that they can have enteral feeds started at any time, especially in the evenings or nighttime if a patient is admitted then and it needs to be started.

Please let me know if this is helpful or if you have any questions. Thank you so much!

By : Amanda

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