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Guideline Summary
Guideline Title
Medication administration. In: A.S.P.E.N. enteral nutrition practice recommendations.
Bibliographic Source(s)
Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J. Medication administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):158-62. [36 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Conditions or disease states requiring enteral nutrition

Guideline Category
Management
Treatment
Clinical Specialty
Family Practice
Gastroenterology
Geriatrics
Infectious Diseases
Internal Medicine
Nursing
Nutrition
Oncology
Pediatrics
Pharmacology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Pharmacists
Physician Assistants
Physicians
Utilization Management
Guideline Objective(s)
  • To examine the available literature related to the ordering, preparation, delivery, and monitoring of enteral nutrition
  • To establish evidence-based practice guidelines for the safe and effective use of enteral nutrition
Target Population

Patients receiving enteral nutrition throughout the lifecycle and throughout all practice settings

Interventions and Practices Considered
  1. Dosage forms and administration
  2. Gastric vs. intestinal delivery
  3. Drug interactions (for drugs added to enteral nutrition, for multiple drugs)
  4. Crushing and diluting medications
Major Outcomes Considered
  • Adverse drug event rates
  • Incidence of drug-related feeding tube obstruction
  • Incidence of other complications attributed to medication
  • Incidence of inappropriate drug administration
  • Drug interaction rates
  • Changes in drug efficacy
  • Mortality related to drug-drug interactions

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

PubMed was used to search and collect the literature. Search was limited to English language journals and abstracts were excluded. All types of literature including research, case reports, and review articles. Government, regulatory, and standard setting websites such as the United States (US) Food and Drug Administration (FDA), US Pharmacopeia, and The Joint Commission on Accreditation of Healthcare Organizations were also utilized. Search terms included enteral nutrition, tube feeding, enteral complications, enteral safety, water safety, medication administration, enteral access device, aspiration, misconnections, enteral microbial growth, infant formulas, medical foods, and enteral formulary.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Weighting According to a Rating Scheme (Scheme Not Given)
Rating Scheme for the Strength of the Evidence

Not stated

Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

The literature and evidence were classified based on the Agency for Healthcare Research and Quality (AHRQ) method.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) established the Enteral Nutrition Practice Recommendations Task Force to examine the available literature related to the ordering, preparation, delivery, and monitoring of enteral nutrition and to establish evidence- based practice guidelines. It was recognized from the onset that there was either an absence of research or the research was of limited strength to support many aspects surrounding the practice of administering enteral nutrition. Therefore, in addition to the existing literature, a consensus of expert opinion based on current knowledge and best practices was used to formulate these practice recommendations.

The strength of each practice recommendation was graded using a method consistent with the 2002 A.S.P.E.N. Guidelines for the Use of Parenteral and Enteral Nutrition in Adult and Pediatric Patients. The grading system was based on a modified version of the method used by the Agency for Healthcare Research and Quality (AHRQ), United States (US) Department of Health and Human Services. After review of the literature cited, the authors used the AHRQ criteria to classify the strength of the evidence supporting each recommendation statement.

Rating Scheme for the Strength of the Recommendations

Grade of Recommendation

  1. There is good research-based evidence to support the guideline (prospective, randomized trials).
  2. There is fair research-based evidence to support the guideline (well-designed studies without randomization).
  3. The guideline is based on expert opinion and editorial consensus.
Cost Analysis

Published cost analysis studies were reviewed.

Method of Guideline Validation
Comparison with Guidelines from Other Groups
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

The draft document was sent to leaders of American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Practice Sections, Clinical Practice Committee, and Board of Directors for review and comment process.

The draft document was also sent to leaders of related medical organizations. Reviews were received back from the following groups: American Society of Health-System Pharmacists (ASHP), Institute of Safe Medication Practices (ISMP), North American Society for Pediatric Hepatology, Gastroenterology, and Nutrition (NASPHGAN), American Academy of Pediatrics (AAP), Dietitians in Nutrition Support, a dietetic practice group of the American Dietetics Association, and U.S. Pharmacopeia (USP).

The document was approved by the A.S.P.E.N. Board of Directors following review by internal and external content experts and the A.S.P.E.N. Clinical Practice Committee.

Recommendations

Major Recommendations

Definitions of the grades of recommendations (A-C) are provided at the end of the "Major Recommendations" field.

Practice Recommendations

  1. Do not add medication directly to an enteral feeding formula. (B)
  2. Avoid mixing together medications intended for administration through an enteral feeding tube given the risks for physical and chemical incompatibilities, tube obstruction, and altered therapeutic drug responses (i.e., do not mix medications together, but do dilute them appropriately prior to administration). (B)
  3. Each medication should be administered separately through an appropriate access. Liquid dosage forms should be used when available and if appropriate. Only immediate-release solid dosage forms may be substituted. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix powder with sterile water. (B)
  4. Prior to administering medication, stop the feeding and flush the tube with at least 15 mL water. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe (> 30 mL in size). Flush the tube again with at least 15 mL water taking into account patient’s volume status. Repeat with the next medication (if appropriate). Flush the tube one final time with at least 15 mL water. Note: Dilution/flush should be less for pediatric doses (minimum 50:50 volume) and at least 5 mL when fluid is not restricted. (A)
  5. Restart the feeding in a timely manner to avoid compromising nutrition status. Only hold the feeding by 30 minutes or more when separation is indicated to avoid altered drug bioavailability. (A)
  6. Use only oral/enteral syringes labeled with 'for oral use only' to measure and administer medication through an enteral feeding tube. (B)
  7. Consult with an adult pharmacist or pediatric pharmacist for patients who receive medications co-administered with enteral nutrition. (C)

Summary

The complexity of enteral nutrition (EN) feedings cannot be underestimated. All healthcare professionals should be vigilant in continuous surveillance of high risk practices, products and systems as they relate to the enterally fed patient. Recognition of ordering, administration, and monitoring steps of EN delivery which may increase risk of complications to the enterally fed patient is essential.

Definitions:

Grade of Recommendation

  1. There is good research-based evidence to support the guideline (prospective, randomized trials).
  2. There is fair research-based evidence to support the guideline (well-designed studies without randomization).
  3. The guideline is based on expert opinion and editorial consensus.
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence ranges from prospective randomized trials to expert opinion/consensus.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Standardized processes for enteral nutrition care including ordering, preparation, administration, and monitoring
  • Optimal care and minimal risk of error
  • Avoidance of tube obstruction, reduced drug efficacy, or increased drug toxicity
Potential Harms

Not stated

Contraindications

Contraindications

Enteral nutrition is contraindicated in a patient with significant hemodynamic compromise.

Qualifying Statements

Qualifying Statements

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Enteral Nutrition Practice Recommendations are based upon general conclusions of health professionals who, in developing such recommendations, have balanced potential benefits to be derived from a particular mode of providing enteral nutrition with known associated risks of this therapy. The underlying judgment regarding the propriety of any specific practice recommendation or procedure shall be made by the attending health professional in light of all the circumstances presented by the individual patient and the needs and resources particular to the locality. These recommendations are not a substitute for the exercise of such judgment by the health professional, but rather are a tool to be used by the health professional in the exercise of such judgment. Use of this document is voluntary and should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed toward obtaining the same result.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Slide Presentation
Staff Training/Competency Material
Wall Poster
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
End of Life Care
Getting Better
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller C, Robbins S, Wessel J. Medication administration. In: A.S.P.E.N. enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):158-62. [36 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan
Guideline Developer(s)
American Society for Parenteral and Enteral Nutrition - Professional Association
Source(s) of Funding

American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

Guideline Committee

The Enteral Nutrition Practice Recommendations Task Force

Composition of Group That Authored the Guideline

Task Force Members: Robin Bankhead, CRNP, MS, CNSN, Chair; Joseph Boullata, PharmD, BCNSP; Susan Brantley, MS, RD, LDN, CNSD; Mark Corkins, MD, CNSP; Peggi Guenter, PhD, RN, CNSN; Joseph Krenitsky, MS, RD; Beth Lyman, RN, MSN; Norma A. Metheny, PhD, RN, FAAN; Charles Mueller, PhD, RD, CNSD; Sandra Robbins, RD, CSP, LD; Jacqueline Wessel, MEd, RD, CSP, CNSD, CLE

Financial Disclosures/Conflicts of Interest

Jacqueline Wessell is on the Abbot Nutrition Speakers Bureau. No other potential conflicts were reported.

Guideline Endorser(s)
Academy of Nutrition and Dietetics - Professional Association
American Society of Health-System Pharmacists - Professional Association
Institute for Safe Medication Practices - Professional Association
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Society for Parenteral & Enteral Nutrition (A.S.P.E.N.) Web site External Web Site Policy.

Print copies: Available in hardcopy from A.S.P.E.N. Telephone: 1-800-727-4567.

Availability of Companion Documents

The following are available:

In addition, the following forms are available in the original guideline document External Web Site Policy:

  • Adult Enteral Nutrition Order Form
  • Pediatric Enteral Nutrition Order Form
  • Standard Enteral Nutrition Label Template (Adult Patient)
  • Standard Human Breast Milk Label Template (Infant Patient)
  • Human Breast Milk Storage Label
Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on February 5, 2010. The information was verified by the guideline developer on March 15, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. Reprint request/permissions should be sent to: Permissions Department, ASPEN; 8630 Fenton St. #412; Silver Spring, MD 20910; Fax: 301-587-2365.

Disclaimer

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