Drug administration via enteral feeding tubes in residential care facilities for individuals with intellectual disability: an observational study

Bifari I, Ahmed Alharbi Y. Unraveling medication errors in enteral tube administration: A cross-sectional study in geriatric patients receiving home health care

Background

Medication administration through enteral feeding tubes requires careful consideration, as several medications are unsuitable for such administration due to interactions with feeding formulas or adverse effects when crushed. These errors can lead to feeding tube obstruction, reduced drug efficacy, or drug toxicity.

Objective

This study aimed to assess medication errors in geriatric patients using enteral feeding tubes who were enrolled in a home health care program.

Method

This was a cross-sectional observational study conducted at the Ministry of Health Government Hospital in Makkah City, Saudi Arabia. Medication errors related to chronic oral drugs in geriatric patients using enteral feeding tubes were evaluated, including inappropriate medications for enteral tube administration, inappropriate preparation, drug-nutrient interaction, and availability of liquid formulation, following established guidelines.

Results

Of the total 233 medications prescribed to 46 patients receiving enteral tube feeding at home, 49.3% exhibited at least one form of medication error, totaling 135 errors. Medication errors were highly prevalent among the patients (93.4%), with the leading cause being the administration of medications unsuitable for enteral feeding tubes (33.3%), predominantly due to the use of controlled release or enteric-coated formulations.

Conclusion

This study underscores the high prevalence of medication errors in older patients receiving enteral feeding at home. To ensure patient safety and optimal outcomes, healthcare professionals should utilize available resources and seek expert advice when selecting medications and dosage forms for tube-fed patients. Pharmacists play a critical role in promoting safe drug use and can greatly contribute by educating patient caregivers on proper medication preparation and administration techniques, thus preventing harm to patients.

A systematic approach for assessing the suitability of enteral feeding tubes for the administration of controlled-release pellet formulations

Enteral nutrition plays an important role for patients who are unable to properly swallow food. In such patients, enteral feeding tubes are often used, through which food, but often also oral medications, are administered. However, this can pose the risk of tube clogging. Compared to the administration of crushed tablets, multiparticulate dosage forms are often considered easier to administer and furthermore have the advantage of enabling the administration of even controlled-release preparations. The objective of this systematic study was to identify tube- and formulation-related factors that contribute to successful administration of coated pellet formulations via a variety of commercially available feeding tube devices. The suitability of enteral feeding tubes for the administration of controlled-release pellet formulations that differed in size and type of starter core and functional coating was investigated in a stepwise approach using a novel in vitro setup. Results of the study indicate that pellet diameter and inner diameter of the feeding tube are by no means reliable parameters for estimating the tube's suitability for pellet administration, but that many other tube and formulation-related factors and combinations thereof must be considered to ensure safe and effective drug administration via enteral feeding tubes.

ESPEN practical guideline: Home enteral nutrition

This ESPEN practical guideline will inform physicians, nurses, dieticians, pharmacists, caregivers and other home enteral nutrition (HEN) providers in a concise way about the indications and contraindications for HEN, as well as its implementation and monitoring. This guideline will also inform interested patients requiring HEN. Home parenteral nutrition is not included but will be addressed in a separate ESPEN guideline. The guideline is based on the ESPEN scientific guideline published before, which consists of 61 recommendations that have been reproduced and renumbered, along with the associated commentaries that have been shorted compared to the scientific guideline. Evidence grades and consensus levels are indicated. The guideline was commissioned and financially supported by ESPEN and the members of the guideline group were selected by ESPEN.

Experiences and needs of home caregivers for enteral nutrition: A systematic review of qualitative research

AIMS

To systematically identify, evaluate and synthesize the qualitative evidence on enteral nutrition of home caregivers.

DESIGN

A qualitative evidence synthesis using the Sandelowski and Barroso methodology.

DATA SOURCES

We reviewed articles from eight databases: CINAHL, Embase, PubMed, Web of Science, Cochrane, CNKI, Wanfang Data and CSTJ. Qualitative, peer-reviewed, original studies published in English or Chinese before April 2020 on home caregivers' experience and needs for enteral nutrition were included. The studies were selected by screening titles, abstracts and full texts, and the quality of each study was assessed by two researchers independently.

REVIEW METHODS

Two researchers independently used qualitative assessment and review tools for quality assessment and thematic synthesis for data analysis.

RESULTS

This review included 10 articles. The themes identified included balance the enteral nutrition, the experiences and feelings in practice and the recommendations to meet challenge.

CONCLUSION

Home caregivers reported that they played an important role and faced greater pressure. Future studies should establish a systematic and standardized follow-up schedule to improve home caregivers' physical and mental health.

IMPACT

The findings established that home caregivers experienced not only changes in their roles and concerns but also spiritual changes. Home caregivers develop different coping strategies to adapt to enteral nutrition without standardized training and support. Although home caregivers make much account of enteral nutrition and feeding issues, they lack of information and support services. Understanding existing problems from a caregiver's perspective can allow interventions to be more clearly developed and well-established training standards established in the future.

Medication management in intellectual disability settings: A systematic review

There is a high level of medication usage among people with intellectual disability due to the presence of significant morbidity and co-morbidities. This review sought to explore medication management and administration in intellectual disability settings, identifying frameworks for practice, analysing whether collaborative practice led to better outcomes, identifying key processes associated with practice, locating tools to support practice and describing metrics for outcome measurement. A systematic review was conducted with analysis of 64 sources which remained following screening and appraisal. Limited evidence was identified with some insight into the processes underpinning medication management and administration. No assessment tools were found, but two potential outcome measures, adherence and errors, were noted. The paucity of guidelines and frameworks is concerning as this is a complex area of practice. There is a need for further practice development and research to be undertaken that takes note of the unique issues that can present in intellectual disability settings.

Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective

The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.

People with intellectual disabilities and their experience of medication: A narrative literature review

BACKGROUND

People with intellectual disabilities are known to have increased medical needs and are prescribed more medication than the general population. Understanding the reality of incorporating medication into their lives would help healthcare professionals provide care in more meaningful and personalised ways.

AIM

A narrative review of the current literature relating to people with intellectual disabilities and their experience of medication/pharmaceutical care.

METHOD

Electronic databases were searched for articles relating to intellectual disabilities and medication administration or pharmaceutical care. Other relevant papers identified from included article reference lists were also identified. A narrative literature was undertaken due to the heterogeneity of the identified papers.

RESULTS

A total of 29 studies from the literature searches were included alongside other relevant papers.

CONCLUSIONS

The published literature noted some aspects of the medication-related experiences of people with intellectual disabilities. However, a greater understanding of medication-related experiences is still required.

Current status and influencing factors of barriers to enteral feeding of critically ill patients: A multicenter study

AIMS AND OBJECTIVES

To investigate the barriers in administering enteral feeding to critically ill patients from the nursing perspective. Our objectives are to provide tailored interventions for addressing identified barriers and propose an optimal enteral nutrition (EN) practice in intensive care unit (ICU).

BACKGROUND

Despite the availability of numerous verified clinical practice guidelines focusing on enteral feeding of critically ill patients, a wide gap remains between the guideline recommendations and actual nutrition performances. Underfeeding is also a global problem. Therefore, to further understand the reasons of the systemic iatrogenic underfeeding in ICUs, several potential issues are investigated.

DESIGN

This research is a cross-sectional descriptive study.

METHODS

A total of 808 nurses were recruited from 10 comprehensive hospitals from different districts in China. The nursing staff demographic, the unit's EN management information and the Chinese version of barriers to enteral feeding critically ill patients questionnaire were the parameters used to collect data via WeChat app. Moreover, the collected data were analysed by descriptive and correlative statistical analysis methods.

RESULTS

Results obtained by multiple linear regression showed that frequency of EN-related training, full-time ICU nutritionist, hospital level, specific protocols for enteral feeding and position were significantly influencing the enteral feeding of ICU patients.

CONCLUSIONS

Enteral feeding barriers of ICU patients are at a moderate level and are influenced by multiple aspects. Hence, hospital departments should strengthen standardisation and systematic EN training, provide ICU full-time nutritionists and distribute medical resources and personnel rationally. Moreover, construction of a localised feeding process and exerting subjective initiative of clinical nurses from an evidence-based guideline are important. Multifaceted tailored interventions should be implemented to address these barriers.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study can be used to inform future intervention and guidelines aimed at addressing these barriers systematically and improving adherence to critical care nutrition guidelines for the provision of enteral nutrition.

Carers' experiences of home enteral feeding: A survey exploring medicines administration challenges and strategies

What is known and objectives

The use of enteral tube feeding at home is becoming more widespread, with patients ranging in age and diseases. Dysphagia and swallowing difficulties can compromise nutritional intake and the administration of oral medications, affecting therapeutic outcomes negatively. Carers’ experiences of medicines administration and medicines optimization have not been explored fully. The objectives of this study were to identify issues carers experience in medicines administration; the strategies they have developed to cope; and suggestions to improve the medicines administration process.

Methods

An online survey was promoted nationally; 42 carers completed it. Descriptive statistical analysis was applied, as well as thematic analysis of open‐ended responses. Results were compared against the 4 principles of medicines optimization.

Results and discussion

93% of respondents administered medications with enteral feeding tubes, but only 62% had received advice from healthcare professionals and only 8% had received written information on how to do so. Responses identified 5 medicines administration issues experienced by carers; 4 strategies they developed to cope; and 3 main areas of suggestions to improve medicines administration via enteral feeding at home.

What is new and conclusion

The 4 principles of medicines optimization have not previously been applied to enteral feeding. We present a novel account of carers’ experiences, for example coping with ill‐suited formulations and a lack of training and support, which should inform better practice (Principle 1). Carers sometimes experience suboptimal choice of medicines (Principle 2). Carers’ practices are not always well‐informed and may affect therapeutic outcomes and safety (Principle 3). There is scope for improvement in carer training, education and support to better support medicines optimization (Principle 4).

Drug administration via enteral feeding tube in residential care facilities for individuals with intellectual disability: A focus group study on guideline implementation

People with profound intellectual disabilities often receive medication through enteral feeding tube (EFT). In a previous study, we found that current guidelines concerning medication preparation and administration through EFT are often not followed in residential care facilities (RCFs) for individuals with intellectual disabilities. The present qualitative study aimed to identify barriers and facilitators experienced by RCF staff members to following guidelines on medication administration via EFT, by conducting focus group interviews. Time constraints, lack of knowledge, lack of clear administration instructions, lack of necessary materials, and limited gastric fluid tolerance in certain residents were identified as barriers to following guidelines. Other influencing factors were the number of staff members, residents, and medications; habits; and the residents' comfort and well-being. To optimize care for this vulnerable patient population with EFT, an intervention can be set up focusing on improving staff members' medication-related knowledge and providing clear administration instructions and the necessary materials.

ASPEN Safe Practices for Enteral Nutrition Therapy [Formula: see text]

Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN.

Knowledge of staff members of residential care facilities for individuals with intellectual disability on medication administration via enteral feeding tube

BACKGROUND

Guidelines for the safe administration of drugs through enteral feeding tube (EFT) are an important tool to minimise the risk of errors. This study aimed to investigate knowledge of these guidelines among staff of residential care facilities (RCF) for people with ID.

METHOD

Knowledge was assessed using a 13-item self-administered questionnaire. Questions reflected key aspects of guidelines on medication administration via EFT. All staff members that administer medication through EFT in Belgian RCFs were invited to participate (n = 553).

RESULTS

Nine out of 10 RCFs participated, and 356 questionnaires were collected. Almost all participants were women (96%), and most (82%) had a non-nursing educational background. Mean self-perceived knowledge of medication administration via EFT was 6.7 (on a 0-10 scale). On average, 5.7 (SD 1.9) out of 13 questions were answered correctly. A nursing degree and previous education on medication administration via EFT were associated with significantly higher scores. Guideline recommendations regarding rinsing of used medicine cups (90% correct answers) and preparation of hard gelatin capsules (89%) were known best. Those regarding the use of protective equipment when crushing toxic substances (4% correct answers), crushing of sustained release and enteric-coated dosage forms (6%), elevation of the patient's backrest (14%) and flushing of the EFT (15%) were known the least.

CONCLUSION

This study identified a substantial lack of knowledge of guidelines for drug administration through EFT among staff of RCFs for people with ID. Our findings call for tailored educational programmes in order to increase knowledge on this subject.

Development and evaluation of an algorithm to facilitate drug prescription for inpatients with feeding tubes

PURPOSE

We aimed to develop and evaluate an algorithm to facilitate drug switching between primary and tertiary care for patients with feeding tubes.

METHODS

An expert consortium developed an algorithm and applied it manually to 267 preadmission drugs of 46 patients admitted to a surgical ward of a tertiary care university hospital between June 12 and December 2, 2013, and requiring a feeding tube during their inpatient stay.

RESULTS

The new algorithm considered the following principles: Drugs should be ideally listed on the hospital drug formulary (HDF). Additionally, drugs should include the same ingredient instead of a therapeutic equivalent. Preferred dosage forms were appropriate liquids, followed by solid drugs with liquid administration form, and solid drugs that could be crushed and/or suspended. Of all evaluated drugs, 83.5% could be switched to suitable drugs listed on the HDF and another 6.0% to drugs available on the German drug market. Additionally, for 4.1% of the drugs, the integration of individual switching rules allowed the switch from enteric-coated to immediate-release drugs. Consequently, 6.4% of the drugs could not be automatically switched and required case-to-case decision by a clinical professional (e.g., from sustained-release to immediate-release).

CONCLUSIONS

The predefined principles were successfully integrated in the new algorithm. Thus, the algorithm switched more than 90% of the evaluated preadmission drugs to suitable drugs for inpatients with feeding tubes. This finding suggests that the algorithm can readily be transferred to an electronic format and integrated into a clinical decision support system.