Desenvolvimento e avaliação de tecnologia educacional digital sobre segurança na administração de medicamentos por sonda enteral / Development and evaluation of digital educational technology on safety in enteral tube administration

As Tecnologias da Informação e Comunicação (TIC) são reconhecidas como ferramentas que estimulam o senso crítico, a reflexão e a autonomia na formação profissional em enfermagem, enquanto estratégia para fortalecimento da cultura de qualidade e segurança, visando à prevenção de incidentes relacionados à administração de medicamentos por sonda enteral. Este estudo retrata uma pesquisa de desenvolvimento ou Design-Based Research (DBR), com objetivo de desenvolver e avaliar uma tecnologia educacional sobre a temática de segurança na administração de medicamentos por sonda enteral. O Ambiente Virtual de Aprendizagem (AVA) foi desenvolvido em três etapas: 1) Planejamento; 2) Desenvolvimento e 3) Avaliação. Na Etapa 1, o planejamento contempla a caracterização do público-alvo, definição da temática e dos objetivos a serem alcançados. A Etapa 2 corresponde ao desenvolvimento da Tecnologia Educacional utilizando a metodologia WebQuest (Introdução, Tarefa, Processo, Avaliação, Conclusão e Créditos). Na Etapa 3 foi realizada a avaliação da tecnologia educacional digital por cinco profissionais da área de Informática e cinco enfermeiros docentes, mediante aprovação do projeto junto ao Comitê de Ética em Pesquisa. A pesquisa resultou no desenvolvimento de uma WebQuest curta sobre a temática de segurança do paciente, com enfoque na proposta de ações estratégicas visando a prevenção de erros e incidentes relacionados à administração de medicamentos por sonda enteral. A avaliação dos aspectos pedagógicos indicou que as características foram plenamente alcançadas em relação à Pertinência, Aplicabilidade e Consistência do Conteúdo; Interação Aluno-aluno, Aluno-grupo, Aluno-professor e Grupo-Professor; Pertinência, Quantidade e Avaliação Educacional das Atividades. Na avaliação dos aspectos técnicos, as características foram plenamente alcançadas em relação às Cores (Qualidade da Interface), segundo a opinião de todos os especialistas em enfermagem e em informática. As contribuições dos especialistas em relação às características parcialmente alcançadas e não alcançadas permitiram a realização de ajustes para implementação futura junto a estudantes do curso técnico em Enfermagem. Vale destacar que não foram relatadas características não alcançadas em relação aos aspectos pedagógicos. Os resultados evidenciam a relevância do domínio dos atributos próprios da WebQuest, visando a superação dos desafios relacionados ao desenvolvimento do pensamento crítico e aplicação de conhecimentos na solução de problemas vivenciados na busca por maior qualidade e segurança na assistência ao paciente, compatíveis com a exigências de ampliação do uso de tecnologias educacionais digitais inovadoras na formação profissional em enfermagem

Information and Communication Technologies (ICT) are recognized as tools that stimulate critical thinking, reflection and autonomy in professional nursing training, as a strategy to strengthen the culture of quality and safety, in order to prevent incidents related to the administration of medicines for enteral tube. This study describes a development research or Design-Based Research (DBR) aiming to develop and evaluate an educational technology on the theme of safety in the administration of medicines by enteral tube. The Virtual Learning Environment (VLE) was developed in three stages: 1) Planning; 2) Development and 3) Evaluation. In Step 1, the planning contemplates the characterization of the target audience, definition of the theme and the objectives to be achieved. The Step 2 corresponds to the development of Educational Technology using the WebQuest methodology (Introduction, Task, Process, Evaluation, Conclusion and Credits). In Step 3, the evaluation of the digital educational technology was carried out by five professionals in the area of Informatics and five nursing professors, after approval of the project by the Research Ethics Committee. The research resulted in the development of a short WebQuest on the subject of patient safety, with a focus on the proposal of strategic actions aimed at the prevention of errors and incidents related to the administration of medicines by enteral tube. The evaluation of pedagogical aspects indicated that the characteristics were fully achieved in relation to the Relevance, Applicability and Consistency of Content; Student-student interaction, Student-group, Student-teacher and Group-Teacher; Relevance, Quantity and Educational Evaluation of Activities. In the evaluation of the technical aspects, the characteristics were fully achieved in relation to the Colors (Quality of Interface), according to the opinion of all specialists in nursing and computer science. The experts' contributions in relation to the partially achieved and unrealized characteristics allowed to make adjustments for future implementation with students of the technical course in Nursing. It is worth mentioning that there were no reported unrealized characteristics in relation to the pedagogical aspects. The results highlight the relevance of the domain of WebQuest attributes, aiming to overcome the challenges related to the development of critical thinking and application of knowledge in the solution of problems experienced in the search for higher quality and safety in patient care, compatible with the requirements of expansion of the use of innovative digital educational technologies in nursing professional training

Enteral Feeding Set Handling Techniques.

BACKGROUND: Enteral nutrition therapy is common practice in pediatric clinical settings. Often patients will receive a pump-assisted bolus feeding over 30 minutes several times per day using the same enteral feeding set (EFS). This study aims to determine the safest and most efficacious way to handle the EFS between feedings. METHODS: Three EFS handling techniques were compared through simulation for bacterial growth, nursing time, and supply costs: (1) rinsing the EFS with sterile water after each feeding, (2) refrigerating the EFS between feedings, and (3) using a ready-to-hang (RTH) product maintained at room temperature. Cultures were obtained at baseline, hour 12, and hour 21 of the 24-hour cycle. A time-in-motion analysis was conducted and reported in average number of seconds to complete each procedure. Supply costs were inventoried for 1 month comparing the actual usage to our estimated usage. RESULTS: Of 1080 cultures obtained, the overall bacterial growth rate was 8.7%. The rinse and refrigeration techniques displayed similar bacterial growth (11.4% vs 10.3%, P = .63). The RTH technique displayed the least bacterial growth of any method (4.4%, P = .002). The time analysis in minutes showed the rinse method was the most time-consuming (44.8 ± 2.7) vs refrigeration (35.8 ± 2.6) and RTH (31.08 ± 0.6) ( P < .0001). CONCLUSIONS: All 3 EFS handling techniques displayed low bacterial growth. RTH was superior in bacterial growth, nursing time, and supply costs. Since not all pediatric formulas are available in RTH, we conclude that refrigerating the EFS between uses is the next most efficacious method for handling the EFS between bolus feeds.

Preparo e administração de medicamentos por sondas enterais pela enfermagem em pacientes com nutrição enteral: propostas para garantir o manejo correto / Preparation and administration of medications through enteral probes by the nursing in patients on enteral nutrition: proposals to guarantee the correct handling

O objeto de pesquisa foi o padrão de preparo e administração de medicamentos por sondas enterais pela enfermagem em pacientes que recebem concomitante infusão de nutrição enteral. Os objetivos foram: identificar quais foram os medicamentos e suas formas farmacêuticas administrados por sondas enterais na Terapia Intensiva, medir o tipo, frequência e chance de erros no manejo de medicamentos de acordo com a forma farmacêutica e construir um elenco de propostas que possa garantir o manejo correto de medicamentos administrados por sondas enterais.Tratou-se de uma pesquisa com desenho transversal de natureza observacional, prospectivo, sem modelo de intervenção. Foi desenvolvida em um hospital do Rio de Janeiro onde foram observados técnicos de enfermagem preparando e administrando medicamentos por sondas enterais na Unidade de Terapia Intensiva. Foram observadas 720 doses de medicamentos sendo preparados e administrados. Os grupos de medicamentos prevalentes foram os que agem no Sistema Cardiovascular Renal (40,55%), seguido pelos que agem no Sistema nervoso (19,85%). As categorias de erro no preparo foram trituração e diluição. Encontrou-se uma taxa de 100% de tritura indevida para comprimidos revestidos e cápsulas de gelatina dura. A diluição insuficiente ocorreu em 100% das doses de xaropes. A tritura insuficiente para comprimidos simples teve uma taxa de 54%. O erro prevalente foi o de diluição, 84%, para medicamentos líquidos. O erro prevalente foi o de tritura para os medicamentos sólidos. Os erros na administração foram manejo indevido da sonda enteral e ausência de pausa. A ausência de lavagem da sonda enteral antes e entre foi o erro mais comum (95%) e em quase 90% das doses não houve pausa para administrar os medicamentos. Observa-se que além dos medicamentos serem administrados sem a tritura adequada, também não houve a lavagem da sonda antes da administração nem a pausa de 15 minutos, reunindo-se condições favoráveis à obstrução da sonda. O preparo e administração inadequados de medicamentos podem levar a perdas na biodisponibilidade, diminuição do nível sérico e riscos de intoxicações para o paciente. Com base nos principais erros encontrados foi construído um elenco de estratégias para diminuir os erros. Para tritura indevida, foram propostas etiquetas que identificam os medicamentos que não podem ser triturados e criado um quadro com as principais siglas identificadoras de medicamentos de liberação controlada. Para o erro de não lavar as sondas foram propostos treinamentos com as equipes de enfermagem. Para pausa foi criado uma lista de medicamentos que necessitam de interrupção da nutrição enteral. Já para tritura insuficente foi criada uma lista de medicamentos alternativos na forma líquida e realização de treinamento relacionado à técnica de preparo. Com este estudo tornou-se evidente que a compreensão apropriada dos fatores que influenciam a terapia medicamentosa por sondas enterais é indispensável para o enfermeiro no que tange à segurança da assistência ao paciente crítico em uso de sondas enterais para nutrição enteral.

The research object was the standard of preparation and administration of medications through enteral probes by the nursing on patients who receive concomitant infusion of enteral nutrition. The objectives were: identify the medications and its dosage forms administered through enteral probes in the Intensive Therapy, measure the type, frequency and possibility of errors in the handling of medications in accordance with the dosage form and make a set of proposals that can guarantee the correct handling of medications administered through enteral probes. It was about a research with transversal drawing in an observationalnature, prospective, without intervention model. It was developed in a hospital of Rio de Janeiro where they observed nursing technicians preparing and administering medications through enteral probes at the Intensive Therapy Unit. Were observed 720 doses of medications being prepared and administered. The prevalent medication groups were the ones that act in the renal cardiovascular system (40.55%), followed by the ones that act in the nervous system (19.85%). The error categories were trituration and dilution. Was found a 100% rate of improper trituration for coated tablets and hard gelatin capsules. The insufficient dilution occurred in 100% of the syrup doses. Insufficient trituration for single tablets had a 54% rate. The prevalent error was dilution 84%, for liquid medications. The prevalent error was trituration for solid medications. The errors in the administration were improper handling of the enteral probes and absence of pause. The absence of rinsing of the enteral probes before and between was the most common error (95%) and in almost 90% of the doses there was no pause to administer medications. It was observed that in addition medications being administered without adequate trituration, also there was neither the rinsing of the probe before the administration nor the 15 minutes pause, gathering favorable conditions to the obstruction of the probe. The inadequate preparation and administration of medications may lead to losses in bioavailability, decrease of the serum level and risk of intoxication for the patient. Based on the main errors found, a set of strategies were built to reduce errors. For improper trituration, were proposed labels to identify the medications that cannot be triturated and created a table with the main acronyms identifying controlled release medications. Already for insufficient trituration, a list of alternative medications in liquid form was created and conducting training related to the preparation technique. With this study it became evident that the proper understanding of the factors influencing drug therapy by enteral probes is indispensable for the nurse in regard to the safety of a critical patient care on the usage of enteral probes for enteral nutrition

[Influence of nutrition product type on a tube feeding administrative task man-hour and the contents of nursing].

AIM: The purpose of this study is to consider the influence which the form of tube feeding nutrition products has on meal delivery operating man-hours, personnel expense, and the quality of nursing. In addition, it is also considers operational efficiency improvement. METHODS: We used liquid nutrition material packaged in a paper container before we changed the nutrition product. After the change of the nutrition product, semi-solid nutrition with ready to hang (RTH) moderately viscous nutrition was used. We investigated the tube feeding administrative task and the contents of nursing using the Industry Engineering technique. RESULTS: We were able to reduce by half the man-hours required for 1 morning tube feeding in 238.1 minutes to 106.1 minutes by changing to RTH semi-solid nutrition. Thereby, we were able to reduce personnel expenses by 514,290 yen per month. The total man-hours which could be spent on nursing increased to 170 from 139. CONCLUSIONS: By using the RTH semi-solid nutrition with moderate viscosity, the operating efficiency of tube feeding management has improved greatly. As a result, the time which can be spent on nursing increased.

Valoración de la efectividad del soporte nutricional por sonda nasogástrica en sala general / Assessment of the efficacy of nasogastric nutritional support in a general ward / Valorização da efetividade do suportenutricional por sonda nasogástricaem enfermaría

La interrupción de la alimentación enteral conduce a un aporte calórico inadecuado, circunstancia que se agrava debido al estado catabólico que presentan los pacientes internados, contribuyendo ambas situaciones al deterioro de su estado nutricional. La malnutrición calóricoproteica se asocia con un mayor número de complicaciones, con un incremento de la estadía hospitalaria y, por lo tanto, con mayores costos. Objetivos. Evaluar la calidad del soporte nutricional por sonda y cuáles son los factores que influyeron en las diferencias entre la cantidad de nutrientes administrados, pautados y teóricamente requeridos. Material y métodos. Pacientes adultos a quienes se les prescribía nutrición enteral por sonda nasogastro/enteral. Se calcularon diariamente las calorías pautadas y las administradas, mientras que los requerimientos calóricos teóricos se calcularon según la ecuación de Harris-Benedict a la que se le aplicaba un factor de estrés y actividad. Asimismo, se evaluaron las causas por las que se interrumpió la nutrición enteral. Resultados. De un total de 40 pacientes consecutivos que recibieron soporte nutricional enteral un 95% presentó administración inadecuada. Hubo una inadecuación de la prescripción médica de la alimentación enteral en un 70% relacionado con el requerimiento calórico total. El bajo ratio de calorías administradas-pautadas afectaban a la Nutrición Enteral, debido a las causas más importantes de interrupción (que acumulan el 80% de las interrupciones):a) relacionadas al personal de enfermería (32.5%), b) incumplimiento en el horario de entrega del alimento (20%), c) problemas mecánicos (12.5%), d) procedimientos diagnósticos (10%) y e) disfunción gastrointestinal(10%). Conclusiones. En nuestra unidad se observó una diferencia importante entre los requerimientos calóricos teóricos y la cantidad efectivamente administrada. El conocimiento de esta situación permitirá ...

Background. The interruption of enteral feeding leads to inappropriate caloric intake, circumstance aggravated by the catabolic state of inpatients and both factors contributing to the deterioration of their nutritional status.Protein-energy malnutrition is associated with more complications, increased hospital stay, and therefore higher costs.Objective. To evaluate the quality of enteral nutritional support and the factors influencing the differences between the amounts of nutrients managed, scheduled and theoretically required.Materials y methods. Adult patients prescribed enteral nutrition by nasogastric/enteral tube. The calories administered and estimated were daily calculated, while theoretical caloric requirements were calculated according to the Harris-Benedict equation with an applied factor of stress and activity. The reasons leading to enteral nutrition cessationwere also evaluated.Results. Of the 40 consecutive patients who received enteral nutritional support, 95% reported inadequate administration. There was an inadequate medical prescription of enteral feeding by 70%, related to total caloric requirements. The low ratio of calories prescribed-administered affected enteral nutrition due to the following main causes of interruption (which accumulate 80% of interruptions): nurses/' work (32.5%), failure in the delivery of the scheduled food (20%), mechanical problems (12.5%), diagnostic procedures (10%) and gastrointestinal dysfunction (10%). Conclusions. In our unit we could observe an important difference between the theoretical energy requirements and the amounts effectively administered. Acknowledging...

A interrupção da alimentação enteral conduza uma contribuição calórica inadequada, circunstância que se agrava devido o estado catabólico que apresentamos pacientes internados, contribuindo ambas as situaçõespara a deterioração do seu estado nutricional. A má nutriçãocalórica-proteica é associada a um maior número decomplicações, com um incremento da estadia hospitalariae, portanto, com maiores custos.Objetivos. Avaliar a qualidade do suporte nutricional porsonda e quais são os fatores que influenciaram nas diferençasentre a quantidade de nutrientes administrados, determinadose teoricamente requeridos.Material e métodos. Pacientes adultos que recebiam prescriçãonutricional enteral por sonda nasogastroenteral. Foramcalculadas diariamente as calorias determinadas e asadministradas enquanto que os requerimentos calóricoseram calculados segundo a equação de Harris-Benedictna qual se aplicava um fator de estresse e atividade. Alémdisso, foram avaliadas as causas pelas quais a nutriçãoenteral foi interrompida.Resultados. De um total de 40 pacientes ...

Safe, timely, convenient, and cost-effective: a single-center experience with bedside placement of enteral feeding tubes by midlevel providers using fluoroscopic guidance.

BACKGROUND: Enteral feeding tube placement has been performed by nurses, gastroenterologists using endoscopy, and interventional radiologists. We hypothesized that midlevel providers placed feeding tubes at bedside using fluoroscopy safely, rapidly, and cost-effectively. METHODS: We retrospectively analyzed bedside feeding tube placement under fluoroscopy by trained nurse practitioners. We compared charges for this method with charges for placement by other practitioners. RESULTS: Nurse practitioners placed 632 feeding tubes in 462 patients. Three hundred seventy-nine placements took place in mechanically ventilated placements. Ninety-seven percent of tubes were positioned past the pylorus. The mean fluoroscopy time was 0.7 ± 1.2 minutes. The mean procedure time was 7.0 ± 5.1 minutes. All tubes were placed within 24 hours of the request. There were no complications. Institutional charges for tube placement were $149 for nurse practitioners, $226 for gastroenterologists, and $328 for interventional radiologists. CONCLUSIONS: The placement of feeding tubes under fluoroscopy by nurse practitioners is safe, timely, and cost-effective.

Bedside assessment of enteral tube placement: aligning practice with evidence.

Since the flexible Levin tube was introduced in 1921, enteral feeding has become ubiquitous. From the out-set, nurses have been responsible for confirming the correct placement of enteral feeding tubes prior to their use for alimentation or medication administration, but current nursing practice doesn't always reflect the best evidence. Although research has established the inadequacy of auscultation to determine proper tube placement, this method is still commonly practiced. The authors examine the research that's been conducted over the past 25 years and compare the accumulated evidence with current practice, as reflected in a convenience sample of 28 New England hospitals. In addition, they evaluate various methods for assessing enteral feeding tubes and make evidence-based practice recommendations.

Families with children who are technology dependent: normalization and family functioning.

This cross-sectional study examined family functioning and normalization in 103 mothers of children ≤16 years of age dependent on medical technology (mechanical ventilation, intravenous nutrition/medication, respiratory/nutritional support) following initiation of home care. Differences in outcomes (mother's depressive symptoms, normalization, family functioning), based on the type of technology used, were also examined. Participants were interviewed face-to-face using the Demographic Characteristics Questionnaire, the Functional Status II-Revised Scale, the Center for Epidemiological Studies-Depression Scale, a Normalization Scale subscale, and the Feetham Family Functioning Survey. Thirty-five percent of the variance in family functioning was explained primarily by the mothers' level of depressive symptoms. Several variables were significant predictors of normalization. Analysis of variance revealed no significant difference in outcomes based on the type of technology used. Mothers of technology-dependent children are at high risk for clinical depression that may affect family functioning. This article concludes with clinical practice and policy implications.

Nursing practice of checking gastric residual volumes based on old dogmas: opportunity to improve patient care while decreasing health care costs.

It is a common practice to check gastric residual volumes (GRV) in tube-fed patients in order to reduce the risk of aspiration pneumonia. However, there is a paucity of scientific evidence to support this practice which consumes significant amounts of health care resources. We conducted a survey of the nursing practice of GRV checks in our hospital as part of a systems improvement project using a standardized questionnaire in a single hospital setting. The questionnaire included questions about the practice of checking GRV including what constituted "high" GRV and adherence to physician orders. We observed a wide variation in the responses of the practice of management of GRV. All the nurses in our hospital checked GRV, whether or not there were physician orders. Nurses' responses to "high GRV" varied from 100 mL to 200 mL at which point they would withold feedings. Some, but not all nurses, would report the "high GRV" and witholding of feedings to the physicians. The wide variation of gastric residual checks, including unnecessary checks and withholding feedings, observed above not only increased health care costs but also has the potential to impact patient outcomes. This calls for a standardized evidence based tube-feeding protocol to check GRV and should be an integral part of hospital policy. For the benefit of the readers, we present the GRV check protocol instituted in our hospital which, based on anecdotal reports, is resulting in decreased interruptions of feedings to our patients and reducing the nursing time consumed, thus potentially decreasing health care costs.

Home enteral nutrition NICE guidelines and nutrition support in primary care.

The Home Enteral Nutrition team provides support to patients who are being fed via enteral feeding tube in the community. The use of the recently developed policy in combination with the National Institute for Clinical Excellence (NICE) guideline on nutrition support will change the way care is provided to patients and enhance service delivery. However, there are difficulties in the implementation of policies and guidelines which often militate against the delivery of high standard of care. This paper was an attempt to apply the Kotter's eight-step change management model in the implementation of the HEN team policy and NICE guideline on nutrition support through training of district nurses, liaison with colleagues and carrying out a clinical audit. The clinical audit was aimed at institutionalizing the new approach for the delivery of quality care. The Kotter's model recognized the urgency needed and it enabled the building of coalitions that is essential in meeting the desired standard in today's NHS.

Enteral tube feeding--from hospital to home.

There are a number of benefits to providing home enteral feeding, however, problems can occur if care is not taken to arrange training and after-care appropriately. It is therefore essential to facilitate an informed and thorough transfer of care to minimize potential problems. This article will address some of the issues that arise when patients who require home enteral feeding are discharged from hospital to their own homes or to care homes. These issues include the knowledge that is required to enable the patient and/or carer to safely manage their feeding tube, the feeding regimen, the continuing support required from health-care professionals, and some of the more common problems that may arise.

Changing from oral to enteral feeding: impact on families of children with disabilities.

The number of children in the U.K. who are being fed enterally at home is increasing. Feeding by nasogastric or gastrostomy tube may not seem particularly abnormal to nurses who care for sick children. However, the initiation of tube feeding can have a significant impact on both the child and the family. Research related to children with disabilities who have feeding problems is focused around the views of their mothers because they are often the main carers of these children. However, eating is a social activity in our society and tube feeding will have an effect on other members of the family. To provide adequate support, nurses need to understand the nature and scale of the impact that continuing with oral feeding or changing to gastrostomy feeding has on the whole family.

Home enteral feeding: part 2 current issues in community practice.

Part 1 provided an overview of enteral tube feeding and management in the community. Due to the limited evidence base there are many aspects of the practical management of patients on home enteral tube feeding (HETF) that has as yet not been standardized, particularly around issues such as the type of syringes and water that should be used in HETF. There are also some areas where the guidelines are clear but difficult to apply in the community (such as with maximum feed 'hanging times') or where further guidance is required (such as for confirming the position of nasogastric tubes in patients on acid-reducing therapy). Finally, as NHS trusts look at further ways to save money, enteral feeding is being increasingly scrutinised and needs to be carefully managed, with the involvement of healthcare professionals who understand patient needs and the commercial HETF market. This article is based on personal views and local discussions about the issues in question and, until further research and national standards are available, are subject to local interpretation.

The impact of HETF for adults with neurological conditions.

The number of patients receiving home enteral tube feeding (HETF) in the UK is growing, despite little evidence that it improves survival or quality of life in many cases. There is also little work that has been done to explore the emotional impact of this invasive procedure on patients or carers. This article draws on a literature review to highlight some of the issues that may arise with patients receiving HETF, focusing particularly on the largest group of these patients: those with neurological conditions. The literature shows that emotional adjustments are required for both patient and carers following the placement of a percutaneous endoscopic gastrostomy. Therefore consideration of the likely emotional and psychological consequences of home enteral tube feeding has implications for clinical practice during the decision-making process for appropriate patient selection. There is a need for community nurses to consider these issues and ensure appropriate support is provided for patients and their carers.