Microbiome profile informs cleansing and storage practices for reusable feeding tube stylets in critical care.

BACKGROUND: Cleansing and storage practices for reusable feeding tube stylets are varied and lack consensus guidelines. Almost 40% of critical care nurses do not cleanse reusable stylets. Our proof-of-concept study aimed to identify potential microbial contamination of stylets before and after cleansing with 70% isopropyl alcohol to establish practice standards. METHODS: This prospective, exploratory pilot study sampled reusable feeding tube stylets using three different stylet sample sets. Set 1 included human participant stylets sampled for microbiome profile precleansing, and postcleansing and reinsertion into feeding tubes (n = 4). Sets 2 and 3 included stylets stored at the bedside. Set 2 included precleansed stylets for microbiome profiles (n = 5). Set 3 included precleansed and postcleansed stylets sampled for quantitative cultures (n = 5). Careful handling and storage protocols were used. Microbiome profiling used 16s ribosomal RNA gene amplicon sequencing. RESULTS: Bacterial species identified on stylets were primarily common microflora and opportunistic pathogens, including Streptococcus pneumoniae, Staphylococcus aureus, Pseudomonas fulva, Cutibacterium acnes, Prevotella melaninogenica, and Lactobacillus paracasei. Microbiological culturing of stylet samples (set 3) did not yield growth for 9/10 samples; Staphylococcus capitis was identified in one postcleansed sample. Mean bacterial species diversity (alpha diversity) decreased following alcohol cleansing (M = 2.54 pre, M = 1.5 post; P = 0.006). CONCLUSION: The abundance of several potentially opportunistic pathogens indicated plausible risk for gut contamination secondary to reinsertion of stylets into small-bore feeding tubes. Stylet cleansing with 70% isopropyl alcohol reduced bacterial burden on the stylets, although viability was unknown. Careful cleansing, handling, and storage protocols for reusable stylets are necessary to minimize contamination.

Migration of Feeding Tubes Assessed by Using an Electromagnetic Device: A Cohort Study.

BACKGROUND: Bedside methods to verify placement of a feeding tube are not accurate for detecting placement within the gastrointestinal tract, increasing risk of pulmonary aspiration. Current guidelines recommend verifying placement every 4 hours, yet the rationale for this recommendation is unknown. OBJECTIVE: To assess spontaneous migration of small-bore feeding tubes in critically ill adults. METHODS: A prospective, repeated-measures cohort study was performed in 2 intensive care units. An electromagnetic placement device was used to assess distal feeding tube location every 24 hours for 7 days. Tube migration between zones-esophageal, gastric, and postpyloric- was considered clinically significant. RESULTS: Feeding tubes were analyzed in 20 patients. Interrater agreement was substantial for round 2 of a blinded analysis of insertion tracings (g = 0.78); 100% agreement was achieved after unblinding. Among 62 outcomes (migration assessments), 4 feeding tubes migrated 8 times (3 forward and 5 retrograde). All migrations occurred in the postpyloric zone and none were clinically significant. Within 24 hours of insertion, 50% of feeding tubes had migrated forward. Repeated-measures analysis showed a greater likelihood of migration in patients with an endotracheal tube (relative risk, 3.46 [95% CI, 1.14-10.53]; P = .03). CONCLUSIONS: No tubes migrated retrograde into the stomach or esophagus, challenging the practice of verifying placement every 4 hours. Verification every 24 hours may be adequate if migration is not suspected. Also, lack of visible anatomical structures on insertion tracings from an electromagnetic placement device make subtle changes in postpyloric placement difficult to identify accurately.

National Survey of Feeding Tube Verification Practices: An Urgent Call for Auscultation Deimplementation.

BACKGROUND: Harm events such as pneumothoraces and pneumonia continue to be associated with feeding tube insertion. Most bedside verification methods are not accurate to discriminate pulmonary from gastrointestinal system. Evidence-based clinical practice guidelines do not support auscultation of feeding tubes in adults, yet auscultation is the most common method used. OBJECTIVES: Our survey assessed national feeding tube verification practices used by critical care nurses, including progress in auscultation method deimplementation, and stylet reinsertion and cleansing practices. METHODS: A national survey of 408 critical care nurses was performed. RESULTS: The majority performed auscultation (311 of 408 [76%]) to verify feeding tube placement. In the final multivariable model, nursing education, facility type, observation of colleagues performing auscultation, and awareness of an institutional policy were associated with auscultation of feeding tubes. Thirty-five percent used enteral access devices to verify initial feeding tube placement. Stylet cleansing methods were variable; 38% of reinserted stylets were not cleansed. DISCUSSION: Minimal progress has been made in deimplementation of auscultation in the past 7 years despite passive knowledge dissemination in research articles, clinical practice guidelines, and procedure manuals. Although pH measure is used as a first-line feeding tube verification method in the United Kingdom, it is rarely used in the United States. Clinical practice guidelines should be updated to incorporate new research on enteral access systems. CONCLUSIONS: Tradition-based practices such as auscultation and certain stylet cleansing methods should be deimplemented. A focused interdisciplinary, multifaceted program is needed to deimplement auscultation practice for adult feeding tubes.

Pneumothoraces Prevented With Use of Electromagnetic Device to Place Feeding Tubes.

BACKGROUND: A US Food and Drug Administration safety letter warned about the risk for pneumothoraces during feeding tube insertion despite the use of electromagnetic placement devices that provide real-time visualization of feeding tube position. OBJECTIVES: To systematically assess pulmonary placement and pneumothoraces in CORTRAK-assisted feeding tube insertions. METHODS: CINAHL, MEDLINE, and Cochrane databases were searched for studies of CORTRAK-assisted feeding tube insertion. Thirty-two studies documenting pulmonary placement and/or complications of feeding tube insertion were found. RESULTS: Operators recognized pulmonary placement on insertion tracings during 202 CORTRAK-assisted feeding tube insertion procedures, resulting in the immediate withdrawal of 199 feeding tubes. One pneumothorax was identified later by radiography. Seven pulmonary placements were not recognized by CORTRAK operators at the time of feeding tube insertion, resulting in 2 pneumothoraces. The incidence of pneumothorax for CORTRAK-assisted feeding tube insertions was 0.02% (3 of 17039). Of the feeding tubes inserted into the pulmonary system - either found during or after the procedure -1.4% (3 of 209) resulted in pneumothoraces (as opposed to the 19% to 28% incidence of pneumothorax for blind feeding tube insertions. Operators recognizing pulmonary placement on CORTRAK insertion tracings may have prevented 97% (202 of 209) of feeding tubes from being inserted farther into the respiratory tract. CONCLUSIONS: Feeding tube insertion with an electromagnetic placement device is advantageous over blind feeding tube insertion because the operator can recognize pulmonary placement early and withdraw the feeding tube, thus decreasing the risk of pulmonary complications.

CORTRAK Superuser Competency Assessment and Training Recommendations.

BACKGROUND: Blind insertion of feeding tubes remains unsafe. Electromagnetic placement devices such as the CORTRAK Enteral Access System allow operators to interpret placement of feeding tubes in real time. However, pneumothoraces have been reported and inadequate user expertise is a concern. OBJECTIVE: To explore factors influencing competency of CORTRAK-assisted feeding tube insertion. METHODS: A prospective, observational pilot study was conducted. Data collection included demographics, self-confidence, clinical judgment regarding CORTRAK-assisted feeding tube insertion, and general self-efficacy. CORTRAK-assisted feeding tube insertions were performed with the Anatomical Box and CORMAN task trainers. RESULTS: Twenty nurses who had inserted a mean of 53 CORTRAK feeding tubes participated. Participants inserted a mean of 2 CORTRAK feeding tubes weekly; each had inserted a feeding tube in the past 7 days. All superusers were competent; 1 required remediation for improper receiver unit placement. Mean (SD) scores were 35 (3.68) on a 40-point scale for self-efficacy, 4.6 (0.68) on a 5-point scale for self-reported feeding tube insertion confidence, and 4.85 (0.49) on a 5-point scale for demonstrated confidence. Participants estimated that 8 CORTRAK-assisted insertions were needed before they felt competent as super users. Confidence with the CORTRAK tracing was estimated to require 10 feeding tube insertions. Six participants continued to assess placement by auscultation, suggesting low confidence in their interpretation of the tracing. CONCLUSIONS: At least 3 observations should be performed to assess initial competency; the number should be individualized to the operator. Interpretation of the insertion tracing is complex and requires multiple performance opportunities to gain competency and confidence for this high-risk skill.

Improved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device.

BACKGROUND: Early enteral nutrition has been shown to decrease complications and improve patient outcomes. Post pyloric feeding is recommended for patients with gastric intolerance or at high risk for aspiration. Feeding tube placement can be challenging and pose risk of pulmonary complications. Reliance on radiographic confirmation for feeding tube placement exposes the patient to radiation. Electromagnetic placement device (EMPD) may offer a method to minimize pulmonary complications, increase successful placement, and decrease radiation exposure to the patient. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of using EMPD verification, instead of routine abdominal radiographic confirmation, for small-bore feeding tube placement. RESULTS: Variables evaluated were adverse events, utilization of radiographs for confirmation, and success rate of feeding tube placement in the ordered location. Two time frames were reviewed. In a 1-year period, 3754 small-bore feeding tubes were placed using EMPD, with zero adverse events noted. Radiographic confirmation was utilized in 0%-29.2% of the EMPD placed tubes. Successful placement of feeding tubes using EMPD ranged from 94%-99.6%. During a 5-year period, 7081 EMPD feeding tubes were evaluated. One adverse event, pneumothorax, occurred during the placement of these 7081 tubes, for a rate of 0.014%. CONCLUSION: Feeding tube placement confirmation is safe and efficacious via EMPD providing an effective method of feeding tube placement with a success rate >94% into the desired location. EMPD is an accurate verification method of distal tip location, eliminating the need for routine abdominal radiographic confirmation.

Varying levels of fidelity on psychomotor skill attainment: a CORTRAK product assessment.

Background: A task trainer is defined as a model that represents a part or region of the human body such as an arm and an abdomen… generally used to support procedural skills training. Concepts for consideration when selecting a task trainer include fidelity and cognitive load. Insertion of small - bore FTs in acutely ill patients continues to be a high - risk skill. The most frequent complication is insertion of the F T into the pulmonary system, which can lead to pneumothorax, pneumonitis and death. Training consists of placing the FT under electromagnetic visual assistance in a task trainer. Objective: This study describes assessment of two task trainers that are used to simulate assisted feeding tube (FT) insertion. Simulation is an excellent approach to close the learning gap and ensure competency. Study selection: This study used a prospective observational design. Participants (n=20) were registered nurses considered to be superusers. They were randomly assigned to order of the task trainer. Findings and conclusions: The findings suggest the learners preferred the low-fidelity task trainer. The clear Anatomical Box scored higher overall (18.35/21) when compared with the human-like task trainer (16.5/21). A higher fidelity task trainer may seem attractive; however, with a lens to cognitive load theory, it may hinder the early learning process. Fidelity requirements vary depending on the training task. Recommendations from this study include: initial instruction should focus on the psychomotor steps for the FT insertion process. The high-fidelity human torso is recommended for performance, final competency and ongoing competency maintenance.

Cortrak-Assisted Feeding Tube Insertion: A Comprehensive Review of Adverse Events in the MAUDE Database.

BACKGROUND: Electromagnetic devices to guide feeding tube placement such as the CORTRAK Enteral Access System have shown promising results; however, researchers in recent studies have expressed concern that a higher level of user expertise may be required for safe use. OBJECTIVES: To review adverse events related to CORTRAK-assisted feeding tube insertion reported in the Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database. METHODS: A retrospective, secondary analysis of the MAUDE database was performed to evaluate adverse events (ie, injury or death of patient) related to CORTRAK. RESULTS: Fifty-four adverse events between January 1, 2006 and February 29, 2016 were identified and reviewed. Most events (98%) involved feeding tube placement in the lungs (37%, left lung; 46%, right lung; 15%, not specified). Lung complications included pneumothorax (77%) and pneumonitis (21%). Death occurred in 17% of lung placements. Clinicians failed to recognize placement in 89% of CORTRAK insertion tracings reviewed. CONCLUSIONS: Lung placement is not unique to CORTRAK and is an inherent risk of all feeding tube insertions. In known or suspected lung placement, feeding tubes should be removed and radiography performed to assess for pneumothorax. Clinicians must observe closely for lung placement and discriminate lung from gastric placement on insertion tracings. Clinicians require specialized training and experience to develop competency in using the CORTRAK device, although the exact amount of experience needed is unknown.

Finding the right fit: implementation of a structured interviewing process for clinical nurse specialists.

PURPOSE AND BACKGROUND: The purpose of this article is to describe how clinical nurse specialists (CNSs) in one organization developed a structured interviewing process for CNS candidates. The process has evolved in relation to implementation of national CNS competencies, growth of the role in the organization, and changes to reporting structure. OUTCOMES: The CNS interview process includes panel interviews with various organizational leaders, CNSs, and team members. A behavioral-based tool relevant to the CNS role is used. Involving CNS peers in the interview ensures the successful hiring and retaining of suitable candidates. Clinical nurse specialists who were interviewed using the current peer interview procedure have reported satisfaction with the experience. IMPLICATIONS: Peer interviews for CNSs provide a forum for meaningful dialogue about the CNS role, competencies, and fit with the organization. This process can be used for other advanced practice disciplines.