August 2014

Infection Prevention

IP Update

Malnutrition screening of hospital patients common but hospitals failing on nutrition care

A new study gives hospitals overall good marks for conducting nutrition screenings within 24 hours of a patient’s admission, but finds that many need to improve other practices to be more effective.

The study, conducted by the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) and published today in A.S.P.E.N’s Nutrition in Clinical Practice journal, found that while most respondents said that screening patients for malnutrition was being done in compliance with The Joint Commission mandate of 1995, fewer than half were familiar with the 2012 Consensus Statement from the Academy of Nutrition and Dietetics/A.S.P.E.N., which recommends specific markers and characteristics for diagnosis of malnutrition.

"Nutrition is a key component of any patient’s overall health and of their post-hospitalization recovery," said the study’s co-author Peggi Guenter, PhD, RN, A.S.P.E.N.’s Senior Director of Clinical Practice, Quality, and Advocacy.

A lack of clinician participation in the nutrition care process along with an inconsistent knowledge and use of available tools and insufficient training of caregivers to identify and treat malnutrition in patients were also found to be a problem among hospitals.

The survey authors call for professional medical societies to further educate their members on the issue of malnutrition and for additional studies and audits of existing practices to determine ideal practices for nutrition care plans. A.S.P.E.N. also believes that the results of this study support the need for a nationally standardized approach to nutrition assessment, diagnosis, and care.

Time of day crucial to accurately test for diseases

Researchers from the University of Surrey and The Institute of Cancer Research, London, investigated the links between sleep deprivation, body clock disruption and metabolism, and discovered a clear variation in metabolism according to the time of day. The finding could be crucial when looking at the best time of day to test for diseases such as cancer and heart disease, and for administering medicines effectively.

The results showed that metabolic processes are significantly increased during sleep deprivation. 27 metabolites, including serotonin, were found at higher levels in periods of sleep deprivation compared to levels during sleep.

Lead author Professor Debra Skene from the University of Surrey, said: "Our results show that if we want to develop a diagnostic test for a disease, it is imperative to take the time of day when taking blood samples into account, since this has a significant effect on metabolism. This is also key for administering medicines and determining when they will be at their most effective."

Nutrition quality, safety drive
optimal outcomes

by Kara Nadeau Della Vecchia

Optimal patient nutrition is key to achieving successful clinical outcomes but the process of delivering nourishment in any setting – acute care, home care, long-term care – is one that is often complex and open to the risk for human error. In this article, Healthcare Purchasing News explores some of the top trends in enteral and parenteral nutrition delivery, and highlights products designed to improve patient care quality and safety.

Preventing tubing misconnections

Envision a patient and the many tubes and connections that clinicians use in the course of providing his/her care, including those for administration of intravenous (IV) fluids, oxygen, enteral nutrition, and epidural pain control. Now consider that the small-bore or "Luer" connectors used to link components (e.g. an oxygen tube to a nebulizer or an IV line to a central venous catheter) are compatible with any delivery system, and it becomes clear how easy it is for a clinician or other caregiver to mistakenly link the wrong device to the wrong delivery site.

According to the Joint Commission, common tubing misconnection errors include:

  • Intravenous infusions connected to epidural lines, and epidural solutions (intended for epidural administration) connected to peripheral or central IV catheters.

  • Bladder irrigation solutions using primary intravenous tubing connected as secondary infusions to peripheral or central IV catheters.

  • Infusions intended for IV administration connected to an indwelling bladder (foley) catheter.

  • Infusions intended for IV administration connected to nasogastric (NG) tubes.

  • Intravenous solutions administered with blood administration sets, and blood products transfused with primary intravenous tubing.

  • Primary intravenous solutions administered through various other functionally dissimilar catheters, such as external dialysis catheters, a ventriculostomy drain, an amnio-infusion catheter, and the distal port of a pulmonary artery catheter.1

The U.S. Food and Drug Administration (FDA) points out that, "in particular, misconnections with enteral feeding tubes and solutions have been associated with death and serious injury."2

To address this often underreported but serious patient safety issue, the FDA, other regulators, manufacturers, clinicians, and healthcare industry associations have come together in a collaborative manner with the International Organization of Standardization (ISO) and the Association for the Advancement of Medical Instrumentation (AAMI) to develop new ISO standards that require small bore connectors to be compatible only with the patient care delivery devices for which they are intended.

The initiative is being rolled out in a phased approach, with the industry first tackling small bore connectors for enteral nutrition delivery. Manufacturers of enteral small bore connectors from across the globe have come together to form the Global Enteral Device Supplier Association (GEDSA), a non-profit trade association, through which they have collaborated to develop a universal, standardized connector design that will replace all existing enteral nutrition connector systems. Designated the "ENFit Connector," GEDSA anticipates this new design will be an approved draft international standard by the end of the year, and a final published standard sometime in 2015. The new connectors will be introduced into the healthcare marketplace in the U.S., Canada and Puerto Rico late 2014/early 2015 and rolled out to other markets starting in Q3 2015.3

Tom Hancock

"These new, safer connectors have been years in the making. They have been carefully tested through a rigorous misconnections assessment, human factors and usability studies, and a robust risk assessment. We are excited to finally introduce the ENFit connector to help address tubing misconnections," said Tom Hancock, Executive Director of GEDSA. "We’ve planned a careful, methodical transition to these new connectors over time to avoid any disruption of therapy. Broad awareness and careful preparation will be the key to a safe transition."

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) has teamed up with GEDSA, AAMI, The Joint Commission, The Institute for Safe Medication Practices, Premier Safety Institute and Novation to introduce "Stay Connected 2014," a comprehensive educational campaign developed to inform and prepare the healthcare community for impending changes to medical device small-bore connectors.4

Peggi Guenter

"You can imagine the education and change that must take place among caregivers to make this transition," said Peggi Guenter, RN, PhD, Senior Director of Clinical Practice, Quality, and Advocacy for A.S.P.E.N. "Right now we are trying to make people aware of these changes so their first exposure isn’t when they open a bag and discover the new connector."

Guenter recommends that clinicians and supply chain professionals examine what is currently being used in their organizations, put into place "thoughtful ordering processes" to phase out the old connector designs and phase in the new, and determine where and how they will stock the new connectors.

"This will require a great deal of coordination among the manufacturers, suppliers, supply chain staff and clinicians," said Guenter.

Guenter notes that A.S.P.E.N. is working with GEDSA on checklists for healthcare organizations with considerations on making the switch to the new connector design. She anticipates that they will be available on the Stay Connected website by the end of the summer.

Minimizing the risk for infection

As with any access site into the body, enteral nutrition administration poses the risk for bacterial contamination and infection. While hand washing is the first line of defense against external contamination, manufacturers have designed enteral feeding systems with features to reduce the risk of infection and enhance patient safety.

Dale ACE (Access Controller for Enteral) Connector

For example, Dale Medical Products, Inc. recently introduced its Dale ACE (Access Controller for Enteral) Connector, a 100 percent closed system connector that controls fluid flow into and out of Salem Sump, Levin, PEG/g-tubes, and select J-tubes. The connector system remains closed to the atmosphere at all times and features a self-closing syringe port. This design helps protect patients against infection and shield caregivers against exposure to bodily fluids. It replaces 5-in-1 connectors and enteral feeding Y-port adapters to provide in-line feeding, suctioning, irrigation, residual checks, and medication delivery without the need to disconnect.

Comfort for the long term

Comfort is a primary concern for patients who must be nourished via feeding tubes, particularly when the device must remain in place over a long time period. To improve the comfort of patients who are living with gastrostomy feeding tubes, and simplify enteral feeding procedures for physicians, Cook Medical introduced its Entuit product line for gastrostomy feeding.

Cook Medical’s Entuit Thrive Balloon Retention Gastrostomy Feeding Tube

The Entuit Thrive Balloon Retention Gastrostomy Feeding Tube has an in-line balloon shaft that may reduce the need to overdilate when physicians place and replace feeding tubes. The Entuit Gastrointestinal Secure Suture Anchor Sets were designed with two options, a standard suture anchor and an adjustable-tension suture anchor. The standard suture anchor can be quickly tightened to secure the stomach wall to the abdomen. The adjustable-tension suture anchor includes a locking mechanism that enables the physician to increase tension during critical points in the procedure and to decrease the tension later, if necessary, to make the patient comfortable. The Entuit Start Initial Placement Gastrostomy Set includes all of the components that are necessary to start a gastrostomy procedure.

Nourishing the smallest patients

The National Association of Neonatal Nurses (NANN) in its position statement, The Use of Human Milk and Breastfeeding in the Neonatal Intensive Care Unit, states: "The use of human milk and breastfeeding are essential components in providing optimal health for the critically ill newborn." It is widely recognized that human breast milk (HBM) provides myriad health benefits for neonates. HBM is easier to digest than formula, its cells, hormones and antibodies protect against illness, and studies have shown that HBM reduces the risk for post-neonatal death.5

While breastfeeding is the optimal delivery route of conveying nutrition, it is not always possible to nourish neonates in the NICU in this manner. For these infants, NANN urges healthcare providers to "strive to initiate enteral feeds when human milk becomes available and when the infant is stable enough to tolerate feedings." 5 The drawback of expressing breast milk, storing it and delivering it via enteral feeding is the loss of valuable nutrients, particularly fat (lipids).

NeoMed’s Oral/Enteral Syringes

NeoMed recently funded an independent study to determine how NICU syringe choice can reduce fat loss in human breast milk. This study concluded that eccentric tip syringes with flat, solid polypropylene O-ring plungers had significantly less fat loss than concentric tip syringes with conical, black elastomeric plunger assembly.6

NeoMed’s Oral/Enteral Syringes are part of the company’s comprehensive Enteral Safety System. Designed with a solid polypropylene plunger head that is flatter than rubber plunger tips, NeoMed Oral/Enteral Syringes create less surface for unwanted lipid/fat adhesion. The offset tip ensures lipids are delivered first in a horizontally-oriented syringe infusion pump. NeoMed’s Enteral Safety System complies with best practice recommendations set forth by The Joint Commission and the FDA.

Reducing the risk for parenteral drug errors

It is estimated that 350,000 patients receive parenteral nutrition (PN) during hospital stays in the U.S., with many others receiving it in alternate care settings, such as in the home or in long term care facilities.7

According to the U.S. Department of Health & Human Services Agency for Healthcare Research and Quality (AHRQ), "the ordering and administration of total parenteral nutrition (TPN) have been associated with high numbers of medical errors and increased risk of death, especially in pediatric patients.8" The Institute for Safe Medical Practices (ISMP) points out how fatal 1,000-fold overdoses can occur, particularly in neonates, when a clinician mistakenly transposes MCG and MG during the course of administering TPN.

In 2014, A.S.P.E.N. published its Parenteral Nutrition Safety Consensus Recommendations, noting how only 58 percent of organizations have precautions in place to prevent errors and patient harm associated with PN.9 Based on practices that are generally accepted to minimize errors with parenteral nutrition administration, the document includes recommendations on prescribing, order review and verification, compounding, and administration. The recommendations are part of A.S.P.E.N.’s Parenteral Nutrition Safety Toolkit, which can be found on the organization’s website at:

Guenter notes, "The appropriate use of this complex therapy aims to maximize clinical benefit while minimizing the potential risks for adverse events. Prescribing, compounding and administering PN in a standardized fashion goes a long way to promote patient safety."

Baxter’s SIGMA Spectrum Infusion Pump
with Master Drug Library

An example of a system designed to help promote safety is Baxter’s DoseEdge Pharmacy Workflow Manager, which helps automate and track the medication process from preparation through dispensing – while providing important documentation for the entire process. To date, the system has identified more than 1.3 million potential medication errors.*

Additionally, Baxter recently secured 510(k) clearance from the FDA for its next-generation SIGMA Spectrum Infusion Pump with Master Drug Library, which enables a hospital to maintain a customized in-house library of facility-defined infusion therapy dosing parameters to minimize the likelihood of drug errors during care. New asset-tracking capabilities will allow hospitals to effectively locate, manage and deploy SIGMA Spectrum inventory, helping to ensure efficient allocation of hospital assets. Baxter will initiate a plan to launch the next-generation SIGMA Spectrum with select healthcare facilities beginning in the summer of 2014.


*Data on file; aggregated from March 2008 through May 2014