Download Reducing Complications and Costs of Blind Tube Placements Using

Reducing Complications and Costs of
Blind Tube Placements Using the
CORTRAK Tube Placement System
In March of 2007, the nutrition support team
at William Beaumont Hospital in Royal Oak,
Michigan analyzed retrospective and
prospective data comparing blind bedside
placement of small bowel feeding tubes to
®
the CORTRAK Enteral Access System. At the
Society of Critical Care Medicine symposium,
February 2008, Beaumont presented their
analysis and observations. This paper
discusses the results of their analysis.
Emerging data now emphasizes the
tremendous capability of enteral nutrition
support to modulate the stress response and
enhance systemic immunity. Some studies
suggest that early enteral nutrition when
compared to parenteral nutrition actually
reduces oxidative stress and hastens the
resolution of the disease process, and costs
less. For enteral nutrition to be most
effective it has been recommended to initiate
small bowel feeding as early as 24-48 hrs
within the course of critical illness.
Unfortunately enteral nutrition is too often
under utilized due to the difficulties accessing
the GI tract particularly with transpyloric
insertions. Beaumont’s analysis has revealed
significant reductions in complications, costs
and time to establishing enteral access while
providing safe and effective enteral nutrition
therapy.
Methodology
Analysis primarily focused on placement
costs and complications, but also included
any perceived negative or positive
consequence when performing blind bedside
placement of small-bore enteral feeding
tubes. Costs of blind placement -radiographs, fluoroscopy, endoscopies, tubes,
and medications were considered.
Complications included inadvertent
pulmonary placements, risky transportation
of critically ill patients to radiology or
endoscopy facilities outside of the ICU. 1 2 ,
Side effects of medications, and the patient’s
mental and physical well-being.
Retrospective data was collected only on
adult medical and surgical ICU patients. This
included the average number of tubes, xrays, procedure time, transpyloric
placements on first attempt, number of
procedures completed by fluoroscopy, and
the percent of tubes replaced for premature
dislodgement.
A Solution
Soon after FDA approval of the CORTRAK,
Beaumont Hospital’s nutrition support team
petitioned and was granted approval to trial
the use of the CORTRAK tube placement
system. (Serendipitously the latter was also
part of an “action plan” in reaction to a
sentinel event due to a pneumothorax from a
blind tube placement).
Beaumont initiated CORTRAK use in
November of 2005. After a brief initial
learning curve, Beaumont’s nutrition support
team prospectively collected data analyzing
the CORTRAK system
Results
Retrospective data revealed that on average,
each procedure required the use of two tubes,
three x-rays ($475) and 40 minutes
procedure time. At 72 hours less than half
(47%) of placements were transpyloric.
These unsuccessful placements usually
resulted in a trip to fluoroscopy ($875) or the
initiation of parenteral nutrition ($1116)
Prospective data was collected from March January 2007. A total of 833 consults
resulted in 572 procedures. On average per
procedure only one tube utilized, 0.32 x-rays,
and required 12 minutes to place or a 70%
reduction in time that reduced patient
discomfort thus improving their well-being.
89% of placements were transpyloric upon
first attempt. Fluoroscopic placements were
reduced by 83% or 20 per month reduced to
3.4 per month. This resulted in a monthly
cost savings of approximately $14,000 and
reduced patient transport out of the ICU
dramatically.
The average factored cost per placement
without the use of CORTRAK was $703. The
factored cost using CORTRAK was $165.
Beaumont’s ten month cost analysis for 572
procedures were reported as follows.
Pre- CORTRAK costs = $403,260
Post-CORTRAK cost =
$94,380
Total cost reduction = $308,880
Discussion
Upon the initial use of the CORTRAK system,
Beaumont required clinicians to correlate
placement findings via CORTRAK to an
abdominal x-ray report by a radiologist. After
a review of more than 350 correlations with
overwhelmingly positive results, postplacement x-ray verification is now left to the
clinician’s discretion. This has resulted in the
elimination of 69% of post placement x-rays.
Beaumont also reports cost savings for all
parenteral nutrition consults that their
service can appropriately convert to enteral
nutrition via the use of CORTRAK.
It has been reported the average hospital
cost per patient-day for parental nutrition is
$139.60. 3 At Beaumont an average consult
results in 8 days on parental nutrition or
$1116.80 per conversion and average seven
conversions per month.
With well over 2,100 CORTRAK placements
since 2005, Beaumont is very happy to
report there have been no complications
due to inadvertent pulmonary placement.
Retrospective data revealed 1.8 pulmonary
complications per 300 blind insertions.
Beaumont also uses a nasal bridle tube
retention device that has significantly
reduced the number of tube replacements by
approximately 50%
The excuses given for not using enteral
nutrition therapies such as “it takes too long
to get a tube properly placed” “aspiration risk
is to high when feeding the stomach,” “the
tubes always fall out, leading to further
delays”, “I don’t want a pneumothorax in my
patient” are un-deniably less plausible when
using the CORTRAK system.
SUMMARY and CONCLUSION
The supporting evidence of providing early
enteral nutrition and the avoidance of
parenteral nutrition, especially in the
critically ill is now well understood.
Several studies have substantiated that small
bowel access and feeding is the most
effective method when providing enteral
support in the acute care setting.
But disappointingly, the repeated negative
experiences when establishing and
maintaining enteral access, often results in
clinicians resorting to less effective and
efficient treatment modalities. Debates at
symposiums and in literature have attempted
to justify alternatives of trans-pyloric feeding.
The American Society of Enteral and
Parenteral Society (ASPEN) recommends
gastric feeding should at least be attempted
as first line nutrition support and when it fails
then access the small bowel. In spite of the
rigorous nursing commitment to control
gastric feeds in the ICU setting, and the
acknowledged high risk of aspiration among
this patient population, 1st time small bowel
access remains a debatable practice.
Regardless of your philosophy of gastric or
post pyloric feeding, the use of the gut is
better than TPN and the safest, most efficient
and cost effective way to establish access is
using the CORTRAK.
This paper published with permission
from William Beaumont Hospital, Royal
Oak, Michigan.
References
3
Foote JA, Kemmeter PR, Prichard PA, et al.
A randomized trail of endoscopic and
fluoroscopic placement of postpyloric feeding
tubes in critically ill patients, JPEN J Parenter
Enteral Nutr. 2004;28:154-157
3
Baskin WN. Acute complications associated
with bedside placement of feeding tubes.
Nutr Pract Clin. 2006;21:40-55
3
DeLegge MH, Basel MDD, et al. Parenteral
Nutrition (PN) Use for Adult Hospitalized
Patients: A Study in a Tertiary Medical center.
Nutrition in Clinical practice 22:246-249.
April 2007.