Bedside To Place Feeding Tubes: Case Study

The Use of Technology at the Bedside to Place Feeding Tubes

Amy D. Kramer

Point Loma Nazarene University

Introduction

Artificial nutritional support is often necessary to enhance the nutritional status of acutely or critically ill patients. Nasogastric and post-pyloric feeding tubes are relied upon to provide the caloric and nutritional support required. There are approximately 1.2 million feeding tubes placed annually in the United States (Koopmann, Kudsk, & Szotkowski, 2011; Krenitsky, 2011). Out of these, it is estimated that approximately 1.9% of feeding tubes are misplaced with complications ranging from pneumothorax, hydrothorax, empyema, pneumonia and death (Krenitsky, 2011; Taylor et al., 2014).

Traditional

methods of placing feeding tubes include blind placement at the bedside requiring X-ray confirmation, insertion by fluoroscopy, direct laryngoscopy, or endoscopy (Kaffarnik, Lock, Wassilew, & Neuhaus, 2013). Although the risks associated with feeding tube placement by fluoroscopy, direct laryngoscopy or endoscopy is minimized, they require trained specialists and equipment, are frequently performed with delay in care, are costly, and increase risks for critically ill patients that need transfer off of the unit for treatment (Kaffarnik et el., 21013; Krenitsky, 2011). Fortunately, technological improvements in the placement of feeding tubes have been made allowing for direct visualization and placement at the bedside through the use of electromagnetic sensing devices such as the Cortrak 2 Enternal Access System (Windle, Beddow, Hall, Wright, & Sundar, 2009).
Cortrak 2 Enternal Access System
The Cortrak 2 system consists of an electromagnetic transmitting stylet and feeding tube, a receiver unit, and an “All-In-One Monitor with integrated visual display terminal, touch screen and embedded computing system” (Corpak Medsystems, 2012). According to the Corpak Medsystems Cortrak 2 product fact sheet:
The Cortrak 2 EAS allows for safer placement, with real-time bedside confirmation of correct placement and reduced patient exposure to X-ray allowing for faster time to therapy. Additional benefits include economical, proven savings for hospitals with dramatically reduced need for X-ray, fewer complications or adverse events, and reduced inappropriate use of TPN. The Cortrak 2 works by the use of a special stylet within the feeding tube that contains an electromagnetic transmitter that generates a real-time signal as the feeding tube is inserted and advanced to desired placement. The signal is transmitted throughout the placement procedure and is detected by a receiver placed on the patient’s epigastric region. The all-in-one monitor displays a real-time representation of the feeding tube tip’s passage as it proceeds to preferred placement (Corpak Medsystems, 2012).
Weighing the Risk versus Benefit of Use

Risks. As with any invasive procedure conducted, the need for and insertion of a feeding tube does come without risks. Complications associated with feeding tube placement includes but is not limited to; intrabronchial intubation resulting in pulmonary injury, pneumothorax, sepsis by the delivery of fluids into the pleural space, and death (Krenitsky, 2011; Simons, & Abdallah, 2012). Although the use of electromagnetic guidance for the placement of feeding tubes can eliminate many of the complications associated with commonly used practices including blind placement at the bedside, endoscopic or radiologic placement; there are risks and limitations to its use as well. Most notably are the costs associated with the purchase of the Cortrak 2 System and the increased cost of specialized feeding tubes required. The cost of the unit alone is approximately $9000 and the number of devices per hospital is usually limited to a single unit per hospital. (Windle et al., 2009). The limited accessibility of equipment and the lack of availability of trained operators to place the specialized feeding tubes can result in a delay in treatment (Krenitsky, 2011). Additional risks associated with the use of the Cortrak 2 System included difficulty in interpreting monitor readings, and system shutdown during placement due to uncharged battery packs (Windle et al., 2009).
Benefits. The introduction of electromagnetic sensing devices such as the Cortrak 2 System for the insertion of feeding tubes allows for safe and effective bedside placement with many noted benefits. The capability to place feeding tubes at the bedside allows for the early establishment of enteral feedings resulting in higher caloric intake, reduced radiation exposure from X-ray confirmation, and the avoidance of endoscopic placement or patient transports to other departments for care (Kaffarnik et al., 2013; Windle et al., 2009).
The use of the Cortrak 2 system monitor allows for a real-time representation of the feeding tube as it is inserted. Potential injuries to patients can be avoided as the clinician has the ability to withdraw the tube and avoid impeding misplacement. The Cortrak 2 System allows for successful placement of feeding tubes with avoidance of pulmonary intubation, confirmation of position that is 100% accurate when compared with X-ray, reduced radiation exposure and cost savings (Taylor et al., 2014). Subsequently, the successful use of electromagnetic guided feeding tube placement may eventually negate the need for verification via X-ray due to the accuracy exhibited by the dual view (anterior and cross-sectional) display of the Cortrak 2 System (Krenitsky, 2011).
Although the initial costs of investing in the Cortrak 2 System may seem relatively high, the long-term cost-savings and improvements to patient safety are a worthwhile investment. Additional cost-savings result from a reduction in the need for fluoroscopic tube placement or endoscopic placement requiring sedation, decrease in the need of radiographic tests for confirmation, and avoiding the need to initiate parenteral therapy (Windle et al., 2009).
Impact of Use

Enteral nutritional support therapy in acute or critically ill patients has tremendous capability to reduce major complications and enhance systemic immunity leading to decreased length of hospital stay and cost-savings to patients and organizations (Kaffarnik et al., 2012; Simons & Abdallah, 2012). The utilization of the technologically advanced Cortrak 2 System allowing for bedside positioning of electromagnetically guided nasointestinal tube feeding has a direct and positive impact on patient care, staff utilization, and organizational process improvement.
The Cortrak 2 System presents many benefits to patient care including the quick and accurate placement of feeding tube allowing for faster time to therapy, decreased exposure to X-ray, and avoidance of potential injury sustained from blind placement. Additionally, the use of electromagnetic placement at the bedside allows trained clinicians the ability to identify misplaced tubes immediately avoiding potential injury to patients and enhancing clinical competence and confidence.

Institutional Benchmarks

A survey was conducted of State, Local and National institutions regarding their knowledge/use of the Cortrak 2 Enteral Access System. The local institutions surveyed included the Naval Medical Center San Diego, and Sharp Grossmont Hospital. Responses from both institutions were negative for the utilization of the Cortrak 2 System with minimal knowledge of the product or its capabilities. The state hospital surveyed was the University of San Diego Health System. The Cortrak 2 System was successfully implemented into practice as a result of efforts made by a Surgical ICU Clinical Nurse Specialist that has resulted in fewer placements via interventional radiology, a reduction in radiographic exposure for confirmation, no lung placements, and maximized feeding times for patients (Cite powerpoint). A final survey was conducted of Walter Reed National Military Medical Center in Bethesda, Maryland. While the ICU CNS was aware of the Cortrak 2 System and in favor of its use, it is not currently utilized at either Military Medical Hospitals in the National Capitol Region.
Conclusion
The Cortrak 2 System has displayed patient, staff and organizational benefits in multiple studies. The Cortrak 2 System has the potential to improve the practice of bedside feeding tube placement resulting in improved patient care outcomes, appropriate utilization of staff time providing patient care, and cost-savings to both patients and organizations. Institutions should consider the use of electromagnetic sensing devices such as the Cortrak 2 System as a standard of care in the placement of nasointestinal feeding tubes.

References
Corpak Medsystems.

(2102). Cortrak ® 2 EAS fact sheet product literature. Confident Placement without X- ray [Brochure]. Buffalo Grove, IL: Author.

http://www.corpakmedsystems.com/Supplement_Material/SupplementPages/cortr ak/COR_FactSht.html

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Koopmann, M., Kudsk, K., Szotkowski, M., & Rees, S. (2011). A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Annals Of Surgery, 253(2), 287-302. doi:10.1097/SLA.0b013e318208f550

Krenitsky, J. (2011). Blind bedside placement of feeding tubes: treatment or threat? Practical Gastroenterology, 3, 32-42.

Metheny, N. A., Stewart, B. J., & Mills, A. C. (2012). Blind insertion of feeding tubes in intensive care units: a national survey. American Journal Of Critical Care, 21(5), 352-360. doi:10.4037/ajcc2012549

Simons, S., & Abdallah, L. M. (2012). Bedside Assessment of Enteral Tube Placement: Aligning Practice with Evidence. American Journal Of Nursing, 112(2),

40-48.
Taylor, S., Allan, K., McWilliam, H., Manara, A., Brown, J., Toher, D., & Rayner, W. (2014). Confirming nasogastric tube position with electromagnetic tracking versus pH or X-ray and tube radio-opacity. British Journal Of Nursing, 23(7), 352-358.
Windle, E., Beddow, D., Hall, E., Wright, J., & Sundar, N. (2010). Implementation of an electromagnetic imaging system to facilitate nasogastric and post-pyloric feeding tube placement in patients with and without critical illness. Journal Of Human Nutrition & Dietetics, 23(1), 61-68. doi:10.1111/j.1365-277X.2009.01010.x

Koopmann, M., Kudsk, K., Szotkowski, M., & Rees, S. (2011). A team-based protocol and electromagnetic technology eliminate feeding tube placement complications. Annals Of Surgery, 253(2), 287-302. doi:10.1097/SLA.0b013e318208f550