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Final-year Pharmacy Student
Drug Information Centre
Department of Pharmacy
The objectives of the study were first to survey current methods of drug administration by enteral feeding tubes, then to evaluate nurses and physicians’ perception of the problem and finally to elaborate practical guidelines to help improve drug administration practices.(1) This study was conducted within the Loëx medical department, a medium- to long-stay hospital for general adult rehabilitative medicine and palliative care, part of Geneva University Hospitals (HUG, Switzerland).
In the Loëx Medical Department, a large proportion of patients are fed through enteral feeding tubes, as they are not able to eat sufficiently or to swallow food. This raises a number of issues for the nursing team, as most pharmaceutical forms used require some manipulation (eg, crushing, dilution or solubilisation) before they can be properly administered by enteral tubes.(2–9) Moreover, nurses and physicians are not always aware of all existing pharmaceutical forms available.
A literature review showed that, although drug administration by enteral feeding tube is currently carried out in different hospitals, there are no standard guidelines for administration through this route.(10–14)
Design of the survey
The different drugs administered to patients through enteral feeding tubes were first identified. Then nondisguised observations of administration methods were made by a pharmacist. Standardised questionnaires were distributed to 10 nurse teams and 18 physicians to evaluate their perception of the problem. The results led to the elaboration of practical administration guidelines intended for nursing teams and prescribing doctors.
Evaluation of practices by observation
At Loëx medical department, 25 out of 269 (9%) patients were fed through an enteral tube. They received on average five different drugs using this route. Seventy-five different drugs were identified (18% laxatives, 15% analgesics, 10% antiepileptics). Twenty-two percent of them were available as liquids and 14% as a dispersible form; 63% were solid forms needing to be transformed (eg, crushed or opened) before being administered by enteric tubes. Eleven percent of drugs were not administered appropriately (for example, in 5.5% of cases, crushing a gastro-resistant or a slow- release tablet, and in 5.5% of cases, existence of a liquid alternative).
Nurses’ hands were disinfected and gloves were worn in 44% and 31% of cases, respectively (see Figure 1). The material used (mortar, pestle and syringe) was judged to be clean in only 25% of all observations.
The enteral tube was often (63%) rinsed out with water before reintroduction for enteral nutrition. On the other hand, the tube was often (19%) not rinsed out before drug administration, and was never rinsed between the administration of different drugs.
Perception evaluation using questionnaires
One hundred percent of nurse teams and physicians answered the questionnaires. Results were generally in agreement with observed practices, apart from issues such as overestimate of available liquid formulations, and they highlighted the frequent occurrence of drug administration problems with enteral tubes and the absence of a standardised method, as well as a lack of knowledge of pharmaceutical forms. The need to draft specific recommendations was mentioned by 90% of responders.
Our observations allowed us to identify several issues.
Only 36% of galenic forms were well adapted for administration via enteral feeding tubes. The lack of therapeutic effect due to the crushing of an enteric-coated tablet could, for example, be costly. Our study also showed that feeding tubes were often obstructed by drugs particles, but changing an enteral tube costs money and could be painful for the patient.
Crushing tablets or opening capsules produces small particles that could be propagated in the air and inhaled by nurses. It can also make nurses sensitive to the product that is in direct contact with the particles. Wearing gloves and masks could protect nursing teams.
Mortars and pestles were not cleaned after each administration, and syringes were used several times without rinsing, which could induce drug cross- contaminations. The observational part of the study led us to the conclusion that each member of the nursing team had his/her own technique of dispensing drugs via enteric tubes.
The second part of the study gave us a lot of information on physicians and nurses’ perception of the problem (see Table 1). We noticed, for example, that nurses believe that physicians’ prescriptions do not consider the use of galenic forms often enough.
Drug–nutrition interactions and problems with the osmolarity of solutions were never taken into account by physicians or nurses. These problems also have to be studied in the future.
Elaboration of guidelines
Based on the literature, on manufacturers’ data and on the results of this study, we elaborated a table of recommendations and some guidelines that are easy to apply and describe good practices for drugs administration using enteral feeding tubes (see Table 2).
This study highlights the everyday problems encountered by nurses with the administration of drugs through enteral feeding tubes. Based on these results, practical guidelines were established as a general drug administration method. A list of recommendations for specific drugs was released in addition to these guidelines. Educational seminars intended for nurses and physicians have also been organised by the pharmacy department. Pharmacists and nurses are currently working on a pocketbook describing whether or not a solid drug can be crushed or solubilised for administration via an enteral tube. This pocketbook is intended to be updated annually by the pharmacy department.