By Enteral Feeding Tube

Nursing2013 survey results Drug administration by enteral feeding tube

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By Peggi Guenter, PhD, RN and Joseph Boullata, PharmD, RPh, BCNSP

LAST SPRING, Nursing2013 conducted a survey in the jour- number of surveys of enteral drug administration prac- nal and online in cooperation with the American Society tices and techniques.13-19 for Parenteral and Enteral Nutrition (A.S.P.E.N.) to explore Surveys suggest that practice differs significantly from nurses’ knowledge of evidence-based guidelines for medica- guidelines, and several common practices could interfere tion administration via enteral feeding tubes. This survey was with appropriate medication delivery.13-19 For example, pre- specifically geared toward best practices for medication de- vious surveys suggest that only 5% to 43% of practitioners livery through an enteral access device and addressed how to flush tubes before or between medications, only 32% to 51% prevent complications such as tube clogging, drug-nutrient administer drugs separately from one another, only 44% to interactions, and inadequate medication delivery. This article 64% dilute liquid medication, and only 75% to 85% avoid reviews the results of the survey, discusses best practices, and crushing modified-release dosage forms. Some of these prac- provides evidence-based rationales. tices may contribute to measurable adverse outcomes—tube occlusion, reduced drug efficacy, and increased drug toxicity Challenges and opportunities in particular.20 Tube occlusion is a frequent problem Respondent profile These studies were completed be- (20% to 45% of tubes become occluded fore publication of A.S.P.E.N. Enteral during the life of the tube) often requir- Here’s a snapshot of the 823 nurses Nutrition Practice Recommendations responding to this survey. ing tube replacement.1-3 Risk factors in 2009.21 This survey was conducted for tube occlusion include increasing Educational level to determine whether nursing practice • RN diploma, 11% tube length, decreasing tube caliber, today is in line with current recom- • associate degree, 19% inadequate water flushing, frequent • bachelor’s degree, 40% mended guidelines. medication delivery, and use of the • master’s degrees or higher, 15% 3 tube to measure residual volumes. • LPN/LVN, 10% What survey results reveal Appreciating the complexity of drug • student, 2% Eight hundred and twenty-three nurses administration through a feeding tube Years of nursing experience from across the country responded to and maintaining appropriate techniques • over 15 years, 51% our survey. For a snapshot of this con- may prevent tube occlusion and de- • 5 years or less, 33% venience sample, see Respondent profile. crease the risk of reduced drug efficacy Primary clinical area The following pages present respons- or drug toxicity. • medical-surgical, 35% es to individual survey questions, cor- Medication administration in pa- • geriatrics, 16% rect answers, and evidence-based ratio- tients receiving enteral nutrition (EN) • intensive care/critical care, 15%. nales. Correct answers are highlighted includes implementing administration Most respondents (62%) worked in red. The percent of responses for techniques that assure bioavailabil- in hospitals, followed by long-term each answer is found at the end of the ity without further complicating the care/subacute care (19%), and home row. Numbers have been rounded. Per- healthcare (7%). Most respondents patient’s overall care. Guidelines for centages don’t always add up to 100% (68%) don’t have a nursing specialty administering medication via enteral certification. because not every participant answered feeding tubes are available,4-12 as are a every question. www.Nursing2013.com December l Nursing2013 l 27

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 1. How often do you care for patients with an enteral 4. Do you hold (stop) feedings while administering feeding tube? medication through the same enteral tube? Frequently 51% Yes 95% No 5% Occasionally 35% Rarely 14% 5. Do you flush the enteral tube before administering medication through it? According to the latest available Nationwide Inpatient Yes 89% No 11% Sample (NIS) data, in 2011 over 269,000 patients received EN during a hospital stay.22 Approximately 5.8% of Guidelines for medication administration include the long-term-care facility residents in the United States receive recommendation: “Prior to administering medication, EN; the prevalence is higher for residents with cognitive stop the feeding and flush the tube with at least 15 mL impairment (18% to 34%).23 Most patients with feeding water.”21 A cleared feeding tube helps ensure delivery of tubes receive not only enteral formula, but also medications the total dose of medication to the patient through this and additional hydration through the device. access device. Residue from the EN formula and from previously 2. How often do you add medications directly to the enteral administered drug products adhere to the lumen of the nutrition formula? feeding tube. The amount will vary with the medication, EN formula, and feeding tube. Flushing of the tube has Frequently 11% been shown to decrease the incidence of tube occlusion.30 Occasionally 10% Although most respondents (89%) know to flush the tube Rarely 6% before administering a medication, 11% do not. Never 72% 6. Do you flush the enteral tube after administering medication through it? 3. If you add medications directly to the enteral nutrition formula, which of the following do you routinely add? Yes 98% No 2% Antibiotics 31% Guidelines for medication administration include the Gastrointestinal medications 59% recommendation: “Flush the tube again with at least 15 mL Electrolytes 35% water, taking into account patient’s volume status. Repeat with the next medication (if appropriate). Flush the tube Other 43% one final time with at least 15 mL water.”21 Flushing water Guidelines for medication administration include the through the feeding tube helps to ensure the delivery of the recommendation: “Do not add medication directly to an entire drug dose to the distal end of the tube and ultimately enteral feeding formula.”21 Although combining medication to the patient. Additionally, the flush reduces drug residue with an EN formula may be convenient, a couple of major within the tube lumen so that the tube is again cleared concerns should be noted. Foremost, data that support before the EN feeding is restarted. The lowest necessary compatibility and stability are required before considering volume needed to clear the tube is recommended for neo- combining drugs with each other or with EN. The physical nates, pediatric patients, and fluid-restricted patients.21 and chemical interactions between a medication and EN In this survey only 2% of the respondents reported that may alter properties of the drug and the nutrients, leading they fail to flush after giving medications. to risk for feeding tube occlusion, altered drug bioavailabil- 20 ity, and/or distorted gastrointestinal (GI) function. 7. If you flush the enteral tube before and/or after drug A number of drugs have been studied and reveal in- administration, which of the following do you use? compatibility and instability with mixing in EN.24-29 In Always Never Depends on fact, 96% of incompatible drug-EN mixtures result in tube the patient occlusion with very few cleared by water flushes.26 Com- patibility is influenced by factors related to the drug (pH, Sterile water 26% 34% 40% alcohol content, mineral content, viscosity, osmolality) and Tap water 70% 10% 20% the EN formula (type and concentration of protein, fiber “Normal” saline 4% 67% 29% 11 content, mineral content). The widely used closed enteral (0.9% sodium chloride) feeding systems would require a break in sterility to add a solution 21 drug, which poses another serious concern. Other 3% 83% 14% Although 72% of respondents say they “never” add medications to EN, 21% do so “frequently” or “occasionally.” This represents a significant proportion of nurses engaging The flush fluids respondents specified as “other” included in the risky procedure. filtered water, cranberry juice, or ginger ale.

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 9. When you give two or more medications via an enteral Guidelines for medication administration include the tube, do you flush the tube between medications? recommendation: “Sterile water is recommended for use in adult and neonatal/pediatric patients before and after No 24% medication administration.”21 Purified or sterile water is Yes, with sterile water 19% the preferred fluid for flushing feeding tubes and diluting Yes, with tap water 55% medications for enteral administration.31 This is based Yes, with other fluid 2% in large part on the fact that microbial contaminants and chemical contaminants are present in the drinking wa- Guidelines for medication administration include the ter supply.32,33 These may include endocrine-disrupting recommendation: “Flush the tube again with at least 15 mL compounds (for example, bisphenol A and some pesti- water taking into account patient’s volume status. Repeat cides that interfere with hormone systems), personal care with the next medication (if appropriate).”21 The flush of products (such as sunscreen and insect repellant), and water through the feeding tube after administering one pharmaceuticals. drug helps to ensure the delivery of the entire dose and re- Sterile water is also recommended for flushing all enteral duces drug residue within the tube lumen so that the tube tubes in immunocompromised and critically ill patients, is again cleared before the next medication is delivered, especially when the safety of tap water can’t be assured.34 reducing the risk of tube occlusion.30 Purified or sterile wa- Water is as good as or better than other fluids (such as juice ter is the preferred fluid for flushing feeding tubes between or soda) at maintaining tube patency.35,36 medications, in part because of contaminants found in tap Although nurses are generally knowledgeable about the water.31-33 need to flush the tube before and after administering medi- When giving two or more medications via an enteral cations, most use tap water instead of sterile water. Only tube, only 19% of survey respondents flush with sterile 26% ”always” use sterile water to flush before or after medi- water between medications, and 55% flush with tap water. cation administration and 70% say they “always” use tap Nearly 25% never flush with any solution between medica- water. This is especially concerning for institutional practice. tions, contributing to the risk of adverse outcomes.

8. When giving two or more medications via an enteral 10. Which type of oral tablets do you crush and administer tube, do you give each medication separately or mix them via enteral tube? (Check all that apply.) together before administering? Immediate-release 95% Always give separately 38% Extended-release 10% Depends on the medications 47% Sustained-release 11% Depends on the patient 2% Enteric-coated 11% Always give together 13%

Guidelines for medication administration include the 11. Which type of hard gelatin capsules do you open recommendation: “Avoid mixing together medications in- and administer via an enteral feeding tube? (Check all that apply.) tended for administration through an enteral feeding tube given the risks for physical and chemical incompatibilities, Immediate-release 93% tube obstruction, and altered therapeutic drug responses.”21 Extended-release 12% When more than one drug is scheduled for administration Sustained-release 13% at the same time, they must be given separately. This is analogous to avoiding mixing I.V. drugs together Guidelines for medication administration include the before administration without data on compatibility and sta- recommendation: “Liquid dosage forms should be used bility, even though they end up together in the bloodstream. when available and if appropriate. Only immediate-release Drug-drug interactions from mixing liquid medications or solid dosage forms may be substituted. Grind simple com- especially from crushing two or more medications together pressed tablets to a fine powder and mix with sterile water. has a high potential for changing molecular structure or Open hard gelatin capsules and mix powder with sterile resulting in altered physicochemical properties.37 This prac- water.”21 tice also has the potential to create a new drug entity with Drug dosage forms include solids (capsules, tablets) unknown characteristics. Predicting problems with stability and liquids (solutions, suspensions). Most solids are when a drug is prepared for enteral feeding tube administra- immediate-release products (compressed tablets, hard tion is difficult enough without complications iinvolving gelatin capsules) that contain the active drug molecule other drugs and excipients (the non-therapeutic ingredients mixed with inactive ingredients. Immediate-release prod- required to formulate the product). ucts are designed to release the drug within minutes of In this survey, 62% of respondents mixed medications at reaching the stomach following oral administration. But least some of the time, if not always. more and more drugs have been introduced as modified- www.Nursing2013.com December l Nursing2013 l 29

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. release products (enteric-coated, extended-release, and h eavy metals that may interact with the administered sustained-release). drug.31 Drugs manufactured for oral administration are de- Nearly half of respondents don’t dilute liquid medica- signed specifically for the healthy GI tract. Destroying tions at all before administering via enteral tube. Among the carefully designed delivery mechanisms by opening those who dilute liquid medications, 38% dilute with tap or crushing solid dosage forms will alter the drug’s per- water and only 13% dilute with sterile water. formance in the GI tract, influencing bioavailability. Least affected are the immediate-release solids, so this is the 14. Do you hold continuous enteral feeding for at least only solid dosage form recommended for feeding tube 1 hour around dosing of any of the following? (Check all administration. Enteric-coated, extended-release, and that apply.) sustained-release tablets and capsules should never be Levofloxacin 26% crushed or opened and therefore can’t be administered by feeding tube.38 Phenytoin 50% Besides altering drug properties, crushing enteric coat- Warfarin 22% ings increases the risk of tube occlusion because coating Other 38% particles tend to clump together in water. When crushed, extended/sustained-release products rapidly release large Medications respondents specified as “other” included amounts of drug at one time, resulting in erratic blood lev- synthroid, famotidine, and ciprofloxacin. els, potentially toxic levels, and even fatalities.39 Guidelines for medication administration include the recommendation: “Restart the feeding in a timely manner 12. Do you dilute crushed medications and powder from to avoid compromising nutrition status. Only hold the opened capsules before administering them? feeding by 30 minutes or more when separation is indicated to avoid altered drug bioavailability.”21 No 4% A small number of medications, such as some fluoro- Yes, with sterile water 22% quinolones and other antimicrobials, antiepileptic drugs, Yes, with tap water 72% levothyroxine, and warfarin, are known to interact suffi- Yes, with another fluid 2% ciently with EN in the GI tract to reduce bioavailability. In these cases, a period of 30 to 120 minutes–depending on the drug–may be needed prior to restarting EN.20,21 13. Do you dilute liquid medications before administering Feedings should be held for at least 60 minutes for the them? drugs listed in the survey question.20,21 This is analogous to No 48% administering drugs orally on an empty stomach. Holding Yes, with sterile water 13% feeding for a sufficient amount of time is more of an issue Yes, with tap water 38% for patients receiving continuous EN. Scheduling these drugs for administration during intermittent feeding regi- Yes, with another fluid 1% mens is much easier. Guidelines for medication administration include the recommendation: “Dilute the solid or liquid medication as 15. Does the pharmacy provide you with ready-to-administer appropriate and administer using a clean oral syringe (≥30 enteral drug products already prepared in an oral syringe mL in size).”21 To be sure that the full dose of medication labeled for the patient? is delivered through the distal end of the feeding tube, the Always 8% drug powder or viscous liquid needs to be diluted.24 Liq- uid drug products contain thickeners and sweeteners that Often 24% increase their viscosity and osmolality. Dilution improves Rarely 32% drug delivery.40-42 Never 36% High osmolality medications contribute to GI intoler- ance and diarrhea. In some cases, these liquids may require Currently there is no “correct” answer to this question, dilution with 150 to 250 mL of water, making them less as pharmacies dispense medications in various ways, even attractive dosage forms than solid immediate-release forms within the same institution and for the same patient. The that are administered in 15 mL of water for feeding tube ideal process would be for the pharmacy to always provide administration. patient-specific, unit-dose, ready-to-administer enteral drug Sterile water or 0.9% sodium chloride (sterile saline) products in oral/enteral syringes. are preferred diluents for most drugs to meet United States If the pharmacy dispenses a liquid medication in a sy- Pharmacopeia standards.21,31 Tap water should be avoided ringe, it should be in an oral or enteral syringe. It should in many cases because, as already noted, it may contain be properly labeled with, at a minimum, patient identifiers, pathogenic microorganisms, pesticides, pharmaceuticals, drug name and dosage, and expiration date.

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Nurses must communicate with the pharmacist when guidelines but just 17% cited them as their primary infor- a patient is to receive a drug through a feeding tube and mation source.18 It’s encouraging that nurses today are more again when the tube has been relocated or removed. Senti- aware of institutional policies on this medication delivery nel event medication errors have occurred when oral or GI process. medications have been drawn up in I.V. (rather than oral) 43 syringes and then inadvertently given I.V. 18. How often do you consult with a pharmacist when you’re The 36% of respondents who report that they never unsure about medication delivery? have ready-to-administer medications are susceptible to in- Never <1% creased risk of wrong-route medication errors. In addition, these nurses may spend inordinate time preparing medica- Rarely 11% tions, a task better left to the pharmacy. Often 39% Always 46% 16. What are your source(s) for information on medication I don’t have access to a pharmacist 3% administration? (Check all that apply.) Institutional policies and procedures 79% In this survey, most (85%) respondents consult either of- A comprehensive, current drug reference 73% ten or always with a pharmacist when they’re unsure about Pharmacy colleagues 70% a medication. It’s been demonstrated that fewer medication Nursing colleagues 57% errors occur when pharmacists and nurses collaborate on medication delivery. In one study of an interdisciplinary ap- Product inserts/prescribing information 43% proach, clinicians reduced the number of medication errors Website(s) 31% and tube occlusions by holding training sessions for nurses, Other 6% promoting practice guidelines, establishing a database of oral-enteral dosage forms, and having pharmacists offer Nurses clearly draw their medication administration patient-specific recommendations.44 information from various printed, electronic, and staff sources. It’s reassuring that 70% of respondents include 19. What nursing actions do you take when you encounter a pharmacists as an information source. In a 1997 survey of clogged feeding tube? (Check all that apply.) critical care nurses, respondents cited clinical experience Flush with warm water 91% (57%), coworkers (22%), and nursing school (13%) as their sources of medication administration knowledge.15 Flush with another fluid 53% Long-term care nurse survey respondents reported using Use an unclogging device 35% 18 similar sources. Remove feeding tube 35% Always consult with an adult or pediatric pharmacist Other 31% for patients who receive medications coadministered with enteral nutrition. The pharmacist can help you determine Clogged or occluded feeding tubes often result from whether a drug or its dosage form is appropriate for ad- protein-based formulas coming in contact with gastric ministration depending on the tube type and location of its acid and/or medications. Routine water flushes are vital to distal end.20 For example, administrating a drug through a prevent tube occlusions. A completely occluded tube is an jejunostomy tube will bypass a major drug administration urgent problem preventing the patient from receiving es- site, the duodenum. sential nutrients, hydration, and medications. The first thing the nurse should do is assess if the tube 17. Does your institution have a nursing policy and procedure is kinked or compressed in any way. Attempt to draw back for medication delivery through an enteral feeding tube? with a syringe and then attempt to flush the tube with warm water. If that doesn’t work, follow institutional proto- Yes 76% col for occluded feeding tubes. No 7% Actions to mitigate the occlusion can include chemical I don’t know 17% or physical declogging regimens.45,46 If these are unsuccess- ful, the tube may need to be removed and replaced. A large majority of nurse respondents acknowledged Over 50% of respondents stated that they flush with that their institution has a nursing policy and procedure for another fluid. Most reported using a carbonated beverage medication delivery through an enteral feeding tube. In a such as cola, ginger ale, or lemon-lime soda; some used nationwide survey published in 1997, only about one-third cranberry juice. Investigators have shown the superiority of nurse respondents were aware of printed guidelines and of water over cranberry juice in flushing feeding tubes. No only about 5% used them as their primary source.15 In data shows that carbonated beverages are more effective another survey, about 70% of nurses were aware of printed than water as a flush solution or as a declogging solution.47 www.Nursing2013.com December l Nursing2013 l 31

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Some studies demonstrate that a sodium bicarbonate- Practice recommendations and pancreatic enzyme solution can be effective in opening oc- procedures for giving drugs through an cluded feeding tubes.48 enteral access device49 Thirty-five percent of respondents also mentioned use of a declogging device. Several of these chemical or mechanical Use only oral/enteral syringes labeled “for oral use only” to devices are on the market. It’s important to have and follow measure and administer medication through an enteral feeding an institutional nursing protocol for using these devices. tube. Consult with an adult pharmacist or pediatric pharmacist for patients who receive medications coadministered with enteral nutrition. Never add medication directly to an enteral Discussion feeding formula. Also follow these additional guidelines to The key findings from this survey include the following, safely administer medication via an enteral feeding tube. discussed in terms of major best practice recommendations. 1. Verify tube tip placement by checking for stomach or • Never add medications to EN formula. Although 72% of small intestine contents, X-ray, or another accepted method. respondents say they “never” add medications to EN, 21% Auscultation alone isn’t acceptable. still do so “frequently” or “occasionally.” • Never mix medications before administering them. Medi- 2. Turn off the enteral formula pump or administration bag. cations should never be mixed together for administration, 3. Flush the tube with at least 15 mL sterile water to check but only 38% “always” give meds separately and 47% think tube for patency and to flush residual feeding formula through. it depends on the patient. (Modify flush volumes throughout as needed for infants, • Flush the tube before and after medication administra- children, and patients with fluid restrictions.) tion, and also between drugs when giving two or more at 4. Don’t mix together medications intended for administration the same time. Although most respondents (89%) know to through an enteral feeding tube because of the risks for flush the tube before administering a medication, 11% do physical and chemical incompatibilities, tube obstruction, not. When giving two or more meds via an enteral tube, and altered therapeutic drug responses. Instead, administer each medication separately through an appropriate access. only 19% flush with sterile water between drugs; 55% flush Liquid dosage forms should be used when available and if with tap water; and 24% don’t flush at all. appropriate. Only immediate-release solid oral dosage forms • Use sterile water, not tap water, to flush the tube and may be substituted. dilute medications. Although nurses are generally knowl- 5. Immediate-release tablets should be ground to a fine powder edgeable about the need to flush the tube before and after and mixed with sterile water before administration. Hard gelatin administering medications, most use tap water instead of capsules should be opened and the contents mixed with sterile sterile water. Only 26% ”always” use sterile water to flush water. Draw up liquid medication with an oral-enteral syringe. before or after medication administration; 70% say they 6. Dilute the solid or liquid medication as appropriate and “always” use tap water. administer using a clean oral syringe (≥ 30 mL in size). Note: Nearly half of respondents don’t dilute liquid medica- Dilution/flush should be less for pediatric doses (minimum tions at all before administering via tube. About 38% dilute 50:50 volume) and at least 5 mL when fluid is not restricted. with tap water; only 13% dilute with sterile water. 7. Connect the syringe to the side medication port on tube end • Only immediate-release oral medications should be if available. given via enteral tube. Most respondents know that only immediate-release oral capsules and tablets should be 8. Gently administer each medication individually through opened or crushed and given via enteral tube. But 25% the tube, flushing it with 15 mL sterile water between each medication (taking into account the patient’s volume status). say they open extended release or sustained release hard gelatin capsules and administer them via enteral tube. 9. Flush the tube with at least 15 mL water following the last • All medications, both liquid and solid, should be diluted medication. before administration. 10. Reconnect and turn on the feeding formula unless Nearly all respondents say they dilute crushed medica- contraindicated. Restart the feeding in a timely manner to avoid tions and powder from opened capsules before administra- compromising nutrition status. Hold the feeding by 30 minutes tion, but only 22% dilute them with sterile water, versus or more only when a lengthy separation is indicated to avoid 72% with tap water. Nearly half (48%) don’t dilute liquid altering drug bioavailability. medications before administration. When compared to previous nursing surveys on medica- Many more nurses now include a pharmacist as a tion administration, this survey shows that overall knowl- key source of information than in the past (70% to edge and translation to practice has improved in several 85% in this survey versus 6% to 12% in past surveys). areas but remains unchanged in others. Many more respon- But many nurses are still mixing medications together dents now flush the tube before and between administra- (38% versus 32% to 51%), not diluting liquid medication of medication (76% to 89% in this survey, versus 5% tions as they should (51% versus 44% to 64%), and to 43% in the past). Unfortunately, however, most are still preparing modified-release medications for tube ad- using tap water for flushing. ministration (25% versus 15% to 25%).

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Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 23. Dorner B, Posthauer ME, Friedrich EK, Robinson GE. Enteral nutrition for older Best practices for medication administration adults in nursing facilities. Nutr Clin Pract. 2011;26(3):261-272. Documented procedures and guidelines for medication 24. Cutie AJ, Altman E, Lenkel L. Compatibility of enteral products with commonly administration through an enteral feeding tube with clear employed drug additives. JPEN J Parenter Enteral Nutr. 1983;7(2):186-191. 25. Holtz L, Milton J, Sturek JK. Compatibility of medications with enteral feedings. step-by-step instructions can assist caregivers in optimiz- JPEN J Parenter Enteral Nutr. 1987;11(2):183-186. ing therapeutic response to the medication and preventing 26. Burns PE, McCall L, Wirsching R. Physical compatibility of enteral formulas with complications such as tube occlusion. As discussed earlier, various common medications. 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A nationwide survey of long-term care facilities to determine Spring, MD: American Society for Parenteral and Enteral Nutrition, 2010. the characteristics of medication administration through enteral feeding catheters. Nutr RESOURCE Clin Pract. 2005;20(3):354-362. Teitelbaum D, Guenter P, Howell WH, Kochevar ME, Roth J, Seidner DL. Definition 19. Boullata JI, Hudson LM, Spencer CT, Preston AM, Oakes BA. Drug administration of terms, style, and conventions used in A.S.P.E.N. guidelines and standards. Nutr Clin by feeding tube: results of a practice-based survey [abstract]. Pract. 2005;20(2):281-285. Nutr Clin Pract. 2007;22:126. Peggi Guenter is the Senior Director for Clinical Practice, Advocacy, and Research Affairs for 20. Boullata JI. Drug administration through an enteral feeding tube. Am J Nurs. the American Society for Parenteral and Enteral Nutrition, Silver Spring, Md. Joseph Boullata 2009;109(10):34-42. is Professor of Pharmacology & Therapeutics at the University of Pennsylvania School of Nursing, and Clinical Pharmacy Specialist in Nutrition, Hospital of the University of Pennsyl- 21. Bankhead R, Boullata J, Brantley S, et al. Enteral nutrition practice recommendations. vania’s Clinical Nutrition Support Services, Philadelphia, Pa. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167. The authors and planners have disclosed that they have no financial relationships related 22. National Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project to this article. (HCUP) from the Agency for Healthcare Research and Quality (AHRQ). 2013. http:// hcupnet.ahrq.gov. DOI-10.1097/01.NURSE.0000437469.13218.7b www.Nursing2013.com December l Nursing2013 l 33