Consensus Recommendation Journal of Parenteral and Enteral Nutrition ASPEN Safe Practices for Enteral Nutrition Therapy Volume 41 Number 1 January 2017 15 –103 © 2016 American Society for Parenteral and Enteral Nutrition 1 DOI: 10.1177/0148607116673053 Joseph I. Boullata, PharmD, RPh, BCNSP, FASPEN, FACN ; jpen.sagepub.com Amy Long Carrera, MS, RD, CNSC, CWCMS2; Lillian Harvey, MD, FACS, CNSC3; Arlene A. Escuro, MS, RD, LD, CNSC4; Lauren Hudson, MS, RD, LDN5; Andrew Mays, PharmD6; Carol McGinnis, DNP, RN, CNS, CNSC7; Jacqueline J. Wessel, MEd, RDN, CNSC, CSP, CLE8; Sarita Bajpai, PhD, RD, CD, CNSC9; Mara Lee Beebe, RD, LD, CNSC10; Tamara J. Kinn, MS, RD, LDN, CNSC11; Mark G. Klang, MS, RPh, BCNSP, PhD12; Linda Lord, NP, ACNP-BC, CNSC13; Karen Martin, MA, RDN, LD, FAND14; Cecelia Pompeii-Wolfe, RD, LDN, CNSC15; Jackie Sullivan, MS, RDN, CD16; Abby Wood, RD, LD, CNSC17; Ainsley Malone, MS, RD, CNSC, FASPEN18; and Peggi Guenter, PhD, RN, FAAN18; ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and Enteral Nutrition Abstract Enteral nutrition (EN) is a valuable clinical intervention for patients of all ages in a variety of care settings. Along with its many outcome benefits come the potential for adverse effects. These safety issues are the result of clinical complications and of process-related errors. The latter can occur at any step from patient assessment, prescribing, and order review, to product selection, labeling, and administration. To maximize the benefits of EN while minimizing adverse events requires that a systematic approach of care be in place. This includes open communication, standardization, and incorporation of best practices into the EN process. This document provides recommendations based on the available evidence and expert consensus for safe practices, across each step of the process, for all those involved in caring for patients receiving EN. (JPEN J Parenter Enteral Nutr. 2017;41:15-103) Keywords enteral nutrition; enteral access; enteral formulas; nutrition; safety Table of Contents Electronic health record (EHR) Enteral access device (EAD) Introduction 15 Enteral nutrition (EN) Assessment and Recommendations 18 Gastric residual volume (GRV) Prescribing and Communicating the Gastrointestinal (GI) Enteral Nutrition Order 22 Head of bed (HOB) Review of the Enteral Nutrition Order 31 Human breast milk (HBM) Enteral Access 36 Intensive care unit (ICU) Procure, Select/Prepare, Label, and Dispense EN 48 Parenteral nutrition (PN) Administration: General 59 Administration: EAD Patency 74 Medication Delivery via Enteral Access Devices 77 Introduction Complication Avoidance and Error Reporting 85 Enteral nutrition (EN) refers to the system of providing nutri- Monitoring and Reassessment 92 tion directly into the gastrointestinal (GI) tract bypassing the Transition of Care 95 1 Documentation and Quality Review Issues 100 oral cavity. Each year in the United States, this nutrition sup- port modality is used in 250,000 hospitalized patients annually 2 Common Terms and Abbreviations Used from infants to older adults. EN is also widely used in sub- acute, rehabilitation, long-term care, and home settings. For Throughout the Document the purposes of this document, EN will include those nutrient Blenderized tube feeding (BTF) formulas and human breast milk (HBM) delivered through an Computerized prescriber order entry (CPOE) enteral access device (EAD). 16 Journal of Parenteral and Enteral Nutrition 41(1) The EN process (Figure 1) is the system within which EN is used. This involves a number of major steps: the initial patient assessment, the recommendations for an EN regimen, the selection of the EAD, the EN prescription, the review of the EN order, the product selection or preparation, the product labeling and dispensing, the administration of the EN to the patient, and the patient monitoring and reassessment, with doc- umentation at each step as required. This process requires a multidisciplinary team of competent clinicians working in con- cert to provide safe nutrition care.3 Although clinician competence is assumed in the EN Use Process, an inherent risk of clinical complications is related to EN and the formulas used, as well as potential errors at each step in the process. Serious adverse events, including fatalities, can occur when lapses allow for errors.1,4 These types of adverse events include the following: Figure 1. The Enteral Nutrition (EN) Use Process. •• Clinical complications of using EN such as GI compli- EN process (eg, EN order templates). Process standardization cations, refeeding syndrome, or gut ischemia may include independent double-checks and automation with •• Process-related errors, including those associated with forcing functions to help improve EN safety. Policies include process steps, such as administration errors and the organization’s mechanisms to maintain competency of misconnections individual clinicians involved in EN. Optimal communication and standardization across all steps of the EN Use Process is a risk management strategy.3 To Methodology reduce the risk of adverse events and improve patient safety, This document focuses on safe practices for EN therapy. The effective communication among all members of the multidis- objective is to provide recommendations based on either evi- ciplinary team is necessary throughout the process.4 dence (when available) or expert consensus that supports safe Collectively, team members must also develop and adhere to practices by clinicians who recommend, prescribe, review, pre- policies and standardized procedures for daily practice and pare, administer, and/or monitor patients receiving EN therapy decision making related to patient care. Standardization does and by their supporting organizational structures. Indications not refer to, and should not lead to, a one-size-fits-all strategy for EN and the ethics surrounding the use of EN are outside of for patient care. Instead, it refers to the development and the scope of this document. implementation of technical and practice standards into a pro- To develop this document, an interdisciplinary group of cess so that all healthcare providers deliver the same level of American Society for Parenteral and Enteral Nutrition safe care.5 Opportunities exist for standardization across the (ASPEN) experts identified key questions related to EN From 1Clinical Nutrition Support Services, Hospital of the University of Pennsylvania and Department of Nutrition, Drexel University, Philadelphia, Pennsylvania, USA; 2Shield Healthcare, Valencia, California, USA; 3Northshore University Hospital, Manhasset, New York, and Hofstra University NorthWell School of Medicine, Garden City, New York, USA; 4Digestive Disease Institute Cleveland Clinic Cleveland, Ohio, USA; 5Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA; 6Baptist Health Systems and University of Mississippi School of Pharmacy, Jackson, Mississippi, USA; 7Sanford University of South Dakota Medical Center, Sioux Falls, South Dakota, USA; 8Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; 9Indiana University Health, Indianapolis, Indiana, USA; 10Mount Carmel West Hospital, Columbus, Ohio, USA; 11Loyola University Medical Center, Maywood, Illinois, USA; 12Memorial Sloan Kettering Cancer Center, New York, New York, USA; 13University of Rochester Medical Center, Rochester, New York, USA; 14University of Texas Center for Health Sciences at San Antonio, San Antonio, Texas, USA; 15University of Chicago, Medicine Comer Children’s Hospital, Chicago, Illinois, USA; 16Aurora Lakeland Medical Center, Elkhorn, Wisconsin, USA; 17Baylor University Medical Center, Dallas, Texas, USA; and 18American Society for Enteral and Parenteral Nutrition, Silver Spring, Maryland, USA. Financial disclosure: None declared. Conflicts of interest: L. Harvey and J. J. Wessel are members of the Abbott Nutrition Speakers Bureau. M. L. Beebe is a member of the Nutricia Speakers Bureau. L. Lord is a member of Nestlé Nutrition and Bard. All other authors have no conflicts of interest to report. Received for publication June 14, 2016; accepted for publication September 14, 2016. This article originally appeared online on November 10, 2016. Corresponding Author: Peggi Guenter, PhD, RN, FAAN, ASPEN, 8630 Fenton St, Suite 412, Silver Spring, MD 20910, USA. Email: [email protected] Boullata et al 17 practice issues with safety implications. These questions were lay press about water contamination are giving clinicians then grouped into relevant sections, including patient assess- and patients a reason to pay closer attention to the source of ment, EN prescribing, order review, EN access, product han- their water. For the patient receiving EN, there are multiple dling, administration, monitoring and reassessment, and points of interface with water and therefore will be discussed transition of care. The term order is used throughout the docu- here briefly. Water is used to hydrate the patient, flush the ment to refer to an EN prescription or the act of prescribing EAD, and dilute medication and powdered formula. EN. Administration was further divided to focus on tube Clinicians should be familiar with the terms used when patency, medications, and complications, as well as general describing water (Table A1).1 Regulations for drinking water approaches. A number of topics crossed sections. These are (Environmental Protection Agency) and bottled water (Food addressed in depth in only one section and