LRCSSL-SS North August 2014 Vicki Bell, Leanne Bowie, Rachael Filby, Aimee Taylor

“Don’t Take it Lying Down” Sharing the journey of Enteral Nutrition from a Large Residential Centre

Early Literature - Summary

•! Showed significantly higher risk of death within 1 year of the procedure

•! Survival was only 50% after 1st year •! Should be the last choice due to high mortality •! PEG will increase risk of aspiration pneumonia •! Feeding tubes do not prevent aspiration pneumonia •! Potential for considerable harm •! Overall survival poor •! Mortality rates substantially higher for those who were tube

fed compared to those not •! Even though widely used can actually worsen feeding

outcomes •! PEG insertion increases mortality & should be avoided •! “We suggest a dedicated attempt at feeding by hand”

History – Enteral Nutrition in LRCSSL-SS North

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1996

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2002

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Surviving Deceased

Speech Pathologist - Pre Procedure

•! Diagnosis – severe/profound dysphagia •! Is enteral nutrition the right way? •! Interdisciplinary forum via Complex Health Care

Meeting •! Explore suitability:

!!anatomical

!!consent/refusal

•! Construct forewarning social story

Speech Pathologist - Post Procedure

•! Ideally management remains an interdisciplinary process

•! Speech Pathologist can be a conduit for communication of person’s needs to appropriate members of the team

•! Continue to work closely with Dietitian

•! Anatomical – striated muscle-use it or lose it! •! Healthy oral environment •! Quality of life – ‘it’s not fair!’

•! Person may request favourite flavours

•! Reversible - may be temporary nutritional support – muscles maintained

•! Small amounts of oral intake may not be exhausting – complete meal is

Why maintain oral intake?

Why not maintain oral intake?

•! CAN BE CONTRA INDICATED

!! if there is a total aversion to food/fluids

•! Signs:

!! physiological

!! physically resisting any food/fluid

!! loudly vocalising when food is anticipated/

presented

Speech Pathology - Summary

•! What’s important for Speech Pathologists?

!!Remain upright (as possible) for delivery

!!Oral hygiene!!!!!

!!Ongoing support and education for support worker

!! Individualised plans

Occupational Therapist - Planning/Seating

•! Wheelchairs and seating •! Shape customised seating systems

•! Social and community inclusion

•! Environmental factors

Positioning

•! Experiencing reflux when in a laying position significantly impacts the individuals risk of aspirating

•! Positioning of trunk, head and neck in an upright posture •! Staff awareness and education includes:

!!No reclining or tilting wheelchairs

!!Applying pelvic straps and harnesses

!!Repositioning prior to delivery of enteral nutrition

Case Study – Customised Shape Seating System

•! Diagnosis of intellectual impairment and

complex physical deformities •! Postural assessment •! Fittings and trial of shape seating

•! Positioning of anatomical regions within the shape

Dietitians should be part of the decision-making process when deciding if enteral nutrition is required and appropriate

•! Benefits of dietitian involvement

!! Contribution to education !! Gathering objective baseline data to measure outcomes

!! Assessing the nutritional status of the person and any complicating factors

!! Assessing volume tolerance to guide initiation of feeding !! Assessing the risk of Refeeding Syndrome

Early involvement of a dietitian

Refeeding Syndrome – what is it?

•! Also known as Nutrition Recovery Syndrome •! Adverse body response that occurs with re-initiation of

nutrition (either enteral or oral) after a period of poor intake or starvation

•! The body suddenly switches from starvation mode, to feeding mode which stimulates insulin release and cellular uptake of electrolytes

•! Results in dangerously low serum levels of phosphate,

magnesium and potassium, thiamine deficiency, and sodium and fluid retention

•! Potential consequences: cardiac failure, arrhythmia,

delirium, seizures and death

Refeeding Syndrome – who’s at risk?

Any instance where nutrition intake is restarted after a period of decreased intake

•! Most significant risk factors: !! Severely underweight

!! Acute weight loss of 5-10% in the previous 1-2 months

!! Significantly reduced/no oral intake for >7 days

!! Abnormal electrolytes prior to re-feeding

!! Prolonged severe vomiting

!! Chronic malabsorption or malnutrition

Case Study 45yo female with CP (Athetoid Quadriplegia) - Spasticity of facial muscles causing bruxism Regular weight 40kg (HWR 37-53kg)

Initial referral

•!Bruxism – laceration of cheeks caused ulceration

•!3.4kg weight loss in 2 months (8.5%)

•!BMI 16 •!Reduced oral

intake •!Commenced

oral nutrition supplements

•!Discussed NGT

8 days later

•!Weight 32kg (loss of 20% body weight

•!BMI under 14 •!Attempt to

insert NGT failed twice

•!Strict intensive oral nutrition support (~80% supplements)

•!High risk of Refeeding Syndrome

3 weeks later

•!Hospitalised with influenza

•!Weight dropped to 30.8kg and stabilised

•!PEG procedure successful

•!Enteral feeding able to be commenced at regular rate

Today

•!40kg •!Healthy •!Happy •!Eats orally

when she wants to

•!Wants to continue using the PEG

What we do best

•! A customised enteral nutrition regime:

!!Never involves overnight delivery or delivery

whilst laying down or reclined

!!Delivery times mimic normal eating patterns

!!Maintain socialisation around mealtimes

•! Maintaining oral intake where possible

•! 6 monthly enteral nutrition reviews (Best Practice)

Preparation

•! After the experience of 1995 staff were very negative & resistive to Enteral Nutrition

•! Months prior to 2001 placement - huge amount time &

resources were given to turning people around to see this as a positive step

•! Those early years proved to be a steep learning curve •! In our experience the preparation/education remains an

important aspect in the continued positive outcomes

Education

•! Why & What is Enteral Nutrition

!! Insertion protocol !! Different tube types !! Care of the site & tube !! Delivery options !! Medication administration !! Tube changing !! Oral hygiene

Wisdom, reflection & experience

•! Sooner rather than later •! Preparation & education remain crucial to success •! Follow up from all team members post procedure needs to be

on going •! Oral hygiene & correct positioning are vital •! Enteral nutrition

!! can be used to support oral intake !! can be short or long term & is easily reversed !! can be used for fluids alone &/or medication administration

•! New technology & more portable equipment means that concern for reduced participation is no longer a barrier

•! Current literature supports that this is the way forward to ensure that positive outcomes continue

SO “Don’t take it lying down” – Positioning, learning & working together remains the key for continued successful outcomes

Literature References Slide 2

•! Abuksis G., Mor M., Plaut S., Fraser G., Nio Y. Outcome of percutaneous endoscopic gastrostomy comparison of two policies & four year experience Clinical Nutrition 2004 23(3):341-6

•! Finucane T.E., Bynum J.P.W. Use of tube feeding to prevent aspiration pneumonia Lancet 1996 348:1421-24

•! Raventos J.M., Kralemann H., Gray D. Mortality Risks of Mentally Retarded and Mentally Ill Patients after a Feeding Gastrostomy American Journal of Mental Deficiency 1982 86(5) 439-444

•! Strauss D., Kastner T., Ashwal S., White J. Tube Feeding & mortality in children with severe disabilities & Mental Retardation Pediatrics 1997 99 358

•! Tokuda Y., Koketsu H. High mortality in hospital elderly patients with feeding tube placement Internal Medicine 2002 41(8) 613-616

Literature References Slides 4-8

•! Stein P. S., Henry R. G. Poor oral hygiene in long term care. AJN 2009; 109(6): 44-50

•! Pace C. C., McCullough G.H. The association between oral microorganisms and aspiration pneumonia in the institutionalised elderly. Dysphagia 2010; 25: 307-322

•! Yoon M.N., Steele C.M. The oral care imperative; the link between oral hygiene and aspiration pneumonia. Topics in Geriatric Rehabilitation 2007; 23(3): 280-288

•! Prahlow J.A., Prahlow T.J., Rakow R.J., Prahlow N.D. AJN 2009 109(6): 38-43.

Tada A, Miura H. Archives of Gerontology and Geriatrics 2012; 55:16-21 •! Van der Maarel-Wierinck C.D., Vanobbergen J. N. O., Bronkhorst E. M.,

Schols J.M.G.A., de Baat C. Oral health care and aspiration pneumonia in frail older people: a systematic literature review. Gerodontology 2013; 30: 3-9

Literature References Slide 20

•! Gray D. S., Kimmel D. Enteral tube Feeding & Pneumonia American Association on Mental Retardation 2006 111(2) 113-120

•! McMahon M.M., Hurley D.L., Kamath P.S., Mueller P.S. Medical & Ethical Aspects of Long-term Enteral Tube Feeding Mayo Clinic Proceedings 2005 80(11) 1461-1476

•! Medlin S. Recent developments in enteral feeding for adults: an update British Journal of Nursing 2012 21(18) 1061-1067

•! Metheny N. A. Preventing complications of Tube feedings: Evidence-Based Practice AJCC 2006 15 360-369