Can Pharmacy and Enteral Nutrition Resources Be Streamlined?

 

The clinical complexities and requirements of your neonatal patient population when dealing with enteral feeding systems impact your resource decisions.

When looking at purchasing an enteral feeding system for the NICU, the focus is on feeding. When looking at enteral administration systems in the pharmacy, the focus is on the medication.

Feeding and medication: One resource for all?

The co-administration of medications along with enteral feeding is necessary, but the NICU and pharmacy have different functions and clinical practice.

NICU Feeding

The goal of enteral feeding in the NICU is to allow neonatal patients to tolerate feedings given directly into the stomach, and to absorb and breakdown nutrients. This allows for optimal growth and healthy outcomes.  “The gastrointestinal tract takes in water and food, extracts energy and nutrients from the food, and expels the remainder as waste.”1

The GI tract also assists in providing immunity to toxins through various mechanisms and this helps to avoid disease.  “The GI tract is the pathway food takes from the mouth, through the esophagus, stomach, small and large intestine within where the nutrients are extracted for the needs of the body. The residue then passes to the rectum where it is evacuated.”2

The enterally fed neonate bypasses the first two steps in the pathway – mouth and esophagus – as feeding tubes are placed OG, NG or ND, NJ and patients are then fed continuously or intermittently, via an infusion pump or by gravity and bolus administration.  The selection of enteral products for the neonatal patient and the choice of feeding depends on many factors: “clinical guidelines contain recommendations that are based on evidence from a rigorous systematic review and evaluation of the published medical literature.”3 Syringes for medication do not routinely need to consider the nutritional requirements, patient’s clinical condition, or their ability handle the nutrition given to them.

The specialized needs of the neonatal and pediatric population need to be recognized when enteral feeding is selected. Regulating agencies such as ASPEN, Academy of Nutrition and Dietetics, HMBANA and others all provide specific guidelines and recommendations for enteral feeding. Products are on the market that provide for the specific needs of the neonate such as the inline warmers, closed lid feeding systems, rotating enteral pumps to give fats first, easy to read NGT numbering, and end holes among other specific features to focus on better outcomes.

NICU Medication

Administration of medications via the enteral route is also essential and tied to the enteral feeding system. But pharmacy focuses on different options when selecting an enteral vendor. Therefore, most hospital systems have historically chosen to allow both the pharmacy and clinical area to choose a primary vendor if the systems can function together.

Pharmacy needs high volume and non-sterile, bulk-packed syringes, not the sterile, individually-packaged units.  Pharmacy draws up medications from various types of bulk packaged liquid containers and needs many adaptors.  Pharmacy focuses on the stability, dose, compatibility, and administration of the drug to the patient. While the medical unit focuses on these things also, the nutritional needs and clinical condition of the patient are also essential. Pharmacy also has specific-need syringes (0.5ml, amber) that function well in clinical use – but these can also be provided as needed from pharmacy vendors. Pharmacy and Clinical units are intertwined with different focuses on clinical practice, and the one supplier resource does not always apply.

Separate needs within the NICU

I always use the analogy of buying a car when talking about enteral systems in the pharmacy and clinical areas. Most people purchase a car because of safety, price, family needs, and many other reasons that work well for your lifestyle. If you are looking at additional features like needing extra rack space, holders for cell phones, or other accessories, you might look to another manufacturer, as these are items not essential to your needs from the car purchase. These items still might be essential for your family, but most people will not overlook a car purchase if it’s a perfect fit because of items that come as accessories for use with that car.

When looking at new enteral systems, especially with the new ENFit designs and regulations changing enteral products, remember to look first for what is best for clinical best practices in the NICU.

Pharmacy defenitely needs to be included in the decision-making process, but it is a separate department with a somewhat different focus. A one-vendor solution does not always apply between enteral feeding and enteral medications.

Inquire with your enteral vendors what options they have for both clinical units and pharmacy. The key is to evaluate what fits the needs of your unit, and what fits the needs of your pharmacy. While efficiency demands streamlining to one resource, meeting those unit needs is the priority, and may require separate sources for the right products.

References:

• New World Encyclopedia, May 23, 2017, http://www.newworldencyclopedia.org/entry/Gastrointestinal_tract (Accessed July 19, 2017).
• University of Missouri. “Anatomy and Function of the Gastrointestinal Tract.” Muhealth.org. http://www.muhealth.org/services/surgical/bariatrics/getting-started/anatomy-and-function-of-the-gi-tract/ (accessed July 19, 2017)
• ASPEN Clinical Resources & Guidelines 2017, http://www.nutritioncare.org/Guidelines_and_Clinical_Resources/Clinical_Guidelines/ (Accessed July 19, 2017)