Evidence-Based Review and Discussion Points.

Abstract

In the pediatric intensive care unit (PICU), effective and safe delivery of enteral nutrition is a necessary aspect of care. As in critically ill adults, enteral nutritional support is associated with lower rates of morbidity and mortality among critically ill children in the PICU. Enteral nutrition is most commonly delivered through a gastric or postpyloric feeding tube.Commonly, postpyloric feeding tubes are placed at the bedside by using a blind insertion technique and radiographic confirmation of the tube’s location. Blind placement of postpyloric feeding tubes is prone to complications (eg, insertion in the bronchial tree or stomach, aspiration during the procedure, and migration of the feeding tube after placement), which require repositioning and repeated radiation exposures to assess the location of the feeding tube. In light of the complications and resource intensiveness of placing postpyloric feeding tubes, a safe and effective method of delivering enteral nutrition is needed in critically ill children. A promising innovation that has been effective in critically ill adults, use of electromagnetic devices to place postpyloric feeding tubes, may enhance safety and quality of care in critically ill children who require enteral nutritional support.The authors of this EBR sought to determine the effectiveness of an electromagnetic device for placing postpyloric feeding tubes in reducing the radiation exposures, intrahospital transports, costs associated with the device, and the number of attempts needed to place the feeding tube. In a quasi-experimental study (N = 73), the authors compared a retrospective control (n = 30), participants who received the standard of care for the placement of a postpyloric feeding tube, with participants (n = 43) who received the intervention condition, postpyloric feeding tubes inserted by using an electromagnetic device. The authors screened patients hospitalized in a 23-bed PICU at a pediatric teaching hospital; participants were less than 18 years of age (including neonates ≥ 3 kg) and required placement of a postpyloric feeding tube for administration of enteral nutrition or medication. The feeding tubes were inserted by trained advanced practice nurses, and data were abstracted from patients’ medical records.The authors conclude that using the electromagnetic device to place postpyloric feeding tubes is a safe and effective method for delivering enteral nutrition in critically ill children. When comparing the outcomes of participants in the control condition with participants who received the intervention, the authors report fewer radiation exposures, placement attempts, intrahospital transports, and tubes used among participants who had the postpyloric feeding tubes placed by an advanced practice nurse using the electromagnetic device. On the basis of their results, the authors suggest that use of an electromagnetic device to place postpyloric feeding tubes can enhance the quality of care for critically ill children.Ann-Marie Brown, phd, cpnp-ac/pc, ccrn, fccm, lead author on this EBR article, provides additional information about the study. She says that the study grew out of a long-standing interest in enhancing nutritional support among critically ill children.Concerned about radiation exposures, feeding tube–associated complications, and the resource intensiveness of managing postpyloric feeding tubes in critically ill children, Brown seized an opportunity to generate evidence for a practice change. She recalls, “Our PICU typically provides enteral nutrition via gastric feeding and this led to multiple placement attempts, bedside x-rays, and trips to radiology to have feeding tubes placed under fluoroscopy.” According to Brown, nursing time was lost, initiation of enteral nutrition was delayed, and unnecessary radiation exposures resulted from the routine care practices in her PICU.Noting the limited evidence on the use of electromagnetic devices to place postpyloric feeding tubes in small infants and the general pediatric population, Brown and her coauthors seized an opportunity to advance the science in this clinical area. “We decided to take the opportunity as we implemented the device at our institution to study its utility not only in terms of effective tube placement, but time and effort to place the tube, and safety in potential radiation exposures,” she comments.Brown encourages readers of the American Journal of Critical Care to consider using an electromagnetic device to place postpyloric feeding tubes in critically ill children who require enteral nutrition or medication administration. “We demonstrated significantly reduced radiation exposures and the number of attempts for successful electromagnetic postpyloric feeding tube placement, thus enhancing patient safety, shortening time to initiating enteral nutrition, and improving staff efficiency,” she says. According to Brown, findings from this study and others provide evidence in support of using an electromagnetic device to place postpyloric feeding tubes as a safe alternative for delivering enteral nutrition.Brown and her coauthors urge PICU providers to take the opportunity to study the effectiveness of electromagnetic devices to place postpyloric feeding tubes. “Our study supports the idea that different [organizational] cultures and care routines across PICUs may result in varying utility of adjunctive devices, warranting individualized evaluation and examination of risk and cost benefits,” she adds.This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Ann-Marie Brown, phd, cpnp-ac/pc, ccrn, fccm, is the director of a research center and a pediatric nurse practitioner in the intensive care unit at Akron Children’s Hospital. She has more than 30 years of experience centered on the care of critically ill neonates and children.As a clinician and scientist, Brown is passionate about generating new knowledge that can influence practice and improve the care of critically ill children. “I maintain my practice in the PICU a few days a month. Why? I still love the bedside, plus it is there that the clinical questions arise and I can work with my nursing, medical, dietitian, and other colleagues in a clinical and research role,” she explains.Brown shared another reason why she maintains a blended role as a clinician, administrator, and scientist. She remarks that, “One of the benefits of research is we have the opportunity to touch the care of children around the world by sharing our findings. So I have the best of both worlds: making a difference by direct contact and the human response, and developing and sharing knowledge to impact many.”