After undergoing throat surgery as part of his cancer treatment, Dr. Clint B. temporarily needed to rely on a feeding tube to maintain proper nutrition. Even with a PhD in psychology and after years of conducting research in technology, gaming, and learning outcomes, Dr. B. was surprised to find that he and his caregiver were woefully ill-prepared for his feeding tube experience.
“We ended up being unnecessarily frustrated, worried, and stressed during an already difficult time. This led to several calls and visits to health care providers. We felt our anxiety and these visits could have been avoided had we been adequately prepared,” Dr. B. said at the American College of Surgeons (ACS) Clinical Congress 2011 Panel Session, What Do I Do When I Get Home?: Pre-Operative Skills Training for Your Patients.
Dr. B. went on to explain that he was so affected by his difficult experience that he decided to find out whether other patients who had used or were using feeding tubes shared his frustration. He invited patients from a variety of medical support blogs to describe the challenges they had encountered when using feeding tubes. Dr. B. received responses from 76 individuals who raised such common questions as the following:
- What can go in the tube?
- How do I clear an obstruction?
- How can I clean it without damaging it?
- Why does the tube keep coming loose when moving about and is this dangerous?
Based on the concerns that the respondents offered, Dr. B. reported, “Although the use of a feeding tube may seem elementary, the data suggest that these aids are anything but intuitive. Patients are distressingly uninformed about the use and maintenance of feeding tubes. This leads to needless anxiety and, doubtless, unnecessary visits to health care professionals. There is also a risk that patients will harm themselves in attempting to solve common feeding tube problems.”
To address the types of challenges that Dr. B. and other researchers have identified with regard to in-home use of feeding tubes, the ACS has developed a Patient Feeding Tube Home Skills Kit (see Figure 1). This new patient education resource applies the same principles that the Surgical Patient Education Committee of the ACS Division of Education has used to develop other patient education programs and is the second in a series of tool kits for in-home postoperative care. Building on the model used to create the first such resource—the ACS Ostomy Home Skills Kit—the feeding tube program provides patients and their caregivers with the tools and information they need to develop the skills needed to experience optimal recovery from an operation and to manage enteral nutrition.
Rationale for the program
As part of the series of skills training programs, the Patient Feeding Tube Home Skills program was created based on the following primary considerations:
- Many patients and their families experience the types of problems that Dr. B. identified.
- Clinical research has shown that a high number of postoperative complications occur when a feeding tube is used in the home setting.
- Shorter inhospital stays have led to greater patient/family responsibility for self-care.
- Surgeons can use this type of patient education to comply with government regulations pertaining to meaningful use of the electronic health record (EHR).
Although home enteral tube feeding is perceived positively in most situations, particularly because it means improved nutrition, strength, and survival, most patients who undergo this type of treatment and their families identify ambulatory restriction, practical problems, and overall distress in their daily lives.1 The amount and quality of information they receive from health care professionals is strongly related to their ability to manage their care, and patients overwhelmingly choose their physicians as their primary source of information about their postoperative care. Unfortunately, caretakers report a lack of consistent, anticipatory education to support the knowledge, coping skills, and confidence patients need to manage the often complex realities of the postoperative experience.2,3
Furthermore, clinical research has confirmed the need for this ACS home skills program. While feeding tube insertion is a safe procedure, complications in the home care setting are high and range from 7 percent to 92 percent within the first two years of tube insertion.4-8 Common complications include the following:
- Development of granulation tissue (67 percent) at the tube insertion site, with 67 percent of patients reporting substantial pain
- A broken or clogged tube (45 percent to 56 percent)
- Tube leakage (56 percent)
- Infection requiring antibiotics (6 percent to 45 percent), gastrointestinal complications (63 percent), and pneumonia (50 percent)4-8
A recent review showed that these complications occur globally, and while the incidence may vary across countries, the complication rate in the home setting remains high.7 Feeding tube complications are associated with family distress, increased health care costs, frequent practitioner visits, and higher rehospitalization rates 4,6-8 For patients who are elderly or have dementia, a study found that in 17 months, 33 patients had 138 separate emergency room (ER) visits; 92 percent of these visits were for unintentional extubation, and another 6 percent were for clogged tubes.9
Moreover, the Agency for Healthcare Research and Quality (AHRQ) Guide to Patient and Family Engagement in Hospital Quality and Safety identifies increasing discharge knowledge and skills as a key strategy to increase engagement, reduce adverse events, and reduce hospital readmissions.10 Many studies report up to a 20 percent incidence of an adverse event within four weeks of hospital discharge, and 75 percent of these adverse events could have been prevented. The authors estimate that the cost of these unplanned hospitalizations was $17.4 billion.11-13 Discontinuity in instructions among providers, misunderstanding of information, and inadequate preparation for discharge were all cited as challenges that could be improved.
In addition, technological advances in surgery, anesthesia, and nursing have accelerated postoperative recovery times and resulted in shorter hospital stays. At present, 65 percent of procedures are performed on an outpatient basis.10
“The patient and their caregivers are playing an increasingly important role in postoperative care. Thus, education and training to best prepare them is critical to a safe discharge and recovery,” said Ajit K. Sachdeva, MD, FACS, FRCSC, Director, ACS Division of Education, and Co-Chair, ACS Patient Education Committee. “With nearly 500,000 patients in the U.S. relying on feeding tubes as part of their treatment plans, the home skills kit will make a widespread impact.”
Providing patients with the skills and information they need to have a safe and effective in-home recovery also has affected a surgeon’s ability to comply with regulatory standards. More specifically, the Centers for Medicare & Medicaid Services’ (CMS) Meaningful Use Stage 2 Core Measures require that eligible providers offer patient-centered education resources to their patients in order to maintain the ability to participate in the Electronic Health Record Incentive Program.14 This regulatory mandate responds to a finding in the Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, which identified that improved health care requires the development of a system designed to serve the needs of patients and that ensures they are fully informed and able to retain control and participate in care delivery.15
The ACS home skills program is ideal for certified providers and hospitals seeking to meet the patient education core meaningful use requirement and improve a patient’s quality of care. “Patient education is recognized as critical to improving the health care system, and now electronic health records all require info button-enabled materials that are ready to print or be e-mailed to the patient with a copy placed in their EHR,” said John M. Daly, MD, FACS, FRCSI(Hon), Co-Chair, ACS Patient Education Committee, and coauthor of this article.
How the program works
To achieve a national consensus on the best methods for teaching patients and their families about feeding tube management, the Patient Feeding Tube Home Skills Kit was developed in collaboration with patients and multiple professional associations (see Table 1). The Patient Feeding Tube Home Skills Kit explains and demonstrates the distinct steps involved in home management and delivery of nutrition through a feeding tube. The educational simulation is intended for patients and/or caregivers, as well as surgeons, nurses, and other health care professionals, to learn and practice the skills necessary for optimal recovery and delivery of enteral nutrition.
The kit includes the following items (see Figure 2):
- A 44-page booklet divided into four easy-to-reference chapters.
- The Skills Simulation Equipment, including the enteral feeding tube (EFT) practice model; syringes and extension set kit; and two medicine cups. The feeding tube and syringe set has a label with the model number to comply with standards, a warning that the tube is for demonstration only, and 1-800 customer service number.
- The instructional video demonstrating feeding tube management supported by a step-by-step checklist to guide skill acquisition.
- A professional medical provider checklist for validation of knowledge and ability.
- A patient evaluation of the home care experience.
Funded through philanthropy
The ACS Surgical Patient Education Program is ideally aligned with the charitable mission of many corporations. With its emphasis on improving care for the surgical patient, the program has provided medical device manufacturers with a way to give back to the surgical community through philanthropic support. For example, Coloplast has been a multi-year partner in the Ostomy Home Skills Kits, and Smith & Nephew has provided funding for the wound care program. Educational grants from these companies have helped fund the development and distribution of the patient skills kits.
As with any new product, the initial expense to produce and evaluate the educational kits is significant. In partnership with the ACS Foundation, the ACS Division of Education has received generous grant funding for patient education programs and sees this resource as a way to not only improve surgical outcomes and the quality of life for patients but also to provide an additional benefit to ACS surgeon members. These educational grants allow the kits to remain affordable.
In this latest venture, the ACS Surgical Patient Education Program will produce, distribute, and evaluate 2,500 Feeding Tube Home Skills Kits over the next two years, funded by an educational grant from Applied Medical Technology, Inc. (AMT).
“Applied Medical Technology is proud to partner with the ACS to support patients and their surgical caregivers with evidence-based education materials on feeding tube management post-discharge. AMT is committed to the care of their patients through education, innovation, quality products, and building customer loyalty. We have focused on enteral feeding for over 25 years and it is our core concern and business,” said AMT founder George Picha, MD, FACS.
The ACS Foundation’s Sustaining Fund, which supports ACS programs that are not fully funded, is an additional source of philanthropic contributions. According to Shane Hollett, Executive Director, ACS Foundation, “The Surgical Patient Education Program, with its emphasis on an optimal care experience for patients, falls perfectly within the crosshairs of the Sustaining Fund’s directive.”
If past experience with the skills kits developed through the ACS Surgical Patient Education Program is any indication, the Patient Feeding Tube Home Skills Kit promises to be a welcome aid to patients. Two trial data collection programs have been completed to assess the effectiveness of the ostomy skills program (see Figures 3 and 4). Results from the ACS Ostomy Trial 1 indicate that ACS Ostomy Home Skills Kit users have significantly greater self-confidence, satisfaction, and knowledge in comparison with patients who have undergone traditional training. These patients also have demonstrated higher skill levels in less time when compared with patients who have undergone traditional lecture education with images.16 Data from more than 400 ostomy patients from Trial 2 identified the skills kit as their best prep resource, presenting fewer complications, using 50 percent fewer resources (visits, calls, and home care nursing), and leading to a 50 percent lower admission rate within the first three weeks following discharge.17
Early surgeon users of the EFT skills kits have offered positive feedback. “This is fantastic material and an excellent patient education curriculum; this is from a person who leads the patient education center. I wholeheartedly support this effort and hope to direct patients to this resource,” said Brian B. Burkey, MD, MEd, FACS, vice-chairman and section head of the Section of Head and Neck Surgery and Oncology, Cleveland Clinic Head and Neck Institute, OH.
To learn more about the ACS Patient Feeding Tube Home Skills Kit, listen to the March installment of The Recovery Room, an ACS-sponsored podcast with experts in surgery, medicine, ethics, and public health about the latest developments in medicine and health care, hosted by Frederick “Rick” L. Greene, MD, FACS. The podcast will be available on the ACS website. For more information, visit the ACS Surgical Patient Education Program website or e-mail Nancy Strand, MPH, RN, Manager, Surgical Patient Education, ACS Division of Education, at firstname.lastname@example.org.
- Kaisa B, Larsson M, Athlin E. Patients’ experiences of home enteral tube feeding (HETF)—A qualitative study. J Res Nurs. 2015;20(7):552-565.
- LeClerc C, Wells D, Craig D, Wilson J. Falling short of the mark: Tales of life after hospital discharge. Clin Nurs Res. 2002;11(3):242-263.
- Sliver H, Wellmen N, Galindo-Ciocin P, Johnson P. Family caregivers of older adults on home enteral nutrition have multiple unmet task-related training needs and low overall preparedness for caregiving. J Am Diet Assoc. 2004;104(1):43-50.
- Crosby J, Duerksen D. A prospective study on tube- and feeding-related complications in patients receiving long term home enteral nutrition. J Parenter Enteral Nutr. 2007;31(4):274-277.
- Alivizatos V, Gavala V, Alexopoulos P, Apostolopoulos A, Bajrucevic S. Feeding tube-related complications and problems in patients receiving long-term home enteral nutrition. Indian J Palliat Care. 2013;18(1):31-33.
- Crosby J, Duerksen D. A retrospective study of tube-related complications of patients receiving long-term home enteral nutrition. Dig Dis Sci. 2005;50(9):1712-1717.
- Ojo O. The challenges of home enteral tube feeding: A global perspective. Nutrients. 2015;7(4):2524-2538.
- Blumenstein I, Shastri Y, Stein J. Gastroenteric tube feeding: Techniques, problems, and solutions. World J Gastroenterol. 2014;20(26):8505-8515.
- Odom SR, Barone JE, Docimo S, Bull SM, Jorgenson D. Emergency department visits by demented patients with malfunctioning feeding tubes. Surg Endosc. 2003;17(4):651-653.
- Agency for Healthcare Research and Quality. Guide to Patient Engagement in Hospital and Health Care Safety. June 2013. Available at: www.ahrq.gov/professionals/systems/hospital/engagingfamilies/index.html. Accessed January 4, 2016.
- Jencks SF, Williams MV, Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med. 2009; 360(14):1418-1428.
- Silow-Carroll S, Edwards J, Lashbrook A. Reducing hospital readmissions: Lessons from top-performing hospitals. The Commonwealth Fund. April 2011. Available at: www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf. Accessed January 14, 2016.
- Kripalani S, Jackson A, Schnipper J, Coleman EA. Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists. J Hosp Med. 2007;2(5):314-323.
- U.S. Department of Health and Human Services. Meaningful Use Stage 2. 2012. Available at: www.hrsa.gov/healthit/meaningfuluse/stage2/. Accessed on January 4, 2016.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press;2001.
- Heneghan KC, Sachdeva AK, Davis E, Bailey HR. Surgical skills patient education program. J Cancer Educ. 2009;24(S1):72.
- Heneghan KC, McGee MF, Bailey HR, et al. Ostomy Home Skills Kit (OSHK) is effective at preparing patients to confidently manage their post-operative recovery. J Cancer Educ. 2015;30(3):320-321.