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Help. Input. Agree. Disagree. Thoughts.

Nurses   (2,203 Views 30 Comments)
by NRNPH NRNPH (New Member) New Member

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I would love some input and bounce ideas off of anyone who is willing to give any thoughts on what they would have done in my situation. I refused to hang a feeding bag for a patient because of huge concern for infection (we searched the areas in hopes that another bag had been prepped but there were none and I would prefer to prevent possible infection rather than chance it). I am typing my thoughts out loud so I apologize if things are over simplified or all over the place. I know you all probably know this and know I don't have to over explain but its my current thought process. Thank you ahead of time.

We have pumps for enteral feedings. Some are prepared by mixing formulas and putting them in refrigerated bags with the tubing required for the pump already attached. I don't know if that image helps but think of an IV bag but filled with formula and the tubing is directly attached to the IV bag with a purple adapter at the end that should have a white cap with a cover cap on it. If you hang the bag you don't get anything in the tubing - you have to prime it through the pump - but squeeze the bag with your hand and the formula moves into the tubing. Not much, but enough to tell me that the bag is open to the tubing which means its open to the formula. The bag and the tubing are non sterile and technically the formula since it is prepared and not sterile either but my focus is on the formula. I refused to hang a formula for the best interest of my patient but a lot of my co-workers don't seem to understand why I didn't do what they would do - I will explain.

As a Nurse its all drilled into our heads that bacteria is everywhere, try to be as clean as possible, etc. to prevent infection. I know we have bacteria in our gut. I know that the pump set is non sterile, that the steps to connecting it to the PEG is non sterile, I get that. So I get this bag from the fridge with nothing in the tubing (normal) and head into the room which i need to wear PPE for. I hang the bag, get the tubing correctly in the pump, then grab the end of the tubing that will attach to the PEG tube so that I can prime the tubing into a container of some sort. I get to the end of the tubing to find that the purple adapter at the end with a white cap and a cover for the cap (this is the portion where you take off the cap cover and connect it to the PEG) is gone. The white portion with the cap screws on and off (which we do not do, they come already screwed on) and somehow it was gone and the purple adapter (its just the open end of the tubing with purple plastic around it so that the white part can screw on and off) was uncovered.

Ok, so I have a bag with tubing that is non sterile, being transported, the white cap got lost somehow, so now the tubing is what I consider "opened." Yes, the formula is in the bag and not in the tubing and doesn't come down the tubing until you prime it - well it does if you squeeze it but not the whole way - so it wouldn't be a big deal to just place the formula into another pump bag we have and use it right? As long as the tubing is just changed out everything should be fine and not a big deal right? My Charge and some other RN's were all telling me that but I just for some reason couldn't understand why they couldn't understand so maybe I am crazy. Anyways reading those things it sounds okay right? Well in my head I kept thinking WRONG. Like felt it in my gut WRONG. Like I am still asking about it WRONG. Because be squeezing the bag and seeing it flow into the tubing shows me that the formula is "open" to the tubing. The white portion that connects to the PEG was gone who knows when and during that time I don't know what the purple "open" tube bumped into or collected sitting in the fridge that we all reach into for patients. So my thought was, bacteria moves and grows through lines right? IV lines etc. That means whatever was in contact with that purple end would moved through the tubing and up to the formula or at least come in contact with the formula because its "open." I can't just connect the white cap on from another tubing set (i'd be screwing on the bacteria at the site that is closest to the PEG site) and I can't just change the bag and the tubing because it was "open" during transport, during it being in the fridge, etc. So in my head I am thinking the formula is no good. The formula was susceptible to whatever because it wasn't closed off with the white portion. The formula is what worried me. Bacteria love formula. Even the smallest colony would have a feast with formula. I didn't trust that simply changing the bagging and tubing would change the fact that the formula technically remained open to whatever because there was nothing on the other end. Ok I apologize about this long tirade. Please, thoughts. Agree? Disagree? Thank you!

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Emergent has 25 years experience and works as a Emergency Room RN.

6 Followers; 2 Articles; 63,548 Visitors; 2,696 Posts

Would you worry so much about a glass of milk or tray of food? 

You are overthinking this IMO. Enteric feeding is not a sterile procedure. 

 

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Just now, Emergent said:

Would you worry so much about a glass of milk or tray of food? 

You are overthinking this IMO. Enteric feeding is not a sterile procedure. 

 

I can see that point. I know enteric isn't a sterile procedure but if that purple cap just gets connected right to whats going into the patient any bacteria that got on that purple end is going to feed off of all that food moving through the tube.

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4 Followers; 17,695 Visitors; 2,727 Posts

Sooooo, why not swab the end with an alcohol pad?

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Emergent has 25 years experience and works as a Emergency Room RN.

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3 minutes ago, NRNPH said:

I can see that point. I know enteric isn't a sterile procedure but if that purple cap just gets connected right to whats going into the patient any bacteria that got on that purple end is going to feed off of all that food moving through the tube.

So what? There's bacteria on forks and spoons too.

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Just now, Wuzzie said:

Sooooo, why not swab the end with an alcohol pad?

not worried about the tubing. worried that formula was open to it. just bacteria in general. i know its non sterile but still you wouldn't just leave a can open without a lid on it and then just use it later right?

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BiscuitRN has 4 years experience as a BSN, RN and works as a School Nurse.

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If there was nothing structurally wrong with the tubing or connector pieces I'd connect it as intended.  If there was something structurally wrong I would dump the formula into a new bag.  I've never heard of formula being a particular "feast" for bacteria.  Sure, it probably has bacteria on it, but so does the fork you'll eat your next meal with.  A small piece of plastic probably doesn't help keep most of that bacteria away.

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1 minute ago, Emergent said:

So what? There's bacteria on forks and spoons too.

i get that but in my head I imagined it as if you left your drink or food uncovered especially in a patient fridge that already has god knows what from nurses in and out of there from patient rooms just open to your food. That's what it is. I saw the formula as uncovered food. Just thought bacteria, uncovered food, bacteria loves the uncovered food, pt is already sick anyways, try to prevent dealing with another issue. Didn't want to "chance" it. I get that you can see it like a glass of milk but to me every decision I make effects that person's life. That's just how it feels to me still. Hence why I didn't hang it.

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Half of me wants to say I over thought it but the other half of me said I don't know the condition of the formula regardless of it being non sterile it was open to the environment around it because nothing was covering the opening. I honestly was thinking to myself I don't want to give my pt bad formula. They were already immunocompromised, doesn't mean its ok to compromise it more.

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Daisy4RN has 20 years experience.

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So if I understand you, it was only the bottom of the tubing that was exposed and you are worried that the feeding itself was somehow tainted from the time you picked it up (just a few minutes), and the bacteria in that short time reached the feeding from the bottom of the tubing? I don't see that as the same as leaving food uncovered.

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4 minutes ago, Daisy4RN said:

So if I understand you, it was only the bottom of the tubing that was exposed and you are worried that the feeding itself was somehow tainted from the time you picked it up (just a few minutes), and the bacteria in that short time reached the feeding from the bottom of the tubing? I don't see that as the same as leaving food uncovered.

oh no. I don't know how long its been "uncovered". It could have been during transport. It's made on the first floor then moved and stored on our floor until we end up needing to use it. So I don't know how long it's been "open". If it happened in such a short trip I would have changed the bagging and be done.

Edited by NRNPH

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Are the nurses mixing formula & then pouring the formula into a bag, putting that bag into the fridge for administration at a later time?  

It's a shame that you couldn't just prepare a new bag/tubing.  It just takes a couple of minutes.  In my experience, formula was always prepared at the bedside for immediate administration.

Also, do you have an infection prevention nurse that you can consult to make sure you are complying with infection prevention protocols?

 

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