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!
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.
Since you don't know how long it had been uncovered, I agree with your decision to not administer it. Although enteral feeding is not a sterile process, we wouldn't feed our PO patients questionable food either.
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?
We don't mix it. I believe the dietary unit does. But correct on the rest. I would have preferred to prepare a new bag/tubing. I didn't have one on that shift and I am sure we do.
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.
If by immunocompromised you mean in the medical sense (neutropenic etc) then I would have done the same thing because it would not be worth the risk bc you are right that you dont know where its been or how long it was opened. I have worked Onc and seen pt's get very very sick from what we think are the smallest things/situations.
If by immunocompromised you mean in the medical sense (neutropenic etc) then I would have done the same thing because it would not be worth the risk bc you are right that you dont know where its been or how long it was opened. I have worked Onc and seen pt's get very very sick from what we think are the smallest things/situations.
You had to have PPE to be around the pt. I always remind myself to be more mindful of my PPE pts and their immune systems.
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 think I would. Like if a can of soda was open by the time it got up to my unit/patient I would serve the can of soda even if technically the soda in the can might be fine.
I think I would. Like if a can of soda was open by the time it got up to my unit/patient I would serve the can of soda even if technically the soda in the can might be fine.
I do understand your concern but why not take it a step further and be concerned about what dietary is doing with it? And you also should have been able to estimate the max time the tubing was exposed, because it should be labeled with the date/time it was mixed/put into the bag with the tubing. If those things aren't happening you have more to worry about.
I fail to see what would be so difficult about nurses mixing/spiking TF at the bedside.
I have zero idea what I'm talking about here but if this is some situation where there's bullk stock of this somewhere that is being mixed, portioned out and spiked in dietary then sent around to floors, you probably have even more things to worry about than the cap on the end of unprimed tubing. Realistically speaking.
Anyway. FWIW, I would've spiked it with new tubing and primed it and hung it.
We don't mix it. I believe the dietary unit does. But correct on the rest. I would have preferred to prepare a new bag/tubing. I didn't have one on that shift and I am sure we do.
I kind of question the whole procedure - from an infection prevention stand, but also the nurses not having a back up supply on the unit.
Specializes in Pediatrics, Pediatric Float, PICU, NICU.
If the formula would have been primed all the way down to the open end where the cap was missing, I wouldn’t have hung it. But the fact that the tubing essentially wasn’t primed at all, so there is a large distance gap between where the end was “exposed” and where the formula is actually being held, yes I think you overthought the situation. I would have hung it after disinfecting the end of the tubing.
This isn’t like giving someone a can of pop that has been opened and sitting out, because that is a direct and short entry from the environment to the pop so the chances of bacteria entering are higher. Those kangaroo feeding bags are feet long, that’s a long distance and not direct. Just my opinion though; it’s definitely a judgement call.
ETA I agree with a previous poster that the entire practice is not optimal. The fact that you don’t have immediate access to a backup supply of formula also would have swayed my decision. If the patient has a condition or is getting medications where the feeds need to be on a strict schedule (ketogenic formula, hypoglycemic issues, etc) and I don’t have a backup supply of formula available, I definitely would have used that formula in this scenario.
Specializes in Surgical, Home Infusions, HVU, PCU, Neuro.
We spike or pour our tube feedings at bedside as well so I do not really understand the whole concept of the bag being mixed beforehand. Our pharmacy mixes our TPN and lipids and they have their proper procedures for that mixology, but to what measures is the dietary department taking when mixing these formulas and transferring them into the administration bag?
I would have also used the formula as well, especially if there was not an available alternative. You state that the patient in question was immunocompromised, so I do understand the concern for risk of infection, however, how much time and feedings were lost due to the feeding not being given? That is nutrients missed that the patient needs in order to aid with the healing process. I'm just curious if the attending doctor for this patient had anything to say as to the missed feedings.
IMO this seems to be overthought, realistically the distal opening of the tubing is a ways from the collection portion on the bag, nor is this process a sterile technique
Personally, I think it's a bit silly that the bags are spiked and left in the refrigerator, I really hope there is something I am missing because it takes close to no time to spike and prime new tubing. Also, not having tubing readily available should you need it, is alarming.
I get what you are saying, but what about that apple on your patients side table? How many times is it touched and moved by hands, gloved or not. You know the patient isn't getting up to rinse it off before taking a nice big bite. (Eww btw.)
Golden_RN, MSN
573 Posts
Since you don't know how long it had been uncovered, I agree with your decision to not administer it. Although enteral feeding is not a sterile process, we wouldn't feed our PO patients questionable food either.