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!
I’m pretty sure this is the tubing we use. That cap is not on there tightly to begin with so it’s not sterile.
I also do not have the pump prime the tubing. I prime it myself.
I think you are way overthinking this. If you are absolutely concerned, wipe it with an alcohol swab as others have suggested.
To me, this is not like an IV line where it hooks into the bloodstream and you really need to watch how you are doing it. It’s tube feeds. And how often are you missing the white cap?
My only question is how long are those feeds sitting in the bags in the fridge before being used? And how long are they then hanging? They are only good for 24 hours. Once they are in the bag. They should not be premixing and putting in the fridge.
Most of my tube feeds are in sealed containers that we screw the tubing into. But every once in a while, we have a type that needs to go into the bag. It’s done at bedside and dated. That’s where your bacteria will collect.
I would give it unless the patient was immunocompromised. But even then, if not giving it meant they would go without feeding for the night, I think the nutrition is more important than the small risk of contamination. I'd also think about where the tube is placed. If its going into the stomach the bugs will be destroyed by stomach acid. If its going into the jejunum, an infectious bug has a better chance to grow. Definitely a judgement call, but I'm 90% for administering the feed.
I personally will not give/admin any consumables that are open but not dated.
If the bag was already spiked and not dated I would not admin without confirmation that it was good, but I would likely still hesitate. I'm funny like that.
I could picture the set-up in my head while reading because these are the exact same bags/tubes/pumps we use for our enteral feed residents. I have to say I am not fond of the new tubes with the end cap and a tube connector that screws on for the reason you describe. They come off way too easily! They occasionally come unscrewed during use and leave the poor resident in a puddle of feeding formula with the end cap hanging loose while the connector is still inserted in their feeding tube and the pump is merrily working away and administering the formula to the bed through the now open end cap. Boy is that a mess!
Why your bags of formula come from another floor and are stored in a refrigerator with the tubing already connected is a mystery. And why there is no back-up feeding formula or equipment available to administer it is also a mystery. Maybe your reluctance to give that feeding should trigger a system review and maybe change the way the formula is delivered to the floor that needs it because that system seems less than ideal to say the least.
As far as your particular situation I would have simply wiped the end cap with an alcohol swab, screwed on a new connector and carried on with business as usual. But I'm guessing from the strange way your feeding formula is delivered you probably didn't have new, unopened clean connectors available so I can't fault you at all. I wouldn't just re-screw on the connector that came loose either, no telling where that's been and cleaning the inside of it would be next to impossible.
Kaisu
144 Posts
I always answer these with "would I want this to be administered to me or someone I love?". The answer is heck NO. I would not administer it.