Enteral Practice Standards
Can anyone share their practices regarding enteral therapy? Specifically, I have 2 questions: 1. For bolus feeders, how many catheter tip syringes do you dispense, one per week, one per day or something different? 2. How do you handle patients who insist on washing out pump sets or gravity sets to use them for multiple days even though the manufacturer recommends a daily change? Do you charge a per diem for every day they are on service or only for the number of sets you send?
Submitted by: Samuel Wachsman, RPh, Manager, Pharmacy Services Horizon Healthcare Services
Response Summary
There were 5 Listserv responses to Samuel’s question. In summary, there were actually three questions asked, the third being is there is a per diem charge for sets whether they used it or not.
Kristen Letzo RN, MSN, CRNI, OCN, Clinical Coordinator, Home Health Resource stated “According to our enteral nutrition coordinator, we send out 1 syringe per week for the bolus feeders. The second scenario, we send 1 set out daily and charge as such. We also attempt to get the patients to use a set daily because that is the manufacturer's recommendation.” There was much discussion regarding the manufacturer’s recommendations and the provider’s liability.
Katherine Werner, MHA, RN, VP Professional Affairs, NHIA stated, “Medical devices go through a process of FDA approval. Following the manufacturer's recommended guidelines is a safer option in terms of the best possible outcome for the patient, because when you use a device as directed you are using the device in the manner in which it received FDA approval. This offers the best protection for the patient in terms of using the device safely and it also offers the best protection for the organization in terms of risk management. If a patient chooses to wash enteral sets as a cost savings measure, I would treat this as an exception to a recommended procedure and document that this was the patient's choice and that the patient/or family member was given instruction and informed of the risks.”
Ken Fagerman, R.Ph., M.M. stated the following regarding enteral pump set use with references, “For economy, enteral pump set reuse has been a common practice and highly variable but with declining costs should be discouraged. Additional considerations are formula composition (i.e. full or diluted), hang time and patient reliability with sanitary compliance. Un-preserved formula will rapidly grow high concentrations of harmful bacterial in as little as 3 hours. Diarrhea, fever, and even pneumonia and septicemia can result.
Preserved formulas (i.e. Potassium sorbate) perform much better under poor patient sanitary conditions, long hang times and high room temperatures and may even be a therapeutic alternative in cases with these reported or repeat problems and I personally encourage their use whenever possible and long term have better outcomes in the homecare situation with their use.”
Fagerman KE, Dean RE. Tap water as a source of enteral feeding contamination. (Lett). Nutr Supp Serv 4:9, 1984.
Fagerman KE, Paauw, JD, McCamish MA, et al: Effects of time, temperature, and preservative on bacterial growth in enteral nutrient solutions. Am J Hosp Pharm 41:1122-1126, 1984
Levy J, Van Laethem Y, Verhaegen G et al: Contaminated enteral nutrient solutions as a cause of nosocomial bloodstream infection: A study using plasmid fingerprinting: JPEN 13:228-234, 1989
David Franklin addressed the third question regarding per diem charges for the bag sets, “The per diem charge represents reimbursement for a multitude of products and services, including the constant availability of clinical staff and all of the other direct and indirect (overhead) expenses incurred. I have often been asked how one can bill for a 30 day per diem when only 15 syringes were sent, and the answer is that you are not billing for syringes. You are billing for a day of therapy and all that this entails. If a patient was on active therapy for 30 days, a 30 day per diem applies. The specific quantity of supplies is not relevant.”
Rock-Pond Analysis
We thank all of the responders to Samuel Wachsman’s questions. Costs, liability, patient concerns and common sense should dictate provider’s practices to not only enteral therapy but to all services that we provide. Standards of practice establish the bar where at a minimum, providers should service their patients. There are unique situations that can arise with patients that can alter the course services away from a standard of practice.