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Mallory Foster
Wendy Phillips
Healthcare costs in the United States are soaring. Efforts to improve patient care, safety, and
outcomes are ongoing goals particularly when they also result in a reduction in the cost of care.
Enteral feeding is the primary means of providing nutrition support to patients who cannot
meet their needs orally; nursing time and supply costs to administer that care are substantial.
One major academic medical center recently converted from an open system (OS) to a closed,
or ready to hang (RTH) system for enteral feeding. This article reviews that transition from
an OS to RTH and documents the costs, nursing perceptions, and lessons learned in the process.
INTRODUCTION
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COST
Handling of EN
Contamination of EN
Contamination of EN can occur during preparation if
modular supplements (such as protein powder/liquid)
are added to the formula, when the feeding is transferred
to the administration container, during assembly of
the feeding system, and during administration to the
patient.5,7,11 Clean technique and proper hand washing
should always be used to prepare and deliver formula
in both an OS and RTH.2
Potential risk reduction from nosocomial infection
from contamination of EN influences some clinicians
in the selection of an OS vs. RTH. Whereas only the
formula itself is sterile in an OS (not the bag it hangs in),
the entire RTH system is sterile because it is not exposed
to the outside environment; it is therefore associated
with a decreased risk of contamination.13,14 However,
prospective trials demonstrating this perceived benefit
are not available. C. difficile infection is one of the most
life-threatening infections associated with hospitalized
patients, especially those on EN.17,18 Any measures that
can be taken to prevent bacterial contamination and
a culture of safe practices surrounding the use of EN
should be the goal.
Both OS and RTH EN formulas are sterile when
packaged, however, once administration has begun,
retrograde movement of bacteria from the GI tract via
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RTH System
Equipment required:
Equipment required:
Bag
1 liter RTH
Tubing
Tubing
Required steps:
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Volume of EN Delivered
Storage
RTH formula containers should not have long-term
exposure to light as some nutrients in the formula such as
riboflavin, vitamin B6, and vitamin A are photosensitive.
Recommended storage of RTH containers is on covered
shelves or in a closed cabinet prior to use to avoid
vitamin degradation. The opaque packaging of the OS
protects the formula from light during storage.
Product Waste
If continued with OS
Formula
$56,501.55
$49,920.52
$52,795.99
$54,549.64
Total cost
$109,297.54
$104,470.16
Cost difference of switching over 8 month period = $4,827.38 and per month = $603.42
Table 3. Cost Comparison of Feeding Sets Used for OS and RTH Systems over Eight Months
UVA Description
Description of
Feeding Set
Quantity
Used
Price/Unit
Total Cost
% Total
Cost of RTH
($109,287.54)
559
$2.26
$1,262.18
1%
809
$4.62
$3,740.85
3%
3,374
$1.70
$5,739.20
5%
10,715
$3.92
$42,053.76
38%
Open System
Closed System
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1 2 3
1 2 3
Ease of Use
1 2 3
1 2 3
1 2 3
1 2 3
Ready to Hang
Mean (3 = best)
RTH
OS
2.83
1.75
Ease of use
2.87
1.86
2.16
2.21
Cost Analysis
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o The remaining volume in the second RTH container does not need to be discarded at the end of
the nocturnal feedingit can be capped and restarted the following evening as long as the total
hang time does not exceed 24 hours
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CONCLUSION
When considering the advantages and disadvantages of
an OS or RTH EN feeding system, the most important
factors to consider are patient outcomes, ease of use,
safety, and cost. Review of the literature reveals that
both the OS and RTH can be safely delivered to patients
when proper procedures are followed. A RTH may
also provide patients with a greater percentage of
their nutrient needs, ultimately leading to improved
nutritional status and improved patient outcomes, but
this will require further study. Although a RTH is more
expensive per unit of volume when compared to the
OS, it is possible that if the RTH saves nursing time,
it may in fact be significantly less expensive due to
savings on labor costs. Other factors that need to be
considered are whether there is a decrease in infectious
risk and waste. Although insufficient evidence exists to
determine if a RTH is superior to OS in terms of cost,
it clearly increases nursing satisfaction, and has been
shown to increase delivery of EN which could also
decrease hospital costs by reducing the incidence of
malnutrition.
References
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Care 2000;3(5):363-366.
3. Seres DS, Valcarcel M, Guillaume A. Advantages of
enteral nutrition over parenteral nutrition. Therap Adv
Gastroenterol. 2013;6(2):157-167.
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Thorson MA, Bliss DZ, Savik K. Re-examination
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PRACTICAL GASTROENTEROLOGY
REPRINTS
Special rates are available for
quantities of 100 or more.
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