Portal de Periódicos da CAPES

Standards for Nutrition Support

2013; Wiley; Volume: 28; Issue: 2 Linguagem: Inglês

10.1177/0884533613475822

1941-2452

Mark R. Corkins, Kathleen C. Griggs, Sharon Groh‐Wargo, Theresa Han‐Markey, Richard A. Helms, Linda Muir, Elaina E. Szeszycki,

Intestinal Malrotation and Obstruction Disorders

The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) is a professional society of physicians, nurses, dietitians, pharmacists, allied health professionals, and researchers. A.S.P.E.N. envisions an environment in which every patient receives safe, efficacious, and high-quality nutrition care. A.S.P.E.N.'s mission is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. These Standards for Nutrition Support: Pediatric Hospitalized Patients are an update of the 2005 standards. They are intended for use in any hospital setting with or without a formal nutrition support team. Audience for Standards: These practice-based standards are intended for use by healthcare professionals charged with the care of pediatric patients receiving nutrition support in hospitals. Level of Care: These Standards of Practice present a range of performance of competent care that should be provided by healthcare professionals caring for pediatric patients receiving nutrition support therapy in the hospital environment. "Shall": indicates standards to be followed strictly. "Should": Indicates that among several possibilities, one is particularly suitable, without mentioning or excluding others, or that a certain course of action is preferred but not necessarily required. "May": Indicates a course of action that is permissible within the limits of recommended practice. These standards do not constitute medical or other professional advice and should not be taken as such. To the extent that the information published herein may be used to assist in the care of patients, this is the result of the sole professional judgment of the attending healthcare professional whose judgment is the primary component of quality medical care. The information presented in these standards is not a substitute for the exercise of such judgment by the healthcare professional. These standards have been developed by the Task Force on Standards for Nutrition Support for Pediatric Hospitalized Patients, reviewed by the A.S.P.E.N. Clinical Practice Committee and approved by the A.S.P.E.N. Board of Directors. These Standards of Practice should be used in conjunction with the previously published A.S.P.E.N. Clinical Guidelines and Standards, which can be accessed at the A.S.P.E.N. Documents Library, http://www.nutritioncare.org/Library.aspx. Pediatric patients and the diseases that lead to their hospitalizations are unique from adult patients. Nutrition is even more important in pediatric patients because they require the substrates for daily metabolism with the added cost of growth.2 Pediatric patients have different percentages of muscle and fat mass and higher resting energy requirements than adults.3 An illness that leads to hospitalization may lead to significant changes in nutrition needs. Malnutrition results in increased immune system vulnerability with greater frequency of infection, higher morbidity and mortality rates, and longer hospital stays.4 Nutrition support in the critically ill child helps reduce the risk of energy and/or protein malnutrition, improves survival, and reduces associated morbidity and mortality.5 The standards presented in this document are intended to provide healthcare professionals with the latest information available to help guide the nutrition care of hospitalized pediatric patients. 1.1. When an organized nutrition support team exists, it shall be directed by a practitioner who, by appropriate education, specialized training, and/or experience, is knowledgeable in delivering nutrition support therapy.14 1.2. An organized nutrition support team should include a dietitian, nurse, pharmacist, and physician, each following standards of practice for their discipline.151617–18 1.3. If a nutrition support team is not established, nutrition support therapy should be managed by an interdisciplinary approach and should include the patient's physician, nurse, dietitian, and pharmacist.14 1.4. Healthcare professionals involved with providing nutrition support to pediatric patients shall be competent to assess the nutrition status, determine the appropriate use of nutrition support, and manage the nutrition support therapy of that population. Nutrition support certification may be considered ideal to document necessary level of knowledge and skills to provide the highest-quality care. 2.1. The policies and procedures shall be developed with the input and review of all members of the nutrition support team.14 2.2. The policies and procedures shall be periodically reviewed and revised as appropriate to optimize patient care.14 3.1. The review of performance should assess the appropriateness and effectiveness of administering nutrition support therapy to individual patients. 3.2. Performance improvement mechanisms should provide a means to initiate policy, procedure, and/or protocol changes that enhance the safety and efficacy of nutrition therapy for hospitalized pediatric patients. Healthcare professionals are faced with hospitalized pediatric patients who run the spectrum from underweight to overweight. Developing a nutrition care plan requires an accommodation for preexisting nutrition status plus the pediatric requirements for growth in the presence of a medical condition that will change with intervention.2021–22 The nutrition care process and administering nutrition support therapy require a series of steps with feedback loops. These steps include nutrition screening, nutrition assessment, formulating and implementing a nutrition care plan, patient monitoring, evaluating the plan, evaluating the care setting, and then either reformulating the care plan or terminating therapy. The nutrition care algorithm is illustrated in Figure 1.14 Nutrition care algorithm. Reprinted from Ukleja A, Freeman KL, Gilbert K, et al; Task Force on Standards for Nutrition Support: Adult Hospitalized Patients and the American Society for Parenteral and Enteral Nutrition Board of Directors. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403-414. 4.1. The policy and procedure for nutrition screening shall be formalized and documented. 4.1.1. All patients shall be screened for nutrition risk within 24 hours after admission.23 4.1.2. The result of the nutrition screen shall be documented and appropriate intervention initiated. 4.1.3. A procedure for nutrition rescreening shall be implemented. 5.1. The nutrition assessment shall be performed within a timely manner as specified by institutional policy by or under the supervision of a registered dietitian with pediatric experience or in conjunction with other healthcare professionals with pediatric nutrition expertise. 5.2. The nutrition assessment shall include assessment of the patient's current nutrition status and nutrition requirements as specified below. 5.3. The pediatric patient's nutrition requirements should include energy, macronutrient (protein, carbohydrate, and fat), fluid, electrolyte, and micronutrient requirements. These findings should be interpreted using pediatric normal laboratory values.28 5.4. Nutrition assessment shall include review and documenting factors relevant to delivering nutrition support therapy. Relevant factors may include, but are not limited to, the following: detailed feeding history, aspiration risk assessment, psychosocial and socioeconomic factors, gastrointestinal tract function, enteral and vascular access, and schedule of diagnostic and invasive procedures. 5.5. Nutrition assessment shall include review and documenting growth using age- and disease-specific charts, as indicated. Refer to Table 1 for growth chart references for several specific medical conditions and syndromes.29 The nutrition care plan is the template for nutrition therapy and is created by analysis of information from many aspects of care, including consultations, therapies, and assessments. The nutrition care plan is a formal statement of the nutrition goals and interventions prescribed for an individual using the data obtained from a nutrition assessment. The plan should include statements of nutrition goals and monitoring/evaluation parameters, the most appropriate administration route of nutrition therapy, nutrition access, anticipated duration of therapy, and training and counseling goals and methods.1 The nutrition care plan should be developed using an interdisciplinary team approach involving the patient and family, nutrition support team, the patient's physician(s), dietitian(s), and other appropriate healthcare professionals with pediatric experience. The nutrition care plan should be developed using a family-centered approach. The nutrition care plan shall address patient/caregiver goals and expectations, document patient/caregiver comprehension of recommended nutrition support therapy, and include patient/caregiver wishes.14 Benchmarks should be established to identify progress toward the desired outcome of therapy and provide objective evidence that the nutrition care plan is providing optimal, appropriate, and resource-efficient care. The nutrition care plan should also establish a family-centered, patient-specific set of goals that can be used to continually assess the efficacy of therapy and adequacy of growth. Appropriate routes of administration shall be defined, identification of intake goals shall be included, and estimated duration of therapy, as well as criteria for discontinuation of therapy, should be discussed.14 The route selected to provide nutrition support therapy shall be appropriate to the patient's medical condition and should be reassessed periodically for continued appropriateness, as well as its adequacy in meeting goals of the nutrition care plan (see Figure 2).14 Route of administration algorithm. EN, enteral nutrition; GI, gastrointestinal; PN, parenteral nutrition. Adapted from Ukleja A, Freeman KL, Gilbert K, et al; Task Force on Standards for Nutrition Support: Adult Hospitalized Patients and the American Society for Parenteral and Enteral Nutrition Board of Directors. Standards for nutrition support: adult hospitalized patients. Nutr Clin Pract. 2010;25(4):403-414. 9.1. Enteral nutrition (EN) should be used in preference to parenteral nutrition (PN) to the greatest extent possible.14 9.2. PN should be used when the gastrointestinal tract is not functional or cannot be accessed, or the patient's nutrient needs are greater than those that can be met through the gastrointestinal tract. 9.3. Oral stimulation should be initiated when children have no or limited oral intake during the first 2 years of life in order to enhance feeding skills and speech.30 10.1. The EN or PN formulation shall be adjusted as appropriate in patients with growth failure and/or organ dysfunction. 10.2. When significant amounts of nutrients are provided through means other than the EN/PN formulation (eg, parenteral infusions, medications, fluids, renal replacement therapy), the formulation should be adjusted accordingly. 10.3. All fluid sources should be considered when determining the patient's nutrition prescription. 11.1. Implementing a nutrition care plan shall have a defined standardized ordering process via hard copy or computerized prescriber order entry (CPOE). 11.1.1. Prescriptions/orders for food or nutrition support therapy products shall be documented in the patient's medical record before administration.31 12.1. Access devices shall be placed by or under the supervision of a physician, nurse, or specially trained healthcare professional who is proficient in placement of access devices in children and who is competent and knowledgeable in recognizing and managing complications associated with placing and maintaining access devices. 12.2. Access devices shall be placed safely, effectively, and humanely in children. For vascular access placement, methods for appropriate sedation or anesthesia, use of sterile technique, and selection of appropriate catheter size and material shall be defined. 12.3. Standard techniques and protocols shall be established and followed for inserting access devices and routine care. 12.4. Proper placement of vascular and enteral access devices shall be appropriately confirmed and documented in the medical record prior to use. For neonates and infants, regular assessment of placement shall be required after insertion to ensure proper placement is maintained. 12.4.1. Central venous access shall be obtained prior to administering central PN. The catheter tip should be positioned in the distal portion of the superior vena cava or at the superior vena cava adjacent to the right atrium.32 Femoral central lines are not recommended for central PN but may be used under emergent conditions. 12.4.2. Peripheral venous access is intended for short-term nutrition support therapy and generally should not be used for longer than 7 to 10 days. If longer nutrition support therapy is required, then a central venous access device shall be inserted.33 12.5. Complications related to an access device and outcome of actions to manage the complications shall be clearly documented in the medical record. 12.6. The access device used for nutrition support therapy should be used only for nutrition therapies on a routine basis unless an emergent need arises. Routine blood draws, medication delivery, and other fluids should not be infused or co-infused in the venous access devices used for nutrition support therapy. 13.1. PN formulations shall be prepared using current and established policies and procedures regarding sterile compounding, compatibility, stability, and labeling.34 These procedures shall be supervised by a licensed pharmacist, and the institution should have available United States Pharmacopeial Convention (USP) USP : Pharmaceutical Compounding—Sterile Preparation for all staff engaged in PN formulation preparation, storage, delivery, and administration.35 13.2. Automated equipment used for the preparation of PN formulations shall be cared for properly within an appropriately designed and constructed sterile products room, ISO class 5 cleanroom, all with environmental quality control as described in USP .35 13.2.1. Policies and procedures for the use of automated compounding devices (ACDs) for PN formulations shall be developed to address responsibilities for operation, calibration and maintenance, staff training, and testing and monitoring compounder performance at all times.36 13.2.2. Personnel shall be trained in proper operation, calibration, and maintenance of the equipment. Additionally, personnel will undergo routine preparation validation through media-fill testing. 13.2.3. Personnel shall be trained to use computer software with appropriate content limits for pediatric formulations to assist in daily use and troubleshooting of ACDs. 13.2.4. Documents generated by the ACD shall be compared with the hard copy or CPOE PN formulation order.14 13.2.5. The operator shall monitor the ACD continuously during the preparation process to ensure the proper operation of the equipment, including verification of accuracy and sterility (pyrogen testing is recommended for high-risk Compounded Sterile Products). 13.3. PN formulations shall be sterile. 13.3.1. PN formulations shall be prepared in a laminar or vertical airflow hood within a sterile products room of appropriate ISO class by an individual trained in aseptic technique under the direction of or by a licensed pharmacist. 13.3.2. The preparation area shall be a class 100 (ISO 5) environment with limited access to decrease the potential for microbial contamination.35 13.3.3. Aseptic technique shall be taught, including garbing, aseptic work practices, cleaning, and disinfection. The aseptic techniques used should be validated on a periodic and routine basis. 13.3.4. Sterility testing shall be performed on a regular surveillance basis. 13.4. PN formulations shall be visually inspected to identify signs of gross contamination, particle formation, or phase separation during the preparation process, during storage, and before and during administration. 13.5. If repackaging from the original containers of intravenous (IV) fat emulsions is conducted, methods shall be taken to promote sterility, including preparation in a laminar or vertical airflow hood and using appropriate infusion hang times.37 13.6. All PN formulations shall be prepared in compatible containers. Methods should be taken to limit the aluminum contamination in PN formulations.38,39 14.1. HBM shall be prepared, labeled, stored, and discarded using current and published guidelines established by the American Dietetic Association (now the Academy of Nutrition and Dietetics) and the Human Milk Banking Association of North American (HMBANA).40,41 These procedures shall be supervised by a registered dietitian, registered nurse, certified lactation consultant, or other qualified healthcare professional, and the institution should have Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities available for all staff engaged in human milk administration.40 14.1.1. Guidelines shall exist for the expression, storage, and handling of expressed HBM.4041–42 14.1.2. Guidelines shall exist for the use of donor HBM as a feeding alternative for infants whose mothers are unable to provide HBM. Donor HBM shall be pasteurized.40 14.2. EN formulations including commercial infant formulas shall be prepared, labeled, stored, and discarded according to the manufacturer's recommendations and using current and published guidelines.40 These procedures shall be supervised by a registered dietitian or other qualified healthcare professional, and the institution should have Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities available for all staff engaged in EN formulation preparation.40 14.2.1. Commercially sterile, ready-to-feed, or liquid concentrate formulas shall be prepared using aseptic technique. For patients in neonatal intensive care settings, for neonatal and infant patients, and for those who may be immunocompromised, commercially sterile ready-to-feed and liquid-concentrate formulas should be used when available and nutritionally appropriate. The powder form of an infant formula should be used only when alternative commercially sterile liquid products are not available.40 14.2.2. Liquid-concentrate and powder infant formulas should be reconstituted with chilled, commercially sterile ingredient water.40,42 14.3. A quality control plan following Hazard Analysis Critical Control Point (HACCP) guidelines should be developed to ensure and assess sanitary techniques in the preparation, handling, storage, and administration of EN formulations.4344–45 14.3.1. A separate room should be available for the preparation of infant formula, HBM, and enteral feedings. In facilities where that is not possible, a dedicated clean space, away from the patient's bedside, with facilities for aseptic technique should be available.40 14.3.2. Preparation equipment shall be sanitized regularly according to institutional guidelines. Upright blenders should not be used for HBM or EN formulation preparation.40 14.4. Guidelines should exist that delineate the institution's response to a preparation error or a manufacturer's recall of an infant formula or enteral formulation.40 15.1. All PN ingredients/components shall be listed on the label. 15.2. Healthcare professionals responsible for the preparation and delivery of PN formulations shall employ methods for detection and prevention of formulation incompatibilities.34 15.2.1. All additions to a PN formulation shall be made in a laminar or vertical airflow hood within a sterile products room under the direct supervision of or by a licensed pharmacist.35 15.2.2. Individuals who inject additives into PN formulations shall be trained in proper sterile technique. 15.2.3. The addition of medications or other nutrients to PN formulations after they have left the pharmacy shall not be done. 15.3. Protocols or software revisions for PN formulators shall be established to define acceptable warning limits of specific nutrients and additives in PN formulations.46 15.4. The sequence of addition of calcium and phosphorus to PN formulations should be optimized to prevent calcium phosphate precipitation.34 15.4.1. Calcium gluconate is the preferred calcium salt and should be used in PN formulations.34,46,47 15.4.2. Phosphorus salts shall be added to the PN formulation before any other formulation additive.34 15.4.3. Calcium should be added near the end of the compounding sequence to take advantage of the maximum volume of the PN formulation.34 15.4.4. Some amino acid products contain phosphate ions. This additional amount of phosphate should be accounted for in the calculation of calcium phosphate solubility. 15.5. When IV medications emergently need to be co-infused, policies and procedures should be developed to guide caregivers as to safe practices for co-infusion of medications, electrolytes and minerals, and PN formulation. 15.6. Deviation from established policies and procedures should require approval by a healthcare professional who is knowledgeable about physical-chemical compatibilities, drug-drug, and drug-nutrient interactions. 15.7. All pediatric patients receiving PN should receive daily parenteral multivitamins in quantities established by the Subcommittee on Pediatric Parenteral Nutrition Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition (now American Society for Nutrition).48 Dosing may need to be adjusted in severe renal and hepatic dysfunction, excessive losses, or in patients receiving long-term PN. In the event of parenteral multivitamin product shortage, multivitamin use may need to be adjusted per patient population. Institutions should follow the considerations for multivitamin administration during shortages as set forth by A.S.P.E.N.49 15.8. All pediatric patients receiving PN should receive daily parenteral trace elements in quantities established by the Subcommittee on Pediatric Parenteral Nutrition Requirements from the Committee on Clinical Practice Issues of the American Society for Clinical Nutrition (now American Society for Nutrition).48 Dosing shall be adjusted for severe renal and hepatic dysfunction, excessive losses, or in patients receiving long-term PN. In the event of a parenteral multiple trace element product shortage, trace elements should be dosed individually. Institutions should follow the considerations for trace element administration during shortages as set forth by A.S.P.E.N.50 15.9. Components added to EN formulations shall be appropriate and compatible with all ingredients and shall be added safely and accurately. 15.9.1. Healthcare professionals responsible for the preparation and delivery of EN formulations shall employ methods for detection and prevention of formulation incompatibilities. 15.9.2. Protocols should be established to define acceptable minimum and maximum amounts of specific nutrients in EN formulations. 15.9.3. Policies and procedures shall be established regarding subsequent additions to EN formulations, including dilution of formula and addition of medications. Any additions to the formulation shall be ordered by the prescribing practitioner or designee and documented by the formulating personnel in the medical record and should be consistent with published guidelines.14,40,51 15.9.3.1. Nutrient additives should be added in the formula room or breast milk preparation area. EN additives shall not be weighed or measured at the bedside but should be prepackaged by pharmacy. 15.9.3.2. All additives shall be included as part of the EN label.51 15.9.3.3. Colorants (food coloring and methylene blue) shall not be added to EN.50,51 Blue dyes have been used in feedings to detect aspiration visually. The safety, sensitivity, and specificity of blue-tinted EN have not been documented.5253545556–57 Case reports have associated the use of FD&C Blue No. 1 with serious adverse events and death, although a direct causal relationship has not been proven.58596061–62 Methylene blue toxicity has also been described.63 Microbial contamination of feedings has been associated with the use of dye dispensed from multiple-dose containers.64 16.1. PN formulation shall be packaged in administration containers that can ensure maintenance of sterility and allow visual inspection during preparation, storage, and administration. 16.1.1. The PN formulations shall be labeled and the content and format of a PN label shall follow the Standard Label Format for Neonates or Pediatrics as recommended by the Task Force for the Revision of Safe Practices for Parenteral Nutrition or as dictated by state laws.34 The PN formulation label should contain a statement indicating that it is for parenteral administration only. 16.1.2. The PN formulation shall be stored in a refrigerator (according to established guidelines) unless the formulation will be administered immediately to the patient.34 16.2. EN formulations shall be packaged in administration containers, which ensure accuracy of volume and cleanliness and minimize the risk for contamination. Refer to A.S.P.E.N. Enteral Nutrition Practice Recommendations.51 16.2.1. Refer to Standard 14 for additional information regarding packaging and labeling of HBM and infant formulas. 16.2.2. Open-system administration containers should be used if the EN formulation will be modified with modular products. 16.2.3. Hospital-prepared EN formulations shall be stored in a refrigerator (per established guidelines) unless the formulation will be administered immediately to the patient.40,51 16.3. EN formulation administration containers shall be labeled accurately with the contents and patient information. Refer to A.S.P.E.N. Enteral Nutrition Practice Recommendations.51 16.3.1. EN labels should be standardized, containing all elements of the order. 16.3.2. EN formulation administration containers should be labeled with the patient's name, medical record identification number, product name and strength, additives, volume, and beyond-use date and hang time. 16.3.3. EN formulation labels should contain delivery site/access and route (enteral), and method of administration. 16.3.4. EN formulation labels should contain a statement indicating a formulation is for enteral administration only. 17.1. Hospital-specific protocols and procedures shall exist regarding techniques used to administer nutrition support therapy. Ideally, these protocols/procedures should be developed by a nutrition support team or committee with expertise in nutrition support therapy. The identified group shall be responsible for periodic review and update of these specific protocols and procedures. 17.2. Nutrition support therapy formulations shall be administered by or under the supervision of trained personnel; administration and tolerance shall be documented in the medical record. 17.3. Prior to administering the formulation to the patient, the label on the formulation shall be checked against the prescribed order and the patient's identity shall be verified per hospital policy to ensure the prescribed formulation is delivered to the appropriate patient and administered by the correct route and for the designated/intended time. 17.4. The administration rate of the prescribed formulation shall be checked each time a new volume of formulation is ordered or initiated, before resuming an interrupted infusion, and periodically during its administration. 17.5. Protocols shall be written to prevent and manage vascular or enteral access device occlusion. 17.6. Each PN formulation shall be inspected prior to and during administration. If visual changes are present, the formulation shall not be administered and the appropriate pharmacist notified. 17.7. A dextrose/amino acid PN formulation with the separate infusion of IV fat emulsion should be used in neonatal and infant patients unless the institution identifies a need for total nutrient admixture formulations that will benefit these particular populations.34,65 17.8. Methods should be established to limit patient exposure to the plasticizer di(2-ethyl-hexyl) phthalate (DEHP) and any other plasticizers that have been identified as potentially harmful while providing EN and PN. Products without the plasticizer DEHP are preferred, especially in patients receiving IV fat emulsions and IV fat emulsion–containing products (eg, propofol).66 17.9. Protocols and procedures shall exist to prevent, diagnose, manage, and monitor patient infections caused by contaminated PN formulations or the equipment/devices used to administer PN. 17.9.1. Infection prevention strategies shall be used to minimize central venous catheter–associated bloodstream infections, including a bundle of targeted, evidence-based catheter insertion practices: use of hand hygiene, maximum sterile barrier precautions during insertion, use of chlorhexidine for skin disinfection before catheter insertion and during central venous catheter dressing change, avoiding the femoral vein insertion site, and prompt removal of unnecessary vascular access devices.67,68 17.9.2. If a multilumen catheter is used, one lumen should be designated exclusively to administer PN. Access ports shall be wiped with an appropriate antiseptic prior to catheter manipulation, and manipulation should be minimized.34,67 Co-infusion of fluids or medications into the PN system should be avoided if at all possible. If no other alternatives are available, a pharmacist shall be contacted to investigate the compatibility and stability issues prior to administration. 17.9.3. Patient care unit–specific data regarding catheter-associated bloodstream infections should be collected. 17.9.4. Administration sets for PN formulations shall include an in-line filter. A 1.2-micron filter may be used for all PN formulations. However, a 0.22-micron filter may be used for dextrose/amino acid formulations.34 17.9.5. IV fat emulsion administered separately from PN formulations should be completed within 12 hours of initiating the infusion. If volume considerations require a longer hang time, the IV fat emulsion dose should be completed within 24 hours of initiating the infusion, divided into two separate doses, each hanging no longer than 12 hours. The IV administration set for the IV fat emulsions shall be replaced within 24 hours of initiating the infusion.67 17.10. A protocol shall be written regarding the maximal rate of administration for IV fat emulsions. Manufacturer recommendations should be considered in formulating this protocol. 17.11. Cycling PN formulations should be considered for patients with or at risk of liver dysfunction, on long-term PN, or those who are stable and active and may benefit from infusion-free periods.69 17.12. A protocol shall be written to minimize the risk of microbial contamination of EN formulations. Please refer to the "Enteral Nutrition Practice Recommendations,"51 A.S.P.E.N. Clinical Guidelines: Nutrition Support of the Critically Ill Child 70 and Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, Second Edition for details.40 17.13. Protocols and procedures should exist to minimize the risk of regurgitation and aspiration of EN formulations.51 17.14. A protocol shall exist to minimize the risk of enteral misconnections.717273–74 17.14.1. Enteral access device administration set connectors shall not be purchased that can physically connect with a female Luer IV line connector.72 17.14.2. Standard Luer syringes shall not be used to administer oral medications or EN. 17.14.3. EN tubes or PN catheters shall be traced from the patient to the point of origin before connecting any new device or infusion. 17.14.4. Tubes and catheters with different infusion or drainage purposes should be routed in different, standardized directions (eg, IV lines routed toward the head; enteric lines toward the feet). 17.15. Protocols shall be established for administering medications through an enteral access device.51 17.15.1. Medications should not be mixed directly with enteral formulations because of potential drug-drug and drug-nutrient interactions and nondelivery of all medications.51 17.15.2. Medications should be administered according to current guidelines.51 17.15.3. Enteral access device(s) should be flushed appropriately before and after each medication administration and before restarting EN administration, taking into account the patient's volume status.49 Clinical protocols for ordering, mixing/compounding, and administering nutrition therapy should be implemented for hospital personnel in order to decrease the risk of adverse events associated with nutrition support therapy. Adverse events, including sentinel events related to the administration of nutrition support therapy and the equipment/access devices, shall be documented and reported per hospital protocol with the goal to prevent similar events in the future and promote a culture of patient safety. The nutrition support team (or committee/group with expertise in nutrition support therapy) should participate in reviewing all such adverse event reports and assist in the development, implementation, and review/revision of relevant nutrition therapy protocols. 19.1. Protocols shall be developed to obtain baseline weight, height, or length and head circumference (if age appropriate) to be plotted on an age- and/or syndrome-appropriate growth curve. There should also be a periodic review of the patient's growth, development, and clinical and laboratory status. The Centers for Disease Control and Prevention recommends using the World Health Organization (WHO) growth curves for patients under the age of 2 years (see Standard 5.5).76 19.2. The frequency of monitoring should depend on gestational age, postnatal age, disease, severity of illness, degree of malnutrition, and level of metabolic stress.75,77,78 19.2.1. Daily or more frequent monitoring may be required for neonates, infants, critically ill patients, and those who have debilitating diseases or infection, are at risk for refeeding complications, are transitioning between PN or EN and oral diet, or have experienced complications associated with nutrition support therapy. Consideration should also be given to the volume of blood required for this monitoring so that only what is necessary is obtained. 19.3. Monitoring parameters should include the following 14,75 : Physical assessment, including clinical signs of fluid and nutrient excess or deficiency Vital signs Actual fluid and nutrient intake (oral, enteral, and parenteral) and measuring output (urine, gastrointestinal, wound losses, chest tube drainage, renal replacement effluent) Weight (length and head circumference in infants with prolonged hospital stay). In neonates in particular, and in patients with selected disease states, an assessment of fluid intake and output should accompany an evaluation of weight gain to determine whether the source of the weight increase is fluid or lean body mass. 19.4. Monitoring parameters may include the following14: Laboratory data (complete blood count, serum and capillary glucose, blood urea nitrogen, creatinine, electrolytes [Na, K, Cl, CO2], calcium, magnesium, phosphorus, liver enzyme tests, triglycerides, serum proteins, or international normalized ratio [INR]; urine glucose, urine sodium, urine specific gravity). The burden of the test, including consideration of the blood volume required to do the test, should be balanced by the benefit or usefulness of the results, particularly in small infants and those who have been on a stable parenteral or enteral regimen. Trace mineral, vitamin, and carnitine serum concentrations may be evaluated in long-term PN-dependent patients or patients at risk for developing deficiencies or excesses of these particular micronutrients. Medication review Changes in gastrointestinal function indicating tolerance of nutrition therapy (such as ostomy output, stool frequency and consistency, presence of blood or fat in the stool, presence of abdominal distention, increasing abdominal girth, nausea, vomiting) 19.5. Abnormal results in monitoring parameters shall be identified.79 Recommended changes in nutrition support therapy formulation, volume, or route and resulting outcomes shall be documented. Verbal communication shall occur for immediate concerns. 20.1. The healthcare provider shall visually inspect the patient's enteral or parenteral access devices and insertion site.14 20.2. Inspection of the nutrition support therapy label, expiration date, and infusion rate setting should be done at least daily and at key decision points (eg, at initiation, shift changes, or rate changes).34 20.3. The healthcare provider shall inspect the nutrition support therapy formulation before administration for signs of gross contamination, particle formation, and phase separation of IV fat emulsions.34 20.4. The healthcare provider shall monitor for any signs or symptoms of infusion-related incidents during administration (ie, allergic reaction, phlebitis, etc). 20.5. The healthcare provider shall review the patient's medication profile for the following14: Potential effects on both nutrition and metabolic status Incompatibilities with nutrition support therapy formulation14 21.1. Appropriate parameters should be measured serially during nutrition support therapy as outlined in Standard 19 and documented.79 21.2. The monitoring parameters should be compared with the goals of the nutrition care plan. If goals are not being met or new problems/risks have arisen, the nutrition care plan should be modified and documented. Adjustments to the nutrition support therapy formulation or volume necessitated by a pediatric patient's growth shall be identified and recommendations documented. The frequency of comparison should be based on gestational and/or postnatal age (in infants) and the disease or condition, medical stability, tolerance of nutrition therapy, and progress toward achievement of goals. 21.2.1. Guidelines for frequency of reassessment for given patient populations and nutrition therapies should be developed. Patients hospitalized for more than 5 days shall be reassessed. Patients malnourished at admission should be assessed more frequently.77,78 21.2.2. Revision of the nutrition care plan goals shall involve the patient, caregiver, and healthcare professionals, as appropriate. 21.2.3. The cost-effectiveness of the updated nutrition care plan shall be evaluated in terms of the potential risks and benefit for the patient. 22.1. During the transition to EN, PN should be continued while EN is increased. 22.2. Adequate oral intake and growth should be demonstrated and documented prior to terminating nutrition support therapy. 22.3. When appropriate, nutrition support therapy should be gradually decreased as oral intake increases so that overall adequate nutrient intake and growth are sustained. 23.1. Hospitals should develop protocols for discharge criteria for home EN and PN support. 23.1.1. Prior to discharge, a designated prescriptive authority should be identified that will monitor the care and communicate with the home care agency. 23.1.2. The nutrition support plan for home should be established during hospitalization before discharge (eg, PN cycling, bolus feedings). 23.2. Patients and/or caregivers should be provided with adequate education in administration and monitoring of home EN and PN prior to hospital discharge to ensure safe administration.