Tube feeding is prevalent in skilled nursing facilities (SNFs) today, but speech-language pathologists can take steps to combat its increased use in this setting.

This prevalence may be due to population increase, a greater number of patients discharged with feeding tubes from acute care settings, and/or the specific populations these facilities service, such as dementia, Alzheimer's and Parkinson's disease, extended brain injury and cardiovascular accidents.

Tube feeding is warranted when a resident has a decreased appetite, decreased fluid intake, decreased consciousness or alertness, and swallowing difficulty due to stroke, brain injury, cancer and/or esophageal disorders. Tube feeding has advantages and disadvantages. It may improve energy or comfort level, improve performance in rehabilitation, decrease risk of dehydration and aspiration, and prolong life. Potential problems are infection at the site of tube placement, increased diarrhea or related discomfort, associated use of restraints, pain, and risk of aspiration.

The five steps to reduce tube feeding are identification, development of a plan of action, education, implementation and organization. To determine If your facility is above the national average for tube feeding usage, identify the residents receiving tube feeding. All staff should be familiar with the policies and procedures concerning evaluation and management.

To develop a plan of action, consider what you can do to reduce the number of residents receiving nutrition through tube feeding. Revise dysphagia policies and procedures and evaluate patients being tubefed upon admission. Recommend instrumental assessments, provide dysphagia therapy as needed, and change the culture of the institution.Education is an essential step in combating the prevalence of tube feeding. Educate clinical staff, medical professionals, residents and families about its benefits and drawbacks. People need to know about any new policies and procedures regarding evaluation and management. Educate the administration on the issue, as well as the related topics of quality of life, cost-effectiveness and patient safety. Providing figures that show the trend of tube feeding usage among residents is especially powerful.

The next step is to implement your plan. Policies may include evaluations for all new residents admitted with tubes, instrumental assessments for residents with a history of dysphagia, and follow-up evaluations every six months. Facilities should implement aggressive feeding programs with individualized feeders, design modified feeding environments, and provide sensory stimulation programs for residents with limited oral (PO) intake.

Free water protocols can be introduced for residents who have had tubes placed due to dehydration. Those with a history of neurological insult resulting in tube placement should receive aggressive dysphagia therapy. Facilities should use natural oral feeding techniques that are individualized for each resident.

The final step is organization. Facilities should provide monthly reports on current and new residents who are on feeding tubes, individuals who were tube-fed and then discharged, and residents who used a feeding tube but have died. Statistics on residents who have gone from total tube feeding to tube feeding plus PO and vise versa also are important. Presented in graph form, this information is valuable to the speech-language pathologist, medical staff and administration. The dietary department can provide a list of the residents' diets to help monitor those who receive tube feeding.

Reducing tube feeding is beneficial for everyone involved. There will be various levels of success in getting residents off tube feeding or advancing to a combination of PO and tube feeding or therapeutic feeding. Residents who cannot tolerate PO should not be forgotten. A swallow evaluation in six months may yield different results. At the end of the day, you will have targeted one of the most important aspects of long-term care: quality of life.

Resource

• Tella Nova Films. (1993). Alzheimer's Disease: Natural Feeding Techniques. Video. Dedham, MA: AliMed Inc.

Peter Rahanis is chief speech-language pathologist at Sea View Hospital Rehabilitation Center and Home in Staten Island, NY. He can be contacted at PeterRahanisSLP@gmail.com.