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Enteral Nutrition – Adult – Inpatient

Enteral Nutrition – Adult – Inpatient - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nutrition


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Enteral Nutrition – Adult – Inpatient
Clinical Practice Guideline
Note: Active Table of Contents – Click to follow link
EXECUTIVE SUMMARY ........................................................................................................... 3
SCOPE ................................................................................................................................... 4
METHODOLOGY .................................................................................................................... 4
DEFINITIONS.......................................................................................................................... 5
INTRODUCTION ..................................................................................................................... 5
RECOMMENDATIONS ............................................................................................................ 6
UW HEALTH IMPLEMENTATION ........................................................................................... 10
APPENDIX A. EVIDENCE GRADING SCHEME(S) ...................................................................... 11
REFERENCES ........................................................................................................................ 12
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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Contact for Content:
Name: Cassandra Kight, PhD, RDN, CNSC
Phone Number: (608) 265-6354
Email Address: ckight@uwhealth.org

Contact for Changes:
Name: Lindsey Spencer, MS - CCKM
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org

Guideline Author:
Name: Cassandra Kight, PhD, RDN, CNSC – Department of Clinical Nutrition Services
Phone Number: (608) 265-6354
Email Address: ckight@uwhealth.org

Coordinating Team Members:
Lesley Appleyard MS, RDN, CNSC – Department of Clinical Nutrition Services
Robin Crist MS, RDN, CNSC -– Department of Clinical Nutrition Services
Kathleen Golos MS, RDN, CNSC – Department of Clinical Nutrition Services
Tracy Schmotzer MS, RDN, CNSC – Department of Clinical Nutrition Services

Review Individuals:
Dustin Andresen, MD – Hospital Medicine
Megan Barry PA, UW Health Inpatient Diabetes Service – Endocrinology
Caitlin Curtis, PharmD, BCNSP, Surgical Nutrition Support - Pharmacy
Jeff Fish, PharmD, FACM, BCCCP, BCPS, Pharmacy – Critical Care
Kylie Harrold, PA-C, MS, RDN, UW Health Physician Assistant – Transplant Surgery
Gwen Klinkner, MS, RN, APRN, BC-ADM, CDE – Nursing Practice Innovation
Erick Tarula, MD - Neurology
Shelley VanDenbergh, MS, RN, GCNS-BC - Hospital Medicine
Philip Trapskin, PharmD, BCPS – Pharmacy/Drug Policy Program

Committee Approvals/Dates:
Nutrition Committee (05/18/2017)
Clinical Knowledge Management (CKM) Council (Last Periodic Review: 08/24/2017)


Release Date: October 2017 | Next Review Date: August 2020













Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
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Executive Summary
Guideline Overview
The Enteral Nutrition (EN) Clinical Practice Guideline provides recommendations for appropriate
use of enteral nutrition in the adult hospitalized patient, recommendations for assessment and
monitoring of the patient receiving enteral nutrition and management of potential complications,
and transition of the patient from enteral nutrition support to an oral diet or transition from the
hospital to home or alternative health care setting while still requiring enteral nutrition.

Key Practice Recommendations
1. EN should be used preferentially over parenteral nutrition (PN) in hospitalized patients who
require non-volitional specialized nutrition therapy
2. Nutrition Assessment
2.1. Prior to initiation of specialized nutrition therapy (either EN or PN), a determination of
nutrition risk should be performed
2.2. Caloric requirements should be determined and then be used to set the goal for delivery
of nutrition therapy
2.3. Protein requirements should be determined independently of caloric needs
2.4. The goal of fluid management is to maintain adequate hydration, tissue perfusion, and
electrolyte balance.
3. Select an enteral access device based on patient-specific factors (e.g. GI anatomy, GI
function, expected duration of EN, facial & skull base fractures and trauma)
4. In the patient at high nutritional risk unable to maintain volitional intake, EN should be
initiated within 24-48 h of admission
5. Monitoring tolerance to EN includes the following actions:
5.1. Identify all changes in physical examination findings, laboratory values, and
anthropometric data
5.2. Evaluate adequacy of provision of EN as a percent of target goal calories
5.3. Identify patients at risk for refeeding syndrome prior to initiation of EN
5.4. Identify patients at risk for development of hyperglycemia while receiving EN
5.5. It has been recommended that interruption of EN should be avoided for gastric residual
volumes < 500 mLs in the absence of other signs and symptoms of intolerance
(nausea, vomiting, bloating, abdominal discomfort or distension) but that close
monitoring is warranted in patients with gastric residuals between 200 and 500 mL,
ensuring that all measures to reduce aspiration risk are initiated
5.6. Evaluation and treatment of causes of diarrhea, constipation, nausea and vomiting
6. Transition from EN to oral diet can commence once a diet has been started, with
adjustments in the enteral feeding schedule to help promote appetite and oral intake
7. Establish tolerance to EN at the goal regimen prior to discharge and coordinate discharge
planning with the patient, physician, dietitian, nurse, social worker, and case manager

Companion Documents
1. Oral and Enteral Electrolytes – Adult – Inpatient – Clinical Practice Guideline
2. Standards of Medical Care in Diabetes – Adult/Pediatric – Inpatient/Ambulatory Clinical
Practice Guideline
3. Prevention, Diagnosis, and Treatment of Clostridium difficile Infection - Adult/Pediatric –
Inpatient/Ambulatory Clinical Practice Guideline
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

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Scope
Disease/Condition(s): Any adult who requires enteral nutrition with a diagnosis, disease, or
condition that precludes their ability to adequately or safely consume an oral diet in sufficient
quantity to meet nutritional needs to maintain health and wellness

Clinical Specialty: The guideline may be used by any healthcare professional responsible for
placement of enteral nutrition orders, management of enteral nutrition, and/or who provides care
to patients receiving enteral nutrition

Intended Users: Physicians, Advanced Practice Providers, Registered Dietitian Nutritionists,
Pharmacists, and Nurses

Objective(s): The objective of this guideline is to standardize adult enteral nutrition initiation,
monitoring, management of potential complications, and transition to either an oral diet or
home/alternative setting to improve patient outcomes and safety at UW Health

Target Population: Adult patients (18 years or older) requiring enteral nutrition

Interventions and Practices Considered: Initiation of enteral nutrition in the adult patient that
includes a review of indication, nutrition assessment for nutrition risk and nutrient needs,
selection of an appropriate enteral access device, parameters to monitor and recommendations
for potential complications, with transition to either an oral diet or home/alternate setting if still
requiring enteral nutrition support therapy.

Major Outcomes Considered:
ξ Enteral nutrition is provided by a feeding tube with the type and tip location selected for
the patient for safety and comfort and length of time therapy is needed
ξ The enteral nutrition formula is appropriate to gastrointestinal and organ function in
sufficient volume to meet energy, protein, and micronutrient needs to provide for weight
maintenance and/or recovery
ξ Enteral nutrition is well-tolerated by the patient as evidenced by satisfactory
gastrointestinal tolerance, metabolic profile, and hydration status
ξ Complications related to the delivery of enteral nutrition are treated effectively to resolve
physiological changes
ξ The patient and/or caregivers are provided instructions regarding management of enteral
nutrition at home

Methodology
Methods Used to Collect/Select the Evidence:
Electronic database searches (e.g., PUBMED) were conducted by the guideline author(s) and
workgroup members to collect evidence for review. Expert opinion and clinical experience were
also considered during discussions of the evidence.

Methods Used to Formulate the Recommendations:
The workgroup members agreed to adopt recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and expert
experience. All recommendations endorsed or developed by the guideline workgroup were
reviewed and approved by other stakeholders or committees (as appropriate).
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Methods Used to Assess the Quality of the Evidence/Strength of the Recommendations:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.

Internally developed recommendations, or those adopted from external sources without an
assigned evidence grade, were evaluated by the guideline workgroup using an algorithm
adapted from the Grading of Recommendations Assessment, Development and Evaluation
(GRADE) methodology (see Figure 1 in Appendix A).

Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the rating scheme(s) used within this document.
Definitions
1. ACG: American College of Gastroenterology
2. DMS: Diabetes Management Service; a group of providers that works with adults who have
high blood glucose (also known as blood sugar) levels during their hospital stay. DMS has
special expertise in the diagnosis and treatment of this condition.
3. EN: Enteral nutrition; the preferred method of feeding in the presence of a functional
gastrointestinal tract when volitional intake is insufficient or unsafe to meet nutrient needs. It
is provided with enteral formulas containing protein, carbohydrates, fats, vitamins, minerals,
and water, and is given through a tube into the stomach or small bowel.
4. EAD: Enteral access device; the tube used for delivery of enteral nutrition. Tube types
include nasogastric, nasoenteric, gastrostomy, gastrojejunostomy, or jejunostomy tube.
5. ES: Endocrine Society
6. GRV: Gastric residual volume; measurement of accessible gastric volume by use of large
syringe (e.g. 60 mL). Gastric residual volume measurement is limited to oro/nasogastric
tubes used for decompression as well as feeding, and gastrostomy tubes.
7. GI: Gastrointestinal; relating to the stomach and small intestine
8. Nasoenteric feeding tube: The feeding tube is inserted through the nose and the tip of the
tube could be located in the stomach, the duodenum, or the proximal jejunum. Providers
should designate desired tube tip location at the time of feeding tube order placement.
9. Oroenteric feeding tube: The feeding tube is inserted through the mouth and the tip of the
tube could be located in the stomach, the duodenum, or the proximal jejunum. Providers
should designate desired tube tip location at the time of feeding tube order placement.
Orally placed feeding tubes in the adult patient are usually limited to those who are on
mechanical ventilation.
10. PN: Parenteral nutrition; PN is intravenous nutrition designed to meet 100% of estimated
nutrient needs if delivered by large diameter vein.
11. POC glucose: Point of care glucose; refers to peripheral measurement of glucose using a
portable glucose monitoring device.
Introduction
Enteral nutrition therapy is specialized nutrition support for patients with a functional
gastrointestinal tract unable to ingest enough nutrition orally to meet their energy, protein, and
micronutrient requirements. EN may provide 100% of estimated energy needs or be used to
supplement oral intake. A variety of formulas are available that provide nutrient profiles to meet
the needs of patients with varying medical conditions. Several considerations are given when
initiating EN such as route of administration and tube tip location, current medications, patient
hemodynamic status, and evidence of malnutrition. Safe delivery of EN encompasses
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monitoring of gastrointestinal and metabolic parameters to prevent complications. The purpose
of this guideline is to provide guidance for selection of patients appropriate for EN, the
appropriate EAD, estimation of nutrient requirements including energy, protein, micronutrients,
and water, selection of the formula, recommendations for parameters to consider for initiation
and advancement of EN, parameters to monitor to prevent development of complications,
suggestions for management of common complications, and transition to home EN if the patient
is unable to consume food orally at discharge.
Recommendations

1. Indications: 1
1.1. EN should be used preferentially over PN in hospitalized patients who require non-
volitional specialized nutrition therapy and do not have a contraindication to the delivery
of luminal nutrients (ACG conditional recommendation, low level of evidence).
1.2. Specialized nutrition therapy in the form of EN should be initiated promptly in the
hospitalized patient who is at high nutritional risk and is unable to maintain volitional oral
intake safely (ACG and UW Health conditional recommendation, low level of evidence).
1.3. Specialized nutrition therapy (EN or PN) is not required for hospitalized patients who
are at low nutritional risk, appear well nourished, and are expected to resume volitional
intake within 5 to 7 days following admission (ACG conditional recommendation, very
low level of evidence).

2. Nutrition Assessment: 1 (ACG conditional recommendation, very low level of evidence)
2.1. Prior to initiation of specialized nutrition therapy (either EN or PN), a determination of
nutritional risk should be performed using a validated scoring system such as the
Nutritional Risk Score 2002 (NRS-2002) or the NUTRIC Score on all patients admitted
to the hospital for whom volitional intake is anticipated to be insufficient.
2.2. An additional assessment should be performed prior to initiation of nutrition therapy of
factors that may impact the design and delivery of the nutrition regimen.
2.3. Caloric requirements should be determined and then be used to set the goal for delivery
of nutrition therapy.
2.4. One of the three strategies should be used to determine caloric requirements: Indirect
calorimetry, Simple weight-based equations, or Published predictive equations.
2.5. Protein requirements should be determined independently of caloric needs, and an
ongoing assessment of protein provision should be performed.
2.6. Daily protein requirements are based on a patient’s age, weight, nutrition status, and
degree of stress imposed by disease or injury. 2 (UW Health Very low quality evidence,
conditional recommendation).
2.7. The goal of fluid management is to maintain adequate hydration, tissue perfusion,
electrolyte balance, and avoiding fluid overload. 2 (UW Health Very low quality
evidence, conditional recommendation).

3. Enteral Access: 3
3.1. Select an EAD based on patient-specific factors (e.g. GI anatomy, GI function, expected
duration of EN, known aspiration risk, facial & skull base fractures and trauma) (UW
Health Very low quality evidence, conditional recommendation).
3.2. Place a short-term nasoenteric or oroenteric EAD in patients who require EN for up to
approximately 4-6 weeks in duration (UW Health Very low quality evidence, strong
recommendation).
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3.3. Place a long-term EAD in patients who require EN for longer than 4-6 weeks (UW
Health Very low quality evidence, strong recommendation)

4. Initiating Enteral Nutrition: 1
4.1. In the patient at high nutritional risk unable to maintain volitional intake, EN should be
initiated within 24–48 h of admission to the hospital (ACG conditional recommendation,
low level of evidence).
4.2. Although early EN should be initiated within 24–48 h of admission, the timing by which
to advance to goal is unclear. When tolerated, feeding should be advanced to goal
within 48–72 h (ACG conditional recommendation, very low level of evidence).
4.3. With reduced tolerance, feeding should be advanced with caution to goal by 5 to 7 days
(ACG conditional recommendation, very low level of evidence)

5. Monitoring Tolerance and Adequacy of EN:
5.1. Monitor and evaluate the patient receiving EN to identify all changes in physical
examination findings, laboratory values, anthropometric data, and outcomes. 3 (UW
Health Very low quality evidence, conditional recommendation).
5.2. Patients on EN should be monitored for adequacy of provision of EN as a percent of
target goal calories, cumulative caloric deficit, and inappropriate cessation of EN (ACG
conditional recommendation, very low level of evidence) 1
5.3. Identify patients at risk for refeeding syndrome prior to initiation of EN. 3. Risk factors
include severely malnourished or starved individuals. 2.
5.3.1. Correct electrolyte abnormalities prior to initiation and during delivery of nutrition.
2
(UW Health Very low quality evidence, conditional recommendation).
5.3.2. Start and increase calorie provision conservatively over the course of 5-7 days.2
(UW Health Very low quality evidence, conditional recommendation).
5.3.3. Minimal initial fluid and sodium provided 2 (UW Health Very low quality evidence,
conditional recommendation).
5.3.4. Supplement with 50-100 mg intravenous/oral thiamine for 5-7 days.2 (UW Health
Very low quality evidence, conditional recommendation).
5.3.5. Supplement with daily multivitamin and mineral. (UW Health Very low quality
evidence, conditional recommendation).
5.4. Identify patients at risk for development of hyperglycemia while receiving EN. Possible
causes of hyperglycemia include preexisting diabetes, undiagnosed diabetes or
prediabetes, stress-induced hyperglycemia and medication-inducted hyperglycemia. 4
(UW Health Very low quality evidence, conditional recommendation).
5.4.1. For patients with no known history of diabetes, correct serum glucose prior to
initiation of EN. (UW Health Very low quality evidence, conditional
recommendation).
5.4.2. For patients with a history of diabetes/hyperglycemia, assess current blood
glucose patterns and insulin requirements prior to initiation of EN. 4 (UW Health
Very low quality evidence, conditional recommendation).
5.4.3. POC glucose testing should be initiated for patients with or without a history of
diabetes receiving EN and PN. 5. (ES High quality, strong recommendation)
5.4.4. POC glucose testing can be discontinued in patients without a prior history of
diabetes if blood glucose values are less than 140 mg/dL without insulin therapy for
24-48 h after achievement of desired caloric intake. 5 (ES very low quality evidence,
weak recommendation)
5.4.5. Begin scheduled insulin such as regular insulin every 6 hours, with or without
glargine, for treatment of persistent hyperglycemia (>180 mg/dL x 3 in 24 hours) in
the setting of EN delivery per UW Health Diabetes Clinical Practice Guideline (see
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Companion Documents section above). (UW Health Very low quality evidence,
conditional recommendation).
5.4.6. Notify provider or DMS and increase glucose monitoring if EN is interrupted for
those patients receiving concurrent insulin therapy. (UW Health Very low quality
evidence, conditional recommendation).
5.4.7. Notify provider or DMS and alter glucose monitoring schedule if EN
administration is changed from continuous infusion to cyclic or bolus/intermittent
feedings for those patients receiving concurrent insulin therapy. (UW Health Very
low quality evidence, conditional recommendation).
5.4.8. Notify provider or DMS if the EN formula carbohydrate-to-fat ratio changes
significantly such as standard formula (25-35% fat) to renal formula ((45-50% fat) or
elemental formula (10% fat). (UW Health Very low quality evidence, conditional
recommendation).
5.5. Measurement of gastric residual volumes to assess tolerance is controversial as neither
the practice nor the method of checking GRV itself is validated. It has been
recommended that interruption of EN should be avoided for GRV < 500 mLs in the
absence of other signs and symptoms of intolerance (nausea, vomiting, bloating,
abdominal discomfort or distension) but that close monitoring is warranted in patients
with gastric residuals between 200 and 500 mL, ensuring that all measures to reduce
aspiration risk are initiated. 2 (UW Health Very low quality evidence, conditional
recommendation).
5.6. For the patient receiving EN who develops diarrhea, an evaluation should be initiated to
identify an etiology and direct management. 1 (ACG conditional recommendation, very
low level of evidence). Prevention/Treatment of Diarrhea includes: 2 (UW Health Very
low quality evidence, conditional recommendation).
5.6.1. Discontinue or reduce dose of offending medication, or replace with alternative
non-diarrhea causing medication. Consider consulting a pharmacist to review
medication list, looking for medications containing sorbitol that may exacerbate
diarrhea.
5.6.2. Change from liquid solution to tablet form or dilute hypertonic medications
5.6.3. Identify and treat underlying medical/surgical issues and infections
5.6.4. Adjust fiber type and/or amount provided; consider decreasing insoluble fiber or
increasing soluble fiber (e.g. guar gum).
5.6.5. Consider an isotonic formula or slower infusion rate
5.7. For the patient who develops constipation: 2 (UW Health Very low quality evidence,
conditional recommendation).
5.7.1. Adjust medications that decrease gastrointestinal motility
5.7.2. Add or adjust bowel regimen, choosing liquid formulations that can be used in a
feeding tube.
5.7.3. Use fiber-containing enteral formulas if no contraindication exists
5.7.4. Increase amount of free water provided
5.7.5. Promote ambulation as able
5.8. For the patient who develops nausea and vomiting: 2 (UW Health Very low quality
evidence, conditional recommendation)
5.8.1. Provide an anti-emetic regimen
5.8.2. Consider prokinetic agents to increase gastric motility. Suggested medications
and dosage: metoclopramide 10 mg IV/PO every 6 hours, erythromycin
lactobionate 1.5 to 3 mg/kg IV every 6 hours, or erythromycin ethyl succinate PO
suspension (same dose). 6
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5.8.3. Reduce, replace, or discontinue medications that delay gastric emptying.
Examples of these medications include opiates, tricyclics, and calcium channel
blockers.
5.8.4. Consider a low fat, isotonic, or more calorically dense formula
5.8.5. Ensure enteral formula and water flushes are delivered at room temperature
5.8.6. Temporarily reduce the enteral infusion rate by 20-25 mL/hour or extend the
infusion time of cycled or intermittent feeds
5.8.7. Obtain post-pyloric enteral access

6. Transition from EN to Oral Feeding: 2 (UW Health Very low quality evidence, conditional
recommendation)
6.1.1. The length of time needed for this transition may vary considerably, depending
on the patient’s underlying illnesses, current medical condition, and degree of
wakefulness.
6.1.2. Once a diet has been started, adjustments in the enteral feeding schedule can
help promote appetite and oral intake; strategies include nocturnal feeding,
intermittent feedings between meals, or stopping EN 1 hour before meals.
6.1.3. When the patient is consuming 60% - 75% of estimated energy and protein
needs, the clinician should consider stopping EN and removing the temporary EAD.
6.1.4. If the patient is unable to demonstrate adequate oral intake for > 4 weeks, a
permanent feeding tube should be considered (such as percutaneous endoscopic
gastrostomy or PEG).

7. Transition to Home or Alternate Healthcare Setting with EN:
7.1. Early discharge planning and active communication with all members of the patient care
team (e.g., physician, dietitian, nurse, social worker, and case manager) are required
for a successful transition. 2 (UW Health Very low quality evidence, conditional
recommendation)
7.1.1. Begin the referral process once the decision for EN therapy is made. 3 (UW
Health Very low quality evidence, conditional recommendation)
7.1.2. Factors to consider for discharge include formula, insurance coverage for the EN
formula, and delivery method (gravity drip, syringe bolus, or pump). (UW Health
Very low quality evidence, conditional recommendation)
7.1.3. Involve representatives of the discharging site (nutrition support clinician, case
manager, or prescriber) and the accepting site or home care team (nutrition support
clinician, home supply company, home health agency) in planning the care
transition. 3 (UW Health Very low quality evidence, conditional recommendation)
7.2. Establish tolerance to EN at the goal regimen prior to discharge. 3
7.3. Patient and caregiver education is important to ensure safe and adequate
administration of EN at home and should begin early in the discharge planning process.
2
(UW Health Very low quality evidence, conditional recommendation)
7.4. A primary clinician who will be responsible for ordering and managing home EN should
be identified prior to patient discharge from the hospital, and the patient should follow
up with this clinician soon after discharge. 2 (UW Health Very low quality evidence,
conditional recommendation)


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org

10


UW Health Implementation
Potential Benefits:
Standardized consideration of indications, nutrition assessment, and initiation and advancement
of enteral nutrition with monitoring to prevent complications will provide patient centered care
and improved patient safety.

Potential Harms:
Harms of implementation are few

Qualifying Statements:
This CPG was prepared utilizing the most recent enteral nutrition guidelines and available
literature. Recommendations may change based upon new published findings. This CPG does
not address nursing specific practices that are referenced in the pertinent UW Health policies
and procedures below.

Pertinent UW Health Policies & Procedures
1. UW Health Policy #2.20AP: Care and Maintenance of Enteral Tubes (Adult & Pediatric)
2. UW Health Policy #2.24AP: Nasal Bridles: Use, Maintenance and Removal Application
(Adult & Pediatric)
3. UW Health Policy #2.3.6: Small-bore Nasoenteric (Dobhoff) Tube Placement
4. UW Health Policy #2.25AP: Placement of Small Bowel Feeding Tube Using Cortrak®
Enteral Access System (Adult & Pediatric)

Patient Resources
1. Health Facts For You #603 - Nasogastric Tube Feedings
2. Health Facts For You #295 - Gastrostomy Tube Feeding
3. Health Facts For You #296 - Jejunostomy Tube Feeding

Implementation Plan/Clinical Tools
1. Guideline will be posted on U-Connect in a dedicated location for Clinical Practice
Guidelines.
2. Release of the guideline will be advertised in the Physician/APP Briefing newsletter.
3. Content and hyperlinks within clinical tools, documents, or Health Link related to the
guideline recommendations (such as the following) will be reviewed for consistency and
modified as appropriate.
ξ Delegation Protocol: Enteral Nutrition ‐ Adult ‐ Inpatient (#46)
ξ Delegation Protocol: Nutrition Support ‐ Developing, Ordering, and Monitoring a Nutrition
Support Care Plan ‐ Adult/Pediatric/Neonatal (#6)
ξ Reference Links in the Diet Order Navigator

Disclaimer
Clinical practice guidelines assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is
understood that some patients will not fit the clinical condition contemplated by a guideline and
that a guideline will rarely establish the only appropriate approach to a problem.

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Appendix A. Evidence Grading Scheme(s)

Figure 1. GRADE Methodology adapted by UW Health and utilized by the American
College of Gastroenterology and the Endocrine Society


GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it
is also possible it is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.

GRADE Ratings for Recommendations For or Against Practice
Strong The net benefit of the treatment is clear, patient values and circumstances
are unlikely to affect the decision.
Weak/conditional
Recommendation may be conditional upon patient values and
preferences, the resources available, or the setting in which the
intervention will be implemented.




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References
1. McClave SA, DiBaise JK, Mullin GE, Martindale RG. ACG Clinical Guideline: Nutrition
Therapy in the Adult Hospitalized Patient. Am J Gastroenterol. 2016;111(3):315-334;
quiz 335.
2. Kozeniecki M, Fritzshall R. Enteral Nutrition for Adults in the Hospital Setting. Nutr Clin
Pract. 2015;30(5):634-651.
3. Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition
Therapy [Formula: see text]. JPEN J Parenter Enteral Nutr. 2017;41(1):15-103.
4. Davidson P, Kwiatkowski CA, Wien M. Management of Hyperglycemia and Enteral
Nutrition in the Hospitalized Patient. Nutr Clin Pract. 2015;30(5):652-659.
5. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in
hospitalized patients in non-critical care setting: an endocrine society clinical practice
guideline. The Journal of clinical endocrinology and metabolism. 2012;97(1):16-38.
6. Hejazi RA, McCallum RW, Sarosiek I. Prokinetics in diabetic gastroparesis. Curr
Gastroenterol Rep. 2012;14(4):297-305.

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 10/2017CCKM@uwhealth.org