/clinical/,/clinical/cckm-tools/,/clinical/cckm-tools/content/,/clinical/cckm-tools/content/delegationpractice-protocols/,/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/,

/clinical/cckm-tools/content/delegationpractice-protocols/inpatient-delegation-protocols/name-97284-en.cckm

201711325

page

100

UWHC,UWMF,

Tools,

Clinical Hub,UW Health Clinical Tool Search,UW Health Clinical Tool Search,Delegation/Practice Protocols,Inpatient Delegation Protocols

Enteral Nutrition - Adult - Inpatient [46]

Enteral Nutrition - Adult - Inpatient [46] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Inpatient Delegation Protocols


Delegation Protocol Number: 46

Delegation Protocol Title:
Enteral Nutrition - Adult - Inpatient

Delegation Protocol Applies To:
University Hospital Inpatients

Target Patient Population:
Adult patients admitted to any inpatient unit at UH who are receiving enteral nutrition

Delegation Protocol Champions:
Josh Medow, MD – Department of Neurological Surgery
Dustin Andresen, MD – Department of Medicine - Hospitalists

Delegation Protocol Reviewers:
Robin Crist, RD – Clinical Nutrition
Cassandra Kight, RD – Clinical Nutrition

Responsible Department:
Clinical Nutrition

Purpose Statement:
The purpose of this delegation protocol is to delegate authority from the ordering provider to Registered
Dietitian Nutritionists to place orders for enteral nutrition (medications and vitamins) and the laboratory tests
required to monitor enteral nutrition.

Who May Carry Out This Delegation Protocol:
Registered Dietitian Nutritionists (RDN’s) who are trained in the use of this delegation protocol and meet
competency requirements defined by the Department of Clinical Nutrition. Recommended, but not required, is
the Certified Nutrition Support Clinician (CNSC) credential from the National Board of Nutrition Support
Certification, American Society for Parenteral and Enteral Nutrition.

Guidelines for Implementation:
1. This delegation protocol is initiated when a provider orders “Consult Nutrition (Inpatient)” and indicates
in the order question “Initiate and Manage Tube Feedings”. The RD will assess and document nutrition
needs. If an initial assessment has already been completed and documented the RD will
reassess/reconfirm needs. Based on this assessment, recommendations will include type of formula,
initiation rate, progression to goal rate, free water, if appropriate, and addition of any modulars,
vitamins, minerals, or fiber.
2. The RDN will complete orders for enteral nutrition (EN) using the tube feeding section of the diet order.
3. The RDN will monitor patient EN tolerance and evaluate appropriateness of advancing EN until goal rate
is reached. Monitoring will be completed daily while advancing with significant findings documented
with short progress notes in Health Link or communicated to primary team.
4. The RDN will continue to monitor patient once goal rate has been achieved. Identified issues with
gastrointestinal tolerance or metabolic abnormalities will be discussed with primary team.
5. The RDN may place orders for volume of water boluses or flushes as appropriate to meet normal
hydration requirements of 25-35 mL/kg. If the patient’s needs vary from “normal” the RDN will order
volume of water only after discussion with primary service. The RDN may use the “continuous water
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

infusion” order for patients with small bowel placement of feeding tube tip or inability to tolerate large
boluses of water into stomach.
6. The RDN may place orders for vitamins and minerals as warranted by the patient’s condition, laboratory
values, or to correct any deficiencies inherent in the EN regimen.
7. The RDN may place orders for protein supplementation (e.g. Beneprotein, ProSource) with EN to meet
estimated protein needs of patient.
8. RDN may place an order for a fiber supplement (such as Nutrisource Fiber/Benefiber, 1-3 packets/day)
for a patient who experiences diarrhea that is not infectious, does not respond to adjustment of
medications associated with diarrhea, or does not respond to a fiber-containing formula.
9. The RDN may place orders for laboratory tests necessary for monitoring safety and efficacy of the
enteral nutrition regimen and other selected noninvasive studies as outlined in the Ordering Laboratory
Tests and Other Non-Invasive Studies (see Table 1). Abnormal results of any test ordered as part of this
protocol will be communicated to primary team.
10. The RDN may place orders for anthropometric measurements.
11. When this delegation protocol is activated, the RDN will reassess at least weekly and document in the
progress note section of Health Link.

Order Mode:
Laboratory Tests: Cosign Required, Protocol/Policy
Medications and Vitamins/Supplements: Protocol/Policy, Without Cosign

References:
1. Mueller C., ed. The A.S.P.E.N Nutrition Support Core Curriculum, 2
nd
Edition. The American Society for
Parenteral and Enteral Nutrition; 2012.
2. Academy of Nutrition and Dietetics Evidence Analysis Library. www.eatright.org
3. http://www.eatrightpro.org/resources/research/evidence-based-resources/evidence-analysis-library.
4. Academy of Nutrition and Dietetics Nutrition Care Manual. Web-based application available within U-
Connect and Health Link. https://uconnect.wisc.edu/depts/uwhc/clinical-nutrition-
services/resources/name-7947-en.file
5. Kozeniecki, M & Fritzshall R. Enteral nutrition for adults in the hospital setting. Nutr Clin Pract. 2015;30:634-
651.
6. UptoDate® (vitamin information). Accessed March 2016.
6.1. Vitamin D: http://www.uptodate.com/contents/vitamin-d3-cholecalciferol-drug-
information?source=search_result&search=holick&selectedTitle=3~4
7. Byham-Gray L, Stover J, & Wiesen K, eds. A Clinical Guide to Nutrition Care in Kidney Disease, 2
nd
Edition.
Renal Dietitians Dietetic Practice Group of the Academy of Nutrition and Dietetics and the Council on Renal
Nutrition of the National Kidney Foundation, 2013.

Collateral Documents/Tools:
UW Health Enteral Nutrition – Adult Inpatient/Ambulatory Clinical Practice Guideline

Approved By:
UWHC Nutrition Committee: May 2011, *June 2014; *November 2016
UW Health Clinical Laboratories Practice Committee: April 2011, *June 2014; *November 2016

UWHC Medical Board: May 2011, *June 2014, * January 2017

Effective Date: January 2017
Scheduled for Review: January 2020
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

* expedited review approval process
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Table 1: Ordering Laboratory Tests and Other Non-Invasive Studies
for Management of Enteral Nutrition (EN)
University of Wisconsin Hospital and Clinics – Clinical Nutrition Services
Laboratory Test Frequency Clinical Conditions
Potassium, magnesium,
phosphorus
Daily as needed while EN advances
to goal per conditions listed, if not
ordered by primary service
Risk of refeeding syndrome
Starvation
Malnutrition
Critical illness
Large electrolyte losses
(diarrhea, vomiting, high output
ostomy)
Glucose, POC Every 6 hours during initiation of
EN
Diabetes
Glucocorticoid medication
Obesity
Impaired glucose tolerance during
admission
Zinc Once Chronic diarrhea: >/= 3 stools/d or
increased frequency and decreased
consistency compared to baseline
for >3 weeks
Pancreatic/ duodenal resection
Proximal small bowel fistula
External pancreatic drainage
Non-Invasive Testing – performed
by the Pulmonary Function Lab
Frequency Clinical Conditions
Metabolic study (Resting Energy
Expenditure, Respiratory Quotient)
by indirect calorimetry
As clinical condition To assess energy requirement of
patients whose metabolic rate is
unlikely to be accurately
determined from predictive
equations. Examples include critical
illness, multiple complications, non-
healing wounds, burns >20%,
extremes of body habitus (morbid
obesity, Body Mass Index (BMI)
<18), and amputations that alter
normal body composition.
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org


Table 2: Oral/Enteral Vitamin/Mineral Repletion for Management of Enteral Nutrition (EN)
University of Wisconsin Hospital and Clinics – Clinical Nutrition Services
Vitamin Adult Dose, Route, Frequency Clinical Condition
Ascorbic Acid
500 mg twice daily x 10 days • Non-healing wound or
pressure ulcer
Cholecalciferol
Dietary Reference Intake for Vitamin
D: Oral/Enteral Adults 19 to 70 years:
Recommended Daily Allowance (RDA): 600
units/day (IOM 2011) Female:
Pregnancy/Lactating: RDA: 600 units/day
(IOM 2011). Adults >70 years: RDA: 800
units/day (IOM 2011).
Vitamin D deficiency
prevention: Oral/Enteral 1,500 to 2,000
units daily to maintain serum 25(OH)D
levels >30 ng/mL (Holick 2011), or other
dose as patient was on at home.
Vitamin D deficiency
treatment: Oral/Enteral 6,000 units daily
(or 50,000 units ergocalciferol once
weekly) for 8 weeks to achieve serum
25(OH)D level >30 ng/mL, followed by
maintenance dose of 1,500 to 2,000 units
daily (Holick 2011).
• To meet Recommended
Dietary Allowances with
inadequate intake or
exposure to sunlight
• Documented Vitamin D
deficiency
• Continuation of Vitamin
D supplementation
patient received at home
for underlying medical
condition (e.g.
osteopenia)
Cystic Fibrosis specific
multivitamin ( softgels
and liquids) and Vitamin D
2 capsules of soft-gels (orally), or 4 mL
liquid (feeding tube)
• Cystic Fibrosis (CF)

Folic acid 1 mg, Oral/Enteral, once daily
• Low serum folate
• Heavy alcohol use
• Pregnancy
• Pregnancy in CF (in
addition to CF
multivitamins)
• Chronic Kidney Disease
(CKD)
• RRT not on Renal
Multivitamin with higher
amount of folic acid
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Multivitamin with
minerals


1 tablet, Oral/Enteral, crushed, once daily


• Recommended EN
regimen fails to provide
100% of RDI for one or
more vitamins
• Increased needs (e.g.
burn, wound healing)
• Prior inadequate
micronutrient intake
• Heavy alcohol intake
• Medications which
interfere with
metabolism of one or
more vitamins
(phenytoin,
phenobarbital,
sulfasalazine)
Pyridoxine 25 mg tablet, Oral/Enteral, crushed, once
daily
• CKD
• Acute Kidney Injury (AKI)
with Continuous Renal
Replacement Therapy
(CRRT)
• Documented deficiency
Renal Multivitamin 1 tablet, Oral/Enteral, crushed, once daily
• CKD, AKI
• Patient on RRT
Thiamine 100 mg tablet, Oral/Enteral, crushed, once
daily
• Risk of refeeding
syndrome
• Heavy alcohol intake
• Documented deficiency
• AKI with CRRT
Vitamin A 15,000 units tablet, Oral/Enteral, once
daily x 10 days
Cystic Fibrosis Patients: continue usual
dose without end date.
• Non-healing wound or
pressure ulcer
• Documented deficiency
• Continuation of home
regimen for CF
Vitamin E 400 – 800 units, Oral/Enteral once daily
• Continuation of home
regimen for CF
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org

Zinc 50 mg tablet, Oral/Enteral, once daily x 10
days
• Non-healing wound or
pressure ulcer
• Documented deficiency

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org