Developing a clinical care pathway to reduce and treat enteric feeding tube site skin excoriation: a quality-improvement pilot study
Skin excoriation is a common complication of enteral tube feeding; however, universal guidelines for treatment do not exist. A quality improvement pilot study to inform the development of a local clinical care pathway was conducted. The enteral nutrition team identified products and assessed patient preference, ease of use, availability, and clinical outcomes for inclusion. This pathway includes gentle site cleansing followed by skin protectant application. For mild skin excoriation (<5 mm), acrylate terpolymer barrier film (3M Cavilon No Sting Barrier Film) was applied once every seven days. Moderate skin excoriation (5–20 mm) received acrylate terpolymer barrier film twice a day for seven days. Severe skin excoriation (>20 mm) received advanced elastomeric skin protectant (3M Cavilon Advanced Skin Protectant) applied once every 3–4 days for 2–4 weeks. Ten patients were included, three were selected for discussion. Adoption of this local clinical care pathway resulted in skin healing and improved patient comfort.
In the UK, the prevalence of enteral feeding in 2011 was estimated at 92 per million or approximately 6 164 patients (Gramlich et al, 2018). In 2015, the British Artificial Nutrition Survey Report showed an increase in patients requiring enteral feeding as home care companies reported supporting 20 214 adult patients with home enteral tube feeding (Stratton et al, 2018).
A common complication, especially in long-term use of enteral feeding, is skin excoriation (McClave and Neff, 2006) with a complication rate of 1-2% (up to an estimated 404 adult patients in the 2015 home health setting). This resulted in significant burdens such as pain, discomfort, isolation, and financial implications from private purchase of dressings and multiple clothing changes (Schrag et al, 2007). Skin excoriation risk factors include repeated tube traction, poor tube positioning, impaired wound healing, gastrostomy infection, gastric hypersecretion, and excessive cleaning with corrosive agents (McClave and Neff, 2006; Schrag et al, 2007; Westaby et al, 2010). Treatment of skin excoriation ranges from skin barrier creams to daily dressing changes. However, universal guidelines do not exist, resulting in varied enteral site management among healthcare providers.
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