A (Functional) Digestive System is a Terrible Thing to Waste

“Patient failed swallow evaluation. Will initiate PPN.”

I can’t tell you how many times I’ve come across this phrase or some variation of it in doctor’s notes. For many reasons, patients in a hospital setting are found to be choking on solids and liquids. In many cases, they will regain the ability to swallow

safely within a few days so we don’t have to provide a long-term plan. For example, a patient who has been extubated may experience swelling of the throat which prevents safe swallowing. If there were no swallowing problems prior to intubated, that person will be able to initiate a diet usually within a few days.

The Problem of NPO

Although going a day or two without any nutrition doesn’t always seem to be a problem, studies have shown that recovery is delayed and complicated with even short periods of inadequate calorie and protein intake. Think about how you’ve felt when you’ve gone a day without eating. I fasted once for religious reasons and it was the most miserable day of my life. I felt weak and shaky by about halfway through the day. Also, according to my family, I was little unpleasant to be around. Our patients may not be able to verbalize how they feel, but a few days of being NPO affects both your physical health and recovery as well as your state of mind.

We often underestimate the problems of inadequate nutrition though. Certainly, if we have a patient who is 100 pounds overweight, a day or two without nutrition might not be seen as negative. In some cases, if their excess weight is contributing to their poor health, we might even see weight loss as being positive. However, in a hospital setting, we have people who are ill. They’re metabolically stressed and compromising their nutrition adds to their problems. In critical care units, we know that patients who receive early nutrition intervention reduces complications, length of hospital stay, readmission rates, cost of care, and most importantly, mortality.

Physicians, especially critical care physicians, understand the risks of NPO. As a medical community, we’re all getting on board with the consensus that providing nutrition is important. However, we don’t always agree on the method

Providing PPN

When a patient fails a swallow evaluation, a dietitian will recommend one of the following two options: provide comfort care with pleasure feeds if the patient wants to pursue hospice/comfort care OR insert a nasogastric tube (NGT) to initiate enteral nutrition. An NGT is easily placed by a nurse and minimally invasive. This small tube is inserted through the nose and ends in the stomach where it can be used to provide tube feed formula and water flushes. Although the end result isn’t quite the same as eating a hamburger and fries, it’s both safe and effective. Because we’re using your digestive system in the way it was intended, we see multiple benefits although too many to list here. Additionally, an NGT is easy to remove as needed.

Some physicians do not prefer to have NGTs placed. Instead, they will order peripheral parenteral nutrition. This prescription means that we provide nutrition

through a vein, bypassing your digestive system and increasing your risk of infection. It’s fairly easy to provide PPN but there are specific criteria for parenteral nutrition that we may not be following.

Why exactly is PPN being ordered above enteral nutrition? These are the most common reasons given as well as my response:

• Patient will pull out the NGT

• Possibly. But we know that it’s the best option for our patients so we need to try an NGT as our first option.

• Too much work to place the tube for only a short period of nutrition support

• It’s also a lot of work if the patient develops an infection.

• Unspecified

• I can’t address this only to say that it’s common to order PPN without giving a reason other than the patient can’t be given an oral diet.

Moving Forward

When you want to make a change in a hospital, that change has to come with your doctors on board. We have some great doctors who understand the risk of PPN and champion the use of EN when needed. If you’re going through the same experience, find a doctor who’s on board. Get your pharmacists to work with you on this project. Provide education to doctors as much as you can. My hospital does a good job, but we can do better and we work to achieve that goal every day.