Nutrition in Clinical Practice

http://ncp.sagepub.com/ Economic Impact of Switching From an Open to a Closed Enteral Nutrition Feeding System in an Acute Care Setting
Wendy Phillips, Brandis Roman and Kendra Glassman Nutr Clin Pract published online 4 June 2013 DOI: 10.1177/0884533613489712 The online version of this article can be found at: http://ncp.sagepub.com/content/early/2013/06/03/0884533613489712

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research-article2013

489712

NCPXXX10.1177/0884533613489712Nutrition in Clinical PracticePhillips et al

Clinical Research

Economic Impact of Switching From an Open to a Closed Enteral Nutrition Feeding System in an Acute Care Setting
Wendy Phillips, MS, RD, CNSC, CLE1; Brandis Roman, MS, RD, CSP2; and Kendra Glassman, MS, RD, CNSC, CSSD1

Nutrition in Clinical Practice Volume XX Number X Month 2013 1 5 2013 American Society for Parenteral and Enteral Nutrition DOI: 10.1177/0884533613489712 ncp.sagepub.com hosted at online.sagepub.com

Abstract
Background: This study compared an open-system (OS) enteral nutrition (EN) delivery system with a closed system (CS). Factors evaluated included nursing time for administration, patient safety factors, and cost of formula and supplies. Materials and Methods: This study analyzed the cost of formula and supplies in 1 major academic medical center. Data were collected on patients requiring EN in acute care settings. Information collected included formula type and amount of formula ordered and delivered. Results: The average daily cost to feed each adult patient using delivered volume with the OS was $3.84 compared with $4.31 if the patient had been receiving EN from a CS. Considering waste costs, the average cost to feed increased to $4.21 compared with $4.80, respectively. After factoring in increased nursing time with the OS, the cost increased to $9.83. For pediatric patients, formula delivery reached 1 L in only 2% of patient days. The average cost to feed each patient each day using actual delivered volume was $1.89 in the OS and $1.94 in the CS. When factoring in the cost of waste, those costs increased to $2.12 and $3.30, respectively. After factoring in increased nursing time with the OS, the cost increased to $8.92. Conclusion: Due to the higher contract price and increased waste of the CS formulas compared with the OS formulas, a higher daily average cost for formula delivered may be incurred by switching to a CS. However, the CS is more cost-effective when factoring in nursing time. (Nutr Clin Pract. XXXX;xx:xx-xx)

Keywords
enteral formulas; adult; pediatrics; costs and cost analysis; outcome assessment

Maintaining nutrition status in patients with acute or chronic illness is essential. Enteral nutrition (EN) support is often indicated in patients with a functional gastrointestinal (GI) tract who are unable to meet their estimated nutrient needs with oral nutrition intake. Ready-to-use EN products come as either closed or open systems. A closed system (CS) consists of a sterile container of prefilled formula that is ready to administer to the patient. Open systems (OS) involve cans, bottles, or tetra-paks of formula that must be poured into an EN feeding bag before delivery to the patient. Healthcare institutions should fully evaluate use of economic resources, including a regular review of the enteral formulary and the EN delivery system. Important factors to consider when reviewing these systems are patient safety and cost factors. The EN delivery system that is least likely to contribute to infection through bacterial contamination would be the safest for the patient. Cost factors that should be considered include price of the formula and supplies, including the amount of formula wasted, and nursing time required to administer the prescribed formula. Complications that can arise due to administration of contaminated formulas include abdominal distension,1 diarrhea,2-4 and bacteremia.5,6 The risk of contamination appears to increase concomitantly with formula manipulation and handling.7-11 Previous research documented in the literature has established that OS EN formulas are a potential source of

nosocomial infection in the acute care setting due to the risk of microbial contamination of these formulas.1-11 Many studies support the use of CS over OS because there is less manipulation and human/environmental contact with the EN formula and feeding administration sets.12-17 Although the CS is generally more expensive in terms of actual product and supply costs, the increased protection against infection may be worth the higher formula cost. However, some studies purport that as long as proper administration procedures and hygiene rules are followed, an OS can be safely used,18-20 and there is no benefit of using one system over another.9,11,21-23 Time required for formula administration by nursing staff is also an important consideration when comparing OS with CS. OS generally require nursing staff to refill formula every 48 hours, depending on facility policies and administration procedures. Interruptions in nutrition support may result when
From 1University of Virginia Health System, Charlottesville, and 2 University of Virginia Childrens Hospital and University of Virginia Department of Pediatrics, Charlottesville. Financial disclosure: None declared. Corresponding Author: Kendra Glassman, MS, RD, CNSC, CSSD, University of Virginia Health System, 700 Walker Square 1b, Charlottesville, VA 22903, USA. Email: kendrabell@yahoo.com.

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formulas are not promptly replaced, with a decrease in nutrient delivery.24 The administration of formulas in an OS, especially when following proper hang time and delivery procedures, involves an increase in nursing time compared with administration of a CS,20,25,26 which leads to the increased expense of healthcare dollars. When surveyed, both nursing and dietetic staff have reported increased satisfaction using a CS vs an OS to administer enteral feeds,24 although this is not a consistent finding in all studies.21 The potential increased hang time (up to 48 hours) with use of a CS compared with an OS has been shown to lead to decreased waste, with resultant cost savings.27 However, another study has shown that due to a larger container (1000or 1500-mL bottles in a CS vs 237- to 250-mL containers in the OS), there would be risk of waste if the total amount delivered in the 24-hour administration period is less than the volume in the CS container.16 Although CS products are often marketed as having a 48-hour hang time, many institutions can use them only with a 24-hour hang time due to the need to change EN tubing every 24 hours (as is the case at the authors institution) and the manufacturer recommendation that only 1 spike set be used per CS container. Waste with CS feeding is of particular concern in pediatric patients, in whom goal EN volumes are often <1 L/d, which is the minimum size in which CS formulas are available. Since current evidence indicates that a CS may be advantageous in terms of reduced nursing time for EN administration, increased probability of optimal formula administration, and a potential for reduced risk of contamination, the clinical nutrition staff at the authors institution elected to consider a switch from an OS to a CS. However, the cost of potential waste associated with a CS was a concern, and as such, the authors undertook this study to evaluate the economic impact of a switch from an OS to a CS at their institution. The primary outcome measure was the difference in formula cost between the 2 systems when considering both delivered volumes and potential for waste.

Nutrition in Clinical Practice XX(X)

collection period was performed for pediatric patients receiving EN using a pediatric formula (those intended for children 13 years of age) during a consecutive 11-week period from April to July 2012. Patients from a variety of settings, including acute care, intensive care, and a transitional care/rehabilitation unit, were studied. Patients receiving formulas not commercially available in a CS container (such as infant formula or formulas reconstituted from powder) were excluded. Similar to the adult study, the following data points were collected from the electronic medical record: type of formula, ordered volume, and actual daily volume received. Actual delivery per the enteral pump was not recorded. Data were also collected for each hospital day, beginning with the first full day of EN, and continued until cessation of EN, hospital discharge, or the end of the study period. For theoretical waste calculations, assumption of a 24-hour hang time with CS was made. For the purposes of this study, 1 L of formula from a CS was considered equivalent to 4 cans of formula in the OS. If the EN order equaled or exceeded 1 L in a 24-hour period (45 mL/h for continuous feeds or a total volume 1 L/d for bolus feeds), the order was determined to be compatible with the CS. To determine cost of theoretically wasted formula in patients receiving <1 L in the CS, the amount of formula (in milliliters) that would have been delivered (were the patient actually receiving EN from a CS) was subtracted from 1 L, and that theoretical waste volume was multiplied by the price per milliliter for that particular formula. To determine the cost of formula waste in the OS, the total amount delivered was converted into the number of cans (rounding up) that would have been opened to deliver that volume in a 24-hour period. The volume of formula delivered was subtracted from the volume of formula from opened cans and was then multiplied by the cost per milliliter for that particular formula. Values used for cost analysis were the hospital costs for the products and may vary between institutions and home infusion companies. A sample calculation is presented in Figure 1. Since the cost of the enteral feeding bag plus the tubing for the OS ($4.50) was very similar to the cost of the spike set/tubing for the CS ($4.55), any change between the OS and CS would be considered cost-neutral with regard to these EN supplies. As such, these costs were not included in this comparison of CS and OS pricing. This study was conducted as a quality improvement project. Because it was a quality improvement project and did not involve any changes in the patients therapy, it was exempt from institutional review board review.

Methods
Data were collected prospectively on all adult patients requiring EN at the authors facility over a consecutive 4-week time period during January and February 2012. Patients in all acute settings, including intensive care, were studied. Information collected included type of formula, ordered volume, and actual daily volume received per nursing documentation in the electronic medical record. Actual delivery per the enteral pump was not recorded. Data were collected for each hospital day, beginning with the first full day of EN, and continued until cessation of EN, hospital discharge, or the end of the study period. Only 24-hour periods were recorded. If EN was discontinued due to discharge or cessation of EN, the last 24 hours of EN received was recorded. After preliminary data on the adult population were presented to the dietitians at this facility, a follow-up data

Results
During the 4-week collection period, 189 data points were collected on 47 adult patients. Eighty-seven percent of the EN orders were compatible to a CS. However, actual volume delivered reached 1 L/d only for 50% of the patient days due to multiple reasons; discussion of these reasons is outside the scope of this study. The average cost to feed each patient each

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Sample calculations for waste amount: Amount ordered: 40 mL/h (960 mL in 24 hours) Amount received per medical record documentation: 840 mL If using 1-L bottles in a CS: 1000 mL 840 mL = 160 mL waste If using 240-mL cans in an OS, 4 cans would need to be opened to provide the ordered volume: 960 mL 840 mL = 120 mL waste Sample calculations for cost associated with the waste: Cost of formula in the CS = 0.0018 cents/mL; cost of formula in the OS = 0.00142 cents/mL In the above example, the 160-mL waste in the CS = $0.28 In the above example, the 120-mL waste in the OS = $0.17 Figure 1. Sample calculations for closed and open enteral nutrition systems. CS = closed system; OS = open system.

$12.00 Average daily cost ($)

Average daily cost ($)

$9.00

$10.00 $8.00 $6.00 $4.00 $2.00 $0.00 $3.84

$9.83

Delivered formula

$8.00 $7.00 $6.00 $5.00 $4.00 $3.00 $2.00 $1.00 $0.00

$7.74

Delivered formula

$4.21

$4.80 $4.31

Delivered formula + wasted formula

$3.30 $1.89 $2.12 $1.94

Delivered formula + wasted formula

Open System Closed System Enteral system type

Delivered formula + wasted formula + extra nursing time to administer open vs closed

Open System Closed System Enteral system type

Delivered formula + wasted formula + extra nursing time to administer open vs closed

Figure 2. Comparison of average daily cost to feed adult patients in each enteral system type.

Figure 3. Comparison of average daily cost to feed pediatric patients in each enteral system type.

day using actual delivered volume with the OS was $3.84 compared with $4.31 if the patient were receiving EN from a CS. Factoring in the cost of waste from each system, the average cost to feed each patient each day was $4.21 compared with $4.80, respectively. Using the estimated increase in nursing time for the OS, the cost increased to $9.83 (Figure 2). Pediatric data included 12 patients, spanning 123 patient days. Mean age was 8 years (median, 9 years; range, 117 years). Two patients were older than 13 years but received pediatric formulas while admitted to mirror their home EN regimens. In only 2% of patient days (3/123) did formula delivery reach 1 L. The average cost to feed each patient each day using actual delivered volume was $1.89 in the OS and $1.94 in the CS. When factoring in the cost of waste from each system, those costs increased to $2.12 and $3.30, respectively. Using the estimated increase in nursing time for the OS, the cost increased to $8.92 (Figure 3).

Discussion
EN delivered via a CS could have many potential benefits, including a reduction in the opportunity for contamination as part of the formula-handling and delivery process and a reduction in nursing time required to refill the feeding bag several times during the day. If nurses are required to refill or change feeding containers less often, there is less chance that the patient will go without feeding due to an empty bag or

container. However, CS EN is not without disadvantages. Typically, formula delivered via a CS is more expensive per milliliter. Furthermore, CS formulas only come in volumes of 1 L or 1.5 L, and significant formula waste can occur if a patient does not receive at least the volume in the CS container before the containers hang time is exceeded. CS formulas may be more difficult to store, depending on the facilitys space for EN products, due to larger container size. The CS is also more difficult to administer feeds for bolus feeds, so facilities may need to stock supplies to administer both OS and CS formulas for this reason. In this study, the costs required to administer EN with the OS were less than the CS when considering costs for formula, both that delivered and that wasted. In adult patients, the CS was $0.59 more per patient day when considering potential waste (14% increase) and $1.18 more per patient day in patients receiving pediatric formulas (56% increase). However, additional costs of an OS need to be accounted for, such as nursing time for EN administration. Although the investigators did not monitor actual nursing time required to administer EN, previous studies have estimated an increase in 1218 minutes per day to administer the OS vs the CS.20,26 Using data obtained from this institutions human resources department regarding nursing wages, it is estimated that 12 minutes of nursing time would cost $5.62 per day. The potential for decreased infection risk may make the switch from OS to CS even more cost-effective. Nosocomial infections undoubtedly increase hospital

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length of stay and healthcare costs and negatively affect patient quality of life. Measures taken to reduce nosocomial infections may be well worth any marginal cost required to implement changes. In this study, most adult patients had at least 1 L of EN ordered for a 24-hour period, thereby meeting the minimum volume of CS containers; however, the actual delivered volume reached ordered volume only half of the time. It could be hypothesized that a CS with a 24-hour hang time could improve the total amount of EN delivered, since medical staff would not need to refill the bag or change the feeding container every 48 hours. This could reduce the amount of time patients do not get feeds due to an empty bag or container. Further studies observing nursing administration using each system could help to identify factors associated with suboptimal nutrient delivery in the CS vs the OS. Contrary to the findings in adults, the patients receiving pediatric formulas had 1 L ordered in only 7% of patient days. Actual formula delivery of 1 L occurred on only 2% of patient days. This ordering practice was most likely related to the fact that many children require EN only as a supplement to oral feeding and therefore would not need large volumes required to provide 100% of estimated needs. Because of this phenomenon, use of CS pediatric formulas could result in increased waste, and it is possible that conversion from an OS to a CS for pediatric formulas would have a larger fiscal impact than with adult formulas. Previously, formula companies offered a 500mL CS container for pediatric formulas; however, those are no longer available. Production of a smaller CS container specifically for pediatric formulas could make a CS more cost-effective in pediatric patients. There are several limitations to this study, the most significant being the theoretical nature of calculations of potential waste. Without direct observation of each EN bag change for each patient, it is impossible to know exact waste in the current OS; current resources did not allow this level of study. Since this facility does not currently use a CS, it is also impossible to know how actual delivery, waste, contamination, and nursing administration time differ between the 2 systems. Last, the number of patients receiving pediatric formulas in this study was small (n = 12), despite the study span of almost 3 months in this population. The sample size was limited by the fact that only patients receiving pediatric formulas were included; many pediatric patients at this institution are fed using breast milk, infant formula, adult formulas, or specialty formulas only available in powdered form (such as elemental or metabolic formulas) and were not included for study since only ready-tofeed formulas using either the OS or CS system were evaluated.

Nutrition in Clinical Practice XX(X)

formulas, resulting in higher daily average costs for formula delivered. In addition, the cost of waste is increased by using a 1-L CS container vs an OS using 8-oz cans, particularly in children receiving pediatric formulas, who often require <1 L of formula per day. However, due to the increased cost of nursing time required to administer the OS system, many facilities decide to use the CS system despite slight increases in total cost of the formula administration system itself.

References
1. Freedland CP, Roller RD, Wolfe BM, Flynn NM. Microbial contamination of continuous drip feedings. JPEN J Parenter Enteral Nutr. 1989;13(1):18-22. 2. Anderson KR, Norris DJ, Godfrey LB, Avent CK, Butterworth CE. Bacterial contamination of tube-feeding formulas. JPEN J Parenter Enteral Nutr. 1984;8:673-678. 3. Okuma T, Nakamura M, Totake H, Fukunaga Y. Microbial contamination of enteral feeding formulas and diarrhea. Nutrition. 2000;16:719-722. 4. Fernandez-Crehuet Navajas M, Jurado Chacon D, Guillen Solvas JF, Galvez Vargas R. Bacterial contamination of enteral feeds as a possible risk of nosocomial infection. J Hosp Infect. 1992;21:111-120. 5. Levy J, Van Laethem Y, Verhaegen G, Perpete C, Butzlet JP, Wenzel RP. Contaminated enteral nutrition solutions as a cause of nosocomial bloodstream infection: a study using plasmid fingerprinting. JPEN J Parenter Enteral Nutr. 1989;13(3):228-234. 6. Baldwin BA, Zagoren AJ, Rose N. Bacterial contamination of continuously infused enteral alimentation with needle catheter jejunostomy clinical implications. JPEN J Parenter Enteral Nutr. 1984;8:30-35. 7. Beattie TK, Anderton A. Microbiological evaluation of four enteral feeding systems which have been deliberately subjected to faulty handling procedures. J Hosp Infect. 1999;42:11-20. 8. Anderton A, Aidoo KE. Decantinga source of contamination of enteral feeds? Clin Nutr. 1990;9:157-162. 9. Weenk GH, Kemen M, Werner HP. Risks of microbiological contamination of enteral feeds during the set up of enteral feeding systems. J Human Nutr Diet. 1993;6:307-316. 10. Chan L, Yasmin AH, Ngeow YF, Ong GSY. Evaluation of the bacteriological contamination of a closed feeding system for enteral nutrition. Med J Malaysia. 1994;49(1):62-67. 11. Patchell CJ, Anderton A, MacDonald A, George RH, Booth IW. Bacterial contamination of enteral feeds. Arch Dis Child. 1994;70:327-330. 12. Beattie TK, Anderton A. Decanting versus sterile prefilled nutrient containersthe microbiological risks in enteral feeding. Int J Environ Health Res. 2001;11:81-93. 13. Bott L, Husson MO, Guimber D, et al. Contamination of gastrostomy feeding systems in children in a home-based enteral nutrition program. J Pediatr Gastroenterol Nutr. 2001;33:266-270. 14. Marlon ND, Rupp ME. Infection control issues of enteral feeding systems. Curr Opin Clin Nutr Metab Care. 2000;3(5):363-366. 15. Vanek V. Closed versus open enteral delivery systems: a quality improvement study. Nutr Clin Pract. 2000;15(5):234-243. 16. Moffitt SK, Gohman SM, Sass KM, Faucher KJ. Clinical and laboratory evaluation of a closed enteral feeding system under cyclic feeding conditions: a microbial and cost evaluation. Nutrition. 1997;13:622-628. 17. Wagner DR, Elmore MF, Knoll DM. Evaluation of closed vs open systems for the delivery of peptide-based enteral diets. JPEN J Parenter Enteral Nutr. 1994;18(5):453-457. 18. Lyman B, Gebhards S, Hensley C, Roberts C, San Pablo W. Safety of decanted enteral formula hung for 12 hours in a pediatric setting. Nutr Clin Pract. 2011;26:451-456. 19. Schroeder P, Fisher D, Volz M, Paloucek J. Microbial contamination of enteral feeding solutions in a community hospital. JPEN J Parenter Enteral Nutr. 1983;7(4):364-368.

Conclusion
At the authors institution, the contract price of the CS formulas is slightly higher per milliliter than the price of the OS

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20. Fagerman KE. Limiting bacterial contamination of enteral nutrient solutions: 6-year history with reduction of contamination at two institutions. Nutr Clin Pract. 1992;7:31-36. 21. Herlick SJ, Vogt C, Pangman V, Fallis W. Clinical research: comparison of open versus closed systems of intermittent enteral feeding in two long term care facilities. Nutr Clin Pract. 2000;15:287-298. 22. Donius MA. Contamination of a prefilled ready-to-use enteral feeding system compared with a refillable bag. JPEN J Parenter Enteral Nutr. 1993;17(5):461-464. 23. Lee CH, Hodgkiss IJ. The effect of poor handling procedures on enteral feeding systems in Hong Kong. J Hosp Infect. 1999;42:119-123.

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24. Rees RG, Ryan J, Attrill HA, Silk DB. Clinical evaluation of two-liter prepacked enteral diet delivery system: a controlled trial. JPEN J Parenter Enteral Nutr. 1988;12:274-277. 25. Luther H, Barco K, Chima C, Yowler CJ. Comparative study of two systems of delivering supplemental protein with standardized tube feedings. J Burn Care Rehabil. 2003;24:167-172. 26. Silkroski M, Allen F, Storm H. Tube feeding audit reveals hidden costs and risks of current practice. Nutr Clin Pract. 1998;13:283-290. 27. Bristol S, Meer M, Bashar A, et al. Financial benefit of closed versus open enteral delivery system [abstract]. Nutr Clin Pract. 2008;23(2): 236-237.

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