Sarah Leahy

UConn Dietetic Intern

Spring 2015
Continuous Quality Improvement
1. Identification of Problem and Rational for Study: The Hospital for Special Care (HSC) is a
unique facility that provides services for a very specific population of individuals. The goal of
this facility is to provide the highest quality of care in each of their specialized units. Patients
come to HSC because of the dedicated and focused care provided. HSC also offers long-term
care in their Step-Down and Transitional units. Adequate nutrition is an important part of the
services proved by HSC. In order to provide this level of care a large portion of the clients
receive and rely on enteral nutrition support. Over 2/3 of the patients receives enteral nutrition
support daily, because they are unable to meet their needs through oral intake.
The HSC currently uses Covidien Kangaroo ePump enteral feeding pumps for all
nutrition support patients. An area for improvement in this facility is the use of the Kangaroo
ePumps without encountering errors or problems. There have been reports from the nursing staff
of error messages on the pumps, pumps clogging and/or turning off. The nutrition and nursing
staff have been working together to identify the problems associated with the ePumps and try to
figure out what may be the cause of these different issues. It is important that the pumps are
reliable, accurate and problem free because such a large portion of the hospital requires them for
nutrition support.
This quality improvement has been ongoing at this facility since the beginning of this
year. It was determined that one of the issues that maybe causing the clogging and error
messages to occur was that the tube feed bag was not being hung the proper distance from the
pump when clamped on the pole. Clogging may also be occurring if the feeding set is being
removed from the pump, this can cause damage and affect the systems accuracy. The valve,
which is located in the feeding pump, may also causing the pump to become clogged due to
altering the flow pressure of the pump, when the pump is opened and closed. Each month the
dietitians have been required to observe enteral feeding pumps and determine if the bag is the
proper distance from the bottom of the bag and the feeding pump. Proper hanging distance is
important to prevent the tubing from clogging and decrease the incidence of error.

2. Measurable indicators: The measureable indicators for this quality improvement is the
physical measurement of the distance from the bottom of the tube feeding bag to the pump,
which is clamped to an IV pole. The required distance is 18 inches from the bottom of the tube
feed bag to the top of the pump. The 18 inches is the recommended minimum distance the bag
should be hanging to prevent the tubing from clogging and to reduce the number of error
messages. Pump/bag distance was measured on the Medical Rehab, Step Down, Close
Observation, Transitional, and Pediatric Units, primarily during the day (7a-3p) and evening (311p) shifts. The distance was measured using a measuring tape and visual eye to assess the
amount of space between the bag and the pump. It was also recorded weather the pump was
running or not and if it was a continuous or intermittent feed regimen.
3. Data Collection: Please see attached spreadsheet. Data was collected for February and March
2015 and put into graphs on spreadsheet two of the excel document.
4. Data Analysis using standards: The standards used to determine data collection criteria were
the operating manual distributed by Coviden. This manual provided instructions for proper setup, loading and unloading of the feeding pumps. The Kangaroo ePump Enteral Feed and Flush
Pump with pole clamp is a programmable closed system pump. The standards from this pump
indicate that to achieve proper accuracy the bottom of the feeding bag must be 18 inches above
the top of the feeding bag. On Page 20 of the manual the 18 inches is recommended to certify
the accuracy of the pump flow rate. The 18 inches prevents the tubing from becoming clogged
and ensures the formula is able to flow accurately. Page 27 of the manual again notes that the bag
should be hung 18 inches above the pump for accuracy and proper formula flow. Attached is a
copy of the poster provided by Coviden with loading and rinsing of the feeding pump. A copy of
this poster was hung by the nurses station on each unit.
5. Discussion of Results: One of the main reasons for collection of this data is to determine if
the staff has been setting the pumps to comply with the Covidien standards. The staff has been
provided education about the 18 inches and about not removing the set from the pump by the RD
based on what unit they work on. The goal of this QI is to improve the pumps accuracy and
prevent feeding pump errors.
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After collection and analysis of data it was observed that approximately half of the pumps
(55 out of 100 pumps observed) of the pumps were hanging the appropriate 18 inches. Attached
is an excel graph, with a visual break down of the results based on the unit. There are two graphs
found in the attached data set, the first graph breaks down the data based on unit and either
yes/no if the pump was the correct height. The second graph is broken down yes or no and then
there is a different color bar graph to represent each of the units. The most data was able to be
collected on the pediatric unit; this unit also had the largest number of pumps that were not the
correct distance. The Medical Rehab unit had the least amount of data collected because most
individuals in this unit do not rely on enteral nutrition support. The Close Observation and Step
Down units had a higher percentage of bags hanging the proper distance that not, however RCU
had more that were not the proper distance. After discussing with different members of the staff,
a majority of the nurses were aware of 18 inch standard and would verbalize their understanding
of the need for the bag to hang a specific distance from the pump to prevent error. One complaint
that was verbalized by many members of the staff was that they are not physically tall enough to
reach the pump and make it 18 inches. A majority of the nurses believe that they too short and
unable to adjust the pump to the required height. Many of the pumps were also screwed to the
pole too tightly and this makes them unable to be adjusted to the proper height. This required the
work of engineering to loosen and adjust the pump.
Another reason that many of the enteral feeding pump and bag were not the standard
height was because there were other pumps on the same IV pole. This prevents the staff from
being able to adjust the pump to the proper height because it was blocked by other items on the
same IV pole. One example was an IV pole that had the Kangaroo ePump, and two Spectrum
Pumps, one was a Lasix drip and the other was for antibiotics. This prevented the enteral pump
from being able to be the proper 18 inches because the other pumps also had to be a reachable
level for the nursing staff to control.
6. Suggested Actions to remedy the problem: Significant data has been collected about the
distance of the feeding tubes and trying to prevent feeding pump errors from occurring. The next
step in this quality improvement is to gain additional data about the different incidences that are
occurring and be able to pin point the cause. It it important to determine if the 18 inches is the
cause or if error is occurring because the feeding set inside the pump is being adjusted. A system
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that requires reporting of all feeding pump incidences needs to be developed between the nursing
and nutrition staff. If incidences are reported it will allow the nutrition staff to gather the
information they need to determine the frequency and the reason behind these errors occurring.
This may not be easy data to obtain because it will be based on accuracy of reporting from
different members of the staff. The next step in the quality improvement will be to obtain
additional data to determine if new feeding bags need to be purchased because of the
inconvenience and inconsistency of the Kangaroo ePumps.

References:
Covidien Manual: http://www.kangarooepump.com/imageServer.aspx?
contentID=34929&contenttype=application/pdf
Nutrition Support Committee Meeting Minutes, January 2015 written by Catherine Cater