Regional Comparison of Enteral Nutrition–Related Admission Policies in Skilled Nursing Facilities

Abstract

Background Nursing home admission policies are one driver of increased and earlier gastrostomy placement, a procedure that is not always medically or ethically indicated among patients needing short-term nutrition support. This important clinical decision should be based upon patient prognosis, goals, and needs. We compared nursing home enteral nutrition-related admission policies in New York City and other regions of the United States. We also explored motivations for these policies. Methods We conducted a telephone survey with skilled nursing facility administrators in New York City and a random sample of facilities throughout the United States about enteral nutrition-related admission policies. Survey data were matched with publically available Centers for Medicare and Medicaid Services facility characteristics data. The relationship between facility location and admission policies was described with regression models. Reasons for these policies were thematically analyzed. Results New York City nursing homes were significantly less likely to admit patients with nasogastric feeding tubes than nursing homes nationwide, controlling for facility characteristics (OR=0.111, 95% CI=0.032, 0.344). Reasons for refusing nasogastric tubes fell into five categories: Safety, capacity, policy, perception of appropriate level of care, and patient quality of life. Conclusion Our findings indicate that enteral nutrition-related admission policies vary greatly between nursing homes in New York City and nationwide. Many administrators cited safety and policy as factors guiding their institutional policies and practices, despite a lack of evidence. This gap in research, practice, and policy has implications for quality and cost of care, length of hospital stay, and patient morbidity and mortality.

Things We Do for No Reason™: Routine early PEG tube placement for dysphagia after acute stroke

“…3 Approximately 45% of patients with stroke are discharged to rehabilitation facilities, 5 which often prefer to have definitive enteral access before discharge. 6 It has been speculated that the observed rates of early PEG tube placement are at least partially related to rehabilitation facility policies. 4…”

“…Some patients, particularly those who are older and have high NIHSS scores, have an even higher likelihood of chronic dysphagia requiring long‐term PEG tube feeding 3 . Approximately 45% of patients with stroke are discharged to rehabilitation facilities, 5 which often prefer to have definitive enteral access before discharge 6 . It has been speculated that the observed rates of early PEG tube placement are at least partially related to rehabilitation facility policies 4 …”

Tutorial on adult enteral tube feeding: Indications, placement, removal, complications, and ethics

“…Additionally, gastrostomy tube feeding is unlikely to help patients with significant aspiration or at high risk of aspiration 35 . Unfortunately, in skilled nursing facilities, to where patients are often discharged after hospitalization, the decision to place a gastrostomy tube is often made based on the facility's policies rather than evidence‐based recommendations 36 …”

“…35 Unfortunately, in skilled nursing facilities, to where patients are often discharged after hospitalization, the decision to place a gastrostomy tube is often made based on the facility's policies rather than evidence-based recommendations. 36…”

Establishing Goals of Care for Patients With Stroke and Feeding Problems: An Interdisciplinary Trigger-Based Continuous Quality Improvement Project

“…Feeding gastrostomy tube placement is often a rate-limiting step in this process, particularly for patients destined for skilled nursing facilities in certain regions. 6 Pressure from professional and regulatory organizations has raised the stakes for the provision of patientcentered and goal-oriented care in stroke. In March 2014, the American Heart Association and the American Stroke Association issued a joint scientific statement outlining the fundamental role and benefits of palliative care (PC) for patients with stroke.…”