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.
As the enterally fed population is increasing, the potential requirement for skin excoriation management can also increase. To address this issue, a local clinical care pathway was developed to reduce and treat enteric site skin excoriation with the goal of providing standardised enteral feeding site care. The local enteral site care pathway is comprised of three categories of management for skin excoriation, hypergranulation, and infection. However, this quality-improvement pilot study specifically pertains to site excoriation management.
Methods
Enteral nutrition documentation
Between 2015 and 2020, the enteral nutrition team strengthened the documentation process and database recording of enterally fed patients. This incorporated manual logs and hospital system records which documented patient interactions, assessment photographs, management of site complications and outcomes. The hospital system/medical record used was EPIC Hyperspace (Epic Systems, Verona, WI, US). Excel (Microsoft, Redmond, WA, US) generated descriptive statistics of the patient caseload, clinical visit encounters and specialist nursing hours rendered.
Sample population
The local department of clinical nutrition supported this pilot study as a quality service improvement initiative. This observational study was conducted according to the Declaration of Helsinki which included a small sample size who voluntarily consented (patient and/or legal guardian) through a written formal consent. Patient anonymity and confidentiality were maintained throughout the study. Health Research Agency (HRA) approval was not required.
Convenience sampling was used, which included adult enterally fed patients cared for by the local enteral nutrition team between 2018 and 2019, irrespective of gender, duration of enteral feeding tube, type of feeding tube, and severity of skin excoriation. Patients with comorbidities and skin healing issues (corticosteroid use, metabolic disorders) were also considered. Exclusion criteria were paediatric age and patients who refused further follow-up. In addition, patients with the presence of swab-confirmed feeding tube infection (bacterial or yeast) with objective cues highlighted in the institutional percutaneous endoscopic gastronomy (PEG) infection monitoring tool (presence of purulent exudate, erythema, pain) were excluded to prevent adverse interaction with the products.
Care pathway development
The enteral nutrition team and tissue viability team evaluated the commonly used products, application methods, and treatment techniques for inclusion into a new enteral site skin excoriation care pathway. The considerations for product selection included patient preferences, clinical efficacy, ease of use, economic cost and availability in the community formulary of the general practitioners and community nurses.
Patient preferences were identified through patients' medical charts, product survey and end users' product experiences. Products which gathered positive survey feedback and subjective reports from patients and carers were designated as ‘well received’. The most well-received products, application methods, and treatment techniques were reviewed for inclusion into the care pathway.
The products were initially trialled with a small number of patients. The tissue viability team provided expert opinions during the development of the local clinical care pathway, selection of the products, and standardisation of the treatment methodologies. The categorisation of common complications and treatment guidelines was simplified by adapting the institutional PEG care infection monitoring tool (Skerratt et al, 2010).
Patient assessment
The institutional PEG infection monitoring tool was used for objective assessment of the enteral feeding tube site. The presence of discharge, erythema, pain, skin excoriation, and mass in the exit site were examined. Skin excoriation size was measured using a medical measuring tape. Assessment for signs of infection (presence of purulent exudate, erythema, pain) and a swab test were also conducted as per institutional guidelines.
Site excoriation was categorised as mild, moderate or severe depending on size of skin excoriation, tube leakage, presence of blister, and verbal/nonverbal cues of pain or discomfort. Mild excoriation exhibited skin erythema less than 5 mm in size and minimal tube leakage (with or without need for dressing changes). Moderate excoriation featured skin erythema between 5 mm—20 mm size and moderate tube leakage (1-2 dressing changes in a day). Severe excoriation demonstrated skin erythema more than 20 mm, moderate to severe tube leakage (multiple dressing changes in a day), and possible presence of denuded areas (loss of epidermis, caused by prolonged moisture and friction).
Patient care
Clinical nurse specialists organised appointments to assess the enteral feeding tube site for excoriation, leakage, or possible infection. If necessary, antibiotics were initiated for infection management following institutional practices. To minimise irritation, the enteral tube site was cleansed with water and gently patted dry. Depending on the level of excoriation, a skin protectant (either acrylate terpolymer barrier film (3M Cavilon No Sting Barrier Film, 3M, St Paul, MN, US) or advanced elastomeric skin protectant (3M Cavilon Advanced Skin Protectant, 3M) was applied. In patients with significant enteral site leakage (ie requiring multiple dressing changes per day, or when leakage soaks clothing), a non-adhesive foam hydrophilic dressing was applied to the surrounding skin once the skin protectant had dried, as needed. The fixation device was assessed and adjusted as needed to ensure a minimal space between the skin and the device of no more than 2 mm (National Nurses Nutrition Group (NNNG), 2013). Health education and advice were provided to the patient and carers to prevent excessive tube traction. Tape or adhesive was used to comfortably secure the enteral feeding tube. The enteral feeding tube site was then monitored for skin excoriation and leakage. Information leaflets highlighting the guidelines and health education were provided to patients and their carers.
Results
Average yearly enteric tube insertion and patient assessments
At our 1000-bed regional trauma and specialist centre, a total of 1 764 patients were discharged with an enteral feeding tube between 2017 and 2020. During this time, the average yearly enteric tube insertions and face-to-face patient assessments specifically for site review have increased (Figure 1). Similarly, with the increase of patients requiring nutritional support, the total amount of specialist nursing hours provided in face-to-face consultations had also increased until 2019 (Figure 2). The decline in 2020 was due to face-to-face patient assessments and consultations being limited by pandemic safety precautions.
Enteric site skin excoriation care pathway
The enteric site skin excoriation care pathway focuses on three levels of skin excoriation severity (mild, moderate, or severe) (Figure 3). For patients with mild skin excoriation (excoriation area <5 mm), the preferred skin protectant is the acrylate terpolymer barrier film applied once a day for seven days. When moderate skin excoriation is present (excoriation area 5 mm to 20 mm), the acrylate terpolymer barrier film is applied twice a day for seven days. If severe skin excoriation is present (excoriation area >20 mm), the advanced elastomeric skin protectant is applied once every 3-4 days for 2-4 weeks until the issue is resolved, or a nursing re-assessment is due.
Once skin improvement is observed, the acrylate terpolymer barrier film can be used once a day for seven days until the skin excoriation is resolved. If the skin excoriation remains unresolved and/or site leakage continues, an enteral nurse specialist should be contacted. Additionally, if the enteral feeding tube has been removed and there is persistent leakage after four weeks, a gastroenterologist or enteral nurse specialist should be consulted.
Representative cases
A cohort of 10 patients participated in this pilot study, of which three representative cases were selected to showcase the use of the enteric site skin excoriation pathway.
Case 1.
Mild excoriation
An 87-year-old male with a 14Fr balloon-retained gastrostomy present for three years, exhibited persistent skin excoriation and pain (Figure 4a). Previous treatments included iodine-containing dressings, zinc oxide, acrylate terpolymer barrier film, and an enzyme alginogel wound healing agent. However, these treatments did not result in skin excoriation improvement. The site soreness interfered with routine community tube changes requiring hospital appointments. The site was rinsed with water and patted dry. As the acrylate terpolymer barrier film had been previously used without skin improvement, the advanced elastomeric skin protectant was applied once every five days with a total of two applications used. The fixation plate was adjusted to no more than 2 mm away from the skin. After seven days, skin recovery was visible and erythema was significantly reduced (Figure 4b). The patient reported no pain at the site and was discharged to community care. The patient maintained improved enteral skin condition and used elastomeric skin protectant for any further minimal excoriation.
Case 2.
Moderate excoriation
A 31-year-old non-verbal female with a long-term jejunal feeding tube (size 15F) presented with persistent skin excoriation and severe site soreness from bilious/jejunal leakage reported as 2-3 translate into mm to be consistent in diameter (Figure 5a). The patient displayed increased aggressiveness during tube manipulation. Patient medical history included metabolic disorder, diabetes and learning disability. The enteral feeding tube site was persistently problematic, with cyclical skin complications and flare=ups related to immunological and hormonal variances along with personnel changes.
Previous management included use of elastomeric skin protectant, iodine dressings, silver nitrate dressings, silver sulfadiazine, manuka honey, antimicrobial hydrofiber dressings, among others, but these were of minimal effect or non-longstanding according to the patient's carers and parents. Three enteral tube replacements were performed between 2015 and 2018 due to tube damage and skin excoriation. A total of 44 encounters with the enteral nutrition team were recorded between 2015 and 2017. As such, a significant carer burden was raised throughout the consultations due to the emotional, financial, and personal impacts of the persistent enteral tube site skin issues.
The site was washed with water and patted dry, followed by application of an advanced elastomeric skin protectant once every four days for a total of three applications. After five days, a reduction in skin erythema and excoriation was noted (Figure 5b). The patient was reported to display less agitation and discomfort with tube manipulation for cleansing and feeding. However, after the completion of the initial prescribed three applications, the site excoriation recurred within two weeks, prompting another set of applications of the advanced elastomeric skin protectant. A total of three applications were required to achieve a reduction in site excoriation and patient discomfort. The patient was later de-escalated to daily applications of elastomeric skin protectant for an indefinite period of time. Additionally, the number of enteral nutrition team encounters dropped to 29 between 2018 and 2020, when the use of the advanced elastomeric skin protectant was added to the patient's care plan.
Following personalised care planning the patient continues to follow treatment for cyclical flare-up for skin excoriation with an acrylate terpolymer barrier film used for mild excoriation and the advanced elastomeric skin protectant used for moderate to severe flare.
Case 3.
Severe excoriation
A 26-year-old non-verbal male with a long-term transgastric-jejunal feeding tube (size 18F) presented with persistent skin excoriation from gastric leakage and hypersecretion (Figure 6a). The site was heavily denuded, displayed extensive erythema, and sometimes bled. The patient showed aggression during tube manipulation, indicating pain at the site. Previous medical history included cerebral palsy and gastric dysmotility.
The enteral feeding tube site was independently managed by a care facility with limited success prior to presentation. The site was washed with water and patted dry. An advanced elastomeric skin protectant was applied every 2-3 days due to the persistent heavy leakage. The fixation plate was adjusted to no more than 2 mm away from the site. After four days, a reduction in the skin redness was observed (Figure 6b). Due to the persistent leakage, proton pump inhibitor medication was initiated, followed by the application of hydrophilic foam dressings changed daily. After seven days, skin epithelialisation was observed at the site (Figure 6c). The patient was able to tolerate tube manipulation for cleaning and feeding, indicating a reduction in pain at the site. After 14 days, a further reduction in redness and an increase in skin epithelialisation was observed (Figure 6d). No non-verbal signs of pain or discomfort with tube manipulation were noted. Due to the persistent leakage, an endoscopic tube re-siting was performed. The old tube site skin closure is ongoing while skin healing nears completion with visible pinkish epidermis and smooth granulation, borders (Figure 6e). The external care facility was trained to provide independent local clinical care management in case of excoriation flare-up.
The advanced elastomeric skin protectant is applied every three days for a total of five applications, followed by an acrylate terpolymer barrier film applied once a day thereafter for the next 1-2 weeks until the excoriation completely subsides.
Discussion
In our organisation, the average yearly enteric tube insertions, patient assessments, and amount of specialist nursing hours for enteral site skin excoriation have been increasing. The estimated average costs of care from specialist nurses or a general practitioner range from £39 to £134 and a minimum cost of £359 is estimated for presentation to the accident and emergency department (Goodman et al, 2017, Curtis and Burns, 2020, King's Fund, 2022). Management of enteral tube site complications warrants multiple clinical/community visits or attendance to the accident and emergency department, which equates to higher cost implications. As such, the need for a more efficient and standardised management system was identified. Prior to this point, the management of patients with enteric site skin excoriation lacked a well-defined clinical care pathway.
The collaboration of the enteral nutrition and the tissue viability team developed the enteric site skin excoriation care pathway. Representative cases presented highlight the resolution of skin excoriation and improvement in patient comfort after implementing the use of this care pathway at our institution.
The key components of the local enteral site skin care pathway include general site care and monitoring, along with the application of a skin protectant. General site care consisted of gentle cleansing with water, use of foam hydrophilic dressings, adjustment of the fixation device, and minimising feeding tube traction or manipulation to prevent further skin excoriation (Blumenstein et al, 2014; Crawley-Coha, 2004; McClave and Neff, 2006). However, it is important to note that patients with bacterial or yeast infection were excluded from this local clinical care pathway, as the required infection management may adversely interact with skin protectant use.
The local clinical care pathway was developed in an easily adaptable manner for community care and may help facilitate independent patient care for enteral site skin excoriation. Reduced specialist nursing supervision or hospital attendance highlights the potential for cost savings with the adoption of the local enteral site skin care pathway. While this study focused on enteral nutrition patients, the recommendations may be applicable to other clinical scenarios with skin excoriation. However, the use of the pathway would need to be examined in larger patient populations and potentially be modified to provide site specific care for the clinical scenario assessed.
Existing literature has recommended the use of skin protectants for the management of enteral site skin irritation; however, these articles only provide treatment suggestions rather than clinical evidence on the use of skin protectants (Blumenstein et al, 2014; Roveron et al, 2018; Schrag et al, 2007). As such, limited evidence exists for the use of skin protectants on enteral site skin excoriation. Published literature exists for the use of acrylate terpolymer film barrier or advanced elastomeric skin protectant in patients with incontinence-associated dermatitis (IAD), moisture-associated skin damage (MASD), and chronic wounds or ulcers (Acton et al, 2020; Dini et al, 2008; Guest et al, 2011; Schuren et al, 2005). Reduced skin irritation and improved patient comfort were reported in these patient populations (Acton et al, 2020; Dini et al, 2008; Guest et al, 2011; Schuren et al, 2005). While the enteral nutrition population is distinct from patients with IAD, MASD, or chronic wounds, the skin irritation, excoriation, and breakdown observed in the populations are similar, indicating potential clinical benefits with the use of these two skin protectants.
Conclusions
The development of the local enteral site skin care pathway was undertaken to create a standardised, readily accessible, and economical list of recommended products and guidelines for local enteral site skin care. The adoption of this local clinical care pathway for site excoriation resulted in skin healing and improved comfort in our quality improvement pilot study. The local excoriation skin care pathway is part of a comprehensive clinical care pathway (including hypergranulation, infection and excoriation) which is applied in the local hospital and available for use as a guideline by partner community teams. The hope is that health-care providers and community services will be able to adopt the model, use these treatments with support of the local tissue viability specialist nurses, and standardise the management of enteral site skin excoriation. If no skin improvement is observed, or if the enteric tube has been removed and the site continues to leak after 4 weeks, consultation with a nutrition nurse specialist or gastroenterology specialist is warranted. Larger, controlled studies will be needed to validate this local enteral skin care pathway and to examine its efficacy in various clinical care settings.
Key points
- To address this issue of a universal lack of guidelines for enteral site management, a quality-improvement pilot study to inform the development of a local clinical care pathway was conducted to reduce and treat enteric site skin excoriation
- The care pathway demonstrates the steps in managing skin excoriation which includes gentle cleansing of the enteral tube exit site followed by application of a skin protectant (either acrylate terpolymer barrier film or advanced elastomeric skin protectant), and application of a non-adhesive foam hydrophilic dressing, as needed. Use of the enteric site skin excoriation pathway in three representative cases resulted in skin healing and improved patient comfort
CPD reflective questions
- What are the risk factors for enteral site skin excoriation?
- How do the differences in institutional treatment of enteral site skin excoriation affect patient care?
- What are the key points of the enteral site skin care pathway?