Transition to Ready to Hang Enteral Feeding System

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Nursing time and supply costs to administer enteral feeding are substantial. One major academic medical center recently converted from an open system (OS) to a closed, or “ready to hang” (RTH) system for enteral feeding. This article reviews that transition from an OS to RTH and documents the costs, nursing perceptions, and lessons learned in the process.

Healthcare costs in the United States are soaring. Efforts to improve patient care, safety, and outcomes are ongoing goals particularly when they also result in a reduction in the cost of care. Enteral feeding is the primary means of providing nutrition support to patients who cannot meet their needs orally; nursing time and supply costs to administer that care are substantial. One major academic medical center recently converted from an open system (OS) to a closed, or “ready to hang” (RTH) system for enteral feeding. This article reviews that transition from an OS to RTH and documents the costs, nursing perceptions, and lessons learned in the process.

Mallory Foster, Dietetic Intern, University of Virginia Health System Dietetic Internship Program Capstone Project Wendy Phillips, MS, RD, CNSC, CLE, FAND, Director, Nutrition Systems, Regional Clinical Nutrition Manager, Morrison Healthcare Carol Rees Parrish MS, RD, Nutrition Support Specialist, University of Virginia Health System, Digestive Health Center of Excellence, University of Virginia Health System, Charlottesville, VA


Healthcare costs in the United States are the highest in the world1 and have become a major concern in recent years. At the same time, undiagnosed and untreated malnutrition in the hospital setting is an often undetected contributor to the growing cost of medical care in this country, as it can lead to further health complications and increased length of stay.1 Thus, efforts to advance nutrition care should be emphasized as a means to improve patient outcomes and decrease the cost of healthcare. Nutrition care practices and protocols should be reevaluated routinely to ensure that resources are used effectively and efficiently.

Enteral feeding is the primary means of providing nutrition support to patients who cannot meet their needs orally. Enteral nutrition (EN) is a cost-effective way of delivering nutrition support,2 has inherent benefits to the gastrointestinal (GI) tract, and is the standard of nutrition care over parenteral nutrition.3 Thus, anything that can be done to improve the efficiency, safety, and delivery of EN is a worthwhile goal.

Open Vs. Ready to Hang System

EN delivery is available in two main systems: an open system (OS) or a “ready to hang” system (RTH), also sometimes called a “closed system.” Using an OS, formula from cans or bottles is “bolused” into a feeding tube with a syringe, or poured into a feeding bag, then administered via a feeding tube into the stomach or intestine using a feeding pump or gravity drip. RTH comes in a sterile, pre-filled formula container (typically 1 liter) that is spiked by the feeding tube, and then fed to the patient via a feeding pump.4 Boluses can also be delivered using RTH by setting the feeding pump to deliver boluses at predetermined times. Both systems have advantages and disadvantages in several areas, including cost, ease of use, and nursing time required.


Factors to consider when evaluating the cost difference between an OS and RTH include actual cost of the formula and tubing, nursing labor, transportation to hospital units, storage, and waste.

OS has been used for many years to deliver EN to patients. Based on current pricing contracts between the Medical Center and formula companies, OS costs less compared to the same volume of a RTH formula.4,5 OS is also convenient when a small volume of formula is needed, as is the case with bolus feeding or in the pediatric population,4 yet it can lead to increased labor and equipment cost.4-8 According to nursing procedures at some facilities, including the hospital in question, only the amount of formula that will be infused within 4 hours (although in the real world, we know how hard this is to achieve) is to be hung at one time in an OS. So nurses must refill feeding bags frequently, up to 6 times per day.9 The tedious protocol (see Table 1) may also occasionally lead to missed EN if the nurse
is unable to refill the bag in a timely manner when it runs out. Additionally, OS requires more handling than the RTH prior to administration, potentially increasing the risk of bacterial contamination.4-8,10-13 Proper prevention methods to decrease the chance of bacterial contamination in the OS increase nursing time.7 The additional time used to ensure an OS system is safe could be spent conducting other nursing tasks.

RTH, also known as a closed system, was developed with the express purpose to reduce the nursing time required to administer EN and to decrease the risk of bacterial contamination by requiring less handling.5,7 Most studies cite an increased amount of nursing time related to an OS as compared to a RTH;4-6 in fact, Luther et al.6 estimated that administering formula using the OS doubles the required nursing time when compared to RTH in a hospital intensive care unit due to the additional steps required to administer the OS (See Table 1). Per manufacturer guidelines, RTH containers are approved to hang for up to 48 hours, yet available tubing sets are only approved to hang for 24 hours; hence, all RTH formula containers must be discarded at 24 hours as they cannot be spiked more than once.7,8 Regardless, 24 hours is a significant improvement over every 4 hours – or up to 6 times per day – if a patient is on a continuous feeding regimen. Although RTH formula has a higher cost when compared to the same volume of OS formula,4,5,7 cost savings may be realized through decreased nursing time, a potential decrease in nosocomial infection, and improvement in delivery of EN to patients.4 Actual practices at individual hospitals should be evaluated to determine if transition to a RTH from an OS achieves these goals.

Handling of EN Contamination of EN

Contamination of EN can occur during preparation if modular supplements (such as protein powder/liquid) are added to the formula, when the feeding is transferred to the administration container, during assembly of the feeding system, and during administration to the patient.5,7,11 Clean technique and proper hand washing should always be used to prepare and deliver formula in both an OS and RTH.2

Potential risk reduction from nosocomial infection from contamination of EN influences some clinicians in the selection of an OS vs. RTH. Whereas only the formula itself is sterile in an OS (not the bag it hangs in), the entire RTH system is sterile because it is not exposed to the outside environment; it is therefore associated with a decreased risk of contamination.13,14 However, prospective trials demonstrating this perceived benefit are not available. C. difficile infection is one of the most life-threatening infections associated with hospitalized patients, especially those on EN.17,18 Any measures that can be taken to prevent bacterial contamination and a culture of safe practices surrounding the use of EN should be the goal.

Both OS and RTH EN formulas are sterile when packaged, however, once administration has begun, retrograde movement of bacteria from the GI tract via the feeding tube is possible in both systems,7,12 as the GI tract is a source of a myriad of microbes.7 Studies have shown that retrograde movement of bacteria in EN feeding systems is very slow, and while bacterial contamination has been found in the distal portions of the feeding tube closest to the patient, bacteria did not reach the feeding container over a 48 hour hang time.7,12


RTH formula containers should not have long-term exposure to light as some nutrients in the formula such as riboflavin, vitamin B6, and vitamin A are photosensitive. Recommended storage of RTH containers is on covered
shelves or in a closed cabinet prior to use to avoid vitamin degradation. The opaque packaging of the OS protects the formula from light during storage.

Volume of EN Delivered

Others have reported an association between longer hang times in the RTH and increased percentage of prescribed EN actually received by the patient.19,21 Perhaps because of the longer hang time, Atkins and Phillips20 found that, on average, an OS provided patients with 74% (range 43-104%) of the ordered EN volume compared to 84% (range 59-101%) with RTH
at one major academic medical center. Though small, (n=60), this study suggests that the RTH may provide patients with a greater volume of their nutrient needs, and confirms results found in other studies.19,21

Product Waste

Formula waste can be a significant cost regardless of which system is used, and the limited research in this area is mixed. Some studies have shown that the RTH leads to decreased formula waste because the EN can hang longer and thus the full volume is delivered to the patient.2,4,7 However, others have noted that RTH can lead to increased formula waste if the entire volume of the container is not used within the recommended
hang time or if hospital culture is difficult to change from years of switching all bags, tubing, etc. at a certain time each day regardless of expiration time of hanging formula.4 Further studies are needed to determine whether one feeding system generates less wasted formula than another.

Cost Analysis

To evaluate the difference in cost between the OS and RTH, purchasing data for an eight month period after transition from the OS to RTH was obtained from the hospital storeroom purchasing department. A small inventory of OS supplies and formulas continued to be purchased even after the transition to the RTH system since not all formulas are available in RTH
containers and because OS containers are used for teaching those patients discharged home on the bolus feeding method. Total cost for formula and supplies for both the OS and RTH systems during the 8 month study period was $109,297.54. For practical purposes of this descriptive study, it was assumed that the same actual volume of formula would have been purchased had the OS alone been used during the study period, the expenses for formula and related supplies would have been $104,470.16. Therefore, RTH cost $4,827.38 more over the 8 month period than would have been spent on the OS system. Since the study period was 8 months, the monthly average increase in overall cost is $603.42 (see Table 2).

Feeding supply costs were also factored in. Total expenses for feeding supplies after the transition to the RTH system, including the cost of bags and tubing required to deliver water flushes as well as the remaining OS products (excluding enteral formula), during the 8 month period were $52,795.99. Had the OS continued to be used, the money that would have been spent on the equivalent tubing and bags would have been $54,549.64 (see Table 2), for a difference of $1,753.65 in favor of RTH. Overall, considering cost of formula and supplies, the OS would have cost the Medical Center $3,073.73 less during the 8 months under consideration. On the other hand, nursing time with each system, a considerable expense, was not factored into the cost differences. An interesting finding was the total expenditure on the feed/flush bags vs. the feed bag alone (see Table 3).

Nursing Satisfaction Survey An Unexpected, but Important Finding

Cost analysis is an important component of evaluating the transition to a RTH, but also important is the effect on nursing satisfaction. A nursing satisfaction survey (see Table 4) was distributed on six hospital units
(n=92). Survey results showed nurses perceive that RTH requires less time to prepare, hang, and manage when compared to OS, which is consistent with other studies6,21 (see Table 5). Nurses also reported that RTH was easier to use, and they perceived formula waste to be comparable between systems. Overall, respondents overwhelmingly preferred the RTH over the OS system: 88% compared to 12%. Nurses play a vital role in patient care, therefore anything that makes their job easier, takes less time, and improves nursing satisfaction is always a worthy goal.

Open text comments left on surveys and visits to nursing units also provided valuable feedback. Nurses reported confusion about which tubing sets to use and the appropriate hang time of RTH EN. Additionally, they reported that the appropriate feeding sets were sometimes difficult to find. Based on these comments, the clinical nutrition team was able to provide improved guidance for nursing staff and in the future expect to see a decrease in costs based on improved selection of appropriate tubing and more efficient use of RTH.

Limitations and Lessons Learned

Actual nursing time associated with delivery of EN was not quantified, making it impossible to attach a monetary value to the nursing time required. The number of patients receiving EN and volume ordered and
delivered were not recorded for the RTH or OS. Amount of wasted formula and supplies due to administration error, confusion about hang times, expiration, labeling errors, or other unknown factors were not evaluated because data was based on retrospective purchasing information. However, total costs spent by an institution on supplies required to deliver EN should be measured and tracked, especially related to administration error and supply management. Evaluating data obtained from the purchasing department, as in this study, provides a place to start.

Comments recorded on the nursing satisfaction survey and visits to the unit supply room’s revealed opportunities for education and process improvement. In the future, observing actual delivery of EN using the RTH and conducting a root cause analysis of systemic issues needed to improve delivery will be used to improve EN practices. Designing clean supply rooms so all supplies are located in a standardized location on all units with clear labeling is important at all healthcare facilities. Nursing education should be delivered in regular intervals in collaboration with both the nutrition and nursing staff, to include overcoming the barriers identified in this project as well as factors identified ia other means related to EN feeding (see Table 6).


When considering the advantages and disadvantages of an OS or RTH EN feeding system, the most important factors to consider are patient outcomes, ease of use, safety, and cost. Review of the literature reveals that both the OS and RTH can be safely delivered to patients when proper procedures are followed. A RTH may also provide patients with a greater percentage of their nutrient needs, ultimately leading to improved nutritional status and improved patient outcomes, but this will require further study. Although a RTH is more expensive per unit of volume when compared to the OS, it is possible that if the RTH saves nursing time, it may in fact be significantly less expensive due to savings on labor costs. Other factors that need to be considered are whether there is a decrease in infectious risk and waste. Although insufficient evidence exists to determine if a RTH is superior to OS in terms of cost, it clearly increases nursing satisfaction, and has been shown to increase delivery of EN which could also decrease hospital costs by reducing the incidence of malnutrition.

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