Enteral Feeding Policy For Adults with Operational Guidelines

Transcription

1 Enteral Feeding Policy For Adults with Operational Guidelines Policy Number: 331 Supersedes: Enteral feeding guidelines Standards For Healthcare Services No/s 7,8,11,13,14,15,16, 18, 19 Version Date Of Reviewer Completed Approved Date New Review No: Review: Name: Action: by: Approved: Date: 0.1 CPRG 3 years Victoria Prendiville Victoria Prendiville Minor amendments to document following CPRG discussion Amendment to as uploaded one did not contain full information CPRG Victoria Prendiville CPRG Brief Summary of Document: This Policy informs best practice and applies evidence based guidelines to inform all those involved in adult enteral feeding in acute, community and mental health care settings. To be read in conjunction with: Insertion Management and Removal of the Nasal Bridle Fixation Device For Naso Enteral Tubes On Adults Policy The Use Of Mitts (Hand Control Mittens) In Adult Patients Policy HD014 Policy on Advance Decisions 008 Consent to Examination or Treatment Policy Adult Parental Nutritional Policy Classification: Clinical Category: Policy Freedom Of Information Status Open Authorised by: Caroline Oakley Job Title Director of Nursing Signature: A signed copy of this document is stored with Corporate Services

2 Responsible Officer/Author: Contact Details: Victoria Prendiville Job Title: Service Lead Nutrition Support Dept Tel No Nutrition and Dietetics Base GGH/PPH Scope ORGANISATION WIDE DIRECTORATE DEPARTMENT ONLY COUNTY ONLY Staff Group Administrative/ Estates Medical & Dental Nursing Allied Health Professionals Ancillary Maintenance Scientific & Professional Other CONSULTATION Please indicate the name of the individual(s)/group(s) or committee(s) involved in the consultation process and state date agreement obtained. Individual(s) Group(s) Date(s) Nutrition and Hydration Steering Group. Date(s) February 2014 Committee(s) Clinical Policy Review Group Date(s) April 2014 RATIFYING AUTHORITY (in accordance with the Schedule of Delegation) A = Approval Required KEY Date Approval Obtained COMMENTS/ POINTS TO NOTE NAME OF COMMITTEE FR = Final Ratification Clinical Policy Review Group A Minor amendments recommended changes Minor amendments approved Date Equality Impact Assessment Undertaken November 2012 Group completing Equality impact assessment Jackie Hooper Victoria Prendiville Please enter any keywords to be used in the policy search system to enable staff to locate this policy Enteral feeding, Nutrition Support, Gastrostomy feeding, Jejunal feeding. Database No: 331 Page 2 of 82 Version 2.0

3 How Will This Policy Be Implemented? Who Should Use The Document? What (if any) Training/Financial Implications are Associated with this document? What are the Action Plan/Timescales for implementing this policy? Document Implementation Plan The Enteral Feeding Policy will be implemented through awareness, education and training sessions to all key staff involved in adult enteral nutrition. An implementation plan will be overseen via the Nutrition and Hydration Steering Group. This document is for use in secondary care, community and mental health settings to inform best practice in relation to enteral feeding as well as provide a HB quality assured document to assist in training HB wide. Patients discharged home with enteral nutrition will be provided with specific Home Enteral Feeding Discharge Information in line with this policy. Attendance at training sessions for all new and current staff involved with adult enteral nutrition. Action By Whom By When Hywel Dda University Health Board Nutrition and Hydration Steering Group to agree and co-ordinate implementation. Phased implementation including strategic launch Training and educational sessions Evaluation Sept 2014 Sept - end 2014 Sept end 2014 Ongoing Database No: 331 Page 3 of 82 Version 2.0

4 CONTENTS HYWEL DDA UNIVERSITY HEALTH BOARD 1. INTRODUCTION POLICY STATEMENT SCOPE AIM OBJECTIVES USEFUL CONTACTS: MAKING THE DECISION TO INITIATE ENTERAL FEEDING Recommendations of the Royal College of Physicians (RCP 2010) Assessment Process Legal and ethical implications Factors to consider Multi Disciplinary Team (MDT) assessment When to commence enteral feeding Explanation of enteral feeding Documentation of the decision making process Pre assessment for gastrostomy tube placement Consent and capacity Adults with capacity Adults who lack capacity Assessing capacity Advance Decisions Lasting Power of Attorney Court Appointed Deputies Best interests Adults with a mental disorder Withdrawing enteral feeding End of Life Care Enteral Feeding Patients with Dementia NASO-GASTRIC TUBE FEEDING (NGT) Indications for Naso-gastric tube placement Contraindications Cautions for nasogastric feeding Assessment for nasogastric feeding Nasogastric feeding tube placement Caring for a nasogastric feeding tube Routine / elective removal of a nasogastric feeding tube Accidental removal of a nasogastric feeding tube Discharge with a naso-gastric feeding tube PERCUTANEOUS ENDOSCOPIC GASTROSTOMY FEEDING (PEG) Indications Contraindications Assessment for Gastrostomy feeding Post PEG Insertion Caring for a PEG Routine and Accidental removal of a PEG Discharging a Patient with a PEG Database No: 331 Page 4 of 82 Version 2.0

5 10. BALLOON RETAINED GASTROSTOMY FEEDING TUBES (BGT) Indications Contra-Indications Assessing a Patient for a Balloon Retained Gastrostomy Pre Balloon Retained Gastrostomy Assessment and Guidance Caring for a Balloon Retained Gastrostomy Post Balloon Retained Gastrostomy Guidance Routine and Emergency replacement of a Balloon Retained Gastrostomy Discharging a Patient with a Balloon Retained Gastrostomy RADIOLOGICALLY INSERTED GASTROSTOMY (RIG) Indications Contra-indications Assessing a Patient for a RIG Pre RIG Insertion Assessment and Guidance Post RIG Insertion Guidance Caring for a RIG Routine and Emergency replacement of a RIG Discharging a Patient with a RIG JEJUNAL FEEDING Indications Assessment of Jejunal Feeding Caring for a Jejunal Feeding Tube Confirmation of Placement of a Naso-jejunal feeding tube Assessment of Tube Displacement: Removal of Jejunal Feeding Tubes Elective / Planned Removal of a Jejunal Feeding Tube Accidental Removal of Jejunal Feeding Tubes Discharge with a Jejunal Feeding Tube ADMINISTERING ENTERAL FEED Positioning Bolus Feeding Pump feeding What to do if a Feeding Pump develops a fault INFECTION CONTROL AND HYGIENE Handwashing Preparation and Storage of Feeds Non sterile Reconstituted feeds (modular, diluted or modified feed) Feed Hanging Times Interruptions to Feeding Safe Use of Enteral Feeding Equipment Enteral Feeding Pumps Enteral Feeding Syringes Giving sets Feeding Reservoirs Safe Use of Water Oral Hygiene GUIDELINES FOR THE ADMINISTRATION OF DRUGS VIA ENTERAL FEEDING TUBES Introduction Guidance on the type of feeding tube Guidance regarding the type of drug Database No: 331 Page 5 of 82 Version 2.0

6 15.4. Administering medication via an enteral feeding tube Water and Fluid Balance Syringe Type and Size Infection Control and Safety Tube Blockage Monitoring patients on enteral feed Administering enteral feed for patients with Diabetes DISCHARGE PLANNING RESPONSIBILITIES TRAINING IMPLEMENTATION FURTHER INFORMATION CLINICAL POLICIES REVIEW GLOSSARY OF TERMS REFERENCES APPENDIX 1 - ADULT PATIENT IDENTIFIED AS AT RISK OF REFEEDING SYNDROME APPENDIX 2 - NASOGASTRIC TUBE FEEDING APPENDIX 3 - DECISION TREE FOR NASOGASTRIC TUBE PLACEMENT IN ADULTS APPENDIX 4 PROCEDURE FOR NASOGASTRIC TUBE INSERTION APPENDIX 5 CORFLO FINE BORE FEEDING TUBES: PLACEMENT GUIDELINE APPENDIX 6 - NASOGASTRIC TUBE POSITION CONFIRMATION RECORD APPENDIX 7 - NASOGASTRIC FEEDING BEDSIDE CHART APPENDIX 8 - NASOGASTRIC FEEDING DISCHARGE RISK ASSESSMENT AND PREPARATION APPENDIX 9 NASOGASTRIC TUBE FEEDING STARTER REGIME APPENDIX 10 PRE GASTROSTOMY ASSESSMENT FORM APPENDIX 11 GASTROSTOMY FLOW CHART APPENDIX 12 - PROCEDURE FOR CHECKING AND REPLACING THE WATER IN A BALLOON RETAINED GASTROSTOMY FEEDING TUBE/LOW PROFILE FEEDING DEVICE APPENDIX 13 GOOD PRACTICE GUIDELINES APPENDIX 14 GASTROSTOMY FEEDING STARTER REGIMEN APPENDIX 15 JEJUNOSTOMY / NASOJEJUNAL TUBE FEEDING REGIME APPENDIX 16 - ADMINISTERING ENTERAL FEED APPENDIX 17 - RISK ASSESSMENT OF PATIENTS SUSCEPTIBILITY TO INFECTION APPENDIX 18 ORAL HYGEINE APPENDIX 19 - STEP BY STEP GUIDE TO ADMINISTERING DRUGS VIA ENTERAL FEEDING TUBES (BAPEN 2003) Database No: 331 Page 6 of 82 Version 2.0

7 44. APPENDIX 20 DRUGS WHICH REQUIRE ENTERAL FEED TO BE STOPPED PRIOR TO ADMINISTRATION APPENDIX 21 THE MANAGEMENT OF BLOCKED FEEDING TUBES APPENDIX 22 NUTRICIA GUIDE TO MANAGING STOMA COMPLICATIONS APPENDIX 23 - DISCHARGE PROCEDURE FOR PATIENTS RECEIVING ARTIFICIAL NUTRITION SUPPORT APPENDIX 24 - MONITORING PATIENTS ON ENTERAL FEEDING PROTOCOL FOR NUTRITIONAL, ANTHROPOMETRIC AND CLINICAL MONITORING OF NUTRITION SUPPORT APPENDIX 25 - PROTOCOL FOR LABORATORY MONITORING ENTERAL NUTRITION SUPPORT APPENDIX 26 - ENTERAL FEEDING - TROUBLESHOOTING GUIDE Database No: 331 Page 7 of 82 Version 2.0

8 1. INTRODUCTION Definition: Enteral feeding is the use of a feeding tube to access the gastrointestinal tract to provide artificial nutrition using a proprietary liquid feed. This may be required when the person is unable to meet their nutritional requirements orally with food and/or fluids. Enteral tube feeding is not an emergency procedure and should be carefully planned. Once access to the gastrointestinal tract is established, the best feeding regimen should be recommended for the patient by a Dietitian. During feeding the patient should be monitored in order to prevent, detect and manage complications (NICE 2006 CG 32). This Policy and operational guidelines aims to provide guidance to all staff working with adult patients. It will optimise the use and efficiency of enteral tube feeding as a means of nutrition support and aims to standardise best practice throughout the Health Board. This will ensure that consistent advice and care is given to patients, families and professionals 2. POLICY STATEMENT To ensure evidence based best practice and consistency across the Health Board in the management of adult patients requiring artificial nutrition support. 3. SCOPE The Policy refers to adults aged 18 years and over. It is for use across secondary, community and mental health services. The Policy will be used by registered Dietitians, nurses, biochemists, pharmacists, doctors, other allied health professionals and students within the scope of individual clinical competence. 4. AIM To develop a Health Board wide Enteral Feeding Policy for Adults facilitated through the collective work of a multidisciplinary team of professionals with a commitment to improving patient care in relation to enteral feeding through promoting evidence based practice. 5. OBJECTIVES To ensure a robust approach to decision making in relation to the placement of enteral feeding tubes across Hywel Dda University Health Board. To ensure consistency in relation to the management of patients receiving enteral nutrition across the Health Board. To co-ordinate a multidisciplinary approach to enteral feeding across Hywel Dda University Health Board based on national guidance, evidence base and best practice. To provide seamless care to patients and to support care closer to home through implementing the Policy within secondary care, primary care, community and mental health services. Database No: 331 Page 8 of 82 Version 2.0

9 6. USEFUL CONTACTS: HYWEL DDA UNIVERSITY HEALTH BOARD Department/Specialist Bronglais General Hospital Dietetics (bleep 122) Glangwili General Hospital (x2067) Prince Philip Hospital Withybush General Hospital Clinical Nurse Specialist Nutrition Endoscopy /5981/5387 (x 8876) (Nurses x 6056) Speech and Language Therapy Cardigan Hospital x 31 BGH x 7010 Pharmacy /5501 Hywel Dda Medicines Information Centre EBME/Equipment Library (x 2425) (x2466) (x 2793) /3110 (bleep 2269) Equipment Library Haverdfordwest Health Centre * *Please note the Community Dietetic Team for Pembrokeshire are located in Haverdfordwest Health Centre.* 7. MAKING THE DECISION TO INITIATE ENTERAL FEEDING Recommendations of the Royal College of Physicians (RCP 2010) Making the decision to place an enteral feeding tube and to start enteral feeding is discussed in detail as part of the Oral feeding Difficulties and Dilemmas report by the RCP (2010). The report includes the following relevant recommendations:- A multidisciplinary nutrition support team of healthcare professionals, ideally but not inevitably led by a doctor with special expertise in nutrition, should be available to work with patients and their families when oral feeding difficulties occur. A member of the team should be available by telephone and ideally at weekends to provide advice. Such teams should be collaborative in nature and not be made up of independent professionals who are focused only on their area. The patient should be at the centre of their efforts. The first question should be what are we trying to achieve? Oral intake, modified as necessary should be the main aim of treatment. Nutrient dense foods or special provision of food (in hospital for example the red tray system is helpful) Even when tube feeding is necessary, this should be additional whenever possible. At the end of life, even if deemed to have an unsafe swallow a risk management approach may offer the patient the best quality of life. If in doubt, a trial of nasogastric feeding with clearly agreed objectives may be appropriate. Tube feeding should then be withdrawn if Database No: 331 Page 9 of 82 Version 2.0

10 failing to achieve the objectives. Nil by mouth should be the last resort, not the initial default option. When artificial nutrition and hydration are required for the medium term or longer this should be managed by the multidisciplinary team together with other health professionals, the patients themselves and their family/carers, at home if possible. The setting may be a care home if the patient has other medical problems. All Trusts and care homes should ensure there are sufficient staff, especially at mealtimes, to assist and feed those patients who require a long time to eat an adequate meal. The full facts of the situation should be understood by all involved to enable a patientcentred decision about artificial nutrition and hydration and the means of delivery. This should never be based on the convenience of the staff or carers or be required as a criterion for admission by any institution. We believe that to be unethical and bad practice Assessment Process Legal and ethical implications The placement of enteral feeding tubes and their use for enteral feeding requires careful consideration of the legal and ethical implications. There are many instances when difficult decisions need to be made whereby the balance of benefits verses burdens must be judged by the clinician and multidisciplinary team. For example, a 90 year old patient may have suffered a dense stroke diagnosed by a CT scan of the brain, with the future prospect of a short and potentially poor quality of life. A quick decision may be required by the medical team as to whether or not a naso-gastric tube should be placed in order to provide a route of access for nutritional support, hydration and medication. However, the patient s close and caring relatives may wish to allow the patient to die peacefully without further medical intervention. It is the responsibility of the patient s clinical team to ensure that due regard to legal and ethical principles are considered as part of patient care Factors to consider Assessment of patients should be carried out on an individual basis. Many factors may influence the decision and include the following: Patient/relatives/carers wishes Advanced decisions Medical condition Quality of life Impact of feeding Prognosis Route Therapeutic aims Length of time requirement for enteral feeding Multi Disciplinary Team (MDT) assessment All patients who are being considered for the placement of an enteral feeding tube should be referred to the Dietitian. Ideally, the decision to place an enteral feeding tube and to commence enteral feeding in hospital or in the community setting, when possible, should be made by the clinician and the MDT in conjunction with the patient and/or relatives/carers. If there are differing opinions on whether enteral feeding or a particular route of feeding is appropriate then a case conference may help the decision-making process. Database No: 331 Page 10 of 82 Version 2.0

11 The MDT may include the consultant, doctor, surgeon, Dietitian, nutrition specialist nurse, ward nurse, speech and language therapist, social worker, occupational therapist, members of the mental health team. The community MDT may include the GP, specialist nurse and members of the Complex Care Team. If feeding is likely to continue following discharge from hospital, then community staff should also be involved When to commence enteral feeding Whilst it is not possible to be explicit about how soon to begin enteral feeding, enteral nutritional support should be considered after 2 to 7 days for all patients who, because of their condition, have not been able to take adequate nutrition orally. When considering commencing enteral nutrition it is important to exercise refeeding precautions. (Refer to Appendix 1 And Hywel Dda University Health Board Re-feeding Policy 2012) Explanation of enteral feeding A full explanation of the enteral tube placement and feeding process must be given by the nutrition specialist nurse and Dietitian as agreed by the MDT and the short and long term goals should be explained to the patient and/or relatives/carers. Appropriate literature must be given to assist the decision making process. EIDO Patient Information on percutaneous endoscopic gastrostomy (PEG) feeding literature can be obtained from the endoscopy department or by contacting the Dietetic team/ Clinical Nurse Specialist (CNS) Nutrition. Patients, relatives and carers should have an open opportunity to request more explanation and information as necessary to make an informed decision Documentation of the decision making process All aspects of the decision making process should be documented. This should include: What was the decision made Where and when the decision was made Why the decision was made (Rationale) Who was involved in making the decision Reference should clearly be made to other factors in decision making that are appropriate to individual cases such as advanced directives, the patient s mental capacity, advocacy arrangements, risk assessments, professional conflict in decision making and how this is overcome i.e. Best Interest decisions etc. Relevant assessments which have influenced the decision should also be documented e.g. swallowing assessment, nutritional assessment. Any views or wishes expressed by the family or carers should also be clearly documented. If the decision is made not to place an enteral feeding tube or having placed the tube that it should not be used for enteral feeding, then the reasons for this should also be clearly documented Pre assessment for gastrostomy tube placement When the Multi-Disciplinary Team whether in secondary care or in the community is considering whether gastrostomy placement is appropriate a gastrostomy feeding pre-assessment should be conducted and documented using the Pre Gastrostomy Assessment Form to support the decision making process. (See Appendix: 11). A key person within the MDT should be assigned to leading the pre-assessment involving other members of the MDT as appropriate. The results of the preassessment should be discussed with the referring consultant/gp to inform the decision making process. Database No: 331 Page 11 of 82 Version 2.0

12 If the decision is made to proceed with gastrostomy placement the patient s Physician, Surgeon or GP should then make a referral to the endoscopy Physician responsible for gastrostomy tube placement Consent and capacity Adults with capacity Adults (aged 16 and over) with capacity must provide their written consent to enteral feeding before it can be administered. The patient should be provided with full information about the procedure so that they can make an informed choice. This should include: the reason enteral feeding is being proposed; the nature of the treatment; the risks and benefits of having/not having the procedure; and any possible alternatives. The patient s consent should be documented on Form 1: Patient agreement to examination or treatment in the usual way (see Policy for Consent to Examination or Treatment, 008). If a patient with capacity refuses to give consent to enteral feeding then this decision must be respected Adults who lack capacity Some adult patients may not have the mental capacity to consent for themselves (Mental Capacity Act (MCA) 2005). In other words they may have an impairment of, or a disturbance in the functioning of, their mind or brain (e.g. a disability, condition or trauma) which means that, at the time the particular decision needs to be made, they are unable to do one or more of the following: understand the information being provided about the need for enteral feeding; retain the information for long enough to make the decision in question; use and weigh the information in reaching a decision; communicate their decision in any way Assessing capacity If there is reason to doubt the patient s capacity to make a decision about enteral feeding, then a formal assessment of capacity should be undertaken and documented. The assessment of capacity should be undertaken by the multi-disciplinary team caring for the patient. Only if the assessment is inconclusive should a second opinion be sought. (Further guidance and support in relation to assessing capacity can be found in the MCA Code of Practice, Health Board policy HD018: Guidance on the Mental Capacity Act, or by visiting the Mental Capacity Act intranet page.) If the lack of capacity to make a decision about enteral feeding is likely to be temporary, or the patient s capacity is fluctuating, a decision needs to be made as to whether it is possible to wait until the patient regains capacity and can consent for themselves, or whether treatment needs to proceed with immediate effect. If a patient is found to lack capacity to make the decision about enteral feeding for themselves, then the decision to proceed must be made in the patients best interests (see below) unless the patient has made an advance decision refusing enteral feeding, or there is someone with the necessary authority who can make the decision on the patient s behalf (see below) Advance Decisions Some patients may have made an advance decision to refuse enteral feeding. If this advance decision is valid and applicable to the situation under consideration then healthcare professionals are legally obliged to respect it. Where the effect of an advance decision to refuse enteral feeding is likely to lead to the patient s death then it must be in writing, be signed, dated and witnessed. It must also contain a statement that reflects that the patient has understood the serious consequences of the refusal such as even Database No: 331 Page 12 of 82 Version 2.0

13 if my life is at risk. If it does not meet with these requirements then an advance decision refusing life sustaining treatment would not be considered valid. For further guidance see Health Board policy HD014: Policy on Advance Decisions. Advance decisions only relate to refusal of treatment. However, a patient may have also indicated their preferences in relation to receiving enteral feeding which, whilst not legally binding, must be considered when making a decision in the person s best interests (see below) Lasting Power of Attorney Some patients may have granted a LPA to a specific person (attorney) who they wish to make decisions on their behalf in the event that they lose decision-making capacity. If a patient has been assessed as lacking capacity, then health care professionals should make reasonable efforts to ascertain the existence of a Lasting Power of Attorney. There are different types of Lasting Power of Attorney which confer different levels of decisionmaking authority. In some cases the LPA may limit the attorney s authority to very specific decisions. It is, therefore, essential that the multidisciplinary team see the LPA documentation to enable clarity regarding what decisions the attorney can make. If they are unable to produce the documentation, or they have not been given the authority to consent on behalf of the patient, then they cannot give consent for enteral feeding and the multidisciplinary team must proceed in the patient s best interests. If the decision about enteral feeding falls within the attorney s authority and the patient lacks capacity then the attorney would be the decision-maker Court Appointed Deputies In circumstances where a person lacks capacity and it is likely that they will lack capacity for future decisions the Court of Protection has the power to appoint a deputy to make decisions for the person. The scope and duration of a deputy s powers are defined by the Court. As with attorneys, you must see the Court of Protection documentation so that you are clear what decisions the deputy can make. If the decision about enteral feeding falls within their authority the deputy would be the decision-maker. If it does not, then you must proceed in the patient s best interests. Deputies cannot make decisions to refuse a treatment considered to be life-sustaining as this would require the authority of the court Best interests For patients who are assessed as lacking capacity and for whom there is no alternative prior authority that makes the decision on their behalf, then a decision regarding whether or not enteral feeding is appropriate should be made in the patient s best interests. The decision-maker, in consultation with professional colleagues and other people interested in the person s welfare (including family, friends or unpaid carers) should consider a number of factors including: the patient s past and present wishes and feelings, beliefs and values the clinical judgement around the likely effectiveness of treatment The views of relatives and others close to the patient, including any attorney or courtappointed deputy who does not have decision-making authority for this decision. If there is no-one appropriate for the decision-maker to consult with about a decision in respect of enteral feeding and the treatment is considered a serious medical treatment (MCA Code of Practice, paragraph 10.42) then an Independent Mental Capacity Advocate (IMCA) must be instructed to represent and support the person. Further information can be found in the MCA Code of Practice, Health Board policy HD018: Guidance on the Mental Capacity Act, or by visiting the Mental Capacity Act intranet page. Database No: 331 Page 13 of 82 Version 2.0

14 If a decision is made that enteral feeding is in the best interests of the patient, then Form 4: Treatment in best interests for patients aged 16 years and over who may lack the capacity to consent to examination or treatment- should be used to document the assessment of capacity and the details of why enteral feeding is in the patient s best interests. Details of the consultation with family or friends must also be documented (see Policy for Consent to Examination or Treatment, 008 for further details) Adults with a mental disorder If a patient is detained and subject to Part 4 of the Mental Health Act (1983) and enteral feeding is necessary as part of the treatment of the patient s mental disorder, feeding may be given despite the patient s objections under the authority of the MHA (1983). For further guidance seek advice from a senior member of staff, the Mental Capacity Act Lead Officer, the Mental Health Act Manager or the Legal Services Department Withdrawing enteral feeding Because enteral feeding is considered a treatment, if it is providing no benefit (e.g. if the patient is dying) then it may be discontinued. Where the patient lacks the capacity to consent to such a decision the safeguards provided by the Mental Capacity Act) must be followed as part of the consideration of withdrawal of enteral feeding. In ethical terms there is no legal difference between starting and withdrawing treatment. In emotional terms it is more difficult to withdraw a treatment once begun than not to start it at all. For this reason there can sometimes be a reluctance to commence enteral feeding for fear it will be difficult to stop. In such circumstances it may be appropriate to start treatment for a time or period, with the provision that the outcome will be reviewed at the end of a specific time period or earlier if needed, to be stopped, changed or continued as appropriate, (CREST 2004) End of Life Care For patients for whom the option to commence enteral feeding has been rejected, it may be necessary to consider their end of life care pathway. Guidelines to support this pathway are contained in the Health Board s Guidelines to support end of life care Enteral Feeding Patients with Dementia This topic is discussed in detail in the RCP 2010 report Oral Feeding Difficulties and Dilemmas. Patients with advanced dementia frequently develop oral feeding problems leading to a reduction in nutritional intake, weight loss and an increased risk of aspiration. This is often associated with the final phase of the illness when it is not possible to understand the patient s wishes. Some doctors and relatives of people with dementia believe PEG feeding to be beneficial including improved quality of life, reduction in aspiration pneumonia and incidence of infections, prevention of malnutrition, prevention/improvement in pressure sores and increased survival. The working party found no evidence of reduced risk of any of these factors. Several studies have suggested that where dementia is the reason for PEG placement, it does not extend life and is associated with a greater mortality. The quality of life in advanced disease is restricted, but eating and drinking are likely to provide some basic satisfaction that is removed by a PEG and nil by mouth. Social interaction is reduced by PEG feeding. Discomfort may be increased as the oral cavity is not regularly moistened. The irritation of a foreign tube may require restraint. Database No: 331 Page 14 of 82 Version 2.0

15 Possibly, severely demented patients lack the potential for physical or neurological rehabilitation, and are not nutritionally deprived. With progress into the advanced stage, metabolic rate falls. This is attributed to muscle wasting which has diminished lean body mass and to a brain that has atrophied. Although many people with advanced dementia may be thin and eat less food they may be in a state of physiological homeostasis. Despite all the reservations, the working party was advised by several sources that the wise reluctance to use artificial nutrition and hydration in dementia cannot be translated into a blanket ban. Best practice was identified as careful hand feeding and that gastrostomy feeding should not be offered in advanced dementia. 8. NASO-GASTRIC TUBE FEEDING (NGT) A fine bore naso-gastric (NG) tube is a long, flexible polyurethane or silicone tube that is passed through the nasal passages via the oesophagus into the stomach. It is commonly used for delivery of feed, fluids and medication. Patients must have a functioning gastro-intestinal (GI)I tract for insertion of a fine bore NGT. Naso-gastric tubes should only be inserted by clinical staff that are appropriately trained in the correct insertion technique as well as the procedure for verifying their positioning Indications for Naso-gastric tube placement Inadequate or unsafe oral intake with an accessible GI tract. Feeding required for < 4 weeks 8.2. Contraindications Conditions which increase the risk of oesophageal perforation or aspiration of gastric contents e.g. GI bleeding, complete intestinal obstruction, uncontrolled vomiting and gastro-oesophageal reflux, oesophageal strictures, existing oesophageal perforation, nasal fracture and bleeds, basal skull fracture Cautions for nasogastric feeding The following groups of patients are at a high risk of incorrect tube positioning, dislodgement and aspiration. These patients should have a risk-benefit assessment with the aims of the naso-gastric tube clearly documented in the patient s notes (See Appendix 2) Appropriate specialist advice should be taken if the patient has: Maxillo-facial disorders Laryngectomy Recent radiotherapy to head and neck Any disorder of the oesophagus e.g. varices. Nasal Continuous Positive Airway Pressure (CPAP) Oro-gastric positioning may be indicated following head injury or neuro surgery. Are comatose/semi-comatose Are ventilated/sedated Have a swallow dysfunction Have recurrent retching/vomiting Need to be nursed prone 8.4. Assessment for nasogastric feeding. Prior to considering a patient for naso-gastric tube feeding please refer to Section 7: Making the decision to initiate enteral feeding. Please refer to Appendix 3 and 4 for a naso-gastric tube feeding assessment form and decision tree. Database No: 331 Page 15 of 82 Version 2.0

16 Misplaced naso-gastric feeding tubes are recognised as a significant risk for patients as the tube can be misplaced into the lungs. In 2011, following reports of patient death and harm caused by misplaced naso-gastric feeding tubes, the National Patient Safety Agency (NPSA) issued a Patient Safety Alert. Between September 2005 and March 2010 there were a further 21 deaths and 79 cases of harm, related to feeding through misplaced naso-gastric tubes reported. Patients requiring naso-gastric tubes should be assessed by the MDT for contraindications, and any other medical conditions that will place them at high risk of developing complications related to naso-gastric feeding Nasogastric feeding tube placement All clinical staff who insert nasogastric tubes must be appropriately trained in the procedure and have a full understanding of the risks and complications associated with the placement of NG tubes. The Health Board currently have naso-gastric tube insertion workshops which can be accessed via Learning and Development. For guidelines on nasogastric feeding tube placement including guidelines on obtaining an aspirate, placement guidelines, a naso-gastric feeding tube position confirmation record and bedside chart refer to Appendices 2-8) Caring for a nasogastric feeding tube For information on caring for a nasogastric feeding tube refer to the appropriate nursing care plan documentation. All patients who have a nasogastric feeding tube inserted for feeding must be referred to the dietitian for appropriate assessment and a feeding regimen. If the dietitian is not available refer to Appendix 10 for a nasogastric feeding starter regimen Routine / elective removal of a nasogastric feeding tube The patient must be referred to the Dietitian prior to discontinuation of enteral feeding for review as to whether oral intake is sufficient and to establish whether further nutritional support is required Accidental removal of a nasogastric feeding tube If the feeding tube is required for nutrition, fluids or medication, it should be reinserted as soon as possible. It may be appropriate to consider the use of Hand Control Mittens to prevent accidental dislodgement (Clinical Policy 171) 8.9. Discharge with a naso-gastric feeding tube For all patients being considered for discharge with enteral nutrition a multi-disciplinary team meeting must be held to ensure that feeding will be managed effectively on discharge and to ensure seamless discharge and co-ordinated care into the community. A nasogastric feeding discharge assessment must be completed by the MDT multidisciplinary team as part of this process (See Appendix: 9) 9. PERCUTANEOUS ENDOSCOPIC GASTROSTOMY FEEDING (PEG) Gastrostomy feeding tubes are designed for long-term feeding as they can be used to deliver feed, medication and/ or fluid. They may be used to provide total nutrition or as a supplement to oral intake. They are made from polyurethane, placed endoscopically/surgically/radiologically and can be held in place inside the stomach with an internal bolster. Careful assessment via a multidisciplinary team is required for all patients considered for gastrostomy feeding to ensure feeding is clinically indicated, to prevent potential problems and to ensure feeding using this method of enteral access is in the patient s best interests Indications Long term enteral tube feeding > 4 weeks. Database No: 331 Page 16 of 82 Version 2.0

17 Patients for whom nasoenteric feeding is contra-indicated i.e. those with upper GI disorders Contraindications Mechanical obstruction of GI Tract Gastric outlet obstruction Imminent Death Coagulation Disorders Ascites Inability to access stomach either endoscopically or trans abdominally due to previous gastric resection, peritoneal dialysis, pregnancy, portal hypertension (with varices) Active Gastric ulcer disease Interposition of colon or liver A high position of stomach Gastritis Gastric neoplasm Gastric varices Peritonitis 9.3. Assessment for Gastrostomy feeding Prior to considering a patient for placement of a PEG tube please refer to Section 7: Making the decision to start enteral feeding. A gastrostomy assessment (See Appendix 11) must be completed to support the decision making process as to whether a patient is suitable for a PEG and to identify and minimise any potential complications post PEG Placement. Ideally PEG pre-assessment should be undertaken by a multi-disciplinary team Post PEG Insertion All patients post PEG placement require close monitoring. Patients must be monitored using the Gastrostomy Flow Chart for the first 72 hours, as per NPSA guidance (2010). (See Appendix 12) This will promote early detection of complications following the procedure and aid a safe recovery. Possible complications can include bleeding, leaking of gastric contents, swelling, and pain and tube displacement. If a patient is discharged before 72hrs (following clinician assessment) the GP and Acute Response Team must be provided with a copy of the Gastrostomy alert. All patients will also receive patient information (provided by Dietetics) including information on recognising potential complications post gastrostomy insertion and what to do in an emergency. Following PEG insertion:- Step 1: The patient is to remain Nil by mouth for 4hours after the procedure unless advised otherwise. Step 2: Commence the feeding regime devised by the dietitian or follow the gastrostomy feeding starter regime (See Appendix 15). NB: Patients who have placement of a prophylactic PEG (i.e. are eating and drinking but may require PEG feeding in the future) should remain NBM and Nil by PEG for 4 hours after the procedure and can then progress to light diet (i.e soup, jelly, yoghurt) and fluids for the first evening post PEG placement. All patients with a Gastrostomy feeding tube must be referred to the dietitian for an appropriate feeding regimen. If the Dietitian is not available refer to Appendix 15 - Starter Regimens Gastrostomy feeding. Database No: 331 Page 17 of 82 Version 2.0

18 9.5. Caring for a PEG For Information on caring for a PEG refer to the appropriate Nursing documentation and care plan. For information on Feeding via a PEG refer to the Dietitian for a feeding regimen or if the Dietitian is not available refer to Appendix 15 : gastrostomy feeding starter regimen 9.6. Routine and Accidental removal of a PEG Routine removal of a PEG can be arranged either with Endoscopy department or by discussing with the CNS Nutrition. The removal of a PEG tube should be an elective decision but there are occasions when a Gastrostomy tube is accidentally removed. Prompt action is required should this occur. If the PEG has been in situ less than 8 weeks the patient must be seen by the medical/surgical team for assessment and decision on tube replacement. If the PEG has been in situ longer than 8 weeks prompt action is required to prevent the stoma site from closing. For In-patients contact the CNS Nutrition or medical team as a matter or urgency. Community patients should contact the CNS Nutrition, Homeward Nurse or medical team as a matter or urgency. A temporary Balloon Retained Gastrostomy tube can be inserted by a person trained and competent to do so to keep the stoma site open Refer to Appendix 14 : NNNNG Gastrostomy feeding: Balloon Gastrostomy tube replacement procedure. If a PEG is accidentally removed in the community:- o Patients should contact their Home Enteral Feeding Company nurse or Nutrition specialist nurse as a matter or urgency within normal working hours. o Outside working hours and on weekend s patients should contact the Acute Response Team (ART). o Tube replacement should only be attempted if the PEG tube has been in situ for longer than 8 weeks. In the event of the feeding tube needing to be replaced or should the patient attend A&E for tube replacement. o The patient will have to be admitted if the insertion of tube is unsuccessful and an alternative route of nutrition /hydration is provided in the interim. o The Dietitian and CNS Nutrition should be informed of all tube replacements Discharging a Patient with a PEG All patients being considered for discharge with enteral nutrition must have a multi-disciplinary team meeting to ensure that feeding will be managed effectively on discharge and to ensure seamless discharge and co-ordinated care into the community 10. BALLOON RETAINED GASTROSTOMY FEEDING TUBES (BGT) Indications Can be used to replace an existing PEG or RIG (if stoma site established > 8 weeks) Contra-Indications Do not replace if:- Original tube in situ less than 8 weeks If surgically placed If gastroplexy sutures are in situ If the patient is in pain or spiking temperature If there are signs of trauma. Database No: 331 Page 18 of 82 Version 2.0

19 Do no replace if correct size tube is not available Assessing a Patient for a Balloon Retained Gastrostomy For information regarding considering placement of a balloon retained Gastrostomy please refer to section 7 Making the decision to Start enteral feeding Pre Balloon Retained Gastrostomy Assessment and Guidance Most balloon retained Gastrostomy feeding tubes are inserted to replace an existing PEG or Radiologically Placed Gastrostomy (RIG) tube. N.B If a Balloon tube is to be replaced percutaneously it must be via an established tract. An established tract is patient specific but is usually considered safer following at least 8 weeks post insertion of a primary placement.. If a Balloon Gastrostomy tube is inserted surgically as a means of providing artificial nutrition prior to the procedure patients must have a pre-gastrostomy feeding assessment form completed see Appendix Caring for a Balloon Retained Gastrostomy For guidance on caring for a patient with a Balloon Retained Gastrostomy refer to the relevant nursing documentation and care plan. All patients with a Gastrostomy feeding tube must be referred to the Dietitian for an appropriate feeding regimen. If the Dietitian is not available refer to Appendix 15 Starter Regimens Gastrostomy feeding. For guidance on checking and replacing the water in a balloon retained gastrostomy feeding tube refer to Appendix Post Balloon Retained Gastrostomy Guidance All patients post surgical balloon retained gastrostomy placement require close monitoring. Patients must be monitored using the Gastrostomy Flow Chart for the first 72 hours, as per NPSA guidance (2010). See Appendix 12. This will promote early detection of complications following the procedure and aid a safe recovery. Possible complications can include bleeding, leaking of gastric contents, swelling, pain and tube displacement Routine and Emergency replacement of a Balloon Retained Gastrostomy Routine replacement of a Balloon Retained Gastrostomy (BGT) can be arranged either with the Homeward Nurse or by discussing with the CNS Nutrition. The removal of a Balloon Retained Gastrostomy tube should be an elective decision but there are occasions when a Gastrostomy tube is accidentally removed. Prompt action is required should this occur. If the BGT has been in situ less than 8 weeks the patient must be seen by the medical/surgical team for assessment and decision on tube replacement. If the BGT has been in situ longer than 8 weeks prompt action is required to prevent the stoma site from closing. For In-patients contact CNS Nutrition or medical team as a matter of urgency. Community patients should contact the CNS Nutrition, Homeward Nurse or medical team as a matter or urgency. A temporary Balloon Retained Gastrostomy tube can be inserted by a person trained and competent to do so to keep the stoma site open Refer to Appendix 14 : Gastrostomy feeding: Balloon Gastrostomy tube replacement procedure. If a BGT is accidentally removed in the community:- o Patients should contact their Home Enteral Feeding Company nurse or Nutrition specialist nurse as a matter or urgency within normal working hours. o Outside working hours and on weekend s patients should contact the Acute Response Team (ART). Database No: 331 Page 19 of 82 Version 2.0

20 o o o HYWEL DDA UNIVERSITY HEALTH BOARD Tube replacement should only be attempted if the BGT tube has been in situ for longer than 8 weeks. In the event the tube has been in for less that 8 weeks the patient must attend A&E for assessment and tube replacement. In all cases,the patient will have to be admitted if the insertion of tube is unsuccessful and an alternative route of nutrition /hydration is provided in the interim. The Dietitian and CNS Nutrition should be informed of all tube replacements Discharging a Patient with a Balloon Retained Gastrostomy All patients being considered for discharge with enteral nutrition should have multi-disciplinary team meeting to ensure that feeding will be managed effectively on discharge and to ensure seamless discharge and co-ordinated care into the community. 11. RADIOLOGICALLY INSERTED GASTROSTOMY (RIG) Indications Long term enteral tube feeding Patients for whom Endoscopic or surgical Gastrostomy placement is contra-indicated e.g due to malignant disease or compromised respiratory function (e.g. MND) Contra-indications Mechanical Obstruction of GI Tract Gastric outlet obstruction Imminent death Coagulation Disorders Ascites Inability to access the stomach either endoscopically or trans-abdominally due to previous gastric resection, peritoneal dialysis, pregnancy, portal hypertension (with varicies) Active Gastric ulcer disease Interposition of colon or liver A high position of stomach Gatritis Gastric neoplasm Gastric varices Peritonitis Assessing a Patient for a RIG Prior to considering a patient for placement of a RIG tube please refer to Section 7: Making the decision to start enteral feeding. Once the decision has been made to place a RIG tube please complete a pre-gastrostomy assessment : Appendix Pre RIG Insertion Assessment and Guidance All patients prior to RIG placement must have had a pre-gastrostomy feeding assessment form completed. If the decision is made to refer for RIG, placement of the tube is undertaken outside the Health Board. Patients will require a consultant referral Post RIG Insertion Guidance All patients post RIG placement require close monitoring. Patients should be monitored using the Gastrostomy Flow Chart for the first 72 hours, as per NPSA guidance (2010). (See Appendix 12 ) This will promote early detection of complications following the procedure and aid a safe recovery. Possible complications can include bleeding, leaking of gastric contents, swelling, pain and tube displacement. All patients with a RIG should be referred to the Dietitian for an appropriate Database No: 331 Page 20 of 82 Version 2.0

21 assessment and feeding regimen. If the Dietitian is not available please refer to Appendix 15 : Feeding Regimens Gastrostomy feeding Caring for a RIG For Information on caring for a RIG please refer to the relevant nursing documentation and care plan Routine and Emergency replacement of a RIG Routine replacement of a Radiologically Inserted Gastrostomy (RIG) can be arranged either with the Homeward Nurse or by discussing with the CNS Nutrition. The removal of a RIG tube should be an elective decision but there are occasions when a Gastrostomy tube is accidentally removed. Prompt action is required should this occur. If the RIG has been in situ less than 8 weeks the patient must be seen by the medical/surgical team for assessment and decision on tube replacement. If the RIG has been in situ longer than 8 weeks prompt action is required to prevent the stoma site from closing. For In-patients contact CNS Nutrition or medical team as a matter of urgency. Community patients contact the CNS Nutrition, Homeward Nurse or medical team as a matter or urgency. A temporary BGT can be inserted by a person trained and competent to do so to keep the stoma site open Refer to Appendix 14: Gastrostomy feeding: Balloon Gastrostomy tube replacement procedure. (after the 8 week period) If a RIG is accidentally removed in the community:- o Patients should contact their Home Enteral Feeding Company nurse or CNS Nutrition as a matter or urgency within normal working hours. o Outside working hours and on weekend s patients should contact the Acute Response Team (ART). o Tube replacement should only be attempted if the RIG tube has been in situ for longer than 8 weeks. In the event the tube has been in for less that 8 weeks the patient must attend A&E for assessment and tube replacement. o In all cases, the patient will have to be admitted if the insertion of tube is unsuccessful and an alternative route of nutrition /hydration is provided in the interim. o The Dietitian and CNS Nutrition should be informed of all tube replacements Discharging a Patient with a RIG All patients being considered for discharge with enteral nutrition should have multi-disciplinary team meeting to ensure that feeding will be managed effectively on discharge and to ensure seamless discharge and co-ordinated care into the community. 12. JEJUNAL FEEDING Jejunal feeding is the administration of enteral feed via a tube that has been placed into the proximal jejunum distal to the ligament of trietz This can be achieved using the following methods: Naso-jejunal (NJ) tube insertion of a flexible, hollow tube through the pyloric sphincter into the jejunum via the nasal passage. This can be placed under direct vision in endoscopy or by bedside tube manipulation technique. (Some tubes may be placed in the duodenum only, depending on indication. Refer to patients medical notes for information regarding insertion procedure). Database No: 331 Page 21 of 82 Version 2.0

22 Surgical jejunostomy (Surgical JEJ) insertion of a tube through the abdominal wall into the jejunum during laporotomy. Percutaneous Endoscopic Jejunostomy (PEJ) insertion of a tube through the abdominal wall into the jejunum under endoscopic guidance. Percutaneous Endoscopic Gastrostomy conversion (PEG-J) a tube is passed through the existing gastrostomy tube and pulled through to the jejunum with an endoscope Indications Poor tolerance of gastric feeding Gastro-paresis Gastric Atrophy Absence of stomach Assessment of Jejunal Feeding Prior to considering a patient for placement of a jejunal feeding tube please refer to section 7 making the decision to start enteral feeding. Ideally the decision to place a jejunal feeding tube should be made by a multi-disciplinary team Caring for a Jejunal Feeding Tube For guidance on caring for a jejunal feeding tube please refer to the appropriate nursing care plan and documentation. All patients requiring jejunal feeding should be referred to the Dietitian for a feeding regimen. If the Dietitian is not available please refer to the jejunal feeding starter regimen in Appendix 16 : Jejunal feeding Confirmation of Placement of a Naso-jejunal feeding tube Aspirate is not normally obtainable from the jejunum. Therefore absence of aspirate is not a contraindication to feeding. Placement by bedside tube manipulation technique: If the NJ has been placed blind at the bedside, the position of the tube should be confirmed by abdominal x-ray prior to using the tube. Placement by direct vision in endoscopy: Endoscopically placed tubes may not need to be x- rayed prior to use. The endoscopist should state whether x-ray is required on the endoscopy report. Once the tube has been confirmed in place, the tube should be marked; close to the nostril so that it is obvious if the tube has been moved. The position of the mark should be checked daily before commencing the feed Assessment of Tube Displacement: NJ / PEG-J: Check the length and position of the marking on the tube and compare with the position documented following initial placement. If position of the tube is in doubt consider abdominal x-ray. It is possible for the tube to migrate into the stomach during use, particularly during coughing or vomiting. If the patient is nauseated or vomiting, the NJ / PEG-J tube should be aspirated. If an aspirate is obtained, this may indicated that the tip of the tube has migrated to the stomach. Any feed or medication being administered through the tube at this time should be stopped and advice sought from medical staff / CNS Nutrition. Jejunostomy: If you think the Jejunostomy tube has dislodged, DO NOT FEED and contact the medical team or CNS nutrition for advice. Database No: 331 Page 22 of 82 Version 2.0

23 12.6. Removal of Jejunal Feeding Tubes Jejunal feeding tubes should only be removed if the patients are meeting their nutritional requirements via an alternative route Elective / Planned Removal of a Jejunal Feeding Tube Naso-jejunal tubes can be removed by pulling as per naso-gastric tubes. PEG-J extension tube can be removed by pulling. If the gastrostomy needs to be removed refer to CNS Nutrition for further guidance. Surgical jejunostomy tubes may need further surgical intervention for removal, particularly if the tube has an internal retaining cuff. Seek advice from surgical team or CNS Nutrition Accidental Removal of Jejunal Feeding Tubes NJ / PEG-J: If jejunal feeding is still required then tube replacement maybe required. Contact the Dietitian / Nutrition Specialist Nurse for further advice Surgical JEJ: Contact surgical team immediately for advice Do not re-insert a feeding tube that is not compatible or licensed for jejunal feeding i.e. a Balloon retained Gastrostomy tube Discharge with a Jejunal Feeding Tube All patients being considered for discharge with enteral nutrition should have multi-disciplinary team meeting to ensure that feeding will be managed effectively on discharge and to ensure seamless discharge and co-ordinated care into the community. 13. ADMINISTERING ENTERAL FEED This section aims to cover the following:- Positioning Bolus feeding Pump feeding What to do if a pump develops a fault Positioning Patients must be fed in an upright as possible, at least 45 degrees, with the head and shoulders elevated. This is to help reduce the risk of aspiration pneumonia and make the patient as comfortable as possible. Maintain this position for minutes after feeding. If at any time the patient becomes short of breath, has sudden pallor or an increased heart rate, stop the feed immediately and seek medical advice Bolus Feeding Bolus feeding involves administering a prescribed volume of feed in a specified dose at a specified time normally via a syringe directly into the enteral feeding tube. Bolus feeding is not advised for patients receiving jejunal feeding. For guidance on administering a bolus feed refer to Appendix 17: Administering enteral feed: Bolus feeding Pump feeding Pump feeding involves administration of enteral feed via an enteral feeding pump. For guidance on administering a pump feed refer to the Appendix 17 : Administering enteral feed: Pump feeding What to do if a Feeding Pump develops a fault Hospital: follow the hospital feeding pump problem solving instructions (found in the ward Nurses Nutrition Resource File). If the problem cannot be resolved contact EBME to arrange a replacement pump. Numbers can be found in Useful Contacts section of this policy. The Database No: 331 Page 23 of 82 Version 2.0

24 procedure for faulty pumps Health Board wide is outlined in Appendix 17: Administering enteral feed: Hywel Dda University Health Board Enteral Feeding Pump EBME Procedure. Community: If an enteral feeding pump requires replacement in the community the patient should be directed to contact their customer care team to arrange a replacement pump. Community pumps will be acceptance tested by the Enteral feeding company nurse. 14. INFECTION CONTROL AND HYGIENE Handwashing Effective hand decontamination must be carried out before starting feed preparation. Disposable gloves and plastic apron are recommended in the event of bodily fluids /feed coming into contact with the person carrying out the feed preparation/administration in a hospital/ nursing home Preparation and Storage of Feeds If preparation is required, feed and equipment should be prepared on a metal surface e.g. treatment trolley, which has been cleaned with detergent and water and disinfected with alcohol (70%) In the patient s own home a smooth washable surface should be used and prepared using a disinfectant spray. Wherever possible pre-packaged, ready to use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution. The Health Board has a contract for sterile, pre-packaged ready to hang enteral feeds. The system selected should require minimal handling to assemble and be compatible with the patient s enteral feeding tube. Should there be concern regarding the compatibility of the patients feeding system with their enteral tube contact the Dietitian/CNS Nutrition. Feeds should be stored in a clean dry area and as per manufacturer s guidance. Always check the feed is in date prior to administration and check that there are no signs of feed curdling. If there are any concerns regarding the feed please contact Dietitian/CNS Nutrition. Always check that the feed name corresponds with the regimen advised by the Dietitian in their prescribed feeding regimen Non sterile Reconstituted feeds (modular, diluted or modified feed) Feeds should be mixed using sterile water in the acute setting and as advised by the Dietitian in the community setting. Feeds should be prepared using a non touch technique. Where ready to use feeds are not available feeds may be prepared in advance, stored in the refrigerator and used within 24hrs.Feeds that are stored in the refrigerator should always be removed 30mins prior to administration to allow time for the feed to reach ambient temperature. All equipment/utensils used should be sterile or heat disinfected (dish washer). If a special feed or fortification is prescribed the mixture should be mixed thoroughly, using an aseptic technique. Any feeds pre-prepared in hospital must be clearly labelled with the patient s details, date of preparation and expiry Feed Hanging Times Sterile Pre-packed feeds can be hung for 24 hrs Non sterile feed (including modular diluted or modified sterile feed) decanted into a sterile reservoir should be hung for up to 4 hours. Under no circumstances should sterile reservoirs be topped up as this increases the risk of infection Interruptions to Feeding If feeding is interrupted the disconnection of giving set from feed should be a last resort. If disconnected, a new giving set will be required each time. Should disconnection be unavoidable it is essential that the patients feeding tube is flushed with water (as advised on feeding regimen) at the time of disconnection. If feeding is interrupted in the patients own home (i.e. disconnection of Database No: 331 Page 24 of 82 Version 2.0

25 the feed from the giving set) for those patients deemed to be at high risk of infection as defined by the Risk Assessment ( Appendix 18), a new giving set should be used each time. For those patients who are not deemed to be at an increased risk of infection and should disconnection be unavoidable it is essential that the patients feeding tube is flushed with water (as instructed on the feeding regimen) at the time of disconnection and the cap replaced on the feeding tube until the necessary time when the feed is reconnected to the patient. During periods of intermittent feeding the feed and enteral feeding equipment should be kept in the fridge and should be hung in a cool, dry place to minimise infection risk. All patients discharged home on enteral nutrition will be provided with clear instruction and information on their enteral feeding regimen including the safe use of equipment etc as part of their patient specific Home Enteral Tube Feeding Discharge Information Safe Use of Enteral Feeding Equipment Enteral Feeding Pumps Enteral feeding pumps should be regularly maintained following manufacturers instructions and cleaned after every use with a detergent wipe or with detergent and water. Feeding pumps should be routinely serviced as recommended by the manufacturer Enteral Feeding Syringes In the acute setting (including outlying hospitals) and for patients fed via the jejuna route a new single use purple enteral syringe must always be used each time the tube is flushed or the patient receives medication. Patients in nursing homes or in their own homes can reuse syringes for up to 7 days providing this has been agreed by the dietitian or further to a risk assessment (See Appendix 18) Giving sets Giving sets are single use items and should be discarded after each feeding episode. Frequent disconnection of the giving set for intermittent feeding should be avoided. If unavoidable refer to recommendations above Feeding Reservoirs Feeding Reservoirs should be labelled with the time and date when first used and discarded after 24hrs or when empty (not more than 24hrs) Safe Use of Water In the acute setting (including outlying hospitals) sterile water only should be used for flushing all enteral feeding tubes. For patients in the community (including own homes and nursing homes) freshly drawn tap water is advisable unless otherwise advised by the Dietitian. Patients with small bowel or jejunal feeding tubes can use cool boiled water unless otherwise instructed by the Dietitian or further to a risk assessment. (See Appendix 18) Oral Hygiene Good oral hygiene procedures established at the start of enteral feeding will prevent the need for high risk dental treatment later. Good oral care is important for reducing and eliminating the bacteria in the mouth that may present a serious risk of aspiration pneumonia. For further guidance on oral hygiene for patients receiving enteral nutrition refer to Appendix 19 : Oral Hygeine. 15. GUIDELINES FOR THE ADMINISTRATION OF DRUGS VIA ENTERAL FEEDING TUBES Introduction Crushing tablets, opening capsules and administration via feeding tubes generally falls outside a drug s product licence. In these circumstances the prescriber and practitioner accept liability for any adverse effects resulting from this administration. Database No: 331 Page 25 of 82 Version 2.0

26 NMC Nursing and Midwifery Council Statement on Crushing:- Crushing tablets must be done with the agreement of the prescriber The reason for crushing must be clearly documented in the patient record. A care plan should identify this intervention It should be monitored and evaluated. Any adverse effects should be reported to the prescriber Guidance on the type of feeding tube The site of feed (where the tip of the enteral feeding tube lies) and therefore the site for drug administration should be known as this may affect the absorption of some drugs. For example digoxin is primarily absorbed in the stomach; administering digoxin via a jejunal feeding tube may significantly reduce the rate of absorption. The route stated on the patient s prescription chart should match the type of enteral tube and the placement of the tip of the enteral tube, for example, naso-gastric (NG), percutaneous endoscopic Gastrostomy (PEG), and naso-jejunal (NJ) Guidance regarding the type of drug Never assume that a drug can be given via a feeding tube. Always consult pharmacy for advice if unsure or refer to: Handbook of Drug administration via Enteral feeding tubes (2 nd ed 2010) or NEWT Guidelines (2 nd ed 2012) Some drugs interact with enteral feed which can significantly affect their absorption (Refer to Appendix 21 : Drug nutrient interactions. It is often necessary to suspend feeding for a few hours prior to and after administration of these medications in order for them to be absorbed effectively. Some drugs can not be crushed under any circumstances Administering medication via an enteral feeding tube For further guidance on administering medication via an enteral feeding tube refer to Appendix 20: Drug Administration flowchart Water and Fluid Balance Only water should be used to flush feeding tubes and to administer medication. Please note that the correct administration of drugs via enteral feeding tubes may include a significant volume of water. The fluid volume should be taken into account in any fluid balance calculations for patients on restricted fluid intake or at risk of complications from excessive fluid intake. Consult medical/surgical team Syringe Type and Size Use a 60 ml purple enteral syringe only to administer medication in the acute setting. (NPSA/2007/19). N.B Medicines should always be measured using an oral/enteral syringe and not a hypodermic syringe. In the community setting a re-usable enteral syringe can be used if instructed by the dietitian and only if marked Re-usable Infection Control and Safety Ensure that hands are clean prior to drug administration and that gloves are worn. Keep exposure to drug powder to a minimum Tube Blockage Inadequate flushing is the most common cause of tube blockage. If an enteral tube becomes blocked refer to Appendix: 22 for guidance on unblocking enteral feeding tubes or consult the CNS Nutrition. Database No: 331 Page 26 of 82 Version 2.0

27 15.9. Monitoring patients on enteral feed For guidance on monitoring patients receiving enteral feeding including troubleshooting and a stoma complications guide refer to Appendiices 23, Administering enteral feed for patients with Diabetes NEW SECTION : For all patients with Diabetes receiving enteral nutrition guidance should be sought from the Diabetes team/diabetes Specialist nurses. Use of IV insulin infusions should be minimised. Premixed human insulin at the time the feed starts and if necessary at mid point of feed is recommended as first line option for poorly controlled type 2 Diabetic patients. Soluble human insulin at start of feed is recommended for bolus feeding. For patients prescribed Glargine or Detemir on admission to hospital receiving continuous feeding with blood glucose level more than 12, soluble human insulin may be administered at the start and if necessary mid point of feed. For patients who are unable to take food/fluids orally and who may have a hypoglycaemic episode administer 1 small container (60ml) of Glucojuice via the feeding tube which contains 15g Carbohydrate. As with all hypo s capillary blood glucose needs to be re-checked after 10-15min and if blood glucose level is less than 4mmol/l, repeat the above and re-check blood glucose 10-15mins later. Follow-up treatment needs to be from a slower release carbohydrate this would have to be a liquid feed and given as a bolus via the feeding tube. The quantity of feed required by bolus is : either patient s own feed which provides between 10-20g carbohydrate (Dietitian to advise on exact amount) or half a Fortisip 125ml Compact (provides 18g carbohydrate) or half a 200ml Fortisip Extra bottle (provides 18g carbohydrate) or half a 220ml bottle of Ensure Plus milkshake (provides 20g carbohydrate). Both the Glucojuice and the feed need to be flushed well with water as per policy. Blood Glucose monitoring should continue 4-6 hourly for the next hours. Please refer to the local Diabetes team/specialist Diabetes nurse (if patient in acute setting) or the General practitioner/community specialist Diabetes Nurse (if patient in Community setting) if hypoglycaemic episodes re-occur. 16. DISCHARGE PLANNING For guidance on discharging patients requiring enteral nutrition at home or in the community refer to Appendix 26: Discharge Procedure for Patients Receiving Enteral Nutrition Support. 17. RESPONSIBILITIES The Nutrition and Hydration Steering Group will be responsible for overseeing the co-ordination and implementation of this policy. Training to support implementation will be overseen and coordinated via the Nutrition and Hydration steering group. Adherence to the policy will be monitored via the Nutrition and Hydration steering group. 18. TRAINING Training will be overseen and co-ordinated via the Nutrition and Hydration steering group, practice development leads and Learning and development department Health Board wide. 19. IMPLEMENTATION An implementation plan will be overseen and co-ordinated via the Nutrition and Hydration Steering group. Database No: 331 Page 27 of 82 Version 2.0

28 20. FURTHER INFORMATION National Institute for Clinical Excellence, National Patient Safety Agency, British Association for Parenteral and Enteral Nutrition. Royal College of Physicians, British Society of Gastroenterology. Parenteral and Enteral Nutrition Group. 21. CLINICAL POLICIES National Institute of Clinical Excellence (NICE): Clinical Guideline 32 Nutritional Support in Adults (2006) Clinical Guideline Infection Control Prevention of healthcare associated infection in primary and community care (2012) Oral Health Guidance National Patient Safety Agency (NPSA) (see intranet site Nutrition web page: Acute Adult Nutrition) Reducing the Harm caused by misplaced naso-gastric feeding tubes in adults, children and Infants (2011) Promoting safer measurement and administration of liquid medicines via oral and other routes. (2007) Harm from flushing of naso-gastric tubes before confirmation of placement (2012) Oral Feeding Difficulties & Dilemmas Royal College Physicians 2010 (see intranet site Nutrition web page: Acute Adult Nutrition) 22. REVIEW This Policy will be reviewed after 3 years, or sooner, as required. 23. GLOSSARY OF TERMS Term Definition AHP Allied Health Professional BAPEN British Association for Parenteral and Enteral Nutrition BDA British Dietetic Association BMI Body Mass Index CRP C Reactive Protein CVA Cerebral Vascular Accident CNS Clinical Nurse Specialist DN District Nurse DOB Date of Birth HETF Home Enteral Tube Feeding IV Intravenous LFT s Liver Function Tests MAC Mid Arm Circumference NG Nasogastric Tube PEG Percutaneous Endoscopic Gastrostomy PEG-J Percutaneous Endoscopic Gastrostomy with jejunal extension PENG Parenteral and Enteral Nutrition Group PPI Proton Pump Inhibitor RD Registered Dietitian RH Residential Home RIG Radiologically Inserted Gastrostomy SALT Speech and Language Therapist U +E s Urea and Electrolytes 24. REFERENCES Anderton A. (1995). Reducing bacterial contamination in enteral tube feeds. British Journal of Nursing 4(7); Database No: 331 Page 28 of 82 Version 2.0

29 All Wales Oral Health Guidance (2012) HYWEL DDA UNIVERSITY HEALTH BOARD BAPEN (2004). Drug administration via enteral feeding tubes. A Guide for General Practitioners and Community Pharmacists. British Association for Parenteral and Enteral Nutrition, Maidenhead. BAPEN (1996) Standards and Guidelines for Nutritional Support in Hospitals (ed. T. Sizer). British Association for Parenteral and Enteral Nutrition, Maidenhead. Boyes, R.J., Kruse, J.A. (1992) Nasogastric and nasoenteric intubation. Critical Care Clinics 8(4): British Society of Gerodontology (2010) Guidelines for the Oral Healthcare of Stroke Survivors. Colagiovanni L. (1999) Taking the tube. Nursing Times 95:21 Supplement. Colagiovanni L. (2000) Preventing and clearing blocked feeding tubes. Nursing Times. 96(17): 3-4. Cotton. P and Williams. C (2003). Practical Gastrointestinal Endoscopy. Fourth Edition. London. Blackwell Science. Clinical resource efficiency support team (CREST 2004) Guidelines for enteral feeding, Scottish working group. Scotland. Dougherty, L. & Lister S. (eds) (2004) The Royal Marsden Manual of Clinical Nursing Procedures, 6th edn. Blackwell Science Ltd, Oxford. Department of Health (2005) Mental Capacity Act, Code of Practice, Department of Constitutional affairs. Department of Health.London. Department of Health. (2009a) Reference guide to consent for examination or treatment, 2 nd edition. Department of Health.London. Fater, K.H. (1995) Determining nasoenteral feeding tube placement. MedSurg Nursing, 4(1): Guidelines for the Management of Norovirus Outbreaks in Acute and Community health and social care settings. (2006) National Public Health Service for Wales. Glycaemic Management During the In-patient Enteral feeding of stroke patients with Diabetes. (2012) British Dietetic Association for In-patient care. BDA. Guidance for Prescribing in Frail Adults (2014) All Wales therapeutics and Toxicity Centre. Vale of Glamorgan. Infection Control Nurses Association (2003) Enteral feeding. Infection control guidelines. ICNA in Partnership with Nutricia. Medicines and Healthcare products Regulatory Agency (MHRA 2000) Single-use Medical Devices: Implications and Consequences of Reuse. MDA DB2000(04) Medicines and Healthcare products Regulatory Agency (MHRA 2000) Enteral Feeding Systems. MDA SN2000(27). Medicines and Healthcare products Regulatory Agency (MHRA2004) Enteral feeding tubes (nasogastric) MDA/2004/026 Mental Capacity Act 2005 Database No: 331 Page 29 of 82 Version 2.0

30 Metheny N. et al. (1990a) Detection if inadvertent respiratory displacement of small bore feeding tubes: a report of 10 cases. Heart Lung 19(6): Metheny N. et al. (1990b) Effectiveness of the ausculatory method in predicting feeding tube location. Nursing Research 39: Metheny N. et al. (1993) How to aspirate from small bore feeding tubes. American Journal of Nursing, May Metheny N. et al. (1993) Effectiveness of ph measurements in predicting feeding tube placement: an update. Nursing Research 42(6): Metheny N. et al. (1994a) Visual characteristics of aspirates from feeding tube as a method for predicting tube placement. Nursing Research 43(5): Metheny N. et al. (1994b) ph testing of feeding tube aspirates to determine placement. Nutrition in Clinical Practice 9(5): National Institute for Clinical Excellence (2006) Nutrition Support for Adults. Oral nutrition support, enteral tube feeding and parenteral nutrition. Clinical Guideline 32. NICE. London. National Patient Safety Agency (2010) Rapid Response Report NPSA/2010/RRR010 Early detection of complications after gastrostomy NPSA. London. National Patient Safety Agency (2007) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes. NPSA.London. National Patient Safety Agency. (2011) Patient safety Alert 2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. NPSA.London. National Nutrition Nurses Group. (2012) Good Practice Guideline. Changing of a Balloon Gastrostomy tube (BGT) into the stomach for Adults and Children. NNNG.London. National Institute for Clinical Excellence (NICE) (2012) Infection control. Prevention of healthcare associated infections in primary and community care. Clinical guideline 139. NICE.London. Neumann M.J., Meyer C.T. (1995) Hold that X-ray: aspirate ph and auscultation prove enteral tube placement. Journal of Clinical Gastroenterology 20(4): Nursing and Midwifery Council (2008) The code: Standards of conduct, performance and ethics for nurses and midwives. London, NMC. Nursing and Midwifery Council (2009) Record keeping: Guidance for nurses and midwives. London, NMC. Oral feeding Difficulties and Dilemmas. Report by the Royal College of Physicians (2010) Payne-James, J., Grimble, G. & Silk, D. (2001) Enteral nutrition: tubes and techniques of delivery. In: Artificial Nutritional Support in Clinical Practice, 2nd edn (eds J. Payne-James, G. Grimble & D. Silk). Greenwich Medical Media, London. Powell K.S. et al (1993) Aspirating gastric residuals causes occlusion of small bore feeding tubes. Journal of Parenteral and enteral Nutrition. 17(3): Pickering. K (2008) Administration of Drugs via Enteral Feeding Tubes. Practical Article. NNNG. (Pages 5-8) Rassias A.J. et al (1998). A prospective study of tracheopulmonary complications associated with the placement of narrow bore feeding tubes. Critical Care 2: Database No: 331 Page 30 of 82 Version 2.0

31 Smyth J 2 nd edition (2012) The NEWT guidelines for administration of medicines to patients with enteral feeding tubes or swallowing difficulties. North East Wales NHS Trust. White. R and Bradnam V 2 nd edition (2010) Handbook of drug administration via enteral feeding tubes. British Pharmaceutical Nutrition Group and Pharmaceutical Press. Database No: 331 Page 31 of 82 Version 2.0

32 25. APPENDIX 1 - ADULT PATIENT IDENTIFIED AS AT RISK OF REFEEDING SYNDROME DEFINITION OF REFEEDING SYNDROME Refeeding syndrome (RFS) is severe fluid and electrolyte shifts associated with initiating nutritional support in malnourished patients and the metabolic implications, which occur as a result of this (Solomon and Kirby 1990). Potential consequences of RFS include: Cardiac failure, pulmonary oedema and dysrhythmias Acute circulatory fluid overload or circulatory fluid depletion Hypophosphataemia Hypokalaemia Hypomagnesaemia and occasionally hypocalcaemia Hyperglycaemia IDENTIFICATION OF PATIENTS AT RISK OF REFEEDING SYNDROME (NICE, 2006) At Risk Those who have one or more of the following:! Very little or no food intake for more than 5 days especially if already undernourished! BMI < 20kg/m 2 *! Unintentional weight loss > 5% within the last 3-6 months* High Risk Patient has one or more of the following:! BMI < 16kg/m 2 *! Unintentional weight loss > 15% within the previous 3-6 months*! Very little or no nutritional intake for > 10 days! Low levels of potassium, phosphate or magnesium prior to feeding Or patient has two or more of the following:! BMI < 18.5kg/m 2 *! Unintentional weight loss > 10% within the previous 3-6 months*! Those with very little or no intake for > 5 days! A history of alcohol or drug abuse or some drugs including insulin, antacids or diuretics and patients on chemotherapy. Extremely high risk Patient has one or more of the following:! BMI < 14kg/m 2 *! Negligible intake for > 15 days! Pre-feeding hypokalemia, hypophosphataemia or hypomagnesaemia Other considerations! Refeeding syndrome can occur in patients receiving oral, enteral or parenteral nutrition. It is less likely to occur in those fed orally (although it is possible) since starvation is usually accompanied by a reduction in appetite! There have been reported cases of re-feeding syndrome occurring in patients with chronic vomiting (hyperemesis gravidarum), prolonged diarrhoea, gastrointestinal obstruction, malabsorption diseases, and poorly controlled diabetes! Refeeding problems can also occur in overweight patients who have eaten nothing for prolonged periods. Particular caution needed in bariatric surgical patients who have developed complications resulting in a significant period of starvation.! Beware of very malnourished, dehydrated patients with renal impairment and consequently normal or high potassium and phosphate levels. The combined effect of rehydration and

33 refeeding can cause significant changes in biochemistry within hours to very low levels. (PENG, 2011) STARTING NUTRITION FOR PATIENTS AT RISK OF REFEEDING SYNDROME At risk patients Introduce feeding at a maximum 50% of total energy requirements for the first 2 days before increasing to full requirements if clinical and biochemical monitoring reveals no abnormalities. Meet full requirements for fluid, electrolytes, vitamins, minerals and trace elements from day 1 of feeding High risk and Extremely High Risk patients Start nutrition support at a maximum of 10kcal/kg/day, increasing levels slowly to meet full needs by 4-7 days. Any increase in feed should be dependent on trends in biochemistry. Using only 5kcal/kg/day in extremely high risk patients, monitoring cardiac rhythm in this group and any others who have or develop cardiac arrhythmias is recommended Provide oral, enteral or intravenous supplements (as appropriate) of potassium, phosphate and magnesium from the outset unless pre-feeding plasma levels are high (e.g. renal impairment). Pre-feeding correction of low plasma levels is unnecessary Provide immediately before and during the first 10 days of feeding: oral thiamine, vitamin B- co strong (or full dose daily intravenous vitamin B preparation if necessary) Provide a balanced multivitamin/trace element supplement once a day Please refer to Adult Refeeding guidelines (Guideline 209) on the Hywel Dda intranet for more detailed information on RFS. Database No: 331 Page 33 of 82 Version 2.0

34 26. APPENDIX 2 - NASOGASTRIC TUBE FEEDING Inserting a nasogastric feeding tube The procedure will be carried out by an appropriate healthcare professional that has received training in the procedure and has been assessed as competent. Placement should be delayed if there is insufficient experienced support available to accurately confirm placement, unless clinically urgent, and then the rationale for any decisions made is recorded in the patient s medical notes. This section includes the procedure for nasogastric tube insertion. Confirmation of Position of a nasogastric feeding tube Any trained health professional/carer/patient prior to using the tube should check that the tube is in position. Confirmation that the tube is in the correct position must be made prior to any use of the tube for flushing, medication or feed etc. This must be completed: On initial insertion Before administering each feed Before giving medication (this is not necessary when pausing a feed to give medications) At least once daily during continuous feeds Following episodes of coughing, vomiting or retching Following evidence of tube displacement (e.g. tape loose or tube appears longer) DO NOT: Use auscultation (the Whoosh test) Use litmus paper Observe the appearance of the aspirate Interpret absence of respiratory distress as an indicator of correct position Confirm position using a 60ml enteral syringe, slowly aspirate fluid from the NG tube (only a small amount is needed i.e.1ml). Place the aspirate on ph indicator stick covering all three squares, wait until there is no further colour change (about 10 seconds) and read the result using the chart on the indicator strips tube. If there is difficulty gaining aspirate please see section... below for guidance. A ph between 1 and 5.5 or below confirms position of the nasogastric tube. Recommended ph Strips and usage Tube position must be checked using ph indicator strips that have a clear definition between ph 5-6 (NPSA 2011). ph strips must be used and stored according to manufacturer s instructions. The reagent section should not be contaminated before use through handling or inappropriate storage. It is not accepted practice to put gastric aspirate onto the syringe wrapping/cover and then to run reagent strips through the aspirate. This may alter the ph reading (NPSA 2011). The lids must be kept on the containers when not in use. One box per patient sharing has a high risk of cross contamination. The box must be decontaminated once it is no longer required for a patient. ph Values A ph of between 1 and 5.5 is a reasonable indicator of gastric placement. (NPSA 2011) The ph of pulmonary fluid is normally above 6 The ph of gastric fluid is normally below 6 Database No: 331 Page 34 of 82 Version 2.0

35 If aspirate values are higher than normal, it can be hard to assess the position of the tube. The appendices of the policy will help individuals to assess and rationalise their decision making in order to make NG tube management as safe as possible. X-Ray Confirmation X-ray should not be used routinely to confirm tube position. When ordering X-rays, please specify to check NG position on the request form and attempt ph x3 of aspirate before requesting an X-ray. X-ray following insertion is indicated if: The patient is unconscious with no gag reflex (ICU). The patient has altered anatomy e.g. known large hiatus hernia, previous surgery on the upper GI tract. Testing of aspirate is inconclusive. Difficult tube insertion. Recent radiotherapy to head and neck / recent surgery to head and neck. Interpreting the XRAY X-rays must be checked by an appropriately trained clinician/advanced nurse practitioner. The result must be recorded in the patient s notes (NPSA 2011). Documentation should include: Who authorised the x-ray Who confirmed the position of the NG tube? This person must be evidenced as competent to do so Confirmation that any x-ray viewed was the most current x-ray for the correct patient The rationale for the confirmation of position of the naso-gastric tube i.e. how was placement interpreted and clear instructions as to required actions. For example: 19 th January 2011, 1030 Dr A Smith Surgical F1 X-Ray taken at 1015 today NG tube passed down midline, past level of diaphragm and deviates to left Tip seen in stomach Plan: NG tube safe to use for feeding Aspiration of gastric contents is sometimes difficult. If aspirate values are higher than normal, it can be hard to assess the position of the tube. Database No: 331 Page 35 of 82 Version 2.0

36 27. APPENDIX 3 - DECISION TREE FOR NASOGASTRIC TUBE PLACEMENT IN ADULTS Estimate NEX measurement (Place exit port of tube at tip of nose. Extend to earlobe, and then to Xiphisterum Insert fully radio opaque nasogastric tube for feeding (follow manufacturer s instructions for insertion) Confirm and document secured NEX measurement Aspirate with a 60 ml enteral syringe using gentle suction Yes Aspirate obtained? No Try the techniques suggested in Appendix 3 Test aspirate on CE marked PH indicator paper for use on human gastric aspirate. If ph <5.5 YES Ph NOT between 1 and 5.5 Aspirate obtained? NO Proceed to X-Ray: ensure reason for X-Ray documented on the request form PROCEED TO FEED OR USE TUBE Record result in notes and subsequently on bedside documentation before each feed, medication/flush YES Competent clinician (with evidence of training) to document confirmation of NG position in stomach NO DO NOT FEED OR USE TUBE Consider re-siting or call for senior advice Database No: 331 Page 36 of 82 Version 2.0

37 28. APPENDIX 4 PROCEDURE FOR NASOGASTRIC TUBE INSERTION Equipment Clinically clean surface ph indicator strips Tissues 60ml enteral syringe Gloves and apron Nasogastric feeding tube Water to flush the feeding tube Lubricating Jelly Glass of water/coloured fluid and a straw (only if the patient has a safe swallow reflex) Action Prior to the procedure, check the medical and nursing notes for complications, e.g. anatomical variations due to surgery or cancer. Assess the patient s requirements. Explain the procedure to the patient (even if the patient appears not to understand). Arrange a signal so that the patient can alert the nurse/ doctor during the procedure e.g. raising their hand. Assist the patient in a semi-upright position. Support the head in a slightly forward position. Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the other side. Alternate nostrils if replacing a tube. Wash hands, put on non-sterile gloves and a disposable apron. Unpack the tube, close the end connectors. If the tube has a guide wire, gently push it into the tube until it is fixed (see manufacturer s guidelines in packet). Check that the tube is not kinked. Place the tip of the tube (the distal opening, if the tube is weighted) at the xiphisternum and measure up to the tip of the nose and then to an ear lobe. Note the measurement on the tube. Rational These may affect the procedure and result in further complications. Patients with head injury or facial trauma may have the feeding tube passed through the mouth and down into the stomach to bypass nasal damage and cerebral oedema. The appropriate tube is inserted to meet the patient s needs and clinical condition and that the tube is acceptable and comfortable. To ensure that the patient understands and is able to give consent, also to co-operate with the procedure. Helps to alleviate fear as the patient has some control over the procedure. Assists swallowing and helps prevent tracheal placement if the swallow is compromised. Helps identify potential obstruction. Prevents nasal irritation and potential ulceration. Minimises cross infection (Anderton 1995). Prevents the tube from coiling back on itself during insertion. Ensures that the correct length of tube is placed in the stomach. Database No: 331 Page 37 of 82 Version 2.0

38 Lubricate the tube. Use a thin coating of water based jelly. If the tube is hydrophilic e.g. Corpak Corflo immerse the distal end of the tube in water to activate the lubricant. Insert the tip of the tube into the chosen nostril, advancing it, horizontally, gently along the floor of the nostril, parallel to the nasal septum, to the nasopharynx and then oropharynx. The patient may sneeze. Reassure. If resistance is met, withdraw slightly and alter the angle of insertion, otherwise try the other nostril. If the patient is able to swallow small sips should be taken at this stage. An assistant may be required to help give thickened fluids to swallow. Facilitates easy passage of the tube. Follow the natural anatomy of the nose. The swallowing action places the epiglottis over the trachea so allowing the tube to enter the oesophagus. Also the patient has something else to focus on. If liquids are contra-indicated, sometimes placing a cold spoon on the tongue may initiate a swallowing reflex. Advance the tube down the oesophagus with successive swallows until the correct measurement or mark is seen at the nostril. If the tip of the tube is in the oesophagus there is a high risk of aspiration. If too much tube is inserted it might kink in the stomach, or pass through the pylorus into the duodenum. Check the position To verify position in the stomach Fix the tube in position. Helps prevent dislodgement. NB. This should be done after successful verification of the tube s position, as it may need to be moved to obtain aspirate. If X-ray is required, the tube should be secured to the nose/cheek. Document Type of tube, size and lot number Name of person inserting the tube The cm measurement on the tube at the exit point from the nostril. The ph value (if gastric aspirate obtained) Which nostril The health care professional reading the X-ray should record the result in the patient s notes. Ease of insertion Dispose of clinical waste as per Trust policy. The guide wire must be placed in the sharps bin. Wash hands as per Health Board policy Tracking and traceability For audit and training requirements Allows the user to assess whether the tube has changed position. Allows staff to compare with previous readings Prevents the same nostril being used To identify whether the tube is safe for use. For tracking and accountability. Useful information for other healthcare professionals inserting subsequent tubes. Prevent contamination and sharps accident. Minimise risk of contamination CAUTION Never advance the tube against resistance, pull back slightly and retry. If the patient shows signs of respiratory distress i.e. coughing gasping or cyanosis, the tube may have entered the trachea. Pull the tube back or remove to allow time to recover. If respiratory distress is prolonged or worsens, seek medical assistance. Top tips Hold the tube straight rather than coiled in your hand. Database No: 331 Page 38 of 82 Version 2.0

39 If the patient has a swallowing difficulty, altered consciousness or inability to cooperate: a) Rotate the tube in your hand so that the tip points slightly upwards. This will position the tip in the correct position on the nasopharyngeal wall. b) Tip the patient s chin towards the chest. c) Advance the tube through the nostril and into the nasopharynx until resistance is felt (usually 12-14cm marking on tube), there may be an involuntary swallow reflex stimulated by the tube. Advance the tube with the swallow. If no reflex, advance the tube slowly or the tube will back up into the mouth. Gentle pressure will allow the tube to pass into the oesophagus. If after 3 attempts NG insertion has failed or pulled out by the patient on three consecutive occasions, escalate as soon as possible to an experienced practitioner (senior nurse/clinician/nurse specialist). NB: A ph of between 1 and 5.5 is reliable confirmation that the tube is not in the lung, however it does not confirm gastric placement as there is a small chance the tube tip may sit in the oesophagus where it carries a higher risk of aspiration. If this is any concern the patient should be sent for X-Ray. Database No: 331 Page 39 of 82 Version 2.0

40 29. APPENDIX 5 CORFLO FINE BORE FEEDING TUBES: PLACEMENT GUIDELINE

41 30. APPENDIX 6 - NASOGASTRIC TUBE POSITION CONFIRMATION RECORD This bedside checklist should be completed for all patients requiring nasogastric tube placement, on insertion and on all subsequent insertions, before administration of artificial nutrition or medication via the nasogastric tube. Date and time of insertion/reinsertion NEX Measurement External length once secured Nostril used on insertion/reinsertion -L/R Aspirate obtain Y/N ph of aspirate (if obtained) x-ray required Y/N Inserted by: X-ray interpretation (if applicable) Date and time of x-ray interpretation Is this the most current x-ray? Y/N Is the x-ray for the correct patient? Y/N x-ray results E.g. NG has passed down midline past level of diaphragm and Deviates to left. It is safe to feed via The NGT. X-ray interpreted by:

42 31. APPENDIX 7 - NASOGASTRIC FEEDING BEDSIDE CHART The position of the nasogastric tube should be checked: -Following initial insertion Addressograph -Before administering each feed. -Before giving medications. -Any new or unexplained respiratory Symptoms or if oxygen saturations decrease. -At least once daily during continuous feeds. -Following episodes of vomiting, Retching or coughing spasms. -When there is suggestion of tube displacement. If you are not able to confirm that the tube is in the stomach it should be removed and reinserted. This should be documented on the nasogastric tube placement bedside checklist. DATE AND TIME ph Result ACTION TAKEN Tube length Signatory DATE AND TIME ph result ACTION TAKEN TUBE LENGTH Signatory Database No: 331 Page 42 of 82 Version 2.0

43 NASAOGASTRIC FEEDING BEDSIDE CHART DATE AND TIME ph Result ACTION TAKEN Tube length Signatory DATE AND TIME ph result ACTION TAKEN TUBE LENGTH Signatory DATE AND TIME ph Result ACTION TAKEN Tube length Signatory Database No: 331 Page 43 of 82 Version 2.0

44 32. APPENDIX 8 - NASOGASTRIC FEEDING DISCHARGE RISK ASSESSMENT AND PREPARATION To be completed for all adult patients being considered for discharge with a NG feeding tube into the community. This assessment record must be completed to fulfil NPSA recommendations which state; A full multidisciplinary supported risk assessment is made and documented before a patient with a nasogastric tube is discharged from acute care to the community (NPSA/2011/PSA002). Process: This assessment must be completed in the discharging hospital by a named healthcare professional. The community healthcare professional accepting care of the patient must be identified by name. Both named healthcare professionals must agree the discharge arrangements before discharge. Either named healthcare professionals can delay or refuse the discharge based on the results of this assessment. Named Healthcare Professionals (HCP) responsible for completion of assessment. HCP from discharging hospital Designation Telephone number HCP from community team Designation Telephone number Consider: Would an MDT meeting facilitate this process? If yes, include everyone involved in care delivery. Example: The person being discharged, Nutricia Home enteral feeding company nurse, Next Of Kin, Home Enteral Feed Dietitian, ward Dietitian, Nursing Home staff, Nutrition Specialist Nurse, Social Worker, Care agency, District Nurse, Speech and Language Therapist, Doctor, GP. (Document details of MDT meeting in medical notes.) Patient demographics Name Dob age NHS number Discharge address Patient number Telephone Mobile number number Expected date of discharge Communication Language spoken Interpreter required YES / NO (circle) details if yes. Information about how patient communicates (hearing, sight, speech, verbal and non-verbal) Database No: 331 Page 44 of 82 Version 2.0

45 Medical history, indication and goals Diagnosis this admission Relevant PMH HYWEL DDA UNIVERSITY HEALTH BOARD Reason for nasogastric tube feeding Goals for NG feeding Discharging medical team Consultant Consent (Delete the option that does not apply by crossing it through and initialling) This patient will be providing their own consent for interventions. (Delete as appropriate, leaving one statement) 1. This patient will be able to take responsibility for overall NG care and any related decisions as required. 2. This patient will be able to take responsibility for NG related decisions but will require assistance to deliver the care. 3. This patient has consented to having an NG tube but wants to delegate responsibility for care to carers. This patient lacked capacity to make decisions about their NG tube at the time of discharge. A decision has been made that using an NG tube to meet their nutrition needs is in their best interests. If the patient s level of capacity changes or if the clinical condition or indication changes, then the healthcare practitioner involved will discuss the situation with the GP and take all appropriate action as necessary. NG tube and insertion procedure details NG tube details: Manufacturer Merck Type of NG Corflo Size 8fr, 96cm long Date inserted This tube is radio-opaque with and without a guide wire and has visible length markings. It fits a female luer syringe and a catheter tip syringe. NEX measurement Date of first planned change Name of person who will change the NG tube every 2-3 months (planned) Telephone number Procedure for urgent / unplanned re-insertions or if ph above 5.5 This NG tube is easy / difficult to insert (circle) If difficult, state how it is managed. Database No: 331 Page 45 of 82 Version 2.0

46 If ph more than 5.5 once, how was this managed / resolved? Cross out the statement that does NOT apply. Correct statement to be signed by person completing this form. It has been possible to confirm the position of the NG tube without x-ray for 7 days. It is expected that this will also be possible in the community. It has been difficult to confirm the position of the NG tube without x-ray. It is expected that the patient will continue to need occasional / regular x-rays in the community. The patient and community team are aware of this. Signed Date Signed Date Cross out the statement that does NOT apply. Correct statement to be signed by person completing this form. This NG tube CAN be re-inserted in the community without any special This NG tube can NOT be re-inserted without special equipment or expertise. All tube changes must happen in the discharging hospital equipment by a competent practitioner. Signed Signed Date Date Position testing history: Last 7 ph readings (complete the week before discharge) Date ph reading Date ph reading Date Time Venue Name of reviewer Designation Telephone number This patient s NG feeding plan will be reviewed by the above named person. They ll liaise with the appropriate health care professionals involved in the care and make the decision with the lead clinician. Training and sign off The following people are taking responsibility for each aspect of care: The named person may not deliver all the care but will take the necessary steps to ensure that the members of the community team delivering that aspect of care are competent to do so, Database No: 331 Page 46 of 82 Version 2.0

47 Aspect of care Named person Designation and contact details NG position checks Administering medication Administering feeds Nasal / oral care Other (state) Database No: 331 Page 47 of 82 Version 2.0

48 33. APPENDIX 9 NASOGASTRIC TUBE FEEDING STARTER REGIME NASOGASTIC TUBE FEEDING STARTER REGIME Patient name: NHS number: Hospital number: DOB: (Patient addressograph) If you have concerns that a patient is at risk of Refeeding Syndrome please refer to the Adult Refeeding Syndrome Policy Number 209 and do not use this regime. Day 1 Date: Day 2 and Onwards Date: Feed type Check feed label Nutrison Nutrison Volume (mls) Rate (mls/hr) Feeding period (Hrs) Rest period (Hrs) Total feed volume (mls) Nutrison Additional information Do not hang feed packs for longer than 24hours or decanted feed for longer than 4hours discard any unused feed. Change and dispose of giving sets every 24hours. Label each giving set with time and date of set up. Only use Purple Enteral Single use syringes. Please see overleaf for nutritional content of feeding regime.! Ensure patient is positioned at a minimum of 45 throughout feeding and for at least 30 minutes after feed has stopped to minimize the risk of aspiration Database No: 331 Page 48 of 82 Version 2.0

49 FLUIDS: If patient is on IV fluids they need to be reviewed by the doctor to prevent fluid overload Flushes with feeds: Flush the tube with 50mls of sterile water before and after each bag of feed Flushes with medication: Flush the tube with 30mls of sterile water at the beginning and end of the medication round, and 10mls in between each medication given. NUTRITIONAL CONTENT OF FEED OVER 24 HOURS: DATE ENERGY PROTEIN SODIUM POTASSIUM (kcals) (g) (mmol) (mmol) DAY DAY ONWARDS Database No: 331 Page 49 of 82 Version 2.0

50 34. APPENDIX 10 PRE GASTROSTOMY ASSESSMENT FORM GASTROSTOMY FEEDING CAN RESULT IN COMPLICATIONS INCLUDING PERITIONITIS AND OCCASSIONALLY DEATH (2 IN 100 CASES). Pt ID Label Addressograph Date of referral: Referred by: Ward / GP Surgery: CVA < 2/ weeks > 4/52 Admission date and Reason Reason for Gastrostomy referral: NG tube attempts If NG tube not attempted, why not Allergies: PMH: (If 3 consider MITT / securing NG prior to making a Gastrostomy referral) Social Circumstances Who will support the patient at home to manage their gastrostomy feed? Is a case conference required? YES NO Gastrostomy feeding considered for long term >6 weeks rather than short term Does the patient have any Respiratory problems? If Respiratory Problems Identified - Recent FCV Result:- Can the patient open their jaw properly? Can the patient lie flat? Does the patient require NIV to lie flat? Warfarin: (INR needs to be 1.5 for PEG) Clopidogrel: (Stop 1 week prior to PEG) Pre Gastrostomy bloods: FBC, U&Es and clotting screen (taken within past week) On antibiotics: (If No: stat dose Augmentin 1.2g 1 hr before or Vancomycin 1g infusion 2hrs before) Contraindications to PEG procedure Ascites: Active Infection (e.g. pneumonia): (if yes wait for acute episode to settle) Past history of abdominal surgery: (if yes please specify) Capacity and Consent YES NO Does the patient have the capacity to make this decision regarding the procedure Procedure and rationale explained Complications /risks explained Patient in agreement / Next of kin consulted Literature provided (EIDO information leaflet) Database No: 331 Page 50 of 82 Version 2.0

51 Note: Consider the following if approval is given for Gastrostomy The patient has capacity: Consent Form 1 will need to be completed. If there is doubt about the patient s capacity: complete an assessment of capacity (using Hywel Dda University Health Board Assessment of Capacity and Best Interests checklist). If the patient is shown to lack capacity, ensure essential checks are made and make a determination of their best interests, recording the steps and outcome. Consent Form 4 should then be completed. Early MDT is advised to support decision making. MDT Assessments Professional Date Recommendations Sign Dietitian: SLT: Others: Nursing Assessment: Temp: Pulse:. BP: Resp:.. SATS: PSPS:. Date taken: OUTCOME GP informed (fax): Send original to Endoscopy Photocopy of this form filed in medical notes Case conference indicated? Further advice required from Medical/surgical team? Gastrostomy agreed? Name: Designation: Bleep No: Database No: 331 Page 51 of 82 Version 2.0

52 35. APPENDIX 11 GASTROSTOMY FLOW CHART On return to ward for first 72 hours Vital signs to be recorded including monitoring stoma site Half hourly for first hour, then hourly for four hours Then four hourly or as the patient s condition requires To give analgesia as prescribed Any concerns with Gastrostomy tube or patient condition NO YES After 4 hours commence on sterile water via the PEG tube as per Dietitian regime Observe for any abdominal pain, respiratory problems, vomiting or distension If no complications during administration then follow Dietitians feed regime Observe for any abdominal pain, respiratory problems vomiting or distension If there is any o pain on feeding o Prolonged or severe pain post procedure o Fresh bleeding o External leakage of gastric contents STOP feed / medication delivery immediately Record MEWS or Track and Trigger score and communicate using SBAR tool to obtain Middle grade /Senior medical advice urgently and consider: Surgical review Contrast study or CT scan Gastrostomy reviewed and safe to use Record MEWS score and communicate using SBAR tool to obtain Middle grade /senior medical advice urgently and consider: Surgical review Database No: 331 Page 52 of 82 Version 2.0 Contrast study or CT scan

53 36. APPENDIX 12 - PROCEDURE FOR CHECKING AND REPLACING THE WATER IN A BALLOON RETAINED GASTROSTOMY FEEDING TUBE/LOW PROFILE FEEDING DEVICE EQUIPMENT 2X 10ml Syringe The water in a Balloon Retained Gastrostomy needs to be checked and replaced on a weekly basis. 1. Wash hands thoroughly 2. Disconnect and flush the tube (if feeding) 3. Pre fill a 10ml luer slip syringe with freshly drawn tap water (not sterile) 4. Hold the tube in place during the procedure ensuring that it remains in the stomach or alternatively, loosely tape the tube to the skin. (as long as no known allergies to tape) 5. Attach an empty 10ml luer slip syringe onto the inflation valve (balloon port) of the feeding tube. 6. Draw back on the plunger until no more fluid comes out of the internal balloon. It may be necessary to do this twice to ensure all the fluid has been removed 7. Compare the volume of fluid withdrawn with the recommended volume advised for inflation, It is normal for a small amount of water to have evaporated from the balloon. 8. If the volume of water withdrawn is the same as the recommended volume, re-inflate the balloon with the water in the syringe. 9. If the volume of water withdrawn is 1ml or less than the recommended volume re-inflate the balloon with a new syringe and the correct volume of freshly drawn tap water. 10. If you have concerns regarding the integrity of the balloon please contact CNS Nutrition for further advice. Database No: 331 Page 53 of 82 Version 2.0

54 37. APPENDIX 13 GOOD PRACTICE GUIDELINES HYWEL DDA UNIVERSITY HEALTH BOARD Database No: 331 Page 54 of 82 Version 2.0

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60 38. APPENDIX 14 GASTROSTOMY FEEDING STARTER REGIMEN If you have concerns that a patient is at risk of Refeeding Syndrome please refer to the Adult Refeeding Syndrome Policy Number 209 and do not use this regime. Patient name: NHS number: Hospital number: DOB: (Patient addressograph) INITIAL REST PERIOD: Following insertion of a gastrostomy all patients should be rested for 4 hours before commencing sterile water, unless advised differently by the medical/surgical team. Refer to gastrostomy feeding flowchart for the first 72hrs post gastrostomy insertion.! Ensure patient is positioned at minimum of 45 throughout feeding and for at least 30 minutes after feed has stopped to minimise the risk of aspiration! DATE STAGE DAY 1 DATE: FEED TYPE CHECK FEED LABEL STERILE WATER NUTRISON VOLUME (MLS) RATE (MLS/HR) FEEDING PERIOD (HRS 4 10 REST PERIOD (HRS) 0 0 TOTAL FEED VOLUME (MLS) 950mls ADDITIONAL INFORMATION Do not hang feed packs for longer than 24hours or decanted feed for longer than 4hours discard any unused feed. DAY 2 DATE: DAY 3 DATE: NUTRISON NUTRISON NUTRISON Change and dispose of giving sets every 24hours. Label each giving set with time and date of set up. Only use Purple Enteral Single use syringes. FLUIDS: If patient is on IV fluids they need to be reviewed by the doctor to prevent fluid overload Flushes with feeds: Flush the tube with 50mls of sterile water before, during and after each bag of feed Flushes with medication: Database No: 331 Page 60 of 82 Version 2.0

61 Flush the tube with 30mls of sterile water at the beginning and end of the medication round, and 10mls in between each medication given. NUTRITIONAL CONTENT OF FEED OVER 24 HOURS: DATE ENERGY PROTEIN SODIUM POTASSIUM (kcals) (g) (mmol) (mmol) DAY DAY Database No: 331 Page 61 of 82 Version 2.0

62 39.. APPENDIX 15 JEJUNOSTOMY / NASOJEJUNAL TUBE FEEDING REGIME IF YOU HAVE CONCERNS THAT A PATIENT IS AT RISK OF REFEEDING SYNDROME PLEASE REFER TO: Syndrome Policy Number 209 and do not use this regime. Patient name: NHS number: Hospital number: DOB: (Patient addressograph)! Ensure patient is positioned at a minimum of 45 throughout feeding and for at least 30 minutes after feed has stopped to minimise the risk of aspiration! FLUID: If patient is on IV fluids they need to be reviewed by the doctor to prevent fluid overload DATE / STAGE FEED TYPE! Check Feed Label VOLUME (mls) RATE (mls / hr) FEEDING PERIOD (hrs) REST PERIOD (hrs) Total feed volume (mls) ADDITIONAL INFORMATION DAY 1 Date: STERILE WATER NUTRISON NUTRISON NUTRISON Do not hang feed packs for longer than 24hours or decanted feed for longer than 4hours - discard any unused feed Change and dispose of giving sets every 24hours. Label each giving set with time and date of set up DAY 2 Date: DAY 3 Date: NUTRISON NUTRISON Flushes with feeds Flush the tube with 50mls of water before, during and after each bag of feed. Only use Purple Enteral single use syringes Please see overleaf for nutritional content of feeding regime. Please be aware that aspirate cannot be obtained from a jejunal tube.. Flushes with medicationsflush the tube with 30mls of water at the beginning and end of the medication round, and 10mls in between each medication given. Database No: 331 Page 62 of 82 Version 2.0

63 NUTRITIONAL CONTENT OF FEED OVER 24 HOURS: DATE ENERGY (kcals) PROTEIN (g) SODIUM (mmol) POTASSIUM (mmol) DAY DAY DAY Database No: 331 Page 63 of 82 Version 2.0

64 40. APPENDIX 16 - ADMINISTERING ENTERAL FEED Bolus feeding Equipment Required for Bolus feeding Sterile Water for flushing. * 60ml single use enteral syringe * Clean disposable gloves and plastic apron How to set up a Bolus feed Position the patient as above Assemble equipment. Check that the feeding regimen is up to date and includes the make and type of feed, the volume and approximate timing of each bolus feed and the volume of water required for flushing before and after each feed. If not please contact the Dietitian. Wash hands thoroughly with soap and water and dry them. Put on a disposable plastic apron and pair of disposable gloves (hospital only unless otherwise instructed) Check that the feed is in date, is the correct feed and is not curdled. Make sure the feed is at room temperature. For each nasogastric feed: check that the position of the tube has not moved and confirm the correct position in the stomach following the guidance in Appendix 4. Using a 60ml single use enteral syringe, flush the feeding tube with water as per feeding regime. Using the same syringe, draw up the feed from the feed pack using a bolus adaptor, or decanted feed, or pour from the bottled feed and attach to the feeding tube Hold the syringe at a comfortable height above the feeding tube and allow to flow by gravity. Do not rush the feed. Keep filling the syringe until the correct amount has been administered. If the feed is going too slowly, raise the syringe higher, or if there are no problems with feed tolerance, put the plunger back into the syringe and gently push the feed into the feeding tube. If the feed is going too quickly, lower the syringe. Flush with water (as instructed on feeding regimen) after the feed has finished to clear the feeding tube. Replace the cap on the tube and close the clamp (if the tube has one) Discard the syringe once used. Place the remaining feed, labelled with date and time, in the fridge. Remove 30 minutes before the next feed. Discard any feed left over if not used within 24 hours Pump Feeding Equipment required for Pump feeding Sterile Water for flushing * 60ml single use enteral/oral syringes * Clean disposable gloves and plastic apron (hospital only) Feed Infinity feeding pump Drip stand Go Bag / Go frame (for mobile patients) Database No: 331 Page 64 of 82 Version 2.0

65 Giving Set Extension set if using a Low profile feeding device. How to set up a pump feed Position the patient as above Assemble equipment. Refer to patient feeding regimen. Wash hands thoroughly with soap and water and dry them, following Health Board Infection Control guidance. Put on a clean plastic apron and pair of disposable gloves. Check that the feed is in date, is the correct feed and is not curdled. Make sure the feed is at room temperature before giving the feed. For each nasogastric feed: check that the position of the tube has not moved and confirm the correct position in the stomach following the guidance in section 3.0. Using a 60ml single use enteral/oral syringe, flush the feeding tube with water (as per feeding regimen or refer to section 11.7 for guidance) Prepare and hang the feed as instructed by the health care professional. Flush with water (as instructed above) after the feed has finished to clear the feeding tube. Replace the cap on the tube and close the clamp (if feeding tube has one) Discard the syringe once used. If there is a break/interruption in feeding refer to section below. Clean the feeding pump daily with detergent, water and a clean damp cloth. This will avoid any spillages of feed drying and affecting how the pump operates. Enteral Feeding EBME Procedure The following procedure outlines the Enteral Feeding Pump responsibilities of the EBME Department and is applicable across Prince Philip hospital, Glangwilli, Withybush and Bronglais Hospital and all Community Hospitals, Procedure for Acceptance Test: Feeding pump Customer Service Representative to arrange delivery of all new feeding pumps, for acute and community hospital ward use, directly to the relevant EBME Dept/Equipment Library at the four acute hospital sites. EBME Dept to acceptance test all new pumps for use on acute and community hospital sites: o Pump serial numbers to be recorded on stand-alone EBME/Equipment Library feeding pump inventory. o Check that performance and electrical safety test results documentation (provided by feeding pump company) is enclosed with the feeding pump and filed for future reference. o o Electrical safety test to be performed if required. EBME/Equipment Library feeding pump inventory labels and tested labels to be attached to each pump. Feeding pump Customer Service Representative to attend acute hospital sites at agreed date confirmed with EBME and Dietetics Departments. Feeding pump Customer Service Representative having performed 6 monthly audits of pumps across each locality within Hywel Dda University Health Board will have a Database No: 331 Page 65 of 82 Version 2.0

66 comprehensive list of all existing pumps and the numbers of pumps required within each locality for each ward (agreed by Dietetics Dept). After acceptance testing has been completed by the EBME Departments, the Customer Service Representative will label pumps with ward names and For Hospital Use Only unless informed otherwise by EBME/Dietetics Depts. In consultation with EBME Dept/Equipment Library, the Customer Service Representative is to distribute the new feeding pumps to wards and withdraw existing feeding pumps from use. Note: pumps to be distributed to wards on both acute and community hospital sites. Customer Service Representative to allocate approximately 2 or 3 spare feeding pumps to EBME Department to be used as replacements in the event of any feeding pumps becoming faulty. Representative to draft list indicating the wards that the new feeding pumps have been allocated to. This is to ensure the feeding pump information is captured prior to 6 monthly audit of feeding pumps. EBME Dept/Equipment Library to add feeding pump locations to EBME Dept/Equipment Library stand-alone feeding pump inventory. Procedure for Pump Servicing: All feeding pumps to be serviced by the feeding pump company in accordance with the feeding pump company specifications and recommendations. Feeding pump Customer Service Representative to inform EBME Dept/Equipment Library and Dietetics Dept at least 2 months in advance when servicing of pumps is due. A plan for servicing of feeding pumps at Acute and Community hospitals across the health board should be communicated to the Dietetics and EBME Departments via the contract review meeting. Procedure for Faulty Pumps: If during clinical use a feeding pump is suspected of being faulty it must be removed from service immediately. Nursing staff to complete Equipment Decontamination Certificate giving details of suspected fault. Contact the Infection Control Team for further information regarding Equipment Decontamination Certificates. The faulty pump must be sent directly to the EBME Dept/Equipment Library with the completed Equipment Decontamination Certificate enclosed. If required, EBME Dept/Equipment Library to provide temporary replacement feeding pump, if available. If available, EBME Dept/Equipment Library to use pre-paid envelopes provided by feeding pump company to return faulty pump. Database No: 331 Page 66 of 82 Version 2.0

67 EBME Dept/Equipment Library to /telephone Customer Service Representative with serial number of faulty pump being returned. Customer Service Representative to order and arrange delivery of replacement new feeding pump to the relevant EBME Dept/Equipment Library. EBME to acceptance test new feeding pump. Stand-alone EBME/Equipment Library feeding pump inventory to be updated with details of new feeding pump. EBME Dept/Equipment Library to distribute the new feeding pump to the appropriate ward. Hywel Dda Community: No EBME involvement with Community feeding pumps. Community feeding pumps to be sent directly to patient s home address. Company feeding pump nurse or Hywel Dda Community Nurse to visit patient s home and complete the Home Enteral Feed Service Acceptance Report form. Completed Home Enteral Feed Service Acceptance Report form to be returned to appropriate Hywel Dda Dietetics Dept. Database No: 331 Page 67 of 82 Version 2.0

68 41. APPENDIX 17 - RISK ASSESSMENT OF PATIENTS SUSCEPTIBILITY TO INFECTION 1. Is the patient at a high risk of Infection? 2. Patients in the following circumstances are at a high risk of infection. Patients fed by a route that bypasses the stomach e.g. Jejunostomy. Patients prescribed Cytotoxics. Patients who are currently being treated for malignant disease with chemotherapy or generalised radiotherapy and are neutropenic. All patients who have received an organ transplant and are currently on immunosuppressive treatment. Patients who within the previous 6 months have received a bone marrow transplant. Patients who receive a daily dose of 40mg prednisolone for more than one week. (Long course corticosteroids) Patients with evidence of impaired cell mediated immunity for example:- o Infection with current symptoms o Severe combined Immune Deficiency Syndrome o Di George Syndrome o Combined Immunodeficiency Syndrome (NICE Clinical Guideline 139: 2012) If the patient is considered at high risk of infection :- A New enteral syringe should be used each time the tube is flushed or the patient receives medication. Cool Boiled or sterile water should be used for flushing the feeding tube and for providing additional fluid if required. Non sterile disposable gloves and disposable apron should be worn during any manipulation of the feeding system. Particular attention should be paid to hand-hygeine. Hands should be washed thoroughly with soap and water and dried before donning and removal of gloves and apron. N.B In some situations patients residing in the community may receive their water from an outside well. If there is any concern regarding the quality of the water cool boiled or sterile water should be advised. Database No: 331 Page 68 of 82 Version 2.0

69 42. APPENDIX 18 ORAL HYGEINE Checklist for signs of poor oral care Plaque and debris (plaque and hard calculus can form quickly in people who are tube fed) Development of infections in the mouth such as ulcers Tooth decay Loose teeth Inflamed and bleeding gums. Pain and discomfort in the mouth Altered taste Dry mouth Fissures on the tongue Inability to wear dentures Bad breath Perform oral care, in accordance with the care plan, for at least 2 minutes, frequently throughout the day. Record all mouth care interventions. When a patient becomes critically ill, enters a high dependency unit or is intubated, their oral care plan should be re-assessed. Tooth brushing When providing mouth care for someone explain what you are going to be doing. Guide the person s hand to touch their face before entering the mouth. Make sure the person is relaxed. If the patient is in a sitting position use a rolled towel at the nape of the neck and position feet flat on the floor. The head and neck should be well supported and the head slightly tilted forward to assist drainage. Stand behind and slightly to the side and allow any toothpaste or saliva to run out of the mouth and onto a towel. If the patient is lying flat the head should be turned to one side to assist drainage. Use a smear of non foaming fluoride toothpaste pressed into a dry brush. A high fluoride toothpaste, (e.g. Duraphat), can be used if acid reflux persists after optimisation of acid suppression therapy (i.e H 2 antagonists, PPIs and raft forming alginates). Check for any residue toothpaste left behind and remove with a slightly damp toothbrush. Spit out, do not rinse High risk dysphagic patients can be helped with suction. Do not use a mouthwash Brush teeth and gums. Wipe the tongue and oral tissues with a soft toothbrush Never place your fingers directly onto the biting surfaces of another person s teeth. Clean the gums regardless of the presence or absence of teeth. Dentures All dentures and partial dentures should be removed and thoroughly cleaned at least once a day. Database No: 331 Page 69 of 82 Version 2.0

70 Lips HYWEL DDA UNIVERSITY HEALTH BOARD Use a toothbrush/ denture brush and soap/ denture cream; avoid toothpaste as it is too abrasive. Scrub dentures over a basin of water, to prevent breakage if dropped, and rinse. Always remove dentures at night, clean and soak in cold water. Apply E45 cream to the lips (check for lanolin intolerance). The use of petroleum jelly is not advised as this is not absorbed and debris can collect on the lips and become an aspiration risk. An alternative to be used is a water based gel. Dry Mouth Xerostomia / dry mouth may result from a number of factors: Medication side effects Mouth breathing Oral suctioning Being on oxygen Being tube fed Artificial saliva sprays and gels can be used to maintain a moist mouth. People who are not fed orally can develop an aversion or sensory defensiveness to having their teeth and gums brushed. This can be avoided with very gradually increased amounts of regular oral care with a soft brush and a suitable tasteless toothpaste e.g. Oranurs Infections Staphylococcal Mucositis is a very distressing infection of the oral soft tissue which may occur in patients with nasogastric or gastrostomy feeding tubes. If Candidiasis is present in the mouth Send a swab for culture to identify infection and use an appropriate topical anti fungal via a syringe or soft toothbrush. It is a preventable condition and the key to prevention is regular, intensive oral hygiene 4 times a day. Dry crusted lips, tongue and soft tissue which may bleed This condition presents a serious aspiration risk. In order to gain access into the mouth, dry cracked lips should be cleaned and moistened with E45 cream or a water based gel The mucus crust inside the mouth should be removed with moistened gauze. If this results in bleeding, cleaning should be completed by wiping with gauze soaked in chlorehexidine (Corsodyl 0.2%) In selected cases, flucloxacillin may be prescribed Angular Chelitis (Found at the corners of the mouth) Treat with an appropriate antu fungal cream applied topically 4 times per day. Ulceration Any ulcers present on lips/mouth should be identified by a doctor and appropriate treatment plan created. Apply Chlorhexidine Gluconate 0.2% gel twice daily Send swab for culture to identify infection if persistent. Database No: 331 Page 70 of 82 Version 2.0

71 If herpetic lip ulcer is present apply Aciclovir 5% cream topically 5 times a day. Start the treatment as soon as possible. If the ulceration is foul smelling, METRONIDAZOLE 400mgs 3 times a day orally. Database No: 331 Page 71 of 82 Version 2.0

72 43. APPENDIX 19 - STEP BY STEP GUIDE TO ADMINISTERING DRUGS VIA ENTERAL FEEDING TUBES (BAPEN 2004) Can the patient still take medication orally? Do not add medication directly to the feed Seek further advice for fluid restricted or paediatric patients, as flushing volumes may need to be reduced. Review all medication. Is it all really necessary? (AWMSG Polypharmacy 2014) Seek advice from Pharmacy on which medicines can be crushed. Wash hands and wear gloves STOP THE FEED Flush the Tube with at least 20-30mls of water or STOP as instructed by dietitian using a 60ml single use enteral syringe. For each naso-gastric feed: check that the position of the tube has not moved and confirm the correct position in the stomach following the guidance in Appendix 4. Do you need to allow a break before administering the medicines? Assemble medication and equipment needed e.g. syringes, pestle and mortar. Prepare each drug separately. Never mix drugs unless instructed by a pharmacist. Soluble Tablets Dissolve in 10-15ml of water. Administer down tube Liquids Shake well. Viscous (thick) liquids dilute with an equal amount of water immediately before administration DO NOT CRUSH:- Enteric Coated (EC) medicines Modified release (MR, SR, LA, XL medicines) Hormone preparations Cytotoxics Seek advice from pharmacy. Tablets Crush uncoated and sugar coated tablets using a pestle and mortar or suitable device Capsules Open capsules and tip powder into medicine pot. Mix with 10-15ml of water. Administer down the tube. If more than one medicine is to be administered - flush between drugs with at least 10ml of water to ensure that the drug is cleared from the tube. Database No: 331 Page 72 of 82 Version 2.0

73 Rinse tablet crusher/containers and/ or draw up water into the syringe used and flush this down tube. This ensures that the whole dose is given. Flush tube with at least 20-30ml of water following administration of last drug using a 60ml single use enteral syringe Do you need to allow a break before restarting the feed? Refer to Table below for further guidance RE-START THE FEED Document medication given on drug chart and record total volume of fluid administered. Discard enteral syringe. For further advice contact Pharmacy Department or Hywel Dda Medicines Information Centre ( Adapted from British Association for Parenteral and Enteral Nutrition. Registered charity and the British Pharmaceutical Nutrition Group Hywel Dda University Health Board. Enteral Feeding Policy (2014) Database No: 331 Page 73 of 82 Version 2.0

74 44. APPENDIX 20 DRUGS WHICH REQUIRE ENTERAL FEED TO BE STOPPED PRIOR TO ADMINISTRATION. Please note: This list is for guidance only and may be subject to review. Always check the most recent BNF or consult pharmacy for guidance. This list is not exhaustive. Feed should be stopped for 1-2 hours before and 1-2 hours after administration of the following drugs. Drug Feed Interactions Therapeutic Class Drug Brand Names Antibiotic Ciprofloxacin Doxycycline Flucloxacillin Isoniazid Levofloxacin Ofloxacin Phenoxymethyl Penicillin/Penicillin V Rifampicin Anti Epileptic Phenytoin * Epanutin Antacid Carbamazepine * Any antacid containing aluminium, magnesium or calcium Tegretol Gaviscon Maalox Bronchodilator Theophylline Nuelin Slo-Phyllin Uniphyllin Drugs Affecting bone metabolism Strontium Ranelate Protelos * Blood levels may be affected by feeds and should be checked regularly (Consult BNF or pharmacy) * Database No: 331 Page 74 of 82 Version 2.0

75 45. APPENDIX 21 THE MANAGEMENT OF BLOCKED FEEDING TUBES In order to prevent a feeding tube from blocking it is essential to flush the tube adequately after feeding or administering medication as advised by the dietitian/clinical Nutrition Specialist nurse (CNS) If a feeding tube occlusion should occur follow the procedure as outlined below. If the occlusion does not clear seek advice from the CNS Nutrition. Never insert anything into the tube to remove the blockage e.g. guide-wire, as this may perforate the tube. Never use acidic solutions e.g. pineapple juice / cola as these can degrade the material of the feeding tube and can also cause the feed to curdle creating further problems. Equipment Required for Procedure Apron Disposable gloves 1 Clean dry equipment tray Disposable 60ml enteral syringe for flushing the feeding tube Solution to unblock the tube; warm water, soda water (available from catering) or sodium bicarbonate 8.4% (1 teaspoon of sodium bicarbonate in 100mls warm water) Sterile water to flush the tube. Eye protection. Procedure to unblock a feeding tube (This is not applicable to NG tubes) Procedure Explain procedure to patient Wash hands with liquid soap and water, rinse and dry thoroughly. Put on disposable apron and gloves. Put on eye protection and attempt to unblock the tube using warm water. If unsuccessful try 10-15ml of soda water or alternatively sodium bicarbonate solution (8.4%) Using a 50ml enteral syringe draw up 10-15ml of chosen solution and attach the syringe to the enteral feeding tube. Draw back on the syringe to create a vacuum. Tilt the syringe so that the solution is at the nozzle end of the syringe, keeping the suction on the syringe. Release the grip on the syringe plunger and the solution will be sucked down the tube Repeat if necessary to remove the solution further down the tube. Cap/clamp tube and leave for 30minutes Flush tube with 30-50mls of sterile water If the feeding tube is clear, confirm tube placement and re-commence feeding If blockage persists contact medical/surgical team or CNS Nutrition Rational Ensure patient consent and co-operation Minimise Infection Eye protection should be worn where there is a risk of bodily fluid or flushing solution splashing into the eyes. 60ml syringe used to reduce barrel pressure in the tube and prevent tube perforation. To ensure any feed debris in the feeding tube is cleared. Database No: 331 Page 75 of 82 Version 2.0

76 46. APPENDIX 22 NUTRICIA GUIDE TO MANAGING STOMA COMPLICATIONS Database No: 331 Page 76 of 82 Version 2.0