Best Practice Guidelines BPG 2 Enteral Feeding

Transcription

1 Best Practice Guidelines BPG 2 Enteral Feeding Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 1

2 DOCUMENT STATUS: Approved DATE ISSUED: 10 th November 2015 DATE TO BE REVIEWED: 10 th November 2017 AMENDMENT HISTORY VERSION DATE AMENDMENT HISTORY V1 March 2014 Developed - Susan Merrick Team Leader Nutrition Support RWT V2 October 2015 Reviewed Susan Merrick Team Leader Nutrition Support RWT REVIEWERS This document has been reviewed by: NAME TITLE/RESPONSIBILITY DATE VERSION Sue Merrick Dietician Team Leader 5 th October 2015 V2 Justine Hewitt QNA 28 th October 2015 V2 APPROVALS This document has been approved by: GROUP/COMMITTEE DATE VERSION Practice Development Group 7 th Jan 2014 V1 Quality & Safety Committee 14 th Jan 2014 V2 Final Quality & Safety Committee 10 th November 2015 V2 Final Reviewed DISTRIBUTION This document has been distributed to: Distributed To: Distributed by/when Paper or Electronic Care and Nursing Care Home Managers Paper Home Staff and Development events in Managers April, July, Oct 2015 Document Location Resource Folders Care Home Managers 26 th November 2015 Electronic/Paper WCCG Intranet DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. RELATED DOCUMENTS These documents will provide additional information: Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 2

3 REF NUMBER DOCUMENT REFERENCE NUMBER TITLE 1. BPG 1 Pressure Ulcer Prevention & Management Final 2. BPG 3 Prevention and Management of Malnutrition Final 3. BPG 4 Infection Prevention Final 4. BPG 9 Medicines Management Final 5. BPG 10 Care Risk Assessment Final 6. BPG 11 Care of the deteriorating Resident Final 7. BPG 12 Care of resident with Diabetes Final 8. BPG 13 Good Record Keeping Final RELATED REFERENCES Links to these documents will provide additional information: VERSION REFERENCES NICE CG Introduction Wolverhampton CCG guidance is in line with guidance set out in NICE CG32, with additional detail based on best practice guidance developed locally, including CP45 The guideline approval process is in line with the process of RWT and the Dietician Team Leader for nutrition support has provided advice to the CCG and has agreed to be the expert advisor to this guideline. Role of the Nutrition and Dietetics Service This service is based at RWT. The team provide specialist advice and support on the instigation and management of enteral feeding to MDTs, patients and carers at New Cross and West Park hospitals and a variety of community settings. 1.1 Using the guideline The guideline and care standards provide a framework for the correct management of care home residents receiving enteral tube feeding and thus should prevent many of problems which can occur in this group of patients. 1.2 Specialist Advice and Support The Clinical Commissioning Group has a dedicated Quality Nurse Advisor Team who will support the implementation of this guideline and can offer specialist advice for any specific queries 1.3 Accountability The guideline applies to all nursing staff in nursing homes. All registered nurses have a duty of care to ensure patients receive appropriate high quality holistic care, treatment and evaluation. Nursing Home Managers are responsible for ensuring that the guideline is implemented and that staff follow best practice. In addition, Nursing Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 3

4 Home Managers must ensure staff access and attend appropriate mandatory training and are competent to undertake enteral feeding. 2.0 Detail 2.1 Feeding route and type of enteral feeding tube It is essential to confirm the type of enteral feeding tube the patient has in situ to ensure that the correct management plan is implemented. Failure to undertake correct care may lead to serious complications. It is the responsibility of the receiving care manager and the discharging team to ensure that the tube type and date of placement is clearly documented, so that the patient s enteral feeding can be correctly managed. The following table outlines the differences between tubes placed in Wolverhampton. The after care standards give additional information about specific types of feeding tubes. Nasogastric tube (NGT) Nasojejunal tube (NJT) Percutaneou s endoscopic gastrostomy (PEG) Radiologicall y inserted gastrostomy (RIG) Jejunostomy tube Tube type and size 8Fr 110cm Insertion method Usually bedside, by a suitable qualified professional Uses For short term feeding (up to month) or when a longer term option is deemed n/a 8Fr Endoscopic For short term post pyloric feeding (when n/a to feed into the stomach) (up to month) or when a longer term option is deemed n/a Freka PEG 15Fr Balloon gastrostom y tube 14Fr Balloon gastrostom y tube or a specific surgicial jejunostom y tube Endoscopic Radiology Usually surgery For long term (>4 weeks) gastric feeding in patients able to undergo endoscopy with sedation For long term (>4 weeks) gastric feeding in patients unable to undergo endoscopy with sedation because they cannot be scoped or because of poor respiratory function For long term (>4 weeks) post pyloric feeding in patients able to undergo a surgical procedure Key management points Position in stomach must be verified before every use with ph paper. Liable to block if not managed appropriately. Relatively easy to replace. Position verified by measurement. Liable to block if not managed appropriately. Replaced in endoscopy. Most common long term feeding tube used in Wolverhampton. Risk of buried bumper leading to surgical intervention. Needs daily advancing and rotating to prevent buried bumper Retained by an internal water filled balloon. If it falls out must be replaced within 2-4 hrs. Tube needs changing every 3-6 months. For balloon retained tubes, management is as for a RIG. Surgical tubes may be retained with a Dacron cuff or sutures. 2.2 Correct administration of feed Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 4

5 Patients are discharged from hospital with a feeding regime. Most patients will be established on a regime which meets their fluid and nutritional requirements (with diet, if taking). Care home residents who require enteral feeding will usually be fed via a feeding pump. However, an alternative method is bolus feeding (administering feed via a syringe in mls doses). It is the care home s responsibility to ensure that nursing staff are competent to set up pump feeds and administer bolus feeds correctly. Failure to do so may result in the incorrect volume of feed being delivered and microbial contamination of feed. Care home managers must identify staff who require training and liaise with their community dietician to arrange this. Care home staff must follow the regime provided by the dietician, and document delivery on the fluid record chart. Problems in complying with this (other than short term, eg D&V for 48hrs) must be communicated to the named dietician and GP Aftercare of a new PEG or RIG tube Many patients are discharged to care homes with feeding tubes placed more than a week previously. However, care home nursing staff must also be competent to manage newly placed enteral feeding tubes. Care standards are provided in the table (Appendix 1) 2.4 Aftercare of an established feeding tube The management of naso-gastric and naso-jejunal tubes does not change after the initial placement. The care of percutaneous (through the skin) tubes does change as the stoma matures. Care standards are provided in the table (Appendix 1) 3.0 Dissemination The care home manager is responsible for ensuring this guideline is disseminated to all staff and can evidence that staff have read it. This can be done via team or individual meetings. 4.0 Monitoring Arrangements Implementation will be monitored utilising Wolverhampton CCG quality monitoring framework e.g. Internal audits Quality Indicators returns Quality monitoring visits 5.0 Appendices 1. Aftercare Standards 2. Care standard checklists Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 5

6 Appendix 1 All enteral feeding tubes at any point after tube placement Nasogastric tube (NGT) Nasojejunal tube (NJT) Aftercare Standards Aftercare standards general Tube type must be documented and the correct checklist in use. Use sterile water for all tube flushes. Date and time of opening must be written on the bottle. Sterile water should be discarded 24hrs after opening and for single patient use. Syringes must be single use Giving sets can be reused for 24 hours, and must then be discarded. Date and time of opening should be written on the bag of feed and discarded after 24hrs. Administered feed and water flushes (including water used to dissolve soluble medications) must be documented on the fluid balance records and follow instructions provided on the feeding regime. Patients should be positioned at o during a feed, and NOT be lying flat when a feed or water is running. Aftercare standards for naso-enteric tubes Position checked with CE marked ph strips covering ph 2-9 before each and every time the tube is used. ph reading must be documented on fluid balance records. Usual ph range for an individual patient must be recorded in the discharge information relating to the NG feed. There must be a management plan relating to tube replacement (planned or unplanned) included in the discharge information relating to NG feeding. The NG tube must be flushed before and after feed and medication, as indicated on feeding regime and documented on fluid balance record. Patient must have the length of tube at nostril documented in feed discharge information Position verified by checking the measurement marks on the tube, prior to each flush. This should be documented on fluid balance records. It should be the same as the discharge length. There must be a management plan relating to tube replacement included in the discharge information relating to the feed. Tube must be flushed before and after feed and medication, as indicated on feeding regime and documented on fluid balance record. Rationale Infection prevention measure To prevent tube blockage and ensure fluid intake records are maintained To prevent aspiration Feeding into a misplaced NG tube can cause pneumonia and lead to death NPSA alert s/?entryid45=59794 To facilitate prompt management of a displaced feeding tube To prevent tube blockage and ensure fluid intake records are maintained To ensure that the tube is still sited into the small bowel, where the ph is neutral and so ph checks are not valid. To facilitate prompt management of a displaced feeding tube NJ feeding tubes are especially prone to blocking. Failure to follow instructions on flushing may lead to an avoidable endoscopy to replace a blocked tube Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 6

7 Percutaneous endoscopic gastrostomy (PEG) Radiologicall y inserted gastrostomy (RIG) Aftercare standards for percutaneous tubes Care immediately post placement (up to 72 hrs post placement) Follow hospital guidance in order to facilitate the early identification of complications immediately post insertion. As for PEG Aftercare of a new PEG or RIG tube The dressing must be removed on the day after placement and left off. The stoma should not be cleaned for the first 7 days to allow the stoma to remain undisturbed while healing. The securing buttons should be cleaned carefully with sterile water. Sutures are usually removed by the radiology team 1-2 weeks after placements If the tube falls out, contact the hospital immediately. Within office hours (9-5 Monday to Friday) contact the dietetics department on and explain the urgency of the call Out of hours contact the surgical assessment unit on or Nothing should be administered down the balloon port. Water should not be withdrawn from the Aftercare of an established feeding tube After 7 days: The site must start to be cleaned daily with soap and water, rinsed and dried thoroughly. The tube must be rotated through 360 o and advanced ~4-5 cm daily. This must be documented as being undertaken. Once sutures are removed the stoma can be cleaned as for a PEG with soap and water. If the tube falls out, a replacement must be inserted within 2-4 hours to prevent the need for a repeat procedure. Within office hours (9-5 Monday to Friday) contact the dietetics department on and explain the urgency of the call Out of hours contact the surgical assessment unit on or Nothing should be administered down the balloon port. Water should not be withdrawn from the balloon unless specifically instructed otherwise Rationale To prevent stoma infection Failure to correctly rotate and advance the tube may lead to buried bumper, where the internal retention flange becomes embedded in the gastric mucosa and requires surgical removal. To prevent stoma infection A stoma will close within 2-4 hrs and if this happens a new procedure would be required To prevent bursting the retention balloon, which could result in a displaced feeding tube Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 7

8 balloon unless specifically instructed otherwise Jejunostomy tubes: i) Balloon tube into the jejunum ii) Surgical jejunostomy tube (MicKey) Likely to be in hospital for > 72 hours. Adhere to recommendations regarding suture removal. Clean stoma as a sterile technique Once sutures are removed the stoma can be cleaned as for a PEG with soap and water. The tube should not be rotated or advanced, unless specifically trained to do so. If the tube falls out, a replacement must be inserted within 2-4 hours. Within office hours (9-5 Monday to Friday) contact the dietetics department on and explain the urgency of the call. Out of hours contact the surgical assessment unit on or To prevent infection around the stoma To avoid damage to the small bowel A stoma will close within 2-4 hrs. and if this happens a new procedure would be required. Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 8

9 Appendix 2 Care standard checklists Daily care management checklist for established PEGs (tube & site) Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed) Twice daily checks Patient name Date of birth Room no. Sterile water labelled with name, time and date of opening (<24hrs) Single use syringes in use. No re-used syringes evident. Feed labelled with date and time of opening (<24hrs) Fluid record chart clearly documents feed and water administered. Consistent with current feeding regime Patient is propped up at o during feed Signed to confirm completed OR, action if deviation from standard Daily checks PEG site clean and dry ( new tenderness and/or erythema &/or discharge site should be swabbed) PEG site cleaned with soap and water, rinsed and dried PEG tube rotated 360 o and advanced ~4-5cm and pulled back to resistance. Fixation plate correctly secured and held ~1cm from skin. No dressing, unless oozing Connector, fixation plate & clamp all present, Wolverhampton Clinical Commissioning securely Group attached Best Practice and clean. Guideline BPG 2 - Enteral Feeding 9

10 Daily care management checklist for NG tubes Patient name Date of birth Room no. Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed) Twice daily checks Sterile water labelled with name, time and date of opening (<24hrs) Single use syringes in use. No re-used syringes evident. Feed labelled with date and time of opening (<24hrs) Fluid record chart clearly documents feed and water administered. Consistent with current feeding regime Patient is propped up at o during feed Signed to confirm completed OR, action taken if deviation from standard Correct ph paper in use (and in date) in closed container. ph reading documented on fluid chart before every time the tube is used Daily checks Nasal hygiene. No ulceration around nostril Tube secured appropriately Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 10

11 Daily care management checklist for established RIGs (tube & site) Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed) Twice daily checks Patient name Date of birth Room no. Sterile water labelled with name, time and date of opening (<24hrs) Single use syringes in use. No re-used syringes evident. Feed labelled with date and time of opening (<24hrs) Fluid record chart clearly documents feed and water administered. Consistent with current feeding regime Patient is propped up at o during feed Signed to confirm completed OR, action taken if deviation from standard Correct ph paper in use (and in date) in closed container. ph reading documented on fluid chart before every time the tube is used Daily checks RIG site clean and dry RIG site cleaned with soap and water, rinsed and dried RIG tube rotated 360 o Fixation plate correctly secured and held ~1cm from skin. No dressing, unless oozing Connectors and fixation plate all present, securely attached and clean. Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 11

12 Wolverhampton Clinical Commissioning Group Best Practice Guideline BPG 2 - Enteral Feeding 12