10 Appendix 7 1 Competence for insertion of nasal bridle 7 2 Nasal bridle care plan 10 3 Discharge care sheet 11

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1 Classification: Policy Lead Author: Brenda Blackett, Nutrition Nurse, on behalf of the Nutrition Steering Group Authors ivision:surgery Unique I: TWCG8(11) Issue number: 4 Expiry ate: February 2021 Contents Section Page 1 Who should read this document 2 2 Key practice points 2 3 Background 3 4 What is new in this version 3 5 Policy 3 Contraindications to nasal bridle 4 6 Standards 4 Insertion of nasal bridle 4 Care of nasal bridle 5 Removal of nasal bridle 6 7 Explanation of terms 6 8 References and Supporting ocuments 6 9 Roles and Responsibilities 7 10 Appendix 7 1 Competence for insertion of nasal bridle 7 2 Nasal bridle care plan 10 3 ischarge care sheet 11 ocument control information ocument Control 12 Policy Implementation Plan 12 Monitoring and Review 13 Endorsement 13 Equality analysis 14 Page 1 of 15

2 1.0 Who should read this document? 1.1 Medical staff who will assess and consider the patients indication and suitability for a nasal bridle referral. Staff who insert and manage nasogastric tubes for enteral feeding or gastric drainage. Staff who insert or manage nasojejunal tubes for enteral feeding. Staff who insert or manage nasal bridles. 2.0 Key Practice Points 2.1 The use of the nasal bridle does not remove the requirement for the routine tube insertion and placement checks, and the EPR documentation prior to and during use of the tube. 2.2 If an NG tube is accidentally displaced 3 times then patients can be considered for insertion of a nasal bridle. 2.3 Nasal bridles are to be used as nasal tube retention device and not as a restraint. For any patient actively pulling out nasal enteral tubes a bridle should not be considered; ongoing management should be discussed with the multidisciplinary team, and should include consideration of 1-1 nursing and the use of posy mitts 2.4 It is recommended that all nasojejunal tubes and non-bedside placement NG tubes are secured where possible with a nasal bridle to minimise the risk of removal/ displacement; therefore reducing subsequent reinsertions requiring radiology/ endoscopy procedures. 2.5 Nasal bridles may also be used for patients with nasogastric tubes inserted for drainage where it is essential in minimising the risk of removal eg: to protect an anastomosis post surgery. 2.6 The nasal bridles will only be inserted by appropriately trained staff after referral from the medical team and assessment that the patient is suitable for the use of this device. 2.7 Contraindications to a nasal bridle: 1. Nasal airway obstruction & abnormalities. 2. Facial and/or anterior cranial fractures 3. Basilar skull fractures 4. Patients that may pull on the device to such a degree as to cause serious injury Page 2 of 15

3 3.0 Background Adequate nutrition in patients is known to be important in improving recovery and reducing length of stay. The Trust expects that staff will work to optimise nutrition for all patients while respecting the right of the person to make decisions about their treatment. The NPSA reports on nasogastric tubes in 2005 and 2011 highlighted the risks of tube insertion and misplacement. The use of a nasal bridle can reduce the need for repeated insertions of nasogastric (NG) / nasojejunal tubes (NJ) (Scott et al, 2009) 4.0 What is new in this version? 4.1 Information on bridle use as a retention device not as a restraint. 5.0 Policy Referral for endoscopic or radiological insertion of nasal enteral tubes should include a request for a nasal bridle. Revised EPR care plan. 5.1 In all patients requiring NG / NJ tube feeding staff will work to increase the chances of the tubes being tolerated by clear explanation, reassurance and in stroke patients where appropriate by inserting the tube on the side of hemi sensory neglect. If an NG tube is accidentally displaced 3 times then patients can be considered for insertion of a nasal bridle. 5.2 An assessment of mental capacity will be made. If the patient has capacity to consent then the bridle will only be used with that consent. If the patient does not have capacity to make decisions around the use of the bridle, or a bridle is to be inserted intra-operatively then a decision will be made in their best interests in consultation with all interested parties as per the Mental Capacity Act Capacity assessment and best interest documentation is to be completed according to Trust policy. 5.3 Nasal bridles are designed to be used as a nasal tube retention device and not as a restraint. Any patient actively pulling out nasal enteral tubes with a bridle inserted is at risk of: Aspiration (if the tube is pulled through the bridle clip whilst enteral feeding is in progress and is malpositioned from the jejunum/ stomach) amage to the nasal septum/ columnella Page 3 of 15

4 For these patients a bridle should not be considered; ongoing management should be discussed with the multi-disciplinary team, and should include consideration of 1-1 nursing and the use of posy mitts. 5.4 Using a small magnet on a flexible rod, a tape is passed behind the nasal septum and fixed to the tube by a clip, preventing the NG / NJ tube from being removed/ dislodged accidentally. 5.5 It is recommended that all nasojejunal tubes and non-bedside placement NG tubes are secured where possible with a nasal bridle to minimise the risk of removal / displacement; therefore reducing subsequent reinsertions requiring radiology / endoscopy procedures. The insertion of a nasal bridle must be requested on the referral for the tube insertion. A nasal bridle should be provided with the patient at the time of the initial procedure along with the tube and the bridle can be placed at the time of the tube insertion. 5.6 Nasal bridles may also be used for patients with nasogastric tubes inserted for drainage where it is essential in minimising the risk of removal eg: to protect an anastomosis post surgery. The nasal bridle may be inserted by the anaesthetist at the time of the procedure. 5.7 The use of the nasal bridle does not remove the requirement for the routine tube insertion and placement checks, and the EPR documentation prior to and during use of the tube. These must continue to be completed as per the Trust nasogastric feeding/ nasojejunal feeding policy. 5.8 Contraindications to a nasal bridle: 1. Nasal airway obstruction & abnormalities. 2. Facial and/or anterior cranial fractures 3. Basilar skull fractures 4. Patients that may pull on the device to such a degree as to cause serious injury 6.0 Standards 6.1 Procedure for insertion of the nasal bridle: Nasal bridles should only be inserted by a competent practitioner who has received training in the insertion and management of the nasal bridle. 1. First ensure that the decision to use the nasal bridle has been clearly documented by the medical team on EPR. 2. Ensure the NG / NJ tube has been inserted, and if possible the position of the tube confirmed as per Trust protocol (if the Page 4 of 15

5 position has not yet been confirmed, the nasal bridle can be inserted to secure the tube and the position changed by repositioning of the tube and clip if required the tube must not be used to administer any feed, fluids or medication until the tube position has been confirmed. 3. Note the cm marking at the nose of the inserted tube. 4. Explain the nasal bridle and procedure to the patient, and agree on a stop sign 5. Using a clean procedure, wear apron and gloves - open the nasal bridle pack (ensure the bridle is the correct size for the inserted tube). 6. Lubricate both of the probes and tape with lubricating gel, and place the first probe of the insertion kit into the nostril to the marked ridge. 7. Place the second probe of the insertion kit into the other nostril. There should be an audible click as the magnets attach- if not then gently manipulate the probes. 8. Remove the guide wire. 9. Gently pull on the 1 st probe to pull the 2 nd probe and the attached tape around the septum. The patient should have equal lengths of tape from each nostril. 10. Cut the tape to remove the insertion probe. 11. Ensure that the NG / NJ tube is correctly positioned. Place the NG / NJ tube and one length of tape into the channel on the clip and then clip it tightly shut. 12. Tie a double knot in the tape just distal to the clip. Trim off any excess tape with the scissors. 13. Securely fix the NG tube to the patient s cheek bone using adhesive plaster to prevent the extra weight of the bridle from pulling on the tape. 14. Clear away all equipment and dispose of as per Trust policy. 15. ocument in the nasal bridle care plan and on EPR that the bridle has been inserted, any difficulties or complications and any epistaxis related to the procedure. Complete the NG / NJ tube care plan as usual. 6.2 Care of the nasal bridle: The insertion and use of the nasal bridle should be documented on EPR and on the EPR Nasal Bridle care plan (Appendix 3) The tape can be gently wiped with a damp disposable cloth to prevent the build up of nasal secretions - the tape must not be removed for cleaning- this would require cutting the tape and therefore necessitate passing a new bridle. If discomfort is experienced around the nares then lubricant aqueous gel can be applied. Page 5 of 15

6 The bridle tapes and columnella should be checked at least twice per day and documented in the nursing evaluation on EPR for signs of the bridle tapes twisting or any pressure damage to the columnella (see manufacturers post insertion care sheet, Appendix 3) 6.3 Removal of the nasal bridle: If the patient has previously consented to the bridle and then withdraws consent, or if the patient becomes distressed by the bridle then it MUST be removed whether the bridle has been assessed as being in the patient s best interest or not. If epistaxis occurs then medical advice should be sought about the continued use of the bridle. If the patient continues to pull on the NG/ NJ tube despite the use of the nasal bridle then it should be removed. The bridle is placed to prevent the NG/ NJ tube from being accidentally removed, not to prevent the patient from deliberately removing it. The bridle may also be removed when the patient no longer requires the NG/ NJ tube. To remove the bridle, simply cut the tape with scissors and remove as with any NG/ NJ tube. On removal of the nasal bridle the EPR care plan should be edited with the removal details and then discontinued. 6.4 Any patient being discharged with a nasal bridle MUST be given a copy of the discharge post insertion care sheet (Appendix 3) for reference. 7.0 Explanation of terms NG Tube nasogastric tube NJ Tube nasojejunal tube EPR Electronic patient record 8.0 References and Supporting ocuments 1. National Patient Safety Agency (2005) & (2011) Reducing the harm caused by misplaced naso gastric feeding tubes in Adults, Children and Infants. epartment of Health, London. 2. Scott, R et al (2009) Use of Nasal Bridle prevents Accidental Nasoenteral Feeding Tube Removal. Journal of Parentral and Enteral Nutrition, olume 33 Number 1, Page 6 of 15

7 3. Anderson, M R et al (2004) The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high-risk dysphagic stroke patients. Clinical Nutrition; ol.23, No.4, Colagiovanni, L. (1999) Taking the tube. Nursing Times; ol.95, No.21, p Elia, M. et al (Eds) (2001) Trends in artificial nutrition support in the UK during BAPEN, Maidenhead. 6. Williams, J. (2005) Using an alternative fixing device for naso gastric tubes. Nursing Times; ol.101, No.35, p Seder, C and Janczyk R (2008) The Routine Bridling of Nasojejunal Tubes is a Safe and EffectiE Method of Reducing islodgement in the Intensive Care Unit. Nutrition in Clinical Practice, olume 23, number 1, Roles and responsibilities 9.1 The policy will be disseminated by the nutrition support team. The nasal bridles will only be inserted by appropriately trained staff after referral from the medical team and assessment that the patient is suitable for the use of this device. 9.2 Appropriate training in the insertion and care of the bridles will be delivered by the nutrition nurses or the company representative. 9.3 The Trust is committed to ensuring that the practitioner is supported in this learning process through teaching and assessment. It is the responsibility for all staff and carers involved in the insertion and postinsertion care of naso-gastric tubes and nasal bridles, to ensure that they are competent to do so and maintain their competence and skills (Appendix 1) Practitioners may identify training needs with regard to the insertion and postinsertion care of NG / NJ tubes and nasal bridles through the appraisal process Appendices 10.1 Appendix 1 Competence for insertion of nasal bridle A copy of this record should be placed in the registered practitioner s personal file, a copy must be stored in the clinical area by the line manager and a copy can be retained by the individual for their Professional Portfolio. Page 7 of 15

8 Competency Checklist Performance Criteria = verbalizes understanding =emonstrates skill Procedure Place patient in supine(preferred position) and RN/ANP at side of bed May be inserted before or after feeding tube Lubricate probes Insert the blue retrieving probe into nostril until first rib is at the bottom of the nostril. Insert white probe into opposite nostril at approximately the same distance. Pull out the orange stylet about ½ to facilitate contact. If magnets do not make contact; gently manipulate the probes side to side or up and down to facilitate contact. If no contact made, advance the catheter probes Once contact made, remove orange stylet Slowly withdraw the blue retrieving probe until umbilical is equal in Teaching Method(s) Meets requirement Y/N Evaluation ate Page 8 of 15

9 length out of both nares. Consider covering the patients mouth to prevent accidental swallowing or aspiration of clip Place clip above the lip and position the feeding tube into the deep channel of the clip Place both ends of umbilical tape on top of the tube near the hinge of the clip. Close clip & snap together verifying the clip is above the lip Tie umbilical tape ends together and trim excess tape emonstrate correct disposal of waste. Performance Criteria = verbalizes understanding =emonstrates skill ocumentation of procedure on EPR Record insertion Activate EPR nasal bridle care plan Assess & document condition of nose after insertion & ongoing ocument removal of feeding tube Teaching Method(s) Meets requirement Y/N Evaluation ate Removal If removing the retaining device & tube, cut one side of tape & slide the remaining out of nose with the feeding tube If removing only the umbilical tape, cut both strands of tape near the clip. While the Bridle clip is good for the life of the tube and should not be tampered with, the clip can be opened by using the Clip Opening Tool by inserting it into the locking mechanism and turning it like a key Trainer signature/ate RN signature/ate Page 9 of 15

10 10.2 Appendix 2 EPR Nasal bridle care plan Page 10 of 15

11 10.3 Appendix 3 ischarge post insertion care sheet Page 11 of 15

12 ocument Control Information Lead Author: Brenda Blackett, Lead Nutrition Nurse, on behalf of the Nutrition Steering Group ocument owner: Brenda Blackett Contact details: Classification: Clinical policy Scope: Trust-wide. Applies to: Clinical staff ocument for public display: Yes Keywords: NG tube, Nasogastric tube, NJ tube, Nasojejunal tube, Nasal bridle Associated ocuments: SRFT Safeguarding ulnerable Adults policy SRFT Mental Capacity Act 2005 policy SRFT Nasogastric Feeding policy NPSA 2005 and 2011 Reducing the harm caused by misplaced naso gastric feeding tubes in adults, children and infants SRFT Restraint, Restriction and eprivation of Liberty policy Unique Identifier: TWCG8(11) Issue number: 4 Replaces: 3 Authorised by: Clinical Effectiveness Committee Authorisation date: 22/02/2018 Next review: February 2021 Policy Implementation Plan The nutrition support team, will be responsible for implementation of the policy. Progress in implementation of this policy will be discussed at the nutrition steering group meetings Page 12 of 15

13 Monitoring and Review The effectiveness of the policy will be reviewed by the Nutrition Steering Group. Any complications related to the bridles will be discussed at the NutritionSteering Group. The Policy will be audited and reviewed yearly as part of the Nutrition Steering group audit programme. Endorsement Endorsed by: Name of Lead Clinician/Manager or Committee Chair Position of Endorser or Name of Endorsing Committee ate Kirstine Farrer (Chair) Nutrition Steering Group November 2017 Jonathon ickers Consultant UGI surgeon January 2018 Craig Smith Stroke Consultant January 2018 Paula Beech Stroke Nurse Consultant January 2018 Pete Turkington Exec Clinical Effectiveness Committee 22/02/2018 Page 13 of 15

14 Screening Equality Analysis Outcomes The Trust is required to ensure that all our policies/procedures meet the requirements of its service users, that it is accessible to all relevant groups and furthers the aims of the Equality uty for all protected groups by age, religion/ belief, race, disability, sex, sexual orientation, marital status/ civil partnership, pregnancy/ maternity, gender re-assignment. ue consideration may also be given to carers & socioeconomic factors. Have you been trained to carryout this assessment? YES If 'no' contact Equality Team for details. Name of policy or document : The aim of the policy is that use of a nasal bridle where indicated can reduce the need for repeated insertions of nasogastric (NG) / nasojejunal tubes ensuring patients receive adequate nutrition/hydration and medication, or gastric drainage appropriately. 1) a) Whom is this document or policy aimed at? 2) a) Is there any evidence to suggest that your end users have different needs in relation to this policy or document; (e.g.health/employment inequality outcomes) (NB If you do not have any evidence you should put in section 8 how you will start to review this data) 3) a) oes the document require any decision to be made which could result in some individuals receiving different treatment, care, outcomes to other groups/individuals? b) If yes, on what basis would this decision be made? (It must be objectively justified) 4) a) Have you included where you may need to make reasonable adjustments for disabled users or staff to ensure they receive the same outcomes to other groups? 5) a) Have you undertaken any consultation/involvement with service users or other groups in relation to this document? 1a) All patients with a nasal bridle cared for by staff employed by Salford Royal NHS Foundation Trust 2a) No 3a)No 3b) 4a) Yes 5a) Yes, divisional consultation with Gastro, nutrition steering group and patient representative Page 14 of 15

15 b) If yes, what format did this take? face/face or questionnaire? (please provide details of this) 5b) face to face, c)has any amendments been made as a result? 6) a) Are you aware of any complaints from service users in relation to this policy? b) If yes, how was the issue resolved? Has this policy been amended as a result? 5c) 6a)No 6b) 7) a) To summarise; is there any evidence to indicate that any groups listed below receive different outcomes in relation to this document? Age isability Sex Race Religion & Belief Sexual orientation Pregnancy & Maternity Marital status/civil partnership Gender Reassignment Carers *1 Socio/economic**2 Positive Yes No unsure Negative* 1: That these two categories are not classed as protected groups under the Equality Act. 2: Care must be taken when giving due consideration to socio/economic group that we do not inadvertently discriminate against groups with protected characteristics Negative Impacts *If any negative impacts have been identified you must either a) state below how you have eliminated these within the policy or b) conduct a full impact assessment: 8) How will the future outcomes of this policy be monitored? Annual audit and review 9) If any negative impact has been highlighted by this assessment, you will need to undertake a full equality impact assessment: Will this policy require a full impact assessment? No (delete) (if yes please Contact Equality Officer on , for further guidance) High/Medium/Low Type/sign:Brenda Blackett date: 10/11/2017 Page 15 of 15