Register No: Status: Public

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1 Nasal Retention Devices - Adults Type: Clinical Guideline Register No: Status: Public Developed in response to: Best practice NPSA guidance Contributes to CQC Regulation 9,12 Consulted With Post/Committee/Group Date Nasal Bridle Working Party April 2016 Dr Ramanathan Kirthivasan Consultant, Stroke April 2016 Helen Clarke Clinical Audit / NHSLA Lead April 2016 Pauline Baker Procurement Manager April 2016 Pauline Bird Clinical Manager for Nutrition & Dietetic April 2016 Services Hilary Bowring A.C.N Medical specialities April 2016 Joanna Clayden Matron Stroke & Neurology Service April 2016 Jill Downey Senior Sister - Stroke Ward April 2016 Lisa Ferrary Speech & Language therapist April 2016 Clive Gibson Safeguarding Matron April 2016 Marie Hellon Michelle Keen Amy Rudd Nutrition Clinical Nurse Specialist Stroke Clinical Nurse Specialist Head & Neck Dietician specialist April 2016 Professionally Approved By; Hilary Bowring A.C.N. Medical specialities April 2016 Version Number 1.0 Issuing Directorate Medicine Ratified by: Document Ratification Group Ratified on: 22 nd September 2016 Implementation Date 5 th October 2016 Executive Team Sign Off October 2016 Next Review Date August 2019 Author/Contact for Information Marie Hellon/ Amy Rudd/ Sibo Maponga Policy to be followed by (target staff) All clinical staff Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with) Incident Policy Consent Policy Mental Capacity Act Policy Safer Restraint Policy Infection and Prevention Policies Nasogastric Feeding Tube Insertion and Management in Adults Use of hand control mittens Document Review History Version No Authored/Reviewed by: Active Date 1.0 Marie Hellon/Amy Rudd 5 October 2016

2 Index 1.0 Purpose 2.0 Introduction 3.0 Scope 4.0 Indication, Contraindications & Complications 5.0 Roles and Responsibilities 6.0 Consent 7.0 Insertion Procedure 8.0 Care of Patient with a Nasal Retention Device (NRD) 9.0 Training 10.0 Implementation and Communication 11.0 Audit and Monitoring Appendix 1 Nasal Device Competence Document Appendix 2 Daily Care Record for Nasogastric Tube Feeding and NRD Check Page 2 of 11

3 1.0 Purpose 1.1 To prevent inadvertent displacement or removal of nasogastric tubes and promote safe and effective feeding using Nasal Retention Device (NRD) and specifically to: provide optimal nutrition minimise patient discomfort by avoiding repeated insertion of nasogastric tubes avoid complications of multiple insertions of nasogastric tubes avoid premature gastrostomy tube placement (GT) reduce physical and financial costs associated with repeat nasogastric insertion procedure including equipment, nursing time and requirement for chest X- ray promote safe use of the NRD 1.2 This procedure is intended to apply to all adult patients deemed appropriate for a NRD after a multi-disciplinary decision based on the clinical need of the individual patient at Broomfield Hospital. The consultant of the patient should be involved in the decision process, and this process must be documented in the medical notes. 1.3 A team of nurses, doctors and the Nutrition CNS will be responsible for implementing the procedure. Only the cohort of doctors and nurses who have been appropriately trained in this technique may carry out this procedure. It is the responsibility of individual clinical staff to ensure that they are competent to undertake this procedure unsupervised and to seek update training. Update training and competence assessment must be considered if a staff member has not undertaken this procedure for an extended period of time. 1.4 Artificial nutrition and use of NRD are associated with legal and ethical implications for practice. It is the responsibility of the clinical team responsible for the patient to ensure that due regard to legal and ethical principles is considered as part of patient care. Decisions from discussions with patients, next of kin and health care professionals regarding legal and ethical implications must be appropriately recorded in the medical records. 2.0 Introduction 2.1 NRD is a method of securing the NG tube inside the nose, reducing the chances of the tube being displaced 2.2 The use of nasogastric tubes (NG) within the acute setting is acknowledged to be best practice to provide the necessary nutritional requirements, in patients with a functioning gut, to promote recovery and reduce complications in a variety of conditions. Patients who are most likely to require nasogastric feeding are stroke patients due to swallowing difficulties. 2.3 The NICE acute stroke guidelines from 2008 state people with acute stroke who are unable to take adequate nutrition and fluids orally should receive tube feeding with a nasogastric tube within 24 hours of admission and be considered for a nasal bridle device or Gastrostomy tube (GT) - PEG (Percutaneous Page 3 of 11

4 Endoscopic Gastrostomy) or RIG (Radiologically Inserted Gastrostomy) if they are unable to tolerate a nasogastric tube People with acute stroke who are unable to take adequate nutrition and fluid orally should be assessed for a NRD if the nasogastric tube needs frequent replacement with NRD 2.4 NG tubes can be inadvertently, dislodged or removed for a variety of reasons resulting in clinical complications and the need for replacement. The main concerns resulting from NG tube displacement are: Re-siting of tubes results in a delay in nutrition being provided to the patient, increasing the likelihood of malnutrition and complications such as refeeding syndrome (Beavan et al 2007) Accidental dislodgement of nasogastric tube is often partial, which can result in aspiration into the lungs which significantly increases the risk of aspiration pneumonia The placement of a nasogastric tube is low risk procedure but can be uncomfortable for the patient and distressing to the individual and their family Increased costs for the procedure including equipment, nursing time and occasional requirement for a chest X-ray 2.5 NG Tube displacement increases the risk of aspiration, suboptimal delivery of nutrition, poor patient experience, which could also influence early placement of a GT. However GT insertion is an invasive procedure with its associated risks of bleeding, perforation, infection and even death. Local experience confirms that this has occurred in Broomfield Hospital. Royal College of Physicians guidelines Gastrostomy feeding should be considered for people with stroke who are unable to swallow adequate amounts orally by four weeks 2.6 Additionally the use of a NRD (also known as a nasal loop) allows nasogastric tubes to stay in place for up to 6-8 weeks (please refer to manufacturers guidance for NG tube life time) before requiring reinsertion. This allows a full assessment of long-term feeding needs, such as insertion of GT if deemed necessary in appropriate patients. 2.7 Recognition is given to the fact that the use of NRD may be associated with some risks and complications. A standardised approach to the process will assist in reducing the risk of complications. 2.8 Acknowledgement is given to NRD being a method of restraint and reference and compliance with the related hospital policies is essential. 3.0 Scope 3.1 This policy applies to all clinical staff responsible for the care of patients who require the use of nasogastric/ nasojejunal tubes. The use of nasogastric/nasojejunal tubes with additional securement of these devices will ensure safe administration of artificial feeding. 3.2 These are adult guidelines to be used in conjunction with policy No, Nasogastric feeding tube insertion and management in adults. Page 4 of 11

5 4.0 Indications, Contraindications & Complications 4.1 Indications Multiple displacements of nasogastric tubes - where there is documented evidence in the patient s notes of inadvertent displacement of the NG tube on more than 2 occasions. Patients requiring NRD as per the Multi-disciplinary team (MDT) and the Clinician s decision. Elective use to retain Nasogastric (NG) / Nasojejunal (NJ) tubes which would be impossible to replace or when replacement would be a high risk, technically difficult procedure; this includes all NG or NJ tubes that need to be placed endoscopically or radiologically. 4.2 Contraindications This procedure should not be undertaken if the patient has: mechanical obstruction of the nasal airway e.g. nasal polyps facial fractures anterior cranial fractures severe clotting disorders nasal trauma or ulceration previous nasal surgery refused treatment Caution must be exercised in patients with behavioural issues or agitation if they are likely to pull on the nasal bridle If the practitioner fails to insert the bridle after 3 attempts, the procedure must be stopped and advice sought from the senior clinician If there is no clinical practitioner who possesses the relevant competencies available for insertion of NSG tube retention device. 4.3 Complications of NRD Use Potential complications of the nasal bridle include: Epistaxis: minor blood on the NRD is common after bridle insertion; however there is a risk more major nosebleeds may occur. Nasal trauma or damage to the nasal septum: may occur either on insertion or because of pressure necrosis or rupture of septum from patients pulling on NRD. In practice these are very rare. Nasal redness and pressure sores: if patients complain of pain inside the nose then the NRD should be removed as this may indicate septal erosion in the back part of the nose. Sinusitis or Rhinitis: infection may be more likely to occur with the bridle or NGT and may require treatment with antibiotics or removal. Page 5 of 11

6 4.3.2 Incidence of these complications should be appropriately reported to the clinical team responsible for the patient in a timely manner in order to ensure appropriate clinical management of the patient. Due consideration should be given to recording adverse events on an incident form /Datix. 5.0 Roles and Responsibilities 5.1 Only the cohort of Doctors and nurses who have been appropriately trained and competencies assessed in application of retention device may carry out this procedure. Clinical staff are responsible to ensure that they are competent to undertake the procedure unsupervised and update their training annually. Update training and competence assessment must be considered if a staff member has not undertaken the procedure for an extended period of time. 5.2 Speech & Language therapist: Swallow assessment should be completed if appropriate. 5.3 Dietician Assessment, guidance and prescription of the most clinically appropriate feeding regime for the patient. On-going assessment and review of the enteral tube feed. 5.4 Nutrition Clinical Nurse Specialist Coordination of education of retention device, including trust training and bespoke training for clinical areas. Staff competencies assessment. Coordination competences assessment. Training of staff. To cascade training & competences assessment. Insertion of NG tube retention device. Responsible to update & review guidelines. 5.5 Clinical staff To refer to the NRD policy and understand their responsibilities of care for the patient. It is the responsibility of staff to ensure that they have received appropriate training and assessment of competences of insertion of the NG tube retention device. Staff are responsible for an annual update to update training or if they have not carried out the procedure for a considerable time. To act in the patients best interest at all time. Ward managers/nutrition link nurses are responsible for keeping an accurate account of staff training & competencies. 6.0 Consent 6.1 Verbal consent must be obtained at an appropriate point of consultation with the patient whenever possible. Where verbal consent cannot be obtained, due regard to legal and ethical principles must be observed when making a best interests decision. Appropriate documentation must be entered into the patient s medical records detailing the reasons why the NRD is being placed (MCA2 and DOLs in appropriate cases). Page 6 of 11

7 7.0 Procedure 7.1 Equipment Required Apron Alcohol-based hand rub Non-sterile gloves Nasogastric tube of appropriate size NRD pack compatible with NG tube size 20-50ml Enteral syringe Glass of water/straw (if appropriate) Tissues Receiver Clean scissors ph indicator strips 7.2 Insertion Procedure Carry out individual risk assessment. Explain procedure, obtain patients history and consent (if able). Agree signal by which patient can bring the procedure to a halt. A second member of staff: Position the patient (semi-recumbent, head tilted slightly forward if patient s condition allows). Wash hands. Apply non sterile gloves and apron. Refer to manufactures guidelines for NRD insertion. Store plectrum to open clip in a plastic bag and attach to patients bed. Note the clip and feeding tube position and document in patient s notes. Document the details of the nasogastric tube insertion and NRD insertion in the patient s notes. 8.0 Care of Patient with a Nasal retention device Daily checks of the nasogastric tube should continue for a patient with a NRD (refer to NG tube guidance). Check the NRD tape and clip are secure. Ensure the tapes are not over-tight. Check that the clip is not causing any pressure to under-lying skin. Page 7 of 11

8 The patient s nose should be checked for redness or pressure sores during each shift. Apply skin barrier as required. The NRD should be cleaned daily; this can be done using warm water or 0.9% saline and gauze. Observe the presence or absence of purulent secretions from the nose or in the mouth or oropharynx. Observe for any signs of tube migration. The NRD should be moved gently up and down and side to side very gently once per day as this helps reduce crusting at the back of the nose. Fill in the daily record for nasogastric feeding and NRD check care record sheet (Appendix 2). 9.0 Training 9.1 Training provision from Nutrition Clinical Nurse specialist and key members of the nasal retention device cohort (i.e. stroke sisters, doctors, dieticians) 9.2 Training can be added to pre-existing clinical skills training (which Nutrition CNS delivers) and also bespoke training for clinical areas Implementation and Communication 10.1 The guidelines will be made available on the Trust s intranet and website The Nutrition Clinical Nurse Specialist will be responsible for communicating the procedure to Estates & Facilities Management Team Audit and Monitoring 11.1 On-going audit on NRD will be carried out to ensure quality improvement. The audit data will be collated and presented in an appropriate forum, Nutrition Strategy Group (NSG) and Broomfield Artificial Nutrition Group (BANG) Datix must be completed in all incidences where harm has occurred, and in the event of untrained staff found to be undertaking this procedure Risk events can be reported to Ward Manager, Matron, Nutrition CNS- the Nutrition CNS can report these events to NSG & BANG - (in the future The Nutrition team). Risks would include: unavailability of appropriately trained staff to insert NRD poor skill mix of staff to provide appropriate care following insertion Product failure or unavailability Page 8 of 11

9 References Anderson M.R., O Connor M. Mayer, P. et al (2004). The nasal loop provides an alternative to percutaneous endoscopic gastrostomy in high risk dysphagic stroke patients. Clinical Nutrition. 23(4): Department of Health (2005). Mental Capacity Act. London, HMSO. Gunn, S.R., Early, B.J., Zenati, M.S. and Ochoa, J.B. (2009). Use of a Nasal Bridle Prevents Accidental Nasoenteral Feeding Tube Removal. Journal of Parenteral and Enteral Nutrition. 33(1) p McGinnis, C. (2011). The Feeding Tube Bridle: One Inexpensive, Safe, and Effective Method to Prevent Inadvertent Feeding Tube Dislodgement. Nutrition in Clinical Practice. 26(1) p National Institute for Health and Care Excellence (2008). Stroke and transient ischaemic attack in over 16s: diagnosis and initial management [CG68]. NICE, London. National Patient Safety Agency (2005). Patient Safety Alert 05. Reducing the harm caused by misplaced nasogastric tubes. NPSA, London. Norton B. et al. (1996). A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke. British Medical Journal.; 312: Popovich, M.J. Lockrem, J.D., Zivot, J.B. (1996). Nasal bridle revisited: an improvement in the technique to prevent unintentional removal of small bore nasoenteraic feeding tubes. Critical Care Medicine. 24(3): Power, S., Smyth, N., Duggan, S., Roddy, M. and Feehan, S. (2010). The nasal bridle: A useful approach to preventing the dislodgement of feeding tubes. European e-journal of Clinical Nutrition and Metabolism. 5(2): Royal College of Nursing (2004). Restraint Revisited rights, risks and responsibility RCN London. The FOOD Trial Collaboration (2005). Effect of timing and method of Enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial. The Lancet. 365: Williams J. (2005) Using an alternative fixing device for naso-gastric tubes. Nursing Times. 101(34): Page 9 of 11

10 APPENDIX 1 NASAL RETENTION DEVICE COMPETENCE DOCUMENT Assessment Demonstrates an understanding of the normal anatomy and physiology of the nasopharynx Demonstrates skill in making appropriate clinical decision for placement of the nasal bridle Communication Adequately explains procedure to the patient and gains their verbal consent Demonstrates good communication skills with the multidisciplinary team Assessment Date 1 Learner and Assessor Signature Assessment Date 2 Learner and Assessor Signature Insertion Demonstrates skill and has experience in placing fine bore nasogastric tubes as per MEHT NG Tube Policy Demonstrates an understanding of the procedure for placing the nasal bridle Demonstrates skill in placing the bridle as per MEHT NRD Guidelines Documents the procedure in the patients notes Maintenance Understands the potential complications of an indwelling NRD Demonstrates skill in assessing patient for signs of any complications Removal Demonstrates skill in safely removing the NRD as per MEHT Guidelines. Documents the procedure in the patients notes This member of staff (Name and Designation) has been trained and assessed as competent in this procedure on (Date) by (Name and Designation)

11 DAILY CARE RECORD FOR NASOGASTRIC FEEDING TUBE AND NASAL RETENTION DEVICE CHECK Patient Surname: First Name NHS / Hospital Number Initial tube length on insertion Date Time ph Length at nose (cm) NRD check Comments Signature or initial Page 11 of 11