This is an official Northern Trust policy and should not be edited in any way Enteral Feeding Infection Control Policy (Interim) Reference Number: NHSCT/12/494 Target audience: This policy is aimed at all members of Trust staff or students working within the Trust who have direct responsibility for the placement of enteral feeding tubes or for the administration of enteral feeds in both adult and paediatric settings. Sources of advice in relation to this document: Naomi Baldwin, Lead Nurse Infection Prevention and Control Replaces (if appropriate): United Hospital Trust s policy on Enteral Feeding Type of Document: Trust Wide Approved by: Policy, Standards and Guidelines Committee Date Approved: 8 March 2012 Date Issued by Policy Unit: 8 March 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves
Enteral Feeding Infection Control Policy (Interim) March 2012
Enteral Feeding Infection Control Policy (Interim) Introduction The term enteral tube feeding describes the delivery of nutrition into an individual s gastro-intestinal tract via a number of devices. Examples include nasogastric tube (NGT), gastrostomy (including percutaneous endoscopic gastrostomy PEG) and jejunostomy feeding. Whilst enteral rather than parenteral feeding is the preferred and most physiological method of artificial feeding, the potential for bacterial contamination and subsequent infection needs to be addressed. Aim The aim of this policy is to ensure uniform standards of infection prevention and control are implemented during the enteral feeding process and are maintained across the Trust. Rationale To ensure that there is a system in place for the safe administration of enteral feeding. Policy Statement All staff dealing with enteral feeding do so in a manner which prevents contamination and reduces the risk of infection. Responsibilities Chief Executive The Chief Executive has overall responsibility for ensuring infection prevention and control is a core part of the Trusts governance and patient safety programmes. Trust Board The Board has collective responsibility for ensuring that appropriate and effective policies are in place to minimise the risks of healthcare associated infections. Director of Infection Prevention & Control It is the responsibility of the Director of Infection Prevention & Control to oversee the development and implementation of infection prevention and control policies. Infection Prevention & Control Team It is the responsibility of the Infection Prevention & Control Team to ensure this policy is reviewed and amended at the review date or prior to this, following new developments in enteral feeding research. 1
Service Managers It is the responsibility of managers to ensure that staff are aware of this policy and that they have the knowledge, skills and facilities to adhere to it. Staff It is the responsibility of staff to ensure that they are aware of this policy and that they have the knowledge and skills to ensure that it is implemented. Policy Context This policy should be read in conjunction with the following: Health & Safety at Work (Northern Ireland) Order 1978; Regional Infection Control Manual (assessed via NHSCT Staffnet or www.infectioncontrolmanual.co.uk ; Trust Hand Hygiene Policy; Trust Decontamination Policies (Community facilities and In-patient facilities); Trust Management of Medical Devices Policy; Trust Records Management Policy; CREST (April 2004) Guidelines for the Management of Enteral Tube Feeding in Adults; ICNA (June 2003) Enteral Feeding Infection Control Guidelines; NICE (June 2003) Infection Control Clinical Guideline 2. Target Audience This policy is aimed at all members of Trust staff or students working within the Trust who have direct responsibility for the placement of enteral feeding tubes or for the administration of enteral feeds in both adult and paediatric settings. Equality, Human Rights and DDA The policy is purely clinical/technical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. Sources of advice in relation to this policy The policy author, responsible assistant director or director as detailed on the policy title page should be contacted in relation to any queries on the content of this policy. Alternative Formats This document can be made available on request on disc, larger font, Braille, audio cassette and other minority languages to meet the needs of those who are not fluent in English. 2
Policy / Actions to be followed Handwashing Hands should be washed: prior to preparing the feeding equipment prior to preparing or decanting feed prior to donning and after removing gloves and aprons prior to manipulation of any part of the feeding system Protective Clothing In hospital / nursing home / residential home / day care centre Disposable non-sterile gloves should be worn when handling feeds or any part of the feeding system. For high-risk patients (see Risk Assessment on page 8-9), sterile gloves should be worn. A disposable plastic apron should be worn. At home Carers caring for relatives in their own home do not require protective clothing unless the patient has an increased risk of susceptibility to infection (see Risk Assessment on page 8-9). Preparation of Feed and Equipment If preparation is required, feed and equipment should be prepared on a metal surface e.g. a treatment trolley, which has been disinfected with Trust disinfectant (see Trust Community or Inpatient facilities Decontamination Policies). In the patient's own home, a smooth washable surface e.g. a melamine tray may be used. Sterile pre-packed feeds should be used whenever possible. These should be used in the largest size available to reduce the number of changes check feeding regime with the Dietitian. Do not pierce the foil on the pre-packed feed pack/bottle prior to connecting the giving set. Feeds should be stored in a clean dry area and rotated to ensure oldest feed is used first. Ensure adherence to the 'use by date' specified on the feed. 3
Feed Hanging Times Sterile Pre-packed Feed - 24 hrs. If disconnection is unavoidable: Wash hands carefully and wear gloves and disposable plastic apron. Use a non-touch technique taking care to avoid touching all connections. Clean connections with an alcohol wipe when disconnecting and reconnecting. Protect exposed end of giving set with clean/sterile cap while disconnected. Do not remove feed from stand it is important to keep the giving set lower than the feed container to avoid reflux from giving set. Giving sets and feed containers are for single use and must be discarded after each feeding session. Sterile Feed decanted into a sterile reservoir using aseptic technique Non-sterile feed (including modular diluted or modified sterile feed) e.g. thickened ready to hang (RTH) feed decanted into a sterile reservoir - 24 hrs - 4 hrs NB: Reservoirs must not be topped up see page 6. Flushing In hospital / nursing home / residential home / day care centre Sterile water to be used for all patients with enteral tube feeding At home The choice of water will depend on a risk assessment of: a) the patient (see Risk Assessment on page 8-9) b) the care environment (see Appendix A) Sterile water must be used: - If the patient is deemed to be at special risk of infection If the patient is being fed through a jejunostomy tube 4
Please note when a large amount of additional fluid is required for hydration of a jejunostomy fed patient, an isotonic fluid e.g. sodium chloride should be used rather than giving large volumes of sterile water via a jejunostomy. Liaise with the Dietician. Once a bottle of sterile water is opened, its contents are no longer sterile and should be discarded after use. In all other situations, cool boiled water can be used: Freshly drawn tap water from the drinking supply should be boiled, cooled and stored in a covered container in the fridge. Any unused water must be discarded after 24 hours. If the care environment is deemed to be unsuitable for the safe use and storage of cool boiled water, sterile water should be used (see Appendix A). Please note sterile water is available in various sized containers from Pharmacy or on script. Equipment Administration Pumps Enteral feeding pumps should be decontaminated daily. Step 1 before cleaning Switch off and unplug pump from the mains before cleaning. Step 2 cleaning pump exterior All equipment should be decontaminated daily with Trust disinfectant or detergent and water, as per Trust Community or Inpatient facilities Decontamination Policies, and allowed to air dry. If a spill occurs, the pump should be wiped clean as soon as possible using hot soapy water and then dried thoroughly. Step 3 Pump Drip Sensor / Rotor Visually examine to verify no feed residue is present and ensure that the rollers are running freely in rotor. If pump is no longer for use, clean as for Step 2 and place in clear plastic bag with green verification of cleaning label attached. Giving Sets Single use giving sets should be discarded after each feeding episode. Right angled giving sets and gastrostomy extension sets should be managed according to the manufacturer's guidance as advice will vary. Frequent disconnection of the giving set will increase the risk of infection. 5
If disconnection is unavoidable: - - wash hands carefully and wear gloves and disposable apron (unless at home see 'Protective Clothing) - use an aseptic non touch technique (ANTT) - clean connections with an alcohol wipe when disconnecting and reconnecting - protect exposed end of giving set with clean / sterile cap while disconnected - do not remove feed from stand giving set must be kept lower than the feed container to avoid reflux Syringes In hospital / nursing home / residential home / day care centre A new single use enteral feeding syringe must always be used each time the tube is flushed or the patient receives medication. At home An enteral feeding syringe for 'single patient use' (i.e. a reusable syringe) may be re-used in accordance with manufacturer's guidance. If a patient is deemed to have an increased risk of infection, a new single use enteral feeding syringe may be used each time the tube is flushed or the syringe may be decontaminated using a cold sterilant as per manufacturer s guidance for high risk patients. (see Risk Assessment page 8-9) Reservoirs Do not top up reservoirs with feed. Reservoirs should be labelled with the time and date when first used and discarded after 24 hrs or when empty (not more then 24 hrs). Decanting Equipment Bottle openers / can openers / scissors should be kept specifically for feeding. They should be washed in a dishwasher or in hot soapy water, rinsed and left to air dry after each use. Utensils e.g. jugs should be washed as described above and stored covered with paper towels or a freshly laundered cloth until required. Oral Hygiene A dentist should assess the patient's oral health when enteral feeding is started. Good oral hygiene procedures should be established at the start of enteral feeding. Oral hygiene should be provided on a minimum twice daily basis. 6
Risk of Infection The patient's risk of infection should be assessed before feeding is commenced as this will influence the nursing management (see Risk Assessment page 8-9). The care environment of patients who are at home should also be assessed, as this will influence advice regarding types of water and syringes (see Risk Assessment page 8-9). If a patient develops diarrhoea, specimens of faeces should be sent to the laboratory for culture & sensitivity and Clostridium difficile toxin testing. Contact the Dietitian who will review the feeding regime. Education of patients, their carers and healthcare personnel Patients and carers should be educated about and trained in the techniques of hand decontamination, enteral feeding and the management of the administration system, including enteral feeding pump, before being discharged from hospital. Community staff should be trained in enteral feeding and management of the administration system. Follow up training and ongoing support of patients and carers should be available for the duration of home enteral tube feeding. References: CREST Guidelines for the Management of Enteral Tube Feeding in Adults, April 2004. National Institute for Clinical Excellence Infection Control Prevention of healthcare associated infection in primary and community care. Clinical Guideline 2, June 2003. 7
Flow Chart for Enteral Feeding Risk Assessment (Taken from CREST Guidelines 2004) 'Risk Assessment of patient's susceptibility to infection' 1. Patients in the following circumstances are at high risk of infection. Is the patient, receiving enteral feeding, at special risk of infection because they are: Being fed by a route that bypasses the stomach e.g. jejunostomy or Prescribed gastric acid reducing therapy e.g. proton pump inhibitors or H 2 antagonists or Immunosuppressed e.g. prescribed immunosuppressants, cytotoxics, long courses of cortico-steriods etc or Has had an organ transplant or Immunocompromised due to disease or Has major injuries such as burns, multiple fractures 2. Is the patient being fed in hospital/nursing or residential home/school/day care centre or is the patient at high risk of infection? YES A new enteral/oral syringe should be used each time the tube is flushed or the patient receives medication or the syringe should be decontaminated using a cold sterilant as per manufacturer s guidance *. NOTE: Sterile syringes must always be used for patients who have jejunostomy tubes or who are immunocompromised etc (see question 1 above). Sterile water to be used for flushing (and as additional water if required). NOTE: A fresh bottle of sterile water should be opened each time water is required. Non-sterile gloves and disposable apron to be worn during any manipulation of the feeding system. Particular attention should be paid to hand hygiene. Hands should be thoroughly washed and dried before donning and after removal of gloves and aprons. NO Is the patient being fed in their own home? YES See overleaf. * Medicines should always be measured using enteral/oral syringes and not hypodermic syringes. Ref NPSA Patient Safety Alert 19 (2007). Oral medicines: Promoting safer measurement and administration of liquid medicine via oral and other enteral routes. 8
Yes, the patient is being fed in their own home? Is the patient's feed/feeding system being managed by the patient themselves or by a family member/carer? Is the home environment, particularly kitchen, maintained in a hygienic condition? (See Appendix A) YES NO YES NO Protective clothing (gloves and aprons) not required, but hands must be thoroughly washed and dried before assembling or manipulating system. If health care workers are managing feed etc, gloves (non-sterile) and aprons to be worn when assembling feeding system and for any subsequent manipulations. Particular care must be given to hand hygiene. Hands should be thoroughly washed and dried before donning and after removal of gloves and aprons. A single patient use enteral feeding syringe should be used for flushing tubing or administering medication*. Syringes labelled by the manufacturer as 'reusable for single patient use' should be cleaned after each use and replaced as per manufacturers' instructions. Cool boiled water may be used for flushing (and as additional water as required). Consider use of new single use enteral feeding syringe each time the tube is flushed or the patient receives medication or decontaminate the syringe using a cold sterilant as per manufacturer s guidance for high risk patients*. Replace cool boiled water with 'sterile water for irrigation. * Medication should be measured using enteral feeding syringes and not hypodermic or IV compatible syringes. 9
Appendix A Assessment of the home environment should be made based on the following criteria:- 1. Raw foods such as meat, fish, eggs and vegetables should never be stored or handled in close proximity to enteral feeds or feeding systems. 2. Water from flower vases, aquaria and nappy buckets should be disposed of down the toilet, not down the kitchen sink. 3. Pets and insects should not be allowed access to the feeds or feeding systems. 4. The sink, taps and work surfaces should be cleaned and disinfected prior to preparing and handling feeds and feeding systems. Particular care should be taken to use the concentration of disinfectant recommended by the manufacturer. Ref: Anderton, A. (2000) Microbial Contamination of Enteral Tube Feeds, How Can We Reduce the Risk? (Published by Nutricia Clinical Care). 10