Classification: Policy Lead Author: Brenda Blackett, Nutrition Nurse Specialist (on behalf of the Nutrition Steering Group) Additional author(s): N/A Authors Division: Surgery Unique ID: TWCG20(11) Issue number: 7 Expiry Date: July 2019 Contents Section Page Who should read this document 2 Key points 2 Background &Scope 2 What is new in this version 3 1 Protocol 3 NG tube feeding / indications and contraindications 3 NG tube insertion 5 2 Standards 8 Checking and confirming tube position 9 3 Training and Competency 14 4 Explanation of terms/ Definitions 15 5 References and Supporting Documents 15 6 Roles and Responsibilities 15 Divisional Audit tool 7 Appendix 1 NPSA Decision Tree for NG tube placement checks in Adults 18 2 NPSA NG tube x-ray interpretation aid 19 3 NG tube placement competency log 20 4 Starter Feeding Regimen 22 5 Procedure for Bolus Feeding 23 6 Discharge Risk Assessment 24 7 Self Insertion of NG tube and Competency 26 8 Monitoring Patients 30 9 Problem Solving 31 10 Community Care Plan 34 Document control information (Published as separate document) Document Control 37 Policy Implementation Plan 37 Page 1 of 35
Monitoring and Review 38 Endorsement 38 Equality analysis 39 Who should read this document? All clinical staff Community based staff with clinical responsibility for patients with nasogastric feeding tubes Key Messages Nasogastric (NG) tube feeding is the choice for patients who require short term enteral feeding i.e. 4-6 weeks. The insertion of the tube will be completed by a competent practitioner, and details of insertion documented on the EPR Nasogastric tube insertion structured note. A maximum of 3 attempts at inserting the tube should be made at one time to prevent trauma to the nasal / oesophageal mucosa, and if difficulty in inserting the tube this should be escalated accordingly via the medical team to ensure adequate attempts are made to secure a safe enteral route for nutrition/ fluid/ medication. The position of a NG tube on initial placement will be confirmed by ph of 5.5 or below as first line test, with x-ray only being used when no aspirate could be obtained or ph indicator paper has failed to confirm the location of the NG, and all the recommended steps to gain an aspirate as documented on the NPSA decision tree (appendix 1) have been followed (except in critical care where x-ray is used in conjunction with ph as first line method) Nasogastric tubes will not be flushed or any liquid / feed introduced through the tube following initial placement, until the tube tip is confirmed by ph testing or x-ray to be in the stomach. The position of the NG tube will be checked and confirmed prior to any feed, medication or fluids being administered via the tube, and the result documented on the EPR NG bedside check and x-ray interpretation document. Whoosh tests, acid/alkaline test using litmus paper, the absence of respiratory distress or interpretation of the appearance of aspirate are never to be used to confirm nasogastric tube position as these are not reliable. Background & Scope All nasogastric feeding in adult patients within Salford Royal NHS Foundation Trust will be initiated and monitored in compliance with the National Patient Safety Agency guidelines and this policy. Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005, and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered wholly Page 2 of 35
preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers. Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via ph testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm. Examination of these incident reports by NHS Improvement clinical reviewers shows that misinterpretation of x-rays by medical staff who did not appear to have received the competency-based training required by the 2011 NPSA alert is the most common error type. Other error types involve nursing staff and ph tests, unapproved tube placement checking methods, and communication failures resulting in tubes not being checked. The reports included 32 incidents where the patient subsequently died, although given many patients were critically ill before the tube was introduced, it is not always clear whether the death was directly related to the misplaced tube. The purpose of this policy is to ensure that all patients requiring nasogastric feeding receive an explicit quality of service and that risks are minimised. This document relates to medical, nursing and support staff that care for patients who require enteral feeding via a nasogastric tube. The same advice, precautions and procedures also apply to orogastric feeding tubes. What is new in this version? New data in the background & scope Additions in the Contraindications section regarding basal skull fractures, partial obstructive pathology in oropharynx or oesophagus preventing passage of the tube (e.g. stricture, tumour); previous partial, total or extended total gastrectomy; bariatric surgery Risks Consent NG training video included in the training section Divisional assurance on staff training and documentation audit. Protocol 1.1 Nasogastric (NG) Tube Feeding Nasogastric tube feeding is the choice for patients who require short term enteral feeding i.e. 4-6 weeks. 1.2 Indications for Nasogastric feeding NG tube feeding is suitable for the patients who: Are malnourished. Have a functioning GI tract. Require short-term tube feeding (up to 4-6 weeks) Page 3 of 35
Have been unable to fulfil their nutritional requirements with normal /modified diet +/- nutritional supplements for >7 days. Are not predicted to fulfil their nutritional requirements with normal / modified diet +/- nutritional supplements for >7 days. Have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns. 1.3 Contraindications Absolute contraindications Non-functioning GI tract e.g. ileus Complete obstructive pathology in oropharynx, oesophagus preventing passage of the tube (e.g. stricture, tumour) Large gastric aspirate and/or high risk of aspiration (includes mechanical pyloric obstruction due to tumour or stricture) Intractable vomiting not resolved by adequate anti-emetic Mask C.PA.P Relative contraindications Basal skull fracture, as the tube may enter the brain if malpositioned - in this instance insertion needs to be under direct vision with a laryngoscope or nasoendoscope (if not available the orogastric route may be used as an alternative) Oesophageal varices Mucositis Vomiting responding to anti-emetics Maxillo facial disorders, surgery or trauma Clinical circumstances where an enteral feeding tube must be inserted under endoscopic or radiological guidance: Partial obstructive pathology in oropharynx or oesophagus preventing passage of the tube (e.g. stricture, tumour) Previous partial, total or extended total gastrectomy Bariatric surgery 1.4 Risks Misplacement of the tube Perforation Pneumothorax Aspiration 1.5 Consent Verbal consent for the procedure should be sought under the guidance of the Trust Consent Policy. To obtain valid informed consent, where a nasogastric tube is to be used for feeding purposes, patients and carers should be made aware of the associated complications which may be caused by tube insertion or misplacement, and the procedures which should be taken to prevent this. Page 4 of 35
If the patient is unable to give informed consent due to incapacity, the tube may be inserted if it is considered to be in the patient s best interests to do so. In these circumstances, wherever practicable the patient s named next of kin should be consulted but the final decision to proceed will always remain with the responsible healthcare professional. Consideration may be given to delaying the procedure if there is a chance that the patient will regain capacity but this should only be considered if it is practicable to do so and providing always that the delay will not adversely affect the patient s clinical condition. For patients who do not have the capacity to consent, in order to comply with the Mental Capacity Act 2005, the following process and EPR documentation needs to be completed: 1. Decision specific Mental Capacity Assessment for insertion of an NG tube for enteral feeding, fluids and/ or medication, completed on the EPR mental capacity assessment form. 2. Best interest documentation form on EPR; which must be completed and state the risks and benefits of an NG tube for enteral feeding, fluids and/ or medication. 1.6 The tube will be inserted using the following Procedure adapted from the Royal Mardsen manual and the NPSA safety alert (2005, 2011 and 2012) Fine bore nasogastric feeding tube insertion by a competent nurse or doctor Nursing Practice Equipment The intention of this practice is to insert a Fine Non Sterile Gloves Bore Nasogastric Tube, following assessment Apron of the patient by medical, nursing and dietetic Nasogastric feeding tube - size 8 staff. or 10Fr 50ml enteral Syringe (purple) 10mls Sterile Water Tape or Anchoring Device ph Indicator Paper with 0.5 graduations or a range of 0-6 Tissues Vomit bowl Glass of water and straw if patient can swallow/ is not NBM Action Rationale 1. Prepare the patient. Introduction of the tube and its function. Arrange a signal by which the patient can communicate if he/she wants the nurse to stop e.g. raising a. To promote dignity and privacy. b. To ensure co-operation and promote confidence. c. To ensure full informed consent. their hand 2. Explain how it will feel. Assist the patient (if Aids relaxation of patient. conscious) to sit upright and support him/her with pillows. 3. Explain the importance of not tilting the To maintain an open passage for the Page 5 of 35
head backwards. If the patient is sedated, it may not be appropriate to sit him/her up. 4. Inspect the nostrils, checking to see which is clear. Ask the patient to blow his/her nose or the nostrils may need cleaning with sterile water. 5. The nurse/doctor should wash her hands and put on a clean disposable apron. Ensure that paper towels are placed comfortably around the patient s neck. A vomit bowl should be at hand. 6. Measure the tube prior to placement using the NEX measurement - measure the distance on the tube from the patient s tip of the nose to the earlobe plus the distance from the earlobe to the bottom of the xiphisternum. 7. Dip the end of the nasogastric tube in sterile water. 8. If the patient is conscious, is not NBM and has a safe swallow, allow them to drink and provide them with a glass of water and a straw. 9. Insert the tube into the nostril, slide it backwards and inwards, and as the tube passes through the naso pharynx ask the patient to sip water if this is appropriate and the patient is able to do so. 10. Maintaining a calm manner and encouraging the patient to take slow even breaths, advance the tube down the oesophagus until it reaches the stomach to the cm marking measured on the tube. 11. If you are unable to pass the tube, try the other nostril. If you are unable to place the tube, seek advice from a senior colleague. 12. If at any time during or following the procedure signs of nasal haemorrhage, respiratory distress e.g. cyanosis or gasping occurs, or if the tube meets any resistance the tube should be withdrawn. 13. Once the tube is inserted safely and correctly, it can be secured to the nose or side of the face with a small piece of nonallergenic tape. Take care not to cover the cm marking at the nostril. 14. Aspirate the tube with a minimum of 1ml, and check ph of aspirate using ph Indicator paper which has 0.5 increments, is CE marked and manufactured to test human gastric aspirate. ph reading must be between 1 and 5.5 tube. a. To aid passage of tube. b. To avoid trauma to the nasal mucosa. c. To identify any obstruction which may hinder intubation. To reduce the risk of cross infection. (This is a clean procedure) To measure the length of the tube which needs to be introduced in order that the tip will lie in the stomach. This activates coating on the tip of the tube and assists with intubation. This will promote passage of the tube into the oesophagus. To help the passage of the tube through the nose. The swallowing action closes the glottis and assists the tube to pass into the oesophagus. Assist relaxation and avoids laryngeal spasm. To prevent undue discomfort and distress to patient. Trauma to the nasal mucosa, the tip may have entered the respiratory system, or obstruction may be present. To prevent any retraction of the tube whilst checking its placement. To allow the cm marking at the nostril to be checked routinely. To confirm the position of the tube is in the correct place for feeding / administering medication Page 6 of 35
to confirm placement A second competent person must check any reading that falls within the ph range of 5 to 6. *If unable to aspirate, follow guidance on the NPSA algorithm (page 2 of NG care plan) before proceeding to x-ray. *If unable to confirm tube position by ph, an x-ray will be required to confirm position 15. Record the procedure and the technique used to confirm the position of the tube on the nasogastric care plan and on the electronic patient record. Document ph reading and NEX measurement on the NG care plan, bedside checklist and electronic patient record 16. Once the position of the tube is confirmed, flush the tube with 10ml sterile water and remove the guide wire, and close the access port. For audit purposes and in the event of a query. Water, feed or medication should only be administered down the tube once the position of the tube has been confirmed. Flushing the tube with water activates the internal lubricant in the tube assisting in the removal of the guidewire. Standards 2.1 Before a decision is made to insert a nasogastric tube, an assessment will be undertaken to identify if nasogastric feeding is appropriate for the patient, and the rationale for any decision will be recorded in the patient s electronic patient record (EPR). 2.2 If there is not sufficient experienced support available to accurately confirm nasogastric tube placement (for example at night) then, unless clinically urgent placement should be delayed until that support is available, and the rationale for any decisions will be recorded in the patient s medical notes. 2.3 Nasogastric tubes used for the purpose of feeding will be radio-opaque throughout their entire length and have externally visible length markings. The tube length will be estimated before insertion using the NEX measurement (place exit port of tube at tip of nose, extend the tube to the earlobe, and then to xiphisternum). 2.4 A maximum of 3 attempts at inserting the tube should be made at one time to prevent trauma to the nasal / oesophageal mucosa, and if difficulty in inserting the tube this should be escalated accordingly via the medical team to ensure adequate attempts are made to secure a safe enteral route for nutrition/ fluid/ medication. 2.5 If at any time during or following the procedure signs of nasal haemorrhage, respiratory distress e.g. cyanosis or gasping occurs, or if the tube meets any resistance the tube should be withdrawn. Page 7 of 35
2.6 The insertion of the tube will be completed by a competent practitioner, and details of insertion documented on the EPR Nasogastric tube insertion structured note. 2.7 The position of a nasogastric feeding tube on initial placement (see NPSA decision tree, appendix 1) will only be confirmed by: First line test method: ph paper Using a 50ml enteral syringe a minimum of 1ml should be withdrawn (aspirated) from the NG tube. The NG tube aspirate must be checked using ph Indicator paper which has 0.5 increments, is CE marked and manufactured to test human gastric aspirate. The ph reading must be between 1 and 5.5 to confirm placement. A second competent person must check any reading that falls within the ph range of 5 to 6. ph value will be recorded on the EPR nasogastric tube insertion structured note (and subsequently on the EPR bedside check structured note following initial placement confirmation). Second line test method: X-ray X-ray is to be used only as a second line test when no aspirate could be obtained or ph indicator paper has failed to confirm the location of the nasogastric tube, and all the recommended steps to gain an aspirate as documented on the NPSA decision tree (appendix 1) have been followed. In Critical Care patients who have a reduced level of consciousness, X-ray is the first line test to confirm initial placement of the NG tube. The request for x-ray must clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube for the purpose of feeding. Page 8 of 35
The ph value obtained or the inability to obtain an aspirate must also be documented on the x-ray request. X-rays must only be interpreted and nasogastric tube position confirmed (see appendix 2, NPSA nasogastric tube x-ray interpretation aid) by someone assessed as competent to do so (completion and achievement of competency of the e-learning module at https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71 ). Please note: Ensure that the remainder of the chest X-Ray is reviewed for any abnormalities. In case of other abnormalities consider whether a radiology hot report may be required. Healthcare professionals are reminded that PACS windows can be manipulated to improve contrast and visualisation. If there is any difficulty in interpretation the advice of a radiologist should be sought. Any nasogastric tubes identified to be in the lung should immediately be removed / repositioned whether in the x-ray department or clinical area. If a member of staff from the clinical area is able to attend radiology to reposition the tube the position must be checked using ph indicator paper, and repeat x-ray taken only if unable to confirm the tube position by obtaining an aspirate. The medical practitioner checking the x-ray to confirm the position of the tube must complete the EPR nasogastric tube x-ray confirmation structured note. The Radiology department is available for advice and has an out of hours SpR on call who can be contacted for advice as required. Page 9 of 35
Please note: Whoosh tests, acid/alkaline test using litmus paper, the absence of respiratory distress or interpretation of the appearance of aspirate are never to be used to confirm nasogastric tube position as these are not reliable. 2.8 Nasogastric tubes will not be flushed or any liquid / feed introduced through the tube following initial placement, until the tube tip is confirmed by ph testing or x-ray to be in the stomach. 2.9 In the following circumstances, patients will NOT be fed unless a ph of between 1 and 5.5 has been obtained and documented OR correct tube placement has been confirmed by a competent person through x-ray and documented: Following initial insertion. Following episodes of vomiting, retching or coughing spasms (note that the absence of coughing does not rule out misplacement or migration). When there is suggestion of tube displacement (for example, loose tape or portion of visible tube appears longer). In the presence of any new or unexplained respiratory symptoms or reduction in oxygen saturation. Please note: Feed must be discontinued and the giving set detached from the naso-gastric tube if there is concern that the tube position has moved it should only be re-connected and feed recommenced once correct placement of the tube has been confirmed. 2.10 Following initial placement, repeat placement checks of ph (as instructed in section 2.6 of this policy) will be made as follows: Before administering each feed. Before giving medication - BAPEN guidance www.bapen.org.uk/res_drugs.html At least once daily. Where feed/medication has already passed through the tube, a minimum of an hour delay without any further feeding will be instigated prior to testing of gastric aspirate using ph paper wherever an aspirate can be obtained. 2.11 The EPR NG bedside check structured note including the risk assessment section needs to be completed and followed before administration of any feed, fluid or medication through the NG tube. Page 10 of 35
2.12 In some situations, such as when patients are fed continuously, when they are treated with acid-reducing medication, and when medications are frequently given down nasogastric tubes, it may not be possible to obtain an aspirate with a ph between 1 and 5.5, and daily x-rays are not practical or safe. In circumstances where the initial placement was appropriately confirmed and documented, and there is no reason to suspect displacement since (i.e. no vomiting, retching or coughing spasms and no unexplained respiratory symptoms) the only practical method of determining if the tube remains correctly placed prior to each administration of medications or feed may be through external observation of the tube. In this instance the risk assessment section on the bedside check structured note on EPR must be completed and followed (for ICU where patients feed continually over 24 hours, the risk assessment on the bedside check flowsheet is to be completed on each shift as ph is unable to be checked). The risk assessment includes: Confirmation that the length of the external tube remains identical to that recorded initially in the patient s notes on insertion. The fixation tapes or plasters have not moved or worked loose. The patient has experienced no vomiting, retching or coughing spasms and has no unexplained respiratory symptoms. There is no coiling of the tube observed in the patients mouth. The tube cm marking at the nostril will be recorded on a minimum daily basis on the EPR bedside check structured note, and prior to administration of any liquid via the nasogastric tube. If there is any indication that the length has changed, appropriate action should be taken to assess tube tip position prior to using the nasogastric tube. Please note: If there is evidence that the tube has become displaced for whatever reason, then only checking the position at the nose would be Page 11 of 35
inappropriate as it could be coiled in the back of the mouth; in this circumstance second line testing through x-ray, or removal /repositioning of the tube if seen to be coiled in the mouth would be appropriate. 2.13 All patients receiving naso-gastric feeding will have a feeding regimen at the bedside encompassing the following areas: Name Ward Hospital number / NHS number Date Enteral feed, sterile water or saline to be administered via the feeding tube Volume to be administered Rate of infusion Flushes of sterile water to be administered Signed, dated and contact / bleep number for the dietitian The feeding regimen documented by the dietitian will take into account the risk of refeeding syndrome (see SRFT Refeeding Policy). 2.14 All patients with a nasogastric feeding tube must have an active EPR NG care plan. A new care plan must be activated as each enteral feeding bottle is commenced with the batch number and expiry date of the enteral feed recorded on the care plan (patients requiring multiple bottles of feed per 24hours will therefore require more than one care plan per day activating). Patient tolerance of NG feed will be monitored Any interruptions to the feeding regimen will be documented and the reason why recorded in the EPR nursing evaluation. Documentation in the nursing care plan reflects the need to position the patient at more than 30 degrees if fed in bed. Page 12 of 35
2.15 Only 50ml purple oral syringes/devices clearly labelled Oral/Enteral, which cannot be connected to intravenous catheters or ports will be used to administer sterile water, feed or medications. Three way taps or syringe tip adaptors will not be used to administer sterile water, feed or medications via a nasogastric tube. 2.16 A full multidisciplinary supported risk assessment will be made and documented before a patient with a nasogastric tube is discharged from acute care to the community (see appendix 6). Community patients having NG tubes cared for by health care professionals will have an active paper NG tube care plan (see appendix 10) For patients discharged with NG tubes district nurses will not replace/repass the NG tube in the community. 2.17 On removal of the NG tube the EPR NG tube insertion structured note for that tube must be edited to include the details of the tube removal. 2.18 Consideration for the use of a nasal bridle to secure the NG tube should the patient experience accidental pullout, displacement or dislodgement of the tube on 3 subsequent occasions should be made. Referral to the Nutrition Support Team for assessment is recommended if the medical team would like to consider a bridle. Please note: nasal bridles are contraindicated on patients with nasal airway obstructions and abnormalities, facial and/ or anterior cranial fractures, basal skull fractures, or patients that may pull on the bridle to such a degree as to cause serious injury, especially those with cognitive impairment. 2.19 If the Nasogastric tube has been pulled out by the patient on at least three occasions in short succession then ongoing management should be discussed with the multi-disciplinary team. This should include consideration of 1-1 nursing, the use of posy mitts, nasal bridle (if a bridle is not contraindicates as documented in section 2.18) and alternative feeding regimes. Documentation of number of re-insertions must be made in the patient clinical records. Training and Competency Healthcare professionals must ensure that if involved with nasogastric tube insertion and position checks they have been assessed as competent through theoretical and practical training 3.1 All indicated staff (medical and nursing) must complete the mandatory SRFT NG competency package; this requires watching the nasogastric tube training video on the trust e-learning portal, attendance at an NG competency workshop which will include a practical demonstration followed by a practical assessment, and for nursing staff completion of an e-learning NG placement and management resource book with e-learning multiple choice questions. Page 13 of 35
NG competency workshops will be facilitated by the Nutrition Support Team, and Learning and development, and can be booked by Trust staff via the e- learning portal. The competency log (Appendix 3) must be signed as completed by the designated assessor / facilitator, and attendance of the workshop will be documented on the Trust learning and development recording system. It is the individual practitioners responsibility to ensure that they are trained and assessed as competent, and this will be monitored by the ward/ unit/ area manager, practice development teams and ward based nutrition link nurses. All staff are advised should they have reduced exposure to NG tube insertion and management, or require a refresher to reassess competencies they should book onto one of the available NG tube workshops as required. All Health care professionals confirming the position of a nasogastric tube for feeding by x-ray must complete and achieve competency in the training resource and assessment on x-ray interpretation of nasogastric tube position available on the Trust e-learning portal x-ray interpretation section, or https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71 3.2 The medical staff employed by the Trust must upload a completed self certificate for the module onto the Trust learning and development recording system (Accessed via the e-learning portal x-ray interpretation) competency log (Appendix 3) must be signed as completed by the designated assessor / facilitator. Explanation of terms & Definitions Terms explained in the document References and Supporting Documents 1. NPSA Alert/2007/19 Promoting safer measurement and administration of liquid and medicines via oral and enteral routes 2. Medical Device Agency (2004) Enteral Feeding Tubes (Nasogastric) MDEA (NI) 2004/29 Department of Health, London 3. National Patient Safety Agency (2005) and (2011) Reducing the harm caused by misplaced nasogastric tubes. Department of Health, London. 4. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 5 th edition (intranet version) Nutritional Support Section 27. Editors Mallett J, Doherty L. Blackwell Science. 5. Guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients. ASPEN Board of Directors. JPEN 1993;17(4):1SA-50SA. 6. Guidelines for the use of enteral nutrition in adult patients. ASPEN Board of Directors. JPEN 1987;11(5):435-439. Page 14 of 35
7. NICE (2006) Nutrition Support in Adults: oral supplements, enteral tube feeding and parenteral feeding. Guideline 32 Department of Health, London 8. NPSA/2012/RRR001 Alert, Harm from flushing of nasogastric tubes before confirmation of placement. Department of Health, London. 9. NHS Improvement patient safety alert 2016 Nasogaastric tube misplacement: continuing risk opf death and severe harm. NHS/PSA/RE/2016/006 Roles and responsibilities The nutrition steering group is responsible for: Updating the policy. Auditing the policy standards. Educating staff with respect to this policy via nutrition study days and additional training at ward level if requested. 6.1 Dissemination of the updated policy to all Trust staff will be via the ADNS, Lead Nurses, Matrons and Medical Directors. 6.2 Practice educators, the nutrition nurse specialist and ward based nutrition link nurses will ensure staff competence in the placement and management of nasogastric tubes. The Trust is committed to ensuring that the practitioner is supported in this learning process, through teaching and assessment. 6.3 It is the responsibility of all staff and carers involved in the insertion and post insertion care of nasogastric tubes to ensure that they are competent to do so and maintain their competence and skills. Practitioners may identify training needs with regard to the insertion and post-insertion care of nasogastric tubes through the appraisal process. 6.4 Divisions will be responsible for auditing compliance with this policy and reporting to the clinical effectiveness committee in order to comply with NHS improvement recommendations. Along with providing assurance that all staff have completed the NG tube training requirements within their division, the following documentation audit must be completed annually. Page 15 of 35
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Appendices Appendix 1 Page 17 of 35
Appendix 2 Page 18 of 35
Appendix 3 Page 19 of 35
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Appendix 4 Starter NG feeding regimen Nasogastric Starter Regimen *Regimen not nutritionally complete, refer to Dietitian as soon as possible* Position of tube must be checked using Merck ph indicator paper- the ph must be less than or equal to 5.5 before giving feed or medication. Refer to NG policy. Patient: Ward: Date: FEED: 1000ml Osmolite 1010Kcal 40g Protein 136g Carbohydrate 34g Fat 38mmol Na+ 38mmol K+ Day 1 STOP!! If patient malnourished or not eaten for 5 days they are at risk of REFEEDING SYNDROME. Give Thiamine 50mg 4 times daily and Vit B Co Strong 2 tabs 3 times daily; continue for 10 days. Check electrolytes using TPN profile; correct if required, monitor daily until electrolytes are normal. 500ml Osmolite @ 25ml/hr x 20 hours 4 hours rest *Check and correct electrolytes if required Day 2 700ml Osmolite @ 35ml/hr x 20 hours 4 hours rest *Check and correct electrolytes if required Day 3 1000ml Osmolite @ 50ml/hr x 20 hours 4 hours rest Use a new giving set every 24 hours, Flush with 30ml sterile water before and after feed/ medication using a purple 50ml female luer lock syringe. Page 21 of 35
Appendix 5 PROCEDURE FOR BOLUS FEEDING Bolus feeding is indicated for agitated, confused patients or patients who do not wish to be attached to an enteral feeding pump most of the day. Please note bolus feeding can be very time consuming if the patient has an 8Fr or 10Fr NG tube in situ. Catheter tip oral / enteral labelled syringes are available from the dietetic department. This procedure should only be attempted following consultation with the ward Dietitian and nutrition nurses. How to bolus feed: 1. Wash your hands. 2. Confirm position of NG tube as per policy guidelines. 3. Check you have one sterile oral / enteral labelled 50ml catheter tip syringe, one sterile oral / enteral labelled 50ml female luer lock syringe the correct feed and sterile water available. 4. If possible sit the patient in the upright position. 5. Flush the nasogastric with 30mls of sterile water, using a 50ml oral /enteral labelled female luer lock syringe 6. Remove the plunger from the 50 ml catheter tip oral / enteral labelled syringe; connect the tip of the syringe to the feeding tube. 7. Slowly pour the required amount of feed into to the catheter tip oral / enteral labelled syringe. This is usually between 200-250mls per bolus. The volume will be decided by a dietitian. 8. Allow the feed to run in slowly, a bolus feed should take 15-20 minutes to complete and should never be flushed down the feeding tube rapidly. 9. When the feed is finished flush the tube with 30mls of sterile water using a 50ml female luer lock oral / enteral syringe and replace the cap on the naso-gastric tube. Page 22 of 35
Appendix 6 Page 23 of 35
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Appendix 7 Page 25 of 35
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Appendix 8 PROCEDURE FOR MONITORING PATIENTS ON NASOGASTRIC FEEDING Monitor Regularity Comments Notes Biochemistry Fluid Balance Charts (on intentional rounding charts) Daily until stable then Weekly. See SRFT refeeding syndrome policy Daily For all abnormalities, liaise with the clinician and biochemist for possible causes and management. In normal and stable circumstances, patients being fed enterally need no more biochemical monitoring than that required by their medical conditions. Monitor fluid input and output over 24 hours, use to prevent over or under hydration Observe feed delivered versus feed prescribed to prevent over or underfeeding When requesting a full nutritional screen for patients select TPN profile. This includes U+E s, Ca, Mg, Phosphate, LFTs, lipids, CRP and blood glucose Large stoma fistula losses-may affect nitrogen and electrolyte requirements Blood/blood products may affect biochemistry Food Intake Charts(on intentional rounding charts) Daily Allow estimation of protein and energy intakes from diet Permit the transition from parenteral/ enteral nutrition to oral diet without energy deficits or overfeeding Vomiting may affect electrolytes Please use Trust Food Record Chart (on intentional rounding charts), discuss with ward dietitian, if unsure of which chart to use. Clinical Observation Charts Daily Persistent pyrexia will increase nitrogen and energy requirements, reduce to baseline when apyrexial. Stool Charts Daily Monitor bowel frequency and Clinical Condition Drug Treatment / Drug Nutrient Interactions Daily Daily consistency Observe for changes which may affect requirement, e.g. sepsis, surgery, fistula development Gastrointestinal side effects: Diarrhoea (antibiotic therapy, laxatives, sorbitol based drugs, hyperosmolar drugs); Constipation (opiates) Nausea (antibiotic therapy, chemotherapy. Inform haematology if the patient is on enteral tube feeding. Consider absorption sites when feeding into small bowel Page 29 of 35
Enteral feeds may alter the absorption and metabolism of certain drugs e.g. Phenytoin, Theophylline, Warfarin, Digoxin, Carbamazepine Monitor therapeutic drug levels. Always liaise with the clinician and/or pharmacist re drug treatments Anthropometry Weekly Frequent measures of body weight may be useful to indicate state of hydration. Cardiac, renal and hepatic failure or malignancies are often associated with ascites of fluid retention. Drug treatments e.g. diuretics, cause fluid loss, others e.g. corticosteroids fluid gain. Use in association with fluid balance charts to interpret. Clothing/dressings Diurnal variations Same scales / Scale Maintenance Page 30 of 35
Appendix 9 Problem Solving Enteral Nutrition Complication Cause Management Nausea and Distention Regurgitation Diarrhoea Constipation Too large boluses / too rapid infusion, medical reason Delayed gastric emptying, tube misplacement Drugs e.g. antibiotics, too rapid infusion, malnutrition Drug Therapy Inadequate fluid Changes in gut motility Review feed type and reduce rate. Aspirate tube regularly - consider anti-emetics or prokinetics or post pyloric feeding Confirm tube position. Elevate head of bed 30-45. Consider prokinetics or post-pyloric feeding. Check: Infective cause - send stool sample for cultures Antibiotic therapy Other drug therapies e.g. hyperosmolar solutions, laxatives, sorbitol based medications Rate and osmolality of feed being infused Consider: Treat infection if present Anti-diarrhoeal medication if no infection Fibre feed Drug modifications Iso-osmolar feeds Establish a definition e.g. include frequency and consistency (profuse water, semi-formed, over-flow) Check: Drugs e.g. opiates - change if appropriate Dehydration - provide additional fluid Motility: increased risk with decreased activity Tube malposition Tube displacement Tube occlusion Metabolic Accidental misplacement Accidental e.g. vomiting, not adequately secured Viscous feed, drugs e.g. tablets not crushed, inadequate flushing Refeeding or concurrent Illness / disease Consider: Enemas / laxatives Fibre feed Constipation may lead to abdominal distention, vomiting and nausea Policy for insertion, confirm position of tube prior to starting feed Monitor the position, fasten securely Flush regularly - unblock using a 50ml enteral syringe to flush the feeding tube with 30-50mls of sterile warm water, then soda water. DO NOT FORCE THE WATER. If still blocked pancreatic enzymes e.g. Creon may be effective in unblocking tubes Daily monitoring first week, especially in the severely malnourished or where concurrent disease. Alter feed and give IV / enteral Page 31 of 35
Infection Contamination of the feed / system supplements as indicated Use sterile feeds and a closed system, Change giving sets every 24 hr. Feeds not hanging for > 24hr. Protocols for setting up feeds. PROBLEM SOLVING - PUMP PROBLEMS Should the enteral feeding pump alarm check in a stepwise manner, from the top (i.e. the bag of feed), down the giving set and pump until you finally check the patient. Use the pump manufacturers manual for guidance. If following the pump checks tube blockage is suspected, use the following procedure to attempt to clear the blockage: Use a 50ml enteral syringe to flush the feeding tube with 30-50mls of sterile warm water, then soda water. DO NOT FORCE THE WATER. If still blocked pancreatic enzymes e.g. Creon may be effective in unblocking tubes. Please Note: Do not use fruit juices, fizzy or carbonated drinks as this will exacerbate the blockage as the acid in the drinks can react with feed / medication and cause damage to the tube. Do not use any implements that can be forced down the tube. Do not use smaller volume syringes (unless trained) as this practice can lead to ruptured tubes due the excess pressure. Page 32 of 35
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