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

Best Practice Guidelines – BPG 2 Enteral Feeding

DOCUMENT STATUS: Approved DATE ISSUED: 4th July 2019 DATE TO BE REVIEWED: 25th February 2022

AMENDMENT HISTORY

VERSION DATE AMENDMENT HISTORY V1 March 2014 Developed - Team Leader Nutrition Support RWT V2 October 2015 Reviewed - Team Leader Nutrition Support RWT V3 February 2019 Final Review – QNA Team V4 August 2019 Amendment to information.

REVIEWERS This document has been reviewed by:

TITLE/RESPONSIBILITY DATE VERSION Dietician Team Leader 5th October 2015 V2 QNA Team 28th October 2015 V2 QNA Team 25th February 2019 V3 Consultant Microbiology 1st August 2019 V4

APPROVALS This document has been approved by:

GROUP/COMMITTEE DATE VERSION Practice Development Group 7th January 2014 V1 Quality & Safety Committee 14th January 2014 V2 Final Quality & Safety Committee 10th November 2015 V2 Final Reviewed

Quality and Safety Committee June 2019 V3 final

DISTRIBUTION This document has been distributed to:

Distributed To: Distributed by/When Paper or Electronic

Document Location

Care Home Managers

Care Home Manager Meeting

Paper / Internet Resource Folder

QACO Paper / Internet Intranet

DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled.

RELATED DOCUMENTS These documents will provide additional information:

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REF NUMBER

DOCUMENT REFERENCE NUMBER

TITLE VERSION

1 BPG1 Pressure Ulcer Prevention & Management V4 3 BPG3 Prevention of Malnutrition V4 4 BPG4 Infection Prevention V4 5 BPG5 Catheter Care V5 6 BPG6 Aseptic Technique V4 7 BPG7 Management of Diabetes Mellitus V2 8 BPG8 Management and Prevention of Falls V4 9 BPG9 Medicines Management V6 10 BPG10 End of Life Care V3 11 BPG11 Care of the Deteriorating Patient V5

RELATED REFERENCES Links to these documents will provide additional information:

REFERENCES

NICE CG32 http://www.nice.org.uk/cg32 NICE CG139 https://www.nice.org.uk/guidance/cg139/chapter/1-Guidance#enteral-feeding

1.1 Introduction

Wolverhampton CCG guidance is in line with guidance set out in NICE CG32, with additional detail based on best practice guidance developed locally, including CP45 The guideline approval process is in line with the process of RWT and the Dietician Team Leader for nutrition support has provided advice to the CCG and has agreed to be the expert advisor to this guideline.

• Role of the Nutrition and Dietetics Service

This service is based at RWT. The team provide specialist advice and support on the instigation and management of enteral feeding to MDTs, patients and carers at New Cross and West Park hospitals and a variety of community settings.

1.2 Using the guideline

The guideline and care standards provide a framework for the correct management of care home residents receiving enteral tube feeding and thus should prevent many of problems which can occur in this group of patients.

1.3 Specialist Advice and Support

The Clinical Commissioning Group has a dedicated Quality Nurse Advisor Team who will support the implementation of this guideline and can sign post you to specialist advice. Contact the Quality Nurse Advisor Team via email: WOLCCG.Qualitynurseadvisorteam@nhs.net

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1.4 Accountability

The Nursing and Midwifery Council advocates that good record keeping is an integral part of care delivery and practice, and is essential to the provision of safe and effective care.

The Home manager is accountable for ensuring that risk assessments are carried out under the requirements of the Health and Safety at Work Act 1974 and the Management of Health and Safety at Work regulations 1999.

The accountability for the care delivered in the care home rests with the senior person on duty who may delegate care to the health care assistant or to temporary (agency) staff so long as they have a robust induction process that provides assurance of competence.

The care home manager is responsible for ensuring dissemination and implementation of these guidelines within the care home.

Care Home Managers must ensure staff access and attend appropriate training and are competent to deliver care to residents who are at risk.

2.0 Detail

2.1 Feeding route and type of enteral feeding tube

It is essential to confirm the type of enteral feeding tube the patient has in situ to ensure that the correct management plan is implemented. Failure to undertake correct care may lead to serious complications. It is the responsibility of the receiving care manager and the discharging team to ensure that the tube type and date of placement is clearly documented, so that the patient’s enteral feeding can be correctly managed. The following table outlines the differences between tubes placed in Wolverhampton. The after care standards give additional information about specific types of feeding tubes.

Tube type

and size Insertion method

Uses Key management points

Nasogastric tube (NGT)

8Fr 110cm Usually bedside, by a suitable qualified professional

For short term feeding (up to month) or when a longer term option is deemed n/a

Position in stomach must be verified before every use with pH paper. Liable to block – if not managed appropriately. Relatively easy to replace.

Nasojejunal tube (NJT)

8Fr Endoscopic For short term post pyloric feeding (when n/a to feed into the stomach) (up to month) or when a longer term option is deemed n/a

Position verified by measurement. Liable to block if not managed appropriately. Replaced in endoscopy.

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Tube type and size

Insertion method

Uses Key management points

Percutaneous endoscopic gastrostomy (PEG)

Freka PEG 15Fr

Endoscopic For long term (>4 weeks) gastric feeding in patients able to undergo endoscopy with sedation

Most common long term feeding tube used in Wolverhampton. Risk of buried bumper leading to surgical intervention. Needs daily advancing and rotating to prevent buried bumper

Radiologically inserted gastrostomy (RIG)

Balloon gastrostomy tube 14Fr

Radiology For long term (>4 weeks) gastric feeding in patients unable to undergo endoscopy with sedation because they cannot be endoscoped or because of poor respiratory function

Retained by an internal water filled balloon. If it falls out must be replaced within 2-4 hrs. Tube needs changing every 3-6 months.

Jejunostomy tube

Balloon gastrostomy tube or a specific surgical jejunostomy tube

Usually surgery

For long term (>4 weeks) post pyloric feeding in patients able to undergo a surgical procedure

For balloon retained tubes, management is as for a RIG. Surgical tubes may be retained with a Dacron cuff or sutures.

2.2 Correct administration of feed

When residents are discharged from hospital with a feeding regime. Most residents will be established on a regime which meets their fluid and nutritional requirements (with diet, if taking). Care home residents who require enteral feeding will usually be fed via a feeding pump. However, an alternative method is bolus feeding (administering feed via a syringe in 100-200mls doses).

It is the care home’s responsibility to ensure that nursing staff are competent to set up pump feeds and administer bolus feeds correctly. Failure to do so may result in the incorrect volume of feed being delivered and microbial contamination of feed. Care home managers must identify staff who require training and liaise with their community dietician to arrange this.

Care home staff must follow the regime provided by the dietician, and document delivery on the fluid record chart. Problems in complying with this (other than short term, e.g. diarrhoea and vomiting for 48hrs) must be communicated to the named dietician and GP.

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2.3. Aftercare of a new PEG or RIG tube Many residents are discharged to care homes with feeding tubes placed more than a week previously. However, care home nursing staff must also be competent to manage newly placed enteral feeding tubes. Care standards are provided in the table (Appendix 1)

2.4 Aftercare of an established feeding tube

The management of naso-gastric and naso-jejunal tubes does not change after the initial placement. The care of percutaneous (through the skin) tubes does change as the stoma matures. Care standards are provided in the table (Appendix 1) 2.5 Prevention of blockages Guidance from NICE to prevent blockages to the enteral feeding tube are to flush the enteral feeding tube before and after feeding or administrating medications using single-use syringes or single – patient – use (reusable) syringes according to the manufacturer’s instructions. Use:

• Freshly drawn tap water for patients who are not immunocompromised • Either cooled freshly boiled water or sterile water from a freshly opened container for

patients who are immunosuppressed. 3.0 Dissemination The care home manager is responsible for ensuring this guideline is disseminated to all staff and can evidence that staff have read it. This can be done via team or individual meetings.

4.1 Monitoring Arrangements

Implementation will be monitored utilizing Wolverhampton CCG quality monitoring framework e.g.

• Internal audits • Quality Indicators returns • Quality monitoring visits

5.1 Appendices

1. Aftercare Standards 2. Care standard checklists

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Aftercare standards – general Rationale All enteral feeding tubes at any point after tube placement

Tube type must be documented and the correct checklist in use. Use freshly drawn tap water or sterile water (immunocompromised patients) for all tube flushes. Date and time of opening must be written on the sterile water bottle. Sterile water should be discarded 24hrs after opening and for single patient use. Purple syringes must be single use Giving sets can be reused for 24 hours, and must then be discarded. Date and time of opening should be written on the bag of feed and discarded after 24hrs.

Administered feed and water flushes (including water used to dissolve soluble medications) must be documented on the fluid balance records and follow instructions provided on the feeding regime.

Infection prevention measure To prevent tube blockage and ensure fluid intake records are

Patients should be positioned at 30-45 during a feed, and NOT be lying flat when a feed or water is running. To prevent aspiration Aftercare standards – for naso-enteric tubes Nasogastric tube (NGT)

Position checked with CE marked pH strips covering pH 2-9 before each and every time the tube is used. pH reading must be documented on fluid balance records, with length of tube at nostril and tube length. pH range for an individual patient must be recorded in the discharge information relating to the NG feed. An aspirate of pH 5.5 or less indicates that the tube is safe to use. The tube should be secured at the nose and cheek or forehead with a suitable tape or nasofix unless a nasal bridle is in place. Usual pH range for an individual patient must be recorded in the discharge information relating to the NG feed.

There must be a management plan relating to tube replacement (planned or unplanned) included in the discharge information relating to NG feeding.

Feeding into a misplaced NG tube can cause pneumonia and lead to death NPSA alert http://www.nrls.npsa.nhs.uk/resource s/?EntryId45=59794 To facilitate prompt management of a displaced feeding tube

To prevent tube blockage and ensure fluid intake records are maintained

Nasojejunal tube (NJT)

Patient must have the length of tube at nostril documented in feed discharge information Position verified by checking the measurement marks on the tube, prior to each flush. This should be documented on fluid balance records. It should be the same as the discharge length.

There must be a management plan relating to tube replacement included in the discharge information relating to the feed. The tube should be secured at the nose and cheek or forehead with a suitable tape or nasofix unless a nasal bridle is in place.

Tube must be flushed before and after feed and medication, as indicated on feeding regime and documented on fluid balance record.

To ensure that the tube is still sited into the small bowel, where the pH is neutral and so pH checks are not valid.

To facilitate prompt management of a displaced feeding tube

NJ feeding tubes are especially prone to blocking. Failure to follow instructions on flushing may lead to an avoidable endoscopy to replace a blocked tube

Appendix 1 Aftercare Standards

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Aftercare standards for percutaneous tubes Care immediately post

placement (up to 72 hrs. post placement)

Aftercare of a new PEG or RIG tube

Aftercare of an established feeding tube

Rationale

Percutaneous endoscopic gastrostomy (PEG)

Follow hospital guidance in order to facilitate the early identification of complications immediately post insertion.

The dressing placed at the time of tube placement must be removed 48 hours placement and left off. The stoma should not be cleaned for the first 14 days to allow the stoma to remain undisturbed while healing.

After 14 days: The site must start to be cleaned daily with soap and water, rinsed and dried thoroughly

To prevent stoma infection

The tube must be rotated through 360o and advanced ~4-5 cm daily. This must be documented as being undertaken.

Failure to correctly rotate and advance the tube may lead to buried bumper, where the internal retention flange becomes embedded in the gastric mucosa and requires surgical removal.

Radiologically inserted gastrostomy (RIG)

As for PEG The securing buttons should be cleaned carefully with sterile water. Sutures are usually removed by the radiology team 1-2 weeks after placements

Once sutures are removed the stoma can be cleaned as for a PEG with soap and water.

To prevent stoma infection

If the tube falls out, contact the hospital immediately. Within office hours (9-5 Monday to Friday) contact the dietetics department on 01902 695335 and explain the urgency of the call Out of hours the patient

If the tube falls out, a replacement must be inserted within 2-4 hours to prevent the need for a repeat procedure. Within office hours (9-5 Monday to Friday) contact the dietetics department on 01902 695335 and explain the urgency of the call Out of hours the patient should attend

A stoma will close within 2-4 hrs. and if this happens a new procedure would be required

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should attend the Emergency Department (ED) at New Cross Hospital (with a spare tube if the patient has one)

the Emergency Department (ED) at New Cross Hospital (with a spare tube if the patient has one). Dial 999 for the resident to be taken to the Emergency Department at New Cross

Nothing should be administered down the balloon port. Water should not be withdrawn from the balloon unless specifically instructed otherwise

Nothing should be administered down the balloon port. Water should not be withdrawn from the balloon unless specifically instructed otherwise

To prevent bursting the retention balloon, which could result in a displaced feeding tube

Jejunostomy Tubes

Rationale

i) Balloon tube into the jejunum

Likely to be in hospital for > 72 hours.

Adhere to recommendations regarding suture removal. Clean stoma as a sterile technique

Once sutures are removed the stoma can be cleaned as for a PEG with soap and water.

To prevent infection around the stoma

ii) Surgical jejunostomy tube (MicKey)

The tube should not be rotated or advanced, unless specifically trained and advised to do so.

To avoid damage to the small bowel

If the tube falls out, a replacement must be inserted within 2-4 hours. Within office hours (9-5 Monday to Friday) contact the dietetics department on 01902 695335 and explain the urgency of the call. Out of hours the patient should attend the Emergency Department (ED) at New Cross Hospital (with a spare tube if the patient has one) Dial 999 for the resident to be taken to the Emergency Department at New Cross.

A stoma will close within 2-4 hrs and if this happens a new procedure would be required.

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Appendix 2 - Care Standard checks. Daily care management checklist for established PEGs (tube & site)

Patient Name

Date of Birth

Room Number

Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed)

Twice daily checks Signed to confirm completed

OR, action if deviation from standard

Sterile water labelled with name, time and date of opening (<24hrs) (for immunocompromised patients)

Single use syringes in use. No re-used syringes evident.

Feed labelled with date and time of opening (<24hrs)

Fluid record chart clearly documents feed and water administered. Consistent with current feeding regime

Patient is positioned upright at 30-45o during feed

Daily Checks PEG site clean and dry ( new tenderness

and/or erythema &/or discharge site should be swabbed)

PEG site cleaned with soap and water, rinsed and dried

PEG tube rotated 360o and advanced ~4-5cm and pulled back to resistance.

Fixation plate correctly secured and held ~1cm from skin.

No dressing, unless oozing

Connector, fixation plate & clamp all present and securely attached and clean.

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Daily care management checklist for NG tubes Patient Name

Date of Birth

Room Number

Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed)

Twice daily checks Signed to confirm completed

OR, action if deviation from standard

Sterile water labelled with name, time and date of opening (<24hrs)( for immunocompromised patients)

Single use syringes in use. No re-used syringes evident. Feed labelled with date and time of opening (<24hrs) Fluid record chart clearly documents feed and water administered. Consistent with current feeding regime Patient is positioned upright at 30-45oduring feed Correct pH paper in use (and in date) in closed container pH reading is documented on fluid balance chart before every time the tube is used Tube length must be documented on fluid chart prior to each time that the tube is used.

Daily Checks

Nostril hygiene. No redness or ulceration around nostril Tube secured appropriately

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Daily care management checklist for established RIGs (tube & site)

Patient name

Date of birth

Room no.

Date and time of check (suggest within 30 mins of starting feed and 30 mins of completing feed)

Twice daily checks Signed to confirm completed

OR, action taken if deviation from standard

Sterile water labelled with name, time and date of opening (<24hrs) ( immunocompromised patient)

Single use syringes in use. No re-used syringes

evident.

Feed labelled with date and time of opening

(<24hrs)

Fluid record chart clearly documents feed and

water administered. Consistent with current feeding regime

Patient is propped up at 30-45o during feed Correct pH paper in use (and in date) in closed

container.

pH reading documented on fluid chart before every

time the tube is used

Daily checks RIG site clean and dry RIG site cleaned with soap and water, rinsed and

dried

RIG tube rotated 360o Fixation plate correctly secured and held ~1cm

from skin.

No dressing, unless oozing Connectors and fixation plate all present, securely

attached and clean.

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