home enteral nutrition support providing home enteral nutrition support in a multidisciplinary team...

Home Enteral Nutrition Support

Providing Home Enteral Nutrition Support in a Multidisciplinary Team

Author and Presenter - Ms. Michele Port P. Dt

Author - Mr. Daniel Morris R.D., MSc.

Objectives

• To understand current best practices in providing home enteral nutrition (HEN). Areas of HEN that will be discussed include:

• Indications

• Objectives

• Patient Selection

• Contraindications

• Home environment and patient and support assessment

• Cost

• Planning

• Monitoring

• Transitional feeding

Home Enteral Nutrition SupportThe Multidisciplinary Team

• Evidence suggests a multidisciplinary support team improves standards of care and increases cost effectiveness of nutritional support 1.

• The ideal Nutrition support team contains a: nurse, dietitian, pharmacist and physician with a consulting team of occupational therapist and social worker available 2.

• Often it is only the community nurse and dietitian who work as a team, but they have access to other team members.

Home Enteral Nutrition SupportThe Multidisciplinary Team

• The multidisciplinary team approach can:

• Improve standard of care

• Increase cost effectiveness

• Ensure appropriate training and counseling of patient/or caregiver

• Reduce complication rates 1

Home Enteral Nutrition SupportObjectives

• The objectives of the multidisciplinary team providing HEN is to provide nutritional support that is:

• Individualized

• Safe

• Effective

• Cost effective 2

Home Enteral Nutrition SupportIndications

• Impaired ability to ingest nutrients:

• Oropharyngeal, esophageal tumours

• Neurological disorders e.g. cerebrovascular accident, multiple sclerosis

• Dysphagia 1, 2


• Impaired absorption of nutrients:

• Surgical resection/bypass e.g. gastrectomy, small bowel resection

• Malignancy of GIT e.g. Ca pancreas

• Inflammatory disorders e.g. Crohn’s disease

• Short bowel syndrome

• Gastrointestinal fistula,

• Radiation enteritis 1


• Miscellaneous:

• Chronic pulmonary disease

• Chronic renal failure

• Anorexia nervosa

• Congestive heart failure

• HIV/AIDS 1


• Pediatric indications:

• Neurological disorders eg. Cerebral palsy

• Failure to thrive

• Short bowel syndrome

• Chronic pulmonary disease

• Inflammatory bowel disease

• Gastroesophageal reflux

• Metabolic disorders

• Chronic renal failure

• Malignancy 1

Home Enteral Nutrition SupportContraindications

• Patient/carer not motivated or able to maintain the discipline involved in delivering HEN 1, 2

Home Enteral Nutrition SupportPatient Selection

• Incapable of meeting nutrition requirements orally

• Agrees to HEN and provides consent

• Compliant

• Willing to have follow up by community nurse and or by dietitian

• No safety issues

• Patient or caregiver can manage therapy in safe manner

• Meeting acceptable standards

• Enteral feeding access 1, 2

Home Enteral Nutrition SupportHome Environment Assessment

• Access to electricity

• Refrigeration for storage of enteral formula

• Telephone for follow up

• Adequate space for several months of formula and equipment

• Home environment safe and clean, no sign of rodents and insects 2

Home Enteral Nutrition SupportPatient and Family Support Assessment

• Is there a partner or family support?

• Is patient able to administer feedings on own?

• Do patient and caregiver understand risks, benefits and responsibilities of HEN 2?

Home Enteral Nutrition SupportCost

• Cost of tube feeding products, tubing pump, syringes are paid by the government or insurance companies in Quebec

• IV poles are provided by CLSC (community health departments) in Quebec

• Replacement tubes are inserted in endoscopy units or by radiology 2

Home Enteral Nutrition SupportNutritional Assessment

• Client History:

• Disease,stage,past history

• Age

• Metabolic demands

• Growth requirements

• Fluid requirements 1


• Medications and supplements:

• Consideration should be given to the method of delivery of medications and supplements 1

• Nutrition history

• The dietitian, through appropriate dietary methodology, will assess the nutrient intake of the client 1


• Anthropometry

• Weight, height, BMI,

• Weight history

• In children, include percentile growth data and head circumference in young children and infants

• If body weight cannot be measured, an estimation of body weight should be obtained from family or caregiver 1


• Biochemical data

• Liver function, renal function

• Serum electrolytes, glucose, phosphate and calcium 1

• Social considerations

• The home environment and the patient/carer's ability to cope with the necessary procedures shall be assessed 1

• Activity pattern and lifestyle

• The recreational and relaxation activities of the client will be considered including how these will impact on home feeding regimen 1

Home Enteral Nutrition SupportPlanning

• When choosing the most appropriate feeding route for HEN you must take into account the expected duration of nutritional support, the conscious state and clinical condition of the patient. Feeding routes include the following but will depend on the practice at your institution:

• Nasogastric

• Gastrostomy

• Nasoduodenal

• Jejunostomy

• Nasojejunal 1


• Methods of delivery of HEN

• The safest and most efficient method of delivery of HEN must be determined clinically for each patient individually. HEN can be delivered by different techniques including:

• Intermittent bolus using a syringe (not used at our institution)

• Gravity infusion

• Pump controlled 1


• Formula selection and timing of feeds for HEN

• The selection of formula should be determined by a combination of factors including: the clinical requirements, mode of delivery tolerance, long-term cost and availability 1

• Formulas should meet estimated nutritional and fluid needs taking into account other sources of fluid/restrictions 1

• Rate and timing of administration of solutions shall be based on patient tolerance and home routine 1


• The implementation of HEN and the responsibilities of the patient and caregiver will be covered in:

• McGill University Health Centre’s (MUHC) - Home Tube Feeding checklist

• MUHC’s Tube Feeding at Home information guide

Home Tube Feeding Checklist:

MUHC Enteral Home Feeding Guide 3

Home Tube Feeding ChecklistPreliminary Information

• Is the patient a candidate for home tube feeding?

• Does the patient/family wish to return home?

• Does the patient have a permanent feeding access? PEG, PEG-J, Jejunostomy)

• Is the feeding well-tolerated at the goal rate and mode. Intermittent vs. continuous?

• Who will be involved with administering the tube feeding at home i.e. patient alone, family member assisting, hired caregiver?

• Will this person be available for teaching and practicing feeding? Determine their availability schedule a.s.a.p.

Home Tube Feeding ChecklistOrdering Equipment and Feeding Product

• In Quebec ordering of equipment and formula is determined by disease(ex.cancer or neurological ) and by coverage i.e. provincial government (RAMQ) vs. private insurance.

• Example of practice: If patient has cancer, equipment and feeding request is sent to Canadian Cancer Society.

• If patient does not have cancer: fax request for equipment and formula to OPHQ if no insurance or fax list of equipment and formula to patient’s insurance company on their behalf.

Home Tube Feeding ChecklistAdditional Equipment

• The OPHQ will provide lV pole, i.e. patient with no private insurance and no cancer). Can be purchased for other cases. Patient will require a medical prescription. ln rare cases CLSC may be able to loan an lV pole. Check with liaison nurse.

• Hospital bed or other. Discuss availability with liaison nurse.

• Complete all required documentation with physician’s signature where required including: prescriptions (feeding product, IV pole, tubing and syringes), RAMQ form (usually insurance wants to a copy of government’s refusal to cover costs before accepting), OPHQ and Canadian Cancer Society.

Home Tube Feeding ChecklistTeaching Material and Practicing

• Complete tube feeding at home booklet, i.e. closed vs. open system. Review all information in the booklet with patient and caregiver if applicable

• If pharmaceutical representative is required:

• Is pharmaceutical representative present or scheduled?

• Has patient received a pump or start up kit?

• Arrange schedule with nurse for patient/caregiver to practice

• Is the observed technique acceptable?

Home Tube Feeding ChecklistDischarge

• Complete discharge summary/transfer of care to CLSC dietitian(community dietitian)

• Fax prescription to pharmacy where feeding product will be obtained to ensure availability at least 24 hours in advance

• Provide patient with samples of tubing, spike sets, syringes, bags. Provide patient with 3 days of formula, 1 set of tubing for each bottle and 3 syringes

Tube Feeding at Home: Open SystemA Brochure Given to Patient at the

McGill University Health Centre (MUHC) 4

MUHC Closed System Brochure Getting Organized

• Checklist for patients and caregivers to set up for a tube feed at home:

• Feeding set (feeding bag with attached tubing)

• Formula at room temperature

• Measuring cup

• Pump

• Pole or wall hook

• Syringe

• Wash hands thoroughly with soap and water.


• Throw out formula if:

• Past its expiry date

• Open for longer than 24 hours in the refrigerator

• Left open at room temperature


• Remember:

• Shake formula well to mix

• Formula should be at room temperature when you start your feeding

• Remove refrigerated formula from refrigerator 30 minutes before using


• The tubing on your feeding bag is called a "set" or a "spike set". This name avoids confusion with the "feeding tube" that takes the formula into your stomach or intestine.

• Close the clamp on the set. Pour the correct amount of formula into the feeding bag.

• Cover any leftover formula. Write the date and time on leftover formula. Put the leftover formula in the fridge.

• Hang the feeding bag on a pole or wall hook that is higher than your head.

MUHC Open System Brochure Getting Organized

• Starting the feeding:

• Hold the end of the set upright to prevent spills.

• Open the clamp.

• Send the formula to the end of the set to get rid of any air.

• Close the clamp.

• If using a pump, attach the set to the built-in receptacle on your pump.

• Open the cap on your own feeding tube and put the end of the spike set into your tube.

MUHC Open System Brochure Getting Organized

• If you are NOT using a pump:

• Open the cap on your feeding tube and put the end of the spike set into your tube.

• Slowly open the clamp on the set.

• If the feeding is too slow, open the clamp more.

• If the feeding is too fast, close the clamp a bit.

MUHC Open System Brochure How to Stop the Feeding

• When your feeding is finished, close the clamp.

• Stop the pump, if using one.

• Take the set out of your tube.

• To flush your feeding tube with water, put the amount of water into a syringe as calculated by the dietitian. Put this water into your tube. Put the cap back on your tube.

MUHC Open System Brochure Cleaning up the Feeding

• Throw out any formula left in the feeding bag.

• Rinse the feeding bag and set with clean cool water.

• Wash the feeding bag and set with warm water and dish soap. Use a clean bottle brush to scrub inside the bag.

• Rinse the feeding bag and set again with warm water.

• Keep your clean feeding bag and set in your refrigerator until you use it again. Do NOT use a dirty feeding bag.

MUHC Open System Brochure

• How to Position yourself Doing Feeding

• You can walk, sit in a chair or propped up in bed (45o).

• Stay in your position for 30 to 60 minutes after tube feeding is finished.

• Do not lie flat when feeding.

MUHC Open System Brochure Personal Care Tips

• Mouth Care

• Brush your teeth as usual.

• To keep your mouth clean, rinse 3 times a day with salt or 1 tsp. baking soda in 2 cups of warm water.

• You can use commercial mouthwash if your mouth is not too sensitive.

• Use a lip cream to keep your lips moist.


• Your feeding tube site

• Clean the skin around your tube every day with warm soapy water and a cotton swab, small piece of gauze or a clean washcloth.

• Rinse with water.

• Allow skin to dry.

• Do not use cream or bandages unless your doctor has told you to do this.


• Weighing Yourself

• If possible, weigh yourself once each week.

• Your dietitian will then be able to make any changes to your feeding if needed.

MUHC Open System Brochure Taking Medication

• You can take some medications through your tube.

• Some medications can be crushed or taken in a liquid form.

• Your pharmacist can tell you what is best.

• Never:

• Mix medications. Each medication must be given separately or your tube could block.

• Mix your medication with your feeding.

MUHC Open System Brochure Taking Medication

• Take medication at the proper time. Some medications are best taken with food and others on an empty stomach.

• Flush your tube with 30 mL (cc) water before giving the medication.

• Dissolve crushed medication in 30 mL (cc) warm water.

• Draw up dissolved medication into your syringe and put it into your feeding tube.

• Flush with another 30 mL (cc) warm water after each medication.

MUHC Closed System Brochure Problems and what to do

• Feeling Sick

• Take your feeding more slowly. Close the clamp more so that the feeding runs more slowly.

• If you are using a pump, decrease the rate to half your usual rate for a few hours.

• Slowly open the cap on your tube to let gas out of your stomach.

• Sit up straight when you administer your feeding.

• Do NOT lie down during, or for 60 minutes after your feeding.

• Walk if you can after your feeding.

MUHC Open System Brochure Problems and what to do

• Diarrhea

• Always use your formula at room temperature.

• Always use very clean equipment.

• Slow down the rate of the feeding on the pump or close the clamp more so that the feeding runs more slowly.

• Do not mix any medication with formula inside the feeding bag.


• Dry Mouth

• Take an extra ___ mL of water each day.

• Try rinsing your mouth with moistened swabs.

• If this is still a problem, call your dietitian.

• Constipation

• Add ___ mL more water into your tube after feedings.

• Tell your dietitian, who may change your formula or ask you to speak to your doctor.


• Blocked feeding tubes

• Flush your feeding tube with 30 ml warm water.

• Try to pull back on the syringe to draw out some liquid. Repeat these steps (1 and 2) several times.

• Note: If your tube is still blocked, call your nurse/doctor. If you can not reach them, go to the hospital emergency department.


• When to call for help

• You are vomiting.

• Your diarrhea lasts for more than 2 days.

• Your constipation lasts for more than 3 days.

• You have a fever that is more than 38.5C or 101F.

• Your tube is clogged.

• Your tube is not in the right place.

• The skin around your feeding tube changes color, is hot to touch, or is oozing liquid.

• If you have difficulty breathing, call immediately.

• If your tube falls out, call immediately.

Home Enteral

Nutrition Support:

Monitoring

Home Enteral Nutrition SupportMonitoring

• HEN protocols should include:

• Periodic review of the patient's clinical and biochemical status and quality of life, that is both realistic for the nutritional support team and patient 1.

• There is an agreed timeframe for follow-up and reassessment by the nurse and dietitian 1.

• Patients receiving HEN feeding shall be reviewed by the nutrition support team after the first 3 months of initial of treatment 1.

• In Quebec often community nurses are at the patient’s home to make sure feeding goes smoothly when patient is discharged

• Follow up can be done by telephone, home care, endoscopy clinic if tube needs replacement.


• The patient should be monitored for:

• Effectiveness of therapy

• Adverse effects

• Clinical changes 1


• Routine monitoring by the multidisciplinary team should include:

• Continued need for HEN

• Adjustment to therapy

• Nutrient intake including energy, protein and fluid needs

• Psychosocial problems

• Review of current medications

• Changes in home environment

• Signs of intolerance to feeds

• Weight changes

• Biochemical changes 1, 2

Home Enteral MonitoringMonitoring

• Discontinuation of HEN

• Protocols should exist which indicate when feeding should be stopped, and when transitional or oral feeding should commence 1.

• Enteral nutrition should be stopped when the nutrition support team and patient/caregiver judge that the patient no longer benefits from the therapy 1.

Home Enteral MonitoringMonitoring

• Moving to transitional feeding

• If the patient starts oral intake, they must be consuming adequate nutrition by this method before HEN is stopped 1.

• Dietetic involvement is important to ensure adequate nutrient intake 1.

• An intermediate period of increasing oral intake and decreasing enteral feeding will often be necessary to assess this 1.

• If swallowing difficulties are present, a speech pathologist/occupational therapist/dietitian (depending on who does swallowing assessments at your institution) will be required to assist in transition from enteral feeding to oral intake, and to minimize aspiration risk 1.

References

• 1. Clinical Practice Guidelines, Home Enteral Nutrition (HEN) in Australia. Australian Society for Parenteral and Enteral Nutrition (AusPEN). Available at http://www.auspen.org.au

• 2. Czink, S. Working towards a standard of practice in home enteral nutrition. Chicago Nutrition Week, ASPEN annual conference, 2008.

• 3. MUHC Home Tube Feeding Checklist

• 4. MUHC Home Tube Feeding Booklet

Thank You

home enteral nutrition support providing home enteral nutrition support in a multidisciplinary team...

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