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Enteral Feeding Policy 2018 149/7

Nutrition and Dietetics of 48

Document Control

Title

Enteral Feeding Policy

Author

Author’s job title Advanced Specialist Dietitians

Directorate Unscheduled care

Department Nutrition and Dietetics

Version Date

Issued Status Comment / Changes / Approval

0.1 June 2018

Draft Initial version for consultation

1.0 Oct 2018

Final Approved by Nutrition Steering Committee. What is different between this and the previous version?

1.1 July 2019

Revision Updated ICU enteral feeding flowchart

Main Contact Munro House Suite 2 North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 Tel: Internal – Email:

Lead Director Director of Nursing

Superseded Documents Enteral Feeding Policy v3.6 November 2012

Issue Date Oct 2018

Review Date Oct 2021

Review Cycle Three years

Consulted with the following stakeholders: (list all)

Nutrition Steering Committee

Community Nurses

Out of hours community nursing team

Childrens community Nurses

Company Enteral Feeding Nurse

HEF Dietitians

Pharmacist

GP

Gastroenterology Nutrition Lead Consultant

Approval and Review Process

Nutrition Steering Committee

Local Archive Reference G:\DIETETICS\Policies, procedures, pathways\Enteral Feeding Policy\updated policy 2018\Enteral Feeding Policy V1.0.docx Local Path G:\DIETETICS\Policies, procedures, pathways\Enteral Feeding Policy\updated policy 2018\Enteral Feeding Policy V1.0.docx Filename Enteral feeding policy 2018

Enteral Feeding Policy 2018 149/7


Policy categories for Trust’s internal website (Bob) Nutrition and Dietetics

Tags for Trust’s internal website (Bob) Nutrition, PEG, NG, NGT, RIG, BGT, JEJ, HEF, HETF, Paediatric, feed, feeding, Dietetic, Dietitian, gastrostomy, nasogastric, naso-gastric, jejunostomy, PEG-J, endoscopy, Endoscopic, radiology, tube, radiologically.

ICU Enteral Feeding Protocol


CONTENTS

Document Control ............................................................................................................... 1

1. Purpose ......................................................................................................................... 4

2. Definitions ..................................................................................................................... 4

3. Responsibilities ............................................................................................................ 7

4. Indications for Enteral Tube Feeding .......................................................................... 9

5. Ethical and Legal considerations of Enteral Tube Feeding (ETF) ............................. 9

6. Infection Control ......................................................................................................... 10

7. Management and Care of Enteral Tubes ................................................................... 10

8. Management and care of the patient with an enteral feeding tube ......................... 14

9. Methods of feed delivery ............................................................................................ 14

10. Starting a feed ............................................................................................................ 15

11. Equipment ................................................................................................................... 16

12. Types of feed .............................................................................................................. 21

13. Water ........................................................................................................................... 22

14. Medication................................................................................................................... 22

15. Discharging a patient from hospital .......................................................................... 23

16. Discharging a patient direct from endoscopy or outpatients .................................. 23

17. Troubleshooting ......................................................................................................... 24

18. What to do in an emergency ...................................................................................... 26

19. Monitoring ................................................................................................................... 27

20. Monitoring Compliance with and the Effectiveness of the Policy ........................... 27

21. Equality Impact Assessment ..................................................................................... 28

22. References .................................................................................................................. 28

23. Associated Documentation ....................................................................................... 29

24. Appendices ................................................................................................................. 30

Appendix 1: ways to reduce risk of infection associated with enteral nutrition processes31

Appendix 2: Decision Tree for nasogastric tube placement checks in adults ................ 32

Appendix 3: NGT risk assessment ............................................................................... 33

Appendix 4: Bicarbonate flush instructions ................................................................... 37

Appendix 5: Out of hours emergency regimen .............................................................. 38

Appendix 6: ICU enteral feeding protocol ..................................................................... 39

Appendix 7: How to prepare cooled boiled water .......................................................... 42

Appendix 8: Refeeding treatment and monitoring sticker .............................................. 43

Appendix 9: Guideline for checking balloon inflation ..................................................... 44

Appendix 10: Gastrostomy Care Checklist ................................................................... 45

Appendix 11: How to bolus feed ................................................................................... 47

Appendix 12: NGT position confirmation chart .............................................................. 48



1. Purpose

1.1. The purpose of this document is to detail the process for providing artificial nutrition enterally via tubes both in hospital and in the community. This includes feeding into the stomach and jejunum.

1.2. The policy applies to all Trust staff especially hospital and community staff dealing with enteral feeding tubes.

1.3. Implementation of this policy will ensure that:

Enteral tube feeding is carried out safely in the hospital and community Correct methods and equipment are used.

2. Definitions

HEF/ HETF

2.1. Home Enteral Feeding/ Home Enteral Tube Feeding – ingestion of liquid complete nutrition (feed) providing the patients nutritional requirements via a feeding tube inserted into the gastrointestinal tract, administered at the patients usual place of residence.

NG/ NGT

2.2. Nasogastric tube – a tube inserted through the nose, down the oesophagus until the tip is in the stomach. Used for feeding, or drainage of stomach contents. In this policy only feeding tubes are discussed.



PEG

2.3. Percutaneous Endoscopic Gastrostomy – A feeding gastrostomy tube inserted using endoscopic guidance through the mouth, into the stomach and out through the abdominal wall. For feeding directly into the stomach, or for drainage of stomach contents. At NDDH, the 15F Freka tube is routinely used. In Exeter, the Corpak medsystems 16F tube is routinely used.

RIG

2.4. Radiologically Inserted Gastrostomy – a balloon retained gastrostomy tube (BGT or G-tube) inserted using radiological (x-ray) guidance into the stomach directly through the abdominal wall. For feeding directly into the stomach, or for drainage of stomach contents. This method of insertion is used if the endoscopic method is not possible.



Capsule Monarch gastrostomy tube

2.5. This is a non-balloon retained tube which is used for patients whose balloon retained tubes do not last. It is inserted via an existing stoma and lasts 1-2 years.

PEG-J

2.6. Percutaneous Endoscopic Gastrostomy with a Jejunal extension – a 9Fr tube passed through an existing Freka 15Fr PEG under endoscopic guidance, into the jejunum, to allow feeding directly into the jejunum. The gastric port can also be used for administration of fluids, medication or feed, or drainage.

Low profile/ Button Gastrostomy

2.7. A low profile balloon retained gastrostomy, inserted through an existing gastrostomy stoma (more than 6 weeks post initial tube placement). The length of the patient’s stoma must be measured using a stoma measuring device, to ensure the correct shaft length of the tube.



Low profile trans-gastric jejunal tube

2.8. A low profile balloon retained gastrostomy with an extension below the balloon which passes into the jejunum. These are placed using endoscopic or radiological guidance.

NJ

2.9. Naso-jejunal tubes – a tube inserted through the nose, oesophagus, stomach and duodenum, into the jejunum, to allow feeding directly into the jejunum.

JEJ/ surgical jejunostomy

2.10. Jejunostomy tube – a surgically placed tube inserted directly through the abdominal wall into the jejunum for feeding. The retaining triangle is usually stitched to the skin. Fresenius Freka 9Fr tube.

3. Responsibilities

Role of Nutrition Steering Group

3.1. The Nutrition Steering Group is responsible for:

Commenting on and ratifying the policy



Role of the Dietitian

3.2. The dietitian is responsible for:

Assessing the nutritional status and estimating the nutritional requirements for all patients who commence enteral feeding

Recommending a suitable feed and feeding regimen for the patient Reviewing patients as clinically required Reviewing all patients at home at least every 6 months Providing equipment for patient on discharge Registering the patient with the Company homecare service and ordering feed and

equipment Arranging training for patient and carers on discharge and as required Arranging for Fresenius Homecare nurse review in the community as required

Role of the Fresenius Kabi Nurse Advisor

3.3. The Fresenius Kabi Nurse Advisor is responsible for:

Visiting patients at home to undertake review as requested by the dietitian Training patients/ carers on care of tubes and how to use the equipment Changing nasogastric and gastrostomy tubes in the community Reviewing and assessing gastrostomy / jejunostomy stoma sites and recommending

treatments to GPs/ District Nurses Troubleshooting as requested by the dietitian

Role of the Ward Nurse

3.4. The ward nurse is responsible for:

Referring all inpatients with enteral feeds to the dietitian Setting up feeds, administering feeds and medications via enteral tubes as per

feeding regimen and prescription chart Monitoring the patient Cleaning and care of the tube and stoma Inserting nasogastric tubes Checking the position of nasogastric tubes using pH test before each use and at least

once daily Ordering the correct feed from the hospital kitchen Using the correct documentation (eg care plan, feed and fluid charts, NG position

check charts)

Role of the Community Nurse

3.5. The community nurse is responsible for:



Ordering enteral and luer syringes as required for the patients at home Seeing patients who require community nurse input relating to their feeding tube/

stoma

Role of the GP

3.6. The GP is responsible for:

Prescribing medications in a form suitable to be administered via an enteral tube Monitoring blood tests if required

Role of the Fresenius Kabi Homecare service

3.7. The Fresenius Kabi Homecare service is responsible for:

Carrying out all responsibilities outlined in their contract Monthly deliveries of feed and equipment to the patient

4. Indications for Enteral Tube Feeding

4.1. Patients who are malnourished or at risk of malnutrition as defined by the malnutrition universal screening tool (MUST) (See Nutrition Policy), and have the following:

Inadequate or unsafe oral intake A functional and accessible gastrointestinal tract

The decision to commence enteral tube feeding should be reviewed daily for patients who are not meeting their nutritional needs orally.

On the intensive care unit (ICU), enteral tube feeding should be commenced within 24 hours on every patient who will not be taking adequate oral intake within 3 days, unless there are definite contra-indications to doing so.

5. Ethical and Legal considerations of Enteral Tube Feeding (ETF)

5.1. ETF should never be started without consideration of all related ethical issues and must be in a patient’s best interests.

5.2. ETF is considered to be a medical treatment in law. Starting, stopping, or withholding such treatment is therefore a medical decision which is always made taking the wishes of the patient into account.

5.3. In cases where a patient cannot express a wish regarding ETF, the doctor must make decisions on ETF in the patient’s best interest. Consulting widely with all carers and family is essential.



6. Infection Control

Potential Hazards

6.1. There are potential hazards associated with enteral feeding which can make it a source for the growth of micro-organisms. Liquid nutrients provide an ideal medium for bacteria and can cause cross contamination to the feeding system during setting up and handling the equipment. Carers and healthcare workers should not handle enteral feeds if they have skin infections, diarrhoea or vomiting and must seek medical advice in such situations.

6.2. Please see appendix 1 or link below for ways to reduce risk of infection associated with the enteral nutrition processes.

http://webarchive.nationalarchives.gov.uk/20120118171803/http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Enteral-Feeding-Care-Bundle-FINAL.pdf

7. Management and Care of Enteral Tubes

NG/NGT

7.1. 8Fr GBUK Enteral polyurethane tubes are used on wards and in the community. Alternative 6Fr Corflo polyurethane tubes are available for use in the community and should be considered for patients undergoing longer term feeding.

7.2. Secure the tube to the patient’s nose or cheek using a suitable fixation such as Tendergrip skin fixation. (See video for insertion and securing of tube).

7.3. Check the position of the tube following insertion and before any water, feed or medication is given, using gastric aspiration and pH testing. Only GBUK enteral pH testing strips should be used in the hospital. (See image). (See video for how to check pH).

http://webarchive.nationalarchives.gov.uk/20120118171803/http:/hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Enteral-Feeding-Care-Bundle-FINAL.pdf

http://webarchive.nationalarchives.gov.uk/20120118171803/http:/hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Enteral-Feeding-Care-Bundle-FINAL.pdf



7.4. For inpatients, document the pH readings on the NG tube position confirmation chart and keep this with the end of bed notes. (appendix 12).

7.5. A pH of 5.0 or less must be obtained before the tube can be used. If an aspirate is unable to be obtained please see appendix 2 (decision tree) for instructions. If the pH is 4.0-5.0 it is possible that the tip of the tube is in the oesophagus. If the pH is more than 5.0 do not administer anything via the tube. Please see flow chart in appendix 2 for instructions. (NB the national flow chart and guidance still states that a pH of 5.5 or less confirms gastric placement. However more recent research indicates that pH 5.0 is the safest cut off, therefore that is used in this policy). https://bmjopen.bmj.com/content/bmjopen/7/11/e018128.full.pdf

7.6. If the patient is on a PPI – proton pump inhibitor (eg lansoprazole) or antacid this could affect regular pH readings. It is important to document readings and if a high reading is usual for that patient. See flowchart in appendix 2. Consult dietitians if not sure whether to use the tube.

7.7. Ensure patient has a risk assessment for NG feeding at home. (See appendix 3)

7.8. Do not feed overnight with NG tube at home, due to risk of tube displacement and aspiration.

7.9. If a NG tube needs to be replaced or inserted at home, contact the dietitians or if out of office hours, go to A&E.

PEG

7.10. 9Fr & 15Fr Freka PEG (Fresenius Kabi) or 16Fr Corflo PEG (Halyard Health)

7.11. Freka PEG – care on day 1 post insertion – see https://vimeo.com/292876194 Ensure that a gastrostomy care checklist is included on end of bed notes (appendix 10).

7.12. Freka PEG – daily care of the tube and stoma – see https://vimeo.com/292875179

Freka PEG - Advance and rotate the tube daily from day 10 after insertion. See https://vimeo.com/292875274 for instructions on how to advance and rotate.

Freka PEG care guide:

https://www.fresenius-kabi.com/gb/documents/Gastrostomy_Feeding_Care_Guideline.pdf

7.13. Corflo PEG – Advance and rotate the tube daily from day 28 after insertion. See https://vimeo.com/292876051 for daily care of the tube and stoma.

7.14. Ensure retention device (white triangle, or white rectangle) is 2mm from the skin to avoid overgranulation or leakage of stomach contents.

7.15. Replace end adaptors, retention devices and clamps when they become broken. (Supplied by the dietitian). See https://vimeo.com/292875354 for instructions on how to do this for the Freka PEG.

https://bmjopen.bmj.com/content/bmjopen/7/11/e018128.full.pdf

https://vimeo.com/292876194



https://www.fresenius-kabi.com/gb/documents/Gastrostomy_Feeding_Care_Guideline.pdf





7.16. Leave clamps open when tubes are not in use, to avoid flattening and weakening of the tube. Only smaller 9Fr tubes should be clamped when not in use to avoid stomach contents coming into tube and causing blockage.

7.17. Freka PEG tubes should last for more than 18 months, but are kept in place indefinitely as long as they are functioning.

7.18. PEG – If a new replacement PEG has been placed in an existing tract the PEG can be advanced and rotated from day one if no signs of trauma. If signs of trauma to site to await medical review prior to advancing & rotating.

RIG/ BGT

7.19. 12Fr, 14Fr or 16Fr Balloon retained gastrostomy (Entral - Halyard Health, GBUK Enteral)

7.20. Clean the tube and stoma daily. https://vimeo.com/292876749

7.21. Advance and rotate weekly from 10 days post insertion. see https://vimeo.com/292876749

7.22. Check balloon inflation weekly. Use cooled boiled water in the balloon. (see https://vimeo.com/292876749 for instructions). See appendix 9 for guideline on checking balloon inflation.

7.23. Ensure retention disc is 2mm from the skin to avoid overgranulation or leakage of stomach contents.

7.24. Leave clamps open when tubes are not in use, to avoid flattening and weakening of the tube.

7.25. Tubes last for 3-6 months, and are routinely changed every 3-6 months. How to change a balloon gastrostomy tube https://vimeo.com/292876483. ONLY DO THIS IF YOU HAVE RECEIVED FACE TO FACE TRAINING AND COMPETENCY.

7.26. Each patient should keep a spare tube and or ENPLUG at home, supplied by the dietitian/ district nurse.

7.27. If RIG/ BGT falls out ENPLUG can be used to keep tract open until trained health professional can place new balloon gastrostomy tube. Place an ENPLUG in the tract and tape over with micropore tape.

Capsule Monarch Gastrostomy

7.28. Clean the tube and stoma daily.

7.29. Advance and rotate the tube weekly from insertion.

7.30. Ensure retention disc is 2mm from the skin to avoid overgranulation or leakage of stomach contents.

7.31. Leave clamps open when tubes are not in use, to avoid flattening and weakening of the tube.







7.32. These tubes should last 1-2 years.

PEG-J

7.33. Freka PEG-J (Fresenius-Kabi) – Daily advance only, DO NOT rotate. See instructions in https://vimeo.com/292876299 on how to advance a PEG-J and daily care.

7.34. Clean the cap, tube and stoma daily (see https://vimeo.com/292876299)

7.35. Flush the jejunal port with sterile water in hospital or cool boiled water in the community. Flush tube at least 4-6hourly and before and after each feed (see https://vimeo.com/292876299)

7.36. Flush gastric port at least daily even if this is not being used. (See https://vimeo.com/292876299)

7.37. Weekly bicarbonate solution flush for jejunal port to avoid blockage. (Appendix 4)

7.38. To change the end of a PEG-J or to unblock, please contact the dietitian.

7.39. PEG-J – If a whole new replacement PEG-J has been placed in an existing tract the PEG-J can be advanced from day one if no signs of trauma. If signs of trauma to site to await medical review prior to advancing tube.

Low Profile/ Button Gastrostomy

7.40. MIC-KEY (Halyard Health) or Freka Belly Button (Fresenius Kabi), various french sizes and lengths.

7.41. Clean the tube and stoma daily (see https://vimeo.com/292876884)

7.42. Advance and rotate weekly from 10 days post insertion. (https://vimeo.com/292876980)

7.43. Check balloon inflation weekly. Use cooled boiled water in the balloon in the community or sterile water in the hospital. (see https://vimeo.com/292876980 for instructions). See appendix 9 for guideline on checking balloon inflation.

7.44. Tubes last for 3-6 months, and are usually routinely changed every 3 months. How to change a low profile gastrostomy tube https://vimeo.com/292877084 ONLY DO THIS IF YOU HAVE RECEIVED FACE TO FACE TRAINING AND COMPETENCY.

7.45. Each patient should keep a spare tube at home & ENPLUG, supplied by the dietitian/ district nurse.

7.46. Stoma length can be checked as necessary or annually by the Fresenius Kabi Nurse or dietitian.

7.47. If low profile/ button gastrostomy falls out ENPLUG can be used to keep tract open until trained health professional can place new low profile/ button gastrostomy. Place ENPLUG in the tract and tape over with micropore tape.











Surgical Jejunostomy

7.48. Clean the cap, clamp and stoma daily

7.49. Flush the tube with sterile water in hospital or cool boiled water in the community. Flush tube at least 4-6hourly and before and after each feed

7.50. Change the transparent dressing and clean the stoma site daily

7.51. Replace the stitches as required usually every 6 weeks. The stitches on this tube’s fixation device must stay in place to hold the tube in. If stitches come out will need to be replaced urgently

7.52. For instructions on care of this tube see video https://vimeo.com/292877236

8. Management and care of the patient with an enteral feeding tube

Mouthcare

8.1. Even if the patient is nil by mouth, the teeth, tongue and gums should be cleaned twice daily using a toothbrush and toothpaste. To freshen the breath and cleanse the mouth, a medicated mouthwash can be used. To moisten the lips, use a moisturising cream or lip balm.

Positioning

8.2. During and for half an hour after feeding the patient should be positioned at least 30 degrees, ideally sitting as upright as possible to avoid regurgitation of feed and aspiration.

9. Methods of feed delivery

9.1. Follow the method of feeding recommended by the dietitian on the feeding regimen. If you feel that a different method would be more appropriate for the patient, please contact the dietitian.

Pump

9.2. The Amika Pump (Fresenius Kabi) is used for enteral feeding (See videos below for how to set up a pump and troubleshooting)

How to use the Amika Enteral feeding pump

https://player.vimeo.com/video/244047260

Troubleshooting the Amika Enteral feeding pump







Amika Pump Quick Reference Guide

Amika Pump Pictorial Reference Guide

9.3. Can be used on a drip stand or in a ruck sack for patients at home who are ambulatory (available from dietitians).

Bolus

9.4. Giving the feed in measured doses using a 60ml enteral syringe.

9.5. For instructions on how to bolus feed see https://vimeo.com/292875552, and appendix 11.

Gravity

9.6. Allowing the feed to drip in using gravity rather than a pump. See https://vimeo.com/292875674 for instructions.

10. Starting a feed

Ward

10.1. Any patient being considered for enteral feeding should be referred to the dietitian. The dietitian will decide on method of feed delivery in consultation with doctors and other healthcare professionals, as required.

10.2. The dietitian will consider the patient’s current and past nutritional status, feeding environment, refeeding syndrome risk, allergies, reason for feeding enterally, proposed time period of enteral feeding, any complications present and patient wishes.

10.3. A written regimen specifying feed, rate of feeding and additional water flushes will be provided by the dietitian. An emergency enteral feeding regimen is available on BOB that can be used to commence feeding out of hours (see appendix 5).

10.4. Ensure that the Gastrostomy care checklist is on the end of bed notes (appendix 10).

Refeeding syndrome

10.5. This potentially lethal condition is often not recognised or inappropriately treated, especially on general wards.

10.6. Patients identified by the dietitian at high risk of refeeding syndrome will have a sticker or documentation by the Dietitian (if sticker not available) inserted in their medical notes recommending suitable vitamin and mineral supplementation. See appendix 8 for further information on refeeding syndrome and a template of the sticker.





Home

10.7. If the patient has a nasogastric tube, a risk assessment (appendix 3) will need to be completed and signed by the consultant.

11. Equipment

Pump and Dripstand or Rucksack

11.1. The Amika pump (Fresenius-Kabi) is used for enteral feeding. It is available on all wards and in the community pumps are arranged by the dietitian. Instructions on setting up the pump can be found here:

How to use the Amika Enteral feeding pump


Troubleshooting the Amika Enteral feeding pump


Amika Pump Quick Reference Guide

Amika Pump Pictorial Reference Guide

The pump should be attached to a drip stand or set up in the rucksack provided if using (ambulatory patients in the community).

Staff using pumps should be assessed as competent as per the local management of medical devices policy.

Cleaning of pumps – decontamination with detergent wipes when visibly soiled and between patient use. If soiled with blood or body fluids, clean according to the infection control manual (1000ppm chlorine).





Giving sets

11.2. Required to feed with the pump.

There are various different giving sets, but the one used on the wards is the Amika mobile set, which can be used with the dripstand or in the rucksack.

If using an Abbott feed bottle, the varioline giving set is required.

If decanting feed a reservoir bag set is required.



Gravity sets are available for feeding without the pump.

Hydrobag – this can be used for water or decanted feed, and any of the giving sets can be attached to it.

Giving sets are available on top up on the wards, and deliveries arranged by dietitian in the community.

Bolus adaptors

11.3. Bolus adaptors are used to insert into a feed bag to access feed using a syringe. They can stay in the feed bag for up to 24 hours with no need to refrigerate.



Easy bottle adaptor

11.4. Easy bottle adaptors are used if an oral nutritional supplement bottle is to be hung with a gravity feeding set or a pump feeding set.

Syringes

11.5. Wards use single use purple enteral syringes

Community patients use re-usable single patient use enteral syringes supplied by community nursing teams. If patient’s tube is directly into the jejunum single use syringes are required in the community also.

Sizes available from 1ml to 60ml depending on requirements.

Do not use clear bladder/ catheter tip syringes with enteral feeding tubes except to aspirate gastric contents from a cone ended tube.

5ml or 10ml clear luer slip syringes are required for changing the water in balloon gastrostomy tubes, also supplied by community nursing teams.

Extension Sets

11.6. These are connected to button gastrostomy tubes to allow a giving set or syringe to be attached for feeding or flushing.



Griplok skin fixation

11.7. Griplok (Velcro dressing) can be used to prevent gastrostomy tubes dangling and secure them in place.

Spare parts

11.8. Spare parts for Freka PEG and other tubes are available from the dietitians.

Spare tubes

11.9. All patients with a balloon retained feeding tube or nasogastric tube will be given a spare to keep at home in case of emergency. Some patients / carers will be trained to replace their own tube at home.

ENPlug

11.10. These are used to keep a gastrostomy stoma open if a tube falls out, or to dilate a tract if it is partially closed. They are available from the dietitians.



Enteral Drainage Bag

11.11. This is used to drain stomach contents for patients who have a gastrostomy for venting or drainage.

12. Types of feed

Sterile commercial feeds

12.1. The majority of patients will be on these feeds. Currently the trust has a contract with Fresenius Kabi so their feeds are used. In hospital they are stored in the kitchen, in the community, the dietitians order the feeds and they are off script – no prescription is required.

Feeds should be stored in a clean dry environment, between 5-25 degrees. Check expiry date before use. Do not add anything to the feed. Discard unused open feed after 24 hours. If feeds have been opened for bolus feeding using a bolus adaptor, they can be used for up to 24 hours and do not need to be stored in the fridge. If opened and decanted aseptically they should be refrigerated below 5 degrees and used within 24 hours.

Decanted sterile feeds

12.2. Feeds which are not ready to hang or require additions must be decanted into a sterile reservoir. The full volume for 24 hours should be decanted using an aseptic no touch technique.

Powdered feeds/ non sterile feeds

12.3. Utensils must be sterile or heat sterilised in a dishwasher. Feeds must be thoroughly mixed using a no touch technique. Sterile water must be used in hospital, cooled boiled water at home to make up powdered feeds. Modified feeds can be refrigerated below 5 degrees for up to 24 hours. Feeds can hang at room temperature for up to 4 hours in hospital, or up to 12 hours at home if the patient is older than 12 months and not immune compromised.



Blended diet

12.4. Blended or puréed foods are increasingly being used for tube feeding. Currently there is not sufficient evidence to endorse the use of these and there are risks of tube blockage, contamination and inadequacy of nutritional content. However, if patients do insist on using these against health care professionals’ advice, a risk assessment should be completed, and the patients should be offered dietetic advice to maintain their nutritional status. https://www.peng.org.uk/pdfs/hcp-resources/risk-assessment-template.pdf Click link for risk assessment.

13. Water

Sterile water

13.1. Sterile water should be used in hospital for

inflating balloons of balloon retained devices

flushing jejunal feeding tubes

making up powdered feeds

all infants under 12 months old

immunocompromised patients.

Cooled boiled water

13.2. Cooled boiled water should be used at home for

inflating balloons of balloon retained devices

flushing jejunal feeding tubes

making up powdered feeds

Hanging water to be administered into the stomach

For instructions on how to prepare cooled boiled water see appendix 7

Tap water

13.3. Freshly drawn tap water should be used for flushing gastrostomy tubes in hospital and at home. See video for how to flush a tube https://vimeo.com/292875446

14. Medication

14.1. See Medication administration via enteral tubes SOP, http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2014/10/Enteral-Feeding-Tube-Medication-Administration-SOP-v2.0.pdf

https://www.peng.org.uk/pdfs/hcp-resources/risk-assessment-template.pdf



http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2014/10/Enteral-Feeding-Tube-Medication-Administration-SOP-v2.0.pdf




14.2. Insulin and glycaemic management – see separate guideline https://www.northdevonhealth.nhs.uk/wp-content/uploads/2017/03/Managing-Hyperglycaemia-in-Acute-Adult-Inpatients-v1.0-Mar17.pdf

14.3. Flush the tube with water before and after each medication

14.4. Give each medication separately and flush water between each

14.5. Do not add medications to feed

14.6. Do not crush enteric coated tablets

14.7. See video for instructions on how to give medications https://vimeo.com/292875803

14.8. Consult Pharmacy for drug nutrient interactions or advice on alternative preparations of medications, or refer to the “handbook of Drug administration via enteral feeding tubes” by Rebecca White and Vicky Bradnam. (Copy available in the dietitians office).

15. Discharging a patient from hospital

15.1. Training will be arranged by the dietitian and may be carried out by the Fresenius Kabi Nurse Advisor

15.2. Written information and seven days supply of equipment will be provided by the dietitian

15.3. Seven days supply of feed will need to be supplied from the ward

15.4. For Nasogastric tubes a risk assessment (appendix 3) will be completed by the trainer and signed by the consultant.

15.5. Dietitian will arrange supplies of feed and equipment, and ongoing supplies for the patient.

15.6. Ward to inform dietitian of any discharge plans

16. Discharging a patient direct from endoscopy or outpatients

16.1. Refer to dietitian with as much notice as possible

16.2. Dietitian will arrange training of the patient/carers, which will either take place in the hospital or in the patient’s home.

16.3. Dietitian will arrange supplies of feed and equipment, and ongoing supplies for the patient.

16.4. For Nasogastric tubes a risk assessment (appendix 3) will be completed by the trainer and signed by the consultant.

https://www.northdevonhealth.nhs.uk/wp-content/uploads/2017/03/Managing-Hyperglycaemia-in-Acute-Adult-Inpatients-v1.0-Mar17.pdf





17. Troubleshooting

Unblocking a tube

17.1. See video https://vimeo.com/292875911

17.2. Ensure all clamps are open and the tube is free from kinks, undo the fixation device.

17.3. Draw up 20ml water in a 60ml enteral syringe.

17.4. Massage the feeding tube around the area of the blockage if visible.

17.5. Attach the syringe to the end of the tube and pull back on the plunger. If anything comes out of the tube, disconnect the syringe and discard the contents.

17.6. Refill the syringe with 20ml water and reattach to the feeding tube. Push and pull on the syringe as firmly as possible.

17.7. Continue to massage the tube while pushing and pulling on the syringe until the blockage is cleared. This can take some time, allow 1-2 hours.

17.8. Once the blockage is cleared, flush the tube with clean water using a push pause massage technique. Clamp the tube and replace the fixation device.

17.9. If unable to clear the blockage, leave for half an hour and try again. If still unable, contact the dietitian.

Overgranulation

17.10. Ensure the fixation device is placed correctly 2mm away from the skin. If loose, this can exacerbate or cause overgranulation.

17.11. If unsure about treating overgranulation contact dietitian or Fresenius Kabi Nurse Advisor (via dietitians)

17.12. Apply double thickness foam dressing for 7-10 days. Leave in situ for 1-3 days

17.13. If not healed, apply hydrocortisone 1% cream up to 3x daily for 10-14 days

17.14. If not healed, and no exudate apply Haelan cream 2x daily for 10-14 days

17.15. If not healed and there is exudate apply keyhole foam or silver dressing, change according to strike through of exudate

17.16. If not healed apply elocon cream once daily for 2 weeks maximum

17.17. If not healed consider silver nitrate with medical guidance. Apply treatment every 3-4 days in conjunction with hydrocortisone 1% cream until completely healed.




Leaking stoma

17.18. Ensure the fixation device is placed correctly 2mm away from the skin. If loose, this can exacerbate leakage. Ensure the patient is positioned correctly when feeding.

17.19. If unsure about treating leakage contact dietitian or Fresenius Kabi Nurse Advisor (via dietitians).

17.20. Check the tube for damage, if damaged, repair or replace tube.

17.21. Check the patient is not suffering with constipation or a chest infection, if so treat the problem.

17.22. Test leakage with pH indicator to determine whether it is stomach acid or a potential infection.

17.23. If pH less than 5.5, leakage is gastric content. Apply barrier cream and a keyhole dressing for 10-14 days at least

17.24. If possible infection, contact GP or Fresenius Kabi nurse advisor via the dietitians

17.25. If still leaking, contact the Fresenius Kabi Nurse advisor via the dietitians.

Diarrhoea

17.26. Possible causes: medication, feed infusion rate, infection, fibre content of feed, malabsorption.

17.27. Review medications

17.28. Check for infective cause

17.29. Keep a stool chart using Bristol stool scale

17.30. Contact the dietitian

Constipation

17.31. Possible causes: medication, lack of fluid, fibre content of feed, changes in gut motility.


17.33. Consider laxatives

17.34. Consider change of feed – contact dietitian

Nausea/ vomiting

17.35. Possible causes: medication, infection, constipation, feed infusion too rapid

17.36. Check for infection




17.38. Contact dietitian, possibly slow feed rate

Discoloured tube

17.39. Possible causes: medication, feed, age of tube

17.40. Continue to use tube as normal

17.41. If unsure contact dietitian for review

Misshapen tube

17.42. Possible causes: age of tube, fungal infiltration of tube

17.43. Continue to use tube as normal

17.44. Monitor tube closely for splits

17.45. If unsure contact dietitian

Internally coated tube

17.46. Possible cause: build up of feed or medication, inadequate flushing technique

17.47. Flush using bicarbonate solution weekly

17.48. Flush using push pause massage technique (see https://vimeo.com/292875446)

Buried bumper

17.49. Cause: insufficient frequency of advance and rotation of the tube.

17.50. Advance and rotate the tube as advised in section 7 or on video https://vimeo.com/292875274

17.51. If suspect buried bumper contact dietitian immediately

18. What to do in an emergency

In office hours

18.1. Contact the dietitians dept at NDDH 01271 322306 or the Fresenius Kabi Helpline 0808 1001990





Out of office hours

18.2. Contact 111 and ask for the out of hours community nurses for problems with tubes.

18.3. Contact Fresenius Kabi Homecare 24 hour helpline 0808 1001990 and speak to a nurse advisor who can troubleshoot over the phone for tube or pump problems or arrange for a replacement pump.

18.4. Go to A&E if the problem cannot be resolved by the out of hours community team or FK homecare helpline.

19. Monitoring

In Hospital

19.1. Adequate monitoring is vital to reduce the incidence of complications, reduce electrolyte and metabolic abnormalities and ensure adequate nutrition is delivered.

19.2. NICE Clinical Guideline 32 provides comprehensive protocols for clinical, laboratory and anthropometric monitoring of patients receiving enteral feeding and these can be accessed from the following link: https://www.nice.org.uk/guidance/cg32/chapter/1-Guidance#monitoring-of-nutrition-support-in-hospital-and-the-community

19.3. Reference to refeeding syndrome monitoring can also be found in appendix 8.

At Home

19.4. Blood testing only if clinical need.

19.5. Weight at least 6 monthly in own home, or monthly in care home.

19.6. Other anthropometry as indicated to be performed by the Dietitian.

20. Monitoring Compliance with and the Effectiveness of the Policy

Standards/ Key Performance Indicators

20.1. Key performance indicators comprise:

20.2. Audit of compliance with NPSA alerts.

20.3. Audit of compliance with national guidance.

Process for Implementation and Monitoring Compliance and Effectiveness

20.4. Monitoring compliance with this policy will be the responsibility of the Senior Nurse or Departmental Manager for the areas in which this policy applies.

https://www.nice.org.uk/guidance/cg32/chapter/1-Guidance#monitoring-of-nutrition-support-in-hospital-and-the-community

https://www.nice.org.uk/guidance/cg32/chapter/1-Guidance#monitoring-of-nutrition-support-in-hospital-and-the-community



20.5. Where non-compliance is identified, support and advice can be provided by the Nutrition steering committee when requested.

21. Equality Impact Assessment

21.1. The author must include the Equality Impact Assessment Table and identify whether the policy has a positive or negative impact on any of the groups listed. The Author must make comment on how the policy makes this impact.

Table 1: Equality impact Assessment

Group Positive Impact

Negative Impact

No Impact

Comment

Age

Disability

Gender

Gender Reassignment

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment), marriage and civil partnership

Pregnancy

Maternity and Breastfeeding

Race (ethnic origin)

Religion (or belief)

Sexual Orientation

22. References

22.1. NICE interactive pathway for nutrition support in adults (8.8.2017) https://pathways.nice.org.uk/pathways/nutrition-support-in-adults

22.2. Infection Control Nurses Association (2003). Enteral Feeding Infection Control Guidelines. Bathgate: Infection Control Nurses Association

22.3. NICE Clinical Guideline 32. Nutrition Support in Adults. February 2006

22.4. NICE Clinical Guideline 2. Infection Control. Prevention of Healthcare-associated Infection in Primary and Community Care. June 2003.

22.5. NPSA alert 05: Reducing harm caused by the misplacement of nasogastric feeding tubes, 22 Feb 2005

22.6. NPSA alert 19: Promoting safer measurement and administration of liquid medicines via oral and other enteral routes 28 Mar 2007

22.7. NPSA alert NPSA/2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults children and infants.

22.8. https://improvement.nhs.uk/documents/194/Patient_Safety_Alert_Stage_2_-_NG_tube_resource_set.pdf NPSA patient safety alert 22.7.2016

https://pathways.nice.org.uk/pathways/nutrition-support-in-adults

http://www.nice.org.uk/guidance/index.jsp?action=byID&o=10978



http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/nasogastric-feeding-tubes/

http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/liquid-medicines/

http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/liquid-medicines/

http://www.nrls.npsa.nhs.uk/resources/?entryid45=129640&q=0%c2%acnasogastric%c2%ac

http://www.nrls.npsa.nhs.uk/resources/?entryid45=129640&q=0%c2%acnasogastric%c2%ac

https://improvement.nhs.uk/documents/194/Patient_Safety_Alert_Stage_2_-_NG_tube_resource_set.pdf



22.9. High Impact Intervention Enteral Feeding Care Bundle

22.10. Administering drugs via enteral feeding tubes, a practical guide (poster) BAPEN 2003

22.11. Reducing healthcare associated infections

22.12. NMC Standards for Medicines Management http://www.nmc-uk.org/Publications-/Standards1/ 2007

22.13. Selecting pH cut offs for the safe verification of nasogastric feeding tube placement: a decision analytical modelling approach. 2017 https://bmjopen.bmj.com/content/bmjopen/7/11/e018128.full.pdf

23. Associated Documentation

23.1. Aseptic and Clean Technique Policy

23.2. Clinical competency for care of patients with NG tubes

23.3. Clinical competency for insertion of NG tubes

23.4. Clinical competency for replacing a balloon gastrostomy

23.5. Infection Prevention and Control Operational Policy

23.6. Standard Infection Control Precautions Policy

23.7. Medication administration via enteral tubes SOP

23.8. Blended diet risk assessment

23.9. Medical Devices management policy

23.10. Managing hyperglycaemia in acute adult inpatients on enteral feeding

23.11. Nasogastric check x-rays SOP

23.12. Nasogastric feeding in adults SOP

23.13. Nutrition Policy

http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Enteral-Feeding-Care-Bundle-FINAL.pdf

http://www.bapen.org.uk/res_drugs.html

http://hcai.dh.gov.uk/files/2011/03/2011-03-14-HII-Enteral-Feeding-Care-Bundle-FINAL.pdf

http://www.nmc-uk.org/Publications-/Standards1/

https://bmjopen.bmj.com/content/bmjopen/7/11/e018128.full.pdf

http://ndht.ndevon.swest.nhs.uk/policies/?p=1222

http://ndht.ndevon.swest.nhs.uk/wp/wp-content/uploads/competency/Under%20take%20the%20care%20of%20individuals%20with%20nasogastric%20tubes.pdf

http://ndht.ndevon.swest.nhs.uk/wp/wp-content/uploads/competency/Insert%20and%20secure%20a%20nasogastric%20tube.pdf

http://ndht.ndevon.swest.nhs.uk/wp/wp-content/uploads/competency/Replacing%20balloon%20gastrostomy%20tubes.pdf





http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2011/03/Medical-Devices-Management-Policy-V4.0-20Aug15.pdf


http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2017/12/Nasogastric-Check-X-rays-SOP-29th-Nov-Updated-May-18.pdf

http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2013/11/Nasogastric-Feeding-in-Adults-SOP-V2.-1-06Jul15.pdf

http://ndht.ndevon.swest.nhs.uk/wp-content/uploads/2014/01/Nutrition-Policy-v2.1-08Jan14.pdf



23.14. Enteral Feeding Videos

Daily Cleaning Of The Freka PEG https://vimeo.com/292875179

Advance And Rotate. Freka https://vimeo.com/292875274

Replacing Cap, Clamp, Triangle. Freka https://vimeo.com/292875354

Flushing Freka https://vimeo.com/292875446

Bolus Feading Freka https://vimeo.com/292875552

Gravity Feeding https://vimeo.com/292875674

Medication Via A PEG https://vimeo.com/292875803

Blocked PEG https://vimeo.com/292875911

Corflo PEG 2N https://vimeo.com/292876051

Day 1 Freka PEG https://vimeo.com/292876194

PEGJ Cleaning And Flushing 2 https://vimeo.com/292876299

Balloon Gastrostomy Change 2 https://vimeo.com/292876483

Balloon Gastrostomy Weekly Care 2 https://vimeo.com/292876749

Low Profile Device Daily Care https://vimeo.com/292876884

Low Profile Device Weekly Care 2 https://vimeo.com/292876980

Low Profile Device Tube Change https://vimeo.com/292877084

Surgical JEJ 2 https://vimeo.com/292877236

24. Appendices




















Appendix 1: ways to reduce risk of infection associated with enteral nutrition processes



Appendix 2: Decision Tree for nasogastric tube placement checks in adults

Guidance taken from NPSA (2011) Reducing

the harm caused by misplaced nasogastric feeding tubes in adults, children and infants

Patient Identification Label



Appendix 3: NGT risk assessment

Source of risk: Nasogastric tube feeding

TYPE OF RISK- identify each separate risk

Indicate if at risk [ ]

A Patient in home setting being unable to feed due to accidental tube removal/ tube blockage. Patient needing emergency community support or hospital attendance.

[ ]

B Misplaced feeding tube not detected prior to use, causing aspiration.

[ ]

C Unable to obtain gastric aspirate therefore unable to commence feeding – delay in nutrition and/or hydration. Patient needing emergency community support or hospital attendance.

[ ]

D Strangulation caused by tubing.

[ ]

E Aspiration as a result of vomiting, regurgitation or accidental dislodgement of the tube by patient and/or other persons.

[ ]

F Delay in discharge due to training needs and patient/carer/parent needing to be competent in all aspects of tube care prior to discharge.

[ ]

G Malfunction of feeding pump, resulting in patient being unable to feed or inappropriate feed administration.

[ ]

H Inadequate stock of feed - patient being unable to have adequate feed/hydration.

[ ]


Risk assessment for discharging a patient with a nasogastric feeding tube from acute care to the community

Patient Identification Label Risk assessment for discharging a patient with a nasogastric feeding tube from acute care to the community



EXISTING CONTROL MEASURES Description of existing controls and assurances – e.g. strategies, business plans, policies, standard operating procedures, training, competent staff, reports, committees, etc.

Indicate [ ] if existing control measures have been discussed with all relevant persons at risk. If not discussed, state reason.

Patient given emergency and out of hours contacts/instructions in the event of accidental tube removal/unable to confirm tube position/tube blockage. Community Nurses providing community support. In the event of this not being adequate, patient needs to attend acute care for assistance.

[ ]

Training provided to patient/carers/parents on correct procedure for checking tube position. Clear written instructions provided on importance of checking tube position and what to do should they not be able to confirm this. Documentation of training completed and signed by patient/carer/parent.

[ ]

Company Nurse (Fresenius Kabi) or Community Nurse scheduled for first review visit in patients home. Yes/No Date:

[ ]

For patients at risk of dislodging tubes (e.g. children) feeding regimen planned for times when patient can be observed.

[ ]

Patient advised to feed with head raised. Feeding regimen arranged to minimise risk of regurgitation/vomiting.

[ ]

Proactive discharge planning with early training for patient/carer/parent.

[ ]

Pumps are serviced and maintained annually by contractor. Patient provided with the telephone number for the 24 hour helpline provided by contractor. Emergency pumps can be delivered within 6 hours.

[ ]

Ward to provide 10 days feed and 7 days’ supply of equipment (enteral syringes and giving sets if needed) on discharge. Contractor provides monthly stock checks. 24 hour helpline with emergency feed deliveries as required. In exceptional circumstances, acute Trust can supply feed until company can deliver. For third party products, supply is arranged locally.

[ ]

Patient Identification Label Risk assessment for discharging a patient with a nasogastric feeding tube from acute care to the community



Indicate [ ] if patient safe to be discharged [ ] Complete assessment sign off below

Indicate [ ] if patient unsafe to be discharged [ ] Complete action plan below

ACTION PLAN – To be completed if further action required to eliminate/reduce the risk

Specific Risk

Further action/training required to control risk (make actions SMART):

Specific risk requiring action – insert A B C etc. to refer back to the above risks. Measurable – state how the risk has been managed. Actions – specific and achievable, stated clearly and communicated widely. Realistic – resource demands / constraints and person responsible. Target date to be achieved.

Target date

Risk assessment for discharging a patient with a nasogastric feeding tube from acute care to the community




Document to be kept in patients’ medical notes

ASSESSMENT SIGN OFF Assessor’s name Consultant / Attending

Consultant name

Assessor’s signature Consultant / Attending Consultant signature

Date of assessment Date signed

Indicate [ ] if appropriate community healthcare professionals have been contacted [ ]



Appendix 4: Bicarbonate flush instructions

Mix 2 tsp of bicarbonate of soda with 50ml warm water.

Draw up in a 60ml enteral syringe.

Attach to jejunal port of feeding tube and flush using push pause massage technique.

Repeat weekly to keep the tube clear.



Appendix 5: Out of hours emergency regimen

Ward…………………………… Out of hours Emergency Enteral Feeding Regimen

Check urea and electrolytes, Magnesium and Phosphate before feed is commenced and daily until values are stable. Correct any abnormal values using intravenous supplements if necessary.

Check position of tube before commencing feed by aspirating a small drop of stomach acid and using a pH indicator strip. If pH is less than 5.5 the tube is in the stomach. Recheck position of tube before each feed or if it is felt it may have been dislodged. Document all readings.

Flush tube with 50ml of water, using a 50ml enteral syringe, before feeding is commenced and after feed is discontinued.

If in any doubt of the suitability of this regimen please consult the doctor in charge of the patient. Complete an e-referral form found under ‘Nutrition and Dietetics’ on ‘BOB’ and send to the dietitian’s

department. Please also leave a message on the dietitian’s answer phone (ext 2306) for urgent review on Monday.

Name of prescriber (print) _____________________ Signature_________________________

DATE FEED TYPE RATE

ml/hr

TIME

hrs

REST PERIOD hrs

TOTAL VOLUME

ml

EXTRA FLUID REQ

Day1

………

Fresubin Original Fibre

25

20

4

500

IV fluid may be required

Day 2

………

Fresubin Original Fibre

50

20

4

1000

IV fluid may be required

Day 3

continue as day 2 until reviewed by a Dietitian

Hospital No .……………………………

Name ….…………………….……….…

Address…………….…………..……….

……………………….………..…………

DOB………..…………….……………..…



Appendix 6: ICU Enteral Feeding Protocol

North Devon District Hospital ICU Enteral Feeding Protocol

If the patient is surgical – ascertain agreement whether patient is suitable for ‘trickle feed’ (10ml/hr x 24hrs) or usual regime below.

Is the patient at high risk of re-feeding syndrome?

ONE or more of the following: Or TWO or more of the following:

- Body Mass Index (BMI) <16 kg/m2. - Body Mass Index (BMI) <18.5 kg/m2. - Unintentional weight loss greater than 15%

within the last 3-6 months. - Unintentional weight loss greater than 10% within

the last 3-6 months. - Little / no nutritional intake for >10 days. - Little / no nutritional intake for > 5 days. - Low levels of serum potassium, phosphate

or magnesium prior to feeding. - History of alcohol or drug abuse including insulin,

chemotherapy, antacids or diuretics.

Start Fresubin Intensive at 20ml/hr x 24hrs, increase rate to target below as per tolerance:

<40kg – 20ml/hr x 24hrs 41-50kg – 30ml/hr x 24hrs 51-60kg – 35ml/hr x 24hrs 61-65kg – 45ml/hr x 24hrs 66-70kg – 50ml/hr x 24hrs >70kg – 50ml/hr x 24hrs

And refer to Dietitian

Replace and continue feeding. Monitor 4 hourly.

Replace 400ml and discard the remainder.

Continue feed at target rate

Replace 400ml, discard remainder and consider gastro-kinetics:

IV Metoclopramide 10mg TDS

IV Erythromycin 75mg QDS

Continue to monitor GRV 4 hourly replacing up to 400ml. If GRV not <400 after 48 hours refer to Dietitian and consider NJ tube placement.

GRV >400ml at 4 hours again

No

If patient is considered at high risk of re-feeding, the following is advised by NICE CG32 (2006):

Carefully restore circulatory volume, monitor pulse rate, intake and output.

Administer vitamins immediately before and during the first 10 days of feeding. ○ Thiamine 200-300mg daily and

Vitamin B co-strong one or two tablets three times per day OR Pabrinex® 1 pair ampoules IV for 3 days. o A balanced multivitamin and

trace element supplement once daily

Supplement potassium, phosphate and magnesium unless pre-feeding plasma levels are high.

Monitor electrolytes daily including urea & electrolytes, phosphate, potassium and magnesium.

Blood glucose should be monitored 4hourly for at least 48 hours.

Commence Fresubin Intensive; Day 1: 15ml/hr x 24hrs

Day 2: 30ml/hr x 24hrs (unless the patient weighs <40kg)

Continue day 2 until review by Dietitian

If the patients creatinine is >300 please use the

above regime with Fresubin Original.

Yes

GRV Protocol

4 hourly GRV <400ml?

Yes No

If patient is transferred to the ward and there is no pre-arranged regime, please run the feed at the rate prescribed on ICU over 20hrs instead of 24hrs. Monitor blood glucose 4 hourly and alert the Dietitian.

If the patients creatinine is >300 please use the above regime with Fresubin Original.



NDHT Enteral Feeding Guidelines

Additional Guidelines for Patients on ICU / HDU

1. Enteral feeding of patients on ICU / HDU should comply with the NDHCT Enteral Feeding Guidelines. However, in the event of a discrepancy between the ICU / HDU–specific appendices and the main guidelines, the ICU / HDU-specific guidelines will take priority. 2. Enteral feeding should not be interrupted, e.g. for physiotherapy or any planned invasive procedures unless specifically requested by the doctor in charge. It should, however, be stopped immediately if aspiration is suspected. 3. The main Trust guidelines cover deadlines for commencement of enteral feeding. However, specifically for ICU:

All intubated (and other critically ill) patients should have enteral feeding commenced within 24 hours unless there are definite contraindications.

Any patient on ICU / HDU who cannot be established on gastric feeding within 48 hours should be considered for nasojejunal feeding.

4. The target rate (based on actual body weight) for each patient's enteral nutritional requirements can be found on the ICU / HDU Nasogastric Feeding Flowchart. It approximates to 20 kCal / kg / 24 hours. 5. Nasogastric or gastrostomy feeding should be given according to the ICU / HDU Nasogastric Feeding Flowchart. For jejunal feeding, see the additional information below. 6. For the sake of clarity, the rate of feed being given should be noted on an hourly basis on the ICU charts in the section used for drug infusion rates. The total amount of feed should be presented in the fluid chart section. 7. Prior to commencement of feeding, the position of the feeding tube should always be checked (see Trust Enteral Feeding Guidelines). It should also be re-checked at any time when movement of the tube is suspected to have occurred. 8. Feeding should be continuous i.e. 24 hours / day. Feed bottles and feeding administration sets, however, must be changed every 24 hours to avoid contamination. 9. To monitor for re-feeding syndrome, baseline magnesium, phosphate and potassium levels should be checked prior to commencement of feeding. They should be re-checked after 24 hours then twice weekly. If levels are stable, reduce or discontinue monitoring after one week of full feeding. 10. In the event a patient remains enterally fed for more than one week, the patient should be referred to the dietitian for detailed assessment of their nutritional needs. An e-referral via BOB should be completed.

P.T.O. FOR ADDITIONAL GUIDELINES REGARDING JEJUNAL FEEDING



Additional Information for Nasojejunal Feeding 12. The North Devon District Hospital ICU Nasogastric Feeding Flowchart does NOT apply to nasojejunal feeding. 13. Feeding should be started at 20 ml / hour and increased by 20 ml / hour every four hours until the target rate is reached. The patient should be observed for signs of intolerance of feeding e.g. abdominal distension or discomfort, feed in gastric aspirate (suggesting feed intolerance or tube migrated to stomach). 14. If the jejunal tube has a gastric lumen, this should be regularly aspirated or placed on free drainage in order to keep the stomach empty.



Appendix 7: How to prepare cooled boiled water

Cooled boiled water should be used for hanging water or making up powdered feeds. Preparation of cooled boiled water:

Empty kettle, fill with freshly run tap water and bring to the boil.

Allow to cool, then decant water into a clean container e.g. a plastic jug or bottle with a lid which has been washed in a dishwasher or a new Applix Pump Set Bag Resevoir if the water is to be hung and given via a pump.

Store in a refrigerator separated from raw foods at 5°C or below for a maximum of 24 hours.

Allow to reach room temperature before administering through the PEG/NGT.

All water must be single patient use only and not shared. Any unused water in a syringe for intermittent use must be discarded. For continuous administration the water must be treated as a sterile enteral feed. Containers must not be topped up or re-used.



Appendix 8: Refeeding treatment and monitoring sticker

This patient is at high risk of re-feeding syndrome Please consider the following guidelines to minimise risk:

Restore circulatory volume and monitor fluid balance and overall clinical status closely until nutrition support is established

Monitor U&Es, LFTs, Mg2+

, PO43-

daily - correct as necessary

Prescribe immediately before feeding commences and for the first 10 days of re-feeding:

Thiamine: 100mg b.d. / t.d.s. - orally / via enteral feeding tube

Vitamin B Co strong 1-2 tablets t.d.s. - orally or Vigranon B 5-

10ml t.d.s. - via enteral feeding tube

Or if unable to take oral / enteral B vitamins give 1 pair ampoules Pabrinex

IV/day (for 3 days)

Multivitamin and mineral e.g. 1 x Forceval capsule / day or 1 x Forceval soluble tablet / day

Refeeding syndrome can be defined as the potentially fatal shifts in fluids and electrolytes that may occur in malnourished patients on refeeding following a period of starvation (NICE, 2006). This is particularly common in patients receiving artificial refeeding, but is possible with oral refeeding (particularly if oral nutritional supplements are prescribed). The patient should be considered at risk of refeeding syndrome if they meet the following criteria (NICE 2006).

If the patient has one or more of the following:

Body mass index <16 kg/m2

Unintentional weight loss >15% in the past three to six months

Little or no nutritional intake for >10 days

Low levels of potassium, phosphate, or magnesium before feeding

Or the patient has two or more of the following:

Body mass index <18.5 kg/m2

Unintentional weight loss >10% in the past three to six months

Little or no nutritional intake for >5 days

History of alcohol misuse or drugs, including insulin, chemotherapy, antacids, or diuretics

If the patient is considered to be at high risk of refeeding syndrome, the following steps are advised by NICE (2006):

Start nutrition support at a maximum of 10 kcal/kg/day, increasing levels slowly to meet or exceed full needs by 4–7 days

Restore circulatory volume and monitoring fluid balance and overall clinical status closely

Provide immediately before and during the first 10 days of feeding: oral thiamine 200–300 mg daily, vitamin B co strong 1 or 2 tablets, three times a day (or full dose daily intravenous vitamin B preparation, if necessary) and a balanced multivitamin/ trace element supplement once daily

Provide oral, enteral or intravenous supplements of potassium (likely requirement 2–4 mmol/kg/day), phosphate (likely requirement 0.3–0.6 mmol/kg/day) and magnesium (likely requirement 0.2 mmol/kg/day intravenous, 0.4 mmol/kg/day oral) unless pre-feeding plasma levels are high. Pre-feeding correction of low plasma levels is unnecessary.



Appendix 9: Guideline for checking balloon inflation

Weekly Care of a Balloon Gastrostomy and Low profile balloon Gastrostomy

Balloon Water Change

Tape the tube in place to prevent the tube from falling out when the water is taken

out of the balloon.

Fill a 5ml or 10ml luer slip syringe with the correct volume of sterile or cooled boiled

water for the balloon.

Attach an empty 5ml or 10ml luer slip syringe onto the balloon port of the

gastrostomy.

Remove the water from the balloon, check the volume obtained, reattach the syringe

and pull back again to make sure all the water is removed.

Remove the syringe and discard.

Attach the filled syringe to the balloon port.

Fill the balloon with the recommended volume of sterile or cooled boiled water.

Remove the tape.

Gently pull back on the tube to ensure that the balloon is filled and correctly placed.

For balloon gastrostomy tubes only, replace the retaining disc 2mm away from the

skin.

For a video of balloon gastrostomy weekly care see https://vimeo.com/292876749




Appendix 10: Gastrostomy Care Checklist

Name or insert label:

Ward:

Date of tube insertion:

Type of tube:

Due date of first advance and rotate (PEG) or advance only (PEG-J) (if tube has been in longer than10 days start completing table below):

Daily cleaning of stoma site and check for stoma leakage, redness, inflammation or over-granulation

Date:

Time:

Document stoma appearance and any dressings or meds applied:

Print name and designation:

10 days after insertion:- daily advance and rotate of PEG tubes or advance only of PEG-J tubes

Date:

Time:




Name or insert label:

Ward:

Date of tube insertion:

Type of tube:

Due date of first advance and rotate (PEG) or advance only (PEG-J) (if tube has been in longer than10 days start completing table below):

Daily cleaning of stoma site and check for stoma leakage, redness, inflammation or over-granulation

Date:

Time:

Document stoma appearance and any dressings or meds applied:


10 days after insertion:- daily advance and rotate of PEG tubes or advance only of PEG-J tubes

Date:

Time:




Appendix 11: How to bolus feed

There are two different methods that can be used for bolus feeding using a 60ml enteral

syringe:

(Method 1)

Measure the required bolus into a measuring jug.

Remove the plunger from the syringe and put aside.

Attach the empty syringe to the end of the PEG tube and hold upright higher than the PEG stoma site.

Pour feed into the syringe from the jug.

Undo the clamp and let feed run into the stomach.

Continue to pour feed as necessary.

Pour water to flush as necessary.

Close clamp and remove syringe. Close PEG end.

This method will not work if the intra gastric pressure is too high but is easier for boluses larger than 50ml.

(Method 2)

Fill the 60ml enteral syringe with feed by dipping the tip into a bowl of feed and pulling up the plunger.

Attach the full syringe to the end of the PEG tube.

Undo clamp on PEG tube.

Slowly push down the plunger and administer the feed into the stomach.

Repeat as necessary. Always close the clamp before removing the syringe from the end of the PEG.

Flush the PEG tube with 50ml water to clear it.

This method is more time consuming if the bolus is larger than 50ml as the syringe will have to be repeatedly removed from the PEG end and filled.



Appendix 12: NGT position confirmation chart

Please refer to decision tree overleaf

The position of the nasogastric tube should be checked:

Following initial insertion (please use placement checklist to record this).

Before administering each feed.

Before giving medications.

Any new or unexplained respiratory symptoms or if oxygen saturations decrease.

At least once daily during continuous feeds.

Following episodes of vomiting, retching or coughing spasms.

When there is suggestion of tube displacement.

Do not use ‘whoosh’ tests or acid alkaline litmus paper to confirm position

If you are not able to confirm that the tube is in the stomach it should be removed and reinserted. This should be documented on the nasogastric tube placement bedside checklist.

Date

Time

pH

Internal Tube Length (cm)

Reason(s) for position check

Checked by Signature, Print Name and designation

If any new or unexplained respiratory symptoms, stop feed and contact medical team


NASOGASTRIC TUBE POSITION CONFIRMATION CHART (ADULTS)

Document Control - North Devon District Hospital · (See video for how to check pH). ICU Enteral...

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