enteral feeding administration policy - adults

Title of Policy: Enteral Feeding Administration Policy Version: 4.1 Issue Date: 18 December 2019 Review Date: 17 June 2022 of 13

ENTERAL FEEDING ADMINISTRATION POLICY - ADULTS

Version 4.1

Name of responsible (ratifying) committee Professional Board

Date ratified 21 November 2019

Document Manager (job title) Lead Clinical Nutrition Nurse Specialist

Date issued 18 December 2019

Review date 17 June 2022

Electronic location Clinical Policies

Related Procedural Documents NG policy

Key Words (to aid with searching) Enteral feeding, pump, syringes

Version Tracking

Version Date Ratified Brief Summary of Changes Author

4.1 01/02/2021 Due to the second wave of the Coronavirus pandemic and continuing exceptional circumstances, the Trust Board have agreed that all

policies which are currently within review date will have their review date further extended by six months

-

4 21/11/2019 General revision, updating J Pratt

3 30/10/2015 Minor changes to ancillary items J Pratt


CONTENTS

QUICK REFERENCE GUIDE .............................................................................................. 3

1. INTRODUCTION .............................................................................................................. 4

2. PURPOSE ........................................................................................................................ 4

3. SCOPE ............................................................................................................................. 4

4. DEFINITIONS................................................................................................................... 4

5. DUTIES AND RESPONSIBILITIES .................................................................................. 5

6. PROCESS ........................................................................................................................ 6

7. TRAINING REQUIREMENTS .......................................................................................... 7

8. REFERENCES AND ASSOCIATED DOCUMENTATION ................................................ 7

9. EQUALITY IMPACT STATEMENT .................................................................................. 8

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS ............................ 9

EQUALITY IMPACT SCREENING TOOL ........................................................................ 10-11

Appendix 1. Standard operating procedure (SOP): Disconnection and flushing an abdominal feeding tube..………………….………………………………………………….…………………...12-13


QUICK REFERENCE GUIDE This policy must be followed in full when developing or reviewing and amending Trust procedural documents. For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document

1. A clean technique must be used when handling enteral feeding equipment. Staff must wash their hands, apply an apron and non-sterile gloves.

2. Enteral feed must be administered using a non-touch technique.

3. Equipment including pumps and stands must be kept clean.

4. Sterile ready to hang feed bags/bottles can be used for a maximum of 24 hours

5. Feed/water containers and administration sets must be changed every 24 hours.

6. Feed must not be decanted unless elemental feed is required, in which case the container and administration set must be changed every 12 hours.

7. Freshly drawn drinking tap water can be used to flush enteral feeding tubes and to provide water to the patient.

8. Enteral ENFit syringes must be used and discarded after each use.

9. Staff administering enteral pump feeding must have received training on how to use the pump, from the medical device training team, and have completed and returned the self verification of competency assessment form.

10. All patients receiving or admitted with enteral feeding are referred to the Dietitians. 11. Patients being discharged on enteral feeding are referred to the Clinical Nutrition Nurse

specialists, for assessment and discharge planning.


INTRODUCTION

The use of the Gastro-intestinal tract to deliver fluid, medications and feed via a tube is common practice in the hospital setting. The nutrients contained within enteral feeds make them an excellent environment for the growth of bacteria and other micro-organisms. Infectious complications such as bacteraemia, septicaemia, pneumonia, diarrhoea and infectious enterocolitis have all been attributed to the administration of enteral feeding solutions which have been contaminated with bacteria (1,2,7). Research has shown that the main sources of bacterial contamination of enteral feeding systems are poor hand hygiene, increased manipulation and hanging times in excess of 24 hours. Good Handwashing techniques, use of non-sterile gloves, minimal handling and employing a non -touch technique all reduce the risk of contamination (1,3,6,7,8,9). Enteral ENFit syringes and feeding tubes that are not be compatible with intravenous lines/intravenous syringes must be used for enteral feeding, or administration of water and medications. I.V compatible syringes and adaptors must not be used due to the risk of wrong route administration, which is a Never Event (5, 11, 14, 15) It is important that staff receive training and are competent in the correct use of enteral equipment, so that they can safely deliver fluids, medications and feed via this route. This policy therefore aims to give evidence-based, best practice guidance to staff to minimise the risks associated with enteral feeding.

1. PURPOSE

This policy is designed to guide all Healthcare professionals in safe enteral administration in adults

2. SCOPE

This policy applies to all healthcare professionals caring for adult patients who require enteral feeding in the hospital setting. ‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

3. DEFINITIONS

ENTERAL FEEDING Using the Gastro-intestinal tract for the delivery of nutrients. For the purpose of this policy it describes artificial nutrition delivered via a tube into the gut.

NON -TOUCH TECHNIQUE No open part of the enteral feeding delivery system, feed or enteral tube should be in contact with the hands, clothes, skin or other non – disinfected surface.

ENTERAL TUBES Tubes placed into the GI Tract for the purpose of administering fluid, medication and/or feed:


Nasogastric (NG) – a tube inserted into the nose, down the oesophagus and into the stomach. Can be placed at the bedside, endoscopy, radiology, surgery Nasojejunal (NJ) - a tube inserted into the nose, down the oesophagus, through the stomach and into the small bowel. Placed in radiology, endoscopy, surgery Gastrostomy (e.g. PEG/ RIG) - a tube inserted directly into the stomach through the abdomen. Can be placed in radiology, endoscopy or surgery Gastrojejunostomy (PEGJ) – a tube placed directly into the stomach as for PEG, then an extension tube is placed through the PEG, down and out of the stomach, into the small bowel. Placed in endoscopy or radiology Jejunostomy (surgical) - a tube placed directly into the small bowel through the abdomen. This is a surgical procedure.

ENTERAL ENFit SYRINGE A purple syringe that is not compatible with intravenous catheters or ports. Solely for the administration of enteral feed, fluid and medications. The end of the tube has an ENFit design which is only compatible with enteral ENFit feeding tubes. CONSUMABLES Plastic items used in enteral administration i.e. administration sets, syringes, extension sets,enteral connectors/adaptors, water containers, integral reservoirs. DECANTING Opening sterile feed bottles/containers and pouring feed into another container/reservoir. SINGLE-USE For use on an individual patient during a single procedure and then discarded. It is not intended to be reprocessed and used again. SINGLE-PATIENT USE May be used for more than one episode of use on one patient only. The device may undergo some form of processing between each use. HEALTH CARE PROFESSIONALS. A registered or trained competent member of staff including doctors, nurses and midwives.

4. DUTIES AND RESPONSIBILITIES

Clinical staff that need to operate enteral feeding pumps must have training from the Medical Devices Team. They must then complete a self verification of competency assessment form and return it to the medical device trainers, who will record this on ESR and issue a competency for 2 years .Staff are responsible for maintaining their own level of competency. Clinical managers are responsible for ensuring the implementation of this Policy, and associated Guideline, and for monitoring compliance at ward level. Clinical managers are responsible for ensuring that appropriate supplies of enteral feeding equipment are available at ward level Clinical Educators/ Practice Development Nurses to disseminate best practice as per Policy. Lead Clinical Nutrition Nurse Specialist is responsible for audit and review of this policy Medical device trainers provide training on enteral feeding pumps and record completion of competency assessment forms on ESR, issuing staff with a 2 year competency.


Clinical engineering are responsible for maintaining a supply of enteral feeding pumps for use by clinical areas Ward teams are responsible for returning spare/ unused/ faulty pumps to the equipment library (clinical engineering).

5. PROCESS

Clinical Practice Guideline

ACTION RATIONALE

Prior to setting up feed wash hands with soap and water and apply non-sterile gloves and an apron.

Feeding tubes, administration sets, water containers and feed bags/bottles must be manipulated using a non-touch technique. Ready to hang sterile feeds, administration sets and water containers should have a maximum hang time of 24hours Enteral feeding tubes should be flushed immediately before and after use with 30-50ml of drinking tap water Medications must be administered individually with a water flush, 10ml, in between each medication. Medication MUST NOT be mixed together in a cup and administered as 1 dose.

. If the feed administration set is disconnected from the patient the distal end must be capped off and the feeding tube flushed with drinking tap water using a non-touch technique. Only adaptors designed specifically for enteral use should be used. Feed administration sets are compatible with water containers. Therefore 1 giving set should be used per 24hours and transferred between feed bag and water bag using a non-touch technique.

Research shows that poor hand hygiene contributes to microbial contamination. 1,3,6,7. To reduce the risk of contamination and maintain patient safety. 8

To maintain a closed system to reduce the risk of contamination. 1,3,6,8,9,12

To maintain tube patency. Delays to tube flushing will result in tube blockage. 1,3,6,7

To maintain tube patency. Mixing medications prior to or during administration will result in tube blockage. 13

To maintain a closed system and safely deliver feed/water. 1,

To maintain tube patency

Enteral adaptors will only be compatible with enteral devices therefore reducing the risk of wrong route administration. 4.

To maintain a closed system and safely deliver feed/water to the patient. 1,3,6,8,9,12


6. TRAINING REQUIREMENTS

Staff must have received training and be able to demonstrate competence prior to setting up enteral feeding.. CNNS teach on a range of formal and informal staff training sessions/courses. Medical Devices Trainers will provide training on enteral feeding pumps on request

7. REFERENCES AND ASSOCIATED DOCUMENTATION

1. Anderton, A. (1990) Microbial contamination of enteral feeds. How can we reduce the risk? Nutricia Clinical Care. 2.Donskey, C.J. The role of the intestinal tract as a reservoir and source for transmission of nosocomial pathogens. Clinical Infectious Diseases, (2004). 39 219-226. 3.Fogg, L. (2007). Home enteral feeding: Part 2 current issues in community practice. British journal of Community Nursing, 12(7) 296-300. 4.Great Britain. National Patient Safety Agency.(2005). Advise to the NHS on reducing harm caused by the misplacement of naso-gastric tubes. 5.Great Britain. National Patient Safety Agency. (2007.) Promoting safer measurement and administration of liquid medicines via oral and other enteral routes.

Feed must not be decanted unless advised by a Dietician or Nutrition CNS. In such circumstances feed, containers and administration sets must only hang for 12 hours.

Single-use purple enteral Enfit syringes must be used with all enteral feeding systems and discarded after each use. Ensure drip-stands and pumps are clean and in working order. If Naso-gastric tube is in situ check position of tube as per PHT NG Policy (adults).

Ready to hang feed should be used wherever possible. Research shows that increased manipulation and decanting of sterile feed increases contamination. Hanging time is reduced to 12 hours with decanted feeds to minimise the risk of contamination. 1,2,3,9,10,12 To comply with NPSA alerts I.V. syringes should not be used due to the risk of wrong route administration.5, 11, 14, 15

To ensure safe administration and maintain patient safety. 4, 16


6.Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in Adults (Clinical Guideline 32) London: NICE. 7.Great Britain. National Institute for Health and Clinical Excellence (2003). Prevention of healthcare- associated infections in primary and community care. Section 4. London: NICE 8.Great Britain. Medicines and Healthcare Products Regulatory Agency. (2006). Single-use Medical Devices: Implications and Consequences of Reuse. DB2006 (04). London: Department of Health. 9.Mathus-Vliegen,E., Bredius M., & Binnekade J. (2006). Analysis of Sites of Bacterial Contamination in an Enteral Feeding System. Journal of Parenteral and Enteral Nutrition, 30 (6) 519-525. 10.Matlow,A., Jacobson,M., Wray R., et al. (2006). Enteral tube hub as a reservoir for transmissible enteric bacteria. American Journal of Infection Control, 34 (3) 131-133. 11.NHS England (2015) Never Events Policy and Framework. www.england.nhs.uk/patient safety/never-events/ 12. Stroud, M., Duncan, H. & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital patients.Gut 52(Suppl VII) vii1 – 12. 13.White R and Bradnam V (2015) Handbook of Drug administration via enteral feeding tubes (3rd

Ed). Pharmaceutical Press, London. 14.http://stayconnected.org/wp-content/uploads/2018/10/GEDSA-Position-Statement-on-FDA- Letter- 2018-.pdf. Accessed 10/10/19 15. https://www.fda.gov/media/115846/download. Accessed 10/10/19 16. PHT Nasogastric Tube Policy (2019)

8. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This policy has been assessed accordingly All policies must include this standard equality impact statement. However, when sending for ratification and publication, this must be accompanied by the full equality screening assessment tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They

are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Working together for patients Working together with compassion Working together as one team Working together always improving

This policy should be read and implemented with the Trust Values in mind at all times.

http://www.england.nhs.uk/patient%20%20%20%20%20%20%20%20safety/never-events/

http://www.england.nhs.uk/patient%20%20%20%20%20%20%20%20safety/never-events/

http://stayconnected.org/wp-content/uploads/2018/10/GEDSA-Position-Statement-on-FDA-%20%20%20%20Letter-%20%202018-.pdf

http://stayconnected.org/wp-content/uploads/2018/10/GEDSA-Position-Statement-on-FDA-%20%20%20%20Letter-%20%202018-.pdf

https://www.fda.gov/media/115846/download.%20Accessed%2010/10/19


9. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

This document will be monitored to ensure it is effective and to assure compliance. The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above. The details of the monitoring to be considered include:

• The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);

• The lead for ensuring the audit is undertaken

• The tool to be used for monitoring e.g. spot checks, observation audit, data collection;

• Frequency of the monitoring e.g. quarterly, annually;

• The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required. In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on the Trust Intranet Trust Intranet -> Policies -> Policy Documentation

• The lead(s) for acting on any recommendations necessary.

• recommendations necessary.

Minimum requirement to be monitored

Lead Tool Frequency of Report of

Compliance

Reporting arrangements

Lead(s) for acting on

Recommendations

Compliance with practice Guideline

Jo Pratt Clinical practice

audit

Yearly Policy audit report to:

• Professional Forum

• Nutrition Steering Group

Senior Nurses

Matrons

Ward managers

Policy audit report to:

•

Policy audit report to:

•


EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy

changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Enteral Feeding Administration Policy - Adults

Date of Assessment

10/10/19 Responsible Department

Nutrition Nurses

Name of person completing assessment

Jo Pratt Job Title Lead Clinical Nutrition Nurse Specialist

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

• Age no

• Disability no

• Gender reassignment no

• Pregnancy and Maternity no

• Race no

• Sex no

• Religion or Belief no

• Sexual Orientation no

• Marriage and Civil Partnership no

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

http://www.legislation.gov.uk/ukpga/2010/15/contents

http://www.legislation.gov.uk/ukpga/2010/15/contents


Stage 2 – Full Impact Assessment

What is the impact Level of Impact

Mitigating Actions

(what needs to be done to minimise / remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance Committee

Clinical Service Centre Procedural Document: Clinical Service Centre Governance Committee

Corporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and


Diversity Committee

1. Standard operating procedure (SOP): Disconnection and

flushing an abdominal feeding tube.

Aim: The HCSW / AHP can safely stop an enteral administration pump disconnect from

an abdominal feeding tube and flush the feeding tube to prevent blockage.

Scope: For HCSW or therapists once they have been supervised by a trained nurse.

1. Demonstrates the importance of explaining the process and gaining consent, adhering to

local policy

2. Ensure patient comfortable maintaining dignity at all times.

3. All equipment required is gathered – 60ml enteral syringe for flushing, water for flushing,

cap for end of administration set.

4. Wash hands and apply non-sterile gloves and apron. Carry out the procedure using a

non-touch technique.

5. Draw up 30-50ml of tap water in the 60ml enteral syringe.

6. Turn off the enteral feeding pump by pressing the start/stop button, then hold down the

on/off button till the pump beeps ( your pump is now switched off).

7. If the abdominal tube has a clamp, close the clamp, if it does not you will need to kink

the tube to prevent back flow of fluid down the tube.

8. Disconnect the administration set from the abdominal feeding tube and cap the end of

the administration set so that it is clean and can be reconnected if required.

Appendix 1


Administration set ends should not be left open to the air as contamination can occur. If

a cap is not available cover end (eg. Gauze packet).

9. Attach the 60ml syringe containing 30-50ml of water (careful not to over tighten).

10. Unclamp / release kink in the abdominal tube, push end of syringe until all water gone.

11. Clamp/ kink tube and remove the syringe.

12. Replace cap on end of abdominal tube.

13. Open clamp / release kink in abdominal tube.

14. Discard syringe, apron, gloves and wash hands.

15. Document on fluid chart the volume of flush and when feed/water stopped.

16. Inform Registered nurse when patient returns so that feed / fluids can be recommenced

if required by a registered nurse.

TUBES MUST BE FLUSHED ON DISCONNECTION TO PREVENT THE TUBE FROM

BLOCKING EVEN IF ONLY DISCONNECTED FOR A SHORT TIME.

HCSW /AHP MUST NOT DISCONNECT/ FLUSH NASOGASTRIC TUBES

COMPETENT RN’S ONLY.

References to Support SOP. Enteral tube Administration policy. (2019) . http://pht/PoliciesGuidelines/ClinicalPolicies/Lists/Links/All%20Links.aspx The Royal Marsden Manual of Clinical Nursing Procedures (2015). The Royal Marsden NHS Foundation Trust

RCN Accountability and Delegation. www.rcn.org.uk .

http://pht/PoliciesGuidelines/ClinicalPolicies/Lists/Links/All%20Links.aspx

http://www.rcn.org.uk/