Gastrostomy Tube Insertion and Aftercare:

(for adults being cared for in hospital or in

the community)

Best practice statement May 2008

© NHS Quality Improvement Scotland 2008

First published May 2008

You can copy or reproduce the information in this document for use within NHSScotland and for educational purposes. You must not make a profit using information in this document. Commercial organisations must get our written permission before reproducing this document.

www.nhshealthquality.org

Gastrostomy Tube Insertion and Aftercare:

(for adults being cared for in hospital or in

the community)

Best practice statement May 2008

This Best Practice Statement has been printed with financial and professional support from NHS Quality Improvement Scotland

3

Contents Introduction

Section 1: Assessment and patient selection

Section 2: Preparation and insertion of gastrostomy tube

Section 3: Immediate post insertion monitoring and care

Section 4: Ongoing care and prevention of complications

Section 5: Discharge planning

Section 6: Follow-up care for the patient with a gastrostomy tube

Section 7: Removal of gastrostomy tube

Section 8: Accidental removal/dislodgement of a gastrostomy tube Glossary Appendix 1: Information leaflet

Appendix 2: Contra-indications to gastrostomy insertion

Appendix 3: Transfer of care documentation

Appendix 4: Pre-insertion care

Appendix 5: Potential complications of insertion

Appendix 6: Guidelines for immediate post insertion care

Appendix 7: Post insertion complications associated with gastrostomy feeding

Appendix 8: Administration of medications via gastrostomy tube

Appendix 9: Infection control issues – good practice

Appendix 10: Enteral tube feeding training checklist Appendix 11: Patient instruction leaflet

Appendix 12: Discharge checklist

Appendix 13: Recommendations for monitoring and follow-up care

Appendix 14: Procedure for removal of gastrostomy tube

Appendix 15: Procedure for replacement of gastrostomy tube

Bibliography

Who was involved in developing the statement?

4

Introduction The Nutrition Nurses in Scotland have worked together to produce this best practice advice aimed at professionals caring for adult patients with a gastrostomy tube in place. It provides advice on care from referral through to the insertion and after care of a patient with a gastrostomy tube. The advice is a consensus of evidence-based information, where it is available, and good practice experience from Nutrition Nurse Specialists (NNSs) working with patients receiving this intervention. A gastrostomy tube is placed through a surgically formed fistula in the abdominal wall into the stomach. The development of the percutaneous method of gastrostomy tube placement was described in the late 1970’s. This method has now replaced the surgical gastrostomy, which was associated with a higher rate of complications (Loser et al 2005). Over the last two decades the use of gastrostomies has been extended from a permanent access route in chronic conditions to a temporary measure for patients undergoing therapeutic treatments or while recovering from trauma (Bankhead et al 2005). In order for the gastrostomy tube to be safe, effective and comfortable, it is important that an informed choice is made of the type of tube and method of insertion that is appropriate to the needs and disease state of the patient. Many types of gastrostomy tubes are available, the most commonly referred to is the Percutaneous Endoscopic Gastrostomy (PEG). The Radiological Inserted Gastrostomy (RIG) is also inserted using a percutaneous method, these two are primary tubes. The low profile gastrostomy tube or “button” can be inserted as a primary tube but most are designed for insertion into a well-established tract and are useful for those prone to pulling on their feeding tube. The balloon replacement gastrostomy is the more commonly used replacement tube. It is intended that these guidelines be incorporated into local practice policies and procedures. The appendices include some checklists and procedures produced by NNSs for use within their specific sites but may be adapted for local need.

Sect

ion

1: A

sses

smen

t and

pat

ient

sel

ectio

n K

ey is

sues

:

• ga

stro

stom

y tu

be p

lace

men

t is

appr

opria

te fo

r the

pat

ient

’s tr

eatm

ent p

lan

• pa

tient

and

thei

r clin

icia

n w

ill be

fully

info

rmed

on

the

proc

edur

e of

gas

trost

omy

inse

rtion

and

pot

entia

l com

plic

atio

ns

• ef

fect

ive

com

mun

icat

ion

rega

rdin

g tre

atm

ent p

lans

occ

urs

betw

een

prof

essi

onal

s fo

r pat

ient

s re

ferr

ed fr

om th

e co

mm

unity

A

ppen

dix

1: s

ampl

e of

an

info

rmat

ion

leaf

let

App

endi

x 2:

con

tra-

indi

catio

ns to

gas

tros

tom

y in

sert

ion

App

endi

x 3:

tran

sfer

of c

are

docu

men

tatio

n St

atem

ent

Rea

son

for S

tate

men

t H

ow t

o de

mon

stra

te s

tate

men

t is

bei

ng

achi

eved

The

patie

nt w

ill be

ass

esse

d by

an

expe

rienc

ed h

ealth

care

pro

fess

iona

l prio

r to

gas

trost

omy

tube

inse

rtion

. A

sses

smen

t is

in c

onsu

ltatio

n w

ith th

e m

ultid

isci

plin

ary

team

car

ing

for t

he

patie

nt.

Pat

ient

will

be fu

lly in

form

ed a

bout

the

proc

edur

e an

d po

tent

ial c

ompl

icat

ions

w

hich

may

occ

ur.

An

Adu

lts W

ith In

capa

city

Act

form

will

be

requ

ired

for p

atie

nts

unab

le to

giv

e in

form

ed c

onse

nt.

Ass

essm

ent e

nsur

es th

at g

astro

stom

y tu

be in

serti

on is

exp

ecte

d to

pro

vide

a

clin

ical

ben

efit

to th

e pa

tient

. A

sses

smen

t will

dete

rmin

e th

at th

ere

are

no c

ontra

indi

catio

ns to

a m

etho

d of

pl

acem

ent.

P

atie

nts

requ

iring

gas

trost

omy

tube

in

serti

on o

ften

have

com

plex

nee

ds.

The

patie

nt w

ill be

abl

e to

giv

e in

form

ed

cons

ent.

The

cons

ulta

nt in

cha

rge

of a

pat

ient

who

is

una

ble

to g

ive

com

pete

nt c

onse

nt is

le

gally

resp

onsi

ble

for d

ecis

ions

of c

are.

Ther

e is

doc

umen

ted

evid

ence

of

asse

ssm

ent i

n th

e pa

tient

’s re

cord

s.

Ther

e is

doc

umen

ted

evid

ence

of

mul

tidis

cipl

inar

y co

nsul

tatio

n in

the

patie

nt’s

reco

rds.

D

ocum

enta

tion

of d

iscu

ssio

n an

d no

te o

f th

e pr

ovis

ion

of In

form

atio

n le

afle

ts.

Sig

ned

cons

ent f

orm

. Th

e co

mpl

eted

Adu

lts W

ith In

capa

city

form

w

ill be

file

d in

pat

ient

’s re

cord

s.

5

Key

cha

lleng

es:

1. T

he p

rimar

y go

al in

gas

trost

omy

inse

rtion

is to

faci

litat

e ca

re a

nd a

void

add

ition

al p

robl

ems

to th

e pr

imar

y di

seas

e. T

he fo

llow

ing

ques

tions

nee

d to

be

cons

ider

ed w

ithin

the

asse

ssm

ent:

• w

hat i

s th

e pr

obab

ility

that

this

trea

tmen

t will

cure

the

dise

ase,

relie

ve th

e sy

mpt

oms

or p

rom

ote

com

fort?

•

will

this

met

hod

of fe

edin

g en

hanc

e qu

ality

of l

ife a

nd n

ot p

rolo

ng d

ying

? •

wha

t are

the

patie

nt’s

bel

iefs

? 2.

Com

preh

ensi

ve p

atie

nt in

form

atio

n le

afle

ts w

ill be

ava

ilabl

e an

d re

gula

rly re

view

ed.

3. I

nfor

mat

ion

give

n sh

ould

be

sym

path

etic

to th

e pa

tient

’s e

duca

tiona

l, et

hnic

and

cul

tura

l nee

ds.

4. E

ffect

ive

com

mun

icat

ion

betw

een

team

s of

pro

fess

iona

ls c

arin

g fo

r the

pat

ient

sho

uld

occu

r to

allo

w s

eam

less

car

e.

6

Sect

ion

2: P

repa

ratio

n an

d in

sert

ion

of g

astr

osto

my

tube

K

ey is

sues

: •

patie

nt is

pre

pare

d fo

r gas

trost

omy

tube

inse

rtion

acc

ordi

ng to

loca

l gui

delin

es

App

endi

x 4:

pre

-inse

rtio

n ca

re

App

endi

x 5:

pot

entia

l com

plic

atio

ns o

f ins

ertio

n

Stat

emen

t R

easo

n fo

r Sta

tem

ent

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

Th

e pa

tient

will

be c

onse

nted

and

pr

epar

ed a

s pe

r loc

al g

uide

lines

. Th

e pr

oced

ure

will

be c

arrie

d ou

t by

ex

perie

nced

per

sonn

el u

sing

evi

denc

e ba

sed

prac

tice.

Th

e m

etho

d of

inse

rtion

mus

t be

docu

men

ted.

Th

e ty

pe a

nd s

ize

of tu

be m

ust b

e do

cum

ente

d.

Cor

rect

pre

para

tion

will

pre

vent

del

ay to

th

e pr

oced

ure

and

min

imis

e th

e ris

k of

so

me

com

plic

atio

ns.

Evi

denc

e is

ava

ilabl

e to

sug

gest

that

this

re

sults

in a

redu

ctio

n in

com

plic

atio

ns o

f in

serti

on.

The

met

hod

of in

serti

on w

ill de

term

ine

the

appr

opria

te im

med

iate

pos

t ins

ertio

n ca

re.

This

will

prov

ide

info

rmat

ion

whi

ch w

ill fa

cilit

ate

good

com

mun

icat

ion

for o

n go

ing

care

.

Evi

denc

e of

pre

para

tion

docu

men

ted

on a

pr

e pr

oced

ure

chec

klis

t. D

ocum

ente

d ev

iden

ce o

f tra

inin

g an

d su

perv

isio

n.

Th

e m

etho

d of

inse

rtion

will

be

docu

men

ted

in th

e pa

tient

’s re

cord

s.

The

type

and

siz

e of

the

tube

will

be

docu

men

ted

in th

e pa

tient

’s re

cord

s.

Key

cha

lleng

es:

1. I

nfor

mat

ion

on th

e pr

epar

atio

n fo

r thi

s pr

oced

ure

shou

ld b

e av

aila

ble

with

in th

e w

ard

or d

epar

tmen

t. 2.

Ava

ilabi

lity

of tr

aini

ng a

nd s

uper

visi

on in

gas

trost

omy

inse

rtion

for s

taff

unde

rtaki

ng th

is p

roce

dure

.

7

Sect

ion

3: I

mm

edia

te p

ost i

nser

tion

mon

itorin

g an

d ca

re

Key

issu

es:

• fo

llow

ing

the

inse

rtion

of a

gas

trost

omy

tube

the

patie

nt w

ill be

mon

itore

d

App

endi

x 6:

Gui

delin

es fo

r im

med

iate

pos

t ins

ertio

n ca

re

Stat

emen

t R

easo

n fo

r Sta

tem

ent

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

Th

e pa

tient

‘s g

astro

stom

y si

te a

nd v

ital

sign

s w

ill b

e m

onito

red.

Th

e ex

it si

te w

ill be

kep

t cle

an a

nd d

ry.

Flui

ds o

r med

icat

ions

can

be

adm

inis

tere

d vi

a th

e ga

stro

stom

y tu

be a

s pe

r loc

al

guid

elin

es.

To e

nsur

e ea

rly d

etec

tion

of c

ompl

icat

ions

pr

inci

pally

pai

n an

d bl

eedi

ng.

To m

inim

ise

the

risk

of p

eris

tom

al

infe

ctio

n.

Follo

win

g an

unc

ompl

icat

ed in

serti

on, t

he

gast

rost

omy

tube

can

be

used

four

hou

rs

follo

win

g th

e pr

oced

ure.

Ther

e is

doc

umen

ted

evid

ence

of v

ital s

ign

reco

rdin

g in

the

patie

nt’s

reco

rds.

Th

ere

is d

ocum

ente

d ev

iden

ce o

f wou

nd

care

in th

e pa

tient

’s re

cord

s.

Pre

scrib

ing

reco

rds.

Key

cha

lleng

es:

1. G

uide

lines

mus

t be

avai

labl

e fo

r sta

ff in

volv

ed in

pos

t ins

ertio

n ca

re.

8

Sect

ion

4: O

ngoi

ng c

are

and

prev

entio

n of

com

plic

atio

ns

Key

issu

es:

• ev

iden

ce b

ased

car

e of

the

gast

rost

omy

tube

will

max

imis

e ap

prop

riate

use

of t

he tu

be a

nd m

inim

ise

the

risk

of a

ssoc

iate

d co

mpl

icat

ions

A

ppen

dix

7: p

ost i

nser

tion

com

plic

atio

ns a

ssoc

iate

d w

ith g

astr

osto

my

feed

ing

App

endi

x 8:

adm

inis

terin

g m

edic

atio

n vi

a an

ent

eral

feed

ing

tube

A

ppen

dix

9: in

fect

ion

cont

rol i

ssue

s –

good

pra

ctic

e

Stat

emen

t R

easo

n fo

r Sta

tem

ent

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

A

ll ca

re w

ill be

take

n to

pre

vent

co

mpl

icat

ions

. Th

e pa

tient

rece

ives

pre

scrib

ed

med

icat

ions

via

gas

trost

omy

tube

in th

e co

rrec

t pre

para

tion.

Th

e pa

tient

rece

ives

pre

scrib

ed e

nter

al

feed

s vi

a th

e ga

stro

stom

y tu

be.

The

patie

nt re

ceiv

es w

ater

flus

hes

via

the

gast

rost

omy

tube

.

To m

axim

ise

qual

ity o

f car

e an

d pr

even

t ha

rm to

the

patie

nt.

Dru

g/fe

ed in

tera

ctio

ns c

an o

ccur

cau

sing

re

duce

d ef

ficac

y an

d tu

be b

lock

age.

P

atie

nt m

eets

flui

d an

d nu

tritio

nal

requ

irem

ents

. Th

is m

aint

ains

pat

ency

of t

he tu

be.

Doc

umen

ted

evid

ence

of t

rain

ing

and

supe

rvis

ion

for s

taff

in c

are

of g

astro

stom

y tu

bes.

D

ocum

ente

d ev

iden

ce o

f car

e in

pat

ient

’s

reco

rds.

A

udit

trail

of g

astro

stom

y tu

be in

serti

on.

Med

icat

ion

docu

men

tatio

n.

Reg

ular

nut

ritio

n sc

reen

ing

docu

men

ted

in

patie

nt re

cord

s.

Doc

umen

tatio

n.

Key

cha

lleng

es:

1.

Ava

ilabi

lity

of a

n ac

cess

ible

edu

catio

n pr

ogra

mm

e ap

prop

riate

to s

taff

need

s.

2. A

udit

tool

: C

olla

tion

of a

udit

data

and

sof

t war

e to

sup

port

audi

t tra

il

9

Sect

ion

5: D

isch

arge

pla

nnin

g K

ey is

sues

: •

Dis

char

ge p

lann

ing

shou

ld b

e co

nsid

ered

from

the

time

of a

sses

smen

t and

sho

uld

be a

n on

goin

g pr

oces

s th

erea

fter.

• E

quip

men

t is

chos

en th

at is

sui

ted

to th

e pa

tient

’s li

fest

yle,

allo

ws

mob

ility

and

refle

cts

the

pref

eren

ce o

f the

pat

ient

. •

Sys

tem

s sh

ould

be

in p

lace

to p

rovi

de s

uppo

rt an

d fo

llow

up

for p

atie

nts

with

gas

trost

omy

tube

s.

App

endi

x 10

: ent

eral

tube

feed

ing

trai

ning

che

cklis

t A

ppen

dix

11: p

atie

nt in

stru

ctio

n le

afle

t A

ppen

dix

12: d

isch

arge

che

cklis

t St

atem

ent

Rea

son

for S

tate

men

t

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

Th

e pa

tient

/car

ers

are

conf

iden

t and

co

mpe

tent

to u

nder

take

the

proc

edur

es

rela

ted

to g

astro

stom

y fe

edin

g.

The

patie

nt/c

arer

s w

ill be

aw

are

of s

uppo

rt av

aila

ble

once

dis

char

ged.

Th

e pa

tient

/car

ers

shou

ld b

e aw

are

of

wha

t to

do in

the

even

t of a

ccid

enta

l di

slod

gem

ent/r

emov

al o

f the

tube

.

Pat

ient

/car

ers

are

able

to d

emon

stra

te tu

be

feed

ing

tech

niqu

es e

nsur

ing

patie

nt s

afet

y.

Pat

ient

/car

ers

are

able

to re

cogn

ise

prob

lem

s if

they

aris

e an

d kn

ow w

hat a

ctio

n to

take

. To

pro

vide

a p

oint

of s

uppo

rt fo

r the

pa

tient

/car

ers.

If

a ga

stro

stom

y tu

be b

ecom

es d

islo

dged

it is

im

pera

tive

that

a re

plac

emen

t is

inse

rted

to

mai

ntai

n st

omal

trac

t pat

ency

.

Con

tract

of l

earn

ing

docu

men

ted

in p

atie

nt

reco

rds.

P

atie

nt in

form

atio

n le

afle

ts a

vaila

ble

(If n

o lo

cally

pro

duce

d le

afle

ts a

vaila

ble,

m

ost g

astro

stom

y tu

be m

anuf

actu

rers

pr

oduc

e ed

ucat

iona

l mat

eria

ls w

hich

may

in

clud

e in

form

atio

n le

afle

ts, t

here

fore

it is

w

orth

con

tact

ing

your

com

pany

re

pres

enta

tive)

. D

isch

arge

che

cklis

t will

be g

iven

to th

e pa

tient

with

con

tact

num

bers

. P

atie

nt in

form

atio

n le

afle

t giv

en to

pat

ient

.

10

Key

cha

lleng

es:

1. A

vaila

bilit

y of

info

rmat

ion/

inst

ruct

ion

leaf

lets

. 2.

Co-

ordi

natio

n of

a d

isch

arge

edu

catio

n pr

ogra

mm

e.

3. G

ood

com

mun

icat

ion

syst

ems

betw

een

all s

uppo

rt se

rvic

es in

volv

ed.

4. I

nfor

mat

ion

give

n sh

ould

be

sym

path

etic

to th

e pa

tient

’s e

duca

tiona

l, et

hnic

and

cul

tura

l nee

ds.

5. A

vaila

bilit

y of

trai

ned

pers

onne

l to

repl

ace

gast

rost

omy

tube

s w

ithin

the

hom

e se

tting

.

11

Sect

ion

6: F

ollo

w-u

p ca

re fo

r the

pat

ient

with

a g

astr

osto

my

tube

K

ey is

sues

: •

patie

nts

with

a g

astro

stom

y tu

be s

houl

d be

mon

itore

d on

a re

gula

r bas

is b

y a

mem

ber o

f the

mul

tidis

cipl

inar

y te

am

• so

me

type

s of

gas

trost

omy

tube

s re

quire

to b

e ch

ange

d in

acc

orda

nce

with

man

ufac

ture

rs in

stru

ctio

ns

App

endi

x 13

: re

com

men

datio

ns fo

r mon

itorin

g an

d fo

llow

-up

care

St

atem

ent

Rea

son

for S

tate

men

t H

ow t

o de

mon

stra

te s

tate

men

t is

bei

ng

achi

eved

Pat

ient

s w

ith g

astro

stom

y tu

bes

requ

ire

regu

lar m

onito

ring

and

follo

w u

p.

Gas

trost

omy

tube

cha

nges

sho

uld

be

plan

ned.

To e

nsur

e th

at g

astro

stom

y tu

be fe

edin

g is

st

ill ap

prop

riate

for t

he p

atie

nt.

To p

rovi

de th

e pa

tient

/car

er w

ith a

poi

nt o

f co

ntac

t. To

min

imis

e th

e ris

k of

com

plic

atio

ns

Dev

elop

ing.

To

pre

vent

the

com

plic

atio

n of

acc

iden

tal

tube

dis

lodg

emen

t/rem

oval

. To

pre

vent

deg

rada

tion

of th

e ga

stro

stom

y tu

be.

Ther

e is

doc

umen

ted

evid

ence

of

mon

itorin

g an

d fo

llow

up.

Th

e pa

tient

will

have

an

appo

intm

ent f

or

gast

rost

omy

tube

cha

nge.

E

vide

nce

of re

plac

emen

t will

be

docu

men

ted

in th

e m

edic

al re

cord

s st

atin

g m

ake

and

size

of g

astro

stom

y tu

be a

nd

how

pos

ition

of t

ube

was

con

firm

ed.

12

Key

cha

lleng

es:

1. G

ood

com

mun

icat

ion

syst

ems

betw

een

all s

uppo

rt se

rvic

es in

volv

ed.

2. A

vaila

ble

reso

urce

s of

per

sonn

el in

prim

ary

care

. 3.

Ava

ilabi

lity

of tr

aine

d pe

rson

nel t

o ch

ange

gas

trost

omy

tube

. 4.

Inf

orm

atio

n gi

ven

shou

ld b

e sy

mpa

thet

ic to

the

patie

nt’s

edu

catio

nal,

ethn

ic a

nd c

ultu

ral n

eeds

.

13

Sect

ion

7: R

emov

al o

f gas

tros

tom

y tu

be

Key

issu

es:

• re

mov

al o

f a g

astro

stom

y tu

be s

houl

d be

a p

lann

ed p

roce

dure

. A

ppen

dix

14: p

roce

dure

for r

emov

al o

f gas

tros

tom

y tu

be

Stat

emen

t R

easo

n fo

r Sta

tem

ent

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

R

emov

al o

f a g

astro

stom

y tu

be s

houl

d be

as

a re

sult

of m

ultid

isci

plin

ary

team

as

sess

men

t of t

he p

atie

nt.

Follo

win

g re

mov

al o

f a g

astro

stom

y tu

be

othe

r mem

bers

of t

he h

ealth

care

team

ca

ring

for t

he p

atie

nt s

houl

d be

info

rmed

.

It is

impo

rtant

that

the

deci

sion

to re

mov

e th

e tu

be is

as

a re

sult

of a

n in

form

ed

disc

ussi

on a

roun

d fu

ture

trea

tmen

t pla

ns

and

oral

inta

ke.

The

patie

nt is

an

inte

gral

par

t of t

his

disc

ussi

on.

It is

impo

rtant

that

the

patie

nt is

stil

l fo

llow

ed u

p to

ens

ure

that

thei

r ong

oing

ca

re is

not

com

prom

ised

and

that

any

ch

ange

s in

hea

lth a

re n

oted

ear

ly.

Del

iver

y of

feed

sup

plie

s ce

ase

and

any

rela

ted

equi

pmen

t is

uplif

ted.

Doc

umen

tatio

n of

mul

tidis

cipl

inar

y di

scus

sion

and

dec

isio

n in

med

ical

re

cord

s.

Pat

ient

’s m

edic

al re

cord

s.

Pat

ient

equ

ipm

ent u

plift

ed fr

om h

ome

setti

ng.

K

ey c

halle

nges

: 1.

Inf

orm

atio

n in

med

ical

reco

rds

of ty

pe o

f tub

e in

pla

ce a

nd h

ow re

mov

ed.

2. A

vaila

bilit

y of

exp

erie

nced

per

sonn

el fo

r tub

e re

mov

al.

14

Sect

ion

8: A

ccid

enta

l rem

oval

/dis

lodg

emen

t of a

gas

tros

tom

y tu

be

Key

issu

es:

• he

alth

care

pro

fess

iona

ls c

arin

g fo

r pa

tient

s w

ith a

gas

trost

omy

tube

sho

uld

be a

war

e th

at th

e st

omal

trac

t will

clos

e ra

pidl

y an

d th

eref

ore

a ne

w tu

be m

ust b

e in

serte

d tim

eous

ly

App

endi

x 15

: pro

cedu

res

for r

epla

cem

ent o

f gas

tros

tom

y tu

be

Stat

emen

t R

easo

n fo

r Sta

tem

ent

How

to

dem

onst

rate

sta

tem

ent

is b

eing

ac

hiev

ed

If

a ga

stro

stom

y tu

be b

ecom

es d

islo

dged

it

is im

pera

tive

that

a re

plac

emen

t is

inse

rted

to m

aint

ain

stom

al tr

act p

aten

cy.

Sho

uld

the

gast

rost

omy

tract

clo

se o

ver

the

patie

nt w

ill no

t rec

eive

thei

r pre

scrib

ed

med

icat

ion

or fe

ed.

Sho

uld

the

gast

rost

omy

tract

clo

se th

e pa

tient

may

requ

ire to

und

ergo

ano

ther

pr

imar

y tu

be in

serti

on.

Evi

denc

e of

repl

acem

ent w

ill be

do

cum

ente

d in

the

med

ical

reco

rds

stat

ing

mak

e an

d si

ze o

f gas

trost

omy

tube

and

ho

w p

ositi

on o

f tub

e w

as c

onfir

med

.

Key

cha

lleng

es:

1. S

yste

ms

shou

ld b

e in

pla

ce to

ens

ure

that

the

gast

rost

omy

tube

is re

plac

ed p

rom

ptly

, pre

vent

ing

the

need

for h

ospi

tal a

dmis

sion

. 2.

Ava

ilabi

lity

of tr

aine

d pe

rson

nel t

o re

plac

e ga

stro

stom

y tu

bes.

3.

.A

vaila

bilit

y of

repl

acem

ent g

astro

stom

y tu

bes

in th

e co

rrect

siz

e fo

r the

pat

ient

.

15

16

Glossary balloon gastrostomy tube

A type of tube retained in the stomach by inflating a balloon with a recommended amount of sterile fluid.

candida

Fungal contamination in lumen of tube.

cannula

A small flexible tube inserted into the vein to allow administration of fluids / medicines.

endoscopy

Procedure using fibre optic instrument to obtain a view of interior gastrointestinal tract (gut)

enteral feed

Prescribed liquid feed given directly into the gut via a feeding tube.

fine bore naso-gastric tube

A narrow tube passed via the nose down the oesophagus (food pipe) into the stomach to allow feed / medicines / water to be given.

fixator

Device that secures the gastrostomy tube in place either externally or internally.

gastro-colic fistula

An abnormal opening between the stomach and the intestine (colon).

gastrostomy

Surgical creation of an artificial opening into the stomach through the abdominal wall.

gastrostomy tube

Tube inserted into the stomach via the gastrostomy to allow feed / medicines / water to be given.

haemorrhage

Steady loss of blood.

low profile (button) device

Gastrostomy feeding device that sits at skin level.

overgranulation

Overgrowth of tissue.

percutaneous endoscopic gastrostomy (PEG)

Method of tube placement i.e. tube placed through abdominal wall using endoscopic guidance.

peristomal

Pertaining to the area of skin surrounding stoma (tube) site.

peristalsis Wave like contraction of gastrointestinal tract (gut) that propels food forwards.

peritonitis

Inflammation of the peritoneum (lining within the abdominal cavity).

17

pneumoperitoneum

The presence of air or gas within the peritoneum (abdominal cavity).

pulmonary aspiration

Inhalation of food/fluids into the lung.

radiological inserted gastrostomy (RIG)

Method of tube placement i.e. tube passed through abdominal wall under x-ray guidance.

stoma

Artificial opening onto abdominal wall.

tract

Pathway from abdominal wall into stomach.

traction removable

Gastrostomy tube that can be removed by pulling the tube away from the abdominal wall.

tube migration Gastrostomy tube pulled into stomach with increased peristalsis

19

Appendix 1: Information leaflet (Reproduced courtesy of SGH; NHSGG&C and NHS Lothian)

20

Appendix 2: Contra-indications to gastrostomy insertion • ascites • total gastrectomy Gastrostomy tube insertion/feeding may be contraindicated in the presence of the following conditions: • bleeding disorders if severe and uncorrected • large hiatus hernia – may mean most of stomach in chest • morbid obesity – can make placement difficult. The need for gastrostomy should be

revised • previous gastric surgery can make placement difficult • liver disease • risk of aspiration with gastro-oesophageal reflux • Crohn’s disease of the stomach or if there has been extensive surgery which could

make placement difficult • disseminated metastatic disease Other considerations • the presence of overlying bowel should be treated with caution – radiological

placement may be required • dementia – gastrostomy placement has not been shown to extend life or improve

quality of life in all patients and may cause distress. The appropriateness of a gastrostomy tube should be considered on a case by case basis.

• assessment of patient’s long term prognosis • availability of future care facilities • availability of healthcare personnel experienced in the technique of gastrostomy tube

insertion • adults with incapacity – it may not be possible to obtain consent from the patient

themselves and appropriate measures should be taken for example “Adults with Incapacity Form”

21

Appendix 3: Transfer of care documentation (Reproduced courtesy of the Scottish Home Enteral Feeding Group)

ENTERAL TUBE FEEDING TRANSFER FORM

PATIENT INFORMATION

Name DOB

Address

Post Code Tel

Carers Details

Tel No.

Diagnosis

GP & DISTRICT NURSE INFORMATION GP Name

Address

Post Code Tel No

D/N Name

Address

Post Code Tel No.

TRANSFERRED FROM Dietitian

Address

Tel.No. Page No.

Consultant Ward No.

Bans Registered YES

Planned Follow up

Medical / Other

Nutrition Nurse Page No.

TRANSFER OF DIETETIC RESPONSIBILITY TO INFORMATION ONLY Dietitian

Address

Tel.No. Page No.

Transfer Date

TUBE INFORMATION Make Size

22

Date Inserted Expected life

Route

Tube changes/removal Required method

Location

EQUIPMENT INFORMATION

Pump Type Serial No

Supplied by

Training Given

If Yes to whom

Ancillaries Giving sets Ongoing Supply from

Syringes Ongoing Supply from

Other Dressings -

Connector-

Ongoing Supply from

Feed Company Home Delivery Local pharmacy

FEED INFORMATION Feed Name Presentation

Delivery

Regimen

Rate

Suggested Feeding Times

ADDITIONS : Water Volume Delivery

Other Delivery

NUTRITIONAL INFORMATION Date Weight Height BMI

Weight Changes Other Anthropometric

Measurements

Biochemistry Carried Out? Date

Results

Oral Diet

Objectives of Feeding

Comments:

Signed Date

23

Appendix 4: Pre-insertion care Task Rational Give a full explanation of the procedure, to the patient and significant others. Provide the patient with an information booklet. Obtain informed consent.

To ensure understanding and address any gaps in knowledge whilst providing opportunities to express concerns and question information provided.

Ensure recent blood results are available pre procedure including full blood count and coagulation studies.

If INR above 1.5 the patient may require vitamin K pre-procedure to correct clotting abnormalities. Note: this level may vary with local policy

Fast for six hours prior to procedure.

To ensure stomach is empty.

Insert cannula.

For venous access during procedure.

Administer prophylactic antibiotic therapy I hour prior to procedure. Note: Check local protocol.

Studies have shown that the use of antibiotics at PEG insertion reduce the risk of infection.

Check medication prescription/ allergies.

To ensure patient tolerance of medications and cleansing solutions.

Pass a fine bore nasogastric tube. For radiological placement only.

To facilitate insufflation with air during procedure.

24

Appendix 5: Potential complications of insertion Risk management: Complications of PEG and RIG insertion are infrequent with a mortality rate of 0.3%--1%, although rare these complications can be life threatening therefore early detection is essential. Complication Cause Detection and prevention Pulmonary aspiration

Associated with endoscopy procedure and use of sedative drugs.

Patient monitored during procedure and protection of airway. Pulse oximetry should be used and oxygen and suction available for use if required.

Peritonitis Can occur as a result of the procedure or can occur after placement if tube migrates from the stomach wall into the peritoneal cavity.

Observe patient, reporting symptoms of sever pain, sudden pyrexia and tachycardia.

Haemorrhage Can occur during procedure.

Coagulation studies should be performed pre procedure. Routine monitoring of pulse and blood pressure during and directly following the procedure to detect haemorrhage.

Infection/sepsis Introduced during or after the procedure.

Strict aseptic technique should be observed during the procedure. The stoma site should be kept clean and dry.

Gastrocolic Fistula The development of a fistula between the stomach and colon, this can occur if colon accidently punctured during procedure.

Observe any change or abnormal GI symptoms.

Pneomoperitoneum Occurs if air escapes during the procedure into the peritoneal cavity.

Patient will report severe abdominal pain.

Appendix 6: Guidelines for Immediate Post Insertion Care Reproduced courtesy of SGH & VI NHS GG&C Percutaneous Endoscopic Gastrostomy: (PEG) Immediate Care

• Observation of vital signs and site. • Water should be commenced six hours after PEG placement followed by feed.

Follow the dietitian’s regimen. If patient is allowed oral intake, this should be introduced at the same time

• Ensure patient is in a head up elevated position of minimum 30˚ during feeding and for one hour after completion of feed if no contraindications

• Flush the tube before and after feeds and medication with minimum of 30ml water • Inspect site daily – if any pain, swelling, redness, or leakage is experienced, obtain a

bacteriological swab and apply appropriate dressing • Clean daily with antiseptic for first 24 hours after insertion and apply dry dressing.

After 24 hours, expose area, cleanse daily with soap and water or proprietary solution, and dry thoroughly

• Rotate the tube daily in a circle (360˚). Ongoing Care • No baths or swimming for two weeks after insertion – shower only • If tube becomes blocked, flush with 50ml soda water • If tube falls out, a replacement requires to be inserted straight away • If the primary tube has been in place for less than two weeks, attempt to reinsert

BUT do not feed via tube without radiological confirmation of position.

25

Radiologically Inserted Gastrostomy (RIG) Immediate Care: RIG

• Observation of vital signs and site. • Water should be commenced four hours after RIG placement followed by feed.

Follow the dietitian’s regimen. If patient is allowed oral intake, this should be introduced at the same time

• Ensure patient is in a head up elevated position of minimum 30˚ during feeding and for one hour after completion of feed if no contraindications

• Flush the tube before and after feeds and medication with minimum of 30ml water • Inspect site daily – if any pain, swelling, redness, or leakage is experienced, obtain a

bacteriological swab and apply appropriate dressing • After 24 hours, cleanse with soap and water or antiseptic, dry thoroughly, and apply

tegaderm dressing (change as required) • If skin sutures are present, these should be cut to skin level after one week.

Ongoing Care • No baths or swimming for two weeks after insertion – shower only • If tube becomes blocked, flush with 50ml soda water or warm water • If tube falls out, a replacement requires to be inserted straight away • If the primary tube has been in situ for less than 2 weeks, attempt to reinsert BUT do

not feed via tube without radiological confirmation of position. • Contact intervention radiology within 48hrs for tube replacement. NB If a decision is taken without the input of the surgical team to replace a dislodged tube prior to 2 weeks post insertion this should be done under the responsibility of the Managing Consultant and a full risk assessment undertaken prior to the procedure and prior to using the inserted tube.

26

27

Appendix 7: Post insertion complications associated with gastrostomy feeding

Complication Reason Tips Treatment Stomal infections Poor compliance or

technique

Good education and technique post insertion

Bacteriological swab and apply appropriate dressing

Peristomal leakage Constipation

Previous infection Immunocompromised patient Immobility Reduced fluid intake

Placement of a larger tube through the tract will not solve the problem Awareness of bowel habits and aim for prevention

Regular skin cleansing and skin protection Fibre enriched feed on advice of dietitian Extra fluid through gastrostomy tube

Aspiration of oesophageal secretions

Poor patient positioning during and after feeds

Ensure patient upright minimum 30˚ if not contraindicated

As per medical assessment Physiotherapy if required

Tube Migration Increased peristalsis

Refer Nutrition Nurse Specialist

As per Nutrition Nurse Specialist assessment

“Accidental” tube removal

Confusional state Consider type of tube .

Explanation and regular reinforcement of benefits

Ensure prompt attention

Overgranulation Previous infection Tube trauma

Rotate tube if not contraindicated Try 1% hydrocortisone cream or Actisorb Silver dressing

Refer to Nutrition Nurse Specialist or Tissue Viability Nurse if troublesome

Candida in tube lumen

Poor hand hygiene Multiple antibiotic therapy

Follow post insertion care procedure Cannot be eradicated

Tube functional but replacement should be planned

Tube blockage Poor flushing technique Incompatible medications

Follow flushing procedure Use liquid/soluble medications

As per flushing/unblocking protocol Seek Pharmacy advice

Balloon deflation Leakage due to osmosis Peristalsis Irregular checking of balloon volume Inappropriate use of balloon port

Check balloon volume weekly Do not use balloon port for feed and medication administration

Replace

Incorrect position of fixator device

Weight changes Increased peristalsis

Daily check Adjust positioning of fixator device

28

Appendix 8: Administering medication via an enteral feeding tube

29

Appendix 9: Infection control issues – good practice • effective hand hygiene • daily cleansing of gastrostomy exit site according to local protocol • daily inspection of exit site and early treatment of redness or exudate. • if there is any suspicion of infection at the exit site a swab must be taken for

microbiology • a topical application can sometimes avoid the necessity for systemic treatment of an

infected gastrostomy exit site • when administering water to maintain gastrostomy tube patency either when flushing or

during drug administration refer to local policy as to which type of water is recommended

• oral, catheter tip syringes or enteral dispensers should be used when administering feed, medication or water via the gastrostomy feeding tube. (Refer to manufacturers instruction’s for care and advice on use of selected device).

If there are any concerns related to infection control it would be advisable to contact the local infection control team. Oral health Oral hygiene is an integral part of general care. This is particularly important when a patient has natural teeth and is nil by mouth. An increasingly stagnant oral environment causing gum disease can develop with poor oral hygiene.

30

Appendix 10: Enteral tube feeding training checklist (Reproduced courtesy of Aberdeen Royal Infirmary)

Name: ________________________________________________________ Has been trained by: _____________________________________________ Subject Date Date Date • Handwashing • Pump feeding • Bolus feeding • Storing feed and equipment • Positioning during feeding • Maintaining tube patency • Skin care – gastrostomy site • Rotation of tube (depending on type) • Mouth care

Pump Training

• Attaching giving set to feed container • Priming the giving set • Attaching set to pump • Setting rate • Attaching giving set to feeding tube Alarms: • No set • Flow error • Hold error • Low battery • System error

Who to contact for advice/trouble shooting

• Senior Nurse on duty • Dietitian • Doctor • Nutrition Nurse Specialist • Commercial Company Nurse if

appropriate

Feeding Regimen

• Type and volume of feed • Rate of feed • Volume of water

31

I have received training on the above points: Signed: Date: Trainer (Signed) Supervised Practice 1. Supervisor: Grade: (Signed) Date: 2. Supervisor: Grade: (Signed) Date: 3. Supervisor: Grade: (Signed) Date: Consider: District Nurse education required Yes No Nursing Home education required Yes No Care assistant education required Yes No

32

Appendix 11: Patient instruction leaflets (Based on information sheet courtesy of Western and Gartnaval Hospitals NHS GG&C)

NB Before and after attending to your gastrostomy always wash your hands

• Inspect gastrostomy site daily - if you notice any pain, swelling, redness or leakage, please contact your Community Nurse or GP.

• Clean around the site of your gastrostomy daily with soap and water paying particular attention to area under disc and dry thoroughly. You do not need to apply talc or a dressing.

• Rotate the gastrostomy tube in a circle daily when you are cleaning it, this helps to prevent adherence of the tube to the entry site and makes cleaning easier

• It is important to flush your gastrostomy tube with 30 - 50mls of water in a syringe before you start the feed and again when feed is finished. This will prevent your gastrostomy tube from becoming blocked. If you are giving yourself medication via your gastrostomy always ensure they are in liquid form and remember to flush your tube before and after with 30 - 50mls water. If several medicines are to go down the tube, flush in between each with 20mls of water.

• If your gastrostomy tube becomes blocked, try putting some fizzy juice (soda water) (use 30-50mls in syringe). If that fails inform your Community Nurse or GP.

• While your feeding is in progress keep yourself semi-upright to allow feed to flow into your stomach to avoid the possibility of being sick if you were lying flat.

• Your type of gastrostomy may be held in position in your stomach with a balloon, if this is the case your Community Nurse will check the volume of sterile water in the balloon weekly.

• No baths for two weeks after your gastrostomy insertion. Shower only to allow stoma site to fully heal.

• If your gastrostomy tube should accidentally come out, do not panic. Contact your Community Nurse or GP as soon as possible so arrangements can be made to replace the tube.

If you have any worries relating to your gastrostomy tube or feeding, please contact:- Your Community Nurse: Tel No.: Your GP: Tel No: Your Dietitian: Tel No: Nutritional Support Sister, West Glasgow Hospitals

Type of tube inserted and date:

INFORMATION FOR PATIENTS AND CARERS : CARE OF YOUR GASTROSTOMY FEEDING TUBE

33

Appendix 12: Discharge checklist (Reproduced courtesy of the SGH, NHSGG&C)

HOME ENTERAL FEEDING DISCHARGE CHECKLIST

It is essential that patients and their carers are given appropriate training, information and equipment to enable them to manage home enteral feeding (HEF) independently in the community. The Dietitian/ Nutrition Nurse Specialist will document what is required for HEF. Training, information and equipment will be given by a range of Health Care Professionals (HCP). This checklist is for the HCP responsible at time of patient’s discharge to ensure that they have everything required and that they understand HEF process.

Patients Requirements to be completed by Dietitian/NNS

Circle as appropriate

Given

Not required

Initials Designation Date

Patient Consent by HCP for Home Enteral Feeding Patient consented for Homeward Infinity Pump: Serial No: Pump Training: To Whom – Name :

Drip Stand Carry Pack Both Nutrison Feed Type: Standard Multifibre Energy EnergyMultifibre 1200 CompleteMultifibre Other…………………. ………… Fortijuce Fortisip FortisipMultifibre Pack Size - 200ml bottle 0.5L 1L, 1.5L Daily requirements ………… No. Packs for d/c 8 14 16 21 28 35 42 48 ----

Syringe Type: 50ml catheter tip Other……………..: Daily Requirements ………………. Syringe Quantity Given : 14 21 28 35 42 48

Infinity Giving Sets 8 16 SPARE TUBE Route: PEG NG RIG

Make _____________ Size ________________

Clinisan & Dressings

Gastrostomy booklet

Gel / Sterile Water Vial / 10ml Syringe PH Paper NG Tape /Tegaderm Dressing Homeward Pack Provided Explained

Patient /CarerSignature ________________________ Print Name __________________ Date __________ Health Care Professional Signature _________________ Print Name _________________ Date __________

Patient Name ………………………… Ward No. ……… D.O.B……………… Unit No. ………………………………. CHI No. ……………………………….. Planned discharge date …………….

34

Appendix 13: Recommendations for monitoring and follow-up care NICE recommend that: • healthcare professionals with the relevant skills and training should review the

indications, route, risks, benefits and goals of the gastrostomy tube at regular intervals.

• people with enteral tubes in the community should be reviewed every 3-6 months or more frequently if there is a change in their clinical condition.

• patients and carers should be trained to recognise and respond to adverse changes in both their well being and in the management of their tube.

35

Appendix 14: Procedure for removal of gastrostomy tube • some gastrostomy tubes are traction removable. It is important that the healthcare

professional removing the tube is aware of the type of tube and the correct procedure for removal.

• patients with non-traction removable gastrostomy tubes should be referred to the

healthcare professional who inserted the primary tube. • after a planned removal of a gastrostomy, a dry dressing should be applied to the site.

The dressing should be changed as required and removed when leakage ceases. • in the event of a patient passing away, the gastrostomy can be secured and left in situ.

36

Appendix 15: Procedures for replacement of gastrostomy tube (Reproduced courtesy of Victoria Infirmary and SGH; ,NHSGG&C) If tube falls out, a replacement requires to be inserted straight away In the event of a replacement gastrostomy tube being required and unavailable, a foley catheter may be used to maintain tract patency, although it is NOT recommended for enteral feed delivery.

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Bibliography: Bankhead RR Fisher CA Rolandelli RH (2005) gastrostomy tube placement outcomes: comparison of surgical, endoscopic and laparoscopic methods. Nutrition in Clinical Practice 20 p607-612 British Medical Association Medical Ethics Committee (2nd edition 2001) Withholding and Withdrawing Life Prolonging Medical Treatment London ISBNO727916157/xvii British Association for Parenteral and Enteral Nutrition (1999) Current Perspectives on Enteral Nutrition in Adults London ISBN 1 899467 20 3 British Association for Parenteral and Enteral Nutrition and The British Pharmaceutical Nutrition Group (2004) Administering drugs via enteral feeding tubes: A practical guide www.bapen.org.uk/pdfs/drugs/26enteral/practical-guide-poster.pdf British Society of Gastroenterologists (2001) Antibiotic prophylaxis in gastrointestinal endoscopy BSG Guidelines in Gastroenterology London CREST (2004) Guidelines for the management of enteral tube feeding in adults. DeLegge MH (2003) PEG placement: Justifying the intervention UpToDate (800) 998-6374 DeLegge MH (2003) Prevention and management of complications from percutaneous endoscopic gastrostomy UpToDate (800) 998-6374 www.uptodate.com Gauderer MWL (2002) Percutaneous endoscopic gastrostomy and the evolution of contemporary long-term access Clinical Nutrition 21(2) p103-110 Glencorse C Meadows N Holden C Eds (2003) Trends in artificial nutrition support in the UK between 1996 and 2002 A report by the British Artificial Nutrition Survey A committee of the British Association for Parenteral and Enteral Nutrition Salisbury Press 70 Limited Loser C Aschl G Hebterne X Mathus-Vliegen EMH Muscaritoli M Niv Y Rollins H Singer P Skelly RH (2005) ESPEN Guidelines on artificial enteral nutrition – Percutaneous endoscopic gastrostomy Clinical Nutrition 24 p 848-861 Medicines and Healthcare Products Regulatory Agency (MHRA) Safety Action Notice SAN(SC)04/03 – 11 Feb 2004 Misuse or modification of medical devices. National Confidential Enquiry into Patient Outcome and Death (2004) Scoping our practice www.ncepod.org.uk National Institute for Health and Clinical Excellence (2006) Clinical Guideline 32 Nutrition Support in Adults ISBN 1-84629-150-X National Health Service Quality Improvement Scotland (2003) Food Fluids and Nutritional Care in Hospitals Edinburgh Scottish Executive www.nhshealthquality.org Nightingale J (2001) ed Intestinal Failure London Greenwich Medical Media Limited

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Nursing and Midwifery Practice Development Unit (2002) Nutrition Assessment and Referral in the Care of Adults in Hospital Best Practice Statement Edinburgh ISBN O 954265211 Nursing and Midwifery Practice Development Unit (2002) Nutrition for physically frail older people Best Practice Statement Edinburgh ISBN O 9542652 2 X Nursing and Midwifery Practice Development Unit (2003) Nasogastric and Gastrostomy Tube Feeding for Children being cared for in the community Best Practice Statement Edinburgh ISBN O-9542652-6-2 Scottish Executive Adults with Incapacity (Scotland) Act 2000 www.hmso.gov.uk/legislation/scotland/acts200/20000004.htm Skipper L Cuffling J Pratelli N (2003) Enteral Feeding Infection Control Guidelines Infection Control Nurses Association ISBN – 0-9541962-0-75 www.icna.co.uk Stroud M Duncan H Nightingale J (2003) Guidelines for enteral feeding in adult hospital patients GUT 52(supplement VII) Tschudin V (2003) Ethics in Nursing The Caring Relationship Edinburgh Butterworth Heinemann Useful Websites British Association for Parenteral and Enteral Nutrition - (BAPEN) www.BAPEN.org.uk Patients on Intravenous and Nasogastric Nutrition Therapy - (PINNT) www.PINNT.com National Nurses Nutrition Group – (NNNG) www.nnng.org/ Parenteral and Enteral Nutrition Group of the British Dietetic Association – (PENG) www.peng.org.uk

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Who was involved in developing the statement? Dorothy Barber Nutrition Nurse Specialist Aberdeen Royal Infirmary. Ann MacCrimmon Nutrition Nurse Specialist Southern General, NHS GG&C Gill McHattie Nutrition Nurse Specialist Southern General, NHS GG&C Contributors Linda Davidson Nutrition Nurse Specialist Victoria Infirmary, NHS GG&C Joan Dimmick Nutrition Nurse Specialist Gartnavel General/Western Infirmary, NHS GG&C Merrie Dwan Nutrition Nurse Specialist RACH, Aberdeen. Christina McGuckin Parenteral Nutrition Nurse

Specialist RHSC, NHS GG&C Patricia McKeown Nutrition Nurse Specialist Royal Infirmary, NHS GG&C Carol Muir Nutrition Sister Edinburgh Royal infirmary, May Shaw Nutrition Sister Queen Margaret Hospital, Dunfermline Avril Smith Gastrostomy Nurse Specialist RHSC, NHS GG&C Nancy Smith Nutrition Nurse Specialist Victoria Infirmary, NHS GG&C Jan Tait Clinical Nurse Specialist in GI Ninewells Hospital, Dundee. Kirsty Turnbull Nurse Specialist in GI Ninewells Hospital, Dundee. Whilst it is recognised that many centres do not have a Nutrition Nurse Specialist (NNS) reference is made throughout the text to the support offered by this role. The National Institute for Health and Clinical Excellence (NICE) in their guidelines “Nutrition Support in Adults” (2006) state that “ ….all people that need nutrition support receive coordinated care from a multi-disciplinary team…….including a specialist nutrition nurse….”. NHS Quality Improvement Scotland (QIS) in their standard “Food Fluids and Nutritional Care in Hospitals” (2003) state that “where complex nutritional techniques are employed, the patient has access to the services of a clinical nutrition support team ……The core membership of which should include a specialist nutrition nurse..” If there is not an NNS, an experienced healthcare professional should be identified as a point of contact. External Reviewers Margaret Aitchinson Endoscopy Unit Manager Crosshouse Hospital Ayrshire & Arran NHS Board Christine Ballantyne Upper GI Nurse Specialist Royal Alexandra Hospital NHS GG&C Andrea Cartwright Senior Nutrition Nurse Basildon & Thurrock NHS Specialist & National Nurses Trust Nutrition Group Chair Tommy Gordon Charge Nurse, Endoscopy Ayr Hospital Unit Ayrshire & Arran NHS Board

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