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PEG Care and Management Policy

1. Purpose

This policy outlines {{org_field_name}}’s commitment to ensuring the safe and effective care of individuals requiring Percutaneous Endoscopic Gastrostomy (PEG) feeding. It aims to establish best practices in line with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, CQC fundamental standards, and the National Institute for Health and Care Excellence (NICE) guidelines. The policy ensures that PEG feeding is conducted in a safe, person-centred, and dignified manner, maintaining the health, well-being, and quality of life of the people we support.

2. Scope

This policy applies to all staff involved in the care, support, and management of people with PEG tubes, including nurses, care assistants, and other healthcare professionals working at {{org_field_name}}. It covers the entire process of PEG management, from insertion to daily care, emergency protocols, and ongoing monitoring.

3. Principles of PEG Care

The following principles underpin our approach to PEG care:

• Dignity and Respect: Ensuring people feel comfortable, informed, and involved in decisions regarding their feeding and care.
• Safety and Hygiene: Maintaining strict infection control measures in line with Regulation 12 – Safe Care and Treatment.
• Person-Centred Care: Developing individualised care plans to align with preferences and medical needs.
• Competent Staff: Ensuring all staff involved in PEG care are trained and assessed for competency in handling PEG tubes safely.
• Regular Monitoring: Conducting routine checks and addressing complications promptly to prevent harm.

4. PEG Insertion, Consent and Mental Capacity

• The decision to insert, replace or materially alter the management of a PEG tube must be made by the appropriately qualified healthcare professionals responsible for the person’s clinical care, following appropriate assessment and multidisciplinary discussion where required.
• Before PEG-related care or treatment is provided, valid consent must be obtained from the person in accordance with Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
• The person must be provided with information about their PEG care and treatment in a form and manner they can understand. This must include, where relevant, the purpose of the treatment, reasonably foreseeable risks, potential complications and available alternatives.
• Consent must be treated as an ongoing process. A person who has capacity may refuse PEG feeding, medication, tube care or other treatment and may withdraw consent at any time. Staff must respect a capacitous refusal and seek appropriate clinical advice where refusal may place the person at significant risk.
• A person’s mental capacity must not be assumed on the basis of their diagnosis, disability, communication difficulty, age or appearance. Where there is reason to doubt the person’s capacity to make a specific PEG-related decision, a decision-specific capacity assessment must be undertaken and recorded in accordance with the Mental Capacity Act 2005.
• Where the person lacks capacity to make the relevant decision, staff must act in accordance with the Mental Capacity Act 2005 and its Code of Practice. Any decision made on the person’s behalf must be in their best interests and must take account of the person’s past and present wishes and feelings, beliefs and values, and the views of appropriate people involved in their care.
• Family members or a person’s next of kin do not automatically have legal authority to consent to treatment on the person’s behalf. Their views should be consulted where appropriate as part of the best-interests process, but decision-making authority must only be exercised by a person who has lawful authority, such as an attorney under a valid Health and Welfare Lasting Power of Attorney or a Court of Protection-appointed deputy acting within the scope of their authority.
• Any valid and applicable advance decision to refuse treatment, relevant court order, Lasting Power of Attorney, deputyship order or other lawful authority must be identified, verified and followed.
• All consent discussions, capacity assessments and best-interests decisions relevant to PEG care must be clearly documented in the person’s care records and communicated to staff involved in providing the care.

5. Daily PEG Tube Care

• Hand Hygiene: All staff must wash hands and wear gloves before handling the tube.
• Site Cleaning: The insertion site must be cleaned with sterile saline and dried to prevent infection.
• Tube Position Check: Staff must ensure the tube remains secure and in the correct position before feeding.
• Flushing: The tube must be flushed before and after feeding and medication administration to prevent blockages.
• Monitoring for Signs of Infection: Redness, swelling, pain, or leakage must be reported immediately to the nurse in charge.

6. Administering PEG Feeds

• Person-Centred Approach: Feeds must be given at a comfortable pace, respecting the individual’s preferences.
• Correct Positioning: The person should be at a 30-45 degree angle during and at least 30 minutes post-feed to prevent aspiration.
• Adhering to Dietician Guidelines: Feeds should only be administered as per the prescribed regimen by a qualified dietitian.
• Monitoring Tolerance: Staff must observe for bloating, discomfort, nausea, or vomiting and report concerns promptly.
• Documentation: Every feed given must be recorded, including type, volume, and any observations.

7. Medication Administration via PEG

• Medicines must only be administered through a PEG tube where this route has been authorised and there are clear instructions for administration within the person’s current medication records, care plan or other approved clinical instructions.
• Before administering any medicine through a PEG tube, staff must confirm that the medicine and formulation are suitable for administration through the person’s specific type of tube.
• Liquid medicines should not automatically be assumed to be suitable for PEG administration. The formulation, concentration, viscosity, osmolality, compatibility with the tube and any interaction with enteral feed must be considered where relevant.
• Tablets or capsules must not be crushed, opened, dispersed or otherwise altered unless suitability has been confirmed by an appropriate healthcare professional, such as the prescriber or pharmacist, and clear instructions are available.
• Modified-release, prolonged-release, sustained-release, enteric-coated, gastro-resistant and other specialist formulations must not be crushed unless specific professional advice confirms that alteration is safe and appropriate.
• Staff must administer medicines individually and must not mix different medicines together unless there is explicit pharmaceutical or prescribing advice authorising this.
• Medicines must not routinely be mixed directly with enteral feed.
• The tube must be flushed with the appropriate type and volume of water before medication administration, between individual medicines where required, and after the final medicine, in accordance with the person’s prescribed regimen, fluid requirements, tube manufacturer’s instructions and current pharmaceutical advice.
• The volume of flush water must be included when monitoring the person’s total fluid intake, particularly where the person is subject to fluid restriction.
• Where an interaction between a medicine and enteral feed is known or suspected, staff must follow specific pharmacy, prescribing or dietetic instructions concerning whether the feed needs to be paused before or after administration.
• Before administering medicines, staff must follow the person’s individual care plan and manufacturer’s or specialist instructions for identifying possible tube displacement or other circumstances in which the tube must not be used.
• If staff cannot confirm that a medicine can safely be administered through the PEG tube, the medicine must not be administered through the tube until advice has been obtained from the prescriber, pharmacist or other appropriate healthcare professional.
• Medication administration must be documented on the person’s Medication Administration Record and any additional PEG documentation required by the service.
• Any medication error, omitted dose, suspected medicine-feed interaction, tube blockage or adverse reaction must be reported and escalated in accordance with the Medication Management and Administration Policy.

8. Preventing and Managing PEG Complications

Staff must be alert to complications associated with PEG feeding and must follow the person’s individual PEG care plan, manufacturer’s instructions and any specialist clinical guidance provided by the person’s dietitian, nutrition team, GP or other responsible healthcare professional.

Blockage

• PEG tubes must be flushed as prescribed and before and after feeds and medicines where required to reduce the risk of blockage.
• If a blockage occurs, feeding and medication administration through the affected tube must stop until the tube has been assessed and it is safe to continue.
• Staff may attempt to clear the blockage only by methods included within their training, the person’s care plan and approved clinical guidance.
• Warm water may be used for irrigation where clinically appropriate. Excessive force must never be applied to the tube.
• Staff must not insert sharp objects or other implements into the PEG tube and must not use carbonated drinks, acidic fluids or other unapproved substances to clear a blockage.
• If the blockage cannot be safely cleared, staff must obtain prompt advice from an appropriate healthcare professional.

Infection, Leakage and Skin Problems

• The PEG site must be observed for redness, heat, swelling, tenderness, pain, discharge, bleeding, leakage, skin breakdown, over-granulation or other abnormal changes.
• Site care must be undertaken in accordance with the person’s individual care plan, specialist instructions and current infection prevention and control procedures.
• Any suspected infection, significant leakage, new pain, deterioration of the site or other concerning change must be reported promptly to the nurse in charge or appropriate senior member of staff and escalated for clinical assessment where required.
• Where systemic infection or sepsis is suspected, emergency medical assistance must be obtained without delay.

Suspected Tube Migration or Displacement

• Staff must recognise changes that may indicate displacement, including an unexpected change in external tube length, looseness, pain, leakage, resistance during flushing, feed intolerance or any other change specified in the person’s care plan.
• Where displacement or migration is suspected, the PEG tube must not be used for feed, fluids or medicines until its position and safety for use have been confirmed in accordance with the person’s clinical management plan.

Complete Tube Dislodgement

• Complete PEG tube dislodgement must be treated as an urgent clinical situation because the gastrostomy tract can begin to close rapidly.
• Feeding, flushing and medication administration through the tract must stop immediately.
• Staff must immediately follow the person’s documented emergency gastrostomy replacement pathway and obtain urgent specialist or emergency medical advice.
• Where no immediate specialist replacement pathway is available, staff must arrange urgent assessment through the appropriate emergency service or Emergency Department.
• Staff must not blindly reinsert a PEG tube.
• A member of staff may only attempt replacement or insertion of a temporary device where this is specifically permitted by an established clinical pathway, is within their professional scope of practice, they have been trained and assessed as competent to undertake the procedure, and the person’s individual clinical plan authorises this action.
• Particular caution is required following recent PEG insertion because displacement of an immature gastrostomy tract may cause leakage of gastric contents into the abdominal cavity and serious complications. Staff must follow the specialist team’s emergency instructions.

Other Complications

• Persistent vomiting, abdominal distension, significant abdominal pain, unexplained diarrhoea, bleeding, respiratory distress, suspected aspiration, inability to tolerate feed, buried bumper syndrome or any sudden deterioration must be escalated for appropriate clinical assessment.
• Staff must document the complication, action taken, professional advice received and the person’s outcome.

9. Training and Staff Competency

• Only staff who have received appropriate PEG training and have been assessed as competent for the PEG-related tasks they are required to perform may undertake those tasks without direct supervision.
• Training and competency assessment must cover the specific PEG equipment, procedures and responsibilities applicable to the people supported by the service.
• Staff must understand the person’s individual PEG care plan, infection prevention measures, feeding and flushing procedures, recognition and management of complications, emergency procedures, medicines administration responsibilities where applicable, and the limits of their role.
• Staff competence must be assessed before they undertake PEG care independently and must subsequently be reviewed at intervals determined by the provider’s training and competency framework.
• Competency must also be reassessed whenever there is reason to question a member of staff’s competence, following a relevant incident or error, where equipment or procedures change, following a significant period during which the skill has not been practised, or where additional training needs are identified through supervision or appraisal.
• Staff who have not demonstrated or maintained the required level of competence must not undertake the relevant PEG procedure independently until they have received appropriate support, retraining and reassessment.
• Records of PEG training, competency assessments, reassessments and any restrictions placed on practice must be maintained.

10. Record-Keeping, Incident Reporting and Documentation

• All records relating to PEG care must be accurate, complete, legible, contemporaneous and maintained securely in accordance with Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and the organisation’s record-keeping requirements.
• The person’s individual PEG care plan must contain sufficient current information to enable staff to provide safe care. This must include, where applicable:
  • the type of gastrostomy tube and relevant device information;
  • the prescribed feeding regimen;
  • prescribed feed and fluid volumes;
  • required water flushes;
  • medication administration instructions;
  • the person’s required position during and after feeding;
  • relevant aspiration risks;
  • known medicine-feed interactions;
  • routine site and tube care requirements;
  • appropriate tube-position or external-length observations;
  • identified risks and the measures required to mitigate them;
  • the actions staff must take if the tube becomes blocked, displaced or dislodged;
  • relevant specialist and emergency contact details; and
  • the agreed review arrangements.
• Staff must document PEG feeds, flushes and medicines administered in the appropriate records.
• Records must include any omitted, delayed or refused feed, fluid, flush or medicine and the action taken in response.
• Staff must document relevant observations of the PEG tube and stoma site, including abnormalities, changes in external tube position where this forms part of the person’s clinical plan, signs of infection, leakage, pain, blockage, displacement, feed intolerance or other complications.
• Staff must record any advice obtained from the GP, dietitian, pharmacist, specialist nutrition team, NHS 111, ambulance service, hospital or other healthcare professional and any resulting change to the person’s care.
• Consent, withdrawal of consent, relevant mental capacity assessments and best-interests decisions must be recorded in accordance with the Mental Capacity Act 2005 and the organisation’s consent and mental capacity procedures.
• The person’s PEG care plan must be reviewed whenever there is a significant change in their condition, nutritional or hydration requirements, medication, feeding regimen, tube type or clinical advice, and at the planned review intervals agreed by the multidisciplinary team.
• Any PEG-related incident, including a medication error, significant blockage, displacement, accidental removal, aspiration event, significant infection or other adverse event, must be reported through the organisation’s incident reporting system and escalated to the Registered Manager or responsible senior person.
• The Registered Manager or delegated responsible person must determine whether an incident meets the criteria for notification to the Care Quality Commission, safeguarding referral, other statutory reporting or the statutory Duty of Candour and must ensure that the appropriate action is taken.

11. Involvement of People We Support, Families, Representatives and Advocates

• People receiving PEG care must be involved, to the maximum extent possible, in the assessment, planning, delivery and review of their care.
• Information about PEG feeding, tube care, medicines, associated risks and available choices must be provided in a way that the person can understand, taking account of their communication needs and any reasonable adjustments required.
• Where the person has capacity, their wishes regarding the involvement of relatives, friends or other representatives must be respected.
• Family members, friends or a person’s next of kin must not be given confidential information or involved in decisions about PEG care solely because of their relationship to the person. Information may be shared where the person has consented, where the recipient has lawful authority to act for the person, or where there is another lawful basis for sharing the information.
• Where the person lacks capacity to make a relevant decision, appropriate family members, carers, advocates and others interested in the person’s welfare should be consulted as required by the Mental Capacity Act 2005 when determining the person’s best interests.
• Where a person has an attorney under a valid Health and Welfare Lasting Power of Attorney or a Court of Protection-appointed deputy, staff must establish the scope of that person’s legal authority before relying upon a decision made on the person’s behalf.
• Where appropriate, the person and any family member, carer or representative who is expected to participate in PEG care must receive sufficient instruction and information to enable them to understand the relevant procedures, potential complications and actions to take in an emergency.
• People receiving care must be provided with appropriate information about relevant support services and how to raise questions or concerns about their PEG care.

12. Emergency Procedures

Staff must follow the person’s individual emergency care plan and act within the limits of their training, competence and role.

Suspected Aspiration or Serious Breathing Difficulty

• Stop the PEG feed immediately.
• Assess the person’s immediate condition and summon assistance.
• Position the person in accordance with their individual emergency care plan and first-aid training, taking account of their condition and level of consciousness.
• Call 999 immediately where the person has severe breathing difficulty, cyanosis, reduced consciousness, signs of airway obstruction or another life-threatening condition.
• Suction must only be undertaken where it is clinically appropriate, appropriate equipment is available, and the member of staff has been trained and assessed as competent to perform the procedure.
• Do not restart the PEG feed until the person has been assessed and it is confirmed that doing so is safe.

Suspected Sepsis or Severe Infection

• Staff must immediately escalate signs of serious infection or suspected sepsis.
• Where the person is acutely unwell or sepsis is suspected, staff must seek emergency clinical assistance without delay, including calling 999 where indicated.
• Staff must continue to monitor the person and provide first aid or other emergency support within their competence pending the arrival of healthcare professionals.

PEG Tube Displacement or Complete Dislodgement

• Stop all feed, fluids and medicines through the tube immediately.
• Do not use a tube where displacement is suspected until its safety and position have been confirmed in accordance with the person’s clinical plan.
• Complete dislodgement must be treated urgently because the gastrostomy tract may begin closing rapidly.
• Follow the person’s gastrostomy emergency replacement pathway immediately and contact the designated specialist service.
• Where timely specialist support cannot be obtained, arrange urgent assessment through the appropriate emergency service or Emergency Department.
• Staff must not attempt blind reinsertion. Replacement may only be undertaken where the member of staff is specifically trained and assessed as competent, the procedure falls within their professional role and an approved clinical pathway authorises them to undertake it.

Significant Bleeding, Severe Abdominal Pain or Sudden Deterioration

• Stop the feed and do not administer further feed, fluids or medicines through the PEG until clinically advised.
• Obtain urgent medical assessment.
• Call 999 where the person’s condition appears life-threatening or is deteriorating rapidly.

Following Any PEG-Related Emergency

• Inform the senior person responsible for the service.
• Record the incident, observations, actions taken and professional advice received.
• Complete the organisation’s incident reporting process.
• Review and update the person’s risk assessment and PEG care plan where necessary.
• The Registered Manager or responsible person must consider whether safeguarding action, statutory notification to CQC or the Duty of Candour is required.

13. Related Policies

• CH11-Safe Care and Treatment Policy
• CH18-Risk Management and Assessment Policy
• CH21-Medication Management and Administration Policy
• CH23-Lone Working and Staff Safety Policy
• CH27-Staff Supervision, Training, and Development Policy
• CH30-Equality, Diversity, and Inclusion Policy

14. Policy Review

This policy will be reviewed annually or earlier if there are changes in CQC regulations, clinical best practices, or business needs. Updates will be made to ensure compliance with CQC standards, NICE guidelines, and emerging best practices in PEG care and management.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
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