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Enteral Feeding Policy

This care service understands enteral feeding to be a means of delivering nutrition into the gastrointestinal tract through a tube, either via the nose or directly into the stomach or small intestine through a stoma in the intestinal wall to provide artificial nutrition using a proprietary liquid feed.

This method of feeding is only necessary or desirable when a person’s nutritional needs are unable to be met orally, for various reasons.

Enteral tube feeding is not an emergency procedure and should be a planned process. Once access to the gastrointestinal tract is established, the optimum feeding regimen for the individual should be recommended for the patient by a qualified dietitian.

During feeding the person using the service must be monitored in order to prevent, detect and manage complications (NICE 2006 CG 32).

Once back in {{org_field_name}} setting, people who use services must be regularly reviewed, and this should include a risk assessment of the environment, equipment and nutritional status.

This policy aims to provide guidance to staff working with people who require enteral feeding.

The policy and procedures which {{org_field_name}} has developed are in line with the applicable national standards for health and social care, relevant legislation and best-practice guidance relating to the management and administration of enteral feeding.

Aim

The aim of this care service is to optimise the use and efficiency of enteral feeding as a means of nutrition support for people who use services and provide high-quality person-centred care following up-to-date guidance and best practice to minimise associated risks.

All staff involved in caring for a person receiving enteral feeding should be adequately trained and feel sufficiently competent to undertake appropriate person-centred care and support.

Staff should be aware of and follow guidelines and procedures relating to the maintenance of an enteral feeding tube, stoma site and other local relevant guidance.

Pre-discharge Planning

This care service understands all people who use services being considered for discharge with enteral nutrition should have multidisciplinary team involvement and approach to ensure that feeding can be managed effectively on discharge and to ensure seamless discharge and co-ordinated ongoing care.

All necessary equipment and feeds must be available in advance and staff trained in the use of and maintenance of such.

This care service understands that a GP and out-of-hours services must be available.

Consent to Enteral Feeding

People who use services deemed to have mental capacity must provide their written consent to enteral feeding before it can be administered. The individual and their family and carers should be provided with full information about the procedure prior to it being undertaken so that they can make an informed choice.

This should include:

The person’s consent will need to have been documented.

If there is reason to doubt the person’s capacity to make a decision about enteral feeding, then a formal assessment of capacity should be undertaken and documented. The assessment of capacity should be undertaken by the multidisciplinary team caring for the person using services.

Decision to Feed Enterally

The decision to feed a person via the enteral route should be made by the multidisciplinary team in consultation with the person who uses services and their family.

If for any reason this is not possible, healthcare professionals should act in the person’s best interest if they are not competent to give consent.

Feeding Against the Will of the Person Using Services

This care service understands that feeding against the will of the person using services is the last resort, should it be an intervention of the care and management of those with severe eating disorders or other mental illness. It should be considered in the context of the Mental Health Act 1983, the Mental Capacity Act 2005 and their respective Codes of Practice.

Where the Mental Capacity Act 2005 (or equivalent Scotland act) is used to authorise enteral feeding, the person should be assessed to see if additional deprivation of liberty authorisation is required.

Feeding Routes

Enteral feeding is used to place feed into a person’s stomach. When necessary it may be possible to feed directly into the duodenum or jejunum (small intestine). The route and type of appliance used will depend on the individual.

Nasogastric Tube Feeding

This care service understands that it is very unlikely that this type of feeding will take place in care home settings due to the significant risks associated with misplacement.

A fine bore feeding nasogastric tube (NG) tube is inserted via the nose into the stomach. Bolus or pump feeding can be used with an NG tube and long-term fine bore tubes should be replaced every four to six weeks, swapping them to the other nostril.

Regular checks of NG tube placement are essential as there is a risk that tubes can be misplaced into the lungs on insertion or move from the stomach.

Percutaneous Endoscopic Gastrostomy

In a percutaneous endoscopic gastrostomy (PEG) procedure, a feeding tube is placed into the stomach of the person through an abdominal stoma or artificial opening. and is retained in the stomach by a flange. Gastrostomies may be placed surgically or radiologically, if necessary.

Button Gastrostomy

This is a small tube that has the same function as a PEG feeding tube, but the button is flush with the person’s abdomen. This button is held in place by a small balloon inside the stomach and the balloon needs to be checked weekly.

Button gastrostomies are used more frequently in children than adults so are unlikely to be seen in a person in a care home setting.

Gastrojejunostomy

This is an endoscopically placed extension of a PEG. The extension is passed through the PEG into the person’s stomach and down past the pylorus into the jejunum. These may be used if there is a problem with the stomach or gastric emptying.

Method of Delivery

The dietitian, in consultation with wider health professionals, will decide on feed type and method of delivery for each individual. Factors considered include:

A written regimen specifying feed, rate of feeding and additional water flushes will be provided by the dietitian for each person to fit the person’s needs.

Infusion (Feed Delivered by Pump)

This care service understands that if a pump is required, the standard rate is usually between 5 and 500ml per hour.

This rate must not be increased unless under direct instruction from the dietitian and documented clearly in the care plan.

Continuous Feeding

Continuous feeding usually refers to feeding over a 16 to 20-hour period. Continuous feeding is used if the person is unable to tolerate large volumes of feed.

It can be used initially, and the person may progress onto an intermittent infusion regime. The feed may be delivered overnight or during the day depending on the individual’s needs and tolerance.

Continuous feeding usually includes a break of at least four hours in a 24-hour period to enable the stomach to re-acidify.

24-hour feeding may be used for people who use services with diabetes who are on sliding scale insulin to control their diabetes.

Intermittent Feeding

This care service understands this to involve periods of feeding using the pump with breaks.

Bolus feeding (without a pump) involves the delivery of a specified volume over a particular period of time and may be given four to six times a day depending on the person’s individual feeding regime.

Administration of this may be with a syringe using only the barrel as a funnel to allow the feed to infuse using gravity. The plunger from the syringe should not be used to push feed through. Bolus feeding can also be administered with bolus feed gravity sets. If there are any signs of intolerance, then another feeding method should be sought from healthcare professionals.

If administering medication through an enteral feeding system, such as a bolus, the correct safety devices and connector combinations should always be used, ensuring that three-way and specific equipment, such as syringe tip adaptors, are used.

Type of Feed

A wide variety of feeds are available. Sterile packs of feed are preferable to those that need decanting as there is less risk of contamination for the person.

The dietitian will select the most suitable feed depending on the individual needs of the person using services.

Some people who use services will be given standard whole protein feeds such as Osmolite, whilst others may require high energy feeds which can be useful when fluid is restricted or to reduce feeding time.

Most feeds are lactose-, gluten- and wheat-free, and suitable for vegetarians, Kosher and Halal diets. However, it should be noted that most feeds are not suitable for vegans and some allergens, which should be checked if there are concerns.

People Who Use Services with Diabetes

People who use services with diabetes are usually given standard formulas of feed but should be monitored frequently as per their care plan and blood glucose results recorded.

Diabetic Monitoring

For all people who use services with diabetes, receiving enteral nutrition guidance should be sought from the diabetes specialist nurse or team.

Illness increases blood glucose levels for people who use services with diabetes, so blood glucose should initially be monitored every four to six hours in case an increase in diabetic medication is required.

The Parenteral and Enteral Nutrition Group (PENG), of the British Dietetic Association, have group guidelines which suggest that blood glucose be maintained between 5.5–11 mmol/l in stressed patients and then tightened to 5.5–8.5 mmol/l once control is established. The PENG also has a Dietetic Outcomes Toolkit available to download at www.peng.org.uk.

Fluid

Feeding tubes should be flushed with water before and after administration of feed, medication and in between medications. This helps to prevent blockage of the tube whilst also contributing to overall fluid contents.

For most people, freshly drawn tap water may be used unless they are immunosuppressed. For immunosuppressed people or those being fed into the jejunum, sterile water should be used from a freshly opened container.

Full fluid requirements can usually be met by feed and flushes, although additional flushes may be requested to meet the person’s daily fluid requirements. A fluid balance chart may be requested to monitor the individual’s input and output, especially when unwell.

The GP or dietitians should be informed of any ongoing loss of body fluids, eg diarrhoea or excessive perspiration, so that the fluid content of the feed can be adjusted accordingly.

Mouth Care/Oral Hygiene

This care service understands that the person will need to maintain good oral hygiene (see Oral Care topic) of their teeth and keep their mouth clean, especially for those who are nil by mouth or have restricted oral intake.

Usual good practice should be followed, and all the surfaces of the teeth, gums and tongue should be brushed at least twice a day using regular toothpaste and a toothbrush.

Advise the person not to lick their lips as it can make dryness and chapping worse. To moisten the lips, people who use services can use a moisturising cream or lip balm.

Artificial saliva or a mouthwash may help if the mouth is dry and should be discussed with the GP or healthcare professional.

Mouth Transition from Tube to Oral Feeding

This care service understands that suitable oral food and fluids would only ever be used after consultation and agreement with the multidisciplinary team.

If agreed, this will be phased in as the feed is reduced to ensure that adequate intake is maintained and should be monitored. The nutritional requirements of the person will need to be calculated by the dietitian who can then advise on how to adjust the feeding regime.

Diarrhoea

Diarrhoea is a relatively common problem in patients receiving enteral food but is seldom related directly to the feed.

The dietitian must be regularly informed of any problems or changes as ongoing diarrhoea can cause dehydration.

Monitoring

Qualified healthcare professionals with relevant skills and training should review the indications, routes, risks, benefits and goals of nutrition support at regular intervals. The time in between reviews depends on the patient, care setting and duration of nutrition support. Intervals may increase as the person is stabilised on nutrition support.

Staff should undertake any specific physiological observations as required and these should be documented in the individual care plan.

The care plan must also include a record of the type of feeding tube in situ and the date when it was placed.

Guidance

This care service adheres to the following evidence-based best practice guidelines.

Dietitians

This care service understands that dietitians are the only qualified health professionals that assess, diagnose and treat diet and nutrition problems.

Speech and language therapists (SLTs) may also be involved to advise and inform new initiatives, policies and guidelines in dysphagia.

Positioning

Tube feeding should be undertaken when the person is sitting or is well-supported, eg by an adjustable bed and/or sufficient pillows, so that their head and shoulders remain at a 45-degree angle for the whole time in which they are fed. This should be maintained for 30 minutes to an hour afterwards. This is to help reduce the risk of aspiration pneumonia and make the person using services as comfortable as possible.

If the person is unable to remain supported at 45 degrees for the entire time in which they are fed, then continuous pump feeding may not be appropriate for that individual. This will need to be fed back to the dietitian or other healthcare professional.

Supporting a person to remain at a 45-degree angle can be particularly difficult while they are asleep, and this is why tube feeding overnight may not be recommended for some.

Continuing to feed a person using services when they are supported at less than a 45-degree angle or if they are lying flat can significantly increase their risk of aspirating stomach contents, which could lead to possible chest infection and/or necessitate hospital admission.

Medication Administration

This care service is aware that when administering medicines through a feeding tube, staff should be aware of the legal and professional consequences of altering a drugs format, eg by crushing a tablet, and that the medicine is being given through an unlicensed route.

Very few medicines, including liquid medicines, are licensed to be given through feeding tubes.

Care staff can only give medicines in an unlicensed way, ie through a feeding tube, when instructed to do so by the prescriber.

Administering Enteral Feed

Bolus feeding involves administering a prescribed volume of feed in a specified dose at a specified time normally through a syringe directly into the enteral feeding tube. Bolus feeding is not advised for patients receiving jejunal feeding.

Pump feeding involves administration of enteral feed via an enteral feeding pump.

What to do if a Feeding Pump Develops a Fault

This care service understands that if an enteral feeding pump requires replacement in the community, the person using services/care staff should contact their customer care team to arrange a replacement pump.

The contact number for this service is:___________________________

Safe Use of Enteral Feeding Equipment

Maintenance

Pumps should be regularly maintained following the manufacturer’s instructions and cleaned after every use with a detergent wipe or with detergent and water. Feeding pumps should be routinely serviced as recommended by the manufacturer.

Enteral Feeding Pumps: Feeding

Giving sets are usually single use items and should be discarded after each feeding episode. Frequent disconnection of the giving set for intermittent feeding should be avoided.

Feeding reservoirs should be labelled with the time and date when first used and discarded after 24 hours or when empty. This should not exceed more than 24 hours.

For people who use services in their own homes and nursing homes, for flushing all enteral feeding tubes, freshly drawn tap water is advisable unless otherwise advised by the dietitian.

People who use services with small bowel or jejunal feeding tubes can use cool boiled water unless otherwise instructed by the dietitian or further to a risk assessment.

Care of the Stoma Area

This care service understands that the area around the person’s stoma/feeding tube site should have the appearance of normal, healthy skin.

If there are signs of stoma infection/over granulation, this should be reported to a healthcare professional.

Other signs to observe and report include:

Tube Blockage

This care service understands that blockage of feeding tubes can occur but that it is usually avoidable.

If blockage does occur, it is usually due to the following.

If the feeding tube does block, it may be able to be unblocked without the need for a hospital admission. Community nursing staff or other trained healthcare professionals should be contacted, and advice and support sought.

Any incident of tube blockage should be recorded in the person’s care plan and staff should investigate why the blockage occurred and learn from it to prevent it happening again.

Enteral Feeding Emergencies

This care service understands people who use services’ care should be focused on minimising risk. Early intervention and management may prevent a clinical emergency occurring for people who use services requiring enteral feeding.

If at any time the person becomes short of breath, has sudden pallor or an increased heart rate, staff should stop the feed immediately and seek urgent medical advice.

Possible complications can include bleeding, leaking of gastric contents, swelling, pain and tube displacement.

Support Provided by Care Staff

This care service will ensure that appropriate discharge planning is completed prior to the transfer from a hospital. It is imperative that care home staff or appropriate community and domiciliary care services are well prepared and ready for the arrival of any person requiring enteral feeding. This will ensure that person-centred care of the highest possible quality can be provided to meet their needs and any continuing treatment required can be provided and supported seamlessly without delay by a specialist service in the community, day hospital or outpatient clinic.

{{org_field_name}} has appropriate professional links with the local enteral feeding specialist team and has up-to-date contact numbers and details readily available.

Contact details for local enteral feeding team services are as follows: ____________________________

Responsibilities of the Care Manager

In this care service, the provision of safe enteral feeding which meets current legislation and nutritional guidelines is the responsibility of the care manager, following guidance from the dietitian. The care manager’s responsibilities and duties include the following.

It is a general and ethical principle that care workers seek and obtain valid, informed consent from the person prior to commencing procedures. Such consent is confirmed as being understood by writing, using gestures or verbally. Consent should be documented in the person’s care plan with any explanation as to why it could not be obtained including mental incapacity, which then should follow the corresponding best interests assessments and procedures.

Line managers have the responsibility to support staff to attend training and maintaining competency. Line managers must also ensure that there is appropriate equipment available and that it is serviced and stored correctly.

Staff will be trained to be aware of the impact that people who use services requiring enteral feeding may have. {{org_field_name}} will expect care staff to:

Infection Prevention and Control

It is essential that staff undertaking this procedure must maintain infection control measures and standards and appropriate personal protective equipment (PPE) should be used.

Infection prevention includes inspection of the stoma site at least daily. The person should be observed for signs of infection, such as pain, swelling, exudate and fever.

Handwashing and effective hand decontamination must be carried out before starting feed preparation. Disposable gloves and plastic aprons are recommended in the event of bodily fluids or feed encountering the person carrying out the feed preparation or administration.

Preparation and Storage of Feeds

This care service understands that wherever possible, pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution.

If preparation is required, feed and equipment should be prepared on a metal surface, eg a treatment trolley, which has been cleaned with detergent and water and disinfected with alcohol (70%).

The system selected should require minimal handling to assemble and be compatible with the person’s enteral feeding tube.

Feeds should be stored in a clean, dry area out of direct sunlight and not on the floor, as per the manufacturer’s guidance.

Staff should check the feed is in date prior to administration and check that there are no signs of “feed curdling” or other contamination. If there are any concerns regarding the feed, the dietitian must be contacted.

Staff should check that the feed name corresponds with the regimen advised by the dietitian for the person using services.

Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in the refrigerator and used within 24 hours. Feeds that are stored in the refrigerator should always be removed 30 minutes prior to administration to allow time for the feed to reach ambient temperature.

All equipment/utensils used should be sterile or heat disinfected or as instructed by the manufacturer. If a special feed or fortification is prescribed, the mixture should be mixed thoroughly using an aseptic technique.

Feed Hanging Times

This care service understands that sterile pre-packed feeds can usually be hung for 24 hours.

Non-sterile feed (including modular diluted or modified sterile feed) decanted into a sterile reservoir should be hung for up to four hours. Under no circumstances should sterile reservoirs be “topped up” as this increases the risk of infection.

If the feed becomes disconnected, a new giving set will usually be required each time. Should disconnection be unavoidable it is essential that the person’s tube is flushed with water or as advised on the feeding regimen at the time of disconnection.

Training

Staff undertaking care of a person requiring enteral feeding must carry out initial training prior to working with the person using services and work within their scope of professional practice and competence. All staff involved in the care of people who have enteral feeding require competency-based training on the administration of feed and stoma/tube care.

People who use services requiring enteral feeding need specialist care and all care home staff who provide care for people must be appropriately trained and supervised according to the demands of their role. This will include:

In addition to the treatment and care of people using services requiring enteral feeding, care staff will also be trained to recognise the signs and symptoms of somebody with signs of a blocked feeding tube, stoma infection, etc.

An update or refresher may be required every three years or more often in some instances.

All care staff must be able to demonstrate clinical competence in accordance with relevant current policies, guidelines and procedures and have a clear understanding of the underlying principles of practice.

All healthcare professionals have a responsibility to work within the scope of their practice and job description and demonstrate current competency at an appraisal or review. All care staff must also attain and maintain infection control, basic life support and anaphylaxis training.


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