Enteral tube feeding adults policy

Contents

1 Policy summary

This policy is guidance for any healthcare professional caring for patients with an enteral feed tube. It covers the types of tubes, types and administration of enteral feed, infection control procedures, storage and preparation of feeds, mouth and stoma care, discharge planning and further education resources. It provides advice and support on how to safely manage and undertake enteral feeding for a patient. It is vital to ensure anyone caring for a person with a feeding tube is competent and confident to do so.

2 Introduction

Enteral tube feeding involves the administration of nutrients and fluids via a tube into the stomach, duodenum or jejunum.

The aim of the policy is to ensure that all patients with an enteral feeding tube receive a high standard of evidence-based care.

3 Purpose

This policy is intended to enable the safe and effective management and care of patients who have an enteral feeding tube to ensure high quality care and treatment for patients in line with best practice and guidelines.

The aim is to:

• reduce and manage the risk of infection and complications associated with enteral tube feeding to patients, colleagues, carers and visitors
• ensure the trust complies with all national and local guidance
• ensure that continuity of care takes place where different people may be called upon to meet the needs of the patient
• provide advice and troubleshooting associated with the care of patients with enteral feeding tubes

4 Scope

The policy applies to all colleagues across the Doncaster physical health and neurodiversity, Doncaster adult mental health and learning disability and Rotherham adult mental health care group who care for adults with an enteral feeding tube.

Colleagues in the North Lincolnshire adult mental health and talking therapies care group should consider the guidance in this policy and apply it in conjunction with advice from the North Lincolnshire and Goole NHS Foundation Trust dietetic department.

5 Procedure or implementation

5.1 Quick guide

5.1.1 Consent

• Obtain consent from the patient to access relevant personal information.
• Refer to relevant Mental Capacity (MCA) guidance where there are concerns regarding capacity.

5.1.2 Patient centred care

• Be aware of the type of tube, method of delivery and type of feed that has been recommended and agreed for the patient.
• Ensure you feel competent in the skills and knowledge needed to provide the patient centred care and treatment necessary in terms of feeding but also appropriate stoma site or tube care.

5.1.3 Minimum content

• Ensure the relevant care and treatment is captured using the appropriate templates on the patient’s clinical record in a timely way:
  • assessment of need or risk
  • care plan
  • interventions
  • monitoring

5.1.4 Education

• Ensure to provide support and education to the patient, carer, family where appropriate.
• Be a source of knowledge and skill for colleagues where appropriate.
• Ensure to remain to date with training in line with relevant competencies for job role.

5.1.5 Escalation

• Ensure you are aware of how to troubleshoot when issues arise.
• Ensure you are aware of whom to contact in an urgent or emergency situation in relation to any tube care and treatment.

5.2 Indications for enteral feedings

Whenever possible, oral intake is always preferred. Enteral feeding is used for adults or children whose nutritional needs cannot be met orally and they are at risk of long-term weight loss, malnutrition and, or dehydration.

Examples of the patient group include dysphagic patients (for example, cancer and neurological conditions), food or fluid refusal, and patients with gastrointestinal problems. Patients must have a functional and accessible gastrointestinal tract for enteral feeding.

The clinical decision to propose an enteral tube as part of clinical treatment should be made by the relevant and involved Multi-Disciplinary team (MDT). Nutritional support may not always be appropriate, for example, late-stage palliative care.

Enteral feeding tubes can be placed, and regimens established at other National Health Service (NHS) Trusts (outside RDaSH) and as such any enteral information must be shared in line with information governance.

5.3 Consent

It is a general, legal and ethical principle that valid consent must be obtained before providing care and, or treatment to a patient. This includes consent for placement of the tube, following this, enteral feed, fluids and, or medication.

If consent cannot be obtained, the principles of the MCA (2005) have to be followed.

If a person’s ability to make a decision regarding nutrition and hydration is doubted, a capacity assessment should be undertaken. If the person lacks capacity and they have made an advance decision to refuse treatment (ADRT) which is valid and applicable in relation to nutrition and hydration, then treatment should not be provided.

If the patient does not have an ADRT then the decision will need to be made in the person’s best interest under the MCA, unless they have a registered lasting power of attorney for health and welfare then consent should be sought from the appointed attorney.

Providing nutrition and hydration under the Mental Health Act 1983 is only appropriate for detained patients who are refusing to eat, not for patients who are unable to meet nutrition and hydration needs orally due to a physical illness.

For further guidance around consent colleagues should refer to the consent to care and treatment policy and the MCA Mental Capacity Act 2005 policy.

5.4 Types of enteral feeding tubes

There are many different types of enteral feeding tubes and clinical colleagues must be aware of the type of enteral feeding tube that their patient has to ensure correct procedures are followed. This information can be found here, enteral nutrition (opens in new window).

5.5 Methods of delivery

The dietitian, in consultation with the patient and, or those involved in the patient’s care, will decide on the method of delivery. Taking into consideration their wishes, nutritional status, environment and any other complications or considerations present.

Feed can be delivered either via infusion (via pump) or bolus. Information on these methods of delivery can be found here, enteral nutrition (opens in new window).

5.6 Types of feed

A wide variety of feeds are available including low or high energy or protein and specialised, for example, soya or peptide based and also feeds  presented in different volumes. Nutritional content and information can be found on the product label.

A written regimen specifying, method of delivery, type of feed and all other relevant additional information will be provided by the dietitian. These regimens are provided to meet the nutrition and hydration needs of the patient following an assessment by the dietitian. Sub optimal regimens will not be recommended. The regimen may include a different combination and presentation of feeds depending on the person’s needs. This must be referred to the dietitian if there are queries or concerns.

5.7 Infection prevention and control precautions

Infection prevention and control precautions will reduce the risks of infection and support patients, colleagues and carers to deliver safe, best practice for the benefits of patients.

5.7.1 Hand hygiene

Hand hygiene must be followed when handling an enteral tube. For guidance please refer to the infection prevention and control manual, hand hygiene procedure.

5.7.2 Personal protective equipment

Personal protective equipment must be worn where appropriate.
For guidance please refer to the infection prevention and control manual, personal protective equipment procedure.

5.7.3 Handling an enteral tube

• Decontaminate hands.
• Don gloves and apron.
• Access enteral feeding tube.
• Remove gloves and apron.
• Wash hands with soap and water.

5.7.4 Preparation and storage of feeds

Ready-to-use feeds (pre-packaged) are often used instead of those requiring decanting, reconstitution or dilution. Specific advice and instruction will be provided by the dietitian should any feed require decanting, reconstitution or dilution.

Hand hygiene, personal protective equipment and clean technique should be followed at all times when handling and preparing enteral feeds.

Feeds should be stored in a cool dry place, off the floor, away from direct sunlight and according to manufacturer’s instructions. Opened feeds can be stored in the refrigerator but must be used within 24 hours.

5.7.5 Administration of ready-to-use feeds

• If refrigerated, remove feed from the fridge half an hour before administration to allow it to reach room temperature.
• Check the feed packaging for any damage.
• Check the expiry date.
• Prepare the connectors or syringes or giving sets required to administer the feed.
• Ensure open connectors do not come into contact with any potential contaminants, for example, clothing, bed clothes or other equipment.

Please refer to section 5.4 for guidance on method of delivery (administration via pump or bolus) to deliver feed.

• Administration sets are single use (inpatient) and must be discarded after each feeding intervention or multi use (community) and washed thoroughly before reuse.
• Dispose of all equipment appropriately.
• Unused feeds can be flushed down the domestic drainage system (if not refrigerating and used or using within 24 hours).

5.7.6 Administration of medicines

With reference and applying the same principles as for consent, separate consent must be obtained to administer medications via an enteral tube.

It is preferable to provide oral medications where appropriate and as agreed by the appropriate clinicians.

Where medicines administration must be via enteral tubes:

• the range of medications should be kept to those which are essential for management of the patient for the duration of their enteral feeding
• there is opportunity for interactions between the medication and the feed or the feeding tube and advice must be sought around these compatibilities
• crushing and, or dispersal of tablets, opening of capsules is rarely covered by the licence and licenced routes of administration for products. Prescribers must be aware of and authorise the unlicensed use

Consequently, an individual care plan should be formulated for the patient regarding their medicines administration detailing the specific medications, doses, administration technique and relevant tube flushing. This should be constructed with support from pharmacy and the prescriber. Additionally, this should be updated as medication needs change.

Useful resource, handbook of drug administration via enteral feeding tubes (opens in new window)

5.7.7 Equipment and ancillaries

The Nutricia nursing service or dietitian should be contacted to provide advice on what equipment and ancillaries is required for the patient, and how to care for these, depending on the type of tube they have.

For inpatient services, feed, equipment and ancillaries required for enteral feeding can be obtained from Evergreen (Tickhill Road Site) and, or ordered via NHS supply chain (known as regional distribution centre (RDC)).

For community services, equipment and ancillaries required for enteral feeding are ordered by the dietitian directly to the patient’s home from Nutricia Homeward.

5.7.8 Flushing the tube

• In an inpatient setting, sterile water must be used.
• In a community setting, freshly drawn tap water can be used.

How to flush a tube can be found here, enteral nutrition (opens in new window).

5.8 Mouth care

Good oral hygiene is essential for all patients especially those who are nil by mouth or taking little amounts orally. Saliva is normally produced when eating and drinking orally regularly and this helps keep the mouth clean. Since saliva production is often reduced when receiving feed enterally the oral mucosa can develop sores.

Guidance on how to provide suitable mouth care in general and more personalised for your patient should be directed to the doctor, nurse, speech and language therapist or dietitian.

5.9 Stoma skin care

A skin assessment at the tube site should be undertaken on a regular basis to assess for any:

• exudate, colour, type, approximate amount, extent of strikethrough onto primary dressing
• odour, offensive, some, none
• pain, site, frequency, severity, related to skin or tube
• surrounding skin,  dry, eczema, maceration, erythema, healthy
• colonisation or Infection, suspected, confirmed (specify organisms)
• hyper granulation tissue, present or absent

If any of the above is present, the doctor and, or the Nutricia nursing service should be contacted for advice.

5.10 Tube care

Information on how to care for a tube can be found here, enteral nutrition (opens in new window).

For further guidance around tube care the Nutricia nursing service should be contacted.

5.11 Discharge planning for community

The patient, family and, or care agencies must be trained to safely manage, care for the tube and administration of nutrition, hydration and medication prior to discharge. The Nutricia nursing service should be contacted for this to be arranged.

The dietitian will also need to be informed to ensure the feed, equipment and ancillaries required is arranged via Nutricia Homeward or transfer out of area as required.

5.12 Education of patients, colleagues and carers

All those involved with the direct care of the patient, including the patient should be trained and educated about enteral feeding, tube or stoma care and management and infection and presentation control measures. This training is provided by the Nutricia nursing service.  Please refer to section 6.

5.13 Safeguarding

If there are concerns about an adult at risk in relation to enteral tube feeding, this should be discussed with the dietitian who will be able to advise and escalate appropriately. Any immediate risk must be escalated to the safeguarding team for advice and support.

6 Troubleshooting

6.1 Accidental tube removal

6.1.1 Permanent feeding tubes (for example, PEG)

If a tube is accidentally removed, maintaining the tract is paramount, as the tract can heal within 2 hours.

• If the tract of the feeding tube has been established less than 4 weeks the site should be covered with a dry dressing and the patient should attend accident and emergency immediately.
• If the patient has an established tract of 4 weeks or more and their balloon gastrostomy or PEG is accidental removed a ‘stoma stopper’ can be inserted to maintain the tract:
  • place a stoma stopper and, or a clean gauze dressing over the stoma site to prevent stomach contents leaking onto the skin or clothes
• Attending nurse to complete a risk assessment to ascertain whether the patient requires urgent or essential hospital admission for intravenous fluid or medicines or if they are safe to stay where they are until a Nutricia nurse can visit the following day.

The following should be contacted via phone following accidental tube removal:

• Monday to Friday 8am to 6pm and Saturday to Sunday 9am to 1pm, Nutricia nursing service phone: 0345 762 3670
• Saturday to Sunday 1pm to 5pm (Doncaster Royal Infirmary Endoscopy) phone: 01302 644171
• Out of hours (single point of access) phone: 01302 566999
• Nutricia nursing service out of hours phone: 0800 093 3672

If a tube has been removed (even if established tract of 4 weeks or more) and there are any signs of trauma to the stoma tract (such as bleeding), or if there are any signs of pain or distress, please seek urgent medical review.

Where tubes have become accidentally dislodged, the removed tube should be discarded as appropriately. Any faulty batches of tubes should be sent back to the manufacturer and reported.

6.1.2 Temporary feeding tubes (for example, NG)

If a tube is accidentally removed or you cannot obtain an appropriate pH aspirate prior to administration, the attending nurse must complete a risk assessment to ascertain whether the patient requires urgent or essential hospital admission for intravenous fluid or medicines or if they are safe to stay where they are until a Nutricia nurse can visit the following day.

If the patient does require urgent or essential hospital admission, the patient must be to be transferred to Doncaster and Bassetlaw Teaching Hospital or The Rotherham NHS Foundation Trust for re insertion.

6.2 Tube complications

Tube blockages is a common complication and can be prevented if the tube is cared for correctly, however if blockages occur information on how to resolve this can be found here, enteral nutrition (opens in new window) or failing this contacting the Nutricia nursing service.

Any other concerns related to the tube which cannot be resolved should be directed to the Nutricia nursing service.

6.3 Enteral feed complications

Please see appendix C.

6.4 Contact details

Contact details for professionals involved in enteral feeding can be found here, enteral nutrition (opens in new window).

7 Training implications

7.1 Enteral tube feeding (adults), any person who is providing direct enteral care or treatment to the patient

• How often should this be undertaken: Annually or as required if competency has not been maintained.
• Length of training: 1 to 2 hours.
• Delivery method: Face to face or virtual or via video or resource library, enteral nutrition (opens in new window).
• Training delivered by whom: Nutricia nursing service or link nurse.
• Where are the records of attendance held: Colleagues to inform L and D team to update electronic staff record system (ESR). Certificate of attendance kept by the colleague.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No additional requirements, other than those outlined within the policy have been identified.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005).

9 Links to any other associated documents

All the policies mentioned in this policy can be accessed via RDaSH Internet:

• MCA Mental Capacity Act 2005 policy
• Consent to care and treatment policy
• Infection prevention and control manual

10 References

• Department of Health (2010), The Health and Social Care Act 2008: Code of Practice on the Prevention and Control of Infections and Related Guidance.
• Mersey Care NHS Trust (2012), Enteral Feeding Clinical Guidance.
• NICE, (2006), Nutritional Support in adults; oral nutrition support, enteral tube feeding and parenteral nutrition, Clinical guideline 32.
• NICE (2012), Infection Prevention and Control of Healthcare Associated Infections in Primary and Community Care, Clinical Guideline 139.
• NPSA (2010), Early Detection of Complications after Gastrostomy.
• Nutricia Limited (2013), Nutricia Nurse or Patient Carer Adult Training Policies and Procedures.
• Smyth JA (2010), The Newt Guidelines for the administration of medication to patients with Enteral Feeding tubes or Swallowing Difficulties, North East Wales NHS Trust.
• Enteral Nutrition, Malnutrition and Food First. By RDaSH Dietetics Team (opens in new window).

11 Appendices

11.1 Appendix A Responsibilities, accountabilities and duties

11.1.1 The trust

The trust has a ‘duty of care’ and a ’duty of confidentiality’ to ensure that all aspects of healthcare record keeping are properly managed. The trust must adhere to the legislative, statutory, and good practice guidance requirements relating to healthcare records management.

11.1.2 The chief executive

The chief executive has overall accountability and responsibility for healthcare records within the trust. This function is delegated to the executive medical director and the executive director of nursing and allied health professionals, who are responsible for driving high quality standards of healthcare record keeping.

11.1.3 The trust’s executive medical director

The trust’s executive medical director (and trust Caldicott guardian) plays a key role in ensuring that NHS and partner organisations comply with current national guidance and relevant legislation regarding the handling and safeguarding of ‘patient identifiable information’. The Caldicott guardian will advise employees on matters relating to the management of patient identifiable information, for example where issues such as the public interest conflicts with duties such as maintaining confidentiality.

11.1.4 Senior managers of the trust

Senior managers of the trust are responsible for the quality of the healthcare records that are generated by all trust employees to ensure patient safety and quality service delivery.

11.1.5 Head of information management and business intelligence

Head of information management and business intelligence will advise the trust on how to maintain an efficient and effective patient information system, which complies with all the data collections required within the NHS.

Clinical leads or service managers or modern matrons:

• the dissemination of this policy to their colleagues
• highlighting the training needs of their colleagues in relation to this policy
• releasing colleagues to attend for training
• supporting colleagues who care for patients with an enteral tube
• monitor compliance with this policy and take immediate action when non-compliance is identified

11.1.6 Dietitians

Dietitians:

• estimation of nutritional requirements and current nutritional intake to advise on an appropriate feeding regimen tailored to environmental circumstances
• advice on the appropriateness of enteral feeding considering medical condition, prognosis and practical circumstances
• management of the patient via Nutricia homeward (the contracted home enteral feeding company) for feeding, equipment and ancillaries and requesting prescriptions from the general practitioner (GP)
• provide ongoing monitoring of nutritional state and tolerance making any necessary amendments to enteral feed regimen or prescription as required
• support dietetic assistants in the management of enterally fed patients
• supporting where appropriate and required with training for patients, colleagues and carers

11.1.7 Speech and language therapist or dysphagia practitioner

Speech and language therapist or dysphagia practitioner:

• assessment and monitoring of dysphagia in enterally fed patients
• provision of advice on the appropriateness of enteral feeding in regard to dysphagia
• highlight any enteral feeding related concerns to the dietitians

11.1.8 The Nutricia nursing service

The Nutricia nursing service:

• training of patients, colleagues and carers on the practical aspects of enteral feeding
• troubleshooting for problems relating to stoma care
• routine changes of tubes where appropriate
• Nutricia have their own training policies and procedures but will work to RDaSH policy

11.1.9 All employees

All employees involved with the care of patients with an enteral feeding tube should be aware of and adhere to the procedures outlined within this policy. All colleagues should be up-to-date with their knowledge and skills and maintain competency by attending relevant training as identified within the policy.

11.2 Appendix B Monitoring arrangements

11.2.1 Breaches in policy

• How: Via IR1 system.
• Who by: Multidisciplinary healthcare professionals.
• Reported to: Care groups.
• Frequency: As identified.

11.2.2 Standards in policy

• How: Dip sample.
• Who by: healthcare professionals.
• Reported to: Physical health leads and governance.
• Frequency: Quarterly.

12.3 Appendix C Troubleshooting enteral feed complications

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

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Document control

• Version: 4.
• Unique reference number: 385.
• Approved by: Clinical policies review and approval group.
• Date approved: 6 February 2024.
• Name of originator or author: Clinical team lead dietitian.
• Name of responsible individual: Executive director of nursing and allied health professionals.
• Date issued: 19 February 2024.
• Review date: 28 February 2027.
• Target audience: All colleagues within the trust (in-patient, community, day services, or care homes) who care for adults with an enteral feeding tube.
• Description of change: 3-year review including, policy summary, scope, grammar and wording updates, discharge planning and accidental tube removal information.

Page last reviewed: November 14, 2024
Next review due: November 14, 2025

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