Download CLMM037 The use of syringes to administer flushes, feeds and

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
NUH Medicines Policy: Code of Practice
THE USE OF SYRINGES TO ADMINISTER FLUSHES, FEEDS AND
MEDICATION VIA THE ORAL AND ENTERAL ROUTES POLICY
Reference
Approving Body
Date Approved
Implementation Date
Version
Summary of Changes from
Previous Version
Supersedes
Consultation Undertaken
CL/MM/037
Senior Management Team
23 November 2016
23 November 2016
1 (supersedes version 3 of CL/CGP/016 and
version 2 of CL/CGP/069)
 Change to make reference to new ISO
connector (ISO 80369-3 ENFit) for enteral
feeding tubes.
 Change to specify the use of ENFit
compatible equipment including bottle
adaptors to withdraw liquid medicines from
medicine bottles.
 Change to use bottle adaptor /enteral
syringe system to measure all doses of
liquid medicines.
 Amalgamation of 2 previous policies, and
move to include this policy as part of the
overall NUH medicines policy
CL/CGP/016 version 3: The Use Of Syringes
To Administer Flushes, Feeds And Medication
Via The Oral And Enteral Routes In Adults
Policy
CL/CGP/069 version 2:
The Use of Syringes to Administer Flushes,
Feeds and Medication via the Oral and Enteral
Routes in Children/ Young People And
Neonates Policy
Adult Nutrition Nurse Specialist
Children’s gastrostomy and stoma Nurse
Digestive Diseases & Thoracics Lead
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Pharmacist
Paediatric Pharmacist
Neonatal Pharmacist
Paediatric Dietitian
Practice Development Matron Children’s
Services
Children’s Nurse Specialist
Neonatal Nurse
Critical Care Governance Matron
Clinical Procurement Matron
Medical Devices Clinical Lead
Medicines Safety Group (Sept 2016)
Medicines Management Committee (Oct 16)
Medical Devices Safety Officer (Sept 2016)
Dietetics
Medicines Safety Officer
Date of Completion of
Equality Impact Assessment
Date of Completion of We
Are Here for You
Assessment
Date of Environmental
Impact Assessment (if
applicable)
Legal and/or Accreditation
Implications
02/10/16
Target Audience
All NUH staff who prescribe, supply and
administer oral liquid medicines.
All NUH staff involved in the process of
02/10/16
02/10/16
This policy must be in place to fulfil
requirements of NPSA alert no 19 Promoting
safer measurement and
administration of liquid medicines via
oral and other enteral routes, 28th March 2007
and to prevent ‘wrong route’ Never Events.
The Department of Health Never Events list
includes:
Wrong route administration of medication;
Oral/enteral medication or feed/flush
administered by any parenteral route
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Review Date
prescribing, supply and administration of feeds
and flushes by the enteral route.
Nov 2019
Lead Director
Medical Director
Author/Lead Manager
Rachel Medcalf
Medicines Safety Officer
Ext 59374
Further Guidance/Information Medicines Management Committee secretary
Ext 59374
Adult Nutrition Nurse Specialist (NCH)
Ext 56754
Digestive Diseases & Thoracics Lead
Pharmacist
Pharmacist, Ext 59374 Bleep 780 5985
Children’s Gastrostomy Nurse, Ext 63536
Paediatric Lead pharmacist, Ext 64410 Bleep
780- 6072
Children’s Dietitian, Ext 62081
Neonatal Clinical Development Nurse,
Ext 69028
Clinical Procurement Specialist (QMC)
Ext 59909
Medicines Safety officer ext 59374
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CL/MM/037 version 1, November 2016
CONTENTS
Paragraph
Title
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Introduction
Executive Summary
Policy Statement
Definitions (including Glossary as needed)
Roles and Responsibilities
Policy and/or Procedural Requirements
Training, Implementation and Resources
Impact Assessments
Monitoring Matrix
Relevant Legislation, National Guidance
and Associated NUH Documents
References
Procedure for the use of ENFit compatible
enteral syringes to administer liquid
medicines via the ORAL route IN ADULTS
5
5
6
7
8
9
11
13
14
16
Appendix 2
Procedure for the use of ENFit compatible
syringes to measure and administer feeds,
flushes and liquid medicines via the
ENTERAL route IN ADULTS
27
Appendix 3
Procedure for the use of oral / enteral
ENFit syringes to administer liquid
medicines or feeds via the
ORAL/ENTERAL ROUTE in CHILDREN
41
Appendix 4
Appendix 5
Appendix 6
Appendix 7
Equality Impact Assessment
Environmental Impact Assessment
Here For You Assessment
Certification Of Employee Awareness
64
67
69
71
11.
Appendix 1
Page
17
18
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1.0
Introduction
1.1
Wrong route administration of oral medicines, flushes or enteral
feeds can cause serious patient harm and may even be fatal.
This policy states the practice required at NUH to reduce the risks of
wrong route administration associated with the use of syringes for
the administration of medication, feeds and flushes via the oral or
enteral routes at NUH.
2.0
Executive Summary
2.1
In 2007 the National Patient Safety Agency issued a patient safety
alert; ‘Promoting safer measurement and administration of liquid
medicines via oral and other enteral routes (1).The alert aimed to
reduce the risk of wrong route administration errors with oral
medicines and enteral feeds. The alert stated a requirement for the
use of oral/enteral syringes and specified the design of enteral
feeding systems to prevent wrong route errors.
In 2012 the Department of Health issued a list of Never Events.
Never Events are serious incidents that are wholly preventable, as
guidance or safety recommendations that provide strong systemic
protective barriers, are available at a national level and should have
been implemented by all healthcare providers (2). Administration of
oral medicines or feeds/flushes by the parenteral route is a Never
Event. There have been wrong route Never Events at NUH due to
parenteral administration of medication intended for oral or enteral
administration (3).
This policy incorporates the requirements of the legacy NPSA alert,
the current NHS England Never Events List and the
recommendations from the NUH serious incident investigations. It
sets out the actions required to reduce the risks of wrong route
administration of oral medicines and enteral feeds/flushes at NUH.
 Oral and enteral ENFit compatible syringes must be used to
measure liquid medicines, feeds and enteral flushes.
 Parenteral (Hypodermic) syringes must NEVER be used for this
purpose.
 ENFit compatible bottle adaptors or ENFit compatible straws
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








must be used with an ENFit compatible oral/enteral syringe to
withdraw liquid medicines from medicine bottles.
3 way taps must not be used for enteral feeding systems.
Adaptors which enable oral/enteral syringes to fit intravenous
ports must not be used.
Enteral feeding tubes and administration/extension sets must
not contain ports nor have end connectors that can be
connected to intravenous syringes or parenteral lines.
Medication prescribed for enteral administration must be
rationalised to the least number without compromising patient
care.
Preparation and administration via the enteral or oral route
should be separated from any parenteral route preparation or
administration.
ENFit oral/enteral syringes used for oral administration or
measuring liquid medicines for enteral administration must be
single use only.
Large ENFit enteral syringes used for enteral administration
must be single use per patient episode of care.
The nurse who prepares the medication must be the nurse who
administers the medication to the patient.
All enteral feeding sets and syringes must be clearly labelled
‘enteral’.
3.0
Policy Statement
3.1
The Trust supports the use of ENFit compatible syringes and enteral
feeding systems to reduce the risk of wrong route administration of
oral medicines, feeds and enteral flushes.
This policy and the associated standard operating procedures, apply
to all practitioners working at NUH or working in affiliated hospitals or
in the community on behalf of NUH, who are involved in prescribing,
supply and administering oral liquid medicines.
This policy and the associated standard operating procedures, apply
to all practitioners working at NUH or working in affiliated hospitals or
in the community on behalf of NUH, who are involved in prescribing,
supply and administering feeds and flushes by the enteral route.
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When practitioners employed by other Trusts or private companies
are contracted to practice in NUH they must comply with all NUH
policies, procedures and guidelines for medicines.
4.0
Definitions
4.1
ISO: The International Standards Organisation
ENFit: a global connector design that complies with ISO 80369-3
while also defining the orientation of the connectors within the enteral
feeding system (female on the administration device and male on the
receiving device).
Oral administration: administered via the mouth
Enteral administration:
method of delivery
administered directly into the gastrointestinal tract
where
fluid is
Enteral/ oral syringe: An ISO 80369-3 ENFit compatible syringe,
labelled ‘ENTERAL’ with purple plunger, used to administer
medication via the mouth OR administer medication, feeds or flushes
via an Enteral Feeding Device.
Enteral Feeding Device:
 Naso-gastric tube
 Naso-jejunal tube
 Gastrostomy tubes (PEG, RIG, Balloon)
 Gastrostomy button
 Replacement gastrostomy tube
 Gastro-Jejunal tubes(PEGJ, PEJ)
 Jejunal tubes
 Jejunostomy tube
 Malecot catheter & Foley catheter (Neonates only)
Single Use: Use once and dispose of immediately
Patient episode of care: a set of drug or feed administrations &
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flushes at a given administration time for an individual patient.
Bottle Adaptor: a plastic insert which fits within the neck of a
medicine bottle to prevent drawing up of liquid medicine into any
syringe other than an ENFit compatible enteral/oral Syringe.
Filter straw: an ENFit compatible filter straw to allow drawing up of
medicines into an ENFIT compatible enteral/oral syringe.
Blunt needle: an ENFit compatible blunt needle.
5.0
Roles and Responsibilities
5.1
Committees
5.1.1 The Medicines Management Committee (MMC) is responsible
for maintaining this policy.
5.1.2 The NUH Medicines Safety Group (MSG) is responsible for
overseeing the Trust wide risk assessment on wrong route
administration of oral medicines, feeds and flushes and informing
MMC of any revision to this policy to mitigate new risks identified, or
due to changes in national guidance or legislation.
5.2
Individual Officers
5.2.1 The Clinical Procurement Matron working with Ward and
Clinical Managers is responsible for ensuring that the correct
equipment is available in the Trust to support the implementation of
this policy.
5.2.2 All health professionals involved in the prescribing, supply or
administration of flushes, feeds or medication via the oral or enteral
routes have a responsibility to adhere to this policy and associated
procedures.
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6.0
6.1
6.1.1
6.1.2
6.1.3
6.1.4
6.1.5
6.1.6
Policy and/or Procedural Requirements
Equipment Requirements
Purple ENFit compatible oral/enteral syringes must be used for
measurement and administration of medicines via the oral and
enteral routes, and for the administration of feeds and flushes via
the enteral route.
ENFit compatible bottle adaptors or ENFit compatible Straws must
be used with an ENFit compatible oral/enteral syringe to withdraw
liquid medicines from medicine bottles.
Intravenous or parenteral (hypodermic) syringes must never be
used for the purpose of administering liquid medicines, feeds or
flushes via the oral and enteral routes (1).
Intravenous 3-way taps must not be used for enteral feeding
Systems (1).
Adaptors which enable oral/enteral syringes to fit intravenous ports
must not be used (1).
Enteral feeding tubes and enteral feed administration and
extension sets used at NUH must not contain any ports that can be
connected to intravenous syringes or have end connectors that can
be connected to intravenous or other parenteral lines (1).
All enteral tubes and enteral equipment must have an ENFit end
that connects to an ENFit enteral syringe only. During the transition
to ENFit enteral feeding tubes, adaptors must be used for any
patients who have not yet had their existing enteral feeding tube
replaced.
6.2
6.2.1
The exception to this is the use of Foley or Malecot urinary
catheters which may be used as a gastrostomy tube in neonates
and children. In these patients an enteral male adaptor must be
connected to the urinary catheter to enable use of an oral / enteral
syringe.
Labelling requirements
Enteral feed administration sets and syringes used in NUH must be
clearly labelled ‘enteral’. (1)
The ward nurse must label the feed administration set with an
‘ENTERAL’ label each time the feed administration set is changed.
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6.3
6.3.1
6.3.2
6.3.3
Administration Process
Medication prescribed for patients with enteral feeding tubes must
be rationalised to the least number of administration episodes
possible without compromising patient care.
The process of preparation and administration of medication via
the oral or enteral route must be separated in time from the
process of preparation and administration of medication via the
parenteral route i.e. intravenous, subcutaneous, intramuscular.
For inpatients, ENFit oral/enteral syringes used for oral
administration or measuring liquid medicines for enteral
administration must be single use only (4, 5).
i.e. use for one drug for one patient for one administration episode
and dispose of immediately.
However one large ENFit enteral syringe can be used for a set of
enteral administrations during a single patient episode of care.
i.e. can be re-used for the same patient during a set of drug or feed
administrations & flushes at a given administration time.
6.3.4
6.3.5
6.3.6
6.4
6.4.1
The enteral syringe must be disposed of immediately after the set
of drug or feed administrations are complete.
Medication drawn up into oral/enteral syringes must be
administered immediately.
The nurse who prepares the medication must be the nurse who
administers the medication to the patient
All used oral and enteral syringes must be treated as
pharmaceutically contaminated waste and disposed of according to
the Trust waste handling and management policy HS/EI/017.
Self-administration
As stated in the NUH Medicines Policy CL/MM/005 Selfadministration of medicines by patients, parents or carers policy, a
patient or carer may administer medicines where selfadministration procedures are in place and where they have been
assessed as competent by a nurse. On children’s wards patients
and carers may participate in medicine administration where the
ward staff consider them competent to do so.
A parent or carer may administer feeds or flushes via the enteral
route once they have been taught the procedure and assessed
competent by a trained nurse. A competency tick list will be
completed as proof of competence and a copy stored in the child’s
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medical notes.
6.5
Legislation /National Guidance
The Medicines Act 1968 governs the supply and administration of
all medicines in the UK. The majority of medicines prescribed in
the UK are licensed under this Act. To remain licensed the
medicine must be given in a licensed form, within a licensed dose
range, by a licensed route and only for conditions where the
manufacturer has tested the medicine for safety.
The administration of medication via enteral feeding tubes is likely
to be outside of the licensed indications and route of administration
included in the product’s ‘Summary of Product Characteristics’ (6).
The dispersing and crushing of tablets and opening of capsules will
also place the medicine outside of its product licence (7).
Under an exemption within the Medicines Act, Medical
Practitioners (doctors and dentists) and Independent Prescribers
may use licensed medicines for indications, doses or routes
outside of the terms of the product licence (6, 7). In addition the
regulations permit these medicines so prescribed to be dispensed
by pharmacists and administered by nurses and midwives.
Refer to Trust Policy for the Procurement and Use of Medicines
without UK Marketing Authorisation and Medicines Used Outside
of their UK Marketing Authorisation (CL/MM/010) (7).
7.0
Training and Implementation
7.1
Training
This is an established policy however the change to the new ENFit
equipment will require training.
Nursing
The Adult Nutrition Nurse Specialist will deliver a training session at
the adult nutrition link nurse meetings for both campuses.
Training will be provided via the Paediatric nutrition link nurses.
The Ward Manager will be responsible for ensuring the training of all
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staff on their ward involved in the administration of medicines feeds
and flushes via the enteral route. The Ward Manager must keep a
record of staff training and copy to the individual members of staff for
their own records.
The Ward Manager is responsible for identifying any gaps in training
for their staff and facilitating further training through the Nutrition link
Nurse for their area.
Pharmacy
The Lead Pharmacist for Paediatrics and Digestive Diseases &
Thoracics Lead Pharmacist will provide training for Pharmacy staff.
Dietetics
Senior Dietitians will provide training sessions for Dietetic staff on the
issues covered in this policy and keep a record of these activities.
Dietitians will be responsible for providing compliant equipment for
home discharge.
7.2
Implementation
The Clinical Procurement Team will ensure ENFit compatible
equipment is available on all wards and departments prior to
implementation of this policy.
Ward Managers are responsible for maintaining adequate stocks of
ENFit compatible enteral syringes and ENFit bottle adaptors on their
ward through liaison with clinical procurement or the material
management assistant for their area.
Training for relevant professional groups will be delivered in advance
of the implementation of the policy.
NUH COMMS will be used to communicate the new equipment and
change in procedures.
Divisional Governance Leads are responsible for distributing and
implementing this policy within their Division.
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The Medicines Safety Group will manage the risk assessment for
wrong route administration of oral medicines, feeds and flushes and
will facilitate audit of adherence to this policy.
7.3
Resources
Enteral syringes and bottle adaptors and straws are already in use
across the Trust. The design of the equipment is changing to ENFit.
There may be an increase in use of equipment due to the
requirement to use an enteral syringe/bottle adaptor system for the
measurement of all liquid medicines.
This policy will require delivery of training via Nutrition Link Nurse
meetings.
8.0
Trust Impact Assessments
8.1
Equality Impact Assessment
An equality impact assessment has been undertaken on this draft
and has not indicated that any additional considerations are
necessary.
8.2
Environmental Impact Assessment
An environmental impact assessment has been undertaken on this
draft and has not indicated that any additional considerations are
necessary.
8.3
Here For You Assessment
A Here For You assessment has been undertaken on this draft and
has not indicated that any additional considerations are necessary.
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9.0
Policy / Procedure Monitoring Matrix
Minimum
requirement
to be
monitored
Responsible
individual/
group/
committee
Process
for
monitoring
e.g. audit
Frequency
of monitoring
Responsible
individual/
group/
committee for
review of
results
Trustwide risk Medicines
assessment
Safety Group
on wrong route
administration
of oral liquids,
feeds and
flushes
Review of
incidents and
review of risk
assessment
Medicines
Safety Group
reporting to
Medicines
Governance
Committee
Trustwide risk Nursing
assessment
Pharmacy
on wrong route Dietetics
administration
of oral liquids,
feeds and
flushes
Audit of policy
as incidents
arise and as
part of
Trustwide biannual
incident
review.
Annual formal
review of risk
assessment
annual
Medicines
Safety Group
Responsible
individual/
group/
committee
for
development
of action plan
Medicines
Safety Group
for Trust wide
actions,
Divisional
Governance
Groups for
local actions
Responsible
individual/
group/
committee
for
monitoring
of action plan
Medicines
Safety Group
Divisional
Governance
Groups for
local actions
Medicines
Safety Group
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Divisional risk Divisional
assessment
Governance
on wrong route Group
administration
of oral liquids,
feeds and
flushes
Review of
incidents and
review of risk
assessment
At least annual Divisional
Divisional
Governance
Governance
Group & share Group
results with
Medicines
Safety Group.
Divisional
Governance
Group
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10.0
10.1
Relevant Legislation, National Guidance and Associated NUH
Documents
1. Legislation: N/A
2. National Guidance:
NPSA alert 2007, Promoting safer measurement and
administration of liquid medicines via
oral and other enteral routes, 28th March 2007
NHS England Revised Never Events Policy and Framework,
March 2015
3. Associated NUH Documents:
NUH Medicines Policy CL/MM/005 Self-administration of
medicines by patients, parents or carers policy
NUH Medicines Policy CL/MM/010 for the Procurement and
Use of Medicines without UK Marketing Authorisation and
Medicines Used Outside of their UK Marketing Authorisation
NUH Medicines Policy CL/MM/008- Drug administration
Procedure for administration of medicines- paediatrics
“Procedure for the use of oral / enteral syringes to administer
liquid medicines or feeds via the ORAL/ENTERAL ROUTE in
children/ young people and neonates”
Procedure for the use of ENFit enteral syringes to administer
liquid medicines via the ORAL route IN ADULTS
Procedure for the use of syringes to measure and administer
feeds, flushes and liquid medicines via the ENTERAL route IN
ADULTS
Working In New Ways” Expanding The Scope Of Professional
Practice Passing Fine Bore Nasogastric Tubes (For Adults
And Paediatrics) Version 4 March 2012
NUH Guideline Enteral Feeding in adults
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11.0
References
1. NPSA alert 2007, Promoting safer measurement and
administration of liquid medicines via oral and other enteral
routes, 28th March 2007
2. NHS England Revised Never Events Policy and Framework,
March 2015
3. NUH Serious Incident investigations NUHWEB116897 and
NUHWEB124058
4. Advice from NUH Infection Control Team (original policy
CL/CGP/016 and CL/CGP/069)
5. NUH Single Use Policy
6. The NEWT Guidelines – for the administration of medication
to patients with Enteral feeding tubes or swallowing difficulties,
accessed 02/11/2016
7. NUH Medicines Policy for Procurement and Use of Medicines
without UK Marketing Authorisation and Medicines Used
Outside of their UK Marketing Authorisation CL/MM/010
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APPENDIX 1
Procedure for the use of ENFit enteral syringes to administer liquid
medicines via the ORAL route IN ADULTS
1. Definition
For the purpose of this procedure a liquid medicine for administration via the
oral route will be termed an oral liquid medicine. Such products include:







A commercially available liquid medicine formulation
Soluble tablets
A specially manufactured liquid medicine
Tablets crushed and mixed in water
Tablets dispersed in water
Capsules opened and mixed in water
Injections administered orally
2. Patient group
This procedure applies to all adults receiving oral liquid medicine via the oral
route.
3. Syringes
All ENFit compatible enteral syringes for use with this policy and
procedure must be sterile (1).
An ENFit compatible enteral syringe must be used to administer oral liquids via
the oral route.
3.1
When to use an ENFit compatible enteral syringe
An ENFit compatible enteral syringe should be used for the measurement
and administration of oral liquid medicine doses for:
 All adult patients even if the dose is a multiple of 5ml
 All controlled drug liquids for accuracy reasons (also see controlled drugs
policy CL/MM/012)
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There will be exceptions where an ENFit compatible enteral syringe can not
be used to measure the liquid e.g. if a bottle adaptor can not fit on to the
liquid bottle. In this case the dose can be measured by pouring the liquid
medicine into a graduated medicine pot if it is a multiple of 5ml. If it is not a
multiple of 5ml then the correct amount can be drawn up using an ENFit
compatible Straw.
3.2
Selection of oral syringe
ENFit compatible enteral syringes are available in a range of sizes. To
maintain accuracy, the smallest syringe for measuring the dose must be
used.
Syringes supplied with oral liquid medicines by manufacturers must not be
used because they may not be just oral syringes i.e. may be syringes with
luer locks which could connect to an intravenous line. There are exceptions,
notably ciclosporin liquid which is incompatible with standard oral syringes,
and the Epistatus brand of midazolam buccal liquid. If in doubt, advice
must be sought from a Pharmacist or Medicines Information.
3.3
Re-use of ENFit compatible enteral syringes
Within the NUH premises, syringes must be single use only in line with the
Trust’s Single Use Policy.
i.e. use for one drug for one patient for one administration episode and
dispose of immediately.
Under no circumstances should the syringe be washed and re-used within
the hospital environment
4 Selection of water to mix with tablets /capsules
4.1
Type of water to use
The type of water used will depend on the patient group.
Table 1
Patient group
Immunocompromised patients
Recommended Water to use with
medication (1)
Sterile water should be considered
for all immunocompromised patients
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All other patients
at NUH (see local protocols)
Freshly drawn drinking tap water
(This is different to tap water see
section 4- Definitions)
Sterile water should be taken from a bottle of Sterile water. A new bottle
must be used for each episode of care (1).
4.2
Volume of water to use
The volume of water used will depend on the individual patient and their
fluid requirements. The volume of water used during administration of
medicines must be recorded on the patient’s fluid balance chart.
If the volume of fluid is not a concern, a minimum of 10-15ml water should
be used to disperse each tablet /mix with crushed tablet or powder from
capsules (2).
5 Measurement of commercial and manufactured liquid medicine doses
5.1
Use of Bottle Adaptors with an ENFit compatible enteral syringe
A sterile ENFit compatible bottle adaptor MUST be inserted into the neck of
the medicine bottle when it is first opened. An ENFit compatible enteral
syringe is the only syringe which will connect to the ENFit bottle adaptor.
An ENFit enteral syringe should be used to measure all liquid medication.
The ENFit compatible bottle adaptor must remain in situ whilst the medicine
is in regular use. If it falls onto the floor or is removed for any other reason it
must be disposed of and replaced with a new one. Bottle adaptors are
single use and must not be washed and re-used.
An ENFit compatible bottle adaptor will be supplied from inpatient pharmacy
with all non-stock liquid medication. The nurse responsible for that patient
will be responsible for inserting the bottle adaptor into the liquid medication
upon first opening.
Stock bottles of liquid medication which is dispensed from pharmacy stores
will not have a bottle adaptor supplied with it. The nurse opening the stock
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liquid medication for the first time will be responsible for inserting the ENFit
compatible bottle adaptor into the bottle.
ENFit compatible bottle adaptors of various sizes will be available on the
ward.
All controlled drug liquids MUST have an ENFit compatible bottle adaptor
inserted for accurate measurement.
5.1.1 Measurement of doses using an ENFit compatible bottle adaptor

Select the oral liquid medicine to be administered.

Shake the bottle if necessary.

Insert an ENFit compatible bottle adaptor if it does not already have
one in place.

Insert the ENFit compatible syringe into the ENFit compatible bottle
adaptor.

Invert the bottle and withdraw the required volume for the dose
prescribed.

Multiple drugs must not be withdrawn into the same syringe.

The original cap of the liquid medication should be replaced with the
bottle adaptor in situ.
5.2 Straws
Straws must only be used when the neck of the medicine bottle is too
large/small for the bottle adaptor to fit. Straws are single use only and
must not be left in the bottle or washed and re-used.
5.2.1. Measurement of doses using an ENFit compatible Straw

Select the oral liquid medicine to be administered.

Shake the bottle if necessary.

Attach an ENFit compatible syringe onto the end of the ENFit
compatible straw.

Insert ENFit compatible straw into the bottle
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
Withdraw the required volume for the dose prescribed.

Dispose of the ENFit compatible straw and replace the lid on the
bottle.
6. Preparation of drugs which are not commercially available as an oral
liquid formulation
If a patient is unable to swallow the medication they are prescribed as a tablet
or capsule, due to their age or swallowing difficulties, then the Ward
Pharmacist or Medicines Information department must be contacted for advice.
The alteration of medical formulations e.g. crushing tablets or opening
capsules is outside of the product licence of the drug (3) and may alter the
patients handling of the drug. Some drugs are not suitable for crushing. (Table
2)
Table 2
Formulation /class of drug
Enteric coated tablets (EC)
Modified release (MR)
/Sustained release (SR)
Chewable tablets
Possible problem from
crushing tablets
The coating may protect the
stomach from damage from the
drug e.g. aspirin, and may cause
gastrointestinal side effects.
The coating may protect the
drug from the acid in the
stomach. (3)
Crushing these drugs may result
in abrupt high or low peaks of
the drug which can be
dangerous to the patient,
especially if the drug has a
narrow therapeutic range (3)
Designed to be partially
absorbed in the mouth, not all
the drug will be absorbed if they
are crushed (3)
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Cytotoxics & hormones
Potential risk of toxicity to the
staff handling the drug (3)
The pharmacist must review the patient’s prescription and discuss with the
Prescriber whether alternative licensed liquid medicine formulations are available
within the same class of drug or whether the drug prescribed could be given by an
alternative route.
Alternative routes of administration include:
 Rectal route
 Transdermal route
 Buccal route
 Sublingual route
 Parenteral route (intravenous, subcutaneous, intramuscular)
If a licensed preparation or route is not available or appropriate for the patient,
then the pharmacist may recommend crushing or dispersing tablets, opening
capsules or manufacturing a suspension for the individual patient. This should be
endorsed onto the drug chart.
6.1
Dispersing tablets in water
•It is not necessary to use an oral syringe.
•Place the tablet(s) into a medicine pot of water.
•Wait for the tablet to disperse / effervescent reaction to be complete. This
may take a few minutes.
•Give the patient the solution to drink.
•Rinse the medicine pot with more water and give this to the patient to drink.
6.2
Crushing tablets
•A ceramic pestle and mortar or tablet crusher must be used.
•Place the required tablet(s) in the mortar or tablet crusher and crush to a
powder.
•Mix the powder with an appropriate volume of water in a medicine pot (see
section 4).
•Draw up the solution into an oral syringe.
•Administer the dose to the patient (see section 7)
•Rinse out the mortar / tablet crusher with water and administer the rinsings
to the patient.
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•The pestle and mortar or tablet crusher must be cleaned thoroughly with a
detergent and water after each use and dried thoroughly using a paper
towel.
6.3
Opening capsules
•Open the capsule and tip the powder into a medicine pot.
•Mix the powder with an appropriate volume of water (see section 4).
•Draw up the solution into an ENFit compatible enteral syringe.
•Administer the solution to the patient (see section 7).
•Rinse the medicine pot and administer the rinsings to the patient.
6.4
Cytotoxics
A ready-made liquid
pharmacy for advice.
should
be
used
wherever
possible.
Ask
For cytotoxic drugs the ENFit compatible syringe must be disposed of in
a cytotoxic waste disposal container.
6.5
Preparation of injections for oral use
Consult pharmacy for advice on which injectable preparations are suitable
for oral/enteral administration and directions for preparation.
 If not already in solution, reconstitute the injection following the
manufacturer’s information or directions from pharmacy as
appropriate.
 Draw up the required dose using an ENFit compatible syringe
connected to an:
o ENFit compatible blunt needle for vials
o ENFit compatible filter straw for glass ampoules
 Remove ENFit compatible needle or ENFit compatible straw before
administration.
6.5.1 Vancomycin
Vancomycin injection is licensed for administration via the oral route for
the treatment of Clostridium difficile.
 The injection must be reconstituted following the manufacturer’s
information using the method described in 6.4.

Remove ENFit compatible needle before administration.
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7
Administration of oral liquid medicines

Check the inpatient prescription chart.

Select the appropriate size ENFit compatible enteral syringes for the
doses prescribed.

Use the methods described in section 5 and 6 to prepare the oral liquid
medicine doses. Prepare and administer one drug at a time.

Complete the usual drug administration checks in the NUH Medicines
Code of Practice.

Insert the ENFit compatible enteral syringe into the inside of the patient’s
cheek and slowly depress the plunger asking the patient to swallow as is
comfortable for them.

Dispose of the used syringe into a sharps container as per the Trust
policy for disposal of pharmaceutically contaminated products.

Sign the inpatient medication chart to record administration of the drug
immediately after it has been given.

Repeat the above steps for each medication prescribed.
The nurse who prepares the medication must be the nurse who administers
the medication to the patient.
If the administration process is interrupted at the point of administration, and
medication has been left unattended drawn up in an unlabelled oral syringe,
then the medication must be discarded. If there is any doubt over which
medication has been administered, then the doctor must be informed
immediately and a decision made whether to omit the medication until the
next administration time.
If the patient finds it difficult or uncomfortable to take the medication via the
syringe then it can be transferred into a medicine pot and given to the
patient to drink. Smaller doses may need diluting with water. If necessary
seek advice from pharmacy.
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8
Discharge & Outpatient supply of medication
For all adults prescribed oral liquid medicines via the oral route on
discharge or as an outpatient, Pharmacy will supply one multi-use ENFit
compatible syringe for each newly supplied oral liquid medication and an
ENFit compatible bottle adaptor. Syringe size will be appropriate to the
volume of medication required.
9
Responsibilities
Ward managers are responsible for maintaining adequate stocks of ENFit
compatible syringes, ENFit compatible bottle adaptors, ENFit compatible
Straws and ENFit compatible blunt needles on their ward through liaison
with the Clinical Procurement team.
Senior Managers (Pharmacists, Dietitians, Nurses, Prescribers) are
responsible for ensuring that all their staff are aware of this procedure and
comply with it.
10.
References
1. Advice from NUH Infection Control Team (original policies CL/CGP/016
and CL/CGP/069 now superseded- available from Medicine Management
Committee)
2. www.bapen.org.uk BAPEN guideline: Administering Drugs via Enteral
Feeding Tubes. A Practical Guide published 2003 updated 2004. Accessed
02/11/2016
3. The NEWT Guidelines – for the administration of medication to patients
with Enteral feeding tubes or swallowing difficulties, accessed 02/11/2016
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APPENDIX 2
Procedure for the use of ENFit compatible syringes to measure and
administer feeds, flushes and liquid medicines via the Enteral route IN
ADULTS
1. Unlicensed route of administration
Administration of medication via the enteral route is usually unlicensed. The
prescriber and practitioner accept liability for any adverse effects resulting from
this route of administration (1). Refer to NUH Medicines Policy for Procurement
and Use of Medicines without UK Marketing Authorisation and Medicines Used
Outside of their UK Marketing Authorisation CL/MM/010. If the prescription
does not clearly specify the route as enteral, the drugs must not be
administered until the prescriber has been contacted and confirmed the route.
2. Definition
For the purpose of this procedure an oral liquid medicine is one which is
intended to be administered normally via the mouth but for clinical reasons
needs to be administered via the enteral route. Such products include:







A commercially available liquid medicine formulation
Soluble tablets
A specially manufactured liquid medicine
Tablets crushed and mixed in water
Tablets dispersed in water
Capsules opened and mixed in water
Injections administered orally
3. Patient group
This procedure applies to all adults receiving oral liquid medication, feeds or
flushes via the enteral route.
4. Syringes
4.1 Selection of ENFit compatible enteral syringe for administration via
enteral tube or enteral feed administration set
If an enteral feed administration set is in use at the time medication is due
then the medication must be administered via the medicines administration
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port. The enteral feed administration set must not be disconnected to allow
administration directly into the enteral tube and then reconnected.
There are different sizes of ENFit compatible enteral syringes available.
All Enteral compatible syringes supplied for this purpose are sterile.
Only purple 60ml ENFit compatible enteral syringes marked ‘ENTERAL’
must be used for the administration of medication, feeds or flushes via the
enteral route.
Parenteral (Intravenous), syringes must never be used.
4.2
Selection of ENFit compatible enteral syringe to measure drug doses
All ENFit compatible enteral syringes for use with this policy and
procedure must be sterile (2).
ENFit compatible enteral syringes are available in a range of sizes. To
maintain accuracy, the smallest syringe for measuring the dose must be
used.
Syringes supplied with oral liquid medicines by manufacturers must not be
used because they may not be just oral syringes i.e. may be syringes with
luer locks which could connect to an intravenous line. There are exceptions,
notably ciclosporin liquid which is incompatible with standard oral syringes.
If in doubt, advice must be sought from the Pharmacist or Medicines
Information
4.3
Re-use of syringes
Within the NUH premises, ENFit compatible enteral syringes for oral
administration must be single use only (3) in line with the Trust’s Single Use
Policy.
i.e. use for one drug for one patient for one administration episode and
dispose of immediately
Large ENFit compatible enteral syringes must be one syringe per patient
episode of care.
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i.e. can be re-used for the same patient during a set of drug
administrations & flushes at a given administration time. Each drug should
be flushed through with water after it has been administered (see section
8).The syringe must be disposed of immediately after the set of drug
administrations and flushes are complete.
5 Water
5.1
Type of water to mix with tablets /capsules /flush enteral tubes
The type of water used will depend on the patient group and type of
enteral tube.
Sterile water should be taken from a bottle of sterile water. A new bottle
should be used for each patient episode of care (2).
Table 1
Patient group
Immunocompromised
patients
Enteral Tube
Enteral tubes feeding
into the stomach
Enteral tubes feeding
in to the jejunum
All other patients Enteral tubes feeding
in to the stomach
Recommended water
for flushes /mixing
with tablets or
capsules (2)
Sterile water should be
considered for all
immunocompromised
patients at NUH (see
local protocols)
Sterile water
Freshly drawn drinking
tap water (this is
different to tap water –
see section 4 definitions)
Enteral tubes feeding Sterile water
in to the jejunum
5.2
Volume of water to use
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The volume of water used will depend on the individual patient and their fluid
requirements but should be sufficient to flush the drug out of the delivery system.
The volume of water used during administration of medicines should be recorded
on the patient’s fluid balance chart.
5.2.1 Dispersing tablets or mixing with crushed tablets or opened capsules
If the volume of fluid is not a concern, a minimum of 10-15ml water should
be used to disperse each tablet / mix with crushed tablet or powder from
capsules (1).
5.2.2 Flushes
Water should be used to flush the enteral feeding system.
Follow instructions from the dietitian.
6 Measurement of commercial and manufactured liquid medicine doses
6.1
An ENFit compatible enteral syringe must be used to measure all controlled
drug liquids and all liquid medication even if it is a multiples of 5ml.
The dose must then be transferred into the barrel of a 60ml syringe prior to
administration via the enteral route (see section 8).
6.1.1 Use of Bottle Adaptors with an ENFit enteral syringe
A sterile ENFit compatible bottle adaptor must be inserted into the neck of
the medicine bottle when it is first opened. The bottle adaptor must remain
in situ whilst the medicine is in regular use. If it falls onto the floor or is
removed for any other reason it must be disposed of. Bottle adaptors must
not be washed and re-used.
6.1.1.1 Measurement of doses using a bottle adaptor

Select the oral liquid medicine to be administered.

Shake the bottle if necessary.

Insert an ENFit compatible bottle adaptor if it does not already have
one in place.

Insert the ENFit compatible syringe into the ENFit compatible bottle
adaptor
Invert the bottle and withdraw the required volume for the dose
prescribed.

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
Multiple drugs must not be withdrawn into the same syringe.

The original cap of the liquid medication must be replaced with the
bottle adaptor in situ.
6.1.2 Straws
Straws must only be used when the neck of the medicine bottle is too
large/small for the bottle adaptor to fit. Straws are single use only and
must not be left in the bottle or washed and re-used.
6.1.2.1. Measurement of doses using an ENFit compatible Straw
 Select the oral liquid medicine to be administered.
 Shake the bottle if necessary.
 Attach an ENFit compatible syringe onto the end of the ENFit
compatible straw.
 Insert ENFit compatible straw into the bottle
 Withdraw the required volume for the dose prescribed.
 Dispose of the ENFit compatible straw and replace the lid on the
bottle.
6.2
Doses which are multiples of 5ml
Doses which are a multiple of 5ml should be drawn up using an ENFit
compatible enteral syringe for accuracy of measurement and transferred to
a 60ml syringe. All Controlled Drugs MUST be measured using an ENFit
enteral syringe.
6.2.1 Measurement of doses using a medicine pot and ENFit compatible
enteral syringe
A medicine pot should only be used if an ENFit compatible bottle adaptor
can not fit on to the bottle neck of the liquid medication.
 Select the oral liquid medicine to be administered
 Shake the bottle if necessary
 Measure the dose required into a graduated medicine pot
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 Select the 60ml ENFit compatible syringe required for enteral
administration
 Draw up the oral liquid medicine from the medicine pot into the enteral
syringe and give as per section 8
 Prepare and administer each drug as an individual process.
 Each drug should be flushed through with water after administration
and the same enteral syringe may be re-used for administration of
flushes and subsequent drugs required within the individual patient’s
episode of care.
 Liquid medication that is not a multiple of 5ml can be drawn up using a
straw and correct size ENFit compatible enteral syringe and
transferred to a 60ml syringe for enteral administration.
7 Preparation of oral drugs which are not commercially available as a
liquid formulation
The alteration of medical formulations for administration via enteral tubes e.g.
crushing tablets or opening capsules, is usually outside of the product licence
of the drug (1) and may alter the handling of the drug. Some drugs are not
suitable for crushing. (Table 2)
Table 2
Formulation /class of drug
comments
Enteric coated tablets (EC)
If crushed enteric coated tablets
break up into small pieces that
clump together when moistened
and can clog the feeding tube
(1)
Modified release (MR)
Crushing these drugs may result
/Sustained release (SR)
in abrupt high or low peaks of
the drug which can be
dangerous to the patient,
especially if the drug has a
narrow therapeutic range (1)
Buccal /sublingual
Designed to avoid the GI tract
and first pass metabolism. The
doses tend to be low and maybe
insufficient if given via an enteral
tube (1)
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Chewable tablets
Cytotoxics & hormones
Designed to be partially
absorbed in the mouth, not all
the drug will be absorbed if they
are crushed (1)
Potential risk to staff from
aerolisation of particles (1)
The pharmacist must review the patient’s prescription and discuss with the
Prescriber whether alternative licensed liquid medicine formulations are available
within the same class of drug or whether the drug prescribed could be given by an
alternative route.
Alternative routes of administration include:
 Rectal route
 Transdermal route
 Buccal route
 Sublingual route
 Parenteral (intravenous, subcutaneous, intramuscular)
If a licensed preparation or route is not available or appropriate for the patient,
then the pharmacist may recommend crushing or dispersing tablets, opening
capsules or manufacturing a suspension for the individual patient.
7.1
Dispersing tablets in water (4)
 Place the tablet in a medicine pot and disperse in 10mls of water
 Use a 60ml ENFit compatible enteral syringe to draw up the dispersed
solution from the medicines pot
 Administer the solution
 Rinse the syringe with more water and administer the rinsings
7.2
Crushing tablets (4)
 A tablet crusher must be used
 Place the required tablet in the tablet crusher and crush to a powder.
 Mix the powder with an appropriate volume of water (see section 5).
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 Draw up the solution into a 60ml ENFit compatible enteral syringe
 Administer the dose to the patient (see section 8)
 Rinse out the tablet crusher with water, draw up into the ENFit
compatible enteral syringe and administer this to the patient
 The tablet crusher must be cleaned thoroughly with a detergent and
water after each use and dried thoroughly using a paper towel.
7.3
Opening capsules(4)
 Open the capsule and tip the powder into a medicine pot
 Mix the powder with an appropriate volume of water (see section 5)
 Draw up the solution into a 60ml ENFit compatible enteral syringe
 Administer the solution to the patient (see section 8 )
 Rinse the medicine pot, draw up into the ENFit compatible enteral
syringe and administer this to the patient.
7.4
Cytotoxics
A ready-made liquid
pharmacy for advice.
should
be
used
wherever
possible.
Ask
For cytotoxic drugs the ENFit compatible syringe must be disposed of in
a cytotoxic waste disposal container.
7.5
Preparation of injections for enteral administration
consult pharmacy for advice on which injectable preparations are suitable
for oral/enteral administration and directions for preparation.
If not already in solution, reconstitute the injection following the
manufacturer’s information or directions from pharmacy as
appropriate.
 Draw up the required dose using an ENFit compatible syringe
connected to a:
 ENFit compatible blunt needle for vials
 ENFit compatible filter straw for glass ampoules
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 Remove ENFit compatible needle or ENFit compatible straw before
administration
7.5.1 Vancomycin
Vancomycin injection is licensed for administration via the oral route for the
treatment of Clostridium difficile.

The injection must be reconstituted following the manufacturer’s
information using the method described in 7.4.

Remove ENFit compatible needle before administration

The solution must be administered to the patient (see section 8)
8 Administration of oral liquid medicine formulations via the enteral route
 Review the inpatient prescription chart to identify the drugs and doses to be
administered via the enteral route for this administration episode.
 Select the appropriate type of 60ml ENFit compatible enteral syringe for
administration of the oral liquid medicine to the patient (section 4 and
Appendix 1)
 Select the appropriate type of water for the patient (section 5 Table 1)
 Proceed to the patient.
 Follow all the administration steps described in NUH medicines Code of
Practice
 Check the patient’s identity.
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 Check the position of the enteral tube following the appropriate Nursing
guideline for the type of enteral tube in place.
 Check the enteral tube or feed administration set back to the patient to
confirm the route and check that the feed administration set is labelled
‘enteral’.
 Stop the feed if there is a feed in progress.
 Flush the enteral tube with an appropriate volume of water for the individual
patient (see section 5).
 Prepare the first dose required using the methods described in section 6 & 7
 If the dose has been prepared in a smaller ENFit compatible enteral syringe,
the medication must be transferred to the 60ml enteral syringe before it can
be administered.
 Attach the 60ml ENFit compatible enteral syringe to the enteral tube or
enteral feed administration port as appropriate. Remove the plunger of the
60ml enteral syringe.
 Eject the contents of the liquid medication into the barrel of the 60ml ENFit
compatible enteral syringe.
 If the medication has been dispersed in a medicine pot draw the contents in
the pot into a 60ml enteral syringe.
 This should then be gravity fed to administer it to the patient if attached
directly to the enteral tube, or using the plunger if administration is via the
enteral feed administration set.
 Sign the inpatient medication chart to record administration of the drug
immediately after it has been given.
 Repeat the above steps for each medication prescribed. The same ENFit
compatible enteral syringe can be used throughout the patient episode of
care.
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 If more than one medicine is to be administered, the enteral tube must be
flushed with at least 10ml water in between each medicine unless another
volume is specified by the Dietitian.
 After the last medicine has been administered, the enteral tube must be
flushed with 30ml water unless another volume is appropriate and specified
by the Dietitian.
 Restart the feed, if it has been stopped.
 Dispose of the used syringe into a sharps container as per the Trust policy
for disposal of pharmaceutically contaminated products.
The nurse who prepares the medication must be the nurse who
administers the medication to the patient.
If the administration process is interrupted at the point of administration, and
medication has been left unattended drawn up in an ENFit compatible enteral
syringe, then the medication must be discarded. If there is any doubt over
which medication has been administered then the doctor must be informed
immediately and a decision made whether to omit the medication until the next
administration time.
9 Administration of Bolus Enteral Feeds
Bolus enteral feeds must be administered using a 60ml ENFit compatible
enteral Syringe. Refer to the appropriate enteral feeding guideline.
10 Aspiration of Gastric Contents to check tube position
ENFit compatible enteral syringes must be used for aspirating all enteral tubes.
11 Discharge
Ward nursing staff are responsible for ensuring parents/carers can safely
prepare and administer the medicines via the enteral tube prior to discharge.
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Ward nursing staff are responsible for notifying the Dietitian and the
Pharmacist in a timely fashion when the discharge is planned.
The prescriber must specify the route of administration on the discharge
prescription.
For all adults prescribed oral liquid medicines via the enteral route on
discharge or as an outpatient, Pharmacy will supply one multi-use ENFit
compatible syringe for each newly supplied oral liquid medication and an
ENFit compatible bottle adaptor. Syringe size will be appropriate to the
volume of medication required.
Dietitians will provide an appropriate supply of ENFit syringes for feeds at
discharge for use in the community.
Multi-use ENFit compatible syringes can be washed and re-used at home
in accordance with the manufacturer’s instructions.
12 Responsibilities
Ward managers are responsible for maintaining adequate stocks of ENFit
compatible syringes, ENFit compatible bottle adaptors, ENFit compatible
Straws and ENFit compatible blunt needles on their ward through liaison
with the Clinical Procurement team.
Senior Managers (Pharmacists, Dietitians, Nurses, Prescribers) are
responsible for ensuring that all their staff are aware of this procedure and
comply with it.
10.
References
1. The NEWT Guidelines – for the administration of medication to patients
with Enteral feeding tubes or swallowing difficulties, accessed 02/11/2016
2. Advice from NUH Infection Control Team (original policy CL/CGP/016
and CL/CGP/069)
3. NUH Single Use Policy
4. www.bapen.org.uk BAPEN guideline: Administering Drugs via Enteral
Feeding Tubes. A Practical Guide published 2003 updated 2004. Accessed
02/11/2016
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BAPEN Administering Drugs via Enteral Feeding Tubes A Practical Guide
(www.bapen.org.uk)
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APPENDIX 3
E09
Title
Date of production/
last revision
Name of authors
Review of procedure
Revision date
Procedure for the use of oral / enteral
ENFit syringes to administer liquid
medicines or feeds via the
ORAL/ENTERAL ROUTE in children.
January
2010/September
2016
young people
and neonates
Suzy Heafield, Karen Chappell, Amanda
Hirst, Ali Wright
Amanda
Hirst,
Lara Morrison, Ali Wright ,
September
2021
Rachel Keay, Andrew Wignell, Kate Nooney
Note that administration of medication via the enteral route is usually unlicensed.
The prescriber and practitioner accept liability for any adverse effects resulting
from this route of administration. Refer to the NUH Medicines Policy for
Procurement and Use of Medicines without UK Marketing Authorisation and
Medicines Used Outside of their UK Marketing Authorisation CL/MM/010
Procurement and use of medicines without marketing authorisation and
medicines used outside their marketing authorisation. If the prescription does not
clearly specify the route as enteral naso-gastric (NG), naso-jejunal (NJ),
gastrostomy, gastro-jejeunal or jejunostomy), the drugs must not be administered
until the prescriber has been contacted and confirmed the route, i.e. it is not
acceptable to give drugs via an enteral tube if they are prescribed orally.
For the purpose of this procedure an oral / enteral ENFit compatible syringe is
one which is intended for use with enteral feeding devices. It is labelled enteral
and is purple to distinguish use from intravenous syringes. The use of such
syringes is in accordance with NPSA alert 19.
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Contents
Section
number
1
2
3
4
5
6
7
8
9
10
11
12
13
Section name
Definition
Patient Group
Syringes
Measurement of commercial and
manufactured liquid medicine doses
Preparation of drugs which are not
commercially available as an oral
liquid formulation
Selection of water to use to mix with
medicines and for flushes via enteral
tubes and
for
inflation
of
balloon inflation devices
Flushes
Administration of oral liquid
medicines and feeds
Discharge
Responsibilities
References
Glossary
Appendices
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1. Definition
For the purpose of this procedure an oral liquid medicine is one which
is intended to be administered normally via the mouth but for
clinical reasons may need to be administered via the enteral
route. Such products include:







A commercially available liquid medicine formulation
Soluble tablets
A specially manufactured liquid medicine
Tablets crushed and mixed in water
Tablets dispersed in water
Capsules opened and mixed in water
Injections administered orally/enterally
2. Patient group
This procedure applies to all children/young people and neonates
receiving oral/enteral liquid medicine and feeds via the oral/enteral
route. This includes the addition of liquid medicines to feeds prior to
administration via feed bottles.
3. Syringes
All oral/enteral ENFit compatible syringes for use with this
procedure must be single use and sterile. The only exception to
this is where re-usable syringes are supplied on discharge from
pharmacy, or by dietitians for home use only.
3.1.When to use an oral/enteral ENFit compatible syringe
An oral/enteral ENFit compatible syringe must be used for the
measurement and administration of all medication, feeds and flushes
to be given via an enteral device, and as well as all oral (or enteral)
liquid medicine doses:
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3.2. Selection of oral/enteral ENFit compatible syringe
Oral/enteral ENFit compatible syringes are available in a range
of sizes from 1ml to 60ml. To maintain accuracy, the smallest
syringe suitable for measuring the prescribed dose must be
used.
The syringes supplied by manufacturers with oral/enteral liquid
medicines as part of the manufacturer’s original pack must not be
used for inpatient use. There are exceptions, e.g. ciclosporin
liquid, the Epistatus brand of midazolam buccal liquid. If in
doubt, advice must be sought from the Pharmacist or Medicines
Information.
For aspiration, flushes and bolus feeds, 20ml and 60ml
syringes are used in children/young adults. On the Neonatal Unit,
5 or 10ml syringes are used for aspirates and the smallest
syringes possible (down to 2.5ml) are used for feeds.
3.3. Re-use of oral/enteral syringes
Within the NUH premises, oral/enteral ENFit compatible
syringes for administration of medication must be single use
only in line with the Trust’s Single Use Policy,
i.e. use one syringe per drug per patient per
administration episode and dispose of immediately in the
appropriate waste disposal container.
For feed administration one oral/enteral syringe can be used
per episode of care,
i.e. one oral/enteral ENFit compatible syringe can be used for
the same patient during a set of feed administrations and
flushes at a given administration time. The oral/enteral ENFit
compatible syringe must be disposed of immediately after the
episode of care in the appropriate waste disposal container
Each drug/feed should be flushed through with water after it
has been administered e x c e p t i n n e o n a t e s w h e r e
t u b e s a r e i n frequent use (see section 7).
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Under no circumstances should oral/enteral ENFit compatible
syringes be washed and re-used within the hospital
environment.
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4. Measurement of commercial and manufactured liquid medicine
doses
4.1. Use of ENFit compatible Bottle Adaptors with an ENFit syringe
A sterile ENFit compatible bottle adaptor must be inserted into the neck of
the medicine bottle when it is first opened. An ENFit compatible enteral
syringe is the only syringe that will connect to the bottle adaptor. The bottle
adaptor must remain in situ whilst the medicine is in regular use. If it falls
onto the floor or is removed for any other reason it must be disposed of and
replaced with a new one. Bottle adaptors must not be washed and re-used.
An ENFit compatible bottle adaptor will be supplied from the Pharmacy
Dispensary with the non-stock liquid medication. The nurse that first opens a
bottle of liquid medicine will be responsible for inserting the ENFit compatible
bottle adaptor.
Stock liquid medication which is dispensed from pharmacy stores will not
have a bottle adaptor supplied with it. The nurse opening that liquid
medication for the first time will be responsible for inserting an ENFit
compatible bottle adaptor.
ENFit compatible Bottle adaptors of various sizes will be available on the
ward.
All controlled drug liquids MUST have an ENFit compatible bottle adaptor
inserted for accurate measurement. The only exception is the Epictetus
brand of buccal midazolam liquid.
4.1.1. Measurement of doses using an ENFit compatible bottle adaptor
 Select the oral (or enteral) liquid medicine to be administered.
 Shake the bottle if necessary.
 Remove the cap of the medication bottle and insert an ENFit
compatible bottle adaptor if the bottle doesn’t already have one.
 Insert the ENFit compatible syringe into the ENFit compatible bottle
adaptor
 Invert the bottle and withdraw the required volume for the
dose prescribed.
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 The original cap of the liquid medication can then be replaced with
the ENFit compatible bottle adaptor in situ.
4.2. Straws
Straws must only be used when the neck of the medicine bottle is too
large/small for the bottle adaptor to fit. Straws are single use only
and must not be left in the bottle or washed and re-used.
4.2.1. Measurement of doses using a ENFit compatible straw
 Select the oral liquid medicine to be administered.
 Shake the bottle if necessary.
 Attach an ENFit compatible syringe onto the end of the ENFit
compatible straw.
 Insert ENFit compatible straw into the bottle
 Withdraw the required volume for the dose prescribed.
 Discard the ENFit compatible straw and replace the lid on the
bottle.
5 Preparation of drugs which are not commercially available as
an oral liquid formulation
If a medication is only available in tablet or capsule form and the
patient is unable to swallow the medication they are prescribed
either due to their age or swallowing difficulties, the Ward Pharmacist
or Medicines Information department must be contacted for advice.
The alteration of medical formulations e.g. crushing tablets or opening
capsules is usually outside of the product licence of the drug and may
alter the patient’s handling of the drug. Some medicines are not
suitable for crushing (see Table 1). However it may be necessary on
occasion to crush and disperse these formulations but only on
pharmacy advice, e.g. temozolomide
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Table 1
Formulation /class
of drug
Possible problem from crushing tablets
Enteric coated
tablets (EC)
The coating may protect the stomach from damage
from the drug e.g. aspirin, and may cause
gastrointestinal side effects.
The coating may protect the drug from the acid in
the stomach, and crushing the tablet may make the
medicine ineffective.
Crushing these drugs may result in abrupt peaks or
troughs of the drug concentration in the blood, which
can be dangerous to the patient, especially if the drug
has a narrow therapeutic range
Modified release
(MR) /Sustained
release (SR)
Buccal /sublingual
Designed to avoid the GI tract and first pass
metabolism. The doses tend to be low and maybe
insufficient if given via an enteral tube
Chewable tablets
Designed to be partially absorbed in the mouth, not all
the drug will be absorbed if they are crushed.
Cytotoxics,
Potential risk of toxicity to the staff handling the drug
immunosuppressants from aerosolisation of particles
& hormones
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5.1 Dispersing or crushing tablets and opening capsules







If there is no information on the drug chart or in reference sources on
the ward consult pharmacy for advice on which tablet preparations are
suitable for crushing or dispersing in water and which capsules may be
opened.
Place the tablet or contents of capsule in a single use medicine pot
with an appropriate volume of water. The volume of water used during
administration of medicines must be recorded on the patient’s fluid
balance chart.
If crushing a tablet, crush to a powder using a ceramic pestle and
mortar or a tablet crusher before adding an appropriate volume of
water, either in the mortar or in a clean single use medicine pot. The
volume of water used during administration of medicines must be
recorded on the patient’s fluid balance chart.
Wait for the tablet or powder to disperse or, for soluble tablets, for the
effervescent reaction to be complete. This may take a few minutes.
It is important not to let the suspended medicine settle to the bottom of
the single use medicine pot or mortar. Mix well before immediately
giving the patient the solution to drink from a single use medicine pot
 or draw up into an ENFit compatible syringe using an ENFit
compatible straw and administer to the patient.
If a tablet crusher or pestle and mortar is used, clean thoroughly with
detergent and water after each use and dry thoroughly using a paper
towel.
If given via an enteral feeding device flush volumes need to be
sufficient to clear the drug from the tube.
If the dose prescribed is a proportion of one or more
tablets/capsules:
 This method should only be used if the tablet or capsule contents
disperse well in water otherwise an inaccurate dose may be drawn up.
If in doubt, seek pharmacy advice.
 Ensure the amount of water used to mix with the medicine is
measured precisely in order to calculate accurately the volume of
solution needed to give the dose as follows:
 Calculate the concentration of the solution:
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Concentration(mg/ml)= Strength of tablet/capsule(mg) X No of tablets/capsules
Volume of water (ml)
 Calculate the volume required for the dose prescribed:
Volume to administer(ml) =
Dose prescribed (mg) Concentration
of solution(mg/ml)
 Mix well before immediately drawing up the required volume into an
ENFit compatible syringe using an ENFit compatible straw and
administering to the patient.
5.2
Preparation of injections for oral /enteral use
 If there is no information on the drug chart or in reference sources on
the ward, consult pharmacy for advice on which injectable
preparations are suitable for oral/enteral administration and directions
for preparation.
 If not already in solution, reconstitute the injection following the
manufacturer’s information or directions from pharmacy as
appropriate.
 Draw up the required dose using an ENFit compatible syringe
connected to a:
o ENFit compatible blunt needle for vials
o ENFit compatible filter straw for glass ampoules
 Remove ENFit compatible needle or ENFit compatible straw before
administration
5.3 Drops for oral use
Some drugs e.g. Nifedipine, alfacalcidol, vitamins are administered as
drops rather than a measured volume.
For children who can take medicines off a spoon:

Calculate the number of drops required for the dose prescribed

Count the number of drops onto a medicine spoon

Administer the drops to the child using the medicine spoon.
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For children who cannot take medicines from a spoon:
There are a number of methods listed below. Select the most
appropriate method for the situation at the time of administration.
 Remove the plunger from an ENFit compatible syringe and count the
drops into the syringe (ensuring syringe is capped off) and then
administer.
 If having oral feeds via bottle or cup the drops could be mixed with
the milk, provided the medicine is compatible with the milk and the
child takes the whole feed. If unsure, check with pharmacy.
 If the baby is about to have an enteral tube feed the drops can be
added to the feed (provided the medicine is compatible with the
feed); then the feed should be administered immediately. If unsure,
check with pharmacy.
5.4 Cytotoxics and immunosuppressants for oral use
 For cytotoxics and immunosuppressants given orally to children who
cannot swallow tablets/capsules or via the enteral tube a ready-made
liquid should be used wherever possible. Ask pharmacy for
advice.
 If a ready-made liquid is not available and a tablet is crushed/ capsule
opened and the contents dispersed in water the nurses administering
the drug must wear gloves and mask to minimise exposure.
 For cytotoxic drugs the ENFit compatible syringe must be disposed of
in a cytotoxic waste disposal container.
6 Selection of water to use to mix with medicines and for flushes
via enteral tubes and for inflation of balloon inflation devices
The type of water used will depend on the patient group and the type
of enteral feeding device (see Table 2). Sterile water should be taken
from a 100ml bottle of sterile water. A new bottle must be used for
each episode of care.
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Table 2
Patient group
1Immunocompromised
patients Local areas to
agree inclusion for their
area e.g. whole ward or
just neutropenic patients
Home
Hospital
Sterile water from a 90
ml bottle of enteral feed
water
Freshly
boiled
cooled water
2 Neonates and Children
< 1 year
Sterile water
4 Children > 1 year
Freshly drawn drinking
Tap water
water from the kitchen.
(This is cold water drawn
from the same tap as that
used for patient
drinking water)
Sterile water
Freshly
boiled
cooled water
3 Children > 1 year with
an enteral feed tube
feeding into the jejunum
Freshly
boiled
cooled water
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7 Flushes
7.1 Volume of flushes
Flush volumes must be appropriate to the patient taking into account
weight and fluid requirements.
7.1.1 Flushes used in Neonates
Neonates cannot tolerate the extra fluid volume incurred
through multiple flushes after each medication. The enteral tubes
are frequently in use to administer milk feeds so there is a low risk of
them blocking. For NG tubes, unless the medication is incompatible
with milk, oral liquid medicines should be given with the feed or
administered and then flushed through with milk. For jejunal
feeding a 1ml flush with water is used following administration of a
feed or a medicine or between medicines.
7.1.2 Flushes used in Children/ Young people
The volume of water used will depend on the individual patient, their
fluid requirements and the type of enteral tube in place, but should
be sufficient to flush the drug or feed out of the delivery system.
The patency of the tube must be established by administering a
5ml water flush using a 20ml or 60 ml ENFit compatible syringe
before administration of any feed/medication.
7.1.2.1 Nasogastric tubes
 Minimum 5ml flush before feed /medication to check patency of
tube
 Ideally flush with a minimum of 5ml after each drug in children
who can tolerate these volumes within their daily fluid balance
(check table in appendix 1 and discuss with pharmacist if fluid
restricted )
 Minimum 10ml flush after feed /last medication
(enough to clear any residual feed/medication from the tube)
7.1.2.2 PEG tubes
 Minimum 5ml flush before feed /medication to check patency of
tube
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
Ideally flush with a minimum of 5ml after each drug in children
who can tolerate these volumes within their daily fluid
balance (check table in appendix 1 and discuss with
pharmacist if fluid restricted )


Minimum 20ml flush after feed/ last medication
(enough to clear any residual feed/medication from the tube). If
fluid restriction in place discuss with doctor or dietitian
7.1.2.3 Gastrostomy button
 Use an extension set to access button
 Minimum 5ml flush before feed /medication ( to check patency of
tube
 Ideally flush with a minimum of 5ml after each drug in children
who can tolerate these volumes within their daily fluid balance
(check table in appendix 1 and discuss with pharmacist if fluid
restricted )
 Minimum 10ml flush after feed / last medication (enough to clear
any residual feed/medication from the device)
7.1.2.4 Nasojejunal tubes, gastrostomy device with jejunal
extension and jejunostomies
 Minimum 5ml flush before feed / to check patency of tube
 Ideally flush with a minimum of 5ml after each drug in children
who can tolerate these volumes within their daily fluid balance
(check table in appendix 1 and discuss with pharmacist if fluid
restricted)
 Minimum 10ml flush after feed / last medication (enough to clear
any residual feed/medication from the tube)
Route
Gastrostomy
Button
Flush to check
patency
5mL
Flush after each
Medicine*
5mL
Flush after Feed/Last
Medicine
10mL
*if child unable to tolerate these volumes within daily fluid allowance, discuss with
Pharmacist.
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8 Administration of oral liquid medicines and feeds










Complete the usual drug administration checks stated in the NUH
Medicines Code of Practice.
Select the appropriate size ENFit compatible syringe for the dose
prescribed.
Always use the smallest syringe possible to maintain
accuracy.
Use the methods described in sections 4 and 5 to prepare the oral
liquid medicine doses for the individual patient.
Prepare one drug at a time
A separate ENFit compatible syringe must be used for each
drug. Under no circumstances should oral liquid medicines be
mixed in the same syringe.
After administration, dispose of the used ENFit compatible syringe
into an appropriate waste disposal container as per the Trust waste
disposal policy
Sign the inpatient medication chart to record administration of the
drug immediately after it has been given.
Repeat the above steps for each medication
prescribed.
On the neonatal unit, it may be necessary to add more than one
medicine to the same feed. In this case prepare and sign for each
medicine separately but the medicines will actually be administered
at the same time. Ensure first that the medicines may be mixed in
the same feed (see section 8.3).
The nurse who prepares the medication must be the nurse who
administers the medication to the patient.
If the administration process is interrupted at the point of
administration, and medication has been left unattended drawn up in
an unlabelled ENFit compatible syringe, then the medication must
be discarded. If there is any doubt over which medication has been
administered, then the doctor must be informed immediately and a
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decision made whether to omit the medication until the next
administration time.
8.1 Administration via the mouth
 Insert the ENFit compatible enteral syringe into the inside of the
patient’s cheek and slowly depress the plunger, asking the patient
to swallow as you do so (age allowing).
8.2 Administration via an enteral feeding device
8.2.1 Bolus feed in children/ young people
 Administer medications prior to giving enteral feeds unless instructed
otherwise
 Select the appropriate type of water for the patient (see section 6,
table 2)
 If NG check the position of the enteral tube following the appropriate
nursing guideline.
 Check the enteral feeding device or feed administration set back to
the patient to confirm the route and check it is labelled ‘enteral’.
 Flush the enteral tube with the appropriate volume of water
(see section 7.1)
 Connect the syringe containing the medication to the enteral tube or
administration set and administer the medicine.
 If more than one medicine is to be administered, the enteral tube
should be flushed with water in between each medicine (see section
6 and 7.1)
 After the last medicine has been administered, flush the enteral
feeding device with water as above.
 Give feed as per feeding plan
8.2.2 Bolus feeds in neonates
 If NG check the position of the enteral tube following the appropriate
nursing guideline.
 Check the enteral tube or feed administration set back to the patient
to confirm the route and check it is labelled ‘enteral’.
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 Connect the ENFit compatible syringe to the enteral tube or
administration set and pour in the required amount of milk. For small
volumes of milk, it may be easier to draw the milk into the syringe
before connecting it to the enteral tube.
 Provided the medication to be given is compatible with the milk,
add the medication/s to the milk using a separate ENFit compatible
syringe for each medication (see section 8.3).
 Allow the feed to go down by gravity or, if necessary, apply a
small amount of pressure with the plunger.
8.2.3 Continuous feed in children/ young people
 Select the appropriate type of water for the patient (see section 6 table 2)
 If NG or NJ check the position of the enteral feeding device following
the appropriate nursing guideline for the type of enteral tube in
place.
 Check the enteral tube or feed administration set back to the patient
to confirm the route and check it is labelled ‘enteral’.
 Stop the feed if there is a feed in progress.
 Flush the enteral tube with the appropriate volume of water
(see section 7.1)
 Connect the ENFit compatible syringe containing the medication to
the enteral tube or administration set and administer the medicine.
Use the side (medicines) port of the giving set nearest to the patient
for delivering medicines. If more than one medicine is to be
administered, the enteral tube should be flushed with water in
between each medicine (see section 7.1)
 After the last medicine has been administered, flush the enteral tube
with water as above to ensure medication has been administered
 Restart the feed if it has been stopped.
8.2.4 Continuous feed in neonate (usually NJ)
 Select the appropriate type of water for the patient (see section 6 table 2).
 If NG or NJ check the position of the enteral feeding device following
the appropriate nursing guideline for the type of enteral tube in
place.
 Check the enteral tube or feed administration set back to the patient
to confirm the route and check it is labelled ‘enteral’.
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 Stop the feed if there is a feed in progress and disconnect the tube
from the pump.
 Connect the ENFit compatible syringe containing the medication to
the enteral tube and administer the medicine. If more than one
medicine is to be administered, the enteral tube should be flushed
with 1ml of water in between each medicine (see section 7.1.1)
 After the last medicine has been administered, flush the enteral
tube with 1ml of water (or feed if appropriate).
 Restart the feed if it has been stopped.
8.3 Adding the medication to the feed in neonates
 It is not appropriate to add medication to a continuous feed as the
medication would be in contact with the feed for a prolonged period
of time.
 Ensure the medication is compatible with the feed (see information
in the pharmacy information files on the Neonatal Unit). Contact
pharmacy for further advice.
 Ensure the whole feed is administered to deliver the complete dose
of medication
8.4 Administration of Bolus Enteral Feeds
8.4.1 Neonates
For aspiration use a 5 or 10ml ENFit compatible syringe and for
feeds use the smallest ENFit syringe possible (down to 2.5ml).
Refer to the appropriate enteral feeding guideline.
8.4.2 Paediatrics
For aspiration, flushes and bolus feeds use a 20ml or
60ml ENFit compatible syringe.
Refer to sections 6 and 7 for guidance on volume and type of
water to use.
Refer to the appropriate enteral feeding guideline.
9 Discharge
Ward nursing staff are responsible for ensuring parents/carers can
safely prepare and administer the medicines orally/via the enteral tube
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prior to discharge. This information needs to be documented on the
parent competency.
Pharmacy will supply one multi-use ENFit compatible syringe for each
newly supplied oral liquid medication and an ENFit compatible bottle
adaptor. Syringe size will be appropriate to the volume of medication
required.
Dietitians will provide an appropriate supply of ENFit syringes for
feeds at discharge for use in the community.
Multi-use ENFit compatible syringes can be washed and re-used at
home in accordance with the manufacturer’s instructions.
Multi-use (7 day) ENFit syringes must not be used for inpatients,
even if carers are administering the medicines or feeds.
10 Responsibilities
Ward managers are responsible for maintaining adequate stocks of
ENFit compatible syringes, ENFit compatible bottle adaptors, ENFit
compatible Straws and ENFit compatible blunt needles on their ward
through liaison with the Clinical Procurement team.
Senior Managers (Pharmacists, Dietitians, Nurses, Prescribers) are
responsible for ensuring that all their staff are aware of this procedure
and comply with it.
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11 References
1. Advice from NUH Infection Control Team
2. www.bapen.org.uk/ BAPEN. Drug Administration via Enteral Feeding
Tubes- A Practical guide, accessed 02.11.2016
3. The NEWT Guidelines – for the administration of medication to
patients with Enteral feeding tubes or swallowing difficulties,
accessed 02/11/2016
4. White, R and Bradnam, V. Handbook of Drug Administration via
Enteral Feeding Tubes, First Edition, Pharmaceutical Press 2006
5. NUH Medicines Code of Practice
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12 Glossary
Oral route
Enteral route
administered via the mouth
administered directly into
the gastrointestinal tract
Oral/ enteral syringe
An oral / enteral syringe is one which
is intended for use with enteral
feeding devices. It is labelled oral
/enteral and has a purple barrel to
distinguish their use from intra venous
syringes.
Enteral feeding device
Naso-gastric tube
Naso-jejunal tube
Gastrostomy button
Gastrostomy tube with balloon
retention device
Percutaneous Endoscopic
Gastrostomy (PEG) tube
Gastrostomy button with
jejunal extension
Jejunostomy button
Jejunostomy tube
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13 Appendices
FLUSHING VOLUMES FOR NPSA COMPLIANT ENTERAL
FEEDING DEVICES
Make, type and size
Foley-8FG;10FG;12FG
Malecot-12FG
Naso-gastric tubes
Medicina 6fr /80cm*
Medicina 8fr/ 80cm*
Medicina 10fr/80cm*
Medicina 12fr
Corflo 6fr / 56cm/92cm*
Corflo 8fr / 56cm*/ 92cm
*Longest length tested
PEG
Medicina / Corflo
Gastrostomy tube
NPSA compliant y port
Gastrostomy Button
extension sets
Mic-key ext set
Mic-key bolus set
Mini extension set
Mini bolus extension set
Feeding sets –Flocare
and Kangaroo
Flushing
Volume
2ml-5ml
3ml-5ml
Suggested flush volume to
standardise care
10ml
10ml
1ml
1.6ml
2.4ml
5ml
5ml
5ml
2ml
3ml
5ml
5ml
2.5ml
2ml
10ml
5ml
2ml
5ml
2ml
6ml
4ml
8ml
10ml
10ml
10ml
10ml
6ml
10ml
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APPENDIX 4
Equality Impact Assessment (EQIA) Form (Please complete all sections)
Q1. Date of Assessment: Insert date
Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if
relevant consider breaking the policy or implementation down into areas)
a) Using data and supporting
b) What is already in place in c) Please state any
Protected
information, what issues,
the policy or its
barriers that still need to
Characteristic
needs or barriers could the
implementation to address
be addressed and any
protected characteristic
any inequalities or barriers to proposed actions to
groups experience? i.e. are
access including under
eliminate inequality
there any known health
representation at clinics,
inequality or access issues to
screening
consider?
The area of policy or its implementation being assessed:
Race and
Ethnicity
Gender
None
N/A
N/A
None
N/A
N/A
Age
None
N/A
N/A
Religion
None
N/A
N/A
Disability
None
N/A
N/A
Sexuality
None
N/A
N/A
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Pregnancy and
Maternity
Gender
Reassignment
Marriage and
Civil Partnership
Socio-Economic
Factors (i.e.
living in a poorer
neighbourhood
/ social
deprivation)
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
None
N/A
N/A
Area of service/strategy/function
Q3. What consultation with protected characteristic groups inc. patient groups have you carried out?
None
Q4. What data or information did you use in support of this EQIA?
None
Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from
surveys, questionnaires, comments, concerns, complaints or compliments?
None
Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups
identified or to create confidence that the policy and its implementation is not discriminating against any
groups
None
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What
Q7. Review date
By Whom
By When
Resources required
Nov 2019
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Environmental Impact Assessment APPENDIX 5
The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the
significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b)
implement mitigating actions.
Area of
impact
Environmental Risk/Impacts to consider
For each question, state (at the end) ‘yes’, ‘no’, or ‘not
applicable’. If any result in a ‘yes’ answer, the necessary
remedial action should then be stated in the next column. One
remedial action may be that the draft policy was amended
accordingly.
Waste and  Is the policy encouraging using more materials/supplies?
materials
 Is the policy likely to increase the waste produced?
 Does the policy fail to utilise opportunities for
introduction/replacement of materials that can be recycled?
Action Taken (where
necessary)
Soil/Land
Yes, may use more
bottle adaptors than
currently used but this is
necessary to manage the
patient safety risk.
NO
Water
 Is the policy likely to promote the use of substances
dangerous to the land if released (e.g. lubricants, liquid
chemicals)
 Does the policy fail to consider the need to provide adequate
containment for these substances? (e.g. bunded containers,
etc.)
 Is the policy likely to result in an increase of water usage?
(estimate quantities)
 Is the policy likely to result in water being polluted? (e.g.
dangerous chemicals being introduced in the water)
 Does the policy fail to include a mitigating procedure? (e.g.
modify procedure to prevent water from being polluted;
NO
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Air



Energy

Nuisances 
polluted water containment for adequate disposal)
Is the policy likely to result in the introduction of procedures
and equipment with resulting emissions to air? (e.g. use of a
furnaces; combustion of fuels, emission or particles to the
atmosphere, etc.)
Does the policy fail to include a procedure to mitigate the
effects?
Does the policy fail to require compliance with the limits of
emission imposed by the relevant regulations?
Does the policy result in an increase in energy consumption
levels in the Trust? (estimate quantities)
Would the policy result in the creation of nuisances such as
noise or odour (for staff, patients, visitors, neighbours and
other relevant stakeholders)?
NO
NO
NO
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APPENDIX 6 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit
The We Are Here for You service standards have been developed together with more than 1,000 staff and
patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe
and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but
with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their
inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization.
Please rate each value from 1 – 3 (1 being not at all, 2 being affected and 3 being very affected)
Value
1.
Polite and Respectful
Whatever our role we are polite, welcoming and positive in the face of adversity, and are always
respectful of people’s individuality, privacy and dignity.
2.
Communicate and Listen
We take the time to listen, asking open questions, to hear what people say; and keep people
informed of what’s happening; providing smooth handovers.
3.
Helpful and Kind
All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of
delivering the help and can be relied on.
4.
Vigilant (patients are safe)
Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates
attention to detail for a clean and tidy environment everywhere.
Score (13)
1
1
1
3
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5.
On Stage (patients feel safe)
We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on stage’
we look and behave professionally, acting as an ambassador for the Trust, so patients, families and
carers feel safe, and are never unduly worried.
6.
Speak Up (patients stay safe)
We are confident to speak up if colleagues don’t meet these standards, we are appreciative when
they do, and are open to ‘positive challenge’ by colleagues
7.
Informative
We involve people as partners in their own care, helping them to be clear about their condition,
choices, care plan and how they might feel. We answer their questions without jargon. We do the
same when delivering services to colleagues.
8.
Timely
We appreciate that other people’s time is valuable, and offer a responsive service, to keep waiting to
a minimum, with convenient appointments, helping patients get better quicker and spend only
appropriate time in hospital.
9.
Compassionate
We understand the important role that patients’ and family’s feelings play in helping them feel better.
We are considerate of patients’ pain, and compassionate, gentle and reassuring with patients and
colleagues.
10. Accountable
Take responsibility for our own actions and results
11. Best Use of Time and Resources
Simplify processes and eliminate waste, while improving quality
12. Improve
Our best gets better. Working in teams to innovate and to solve patient frustrations
TOTAL
1
1
1
1
1
1
1
1
14
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APPENDIX 7
CERTIFICATION OF EMPLOYEE AWARENESS
Document Title
The Use Of Syringes To Administer Flushes, Feeds
And Medication Via The Oral And Enteral Routes
Policy
Version (number)
1
Version (date)
23 November 2016
I hereby certify that I have:
 Identified (by reference to the document control sheet of the above
policy/ procedure) the staff groups within my area of responsibility to
whom this policy / procedure applies.
 Made arrangements to ensure that such members of staff have the
opportunity to be aware of the existence of this document and have the
means to access, read and understand it.
Signature
Print name
Date
Division/
Directorate
The manager completing this certification should retain it for audit and/or other
purposes for a period of six years (even if subsequent versions of the
document are implemented). The suggested level of certification is;
 Clinical Divisions - Divisional General Manager or nominated deputies
 Corporate Directorates - deputy director or equivalent.
The manager may, at their discretion, also require that subordinate levels of
their directorate / department utilize this form in a similar way, but this would
always be an additional (not replacement) action.
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