Download Enteral Tube Administration Policy Adults

Enteral Tube Administration Policy (Adults)
Reference Number
3.65
Version
2
Name of responsible (ratifying) committee
The Nutrition Steering Group
Date ratified
08/09/2011
Document Manager (job title)
Clinical Nutrition Nurse Specialist
Date issued
27/09/2011
Review date
September 2013
Electronic location
Clinical Policies
Related Procedural Documents
NG policy
Key Words (to aid with searching)
Enteral Administration, Adult, Policy
Enteral Tube Administration Policy (Adults):
Issue 2. 29/09/2011
Page 1 of 27
CONTENTS
1.
2.
3.
4.
5.
6.
7.
8.
9.
QUICK REFERENCE GUIDE....................................................................................................... 3
INTRODUCTION.......................................................................................................................... 4
PURPOSE ................................................................................................................................... 4
SCOPE ........................................................................................................................................ 4
DEFINITIONS .............................................................................................................................. 5
DUTIES AND RESPONSIBILITIES .............................................................................................. 5
PROCESS ................................................................................................................................... 6
TRAINING REQUIREMENTS ...................................................................................................... 7
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 7
MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF, PROCEDURAL
DOCUMENTS .............................................................................................................................. 8
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. Enteral feed must be administered using a non-touch technique.
2. Feed hydrobags and administration sets must be labeled with date of commencement and
changed every 24 hours.
3. Feed must not be decanted unless elemental feed is required, in which case the Hydrobag
must be changed every 12 hours.
4. Enteral syringes must be used and discarded after each use.
5. PHT staff administering enteral pump feeding must have received training on how to use the
pump.
6. All patients receiving or admitted with enteral feeding are referred to the Dietitians.
7. Patients being discharged on enteral feeding are referred to the Clinical Nutrition Nurse
specialists, for assessment and discharge planning.
8. Enteral syringes, milk straws and filters must be used when adding 30% sodium chloride to
feed.
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1. INTRODUCTION
The use of the Gastro-intestinal tract to deliver fluid, medications and feed via a tube has become common
practice in the hospital setting. The nutrients contained within enteral feeds make them an excellent
environment for the growth of bacteria and other micro-organisms. Infectious complications such as
bacteraemia, septicaemia, pneumonia, diarrhoea and infectious enterocolitis have all been attributed to the
administration of enteral feeding solutions which have been contaminated with bacteria (1,2,7).
Research has shown that the main sources of bacterial contamination of enteral feeding systems are poor
hand hygiene, increased manipulation and hanging times in excess of 24 hours. Good
handwashing techniques, use of non-sterile gloves, minimal handling and employing a non -touch
technique all reduce the risk of contamination (1,3,6,7,8,9).
NPSA Alert 19 (2007), recommends the use of enteral syringes/enteral feeding systems that must not be
compatible with intravenous lines/intravenous syringes.( Appendix 6) I.V compatible syringes and adaptors
must not be used in the enteral administration of feed, fluid or medicines due to the risk of wrong route
administration (5)
It is important that staff are competent in the correct use of enteral equipment so that they can safely
deliver fluids, medications and feed via this route. This policy therefore aims to give evidence-based, best
practice guidance to staff on minimising the risks associated with enteral administration
2. PURPOSE
This policy is designed to guide all Healthcare professionals in safe enteral administration in adults.
3. SCOPE
This policy applies to all competent healthcare professionals caring for adult patients who require enteral
administration in the hospital setting.
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4. DEFINITIONS
ENTERAL FEEDING
Using the Gastro-intestinal tract for the delivery of nutrients. For the purpose of this policy it describes
artificial nutrition delivered via a tube into the gut.
NON -TOUCH TECHNIQUE
No open part of the enteral feeding delivery system, feed or enteral tube should be in contact with the
hands, clothes, skin or other non – disinfected surface.
ENTERAL TUBES
Tubes placed into the GI Tract for the purpose of administering fluid, medication and/or feed. This could be
nasogastric (NG), nasojejunal (NJ) gastrostomy (e.g. PEG) gastrojejunostomy, jejunostomy (e.g.surgical,
PEJ) (Appendix 6)
ENTERAL SYRINGE
A purple syringe that is not compatible with intravenous catheters or ports. Solely for the administration of
enteral feed ,fluid and medications.(Appendix 6)
CONSUMABLES
Plastic items used in enteral administration i.e. administration sets, syringes, extension sets, enteral
conectors/adaptors, water containers, integral reservoirs .(Appendix 6.)
DECANTING
Opening sterile feed bottles/containers and pouring feed into another container/reservoir.(Appendix 2)
SINGLE-USE
For use on an individual patient during a single procedure and then discarded. It is not intended to be
reprocessed and used again.
SINGLE-PATIENT USE
May be used for more than one episode of use on one patient only. The devise may undergo some form of
processing between each use.
HEALTH CARE PROFESSIONALS.
A registered or trained competent member of staff including doctors, nurses and midwives.
5. DUTIES AND RESPONSIBILITIES
Clinical managers are responsible for ensuring the implementation of this Policy and associated Guideline
and monitoring compliance.
Clinical Educators/ Practice Development Nurses to disseminate best practice as per Policy.
CNNS team to have a high ward profile to help embed the policy into practice.
.
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6. PROCESS
Clinical Practice Guidelines
ACTION
Prior to setting up feed wash hands with
soap and water and apply non-sterile
gloves.
RATIONALE
Research shows that poor hand hygiene
contributes to microbial contamination. 1,3,6,7.
Ensure drip-stands and pumps are clean
and in working order.
To reduce the risk of contamination and
maintain patient safety. 8
If Naso-gastric tube is in situ check position
of tube as per PHT Policy for Insertion and
Maintenance of fine bore feeding tubes in
Adults (2007)
To ensure safe administration and maintain
patient safety.4
Administration sets, water bags and feed
bags must be changed every 24hours using
a non-touch technique (Appendix 1A)
Ready to hang sterile feed should have a
maximum hang time of 24hours.
To maintain a closed system to reduce the risk
of contamination. 1,3,6,8,9,11
Administration sets, water bags and feed
bags must be labelled with the date and
time that they were set up.
To enable staff to change the sets at the
appropriate time. 3,6,7,9
If the feed administration set is
disconnected from the patient the distal end
must be capped off and the feeding tube
flushed with drinking tap water using a nontouch technique.
To maintain a closed system and safely deliver
feed/water. 1,
To maintain tube patency
Only adaptors designed specifically for
enteral use should be used. (Appendix 10)
Enteral adaptors will only be compatible with
enteral devices therefore reducing the risk of
wrong route administration. 4.
Feed administration sets are compatible
with water bags. Therefore 1 giving set
should be used per 24hours and transferred
between feed bag and water bag using a
non-touch technique.
Feed must not be decanted unless advised
by a Dietician or Nutrition CNS. In such
circumstances feed and reservoirs must
only hang for 12 hours.
Enteral Tube Administration Policy (Adults)
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To maintain a closed system and safely deliver
feed/water to the patient. 1,3,6,8,9,11
Ready to hang feed should be used wherever
possible. Research shows that increased
manipulation and decanting of sterile feed
increases contamination. Hanging time is
reduced to 12 hours with decanted feeds to
minimise the risk of contamination.
Issue 2 29/09/2011
1,2,3,9,10,11
Single-use purple enteral syringes must be
used with all enteral feeding systems and
discarded after each use. (Appendix 10)
Enteral tubes should be flushed with
drinking tap water pre and post feed and
medication administration.
All patients requiring discharge with enteral
feed must be referred to the CNNSs.
To comply with NPSA alerts I.V. syringes
should not be used due to the risk of wrong
route administration.
5.
To maintain tube patency. 1,3,6,7.
To ensure safe discharge.
7. TRAINING REQUIREMENTS
Staff must be able to demonstrate competence prior to setting up enteral equipment. Clinical
managers/Ward managers are responsible for ensuring competence.
CNNS teach on a range of formal and informal staff training sessions/courses.
CNNS team to co-ordinate the Nutrition Champions role.
Nutrition Champions to act as Nutrition resource at ward level and audit practice.
Medical Devices Training- to provide training to ward staff on enteral pumps. This can be arranged directly
by contacting medical devices at QAH Ext 5735, 6976, or 3786, alternatively Ward Managers can book
staff onto the Setting Direction Study Day.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Anderton, A. (1990) Microbial contamination of enteral feeds. How can we reduce the risk? Nutricia
Clinical Care.
2.Donskey, C.J. The role of the intestinal tract as a reservoir and source for transmission of nosocomial
pathogens. Clinical Infectious Diseases, (2004). 39 219-226.
3.Fogg, L. (2007). Home enteral feeding: Part 2 current issues in community practice. British journal of
Community Nursing, 12(7) 296-300.
4.Great Britain. National Patient Safety Agency.(2005). Advise to the NHS on reducing harm caused by
the misplacement of naso-gastric tubes.
5.Great Britain. National Patient Safety Agency. (2007.) Promoting safer measurement and administration
of liquid medicines via oral and other enteral routes.
6.Great Britain. National Institute for Health and Clinical Excellence (2006). Nutrition Support in Adults
(Clinical Guideline 32) London: NICE.
7.Great Britain. National Institute for Health and Clinical Excellence (2003). Prevention of healthcareassociated infections in primary and community care. Section 4. London: NICE
8.Great Britain. Medicines and Healthcare Products Regulatory Agency. (2006). Single-use Medical
Devices: Implications and Consequences of Reuse. DB2006 (04). London: Department of Health.
9.Mathus-Vliegen,E., Bredius M., & Binnekade J. (2006). Analysis of Sites of Bacterial Contamination in an
Enteral Feeding System. Journal of Parenteral and Enteral Nutrition, 30 (6) 519-525.
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10.Matlow,A., Jacobson,M., Wray R., et al. (2006). Enteral tube hub as a reservoir for transmissible enteric
bacteria. American Journal of Infection Control, 34 (3) 131-133.
11. Stroud, M., Duncan, H. & Nightingale, J. (2003). Guidelines for enteral feeding in adult hospital
patients.Gut 52(Suppl VII) vii1 – 12.
9. MONITORING COMPLIANCE WITH, AND THE EFFECTIVENESS OF,
PROCEDURAL DOCUMENTS
The effectiveness in practice of this procedural document will be monitored by the CNNS using
annual audit. This Audit will involve spot checks/ observation of ward staff practice, and a
relevant Staff Questionnaire.
The following 8 standards are used to measure practice:
1. All staff involved in the care of patients receiving enteral feeding must be trained and
updated to use enteral equipment.
2. Prior to setting up feed or manipulating the system all staff report it is necessary to perform
the recommended 7 stage hand washing technique, apply non-sterile gloves, and use a nontouch technique.
3. All enteral pumps should be clean, with a displayed service date.
4. All Drip stands attached to enteral pumps should be clean and in good working order.
5. All enteral administration sets, and water bags must be changed every 24hrs, indentified by
labeling this equipment with the date and time it was set up.
6. If the feed administration set is disconnected from the patient the distal end must be capped
off.
7. Enteral feed must not be decanted unless advised by a Dietitian or CNNS. In such
circumstances feed and reservoirs must only hang for 12 hours.
8. Single-use purple enteral syringes must be used with all enteral feeding systems and
discarded after use.
The results of the audit will be disseminated to Heads of Nursing, Clinical Managers, Ward
Managers, Clinical Educators/ Practice development nurses
APPENDIX 1A
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FEED/WATER ADMINISTRATION VIA THE APPLIX PUMP – GRAVITY PRIMING METHOD
EQUIPMENT:-
Bag of feed or Hyrdrobag
Administration set
Applix Smart Pump and Dripstand
50ml Enteral syringe and glass of drinking tap water
Non-sterile gloves
1. Wash hands and apply non-sterile gloves. Carry out the procedure using a non-touch technique.
2. Check the expiry date on the feed bag, shake well and twist off cap. If using hydrobag close clamp on
bottom of bag open blue cap and fill with amount of water required, close blue cap.
3. Double click to close clamp on Administration Set and attach Administration Set to feed bag or
Hydrobag. If using hydrobag undo clamp on bag.
4. Hang bag on drip stand. Place the end of the set in an empty container to catch the drips. Ensure drip
container is lower than feed/hydro bag.
5. Squeeze drip chamber so that chamber half fills with feed /water – do not overfill.
6. Open clamp allow feed/water to fill the set. Turn off clamp when feed /water reaches end of
Administration Set.
7. Open the door on pump.
8. Locate the clamp on the set and hook into position in pump.
9. Gently pull down on administration set and press into groove at the bottom. Double click the pump door
shut. Do not use the lever to close the door.
10. Label feed/water bag and Administration Set with time and date of setting up.
11. Flush the patients enteral tube with 30 – 50 ml of tap drinking tap water
12. Remove cap from end of Administration Set and connect administration set to feeding tube. Undo any
clamps on patients tube
13. Turn on pump - set hourly rate - start pump.
14. At end of feed/water administration switch off pump and disconnect administration set from patients tube.
Cap end of Administration Set.
15. Flush patient’s tube immediately with 30 –50 ml drinking tap water and cap off tube.
16. Check date and time on administration set – if > 24hrs use (or if next administration will exceed 24 hr
use) discard administration set.
APPENDIX 1B
FEED/WATER ADMINISTRATION VIA THE APPLIX SMART PUMP – PUMP PRIMING METHOD.
EQUIPMENT:-Bag of feed or Hyrdrobag
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Administration set
Applix Smart Pump and Dripstand
50ml Enteral syringe and glass of drinking tap water
Non-sterile gloves
1. Wash hands and apply non-sterile gloves. Carry out the procedure using a non-touch technique.
2. Check the expiry date on the feed bag, shake well and twist off cap. If using hydrobag close clamp on
bottom of bag open blue cap and fill with amount of water required, close blue cap.
3. Double click to close clamp on Administration Set and attach Administration Set to feed bag or
Hydrobag. If using hydrobag undo clamp on bag.
4. Hang bag on drip stand. Ensure drip chamber is lower than the feed/water bag. Place the end of the set
in an empty container to catch the drips.
5. Squeeze drip chamber so that chamber half fills with feed /water – do not overfill.
6. Open the door on pump.
7. Locate the clamp on the Administration Set and hook into position in pump.
8. Gently pull down on Administration Set and press into the groove at the bottom Double click door shut –
Do not use the lever to close the door.
9. Turn on pump
10. Press and hold the bag symbol on the pump until feed/water is at the end of the administration set.
11. Label feed/water bag and Administration Set with time and date of setting up.
12. Flush the patients enteral tube with 30 – 50 ml of tap drinking tap water
13. Remove cap from end of Administration Set and connect set to feeding tube. Press rate ↑or ↓ to set
hourly rate. Start pump.
14. At end of feed/water administration, switch off pump and disconnect administration set from patient’s
tube. Cap end of Administration Set.
15. Flush patient’s tube immediately with 30 –50 ml drinking tap water and cap off tube.
16. Check date and time on administration set – if > 24hrs use (or if next administration will exceed 24 hr
use) discard administration set.
APPENDIX 2
HOW TO DECANT ELEMENTAL SIP FEED.
EQUIPMENT:
Non-Sterile Gloves
Elemental Sip Feed Cartons
Applix pump Bag Reservoir set
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Pump and Drip-Stand
Enteral syringe and glass of drinking tap water.
1. Wash hands
2. Apply non-sterile gloves. Carry out the procedure using a non-touch technique.
3. Check the expiry date on the cartons and shake well. N.B. Remember that decanted feed can only hang
for 12hours-so decant the appropriate amount of feed.
4. Close the clamp on the feeding line of the reservoir.
5. Hang bag reservoir on drip stand.
6. Open lid of bag reservoir and decant elemental feed into the reservoir. Securely close lid on reservoir.
7. Squeeze drip chamber so that chamber half fills with feed /water – do not overfill.
8. Open clamp allow feed/water to fill the set. Turn off clamp when feed /water reaches end of
Administration Set.
9. Open the door on pump.
10. Locate the clamp on the set and hook into position in pump.
11. Gently pull down on set and press into groove at the bottom. Double click the pump door shut. Do not
use the lever to close the door
12. Label the bag reservoir with the date, time, type and quantity of feed.
13. .. Flush patients enteral tube with 30-50mls of drinking tap water to ensure tube patency
14. .Connect feed administration set to patient and start pump.
15. .At the end of administration or after 12 hours, turn off feed and disconnect. Discard any remaining feed.
16. Flush patient’s enteral tube with 30-50mls of drinking tap water to ensure tube patency.
APPENDIX 3
HOW TO BOLUS FEED VIA A PEG.
EQUIPMENT:
Non-Sterile gloves
Pack of feed/carton
Empty cup/glass
Enteral catheter tip syringe
Glass of drinking tap water
Bolus adaptor (for feed bag only)
White funnel adaptor (to attach enteral syringe to PEG)
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1. Wash hands
2. Apply non-sterile gloves. Carry out the procedure using a non-touch technique.
3. Check the expiry date on the cartons/pack of feed and shake well.
4. If using feed pack-attach bolus adaptor into port on feed pack by piercing valve and screwing on
securely. This allows attachment of 60ml enteral catheter tip syringe.
5. If using cartons decant into a clean cup.
6. Prior to bolusing feed flush the patients tube with 30-50mls of drinking tap water using an enteral syringe.
7. Using an enteral catheter tip syringe either attach to bolus adaptor on feed pack or place in feed filled
cup.
8. Draw up the feed by withdrawing the plunger on the syringe until full.
9. Clamp PEG tube and unscrew hub.
10. Attach funnel adaptor and 60ml enteral syringe.
11. Undo clamp on PEG
12. Depress plunger on syringe to expel feed into PEG.
13. Repeat steps 6-11 until desired amount of feed has been given.
14. At end of feed flush 30-50mls of drinking tap water through PEG to maintain patency and cap off hub on
PEG tube. Open clamp.
APPENDIX 4
HOW TO UNBLOCK AN ENTERAL FEEDING TUBE.
EQUIPMENT
Non-sterile gloves
10ml enteral syringe
Glass of drinking tap water
1. Ensure all the clamps are open and the tube is not kinked.
2. Ensure distal port/hub is free of feed/medication/debris.
3. If tube looks clear and it is a suspected blocked hub/port change hub.
4. If blockage is visible in tube massage this area.
5. Fill a 20 ml syringe with 10ml of water.
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6. Attach the 20ml enteral syringe to distal port.
7. Using a push/withdraw action with the plunger of the syringe try to flush the tube.
8. If blockage does not clear leave for half and hour and try again-as blockage may have dispersed.
9. Contact Nutrition CNS’s on 5918 or Bleep 1813/1484. if above methods do not clear tube.
To prevent tube blockages you must:
1. Flush the enteral tube with 30 –50ml tap water as soon as the feed finishes.
2. Flush the tube before and after feed administration with 30-50 ml tap water.
3. Ensure medications are completely dispersed/dissolved prior to administration – see Procedure for the
Administration of Medicines
4. Flush the tube in between each medication with 10ml tap water if administering more than one
medication.
APPENDIX 5
HOW TO ADD SALT SOLUTION TO 500ML BAG OF FRESUBIN ENERGY FEED
EQUIPMENT:
Sterile Gloves
Dressing Trolley/Tray
1 x 500ml bag of Fresubin Energy feed
1 x 10ml Enteral Syringe
1 x Sartorius/Pall syringe filter.
2 x Enteral Milk Straw
1 x 10ml Ampoule of 30% NaCI (salt)
Ampoule Opener

Wash Hands and clean trolley/tray

Wash Hands again

Open Salt (NaCI) ampoules and place on Trolley.

Twist off cap on bag of feed and place bag on edge of trolley

Open sterile gloves. Use green sheet as sterile field

Open milk straws, 10ml syringe and syringe filter onto sterile field

Put on gloves

Attach the Milk Straw to syringe and draw up 6 mls ONLY of Salt (NaCI),

Remove milk straw, then attach syringe filter and new milk straw to syringe.
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.

Firmly push the Milk Straw through the one way valve system on the Fresubin Energy feeding
bag - you will need to hold the straw close to the end that goes into the bag of feed. Push
and twist until 2cm of straw has gone into the bag.

Inject Salt solution into bag of feed. When syringe is empty remove syringe and syringe filter
from milk straw but leave straw in feed bag to allow remaining solution in the straw to go into
the bag of feed via gravity (ensure that end of straw that was attached to syringe is elevated
above the bag of feed).

Remove milk straw.

Shake the bag of feed thoroughly to disperse the salt solution.

Discard used equipment. Place salt ampoules in sharps box. Remove and discard gloves.

Proceed to set up the feed as per usual. Attach additive label to bag to state that 6 mls of
30% NaCL has been added to feed.
Ordering information: the ward will need to order milk straws and syringe filters. Both are stock
items and can be ordered via Oracle iProcurement
Milk Straw Medicina CO20 (Pack 200)
£71.583 per pack 200
NHS Supply Chain/Bridgewater
FVK137
Filter Syringe 0.2 Micron Ministart Filter to fit onto syringe double luer lock SARTORIUS
16534K (Pack 50) NHS Supply Chain/Bridgewater FTC198 £17.209 per pack 50
Or
Filter Syringe 0.2 Micron Hydrophilic membrane 22mm diameter double luer lock. Pall
Pharmassure PH1002 ordered as a singular item 54p each NHS Supply Chain/Bridgewater
FTC086
APPENDIX 6
HOW TO ADD SALT SOLUTION TO 1 LITRE BAG OF FRESUBIN ENERGY FEED
EQUIPMENT:
Sterile Gloves
Dressing Trolley/Tray
1 x 1 litre bag of Fresubin Energy feed
1 x 20ml Enteral Syringe
1 x Sartorius/Pall syringe filter.
2 x Enteral Milk Straw
2 x 10ml Ampoule of 30% NaCI (salt)
Ampoule Opener

Wash Hands and clean trolley/tray

Wash Hands again

Open Salt (NaCI) ampoules and place on Trolley.
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Issue 2 29/09/2011

Twist off cap on bag of feed and place bag on edge of trolley

Open sterile gloves. Use green sheet as sterile field

Open milk straws, 20ml syringe and syringe filter onto sterile field

Put on gloves

Attach the Milk Straw to syringe and draw up 12 mls ONLY of Salt (NaCI),

.

Remove milk straw, then attach the syringe filter, and new milk straw to syringe.

Inject Salt solution into bag of feed. When syringe is empty remove syringe and syringe filter
from milk straw but leave straw in feed bag to allow remaining solution in the straw to go into
the bag of feed via gravity (ensure that end of straw that was attached to syringe is elevated
above the bag of feed).

Remove milk straw.

Shake the bag of feed thoroughly to disperse the salt solution.

Discard used equipment. Place salt ampoules in sharps box. Remove and discard gloves.

Proceed to set up the feed as per usual. Attach additive label to bag to state that 12 mls of
30% NaCL has been added to feed.
Firmly push the Milk Straw through the one way valve system on the Fresubin Energy
feeding bag - you will need to hold the straw close to the end that goes into the bag of feed.
Push and twist until 2cm of straw has gone into the bag.
Ordering information: the ward will need to order milk straws and syringe filters. Both are stock
items and can be ordered via Oracle iProcurement
Milk Straw Medicina CO20 (Pack 200)
£71.583 per pack 200
NHS Supply Chain/Bridgewater
FVK137
Filter Syringe 0.2 Micron Ministart Filter to fit onto syringe double luer lock SARTORIUS
16534K (Pack 50) NHS Supply Chain/Bridgewater FTC198 £17.20 per pack 50
Or
Filter Syringe 0.2 Micron Hydrophilic membrane 22mm diameter double luer lock. Pall
Pharmassure PH1002 ordered as a singular item 54p each NHS Supply Chain/Bridgewater
FTC086
APPENDIX 7
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
HOW TO ADD SALT SOLUTION TO 500ML BAG OF
FRESUBIN ORIGINAL FEED
EQUIPMENT:
Sterile Gloves
Dressing Trolley/Tray
1 x 500ml bag of Fresubin Original feed
1 x 10ml Enteral Syringe
1 x Sartorius/Pall syringe filter.
2 x Enteral Milk Straw
1 x 10ml Ampoule of 30% NaCI (salt)
Ampoule Opener

Wash Hands and clean trolley/tray

Wash Hands again

Open Salt (NaCI) ampoules and place on Trolley.

Twist off cap on bag of feed and place bag on edge of trolley

Open sterile gloves. Use green sheet as sterile field

Open milk straws, 10ml syringe and syringe filter onto sterile field

Put on gloves

Attach the Milk Straw to syringe and draw up 7 mls ONLY of Salt (NaCI),

.

Remove milk straw, then attach syringe filter and new milk straw to syringe.

Inject Salt solution into bag of feed. When syringe is empty remove syringe and syringe filter
from milk straw but leave straw in feed bag to allow remaining solution in the straw to go into
the bag of feed via gravity (ensure that end of straw that was attached to syringe is elevated
above the bag of feed).

Remove milk straw.

Shake the bag of feed thoroughly to disperse the salt solution.

Discard used equipment. Place salt ampoules in sharps box. Remove and discard gloves.

Proceed to set up the feed as per usual. Attach additive label to bag to state that 7mls of 30%
NaCL has been added to feed.
Firmly push the Milk Straw through the one way valve system on the Fresubin Original
feeding bag - you will need to hold the straw close to the end that goes into the bag of feed.
Push and twist until 2cm of straw has gone into the bag.
Ordering information: the ward will need to order milk straws and syringe filters. Both are stock
items and can be ordered via Oracle iProcurement
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
Milk Straw Medicina CO20 (Pack 200)
£71.583 per pack 200
NHS Supply Chain/Bridgewater
FVK137
Filter Syringe 0.2 Micron Ministart Filter to fit onto syringe double luer lock SARTORIUS
16534K (Pack 50) NHS Supply Chain/Bridgewater FTC198 £17.209 per pack 50
Or
Filter Syringe 0.2 Micron Hydrophilic membrane 22mm diameter double luer lock. Pall
Pharmassure PH1002 ordered as a singular item 54p each NHS Supply Chain/Bridgewater
FTC086
APPENDIX 8
HOW TO ADD SALT SOLUTION TO 1 LITRE BAG OF FRESUBIN ORIGINAL FEED
EQUIPMENT:
Sterile Gloves
Dressing Trolley/Tray
1 x 1 litre bag of Fresubin Original feed
1 x 20ml Enteral Syringe
1 x Sartorius/Pall syringe filter.
2 x Enteral Milk Straw
2 x 10ml Ampoule of 30% NaCI (salt)
Ampoule Opener

Wash Hands and clean trolley/tray

Wash Hands again

Open Salt (NaCI) ampoules and place on Trolley.

Twist off cap on bag of feed and place bag on edge of trolley

Open sterile gloves. Use green sheet as sterile field

Open milk straws, 20ml syringe and syringe filter onto sterile field

Put on gloves

Attach the Milk Straw to syringe and draw up 14 mls ONLY of Salt (NaCI),

.

Remove milk straw, then attach the syringe filter and new milk straw to syringe.

Inject Salt solution into bag of feed. When syringe is empty remove syringe and syringe filter
from milk straw but leave straw in feed bag to allow remaining solution in the straw to go into
the bag of feed via gravity (ensure that end of straw that was attached to syringe is elevated
above the bag of feed).

Remove milk straw.
Firmly push the Milk Straw through the one way valve system on the Fresubin Original
feeding bag - you will need to hold the straw close to the end that goes into the bag of feed.
Push and twist until 2cm of straw has gone into the bag.
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011

Shake the bag of feed thoroughly to disperse the salt solution.

Discard used equipment. Place salt ampoules in sharps box. Remove and discard gloves.

Proceed to set up the feed as per usual. Attach additive label to bag to state that 14mls of
30% NaCL has been added to feed.
Ordering information: the ward will need to order milk straws and syringe filters. Both are stock
items and can be ordered via Oracle iProcurement
Milk Straw Medicina CO20 (Pack 200)
£71.583 per pack 200
NHS Supply Chain/Bridgewater
FVK137
Filter Syringe 0.2 Micron Ministart Filter to fit onto syringe double luer lock SARTORIUS
16534K (Pack 50) NHS Supply Chain/Bridgewater FTC198 £17.209 per pack 50
Or
Filter Syringe 0.2 Micron Hydrophilic membrane 22mm diameter double luer lock. Pall
Pharmassure PH1002 ordered as a singular item 54p each NHS Supply Chain/Bridgewater
FTC086
APPENDIX 9
HOW TO ADD SALT SOLUTION TO 500ML BAG OF SERVIMED OPD FEED
EQUIPMENT:
Sterile Gloves
Dressing Trolley/Tray
1 x 500ml bag of Servimed OPD feed
1 x 10ml Enteral Syringe
1 x Sartorius/Pall syringe filter.
2 x Enteral Milk Straw
1 x 10ml Ampoule of 30% NaCI (salt)
Ampoule Opener

Wash Hands and clean trolley/tray

Wash Hands again

Open Salt (NaCI) ampoules and place on Trolley.

Twist off cap on bag of feed and place bag on edge of trolley

Open sterile gloves. Use green sheet as sterile field

Open milk straws, 10ml syringe and syringe filter onto sterile field

Put on gloves

Attach the Milk Straw to syringe and draw up 5 mls ONLY of Salt (NaCI),

.
Remove milk straw, then attach syringe filter and new milk straw to syringe.
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011

Firmly push the Milk Straw through the one way valve system on the Servimed OPD feeding
bag - you will need to hold the straw close to the end that goes into the bag of feed. Push
and twist until 2cm of straw has gone into the bag.

Inject Salt solution into bag of feed. When syringe is empty remove syringe and syringe filter
from milk straw but leave straw in feed bag to allow remaining solution in the straw to go into
the bag of feed via gravity (ensure that end of straw that was attached to syringe is elevated
above the bag of feed).

Remove milk straw.

Shake the bag of feed thoroughly to disperse the salt solution.

Discard used equipment. Place salt ampoules in sharps box. Remove and discard gloves.

Proceed to set up the feed as per usual. Attach additive label to bag to state that 5mls of 30%
NaCL has been added to feed.
Ordering information: the ward will need to order milk straws and syringe filters. Both are stock
items and can be ordered via Oracle iProcurement
Milk Straw Medicina CO20 (Pack 200)
£71.583 per pack 200
NHS Supply Chain/Bridgewater
FVK137
Syringe Filter 0.2 Micron Ministart Filter to fit onto syringe double luer lock SARTORIUS
16534K (Pack 50) NHS Supply Chain/Bridgewater FTC198 £17.209 per pack 50
Or
Syringe Filter 0.2 Micron Hydrophilic membrane 22mm diameter double luer lock. Pall
Pharmassure PH1002 ordered as a singular item 54p each NHS Supply Chain/Bridgewater
FTC086
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
APPENDIX 10 ENTERAL EQUIPMENT
Name
Description
Order No
NHS
Quantity
Stock No
Cost
NG/NJ TUBES
Merck 6fg weighted NG tube
Merck 8fg weighted NG tube
Fine bore NGT for enteral administration
of water or standard feed into the
stomach. Use for difficult insertions. DO
NOT USE ROUTINELY-SMALL BORE –
BLOCKS EASILY.
Recommended Tube: Fine bore NGT for
enteral
administration
of
water,
medications and any type of feed into the
stomach
090120004
FWM243
Each
£10.97 each
090120012
FWM301
Each
£10.97 each
7752053
7752053
Pack 30
£0.90
7751101
7751101
Pack 30
£0.90
7752316
7752316
Pack 30
£0.90
7751694
7751694
Pack 30
£0.90
ADMINISTRATION SETS
To allow administration of feed or water
Administration Sets – Pump Set (Easy
via a giving set for either gravity or pump
Bag)
feeding via an enteral tube.
For the administration of water via an
Water Bags (Hydrobags)
administration set into an enteral tube
To allow 2 bags of feed or 1 bag of feed
Y Pump Set (EasyBag)
and a water bag to hang simultaneouslywhen 1 bag finishes next one starts.
Applix pump set – bag reservoir
For decanting feed
Enteral Tube Administration Policy (Adults):
Issue 2. 29/09/2011
Page 20 of 27
Name
Description
NHS
Stock No
Quantity
Cost
FTA145
FTA146
FTA147
FTA148
FTA156
FTA149
FTA189
Box 100
Box 100
Box 100
Box 100
Box 100
Box 50
Box 50
£9.34 per box
£8.86 per box
£8.86 per box
£13.31 per box
£17.38 per box
£18.39 per box
£18.48 per box
Box 200
£80.58 per box
Box 200
£75.31 per box
Single
£0.47
ENTERAL SYRINGES
Enteral Syringes
purple single use oral/enteral syringes
which attach directly onto male luer
connections-e.g. PEG hubs/ NGT
connections. Available in the following
sizes:
1ml
2.5ml
5ml
10ml
20ml
60ml female luer lock
60ml catheter tip
ADDITIONAL ITEMS
Medicina Milk straw
Medicina Medicine straw
Filter
Enteral Tube Administration Policy (Adults)
Page 21 of 27
To be used with enteral syringe to add
30% NaCl solution to Ready to Hang Feed FVK137
Bag.
Attaches to enteral syringe to draw up
FVK136
medicines.
To be used with enteral syringe and milk
straw to draw up 30% NaCl from glass FTC 086
ampoule
Issue 2 29/09/2011
APPENDIX A
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
To be completed by the author of the document and attached when the document is submitted for ratification: a
blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
CHECKLIST FOR REVIEW AND RATIFICATION
TITLE OF DOCUMENT BEING REVIEWED:
1
2
COMMENTS
Title
Is the title clear and unambiguous?
Yes
Will it enable easy searching/access/retrieval??
Yes
Is it clear whether the document is a policy, guideline, procedure,
protocol or ICP?
Yes
Policy
Introduction
Are reasons for the development of the document clearly stated?
3
YES/NO
N/A
Yes
Content
Is there a standard front cover?
Yes
Is the document in the correct format?
Yes
Is the purpose of the document clear?
Yes
Is the scope clearly stated?
Yes
Does the scope include the paragraph relating to ability to comply,
in the event of a infection outbreak, flu pandemic or any major
incident?
4
5
Are the definitions clearly explained?
Yes
Are the roles and responsibilities clearly explained?
Yes
Does it fulfill the requirements of the relevant Risk Management
Standard? (see attached compliance statement)
Yes
Is it written in clear, unambiguous language?
Yes
Evidence Base
Is the type of evidence to support the document explicitly
identified?
Yes
Are key references cited?
Yes
Are the references cited in full?
Yes
Are associated documents referenced?
Yes
Approval Route
Does the document identify which committee/group will approve it?
Enteral Tube Administration Policy (Adults):
Yes
Issue 2. 29/09/2011
Page 22 of 27
6
Process to Monitor Compliance and Effectiveness
Are there measurable standards or KPIs to support the monitoring
of compliance with the effectiveness of the document?
7
Review Date
Is the review date identified?
6
Yes
Dissemination and Implementation
Is a completed proposed implementation plan attached?
7
Yes
Yes
Equality and Diversity
Is a completed Equality Impact Assessment attached?
Yes
APPENDIX A
cont……
Checklist for the Review and Ratification of Procedural Documents and
Consultation and Proposed Implementation Plan
CONSULTATION AND PROPOSED IMPLEMENTATION PLAN
Date to ratification committee
Groups /committees / individuals involved in the
development and consultation process
Developed by CNNS team.
Presented at the Nutrition Steering Group.
Is training required to support implementation?
This was a review of an existing policy and
training is on going.
If yes, outline plan to deliver training
As a result of the 2011 policy audit, each CSC has
developed an action plan, each plan identifies
areas for improvement and how this will be
achieved.
Each CSC will report back progress through their
Governance meetings.
Outline any additional activities to support
implementation
CNNS to support CSC with any additional training,
including regular visits to ward areas to monitor
practice.
Individual Approval
If, as the author, you are happy that the document complies with Trust policy, please sign below and send the document,
with this paper, the Equality Impact Assessment and NHSLA checklist (if required) to the chair of the committee/group
where it will be ratified. To aid distribution all documentation should be sent electronically wherever possible.
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
Name
Selena Rogers, Joanne Pratt
Date
27/09/2011
Signature
Committee / Group Approval
If the committee/group is happy to ratify this document, would the chair please sign below and send the policy together with
this document, the Equality Impact Assessment, and NHSLA checklist (if required) and the relevant section of the minutes
to the Trust Policies Officer. To aid distribution all documentation should be sent electronically wherever possible.
Name
Dr T Trebble
Signature
(see attached email)
Date
08/09/2011
If answers to any of the above questions is ‘no’, then please do not send it for ratification.
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Issue 2 29/09/2011
APPENDIX B
EQUALITY IMPACT ASSESSMENT
To be completed by the author of the document and attached when the document is submitted for
ratification: a blank template can be found on the Trust Intranet. Home page -> Policies -> Templates
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the appropriate
committee for consideration and approval.
Stage 1 - Screening and Scoping
Date of assessment : 27/09/2011
Department : Clinical Nutrition Nurse Specialist
Name and Job title of person responsible for assessment:
Selena Rogers Nutriton Nurse Specialist
Policy / Function:
Enteral Tube Administration Policy (Adults)
Aims and objectives of policy/function
This policy aims to give evidence-based, best practice guidance to staff on minimising
the risks associated with enteral administration.
Who is involved in the assessment? PHT staff and patients.
Who should benefit from the policy/function provided?
PHT staff and patients.
The following questions should be
considered during the screening
process.
1
2
3
4
What evidence is there already held on
the impact on different groups?
Complaints, surveys, reports, summarise
the main points
Yes/
No
N/A
Explain
As per question 4.
Audit of practice
performed as part
of this policy
review.
What evidence is there to show the
policy/function is meeting people’s
requirements
Can this assessment be linked to an
existing or planned function/policy review
Yes
This assessment
forms part of a
policy review
Assess how the policy/function meets
different needs. (e.g age, gender, race,
disability, sexual orientation,
religion/belief
N/A
This policy
directs staff in the
safe
administration of
enteral feeding it
does not identify
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
groups of
patients
individually.
5
Does the policy/function contribute to
equality, diversity and human rights?
If yes – identify how
Yes
It is non
discriminatory.
If no – could it?
NO
6
Are there any obvious barriers to different
groups accessing the aims of the
policy/function? (e.g. age, gender, race,
disability, religion)
If you have identified potential
discrimination, are the exceptions valid,
legal and/or justified?
N/A
7
8
What could be changed to reduce
/remove the barriers
N/A
No
9
Is there any other information, which
could influence making improvements to
the policy/function? e.g. from partner
organisations
Does the policy/function affect one group less or more favourably than
another on the basis of
10

Race
NO
 Ethnic origin (including gypsies
and travellers)
NO

Gender
NO

Religion or belief
NO
 Sexual orientation including
lesbian, gay and bisexual people
 Age

Disability - learning disabilities,
physical disability, sensory
impairment and mental health
problems ,e.g dementia
NO
NO
NO
Does this policy/function affect individual
human rights?
If the answer to any of the above
questions is yes, a full impact assessment
is required, go on to stage 2. If no, the
EIA is completed,
Stage 2
11
Consult formally on the policy/function
procedure and any options with relevant
stakeholders (using a range of
accessible and appropriate methods and
venues.) This could involve a survey,
focus groups or the use of consultants,
depending on the level of impact.
Enteral Tube Administration Policy (Adults)
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Issue 2 29/09/2011
Publish results of assessments. Develop
actions / improvements and set as
objectives ( action plan form)
Include objectives in the service equality
action plan and report to the Equality and
13
Diversity Committee and Divisional
Review
Once the final option is chosen, the
14
outcomes must be monitored regularly
to check for unexpected adverse impacts
If the answers to any of the above questions is ‘yes’ you will need to complete a full Equality Impact
Assessment (available from the Equality and Diversity website) or amend the policy such that only an
disadvantage than can be justified is included. If you require any general advice please contact staff
in the Equality and Diversity Department on 02392 288511
12
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