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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) Page 2 of 27 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. Enteral Tube Administration Policy (Adults) Page 3 of 27 Issue 2 29/09/2011 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. Enteral Tube Administration Policy (Adults) Page 4 of 27 Issue 2 29/09/2011 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. . Enteral Tube Administration Policy (Adults) Page 5 of 27 Issue 2 29/09/2011 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) Page 6 of 27 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. Enteral Tube Administration Policy (Adults) Page 7 of 27 Issue 2 29/09/2011 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 Enteral Tube Administration Policy (Adults) Page 8 of 27 Issue 2 29/09/2011 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 Enteral Tube Administration Policy (Adults) Page 9 of 27 Issue 2 29/09/2011 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 Enteral Tube Administration Policy (Adults) Page 10 of 27 Issue 2 29/09/2011 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) Enteral Tube Administration Policy (Adults) Page 11 of 27 Issue 2 29/09/2011 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. Enteral Tube Administration Policy (Adults) Page 12 of 27 Issue 2 29/09/2011 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. Enteral Tube Administration Policy (Adults) Page 13 of 27 Issue 2 29/09/2011 . 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. Enteral Tube Administration Policy (Adults) Page 14 of 27 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) Page 15 of 27 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) Page 16 of 27 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) Page 17 of 27 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) Page 18 of 27 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) Page 19 of 27 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) Page 23 of 27 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. Enteral Tube Administration Policy (Adults) Page 24 of 27 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) Page 25 of 27 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) Page 26 of 27 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 Enteral Tube Administration Policy (Adults) Page 27 of 27 Issue 2 29/09/2011