Nasogastric Feeding Policy

Nasogastric Feeding Policy

Reference Number: TWCG20(11) Version Number: 9 Issue Date: 01/12/2020 Page 1 of 45

It is your responsibility to check on the intranet that this printed copy is the latest version


Lead Author: Brenda Blackett, Nutrition Nurse Specialist

Additional author(s) Dr Adnan Gebril and Kirstine Farrer Consultant Dietitian IF

Division/ Department:: Nutrition Support Team on behalf of the Nutrition Steering Group

Applies to: Salford Royal Care Organisation

Approving Committee: Clinical Advisory Group (CAG)

Date approved: 30/11/2020

Expiry date: November 2025

Contents

Contents

Section Page 1 What is the policy about? 2

2 Where will this document be used? 2

3 Why is this document important? 2

4 What is new in this version? 3

5 What is the Policy:

5.1 Protocol 3

5.2 Nasogastric feeding tube insertion 5

5.3 Standards 7

5.4 Training and competency 13

6 Roles and responsibilities 14

7 Monitoring document effectiveness 15

8 Abbreviations and definitions 15

9 References and Supporting Documents 16

10 Document Control Information 17

11 Equality Impact Assessment (EqIA) screening tool 18

12 Appendices:

Appendix 1 NPSA Decision Tree 20

Appendix 2 NPSA Safety Alert x-ray interpretation aid 21

Appendix 3 Competency log 22

Appendix 4 Starter feeding regimen 25

Appendix 5 Bolus Feeding 27

Appendix 6 Discharge Risk Assessment 28

Appendix 7 Self-Insertion of Nasogastric feeding tube 30

Appendix 8 Patient monitoring 34

Appendix 9 Problem solving 36

Appendix 10 Paper care plan 38

Appendix 11 Pathway for displaced NG tube during Covid 19 Pandemic 43

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)




1. Overview (What is this policy about?) 1.1 The purpose of this policy is to ensure that all patients requiring nasogastric feeding

receive an explicit quality of service and that risks are minimised. This document relates to medical, nursing and support staff that care for patients who require enteral feeding via a nasogastric tube. The same advice, precautions and procedures also apply to orogastric feeding tubes.

If you have any concerns about the content of this document please contact the author or advise the Document Control Administrator.

2. Scope (Where will this document be used?)

2.1 This document is for use at Salford Royal NHS Foundation Trust 2.2 Applies to adult patients

3. Background (Why is this document important?)

3.1 All nasogastric feeding in adult patients within Salford Royal NHS Foundation Trust must be initiated and monitored in compliance with the National Patient Safety Agency guidelines and this policy.

3.2 Use of misplaced nasogastric and orogastric tubes was first recognised as a patient safety issue by the National Patient Safety Agency (NPSA) in 2005, and three further alerts were issued by the NPSA and NHS England between 2011 and 2013. Introducing fluids or medication into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube is a Never Event. Never Events are considered ‘wholly preventable where guidance or safety recommendations that provide strong systemic protective barrier are available at a national level, and should have been implemented by all healthcare providers.

Between September 2011 and March 2016, 95 incidents were reported to the National Reporting and Learning System (NRLS) and/or the Strategic Executive Information System (StEIS) where fluids or medication were introduced into the respiratory tract or pleura via a misplaced nasogastric or orogastric tube. While this should be considered in the context of over 3 million nasogastric or orogastric tubes being used in the NHS in that period, these incidents show that risks to patient safety persist. Checking tube placement before use via pH testing of aspirate and, when necessary, x-ray imaging, is essential in preventing harm.

Examination of these incident reports by NHS Improvement clinical reviewers shows that misinterpretation of x-rays by medical staff occurs if medical staff have not completed the competency-based training required by the 2011 NPSA alert. Other error types involve nursing staff and pH tests, unapproved tube placement checking methods, and

Group arrangements:

Salford Royal NHS Foundation Trust (SRFT)




communication failures resulting in tubes not being checked. The report included 32 incidents where the patient subsequently died, although given many patients were critically ill before the tube was introduced, it is not always clear whether the death was directly related to the misplaced tube.

4. What is new in this version?

Guidance on placing a nasogastric feeding tube in relation to Covid-19 SARS Cov-2 risk and additional PPE required for staff inserting the naso-gastric tube.

Out of hours starter regimen in line with Salford Royal NHS Foundation Trust refeeding syndrome policy.

Addition of the NG tube replacement pathway (appendix 11) during the Covid Pandemic to provide guidance on minimising emergency room attendances as well as avoiding hospital admissions. Note Out of area Salford residents will be redirected to their local emergency room.

5. Policy

5.1 Protocol

5.1.1 Nasogastric (NG) Tube Feeding

Nasogastric tube feeding is the choice for patients who require short term enteral feeding i.e. 4-6 weeks.

5.1.2 Indications for Nasogastric feeding NG tube feeding is suitable for the patients who:

Are malnourished.

Have a functioning GI tract.

Require short-term tube feeding (up to 4-6 weeks)

Have been unable to fulfil their nutritional requirements with normal /modified diet +/- nutritional supplements for >7 days.

Are not predicted to fulfil their nutritional requirements with normal / modified diet +/- nutritional supplements for >7 days.

Have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns.

5.1.3 Contraindications Absolute contraindications

Non-functioning GI tract e.g. ileus

Complete obstructive pathology in oropharynx, oesophagus preventing passage of the tube (e.g. stricture, tumour)

Large gastric aspirate and/or high risk of aspiration (includes mechanical pyloric obstruction due to tumour or stricture)

Intractable vomiting not resolved by adequate anti-emetic




Relative contraindications

Mask C.PA.P

Basal skull fracture, as the tube may enter the brain if malpositioned - in this instance insertion needs to be under direct vision with a laryngoscope or naso-endoscope (if not available the orogastric route may be used as an alternative)

Oesophageal varices

Mucositis

Vomiting responding to anti-emetics

Maxillo facial disorders, surgery or trauma

Clinical circumstances where an enteral feeding tube must be inserted under endoscopic or radiological guidance:

Partial obstructive pathology in oropharynx or oesophagus preventing passage of the tube (e.g. stricture, tumour)

Previous partial, total or extended total gastrectomy

Any previous bariatric surgery 5.1.4 Risks

Misplacement of the tube

Perforation

Pneumothorax

Aspiration

5.1.5 Consent

Verbal consent for the procedure and testing for Covid-19 SARS should be sought under the guidance of the Trust Consent Policy. To obtain valid informed consent, where a nasogastric tube is to be used for feeding purposes, patients and carers should be made aware of the associated complications which may be caused by tube insertion or misplacement, and the procedures which should be taken to prevent this.

If the patient is unable to give informed consent due to incapacity, the tube may be inserted if it is considered to be in the patient’s best interests to do so. In these circumstances, wherever practicable the patient’s named ‘next of kin’ should be consulted but the final decision to proceed will always remain with the responsible healthcare professional. The hospital communications book will be used to aid understanding and communication if the patient has learning disabilities. Staff are also aware of using interpreters if required. Consideration may be given to delaying the procedure if there is a chance that the patient will regain capacity but this should only be considered if it is practicable to do so and providing always that the delay will not adversely affect the patient’s clinical condition. For patients who do not have the capacity to consent, in order to comply with the Mental Capacity Act 2005, the following process and EPR documentation needs to be completed:




1. Decision specific Mental Capacity Assessment for insertion of an NG tube for enteral feeding, fluids and/ or medication, completed on the EPR mental capacity assessment form. 2. Best interest documentation form on EPR; which must be completed and state the risks and benefits of an NG tube for enteral feeding, fluids and/ or medication.

5.2 Nasogastric Feeding tube insertion

5.2.1 The tube will be inserted using the following Procedure adapted from the Royal Marsden manual and the NPSA safety alert (2005, 2011 and 2012)

Fine bore nasogastric feeding tube insertion by a competent nurse or doctor

Nursing Practice Equipment

Risk Assessment to be completed for Covid-19 SARS Co-2.

Access to EPR

If the individual has no symptoms and a negative COVID -19 SARS PCR test performed 72 hours prior to NG tube insertion proceed as outlined below. For these individuals you do not need to take Airborne precautions provided the patient has no other infectious agent transmitted via droplet or airborne infection route.

Access to EPR

For medium or high risk patients (i.e. those with proven, suspected Covid 19 SARS Co-2

or who have refused a swab in the last 72 hours) you must take airbourne precautions

In addition to the list of equipment below you will also require:

FFP3 respirator

Access to a side room/clinical

examination room away from

main ward with downtime

following insertion.

The intention of this practice is to insert a Fine Bore Nasogastric Tube, following assessment of the patient by medical, nursing and dietetic staff.

Non Sterile Gloves

Apron

Gown

Fluid resistant surgical mask (blue)

Eye protection

Nasogastric feeding tube - size 8 or 10Fr




50ml ENFIT enteral Syringe

10mls Sterile Water

Tape or Anchoring Device

pH Indicator Paper with 0.5 graduations or a range of 0-6

Tissues

Vomit bowl

Glass of water and straw – if patient can swallow/ is not NBM

Action Rationale

1. Prepare the patient. Introduction of the tube and its function. Arrange a signal by which the patient can communicate if he/she wants the nurse to stop e.g. raising their hand

a. To promote dignity and privacy. b. To ensure co-operation and promote confidence. c. To ensure full informed consent.

2. Explain how it will feel. Assist the patient (if conscious) to sit upright and support him/her with pillows.

Aids relaxation of patient.

3. Explain the importance of not tilting the head backwards. If the patient is sedated, it may not be appropriate to sit him/her up.

To maintain an open passage for the tube.

4. Inspect the nostrils, checking to see which is clear. Ask the patient to blow his/her nose or the nostrils may need cleaning with sterile water.

a. To aid passage of tube. b. To avoid trauma to the nasal mucosa. c. To identify any obstruction which may hinder intubation.

5. The nurse/doctor should wash her hands and put on a clean disposable apron. Ensure that paper towels are placed comfortably around the patient’s neck. A vomit bowl should be at hand.

To reduce the risk of cross infection. (This is a clean procedure)

6. Measure the tube prior to placement using the NEX measurement - measure the distance on the tube from the patient’s tip of the nose to the earlobe plus the distance from the earlobe to the bottom of the xiphisternum.

To measure the length of the tube which needs to be introduced in order that the tip will lie in the stomach.

7. Dip the end of the nasogastric tube in sterile water.

This activates coating on the tip of the tube and assists with intubation.

8. If the patient is conscious, is not NBM and has a safe swallow, allow them to drink and provide them with a glass of water and a straw.

This will promote passage of the tube into the oesophagus.

9. Insert the tube into the nostril, slide it backwards and inwards, and as the tube passes through the nasopharynx ask the patient to sip water if this is appropriate and the patient is able to do so.

To help the passage of the tube through the nose. The swallowing action closes the glottis and assists the tube to pass into the oesophagus.




10. Maintaining a calm manner and encouraging the patient to take slow even breaths, advance the tube down the oesophagus until it reaches the stomach to the cm marking measured on the tube.

Assist relaxation and avoids laryngeal spasm.

11. If you are unable to pass the tube, try the other nostril. If you are unable to place the tube, seek advice from a senior colleague.

To prevent undue discomfort and distress to patient.

12. If at any time during or following the procedure signs of nasal haemorrhage, respiratory distress e.g. cyanosis or gasping occurs, or if the tube meets any resistance the tube should be withdrawn.

Trauma to the nasal mucosa, the tip may have entered the respiratory system, or obstruction may be present.

13. Once the tube is inserted safely and correctly, it can be secured to the nose or side of the face with a small piece of non-allergenic tape.

Take care not to cover the cm marking at the nostril.

To prevent any retraction of the tube whilst checking its placement. To allow the cm marking at the nostril to be checked routinely.

14. Aspirate the tube with a minimum of 1ml, and check pH of aspirate using pH Indicator paper which has 0.5 increments, is CE marked and manufactured to test human gastric aspirate.

pH reading must be between 1 and 5.5 to confirm placement

A second competent person must check any reading that falls within the pH range of 5 to 6.

*If unable to aspirate, follow guidance on the NPSA algorithm (Appendix 1) before proceeding to x-ray. *If following the steps in the algorithm does not allow successful aspiration and confirmation by pH, an x-ray will be required to confirm position

To confirm the position of the tube is in the correct place for feeding / administering medication

15. Record the procedure and the technique used to confirm the position of the tube on the nasogastric care plan and on the electronic patient record. Document pH reading and NEX measurement on the NG care plan, bedside checklist and electronic patient record

For audit purposes and in the event of a query.

.




5.3 Standards

5.3.1 Before a decision is made to insert a nasogastric tube, an assessment will be undertaken

to identify if nasogastric feeding is appropriate for the patient, associated risk to staff to undertake this Aerosol Generating Procedure and the rationale for any decision will be recorded by the medical team in the patient’s electronic patient record (EPR).

5.3.2 If there is not sufficient experienced support available to accurately confirm nasogastric

tube placement (for example at night) then, unless clinically urgent placement should be delayed until that support is available, and the rationale for any decisions will be recorded in the patient’s medical notes.

5.3.3 Nasogastric tubes used for the purpose of feeding will be radio-opaque throughout their

entire length and have externally visible length markings. The tube length will be estimated before insertion using the NEX measurement (place exit port of tube at tip of nose, extend the tube to the earlobe, and then to xiphisternum).

5.3.4 A maximum of 3 attempts at inserting the tube should be made at one time to prevent

trauma to the nasal / oesophageal mucosa, and if difficulty in inserting the tube this should be escalated accordingly via the medical team to ensure adequate attempts are made to secure a safe enteral route for nutrition/ fluid/ medication.

5.3.5 If at any time during or following the procedure signs of nasal haemorrhage, respiratory

distress e.g. cyanosis or gasping occurs, or if the tube meets any resistance the tube should be withdrawn.

5.3.6 The insertion of the tube will be completed by a competent practitioner, and details of

insertion documented on the EPR Nasogastric tube insertion structured note.




5.3.7 The position of a nasogastric feeding tube on initial placement (see NPSA decision tree,

appendix 1) will only be confirmed by: First line test method: pH paper

Using a 50ml enteral syringe a minimum of 1ml should be withdrawn (aspirated) from the NG tube.

The NG tube aspirate must be checked using pH Indicator paper which has 0.5 increments, is CE marked and manufactured to test human gastric aspirate.

The pH reading must be between 1 and 5.5 to confirm placement.

A second competent person must check any reading that falls within the pH range of 5 to 6.

pH value will be recorded on the EPR nasogastric tube insertion structured note (and subsequently on the EPR bedside check structured note following initial placement confirmation).

Second line test method: X-ray X-ray is to be used only as a second line test when no aspirate could be obtained or pH indicator paper has failed to confirm the location of the nasogastric tube, and all the recommended steps to gain an aspirate as documented on the NPSA decision tree (appendix 1) have been followed.

In Critical Care patients who have a reduced level of consciousness, X-ray is the first line test to confirm initial placement of the NG tube.

The request for x-ray must clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube for the purpose of feeding.




The pH value obtained or the inability to obtain an aspirate must also be documented on the x-ray request.

X-rays must only be interpreted and nasogastric tube position confirmed (see

appendix 2, NPSA nasogastric tube x-ray interpretation aid) by someone assessed as competent to do so (completion and achievement of competency of the e-learning module at https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71 ). Please note: Ensure that the remainder of the chest X-Ray is reviewed for any abnormalities. In case of other abnormalities consider whether a radiology hot report may be required.

Healthcare professionals are reminded that PACS windows can be manipulated to improve contrast and visualisation. If there is any difficulty in interpretation the advice of a radiologist should be sought.

Any nasogastric tubes identified to be in the lung should immediately be removed/ repositioned whether in the x-ray department or clinical area. If a member of staff from the clinical area is able to attend radiology to reposition the tube, the position must be checked using pH indicator paper, and repeat x-ray taken only if unable to confirm the tube position by obtaining an aspirate.

The medical practitioner checking the x-ray to confirm the position of the tube must complete the EPR nasogastric tube x-ray confirmation structured note.

The Radiology department is available for advice and has an out of hours SpR on call who can be contacted for advice as required.

https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71




Please note: Whoosh tests, acid/alkaline test using litmus paper, the absence of respiratory distress or interpretation of the appearance of aspirate are never to be used to confirm nasogastric tube position as these are not reliable.

5.3.8 Nasogastric tubes will not be flushed or any liquid / feed introduced through the tube

following initial placement, until the tube tip is confirmed by pH testing or x-ray to be in the stomach.

5.3.9 In the following circumstances, patients will NOT be fed unless a pH of between 1 and

5.5 has been obtained and documented OR correct tube placement has been confirmed by a competent person through x-ray and documented:

Following initial insertion.

Following episodes of vomiting, retching or coughing spasms (note that the absence of coughing does not rule out misplacement or migration).

When there is suggestion of tube displacement (for example, loose tape or portion of visible tube appears longer).

In the presence of any new or unexplained respiratory symptoms or reduction in oxygen saturation.

Please note: Feed must be discontinued and the giving set detached from the nasogastric tube if there is concern that the tube position has moved – it should only be re-connected and feed recommenced once correct placement of the tube has been confirmed.

5.3.10 Following initial placement, repeat placement checks of pH (as instructed in section

5.3.7 of this policy) will be made as follows:

Before administering each feed.

Before giving medication - BAPEN guidance www.bapen.org.uk/res_drugs.html

At least once daily.

Where feed/medication has already passed through the tube, a minimum of an hour delay without any further feeding will be instigated prior to testing of gastric aspirate using pH paper wherever an aspirate can be obtained.

5.3.11 The EPR NG bedside check structured note including the risk assessment section needs

to be completed and followed before administration of any feed, fluid or medication through the NG tube. If a patient is received on shift with feed in progress and medications or flushes are required to be given, then a risk assessment should be completed to confirm the tube position has not moved prior to administration. If there is any indication that the length has changed, appropriate action should be taken to assess tube tip position prior to using the nasogastric tube.

http://www.bapen.org.uk/res_drugs.html




5.312 In some situations, such as when patients are fed continuously, when they are treated

with acid-reducing medication, and when medications are frequently given down nasogastric tubes, it may not be possible to obtain an aspirate with a pH between 1 and 5.5, and daily x-rays are not practical or safe.

In circumstances where the initial placement was appropriately confirmed and documented, and there is no reason to suspect displacement since (i.e. no vomiting, retching or coughing spasms and no unexplained respiratory symptoms) if a pH between 1 and 5.5 cannot be obtained (this must be attempted) the only practical method of determining if the tube remains correctly placed prior to each administration of medications or feed may be through external observation of the tube.

In this instance the risk assessment section on the bedside check structured note on EPR must be completed and followed.

The risk assessment includes:

Confirmation that the length of the external tube remains identical to that recorded initially in the patient’s notes on insertion.

The fixation tapes or plasters have not moved or worked loose.

The patient has experienced no vomiting, retching or coughing spasms and has no unexplained respiratory symptoms.

There is no coiling of the tube observed in the patients’ mouth.

If a patient feeds continually over 24 hours in the critical care unit, the risk assessment on the bedside check flowsheet is to be completed on each shift as pH is unable to be checked. If there is any indication that the length has changed, appropriate action should be taken to assess tube tip position prior to using the nasogastric tube.




Please note: If there is evidence that the tube has become displaced for whatever reason, then only checking the position at the nose would be inappropriate as it could be coiled in the back of the mouth; in this circumstance second line testing through x-ray, or removal /repositioning of the tube if seen to be coiled in the mouth would be appropriate.

5.3.13 All patients receiving nasogastric feeding will have a feeding regimen at the bedside encompassing the following areas:

Name

Ward

Hospital number / NHS number

Date

Enteral feed, sterile water or saline to be administered via the feeding tube

Volume to be administered

Rate of infusion

Flushes of sterile water to be administered

Signed, dated and contact / bleep number for the dietitian

The feeding regimen documented by the dietitian will take into account the risk of refeeding syndrome (see SRFT Refeeding Policy).

5.3.14 All patients with a nasogastric feeding tube must have an active EPR NG care plan.

A new care plan must be activated as each enteral feeding bottle is commenced with the batch number and expiry date of the enteral feed recorded on the care plan (patients requiring multiple bottles of feed per 24hours will therefore require more than one care plan per day activating).

Patient tolerance of NG feed will be monitored Any interruptions to the feeding regimen will be documented and the reason why

recorded in the EPR nursing evaluation.




Documentation in the nursing care plan reflects the need to position the patient at more than 30 degrees if fed in bed.

5.3.15 Only 50ml ENFIT syringes clearly labelled “Oral/Enteral”, which cannot be connected to

intravenous catheters or ports will be used to administer sterile water, feed or medications. Three way taps or syringe tip adaptors will not be used to administer sterile water, feed or medications via a nasogastric tube.

5.3.16 A full multidisciplinary supported risk assessment will be made and documented before a

patient with a nasogastric tube is discharged from acute care to the community (see appendix 6).

Community patients having NG tubes cared for by health care professionals will have an active paper NG tube care plan (see appendix 10)

For patients discharged with NG tubes district nurses will not replace/re-pass the NG tube in the community, therefore there should be an agreed and documented discharge plan for management of tube replacement. There is a designated Abbott helpline for Salford community patients 09:00-17:00 Mon – Friday telephone: 07825 297353 or an out of hours helpline 0800 0183799. The community dietetic team based at Sandringham House will be aware of all home enteral tube fed patients in Salford and can give first line advise on unblocking feeding tubes (telephone: 0161 206 2447).

For community patients from the Salford locality with a misplaced NG tube during the Covid pandemic see the pathway. ( appendix 11)

5.3.17 On removal of the NG tube the EPR NG tube structured note for that tube must be

updated to include the details of the tube removal. 5.3.18 Consideration for the use of a nasal bridle to secure the NG tube should the patient

experience accidental pullout, displacement or dislodgement of the tube on 3 subsequent occasions should be made. Referral to the Nutrition Nurse for assessment is recommended if the medical team would like to consider a bridle. Please note: nasal bridles are contraindicated on patients with nasal airway obstructions and abnormalities, facial and/ or anterior cranial fractures, basal skull fractures, or patients that may pull on the bridle to such a degree as to cause serious injury, especially those with cognitive impairment.

5.3.19 If the nasogastric tube has been pulled out by the patient on at least three occasions in

short succession then on going management should be discussed with the multi-disciplinary team. This should include consideration of 1-1 nursing, the use of posy mitts, nasal bridle (if a bridle is not contraindicated as documented in section 5.3.18) and alternative feeding regimens.

Documentation of number of re-insertions must be made in the patient clinical records.




5.4 Training and Competency

5.4.1 Healthcare professionals must ensure that if involved with nasogastric tube insertion and position checks they have been assessed as competent through theoretical and practical training.

Preceptorship nurses are not to insert NG tubes until they have completed the training at their 6 month consolidation. They will receive NG management training at the start of the preceptorship program which will allow them to use NG tubes safely.

5.4.2 All indicated staff (medical and nursing) must complete the mandatory SRFT NG

competency package; this requires watching the nasogastric tube training video on the

trust e-learning portal, attendance at an NG competency workshop which will include a

practical demonstration followed by a practical assessment, and for nursing staff

completion of an e-learning NG placement and management resource book with e-

learning multiple choice questions.

NG competency workshops will be facilitated by Learning and development, and can be booked by Trust staff via the e-learning portal.

The competency log (Appendix 3) must be signed as completed by the designated assessor / facilitator, and attendance of the workshop will be documented on the Trust learning and development recording system.

It is the individual practitioners’ responsibility to ensure that they are trained and assessed as competent, and this will be monitored by the ward/ unit/ area manager, practice development teams and ward based nutrition link nurses. All staff should they have reduced exposure to NG tube insertion and management, or require a refresher to reassess competencies they should book onto one of the available NG tube workshops or contact the Nutrition nurses for a ward-based update session as required (see appendix 3 for training update competency sheet).

All Health care professionals confirming the position of a nasogastric tube for feeding by x-ray must complete and achieve competency in the training resource and assessment on x-ray interpretation of nasogastric tube position available on the Trust e-learning portal x-ray interpretation section, or https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71

5.4.3 The medical staff employed by the Trust must upload a completed self-certificate for the module onto the Trust learning and development recording system (Accessed via the e-learning portal x-ray interpretation) competency log (Appendix 3) must be signed as completed by the designated assessor / facilitator.

6. Roles and responsibilities

6.1 The nutrition and hydration steering group is responsible for:

Updating the policy.

Auditing the policy standards.

https://www.salfordlearning.nhs.uk/salford/course/view.php?id=71




Educating staff with respect to this policy via nutrition study days and additional training at ward level if requested.

6.2 Dissemination of the updated policy to all Trust staff will be via the ADNS, Lead Nurses,

Matrons and Medical Directors. 6.3 Practice educators, the nutrition nurse specialist and ward based nutrition link nurses will

ensure staff competence in the placement and management of nasogastric tubes. The Trust is committed to ensuring that the practitioner is supported in this learning process, through teaching and assessment. 6.4 It is the responsibility of all staff and carers involved in the insertion and post insertion

care of nasogastric tubes to ensure that they are competent to do so and maintain their competence and skills. Practitioners may identify training needs with regard to the insertion and post-insertion care of nasogastric tubes through the appraisal process.

7. Monitoring document effectiveness

7.1 The Nutrition Dashboard Nasogastric tube section should be accessed by ward managers, matrons and divisional leads to review their clinical area.

7.2 Divisions will be responsible for auditing compliance with this policy and reporting to the

clinical effectiveness committee in order to comply with NHS improvement recommendations. Along with providing assurance that all staff have completed the NG tube training requirements within their division, the following documentation audit must be completed annually.




.

8. Abbreviations and definitions

Explained within the document

9. References and Supporting Documents

9.1 References

1. NPSA Alert/2007/19 Promoting safer measurement and administration of liquid and medicines via oral and enteral routes

2. Medical Device Agency (2004) Enteral Feeding Tubes (Nasogastric) MDEA (NI) 2004/29 Department of Health, London

3. National Patient Safety Agency (2005) and (2011) Reducing the harm caused by misplaced nasogastric tubes. Department of Health, London.

4. The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 5th edition (intranet version) Nutritional Support Section 27. Editors – Mallett J, Doherty L. Blackwell Science.

5. Guidelines for the use of parenteral and enteral nutrition in adult and paediatric patients. ASPEN Board of Directors. JPEN 1993;17(4):1SA-50SA.

6. Guidelines for the use of enteral nutrition in adult patients. ASPEN Board of Directors. JPEN 1987;11(5):435-439.




7. NICE (2006) Nutrition Support in Adults: oral supplements, enteral tube feeding and parenteral feeding. Guideline 32 Department of Health, London

8. NPSA/2012/RRR001 Alert, Harm from flushing of nasogastric tubes before confirmation of placement. Department of Health, London. 9. NHS Improvement patient safety alert 2016 – Nasogastric tube misplacement: continuing risk of death and severe harm. NHS/PSA/RE/2016/006 10. COVID-19: Guidance for the remobilisation of services within health and care settings, Infection prevention and control recommendations, accessed 19.11.20 https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf

9.2 Related SRFT/PAT documents

SRFT Medicines policy SRFT Enteral Feeding and Medication policy SRFT Refeeding policy SRFT Consent to treatment policy

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/910885/COVID-19_Infection_prevention_and_control_guidance_FINAL_PDF_20082020.pdf






10. Document Control Information

Part 1

Must be fully completed by the Author prior to submission for approval

Name of lead author: Brenda Blackett

Job Title: Nutrition Nurse Specialist

Contact number: 0161 206 1437

Email address: [email protected]

Consultation: List persons/groups included in consultation. N.B Include Pharmacy/PADAT/D&T/MMG for

documents containing drugs.

Indicate whether feedback used (FU), not used (FNU) or not-received (NR)

Name of person or group Role / Department / Service / Committee

/ Corporate Service

Date Response:

FU / FNU / NR

Nutrition and Hydration

Steering Group

Committee SRFT – task and finish group

with Mr Dominic Slade and Dr Adnan Gebril

co-opted in for their expertise

Nov 2020 FU

Medicines Management Committee SRFT Oct 2020 FU

Simon Featherstone Clinical Advisory Group (CAG) 30/11/2020 FU

EqIA sign off: See Appendix 11

Name: (Insert named lead from EDI Team) Date:

J McMahon 23/11/2020

Communication plan:

Via Nutrition Steering group, ADNS, Ward managers, update training.

Part 2

Must be fully completed by the Author following committee approval.

Failure to complete fully will potentially delay publication of the document.

Submit to Document Control/Policy Support for publication.

Approval date: Method of document approval:

30/11/2020 Formal Committee decision

Yes

Chairperson’s approval

Yes

Name of Approving

Committee

Clinical Advisory Group (CAG)

Chairperson Name/Role Simon Featherstone SCO Director of Nursing

Amendments approval: Name of approver, version number and date. Do not amend above details.

Amendments approved 23.10.20

Part 3

Must be fully completed by the Author prior to publication

Keywords & phrases: Nasogastric Feeding’ ‘pH paper’ ‘refeeding syndrome’ ‘tube feed’

Document review

arrangements

Review will occur by the author, or a nominated person, within five years or earlier

should a change in legislation, best practice or other change in circumstance

dictate.




11. Equality Impact Assessment (EqIA) tool

The below tool must be completed at the start of any new or existing policy, procedure, or guideline development or review. N.B. For ease, all documents will be referred to as ‘Policy*’. The EqIA should be used to inform the design of the new policy and reviewed right up until the policy is approved and not completed simply as an audit of the final Policy itself.

All sections of the tool will expand as required.

EqIAs must be sent for review prior to the policy* being sent to committee for approval. Any changes made at committee after an EqIA has been sign off must result in the EqIA being updated to reflect these changes. Policies will not be published without a completed and quality reviewed EqIA.

Help and guidance available:

Click here for the Policy*EqIA Tips for Completion QRG

Email the Group EDI Team: [email protected] for advice or training information.

Submission of policy* documents requiring EqIA sign off to: [email protected]. Allowing an initial four week turnaround.

Where there is a statutory or significant risk, requests to expedite the review process can be made by exception to the Group Equality & Inclusion Programme Manager [email protected]

1. Possible Negative Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age None ers.

Disability The Policy covers adults with cognitive Impairment. Patients would have their mental capacity assessed See section in document 5.1.5 re consent and informed consent

Mental Capacity Assessments documented on EPR. Decisions around NG insertion made with the managing consultant and based on the best interest of each individual patient with the involvement of family and carer

Ethnicity Access to interpreter services, written information available in different languages. Dietary Requirements

Clinical staff aware of how to book interpreters Tube feeds are Halal / Kosher/ vegan if required dietitians aware of appropriate feeds and the ward housekeeper will order the feeds.

Gender none

http://nm-ashanti.pat.nhs.uk:86/DMS/Default.aspx?tabid=8541&pnode=8&seltype=0

mailto:[email protected]






Marriage/Civil Partnership none

Pregnancy/Maternity none

Religion & Belief none

Sexual Orientation none

Trans none

Other Under Served Communities (Including Carers, Low Income, Veterans)

none Carers involved in all communication

3. Combined Action Plan

Action (List all actions & mitigation below)

Due Date Lead

(Name & Job Role)

From Negative or Positive Impact?

To share the communications booklet and discuss this at the next NHSG meeting

27.11.20 Brenda Blackett Negative

Mental Capacity Assessments documented on EPR

Positive

Clinical staff aware of how to book interpreters

Positive

Appropriate feeds and the ward housekeeper will order the feeds.

Positive

Wide dissemination of the hospital communications booklet

Negative

2. Possible Opportunity for Positive Impacts

Protected Characteristic Possible Impact Action/Mitigation

Age none

Disability yes Wide dissemination of the hospital communications booklet. Will ensure this is part of training delivered

Ethnicity none

Gender none

Marriage/Civil Partnership none

Pregnancy/Maternity none

Religion & Belief none

Sexual Orientation none

Trans none


none

4. Information Consulted and Evidence Base (Including any consultation)

Protected Characteristic Name of Source

Summary of Areas Covered

Web link/contact info




5. EqIA Update Log (Detail any changes made to EqIA as policy has developed and any additional impacts included)

Date of Update Author of Update Change Made

Discussion regarding use of hospital communication booklet to remind staff to use

it if appropriate.

Kirstine Farrer

Age n/a

Disability n/a

Ethnicity n/a

Gender n/a

Marriage/Civil Partnership n/a

Pregnancy/Maternity n/a

Religion & Belief n/a

Sexual Orientation n/a

Trans n/a


n/a

6. Have all of the negative impacts you have considered been fully mitigated or resolved? (If the answer is no please explain how these don’t constitute a breach of the Equality Act 2010 or the Human Rights Act 1998) n/a – clinical updates to this policy in light of Covid 19

Impact has been mitigated as described above in sections 1 & 2

7. Please explain how you have considered the duties under the accessible information standard if your document relates to patients?

We have considered this within the Trust consent policy which should be used in conjunction with this policy.

When clinicians are discussing the possibility of commencing naso gastric feeding the team would consider: If they have any information or communication needs, and find out how to meet their needs; Record those needs clearly and on EPR, in the dietetic record there is a section on consent; Highlight or ‘flag’ the person’s file or notes so it is clear that they have information or communication needs and how those needs should be met; Share information about people’s information and communication needs with other providers of NHS and adult social care, when they have consent or permission to do so e.g. we would consider GDPR when commencing home enteral tube feeding; Take steps to ensure that people receive information which they can access and understand, and receive communication support if they need it. The policy will be available to staff in different formats, including large print, enlarged on computer screen and/or on different colour paper. This would also include all Appendices

8. Equality Impact Assessment completed and signed off? (Insert named lead from EDI Team below). Please also add this information within Section 11.

Name: Date: 23/11/2020 Reviewed by Kirstine Farrer Consultant Dietitian and co-chair of NHSG 23/11/20




12. Appendices

Appendix 1




Appendix 2




Appendix 3










Appendix 4

Starter NG feeding regimen *Regimen not nutritionally complete, refer to Dietitian as soon as possible* Position of tube must be checked using pH indicator paper- the pH must be less than or equal to 5.5 before giving feed or medication. Refer to NG policy. NICE define patients to be at risk of refeeding syndrome please note 10kcals/kg/day or in extremely high risk cases 5kcals/kg/day (e.g. 40kg patient at extremely high risk should only have 200kcals on day 1 Patient: Ward: Hospital Number: FEED: 500ml Osmolite 1.0 by Day 4 500Kcal 20g Protein 68g Carbohydrate 17g Fat 19mmol Na+ 19mmol K+ Day 1 Check electrolytes using TPN profile; correct if required, monitor daily until electrolytes are normal. Give Thiamine 50mg 4 times daily and Vit B Co Strong 2 tabs 3 times daily; continue for 10 days. 200ml Osmolite @ 10ml/hr x 20 hours, 4 hours rest Day 2 300ml Osmolite @ 15ml/hr x 20 hours, 4 hours rest *Check and correct electrolytes if required Day 3 400ml Osmolite @ 20ml/hr x 20 hours, 4 hours rest *Check and correct electrolytes if required Day 4 500ml Osmolite @ 25ml/hr x 20hrs, 4 hours rest *Check and correct electrolytes if required Use a new giving set every 24 hours, Flush with 30ml sterile water before and after feed/ medication using a purple 50ml female luer lock syringe.




Starter NG feeding regimen for patients with a cow’s milk protein allergy. Feed is stored on the Stroke Unit and H8 ward (intestinal failure unit) as this is not a standard feed in the Trust. *Regimen not nutritionally complete, refer to Dietitian as soon as possible* Position of tube must be checked using pH indicator paper- the pH must be less than or equal to 5.5 before giving feed or medication. NICE define patients to be at risk of refeeding syndrome please note 10kcals/kg/day or in extremely high risk cases 5kcals/kg/day (e.g. 40kg patient at extremely high risk would only need 200kcals on day 1) Patient: Ward: NHS number: Hospital number: FEED: 500ml Nutrison Soya Feed by day 4 500Kcal 20g Protein 61g Carbohydrate 19g Fat 22mmol Na+ 19mmol K+ Day 1 Give Thiamine 50mg 4 times daily and Vit B Co Strong 2 tabs 3 times daily; continue for 10 days. Check electrolytes using TPN profile; correct if required, monitor daily until electrolytes are normal. 200ml Nutrison Soya @ 10ml/hr x 20 hours, 4 hours rest Day 2 300ml Nutrison Soya @ 15ml/hr x 20 hours, 4 hours rest *Check and correct electrolytes if required Day 3 400ml Nutrison Soya @ 20ml/hr x 20 hours, 4 hours rest *Check and correct electrolytes if required Day 4 500ml Nutrison Soya @ 25ml/hr x 20 hours, 4 hours rest *Check and correct electrolytes if required

Use a new giving set every 24 hours, Flush with 30ml sterile water before and after feed/ medication

using a purple 50ml enteral syringe




Appendix 5

PROCEDURE FOR BOLUS FEEDING Bolus feeding is indicated for agitated, confused patients or patients who do not wish to be attached to an enteral feeding pump most of the day. Please note bolus feeding can be very time consuming if the patient has an 8Fr or 10Fr NG tube in situ. Catheter tip oral / enteral labelled syringes are available from the dietetic department. This procedure should only be attempted following consultation with the ward Dietitian and nutrition nurses. How to bolus feed: 1. Wash your hands. 2. Confirm position of NG tube as per policy guidelines. 3. Check you have one sterile oral / enteral labelled 50ml catheter tip syringe, one sterile oral / enteral labelled 50ml female luer lock syringe the correct feed and sterile water available. 4. If possible sit the patient in the upright position. 5. Flush the nasogastric with 30mls of sterile water, using a 50ml oral /enteral labelled female luer lock syringe 6. Remove the plunger from the 50 ml catheter tip oral / enteral labelled syringe; connect the tip of the syringe to the feeding tube. 7. Slowly pour the required amount of feed into to the catheter tip oral / enteral labelled syringe. This is usually between 200-250mls per bolus. The volume will be decided by a dietitian. 8. Allow the feed to run in slowly, a bolus feed should take 15-20 minutes to complete and should never be flushed down the feeding tube rapidly. 9. When the feed is finished flush the tube with 30mls of sterile water using a 50ml female luer lock oral / enteral syringe and replace the cap on the nasogastric tube.




Appendix 6







Appendix 7













Appendix 8

PROCEDURE FOR MONITORING PATIENTS ON NASOGASTRIC FEEDING

Monitor

Regularity

Comments

Notes

Biochemistry Daily until stable then Weekly. See SRFT refeeding syndrome policy

For all abnormalities, liaise with the clinician and biochemist for possible causes and management. In normal and stable circumstances, patients being fed enterally need no more biochemical monitoring than that required by their medical conditions.

When requesting a full nutritional screen for patients select ‘TPN profile’. This includes U+E’s, Ca, Mg, Phosphate, LFTs, lipids, CRP and blood glucose

Fluid Balance Charts (on intentional rounding charts)

Daily Monitor fluid input and output over 24 hours, use to prevent over or under hydration Observe feed delivered versus feed prescribed to prevent over or underfeeding

Large stoma fistula losses-may affect nitrogen and electrolyte requirements Blood/blood products may affect biochemistry Vomiting may affect electrolytes

Food Intake Charts(on intentional rounding charts)

Daily Allow estimation of protein and energy intakes from diet Permit the transition from parenteral/ enteral nutrition to oral diet without energy deficits or overfeeding

Please use Trust Food Record Chart (on intentional rounding charts), discuss with ward dietitian, if unsure of which chart to use.

Clinical Observation Charts

Daily Persistent pyrexia will increase nitrogen and energy requirements, reduce to baseline when apyrexial.

Stool Charts Daily Monitor bowel frequency and consistency

Clinical Condition

Daily Observe for changes which may affect requirement, e.g. sepsis, surgery, fistula development

Drug Treatment / Drug Nutrient Interactions

Daily Gastrointestinal side effects: Diarrhoea (antibiotic therapy, laxatives, sorbitol based drugs, hyperosmolar drugs); Constipation (opiates) Nausea (antibiotic therapy,

Inform haematology if the patient is on enteral tube feeding.




chemotherapy. Consider absorption sites when feeding into small bowel Enteral feeds may alter the absorption and metabolism of certain drugs e.g. Phenytoin, Theophylline, Warfarin, Digoxin, Carbamazepine Monitor therapeutic drug levels. Always liaise with the clinician and/or pharmacist re drug treatments

Anthropometry Weekly Frequent measures of body weight may be useful to indicate state of hydration. Cardiac, renal and hepatic failure or malignancies are often associated with ascites of fluid retention. Drug treatments e.g. diuretics, cause fluid loss, others e.g. corticosteroids fluid gain. Use in association with fluid balance charts to interpret.

Clothing/dressings Diurnal variations Same scales / Scale Maintenance




Appendix 9

Problem Solving Enteral Nutrition

Complication

Cause

Management

Nausea and Distention

Too large boluses / too rapid infusion, medical reason

Review feed type and reduce rate. Aspirate tube regularly - consider anti-emetics or prokinetics or post pyloric feeding

Regurgitation Delayed gastric emptying, tube misplacement

Confirm tube position. Elevate head of bed 30 - 45°. Consider prokinetics or post-pyloric feeding.

Diarrhoea Drugs e.g. antibiotics, too rapid infusion, malnutrition

Check: Infective cause - send stool sample for cultures Antibiotic therapy Other drug therapies e.g. hyperosmolar solutions, laxatives, sorbitol based medications Rate and osmolality of feed being infused Consider: Treat infection if present Anti-diarrhoeal medication if no infection Fibre feed Drug modifications Iso-osmolar feeds Establish a definition e.g. include frequency and consistency (profuse water, semi-formed, over-flow)

Constipation Drug Therapy Inadequate fluid Changes in gut motility

Check: Drugs e.g. opiates - change if appropriate Dehydration - provide additional fluid Motility: increased risk with decreased activity Consider: Enemas / laxatives Fibre feed Constipation may lead to abdominal distention, vomiting and nausea

Tube malposition

Accidental misplacement Policy for insertion, confirm position of tube prior to starting feed

Tube displacement

Accidental e.g. vomiting, not adequately secured

Monitor the position, fasten securely

Tube occlusion Viscous feed, drugs e.g. tablets not crushed, inadequate flushing

Flush regularly - unblock using a 50ml enteral syringe to flush the feeding tube with 30-50mls of sterile warm water, then soda water. DO NOT FORCE THE WATER. If still blocked pancreatic enzymes e.g. Creon may be




effective in unblocking tubes

Metabolic Refeeding or concurrent Illness / disease

Daily monitoring first week, especially in the severely malnourished or where concurrent disease. Alter feed and give IV / enteral supplements as indicated

Infection Contamination of the feed / system

Use sterile feeds and a closed system, Change giving sets every 24 hr. Feeds not hanging for > 24hr. Protocols for setting up feeds.

PROBLEM SOLVING - PUMP PROBLEMS Should the enteral feeding pump alarm check in a stepwise manner, from the top (i.e. the bag of feed), down the giving set and pump until you finally check the patient. Use the pump manufacturers’ manual for guidance. If following the pump checks tube blockage is suspected, use the following procedure to attempt to clear the blockage: Use a 50ml enteral syringe to flush the feeding tube with 30-50mls of sterile warm water, then soda water. DO NOT FORCE THE WATER. If still blocked pancreatic enzymes e.g. Creon may be effective in unblocking tubes. Please Note:

Do not use fruit juices, fizzy or carbonated drinks as this will exacerbate the blockage as the acid in the drinks can react with feed / medication and cause damage to the tube.

Do not use any implements that can be forced down the tube.

Do not use smaller volume syringes (unless trained) as this practice can lead to ruptured tubes due the excess pressure.




Appendix 10










Appendix 11

NG tube replacement pathway during COVID pandemic

Aim

To treat Salford residents with a misplaced NG feeding tube who are referred from primary care.

Patients who are out of Salford area should be directed to their local ED.

Aim of the pathway is to provide guidance around replacement of a displaced Naso-Gastric

(NG) tubes by minimising Emergency Department (ED) attendances as well as avoiding

hospital admissions during Covid 19. It’s worth advising GP when referring patients to contact

either the community dietetic team or the Abbott community nutrition nurse during working

hours as a first point of contact and Abbott helpline out of hours before sending patients to the

hospital, see section 5.3.16 for contact telephone numbers.

All patients with misplaced NG tube fed patients should be admitted to ED then EAU if

intervention in primary care has failed to unblock the feeding tube. Patients should be admitted

to hospital if the above is unsuccessful and NG tube is needed for fluid intake and medication.

Patients who are dependent on the tube for fluid intake and medication should be urgently

reviewed on the same day. This should be resolved as inpatient.

Patients who are directly referred by District/community nutritional nurses to hospital should be

discussed with medical on-call team (RMO on bleep 3693).

• Time of referral (working hours versus out of hours).

• Urgency of tube replacement.

• AGP (aerosol generating procedure) requiring full PPE equipment (NGT insertion is

classified as AGP during COVID pandemic).

On arrival to ED:

Patients who are suspected or confirmed COVID will be isolated until RMO is informed on bleep

3693.

Patients will have second screening for COVID by ward clerks to rule out any risks to other

patients and staff.

Patients including those with displaced NG tube should be moved to EAU as soon as possible

after discussion with EAU coordinator.

Step 1: Mon-Fri 7.30am-3pm, nutritional nurses should be contacted first on bleep 3413. If they

are unable to provide assistance (including any time 3pm-7.30am and weekends/bank holidays)

then move to next step.




Step 2: Inform RMO on bleep 3693 who will ask competent nursing/ medical junior staff to

attempt NG tube replacement. If unsuccessful then move to next step

Step 3: Ask acute medicine/Gastro consultant 9am-9pm (any other time please ask medical

SPR on-call) who will make further attempt. Meanwhile to discuss with Gastroenterologist about

further plan.

*NGT insertion is classified as AGP for medium and high risk patients based on the latest national/NCA ICP NCA policy link using the following:

1. Full PPE (Full sleeve gown, Respirator/FFP3 mask or hood, single use gloves and

eye/face protection using goggles or face screen.

2. Side room while NGT insertion is taking place. Patients who are COVID positive

should be nursed in a side room or a bay with other COVID positive patients if felt

appropriate as per Trust guidance.

*in low risk patients NG tubes can be inserted in the open bay using blue mask, gloves, apron and visor. Low risk - no symptoms and a negative COVID -19 SARS PCR test performed 72 hours prior to NG tube insertion Please follow the flow chart

http://intranet.srht.nhs.uk/search/?q=admission+screening+and+inpatient+pathways+during+COVID-19