ENTERNAL FEEDING & MANAGEMENT POLICY AND PROCEDURE

The purpose of this policy is to demonstrate that Sensible Health Pty Ltd understands that some of our participants may require additional support with their activities of daily living including enteral feeding and nutrition management. Sensible Health Pty Ltd will ensure that any support provided to a participant of this nature is done in partnership with that participant to ensure their needs and preferences are given priority.

DEFINITIONS

Term	Definition
Enteral feeding	is a method of supplying nutrients directly into the gastrointestinal tract Enteral feeding describes Orogastric, Nasogastric and Gastrostomy tube feeding. The reasons for this to occur can be due to a participant: Who is unable to consume adequate nutrients.Has impaired swallowing.Facial or oesophageal structural abnormalities.Eating disorders.Congenital anomalies.
Enteral feeding tubes can be used to	Administer bolus, intermittent feeds and continuous feeds.Medication administration.Drainage and aspiration of the stomach contents.Feeds can be administered with a syringe, via gravity or a pump.
Orogastric Tube	a thin, soft tube passed through the participant’s mouth to the oesophagus and into the stomach.
Nasogastric Tube	is thin, soft tube passed through the participant’s nose, down the back of the throat, through the oesophagus and into the stomach.
Gastrostomy Tube	a feeding tube which is inserted through the abdominal wall and directly into the stomach
Percutaneous Endoscopic Gastrostomy tube	a gastrostomy tube which is held in place with an internal fixator.
Gastrostomy-Button	a skin level button gastrostomy tube inserted into a pre-formed stoma.

Background

Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into a participant’s stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate (for example, because of dysphagia or sedation).

PEGs can become encrusted with feed or medications and colonised with bacteria or yeasts if not flushed regularly. This can result in damage to the tube, and the need for premature replacement. Even when the PEG is not currently being used for feeds it should be flushed with water at least once per day.

Taking care of the PEG site is important to reduce the risk of skin breakdown and infection – the site is really a type of wound, and as such it is normal for the skin to be slightly red around the edge of the hole. Other than this slight redness, within a few days after insertion a healthy PEG site should look like normal skin, without excessive irritation, pus or blood.

The PEG site should be washed daily as part of normal hygiene using warm soapy water, and then rinsed and dried thoroughly. The external flange will need to be lifted to clean around the tube. The PEG site should not be covered with a dressing or ointments, as this can cause dampness, skin damage and infection.

Enteral feeding can be given in 3 different ways:

1. via a pump – used for continuous or intermittent feeds where the formula is given without stopping over 8-24 hours.
2. via gravity drip – used to give larger amounts of formula over a shorter period of time usually 4 to 6 times each day.
3. via a syringe – this is the fastest method where larger amounts of formula are given at a time. Feeding using a syringe or gravity drip can also be called bolus feeding.

PRINCIPLES OF ENTERAL FEEDING AND MANAGEMENT

• To follow personal hygiene and infection control procedures.
• To confirm the need and consent for enteral feeding,
• To introduce food via a tube according to the support plan.
• To monitor the rate and flow of feeding and take appropriate action to adjust if required.
• To keep the stoma area clean and monitor and report signs of infection.
• To check that the tube is correctly positioned, and monitoring equipment is in operation.
• To follow procedures to respond to malfunction
• To document a request to review mealtime plan where required.
• To liaise with health practitioners to explain/demonstrate requirements
• To recognise and respond to symptoms that could require health intervention

Policy

All enteral feeding and nutrition management support will be delivered by appropriately trained staff and in line with a Complex Care Plan that is developed with the relevant health practitioner and the participant and/or family.

This policy has been developed to ensure that all participants at Sensible Health Pty Ltd requiring enteral feeding and nutrition management receive the best quality support relevant to their individual needs.

This policy will also guide the actions of our staff by providing a framework for competency and action to promote the delivery of best practice supports in this area.

Procedures

• Our service delivery model is based on person centred approaches. As such all participants and or their family/carer are involved in the assessment and development of the plan for enteral feeding and nutrition management.
• If a participant requires enteral feeding and nutrition management a Complex Care Plan will be developed in partnership with a nominated health practitioner specifically for the participants needs.
• This care plan will be developed in partnership with the participant, their family/carer and any relevant health professional (with the consent of the participant/family). The plans include nature and frequency of the procedure, who will deliver it, timeframes for review by a health professional, any potential or actual risks involved and how incidents and emergencies are managed and actions/procedures to refer any situation that requires further expertise to the appropriate agency or health professional.
• Wherever possible it is the preference of Sensible Health Pty Ltd to have any form of complex care delivered by qualified nursing staff. Where this is not possible, or not the preference of the participant/family, we will ensure that the preferred support worker(s) is provided with the appropriate training from a qualified and experienced health professional. This training will encompass the specific needs of each participant’s, the type of enteral feeding and nutrition management required and will comply with the NDIS High Intensity Support Skills Descriptor for providing enteral feeding and nutrition management.
• All staff required to deliver enteral feeding and nutrition management will have a training plan devised to ensure they can competently deliver the type and nature of enteral feeding and nutrition required including an ability to:
• confirm need and consent for enteral feeding,
• introduce food via tube according to plan.
• monitor rate and flow of feeding and take appropriate action to adjust if required, keep stoma area clean and monitor and report signs of infection.
• check that the tube is correctly positioned, monitor equipment operation.
• follow procedures to respond to malfunction e.g., blockages, follow procedures to document a request to review mealtime plan where required.
• liaise with health practitioners to explain/demonstrate requirements (e.g., hospital staff),
• recognise and respond to symptoms that could require health intervention e.g., reflux, unexpected weight gain or loss, dehydration, allergic reaction, poor chest health.
• Understand basic anatomy of the digestive system.
• equipment components, function, cleaning and maintenance procedures.
• stoma care requirements and procedures, awareness of risks associated with departing from plan and ability to explain these risks to others including carers,
• the impact of associated health conditions and complications that interact with enteral feeding e.g., related cardiac or respiratory disorders, very complex physical disability, severe epilepsy, symptoms that indicate the need for intervention e.g., poor chest health, dehydration, reflux, factors that may require immediate adjustment e.g., rate, flow and quantity of food. When working with people who have very complex physical disability, workers will also be trained in positioning and turning to maintain airway safety and avoid choking risk and in pressure care.

All training and training plans will be delivered and devised by and in partnership with a qualified health practitioner.

All enteral feeding and nutrition management must be done in accordance with the Sensible Health Pty Ltd Waste Management and Infection control policy and procedures.

As part of the development of a Complex Care Plan contingencies and actions will be documented by the attendant health professional to manage any emergency or actions that require escalation. If staff are ever in doubt about the health and wellbeing of a participant, they must contact the attendant health professional and/or the Ambulance service immediately.

Processes for using enteral feeding tubes

Summary of processes for using enteral feeding tubes
Preparation	Perform hand hygiene before starting feed preparationWherever possible, use pre-packaged, ready-to-use feedsDecanting, reconstitution and diluting is NOT recommended.If decanting, reconstitution or dilution is required, use a clean working area and equipment dedicated for enteral feed use Mix feeds with cooled boiled water or freshly opened sterilised water using an aseptic non-touch technique
Administration	Perform hand hygiene immediately before administration Use minimal handling and aseptic non-touch technique to connect the administration system to the enteral feeding tube For nursing staff only: Use aseptic non-touch technique for the administration of medications Discard administration sets and feed containers appropriately and as per the care plan
Care of insertion site and enteral feeding tube	Perform hand hygiene immediately before commencing Wash the stoma daily with water and dry thoroughly Flush the enteral feeding tube with fresh tap water before and after feeding or administering medications (use cooled boiled water or sterilised water for people who are immunosuppressed)

1. Medication Administration via an Enteral tube

*Only nursing staff who are trained in the administration of medication may deliver medications via an enteral tube, including a PEG or nasogastric tube.

If the feeding tube dislodges:

*Community support professionals are not to remove or replace any type of enteral feeding tube.

Should a nasogastric or PEG tube fall out, contact your supervising registered nurse or immediate supervisor to advise of the situation. In younger participants, their parent will be familiar with replacing the tubing. In other circumstances, do not panic – a nasogastric tube can be replaced by the participant’s doctor. A PEG tube is also readily replaced – cover the stoma with a piece of gauze secured with Micropore tape (if available) and arrange for the participant to see their local doctor or the emergency room for replacement of their feeding tube

2. Formula Storage

Formula should be stored following the steps below:

• Store unopened tin/bottle/cartons of formula in a dry, cool place
• Keep unused, opened formula in the fridge
• Throw away any formula not used in 24 hours
• Do not heat the formula

3. Feeding position

Participant positioning during a feed is vital to the assistance of digestion throughout the procedure and reduces risks associated with enteral feeding. Always, where possible, assist the participant into a sitting position. They should never be lying flat whilst having a feed. If the participant is unable to sit in a chair with their head must be raised to at least a 30-degree angle or on three pillows to maintain elevation whilst they are having their feed. This position should be maintained for 30-60 minutes after their meal to further assist in the digestive process and reduce feeding risks.

4. Medication administration

Following the participant’s support plan and Sensible Health Pty Ltd Management of Medication Policy take the following steps to administer medication via an Enteral tube. Medications should be in a liquid form, if possible, if not, tablets should be crushed and mixed with water to make a soup-like mixture. Do not mix medicine with the feeding formula and do not mix medicines together. Each one should be given separately. Flush the feeding tube before and after each medication. Some medications should not be given while the feeds are running as they can react with the feed, this will be specified in the participant support plan.

5. Oral Care

Oral care is very important to participants who have enteral tubes for feeding. Some eating through their mouth and some are not, it is still important to maintain a healthy oral environment. The following points are suggestions for maintaining good oral hygiene.

• Brush their teeth at least twice daily with toothpaste and a soft brush.
• If tolerated, ice chips or sugarless gum can be used to prevent a dry mouth.
• Use a lip cream to prevent dry lips. And encourage participant to breathe through their nose.
• Report any bleeding or mouth problems to the Registered nurse.

6. An Enteral tube may become blocked for the following reasons:

• medications have not been crushed sufficiently before giving through the feeding tube.
• An insufficient flush that is <40mL of water before, between and after giving medications.

Constipation means bowel movements that are hard, or difficult to pass. Possible causes of constipation are, not enough fluid, not enough fibre in the formula, not enough exercise and some medications.

The Enteral tube is coming out. If this happens the Support worker must not reuse this tube. They must follow the procedures in the participant support plan and contact the Registered nurse and appropriate health practitioner or Registered Nurse. The support worker may need to organise the participant to go to the emergency department of the nearest hospital. (call 000 if unsure, do not move the participant in the case that there is no guideline in the support plan)

In all these cases everything should be documented and further communicated to the Registered nurse and appropriate health professionals who will be contacted to adjust the care and treatment of the participant and their support plan.

7. Roles and Responsibilities

Sensible Health Pty Ltd’s Registered nurse is responsible for the overall clinical management and medication management of a high intensity supported participant’s care. This policy is to be used in conjunction with Sensible Health Pty Ltd’s Medication Policy (where required). The participant’s support plan and mealtime preparation and delivery plan are also included and overseen by a relevant health practitioner (e.g., Dietician, Speech Therapist, Occupational Therapist). This support plan will be regularly reviewed where procedures and information will be given to the participant/carer/advocate. Sensible Health Pty Ltd’s participants are ensured their desired level of involvement is respected and maintained. Sensible Health Pty Ltd will ensure that each participant requiring enteral feeding and management will receive nutrition, fluids and medications, relevant and proportionate to the individual needs.

Please Note: The replacement of Nasogastric tubes is high risk and will be only done byRegistered nurse or a qualified health practitioner. In some cases, support workers Registered nurses may respond when PEG tubes become dislodged. This is only appropriate when the balloon device tube is in position and stable (after the initial tube has been replaced by balloon device), and there is active oversight by a health practitioner.

 Registered Nurses may:

• Replace a PEG tube
• Supervise and guide the community support professional in the provision of nutritional or enteral stoma care
• Only work within the scope of their practice and prior experience

Community Support Professionals may:

• Perform any task on the care plan apart from those that must be performed by a registered nurse as nominated above
  • Assist with the administration of enteral feeds and flushes once assessed as being competent in this skill
  • Clean stoma site
  • Observe and report if stoma site red, painful or swollen
  • Observe and report if tubing becomes dislodged

Community Support Professionals must:

• Follow the care plan as provided by Sensible Health Pty Ltd
• Report to their supervisor/coordinator any changes or variations for advice
• Not change any care or feeding plan
• Take part in training on use of equipment, manual handling and risk management as determined by Sensible Health Pty Ltd
• Report any issues arising from the delivery of care to their Sensible Health Pty Ltd coordinator for further advice
• Identify and report to their supervisor any gaps in their ability to deliver the required service.

8. Support plan

Sensible Health Pty Ltd’s participant support plan is developed with the involvement of the participant/carer/advocate, Registered nurse and health practitioners (e.g., dietician, speech therapist, occupational therapist). Included in the plan is the mealtime preparation and delivery of the Percutaneous Endoscopic Gastrostomy (PEG) feeding or Nasogastric (NG) feeding regime.

Frontline workers will confirm consent for the need for enteral feeding from the participant/carer/advocate. The participant’s health status will have regular reviews by Registered nurse or a qualified health practitioner (e.g., Dietician, Speech Therapist, Occupational Therapist). The support plan will identify how risks, incidents and emergencies will be managed, including required actions and escalation to ensure participant safety and wellbeing.

A participant‘s mealtime preparation and delivery plan are to be reviewed weekly monthly to ensure there are strategies in place for acting upon information from the participant/carer/advocate, support worker and health professional (e.g., Dietician, Speech Therapist, Occupational Therapist).

Frontline staff are to follow documentation procedures this includes:

• Recording the length of time allocated for mealtime assistance, this will provide an indication of the intensity of support required for Sensible Health Pty Ltd.
• Document and monitor the rate and flow of feeding.
• Record the daily input and output, monitoring for dehydration.
• Document and communicate to Registered nurse a participant/carer/advocate request for a change of mealtime.
• Record any changes requested by a health practitioner (e.g., Dietician, Speech Therapist, Occupational Therapist).
• Record and communicate to Registered nurse any signs or symptoms of unexpected weight gain or weight loss.

9. Staff training

Sensible Health Pty Ltd’s frontline staff providing support for enteral feeding and management have relevant additional qualifications and experience. Frontline staff are trained to be aware of the impact of associated health conditions and complications that interact with enteral feeding such as severe epilepsy, severe dysphagia, complex physical disability. Sensible Health Pty Ltd’s frontline staff will have received training (according to their training plan), relating specifically to each participant’s needs and their support plan / mealtime preparation and delivery plan. Frontline staff will be trained in behaviours of concern where a participant may frequently dislodge their feeding tubes becoming high risk participants and the associated risks. This training will also include the following:

• people who are unable to feed themselves.
• people with complex communication.
• basic anatomy of the digestive system.
• equipment components, function, cleaning and maintenance procedures.
• stoma care requirements and procedures.
• awareness of risks associated with departing from the plan
• communication techniques to explain risks to participant/carer/advocate and other support workers
• the impact of associated health conditions and complications that interact with enteral feeding e.g., related cardiac or respiratory disorders.
• very complex physical disability; severe epilepsy.
• symptoms that indicate the need for intervention e.g., poor chest health, dehydration, reflux.
• factors that may require immediate adjustment e.g., rate, flow and quantity of food.
• positioning and turning to maintain airway safety and avoid choking risk and in pressure care.
• Positioning the participant during and after the PEG feed
• Safe work practices to prevent and control infection and PPE
• Waste management
• Documentation

Observe, document and report – Includes STOMA CARE

Should any of the following conditions or symptoms be observed by the community support professional, they are to document what has been observed, and report same to their supervising registered nurse or line manager, who should then arrange for a medical review:

• Skin breakdown or excoriation about the stoma site
• Signs of infection – redness, swelling, bleeding, discharge, odour
• Folliculitis (inflamed hair follicle)
• Tube placement is too tight or too loose
• Gastric fluid leaking from stoma site
• Tube or device displacement, discolouration or blockage
• Diarrhoea, constipation, nausea, vomiting
• The incorrect port (balloon port) is used to administer feed or medication

PPE required for PEG feed

• Disposable gloves (powder free)
• Feeding pump
• Feeding pump frame
• Tube feed
• Giving sets and accessories
• Spare feeding tubes
• Syringes
• Carriers’ packs
• Connecters
• Liquid formula
• Measuring cup

Monitoring and Review

Sensible Health Pty Ltd Management Team will review this policy and procedure at least annually. This process will include a review and evaluation of current practices and service delivery types, contemporary policy and practice in this clinical area, the Incident Register and will incorporate staff, participant and another stakeholder feedback. Feedback from service users, suggestions from staff and best practice developments will be used to update this policy.

Sensible Health Pty Ltd Continuous Improvement Plan will be used to record and monitor progress of any improvements identified and where relevant feed into Sensible Health Pty Ltd service planning and delivery processes.