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For: G.Ps, nurses, care staff, care home managers and other staff working within care homes or for care agencies

Aim: To set standards and provide guidance to support consistent, high quality and safe care for patients who are tube fed in the community

Background: All patients who have a feeding tube should have access to the same level of high

quality care, whether they live at home or in a care home and whether or not the feeding tube is

currently in use.

The following pages can support the patients’ tube feeding care plan and can be used to assist

implementation of the following minimum standards required for good feeding tube care in adult,

community care settings:

Minimum standards for good feeding tube care in adult, community care settings

1. Any care home or care agency which accepts a tube fed patient ensures that all relevant staff have received

training provided by an Abbott Nursing Adviser (ANA) prior to the patients admission/acceptance

2. All staff who care for a patients feeding tube and/or administer feed, water or medications via the patients

feeding tube (including bank staff) have received training from an ANA within the last 12 months

3. Annual update training by the ANA is accepted when offered and attendance at this training by all relevant

staff is prioritised and considered mandatory by the care home/care agency

4. Staff provide daily care of feeding tube and stoma as advised by the ANA

5. Patients who are tube fed have a personalised, tube feeding care plan which includes their current feeding

regimen (as provided by the patients managing Dietitian), and staff key roles and responsibilities.

The care plan must also include a record of:

a. The type of feeding tube in situ and the date when it was placed

b. How often ‘advance and rotate’ should be undertaken (as advised by the ANA)

c. Completion of each ‘advance and rotate’ (including date and signature of staff member who

undertook this)

d. For balloon gastrostomies only the care plan must also include a record of:

i. Volume of sterile water to be used to inflate balloon

ii. How often balloon check should be completed

iii. Completion of each balloon check (including date, volume of water withdrawn, volume of

sterile water replaced, signature of staff member who undertook this)

iv. Record of each tube change (including date, signature of staff member who changed tube)

6. Staff work with Abbott Hospital to Home (H2H) to ensure that adequate feed and plastics supplies are

maintained - to avoid either overstocking or running out of stock before the next delivery

7. Staff understand which equipment/ products are provided and how to use these for each task

8. Staff know who to contact in the event of concerns about a patient or a change in their requirements

9. Care Home and care agency managers are responsible for ensuring that this guideline is implemented and

that all staff follow best practice

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Positioning during feeding

Tube feeding should take place while patients are sitting or well supported (e.g. by an adjustable bed

and/or adequate pillows) so that their head and shoulders remain at a 45 degree angle for the entire time

over which they are fed AND for at least 30 minutes afterwards

If a patient is unable to remain supported at 45 degrees for the entire time over which they are fed, then

continuous pump feeding may not be appropriate for that patient. Supporting a patient to remain at a 45

degree angle can be particularly difficult while patients are asleep and this is why tube feeding overnight

may not be recommended

Continuing to feed a patient when they are supported at less than a 45 degree angle or if they are lying flat

(0 degrees) can significantly increase the patients risk of aspirating stomach contents, which could lead to

possible chest infection and/or hospital admission

Equipment and supplies – What will be provided?

The patient’s Dietitian will order all the equipment and feed required for each patient and this will usually be

delivered directly to the Care Home or patients own home by Abbott Hospital to Home (H2H).

What equipment will be provided each month?

Feeding regimen Tube type

Pump fed (continuous or bolus) Bolus fed manually

Balloon gastrostomy or button

Giving sets

50ml or 60ml ENFit syringes for administration of water flushes and medications

Extension sets (buttons only)

Feed

Reservoir containers (if required)

8 x 5ml or 10ml or 20ml syringes for checking and re-inflation of balloon only

4 x plastic ampoules of sterile water for balloon re-inflation

50ml or 60ml ENFit syringes for administration of water flushes, feed boluses and medications

Extension sets (buttons only)

Feed

8 x 5ml or 10ml or 20ml syringes for checking and re-inflation of balloon only

4 x plastic ampoules of sterile water for balloon re-inflation

PEG Giving sets

50ml or 60ml ENFit syringes for administration of water flushes and medications

Feed

Reservoir containers (if required)

50ml or 60ml ENFit syringes for administration of water flushes, feed boluses and medications

Feed

Jejunostomy Giving sets

50ml or 60ml ENFit syringes for administration of water flushes and medications

Feed

1000ml packs sterile water

N/A

Please note: syringes for measuring medicines cannot be provided through H2H (see Medicines given via feeding tubes below)

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What can be given via a feeding tube?

Prescribed feed

o This will be provided as either packs of feed (500ml, 1000ml or 1500ml) or nutritional supplements

(200ml or 125ml bottles)

Water

Tube type Water type

PEG/balloon gastrostomy = Freshly run, tap water

Jejunostomy /PEG-J = Sterile water

Medicines (see Medicines given via feeding tubes below)

Other products

o Diabetic hypo treatment (see Treating a diabetic hypo (low blood glucose) below)

o Occasionally the patients Dietitian may advise administration of another product (such as a probiotic

drink) via a patients feeding tube, however products which have not been advised by the patients

Dietitian should not be given

Medicines given via feeding tubes (See Appendix 1 ‘Form for administering Medicines via Enteral Feeding Tube’)

*Very few medicines (including liquid medicines) are licensed to be given via feeding tubes

Care staff can only give medicines in an unlicensed way (i.e. via a feeding tube*) when instructed to do so

by the prescriber

CQC Frequently Asked Questions: How should medicines be administered safely via enteral feeding tubes? states:

o Written information should be available to staff administering medicines on how to prepare and administer each medicine safely, including oral liquid medicines.

o A care plan should be in place to cover medicines administration via an enteral tube covering the relevant issues

o Guidance from the prescriber and in addition, a pharmacist, should be sought on each medicine.

o A clear record of administration (including the route) should be made on the MAR chart or equivalent e.g. “via PEG”

Not all medicines can be given via a feeding tube and it is essential to check with a pharmacist that all of the patient’s prescribed medicines can be safely given via their feeding tube

Liquid medicines and soluble tablets are usually the best format for medicines given via a feeding tube, however not all liquid medicines will be suitable

If tablets need to be crushed and/or dispersed or if capsules need to be opened, the patients care record must contain a specific written instruction from the patients GP to do this

Tube feeding can change the way that some medicines work within the body. This means that some medicines (e.g. phenytoin) must be given during a break from feeding; and other medicines (e.g. pancreatin) must be given at the same time as feeding

50ml or 60ml ENFit syringes are provided and should be used to give both water flushes and medications

o If smaller syringes (1ml, 5ml or 10ml) are needed to measure liquid medicines these should be

requested from the pharmacy which dispenses the medicine

o Syringes smaller than 50ml should not be used to give a medication via a feeding tube and will not

be provided by H2H

Medicines must be given one at a time, with a flush of at least 20ml of water in between different

medicines

When giving medicines via a feeding tube, health care professionals must be aware:

Of the legal and professional consequences of altering a drugs format (e.g. by crushing a tablet)

That the medicine is being given via an unlicensed route*

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Stoma care

‘Advance and rotate’ usually needs to be completed at least once per week. The ANA will tell you how often advance and rotate should be completed for each patient – this should also be recorded in the patients care plan

If ‘advance and rotate’ is not completed as advised by the ANA, there is a risk that the stomach lining can

start to grow over the ‘bumper’ causing a complication called ‘buried bumper syndrome’. Buried bumper

syndrome is fairly rare but when it does happen it’s usually due to poor care. If the ‘bumper’ becomes

completely buried, the tube can no longer be used to give feed, fluid or medication. If ‘buried bumper’ does

occur, the only solution is hospital admission to surgically remove the PEG, and to place a new PEG if

appropriate

Even if a feeding tube is not in use, ‘advance and rotate’ still needs to be completed as advised by the ANA

There is no need to advance and rotate more often than once per day, and doing so could irritate the stoma causing inflammation and discomfort/pain for the patient

Balloon gastrostomy care

Balloon gastrostomies are held in place in the stomach by a balloon, which is inflated with sterile water

Checking the balloon volume

Balloon volume must be checked regularly – how often to do this will be advised by the ANA (most balloons

need to be checked weekly; Freka balloon gastrostomies only need to be checked once every 6 weeks):

o Using a new 5ml, 10ml or 20ml syringe (as advised by the ANA), withdraw water from the balloon

Record – Date; Name/signature of trained staff member who is undertaking this check; Volume of water withdrawn

o Discard this water

o Using a new plastic ampoule of sterile water and a new 5ml, 10ml or 20ml syringe, re-inflate balloon with required volume of sterile water (as advised by the ANA)

Record on a specific recording chart - the volume of water used to re-inflate the balloon.

Changing the balloon gastrostomy

Patients must have their first balloon gastrostomy replaced in hospital but after that, balloon gastrostomies

can be replaced in the community. Training on balloon gastrostomy replacement can be provided by the ANA

Most balloon gastrostomies will need to be changed every 4 months but Freka balloon gastrostomies only

need to be changed every 9 months. The ANA will advise how often the balloon gastrostomy should be

changed

Each balloon gastrostomy change must be recorded in the patients care plan, together with the date and the

name of the trained staff member who changed the tube

What does ‘Advance and rotate’ mean?

‘Advance and rotate’ means that the feeding tube is pushed inwards by a couple of centimetres and then rotated through 360 degrees

before being gently pulled back so that the internal ‘bumper’ sits flush against the stomach wall again.

Record each ‘advance and rotate’ on a recording chart

and include date and name of staff member completing

this task

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Stoma infection/ over granulation

The area around the patient’s stoma/ feeding tube should have the appearance of normal, healthy skin

If there are any signs of the following, staff should contact the ANA for advice:

o Red or inflamed skin

o Evidence of bleeding (presence of fresh or dried blood)

o Signs of leakage of stomach contents around the feeding tube

o Excess skin production (over granulation) around the feeding tube site

Tube blockage

Blockage of feeding tubes can occur but is usually avoidable

If blockage does occur it is usually due to either:

o Failure to flush the tube with water as soon as feed administration has finished or a medicine has been

given

o Failure to give medicines separately (with a flush of at least 20ml of water in between medicines) or

o Failure to flush the tube with water between giving feed and medicines

If the feeding tube does block, it can usually be unblocked without the need for a hospital admission, and staff

should follow the troubleshooting advice provided by the ANA at previous training or over the telephone at

the time of the blockage. Use of specialist products designed to clear blockages is not usually recommended

or required

Any incident of tube blockage should be recorded in the patients care plan and staff should investigate why

the blockage occurred and learn from it to prevent it happening again

Tube fed patients who have diabetes and are at risk of a hypo (low blood glucose)

See https://www.chilternccg.nhs.uk/wp-content/uploads/2017/07/Diabetes-Care-Standards-

Guidance.pdf for more information on treating hypos

Follow above guidance and ensure patient has a personalised care plan which details how to treat hypos

Maintain a separate ‘hypo box’ for each tube fed patient who is at risk of hypos, which should contain:

o At least 4 x 60ml bottles Glucojuice (purchase this over the counter from a pharmacy)

o 1 x 50ml/60ml ENfit syringe

o 1 x 220ml bottle Ensure Plus

If a tube fed patient has a hypo:

o Using 50ml/60ml ENFit syringe, flush tube with 20ml water, then give 1 x 60ml bottle Glucojuice (which contains 15g fast-acting carbohydrate). Flush tube with 20ml water

o After 5 – 10 minutes, if the patient does not feel better/their blood glucose is still less than

4 mmol/l repeat above steps

o When the patient starts to feel better or their blood glucose is greater than 4 mmol/l:

If next feed is due – follow feeding regimen

If next feed is not due, using 50ml/60ml ENFit syringe flush tube with 20ml tap water then give 100ml

bolus of Ensure Plus. Flush tube with 20ml tap water

o If pt does not start to feel better/is unresponsive they will need emergency treatment - dial 999 for a

paramedic

Restock hypo box as above

Please note: Polycal Liquid should NOT be requested or used as a hypo treatment

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Who can provide support?

Abbott Nurse Advisers (ANAs) who are responsible for:

Hospital 2 Home (H2H) who are responsible for:

Delivering giving sets, syringes and other plastics; and dispensing and delivering feed

Contact details for Abbott Hospital to Home (H2H) - 0800 0183 799

Training

Training of patient/carer prior to acute discharge,

within 1 working day of receipt of referral

Training of patient/carer in the community prior to

tube placement

Training of community staff including community

nurses/care home staff/special school staff/hospice

staff/care agency staff etc. as required

At least annual planned refresher training for all

care homes/special schools/care agencies where

there are tube fed residents/pupils

All training should include – pump use (if

appropriate), bolus feeding (if appropriate), testing

of balloon volume (if appropriate), water flushing,

administration of medication, tube and stoma care,

trouble-shooting including avoiding and managing

tube blockage, signs and symptoms of stoma

infection, compromised tube patency etc, changing

of NG/balloon gastrostomy tubes (if appropriate)

Tube/stoma review

At least 6 monthly planned review of patency/

health of all patients feeding tubes and stomas

Review of feeding tube/stoma at other times

according to the changing needs of the patient

Timely referral for PEG/RIG replacement if tube

patency deteriorating. Route for referral will be via

ANA who will inform pts GP and dietitian

Undertake stock check each time a patient is visited

Routine tube replacement

Community routine replacement of balloon

gastrostomies and buttons as advised by Dietetic

Departments

Troubleshooting

Providing telephone trouble shooting service for

community patients during normal working hours.

Telephone response to patient/carer required

within 2 hours

24 hour helpline for patients/carers manned by a

suitably qualified nurse

Communication

Provide the patient/carer with all relevant contact

numbers including an out of hours helpline

Provide written record of all patient contacts to

the relevant Dietetic Department within 24 hours

of that contact

Keep up to date with relevant policies issued

nationally and by the Trusts/Dietetic Departments

Provide the relevant Dietetic Department with the

date/s of training and a list of the names and staff

grades of all staff who attended, within 48 hours

of the training session

Communicate any concerns regarding patient care

to the relevant Dietetic Department within the

same working day

Communicate any observed under or overuse of

feed products or consumables to the relevant

Dietetic Department within 2 working days

Inform the relevant Dietetic Department of any

patient/carer who declines any offered training/

review

Inform the relevant Dietetic Department of any

care home/special school/hospice/care agency

etc. which declines or does not accept any offered

training/review

Contact details for Buckinghamshire Abbott Nurse Advisers (ANAs):

North Buckinghamshire – Christine Altenor 07553 345647 caltenor@abbott.com

South Buckinghamshire – Gemma Wilkins 07901 514120 gemma.wilkins@abbott.com

Who can provide support?

Abbott Nurse Advisers who are responsible for:

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Community Pharmacists who are responsible for:

Community Dietitians (employed by Buckinghamshire Healthcare NHS Trust) who are

responsible for:

Dispensing medicines

Providing advice about whether medicines can be safely given via a feeding tube and if not, what alternative

may be suitable

Contact the community pharmacy which dispenses medicines for the tube fed patient

Assessing the patient’s nutritional requirements

Advising on and providing a feeding regimen for the patient

Ordering equipment and feed from H2H

Providing ongoing support for tube fed patients in the community

Contact details for Buckinghamshire Healthcare NHS Trust Community Dietitians: 01494 734825

Other useful resources

UK Medicines Information guidance:

o Crushing tablets or opening capsules in a care home setting

o What are the therapeutic options for patients unable to take solid oral dosage forms?

Handbook of Drug Administration via Enteral Feeding Tubes (3rd Edition, 2015) by Rebecca White and Vicky Bradnam ISBN 978-0-85711-162-3

NICE CG 32 Clinical Guideline - Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition

NICE QS 24 Quality standard for nutrition support in adults

CQC Regulations and Appendix 2 CQC FAQs: How should medicines be administered safely via enteral feeding tubes?

Nasogastric (NG) tubes

Nasogastric tubes are rarely used outside hospitals due to the significant risks associated with misplacement https://improvement.nhs.uk/news-alerts/nasogastric-tube-misplacement-continuing-risk-of-death-severe-harm/.

If your Home is requested to care for a patient with an NG tube, the following support must be agreed and provided by the discharging hospital, prior to admission of the patient into your Home:

Specific training for all staff who will be caring for the pts NG tube

Recording sheet to record gastric pH and position of tube prior to each use of NG (i.e. before administering any feed, water or medications)

Protocol provided by discharging hospital, which staff must follow if position of NG cannot be confirmed by pH and tube position. Protocol must be valid 24 hours per day and must include which hospital unit/ward is aware of patient and will accept their admission, and which staff member/s at the hospital need to be notified that NG position cannot be confirmed

Please note: this support CANNOT be provided in the community by GPs, District Nurses or ANAs

Developed by

Alison Smith, Prescribing Support Dietitian and Jacqui Kent, Care Homes Pharmacist; Aylesbury Vale & Chiltern CCGs in collaboration with Buckinghamshire Healthcare NHS Trust Dietitians and Nutrition Specialist Nurse; and Abbott Nurse Advisers

Date ratified Version 2 Feb 2018 (Medicines Management Sub Committee)

Review date Feb 2021

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Appendix 1

Form for Administering Medicines via Enteral Feeding Tubes

Please note: This form can be completed by anyone with the appropriate authority to do so. It does

not have to be completed by the patients GP

It is recommended that the Prescriber, Community Pharmacist and Care Home Manager are all in

agreement on the administration of medication via a patient’s feeding tube.

All persons administering medication via feeding tubes must be aware of the legal implications of

manipulating a drug prior to administration, and must take advice before commencing this. If a

tablet crusher is to be used, a separate tablet crusher must be used for each patient

Patient name: _____________________________ Date of Birth: ________________________

Care Home name: ______________________________________________________________

Date of last medication review: _______________________________________________________

Name of GP/Pharmacist who completed last medication review: ___________________________

Drug name Notes to support safe administration

1.

2.

3.

4.

5.

6.

7.

8.

Prescriber Signature: ____________________ Date: __________________

Please note: Prescriber signature is not required if the MAR/each prescription makes it clear that

the medication is to be administered via the enteral feeding tube

Community Pharmacist Signature: ____________________ Date: __________________

Care Home Manager Signature: ____________________ Date: __________________

This form to be reviewed at least 6 monthly - Date next review due: _________________________

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Appendix 2

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