ordering of enteral feeds for community patients standard ......enteral feeding products and...

Ordering of Enteral Feeds for Community Patients Standard Operating Procedure

V2.0

October 2020

Ordering of Enteral Feeds for Community Patients Standard Operating Procedure V2.0 of 14

Table of Contents

1. Introduction ................................................................................................................... 3

2. Purpose of this Standard Operating Procedure ............................................................ 3

3. Ownership and Responsibilities .................................................................................... 3

3.4. Role of the Managers ............................................................................................ 4

3.5. Role of Individual Staff ........................................................................................... 4

4. Standards and Practice ................................................................................................ 5

4.1. Qualifications, training and experience: ................................................................. 5

4.2. Professional / Team Lead responsibilities: ............................................................ 5

4.3. Approved Dietitians responsibilities ....................................................................... 6

4.4. Approved Dietitian must fulfil the following competencies: .................................... 6

5. Dissemination and Implementation ............................................................................... 7

6. Monitoring compliance and effectiveness ..................................................................... 7

7. Updating and Review .................................................................................................... 8

8. Equality and Diversity ................................................................................................... 8

8.2. Equality Impact Assessment.................................................................................. 8

Appendix 1. Governance Information .................................................................................. 9

Appendix 2. Equality Impact Assessment .......................................................................... 11

Appendix 3. Authorised list of Dietitians eligible to order enteral feeds .............................. 13

Appendix 4. Certificate of Competence.............................................................................. 14

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1. Introduction

1.1. This procedure was introduced in 2017 to support a change of practice in the management of enteral feed provision for patients receiving enteral nutrition in the community.

1.2. Historically General Practitioner’s (GP’s) were responsible for the prescription

and delivery of all enteral feeds and nutritional products to patients enterally fed at home.

1.3. In 2017 Cornwall moved to an ‘off script’ process, which meant FP10 prescriptions were no longer required for enteral feeds and GP’s transferred prescription and ordering responsibilities to Home Enteral Feeding Specialist Dietitians.

1.4. This change in procedure was supported by Kernow CCG .

1.5. This procedure was agreed with the Medication Practice Committee and Therapies Governance group within the Royal Cornwall Hospitals Trust (RCHT).

1.6. This version supersedes any previous versions of this document.

2. Purpose of this Standard Operating Procedure

2.1. This procedure is required to support Dietitians managing enteral feed provision for patients receiving enteral nutrition in the community.

2.2. It allows those Dietitians who have been approved by the Professional Lead to order feeds and nutritional products (within borderline substances range) without requiring an FP10 prescription.

2.3. This procedure is essential to ensure safe and effective ordering of enteral feeds and nutritional products for home enterally fed patients in the community by Dietitians - either for patients in their own homes or care homes, respite centers and special schools. The ordering of enteral feeds does not require General Practitioners to prescribe the feeds and procurement is led solely by Dietitians experienced in the management of patients receiving home enteral nutrition, who monitor the patients’ nutritional needs, and request feeds and nutritional products from the contracted “enteral feeding company” as part of this process

3. Ownership and Responsibilities

3.1. This procedure has been developed by the Dietetic Department within RCHT after consultation with Pharmacy, Therapies Governance Lead, and Prescribing Optimisation Lead within KCCG.

3.2. The Cornwall Commissioning Prescribing Committee agreed that Cornwall should adopt an “Off Script” approach for ordering of enteral feeds for patients in the community (May 2015).


3.3. Governance arrangements are required through Therapies Governance

Committee, Medication Practice Committee within the RCHT, and Prescribing Optimisation team within KCCG.

3.4. Role of the Managers Line managers for Dietitians providing a clinical service to patients receiving home enteral nutrition are responsible for:

Appointing appropriately experienced Dietitians who provide a service to home enterally fed patients, who are HCPC registered and meet the criteria to be able to facilitate ordering of enteral feeds.

Monitoring HCPC registration

Ensuring training on registration system is provided by the Enteral Feeding company contracted to supply home enteral feeding services and that all staff working with home enterally fed patients are trained

Providing clinical supervision

Ensuring Governance arrangements are in place.

Dietitians able to order feeds must be agreed in advance by the Lead Dietitians, and Professional Lead will then ensure an up to date electronic list is kept within the Therapies department. These Dietitians must provide a service to patients requiring home enteral feeding within their role. This list is reviewed annually as of 1st April each year and as changes occur.

Lead Dietitians’ to review individual staff compliance to the policy in staff PDRs.

Ensure Dietitians ordering feeds/nutritional products fulfil competencies and sign check list and sign off (Appendix 4)

3.5. Role of Individual Staff

All staff members are responsible for:

Having at least 12 months clinical dietetic experience before ordering feeds for patients receiving home enteral nutrition.

Being aware of nutritional products supplied by the Enteral Feeding Contract and be experienced in use of enteral feed products for patients at home – being aware of clinical indications and nutritional provision.

Having received training on use of patient registration system (PRS) used by contracted Enteral Feed Provider.

Having received induction on the remit of the Peninsula Enteral Feeding contract by the Lead Dietitian or Professional Lead.

Having completed the formal process of sign off and completion of competencies checklist for ordering feeds. Certificates to be kept in staff personal file.


Justifying clinical indication for use of specific enteral feeding products within documentation / records.

Keeping General Practitioners informed of patients feeding requirements and any significant changes to feed provision, to guide clinical management.

Ordering feeds/nutritional products to minimise wastage at home.

If delegating the ordering on PRS to an assistant, should give clear and concise instructions and retain clinical responsibility for this ordering, so will require checks to be in place to ensure accuracy of orders.

Reporting any issues with the procedure in ordering feeds to Lead Dietitian involved in the contract and Enteral Feed supplier as appropriate.

4. Standards and Practice

4.1. Qualifications, training and experience:

4.1.1. Necessary qualifications and experience required to order enteral feed and nutritional products:

HCPC registered Dietitian

1 year NHS experience post HCPC registration

Work with home enterally fed patients

4.1.2. Persons authorised to order enteral feeds and nutritional products then need to:

Have training with the enteral feed company representative on use of the PRS system.

Complete Off Script competencies

4.2. Professional / Team Lead responsibilities:

4.2.1. It will be the responsibility of the Professional Lead to hold a valid secure e-list of Dietitians approved to order feeds/nutritional products via the PRS system. (Appendix 3)

4.2.2. The Dietitians competence will be signed off by their Lead Dietitian or Professional Lead. The Dietitian will also sign a “Sign Off” certificate and confirm they have necessary competencies (Appendix 4) and this will be kept within their personal file.

4.2.3. The Lead Dietitian will inform the Professional Lead that a Dietitian is

now eligible to order feeds/nutritional products via the PRS system for patients receiving home enteral feeding in the community.

4.2.4. The Professional Lead will update the authorised Dietitians electronic list,

which will also be reviewed annually on 1st April.


4.2.5. Only individuals who have been signed off by the Lead Dietitians’ / Professional Lead will order enteral feeds/nutritional products via PRS for patients receiving home enteral feeding.

4.3. Approved Dietitians responsibilities

4.3.1. Once approved and competencies completed the Dietitian will be allowed to order feeds/nutritional products or delegate ordering of feeds to Assistants via the Patient Registration system (PRS) of the company awarded the contract for supply of enteral feeding services across Cornwall.

4.3.2. If this is delegated to Assistants, there should be clear lines of accountability, and responsibility remains with the Dietitian. Any Assistant ordering feeds should fulfil competencies required and only order on instruction of a Dietitian.

4.3.3. There will be a limited number of patients requiring specialist feeds not

covered by the enteral feeding contract, and these will need to be requested via the FP10 route for General Practitioners to prescribe.

4.3.4. Home Enterally fed patients will only be assessed by an approved Home

Enteral Feeding Dietitian.

4.3.5. Feed most appropriate to meet patients’ nutritional and clinical needs will be ordered from the Enteral Feed Provider via the patient registration system (PRS), specifying type of feed, pack size, number of packs per day/month, length of feed provision per delivery (usually 1 month, but less if clinically indicated). Additional specific requirements may be made by the supplier.

4.3.6. Nutritional / feed requirements will be reviewed on a routine basis and

feed orders amended according to patients needs

4.3.7. Communicate patients nutritional needs, intake, deficiencies and tolerance issues to all appropriate healthcare, including written correspondence to GP

4.3.8. Feed Ancillaries will be ordered by PRS system by Dietitians/Dietetic

Assistants.

4.4. Approved Dietitian must fulfil the following competencies:

4.4.1. Be familiar with the nutritional content of the products on contract and also of alternatives that maybe required to meet specific and specialist patient requirements (any alternative products would need to be requested and justification given to the patients’ GP to allow prescribing via FP10 route).

4.4.2. Keep up to date with dietetic knowledge of products available, indications and clinical use with patients requiring enteral feeding, often long-term, within the community.


4.4.3. Order feed to meet individual patients nutritional requirements

4.4.4. Communicate any nutrient or clinical concerns or need for monitoring to the patients’ GP

4.4.5. At commencement of enteral feeding and at routine reviews, communicate details of patients nutritional requirements and feed /nutrient provision to the patients’ GP on an annual basis (minimum requirement)

5. Dissemination and Implementation

5.1. This document will be approved via the Therapies Governance group and Medication practice committee, before Dietitians are able to order feed for home enteral feeding patients in community.

5.2. Dietitians’ ordering enteral feeds and nutritional products for home enterally fed patients, have been agreed by the KCCG, and formed part of the Contract for Enteral Feeding Products and services effective from 1st April 2017. The practice of ordering enteral feeds affects a small number of Dietitians who provide dietetic services to patients receiving home enteral nutrition in the community and has been in place since April 2017.

5.3. The document will be made available on the document library. Significant updates will be communicated via Trust wide email.

5.4. This document will be disseminated by the author and HEF teams / Department Leads made aware of the document.

6. Monitoring compliance and effectiveness

Element to be monitored

1. Valid up to date list of authorised staff, compliance, eligibility, and frequency of errors.

2. System for PRS across Peninsula.

Lead 1. Professional Lead Dietitian 2. Peninsula Enteral Feeding Contract Monitoring group

Tool 1. Review of staff authorisation lists with reassurance by PRS trained Dietitians and Lead Dietitian on maintenance of skills.

2. User access uptime and complaints reporting.

Frequency 1. Annually 2. Quarterly contract meetings

Reporting arrangements

1. Through Therapies Governance Committee. 2. Home Enteral Feeding team meetings and Peninsula Home

Enteral Feeding meetings regarding ordering enteral feeds on PRS, which will feed into the Local and Peninsula Contract Monitoring groups. Reporting back to Professional Lead to give assurance.

Acting on recommendations and Lead(s)

1. Non-compliance will be reported to the Professional Dietetic Lead, required actions will be identified and completed in specified timeframe.

2. Contract Monitoring Lead from PPSA

Change in Using an off script system with authorised Dietitians has:


practice and lessons to be shared

greatly improved accuracy of orders, & reduced number of order errors and queries Improved efficiency of ordering process Better system for both Health care professionals and patients Lead HEF Dietitian will continue to monitor this

7. Updating and Review

The process of ordering of enteral feeds for home patients will be under continuous review, as part of safety and quality monitoring as part of contract. Will be reviewed every 3 months as part of local and Peninsula contract review meetings. Procedure will be reviewed fully in 3 years unless it becomes obvious that changes are required.

8. Equality and Diversity

8.1. This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and Diversity statement which can be found in the 'Equality, Inclusion & Human Rights Policy' or the Equality and Diversity website.

8.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

http://www.rcht.nhs.uk/GET/d10268876

http://www.rcht.nhs.uk/GET/d10268876

http://intranet-rcht.cornwall.nhs.uk/shelf/equality-and-diversity/


Appendix 1. Governance Information

Document Title Ordering of Enteral Feeds for Community Patients Standard Operating Procedure V2.0

This document replaces (exact title of previous version):

Local procedure for the ordering of enteral feeds / nutritional products by Dietitians, for patients in the community receiving home enteral feeding V1.0

Date Issued/Approved: 13th October 2020

Date Valid From: October 2020

Date Valid To: October 2023

Directorate / Department responsible (author/owner):

Jenna Chowney Highly Specialist Home Enteral Feeding Dietitian

Contact details: 01209 318060

Brief summary of contents Procedure for authorised Dietitians to prescribe and order enteral nutrition for community patients

Suggested Keywords: Home Enteral feeding / HEF / HEN / Enteral Nutrition / prescribing / ordering / dietitian.

Target Audience RCHT CFT KCCG

Executive Director responsible for Policy:

Medical Director

Approval route for consultation and ratification:

Therapies and then Divisional Governance Committee

General Manager confirming approval processes

Richard Andrzejuk

Name of Governance Lead confirming approval by specialty and care group management meetings

Kevin Wright

Links to key external standards None required

Related Documents: None required

Training Need Identified? Yes – authorised HEF dietitians requiring access to patient portal system

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder

Clinical / Dietitians


Version Control Table

Date Version

No Summary of Changes

Changes Made by (Name and Job

Title)

April 2017 V1.0 Initial issue – Stored locally on S: drive and not uploaded to the DL

Mary France Lead Dietitian

June 2020 V2.0

Update of information in summary/introduction Change of layout to reflect updated SOP template Moved some information in V1 ‘Purpose of this procedure’ to ‘standards and practice’ section. Small changes to wording throughout document

Jenna Chowney Highly Specialist HEF Dietitian and Team Lead

All or part of this document can be released under the Freedom of Information

Act 2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust

Policy for the Development and Management of Knowledge, Procedural and Web

Documents (The Policy on Policies). It should not be altered in any way without the

express permission of the author or their Line Manager.


Appendix 2. Equality Impact Assessment

Section 1: Equality Impact Assessment Form

Name of the strategy / policy /proposal / service function to be assessed Ordering of Enteral Feeds for Community Patients Standard Operating Procedure V2.0

Directorate and service area: Therapies and Dietetics

Is this a new or existing Policy? Existing

Name of individual/group completing EIA Jenna Chowney

Contact details: 01209 318060

1. Policy Aim Who is the strategy / policy / proposal / service function aimed at?

Dietitians who are authorised to contribute to “Off Script” ordering of enteral feeds for home patients (children and adults). Also for information for all Dietitians within service. As part of Governance assurance for RCHT and Prescribing Optimisation team within KCCG

2. Policy Objectives To have standard procedure for ordering feeds for patients receiving home enteral nutrition

3. Policy Intended Outcomes To ensure safe and effective practice

4. How will you measure the outcome?

Adherence to practice Review total number of errors

5. Who is intended to benefit from the policy?

Patients General Practitioners Commissioners

6a). Who did you consult with?

b). Please list any groups who have been consulted about this procedure.

Workforce Patients Local groups

External organisations

Other

Please record specific names of groups:

Pharmacy Therapies Governance Lead Prescribing Optimisation Lead within KCCG.

c). What was the outcome of the consultation?

Agreed


7. The Impact Please complete the following table. If you are unsure/don’t know if there is a negative impact you need to repeat the consultation step. Are there concerns that the policy could have a positive/negative impact on:

Protected Characteristic

Yes No Unsure Rationale for Assessment / Existing Evidence

Age x

Sex (male, female non-binary, asexual etc.)

x

Gender reassignment x

Race/ethnic communities /groups

x

Disability (learning disability, physical disability, sensory impairment, mental health problems and some long term health conditions)

x

Religion/ other beliefs x

Marriage and civil partnership x

Pregnancy and maternity x

Sexual orientation (bisexual, gay,

heterosexual, lesbian) x

If all characteristics are ticked ‘no’, and this is not a major working or service change, you can end the assessment here as long as you have a robust rationale in place.

I am confident that section 2 of this EIA does not need completing as there are no highlighted risks of negative impact occurring because of this policy.

Name of person confirming result of initial impact assessment:

Jenna Chowney, Highly Specialist HEF Dietitian and Team Lead

If you have ticked ‘yes’ to any characteristic above OR this is a major working or service change, you will need to complete section 2 of the EIA form available here: Section 2. Full Equality Analysis For guidance please refer to the Equality Impact Assessments Policy (available from the document library) or contact the Human Rights, Equality and Inclusion Lead [email protected]

http://doclibrary-rcht-intranet.cornwall.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/ChiefExecutive/Templates/Section2FullEqualityAnalysis.docx

mailto:[email protected]


Appendix 3. Authorised list of Dietitians eligible to order enteral feeds

Authorised list of Dietitians eligible to order enteral feeds/ nutritional products for Home Enteral Feeding patients via PRS system and who have completed the above process and

who have agreed to comply with the above Policy. A signed Certificate with the signatories as noted below is in the Dietitian’s Personnel file.

Dietitian Name Team Lead

Name + sign off date

Professional Lead Name + sign off date


Appendix 4. Certificate of Competence

Certificate of Competence in ordering enteral feeds and nutritional

products for Home Enterally Fed patients

Competencies Checklist Staff name, signature and date

Lead Dietitian

Be familiar with the nutritional content of the products on contract and also of alternatives that maybe required to meet specific and specialist patient requirements (any alternative products would need to be requested and justification given to the patients’ GP to allow prescribing via FP10 route).

Keep up to date with dietetic knowledge of products available, indications and clinical use with patients requiring enteral feeding often long-term within the community.

Order feed to meet individual patients nutritional requirements

Communicate any nutrient or clinical concerns or need for monitoring to the patients’ GP

At commencement of enteral feeding and at routine reviews, communicate details of patients nutritional requirements and feed /nutrient provision to the patients’ GP

The below noted Dietitian is eligible to order enteral feeds/ nutritional

products on a named patient basis on PRS system: To enable a dietitian to be eligible to order enteral feeds/nutritional products on PRS

system for Home Enteral Feeding patients, they must have completed the above process and have agreed to comply with the above policy

Signature Sign off date

Dietitian (name block capitals)

…………………………………………

Team Lead(name block capitals)

………………………………………………..

Professional Lead Dietitian (name block capitals)

…………………………………………