Preamble
BigDog Support Services Pty Ltd (BigDog) ensures that each client requiring enteral feeding and management receives appropriate nutrition, fluids and medication, relevant and proportionate to their individual needs.
Percutaneous Endoscopic Gastrostomy (PEG)
Percutaneous – any medical procedure where access to inner organs or other tissues is done via needle puncture to the skin, rather than using an open approach where inner organs or tissues are exposed, typically with the use of a scalpel.
Endoscopic – surgery using a scope through a small incision. Also called minimal invasion surgery. Reduced body cavity invasion.
Gastrostomy – a process of creating an artificial external opening into the stomach for nutritional support.
PEG feeding tubes have been in use since the early 1980's. They are used increasingly for long term enteral nutrition where people cannot maintain adequate nutrition with oral intake. Tube feeding, or enteral nutrition, is a way food can get into the body if the person is unable to eat or unable to eat enough. Food in liquid form is given through the stomach or small intestine. A dietitian will advise on the most appropriate formula for each client’s needs. The mixture will include fluid, protein, fat, carbohydrates, vitamins and minerals. There are lots of different reasons why a client may need to have a feeding tube. Tube feeding may be used to make sure they get all the nutrition and water they need because of a medical condition, which means they’re not able to have their nutrition through their mouth or maybe they are unable to swallow safely.
They may find they need a feeding tube even if they are still able to eat and drink. There are several reasons for this; it might be because they have a medical condition that means they burn energy very quickly, making it difficult to maintain a healthy weight, or a condition that means they just don’t feel hungry and therefore don’t eat enough to get all the nutrition they need. If this is the case, they will have a feeding tube and it will be used to supplement their oral dietary intake.
Plan Development
Each client is involved in the assessment and development of the plan for their enteral feeding and management. With their consent, the client's health status is subject to regular and timely review by an appropriately qualified health practitioner.
Health practitioners may include; a Registered Nurse, Dietitian, Speech Pathologist, Pharmacist, Medical Specialist, General Practitioner and Stomal therapist deemed competent by training.
The plan identifies how risks, incidents and emergencies will be managed, including required actions and escalation to ensure client wellbeing.
The enteral feeding and management plan must also include an Action Plan to address any incident or emergency in relation to the PEG e.g. blockage, dislodgement, leak, infection, Dysreflexia. The Action Plan must also identify a clear path for the escalation of any incident or emergency in a timely manner.
This enteral feeding and management plan will continue to be overseen by a health professional. The regularity of plan reviews is at the discretion of the health professional and will be supported by BigDog
Any changes in client’s needs, including any incidents or emergencies, will require a plan review.
Policies and Procedures
Appropriate policies and procedures are in place, including a training plan for workers, that relate to the support provided to each client who has enteral feeding needs.
The requirements of this role will be clearly documented in an enteral management plan that has been developed and is overseen by an external health practitioner. Both the training plan and the management support plan will include the identification of risks including actions and escalations.
Support Worker Training
All workers working with a client who requires enteral feeding have completed training, relating specifically to each client’s needs, type and method of enteral feeding and regime, and high intensity support skills descriptor for enteral feeding, delivered by an appropriately qualified health practitioner or person that meets the high intensity support skills descriptor for enteral feeding.
BigDog will ensure that the worker has the relevant knowledge and has received client specific training in order to safely support the client in the community.
All client specific training will be delivered by an appropriately qualified Registered Training Organisation (RTO).
Procedure
PEG feeding tube
A PEG is placed in the stomach during a procedure. Some PEGs have a tube always available and some PEGs are flat ("buttons" or "profile")
Correct feeding position
Never give feeds while the person is lying flat
Sit in a chair or lie with the head raised on 3 pillows
Remain in the elevated position for at least 30 minutes after feeding
Care for a PEG tube and stoma
Ensure the PEG is in the correct position
Inspect the stoma site daily for redness and swelling
Wash, rinse and dry the skin around the stoma daily
Turn the tube daily 180 degrees and move the tube up and down in the stoma approx. 1.5cm
Check the water in the balloon weekly and if necessary, add additional sterile water
Know when the tube is due to be changed
Contact your coordinator or the client’s doctor if you notice redness, pain or swelling or discharge around the tube site or if the feeding tube moves out of position.
How long does a PEG tube last?
This depends on the type of tube inserted, and how it is looked after.
A PEG tube can last up to a year but will need to be changed every so often due to the stomach acids. The tubes can become blocked by food, residue or medications. It should be flushed well after each use.
If the PEG tube falls out, it is important to have another tube placed as soon as possible to prevent the hole closing over.
The PEG tube can be replaced by another tube or by a low-profile device, also called a ‘button’. The client should discuss this option with their doctor when their PEG tube is due to be changed.
If the PEG tube is no longer needed it can be simply removed and the exit hole will quickly close over. Sometimes it may require a small operation by a surgeon to repair the hole once the tube is removed.
PEG Feeding
Tube feeding can be given in two ways - using a pump or using a syringe (bolus feed)
A pump is used for continuous or intermittent feeds where a mixture is given without stopping over a period of time, whereas feeding using a syringe is a fastest method where larger amounts of formula are given at a time. Feeding using a syringe is called bolus feeding.
Maintenance
Flushing a gastrostomy tube
The tube needs to be flushed twice per day with 60ml of water.
Wash hands
Ensure the syringe is clean and functioning
Use the plunger to draw water into the syringe
Flush by gently pushing the plunger of the syringe
When finished kink the tube and remove the syringe
Close the cap on the gastrostomy tube ensuring it is secure
Caring for equipment
Wash all equipment in warm, soapy water and rinse thoroughly with clean water
Dry well and store in a covered container
Feeding tubes should be replaced regularly
Feeding sets should be replaced every 24 hours or as needed. Do not use the same set for more than 3 days.
For water flushes use 1 syringe per month. If using a syringe to give bolus feeds or medicine use 2 syringes per week.
Storage of Formula
Use enteral feeds within 24hrs of opening
Store unopened feeds in cool, dry place
Refrigerate all open feeds with caps on
Feeding Pump Maintenance
Whenever possible keep the pump connected to the power supply, the battery backup will last up to 24 hours. The feeding pump will only beep if something is wrong. If the feeding pump is beeping turn off and check for the following:
The feed has run out
The tubing is kinked
Feed blocked in the tube – flush tube with water
Body position – straighten up
Low battery
Air in tube – disconnect and run formula through into the sink until the air bubble runs through
To help prevent beeping:
The chamber on the feeding set should not get too full. If the chamber has over filled, lift the chamber upside down and empty some of the liquid back into the formula container. As feed drips into the chamber it needs to be falling in the middle, not down the sides of the chamber.
Sit up as much as possible
Tube feeding problems
Diarrhoea
Loose bowel movements that are not normal. Possible causes include:
Medicines or antibiotics
Feeding formula too fast or too cold
Contamination of formula through ineffective hygiene practices
To prevent diarrhoea:
Encourage the client to relax during feeds
Don't feed cold formula. Take the formula out of the fridge 30 minutes before required
Use warm, not cold water for the water flush
Make sure all equipment is clean
Wash hands well before handling formula, equipment or feeding tube
Keep unused formula covered and refrigerated and discard after 24 hours
If the client has diarrhoea:
They need to have an extra 2 - 4 cups of water or sports drink to replace lost fluids
Contact the doctor if diarrhoea lasts more than 24hrs
If using a pump, it may be necessary to slow down the rate
If on bolus feeds give less formula more often
Upset stomach
Including nausea, vomiting, bloating, heartburn or stomach pain. To prevent upset stomach:
Don't feed cold formula
Don't rush feeds
Don't allow the client to lie flat during or just after the feed (30 - 60 mins)
Don't allow the client to exercise or bend over after the feed.
Have the client wear loose waisted clothing.
If the client has a stomach ache:
Give smaller feeds more often - or skip feeds if feeling unwell
Air may be trapped in the stomach. Letting air out of the stomach is called venting. To do this, attach a 60 ml catheter tip syringe, without the plunger, to the feeding port. Lower the syringe below the stomach. Allow contents and air to fill the syringe. Drain contents back into the stomach by raising the syringe above the stomach.
Clients who have a low-profile PEG may have a venting tube which can be pushed into the PEG to let the air escape.
Constipation
Bowel movements that are hard or difficult to pass. Possible causes include:
Not enough fluid
Not enough fibre in the formula
Not enough exercise
Some medicines
If the client is constipated, then:
Ask about having more water in the formula
Increase physical activity if able
Ask about increasing the fibre in the formula
Review medication and possibly add a liquid laxative
Tube Issues
Tube coming out
Do not use the PEG feeding tube if it has been dislodged from the tube site.
Call the Doctor or go to the emergency department of the hospital
If the PEG tube comes out completely it will need to be replaced as soon as possible as the tract begins to close within 1 - 2 hours
Blocked Tube
To prevent a blocked tube:
Crush medications well before giving through a feeding tube.
Flush the feeding tube well before and after giving medications.
Do not mix medicine with formulas.
Flush the tube every 4 – 8 hrs if overnight
Begin and finish each feeding session with a water flush
If the tube becomes blocked:
Check that the tube is not kinked.
Gently massage the tube with the fingers from the insertion site out.
Try to flush the tube with water.
If the tube remains blocked report the problem
Oral Care
Keeping the mouth moist and clean is important for comfort. Good mouth care may help prevent bad breath, mouth dryness, infections and irritations.
Chewing stimulates the production of saliva which on average amounts to about litre per day. Saliva baths the teeth and mucous membranes in the mouth which is essential for mouth health. Research indicates that good oral hygiene is linked to a reduced risk of heart disease, probably because good oral cleanliness reduces the risk of dangerous bacteria in the body.
If assisting the client with their oral care wet a soft toothbrush with water only and brush all surfaces of the teeth and gums. This process can be followed by the application of a very small amount of tooth paste to the surface of the teeth.
Mouth care should be attended to at least twice per day.
Summary
Enteral feeding is important for providing nutritional support but can be dangerous if performed incorrectly.
Feeding using a pump and medicine delivered through the feeding tube forms part of the formal training program and must be signed off by a Registered Training Organisation.
Supporting Documents
Policies
1.1
Forms
NGO Course Report
NGO User Report
Training Attendance Sheet
Information Sheets
Gastrostomy Guide
Tube Feeding at Home
Tube Feeding Fact Sheets
Training
PEG Feeding Akadia Training
Legislation
Health Act 1937 (QLD)
Health Regulation Act 1996 (QLD)
National Disability Insurance Scheme Act 2013
NDIS (Provider Registration and Practice Standards) Amendment Rules 2021
NDIS Practice Standards and Quality Indicators
BigDog Support Services Pty Ltd (BigDog) is a registered NDIS provider and is required to apply the scheme’s practice standard and quality indicators.
The standards have been developed to create an important benchmark to assess provider performance and ensure that high quality and safe supports and services are provided to NDIS participants.
The four core modules are:
1.0 Rights and Responsibilities;
2.0 Governance and Operational Management;
3.0 The Provision of Supports; and
4.0 The Support Provision Environment.
The supplementary modules cover:
5.0 Specialist Support
5.1 High intensity daily personal activities
5.2 Implementing behaviour support plans
5.1 High Intensity Daily Personal Activities
These NDIS Practice Standards set out the responsibilities of BigDog when providing supports and services to clients that require the following.
5.1.1 Complex Bowel Care
5.1.2 PEG Feeding and Management
5.1.3 Severe Dysphagia Management
5.1.4 Tracheostomy Management
5.1.5 Urinary Catheter Management
5.1.6 Ventilator Management
5.1.7 Subcutaneous Injections
5.1.8 Complex Wound Management
5.1.2 PEG Feeding and Management
Enteral (Naso-Gastric Tube – Jejunum or Duodenum) Feeding and Management
Each participant requiring enteral feeding and management receives appropriate nutrition, fluids and medication, relevant and proportionate to their individual needs.
Human Services Quality Standards
The Standards set a benchmark for the quality of service provision. Each Standard is supported by a set of performance indicators which outline what BigDog is required to demonstrate to meet that standard.
3 Responding to Individual Need
The assessed needs of the individual are being appropriately addressed and responded to within resource capacity.
3.3 BigDog ensures that services to the individual/s are delivered, monitored, reviewed and reassessed in a timely manner.
6 Human Resources
Effective human resource management systems, including recruitment, induction and supervisory processes, result in quality service provision.
6.3 BigDog provides people working in BigDog with induction, training and development opportunities relevant to their roles.
Delegation of Authority
Name Position Details
Steven Paull Director
Courtney Carroll Director
David Burrett Operations Manager
Monique Paull HR Manager Lawyer
Authorise review and implementation
Authorise review and implementation
Ensure information dissemination
Ensure compliance by employees
Version Details
This policy will be reviewed every twelve (12) months unless circumstances deem it necessary to review earlier. The review process will involve an analysis of the usefulness of the policy and to note any changes which are required to improve the policy. If minor changes are made in wording or to clarify the intent, the version number will indicate this by adding a ‘point’ i.e. Version 1.0 indicates the original version and 1.1 with the first round of minor changes made. A significant change or intent of the policy will be indicated by a whole new number i.e. Version 2.0.
The following rules also apply in interpreting this policy:
• Headings are for convenience only and do not affect interpretation.
• A singular word includes the plural and vice versa.
• A word that suggests one gender includes the other genders.
January 2023
March 2024
6.0 Included Human Services Quality Framework (HSQF) and Child Protection Act and the term “Participant” is returned to “Client” to allow for policies to cover NDIS and HSQF
6.1 Disability Services Act 1986 replaced with Disability Services and Inclusion Act 2023 and policy review process included