Issue 123 nasogastic feeding of adult patients in the community setting

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COMMUNITY

NASOGASTRIC FEEDING OF ADULT PATIENTS IN THE COMMUNITY SETTING Sean White Home Enteral Feed Dietitian, Sheffield Teaching Hospitals NHS Foundation Trust

Anne Mensforth Nutrition & Dietetic Service Manager, Leicestershire Partnership NHS Trust

For full article references please email info@ networkhealth group.co.uk

BAPEN’s new NG specialist interest group (SIG) will debate complex issues, advance practice and aims to share policies, protocols and resources. It is hoped that the group will address some of the issues highlighted in this article.

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When a patient is unable to meet their nutritional requirements via the oral route, the placement of an enteral feeding tube may be considered. The chosen route of feeding is influenced by number of factors, including the length of time that enteral feeding may be required, patient choice and presence of any contraindications to tube placement.

If enteral feeding is likely to be required for less than four weeks, a nasogastric tube (NGT) is usually the tube of choice.1 When enteral feeding is required for longer, a gastrostomy or jejunostomy feeding tube should be considered, to avoid some of the problems associated with nasogastric (NG) feeding that will be discussed in this article. However, some patients may remain on longer-term NG feeding for a number of reasons including: • patient choice; • peri-operative enteral feeding; • contraindications to placing an enterostomy feeding tube; • to meet nutritional requirements while waiting for an elective enterostomy feeding tube to be placed; • the requirement for a period of time on an elemental feed, when unable to take this orally; • unclear evidence base regarding feeding route choice during and following chemoradiation for head and neck cancer.2 A clinically stable patient, with the appropriate training and support, can be transferred to their own home or residential care to continue enteral feeding. Gastrostomy feeding remains the dominant route of enteral feeding in the community setting, with just 17% of adult patients on home enteral feeding (HEF) fed via a NGT and a further 4% fed via a naso-duodenal or naso-jejunal tube.3 The aims of this article are to discuss: • potential problems associated with NG feeding in the community setting and strategies to overcome them;

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• discharge planning for a patient on NG feeding; • the importance of specialist teams supporting patients on home NG feeding.

NASOGASTRIC TUBE PLACEMENT

Most NG feeding is currently initiated in hospital, with relatively few adults discharged to the community while continuing NG feeds compared to those on gastrostomy feeding. A range of social, psychological and practical problems exists in the context of HEF,4 but this article will focus on practical issues regarding NG feeding, including the avoidance of tube displacement and requirement to confirm correct NGT position following initial placement and prior to each administration of feed, medication or water.5 The risks associated with NG feeding were identified as far back as 1851, where patients were said to be ‘drowning with chicken broth’, and NG feeding was described as ‘a troublesome task and if confided to ignorant keepers is also a perilous one’.6 This observation could still apply in today’s NHS. The NPSA Patient Safety Alert published in March 2011, highlighted reports of 21 deaths and 79 cases of harm as a result of feeding into NG tubes placed in a patient’s lungs.5 Misplacement of a NGT into the lung became a ‘never event’ in England from 2009.7 All incidents or near misses should be reported and NHS Trusts are expected to have rigorous systems in place to support staff in safe placement of NGTs.8

Table 1: Risk assessment prior to discharge home Risk

Management strategies

Displaced tube

1. Appropriate tube securement method used, e.g. nasal/cheek securement dressings or bridles.

2. Review of any tube displacement history while in hospital.

3. Consider use of mittens (would require reference to, and compliance with local ‘restraint’ policy).

4. Clear care pathway to deal with displaced tubes.

Unable to confirm correct position of tube

1. If possible, identify and resolve issue prior to hospital discharge.

2. Patient given strategies to obtain aspirate and guidance on interpretation of pH of aspirate.

3. Clear care pathway to deal with inability to confirm correct tube position.

Aspiration

1. Alter feeding method or rate of feed delivery to minimise aspiration risk.

2. Position patient at an angle of greater than 30 degrees.

3. Avoid unsupervised and overnight feeding where the patient is unable to discontinue their own feeds in the event of problems.

Ability to feed via NGT at home.

1. Confirm patient or carers competence to perform feeding method and check NGT position prior to discharge home, including problem solving strategies.

2. Appropriate support arranged for patient, e.g. community nurse, HEF team and care agency visits.

Correct gastric positioning of the tube should be confirmed by checking that fluid withdrawn via the tube has a pH of 5.5 or below, and the external length of the NGT should be documented and re-checked before each feed. Radiography is the alternative method if aspiration is unsuccessful.

While hospital inpatients may return to the x-ray department if there is uncertainty regarding tube position, frequent referrals from the community for this purpose would be impractical9 and, indeed, the x-ray ‘snapshot’ could not be relied on to provide assurance later on arrival home.

DISCHARGE PLANNING

Discharge planning for HEF should commence as early possible, to identify and overcome possible barriers to a seamless and safe transition to the community setting.10 HEF is a recognised cause of stress and anxiety for patients and their families,11 and for patients with NGTs, the tasks are complicated by the additional safety considerations with this method of feeding. NICE quality standard QS24 alludes to the importance of patient/carer competence and confidence in the management of their own enteral nutrition.12 A range of topics must be included in pre-discharge training, including confirming tube position, feed administration methods and troubleshooting related to frequently encountered problems.1 A lower incidence of enteral-feed-related complications and improved

carer knowledge was observed when caregivers received comprehensive training on nasogastric care prior to discharge of a patient from hospital on NG feeding.13 Patients or carers must be informed of the risks associated with not confirming tube position and advised on the actions to take if they experience problems. Any recurring difficulties confirming tube position identified in hospital should be addressed during the pre-discharge training, though pressure to free hospital beds may limit the time available for patients to practise.

Nevertheless, discussion regarding potential scenarios and practical solutions increases confidence and empowers the patient to safely selfmanage problems once home. This in turn may reduce reliance on community health services and lower the incidence of readmission to hospital with tube-related problems. However, there remains contention about how to manage patients who are unable to confirm NGT position in the community, with the only risk-free option being admission to hospital for radiological confirmation.14 The discharging clinical team should complete a rigorous risk assessment and ensure care pathways are in place to ensure feeding can be maintained, prior to a patient being transferred to the community setting on NG feeding (Table 1).5 Good working relationships and lines of communication between the hospital and the www.NHDmag.com April 2017 - Issue 123

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COMMUNITY HCPs supporting patients at home are essential to facilitate a smooth transition into primary care. On discharge, detailed referrals should be forwarded to the HEF team, district nurse and GP, with arrangements made to ensure that the patient has a supply of all the equipment they require to safely continue NG feeding at home including: • supply of feed, syringes and other ancillaries as required; • spare NGT securement dressings; • adequate supply of pH paper, based on estimated usage; • a spare NGT for use in the event of a displacement or for routine replacement; • written information about the care of the tube, feeding method and complication management; • contact details for supporting health professionals in the community and hospital.

NG FEEDING AT HOME

With the right support and systems in place, patients can safely NG feed at home.15 However, lack of immediate access to HCPs with the knowledge and skills to resolve issues in the community, or direct access to radiology, can result in prolonged periods without feed, water or important medications.

Rigorous multidisciplinary, cross-healthcare-setting solutions are needed to manage these problems efficiently when they occur, with the least distress to the patient.

Complications patients may face, and strategies for their management are discussed below.

Problem 1: Unable to obtain a gastric aspirate Potential causes: • A small volume of gastric contents.

• The tip of the NGT not sitting in gastric contents.

• The exit port of the NGT being too close to the gastric mucosa.

• The NGT may have migrated into the duodenum, coiled back up into the oesophagus, or worse-case scenario be in the lungs.

Management strategies: 1. Lie patient on left-hand side. This may encourage the tip of the NGT to fall into the natural reservoir of the stomach.

2. Blow a small volume of air via a syringe down the NGT, to push tip away from gastric mucosa.

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3. Check the tube remains at the previous external length measurement. If necessary, advance or withdraw the tube slightly, to encourage NGT to fall into the gastric contents.

4. If safe to do so, ask the patient to take oral fluids.

5. Wait and try again later.

HEF recommendations: The patient should have clear guidance on what to do in the event of obtaining no gastric aspirate. This will include seeking advice from community HCPs such as the HEF team or district nurses, or contact details for hospitalbased nutrition nurses or dietitians, depending on the structure of local services. If hospital admission is required, care pathways should be designed to allow the patient efficient access to radiology services, to allow feeding to recommence as soon as possible.

Problem 2: Aspirate obtained above pH 5.5 Potential causes: • Proton pump inhibitor (PPI) medication, e.g. omeprazole or lansoprazole.

• H2-receptor antagonists, e.g. ranitidine.

• Antacids, e.g. Gaviscon.

• Frequent bolus feeds or continuous pump feeding not allowing gastric aspirate pH to drop.

Management strategies: 1. Allow longer breaks between bolus feeds, or between pump feeding sessions, to allow pH to drop below pH 5.5.

2. Seek advice from the prescriber regarding the need for, and the timings of, antacid medications.

3. If safe to do so, offer oral fluid of an acidic nature (e.g. fresh orange or pineapple juice) to reduce the pH of the aspirate.

4. Be aware of other signs of tube migration or displacement, such as external tube measurement, respiratory distress or recent coughing, retching or vomiting.

HEF recommendations: A small number of patients will not be able to gain an aspirate of pH 5.5 or below. Having completed further risk assessment and discussion with clinical governance or the medical team, it may be appropriate in this situation, when there is no reason to suspect displacement since initial insertion, to assess tube position through external observation of the tube.5 Patients should always

be clear about the actions to take when they are unable to confirm the position of their NGT. Problem 3: Displacement of NGT Potential causes: • Coughing or vomiting.

• Inadvertently or intentionally pulling the tube.

Management strategies: Local strategies need to be developed to minimise the risk of displacement and to ensure that a patient is aware of what to do in the event of this occurrence.

These may include the following: 1. Ensure that the tube is well secured at the nose or to the cheek. A number of options are available including nasal securement devices or dressings, e.g. opsite, tegaderm, hypafix.

2. If NGT displacement is likely, the insertion of a nasal bridle may be considered as per local policy.

3. Consider how the feeding method may affect risk of displacement. Bolus feeding may present lower risk due to less time attached to a giving set that could increase likelihood of pulling at NGT. 4. Ensure the patient is on appropriate antiemetic treatment to control vomiting.

HEF recommendations: The risk of NGT displacement should be considered carefully before discharging a patient home, and plans for replacement agreed. Some patients may wish to remove and replace their own NGT and training for them or their carer should be considered.16 Assuming this can be accomplished safely, it will empower the patient and reduce demands on community health professionals and acute services.17 Alternatively, efforts should be made to increase the availability of competent community health professionals, such as HEF dietitians or nursing staff appropriate to local arrangements. Barriers to achieving and maintaining competence and confidence may include infrequent NGT placements, where patient numbers are low.

If acute hospital attendance is necessary, there should ideally be a designated area, such as a medical assessment unit or ambulatory care area, to reduce the burden on emergency departments and improve the experience for patients.18

IMPORTANCE OF HEF TEAM SUPPORT

Being discharged on HEF is a cause of stress and anxiety for patients and their families.11 With the low prevalence of patients on HEF and even fewer on home NG feeding, generalist HCPs such as district nurses and GPs are unlikely to have sufficient exposure to this practice to deal with the problems described in a safe and efficient manner.

Centralising the source of expertise within a HEF team can have benefits for patients and HCPs. Having completed competency based training, HEF team members are able to take on the responsibility for tube placements/replacements and problem solving. Nurses, or dietitians with extended roles, are ideally placed to take on these tasks and in some areas where there are competent HCPs, there is a move towards the initial placement of NGTs and commencement of enteral feeding in the community setting.

Positive outcomes from specialised HEF teams managing NG feeding may include: • reduced admissions to hospital, and associated cost savings;19 • improved compliance with enteral feed plans and medication regimens due to reduced incidence of problems; • empowerment of patients and community HCPs to manage NGT-related complications, through training and education; • maintenance of a central source of expertise for the local health region; • strengthened bids for additional staff resource to care for this select group of community based patients.

CONCLUSION

With an estimated prevalence of malnutrition in adults in England of 5% and 30% of adults on admission to hospital,20 it could be argued that dietitians treating malnourished patients in the community should have available to them a full toolkit of nutrition support interventions, including NG feeding. A more widespread uptake of this practice may result in more timely initiation of the right nutrition support option for the patient. Further research is required to assess the staff resource required to support this novel approach and to investigate the possible economic and health benefits. www.NHDmag.com April 2017 - Issue 123

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