Enteral feeding - Nationalarchives.gov.uk

High Impact Intervention
Enteral feeding care bundle
Aim
To reduce the risk of infection associated with enteral feeding.
Context
The aim of the care bundle, as set out in this high impact intervention (HII), is to ensure appropriate
and high quality patient care. Regular auditing of the care bundle actions will support cycles of
review and continuous improvement in care settings.
Registered providers must audit compliance against key policies and procedures for infection
prevention, inline with the relevant legislation at the time of publication 1 .
Enteral feeding is concerned with using the gastrointestinal tract for the delivery of nutrients,
consuming oral supplements and all types of tube feeding. This method of feeding has resulted in a
range of different routes and systems for delivery of nutrition, and more patients are now being fed
using home enteral feeding tubes in the community setting. In 2007 there were 21,858 (point
prevalence) adult home enteral tube feeding patients registered via the British Artificial Nutrition
Survey 2 .
The need for education and training in infection prevention and control is vital for the provision of the
clean and safe care of all enteral feeding systems. The National Institute for Health and Clinical
Excellence (NICE) 3 found that 30% of feeds were contaminated with a variety of micro-organisms,
largely due to the poor preparation or poor administration of feeds. While the research found that
the rates of contamination were highest in home settings and thus reinforced the need to focus on
infection prevention and control practices within the community setting 4 , this HII and the care actions
are also relevant for the acute care setting.
The care actions outlined are based on the NICE guidelines 3 as well as additional acute and primary
care enteral guidance 4,5,6,7 to form the basic elements to reduce the risk of health care associated
infection.
This HII is not meant to replace existing guidelines but to act as a simple method for improving the
reliability of the clinical process. Where local guidance and policies already exist, their use in
clinical practice can be assessed by using this care bundle or by tailoring the review tool to meet
local needs.
Staff competence and training:
In line with policy, staff should be appropriately trained and competent in any stated procedure or
care process. Assessment of competence is not a specific care action within the HII as it is a prerequisite
for any care delivered. Registered care providers will have mechanisms for assuring
training, assessment and recording of competence
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Elements of the Care process
The following actions are outlined as good practice for reducing the risk of infection associated with
enteral nutrition.
Reducing risks of infection associated with enteral nutrition processes
1. Hand hygiene and PPE
Disposable apron worn.
Hands are decontaminated immediately before and after each episode of patient contact using
the correct hand hygiene technique. Use of the WHO ‘5 moments of hand hygiene’.
2. Selection of enteral feeding systems
Pre-packaged, ready to use feeds are where possible used in preference to feeds requiring
decanting, reconstitution or dilution 3 .
3. Preparation and storage of feeds
Feeds are stored according to manufactures instructions and where applicable food hygiene
legislation.
A clean working area is prepared and only equipment dedicated for enteral feed are used when
decanting, reconstituting or diluting feeds 3 .
Additions to sterile feeding containers are made only when there is no alternative and following
an initial risk assessment.
4. Set up of the enteral feeding system
Aseptic technique is used when connecting and flushing enteral feeding tubes 3 .
Gloves and apron are worn and disposed off in line with local policy immediately after use.
Line should be labelled and dated and signed and documented in patient records.
5. Hang time
The ‘hang time’ for closed enteral feeding systems does not exceed 24 hours /non-sterile
feeding systems does not exceed 4 hours 3 .
6. Single patient use equipment
Single patient use equipment is stored clean in a lidded container marked with the patients
name.
Single use equipment is immediately discarded after use 7 .
7. Water flushes
Sterile water is used to flush enteral feeding tubes in hospitalised patients, all patients fed via
the jejunum or immuno-compromised patients 6 .
Freshly drawn tap water is used for all other patients.
Single –use syringes or re-usable single patient use syringes used to flush. or reusable syringe
is washed, dried thoroughly and stored in an airtight container until re-use.
Tap water (freshly drawn or boiled water) to be used in non hospitalised patients 6 .
Where used, sterile water bottles are dated when opened and discarded in line with
manufacturers instructions.
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8. Stoma site
Sterile stoma dressing techniques are carried out for the first 3 days after initial placement.
After 3 days (if the site is uncomplicated) the stoma site is washed daily with water and dried
thoroughly.
Dressings are used if the gastrostomy site is discharging or the patient chooses to have them 9 .
Using the care bundle and the electronic tool
The use of this care bundle will support cycles of review and continuous improvement, which will
deliver appropriate and high quality patient care.
Audits of compliance to the care bundle should be carried out regularly and the results recorded at
the point of care. They should be carried out by peers and the results can be collected manually or
electronically depending on what is appropriate. The use of an electronic, graphical package such
as the HII electronic tool provided is recommended, as this will increase the understanding and
usefulness of the overall results.
The electronic tool will:
Collect, collate and produce different views of the information.
Clearly identify when actions within the care bundle have or have not been performed.
Provide information to support the development of plans to resolve any issues and improve the
quality of care.
Support a culture of continuous improvement.
Recording and making sense of the results
Print an audit sheet from the HII electronic tool or alternatively create one such as the example
below.
When a care bundle action is performed, insert a Y in the relevant column. If the action is not
performed, insert an X in the relevant column.
When the care action is not performed, as it is not applicable (for example local policy has
determined it as not applicable in all or certain situations) insert an N/A to demonstrate that local
policy is being adhered to. (This is then recognised as a Y when total compliance is been
calculated).
Calculate the totals and compliance levels manually or enter the results into the HII electronic
tool to calculate these for you.
The goal is to perform every appropriate action of care every time it is needed and achieve
100% compliance with the care bundle. The “All actions performed” column should be filled with
a Y when all the appropriate actions have been completed on every required occasion. See the
example below.
Where actions have not been performed, overall compliance will be less than 100%. This
provides immediate feedback for users of the tool on those care bundle actions not completed,
and action can then be taken to improve compliance levels.
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Example audit sheet
1
2
3
4
5
Total number of times an
individual action was
compliant
Actions
% when action of care was
given
Care action
1
Care action
2
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Care action
3
Care action
4
All actions
Y N Y Y N
Y Y N Y N
Y Y N/A Y Y
Y Y Y N N
Y Y Y Y Y
5
100%
4
80%
This example tool shows that while most care actions were performed, on only two occasions
were ALL actions performed correctly while all actions was only 40% and as a result the risk of
infection was significantly increased. (Please note for observation no 3. the N/A was calculated
as a Y and overall compliance was achieved).
When the information has been entered into the HII electronic tool a compliance graph for each
action of care and for overall compliance to the care bundle can be produced. This will show
where to focus the improvement efforts to achieve full compliance and achieve high quality
patient care.
4
80%
4
80%
2

References:
1 Department of Health. The Health and Social Care Act 2008: Code of Practice on the prevention and
control of infections and related guidance. Department of Health, London, 14 Dec 2010. Available at
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_1226
04
2 BAPEN (2008) Annual BANS Report 2008. Artificial Nutrition Support in the UK 2000-2007. A report by
the British Artificial Nurtrition Survey (BANS), a committee of BAPEN www.bapen.org.uk
3 National Institute for Clinical Excellence. (2003) Infection control, prevention of healthcare associated
infection in primary and community care - NICE Guideline. London: National Institute for Clinical
Excellence
4 National Collaborating Centre for Acute Care, February 2006. Nutrition support in adults Oral nutrition
support, enteral tube feeding and parenteral nutrition.
National Collaborating Centre for Acute Care, London. Available from www.rcseng.ac.uk
5 National Institute for Clinical Excellence (2006) Quick reference guide. Nutritional Support in Adults. Oral
nutritional support, enteral tube feeding and parenteral nutrition. www.nice.org.uk
6 Infection Control Nurses Association (2003) Enteral feeding – infection control guidelines www.ips.uk.net
7 MHRA DB 2006 (04) Single use medical devices: Implications and consequences of reuse.
http://www.mhra.gov.uk/Publications/Safetyguidance/DeviceBulletins/CON2024995. (last accessed
18/06/2010
8 Infection Prevention Society (2010) Quality Improvement tools. www.ips.uk.net (Documents still awaiting
publication as of 18/06/2010)
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