Overview

• Homewise Health (HWH) is committed to supporting our staff as they provide care for those living with a Percutaneous Endoscopic Gastrostomy (PEG) or other enteral feeding tubes. 
• HWH will work with each of our clients who have an enteral feed to make sure they receive the support required to meet their specific needs. The Clinical Care Managers (CCMs) will engage with each client and their support and health network when assessing and developing a plan for the management.
• When appropriate the HWH team will provide education, management, and monitoring to the carers and family to ensure safe and best practice care in the community. 

• Supporting clients to eat naturally by oral means is always preferred. However, some people cannot eat or drink safely or are at risk of malnutrition. These problems are often associated with:
  • neuromuscular disorders that affect chewing and swallowing coordination that may result in aspiration (e.g. dysphagia associated with cerebral palsy, motor neurone disease, brain injury, Huntington’s disease, stroke)
  • medical problems and/or structural abnormalities of the gastrointestinal tract, e.g. inflammatory bowel disease, cancers, hepatic, renal or respiratory failure, anorexia, HIV/AIDS
  • cognitive impairments that affect the capacity to coordinate chewing and swallowing safely
  • fatigue associated with illness
  • failure to thrive or severe reflux in infants
  • reduced level of consciousness.
• Enteral tube feeding can provide nutrition to a person at risk of malnutrition and/or choking. It can be used to:
  • administer bolus, intermittent feeds or continuous feeds
  • administer medication
  • facilitate free drainage and aspiration of the stomach contents
  • facilitate venting/decompression of the stomach.
• There are many types of enteral feeding tubes, this policy covers the most commonly used as described in the table below.

Peg Tube

• Most of our clients who have a long term enteral feed will have a PEG tube. 
  • This is a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. 
  • The PEG feeding tube is situated in either the stomach or the small intestine.
• Children sometimes need G-tubes for different kinds of health problems, including:
  • congenital (present at birth) problems of the mouth, esophagus, stomach, or intestines
  • sucking and swallowing disorders (due to premature birth, injury, a developmental delay, or another condition)
  • failure to thrive (when a child can't gain weight and grow normally)
  • extreme problems with taking medicines
• Adults PEG Feeding is prescribed when a person cannot eat, digest or absorb food. 
  • This may be due to difficulty in swallowing from cancer, surgery, stroke, trauma, burns, anorexia, inflammation of the pancreas or irritable bowel disease. 
  • The PEG tube can also be used to take air and fluid out of the stomach. 
• Adults with a PEG feeding tube are taught to manage their PEG feeding, cleaning and care of the PEG stoma site and equipment. 
  • People who are older, vulnerable, disabled or intellectually impaired will require physical support to manage their PEG food preparation, stoma site and equipment. 
  • Family members and professional carers can be taught to support a person or provide PEG feeding. 
  • People who are PEG feed should be weighed each week and maintain a weight chart to share with their Doctor and Dietician.
• Clients should always be involved in decisions that affect them including whether to use a feeding tube. 
  • This should be decided together with the client's family/carer/guardian after assessment by a speech pathologist, dietitian, gastroenterologist and/or paediatrician.
• Where nutrition intake is the concern, tube feeding may supplement a person’s oral intake. 
• If there are safety concerns for a person with severe dysphagia and chronic aspiration, all nutrition and hydration are administered via tube.

• when clients are supported that need enteral tube feeding
• to all HWH employees including key managers supporting clients with enteral tube feeding needs

Policy

• assess all clients during the entry process for nutrition and swallowing as part of a comprehensive health assessment, which is reviewed at least yearly (or more often if there are significant changes to a client's health)
• decisions on whether to use tube feeding must be person-centred and involve the participant, their family, carer, guardian
• the person-centred assessment should assess the client's home environment and lifestyle
• clients should be provided additional support when making decisions about tube feeding such as specialised advice from a dietician
• clients that require tube feeding will be involved in making an enteral feeding management plan that suits the individual
• clients being tube-fed should be provided opportunities and supported to enjoy the oral intake
• only workers trained in tube feeding can support clients with tube feeding.

• Blended, or Blenderized, Diets (BD) are basically just meals that have been 'liquefied' into a fine puree so that they can fit into the PEG feeding tube. 
  • The meals can be homemade or purchased from a food preparation company. Foods are blended with cool boiled water to create a liquid consistency. 
  • Some good foods to consider blending include bananas, apples, peaches, pears, plums, avocados, oats, rice, sweet potatoes, green beans, squash, peas, chicken, turkey, and beef. 
• Some clients will choose a prepared powder formula such as Sustagen or prepared meals such as Nutrision Advanced Diason 1000ml.
• The dietitian will advise the client of their nutritional needs. 
  • A client will be prescribed a liquid formula containing the nutrients that their body needs. This includes protein, fat, carbohydrate, fluid, vitamins and minerals. 
  • Carers are not to cut down on the amount of formula prescribed. 
  • Do not give other liquids in place of the formula.

• Tube feeding can be given in 3 different ways – using a pump, using a gravity drip or using a syringe. 
  • A pump is used for continuous or intermittent feeds where the formula is given without stopping over 8-24 hours. 
  • A gravity drip is used to give larger amounts of formula over a shorter period of time usually 4 to 6 times each day. 
  • Feeding using a syringe is the fastest method where larger amounts of the formula are given at a time. Feeding using a syringe or gravity drip can also be called bolus feeding.

• Never give PEG feeds while the client is lying flat. 
• The client should sit in a chair or lie with their head raised to at least 30 degrees or on three pillows. Client to remain in this elevated position after feeding e.g. for 30-60 minutes after a feed.  

• Hand hygiene and PPE - gloves
• Use clean equipment
• Use the directions given on the tin, or as recommended by the dietitian 
• Measure powder and fluids carefully 
• Mix the powder into the fluid well
• Make sure there are no lumps left in the feed 
• Do not heat the formula
• If using a prepared meal such as Nutrison ensure the pack is intact before opening

• Store tins of powder in a dry, cool place 
• Keep unused, made-up formula covered and in the fridge 
• Throw away any made-up formula after 24 hours 
• Do not heat the formula If the formula is in cans or long-life cartons
• Store in a cool dark place
• Ensure to shake them well before feeding
• Check the expiry dates
• Refrigerate any unused portion of the formula and use within 24 hours or discard
• Allow refrigerated foods to come to room temperate before given (usually remove from fridge 30 mins before given)

• The PEG tube will require cleaning daily, generally, this is done before and after meals.
• Before meals or medication is often called prime the tube and the post meals or medication is often called a flush of the feeding tube.
• Use a clean syringe with each prime or flush. 

1. Medications are to be given through the medication port of the connector/feeding tube
2. Medications should be in liquid form 
3. Crush tablet mediations to a fine powder using a pill crusher and mix with cool boiled water 
4. Each mediation should be given separately 
5. Flush the feeding tube before and after medications AND in-between each medication.

• Although the client may not be eating in the normal way, it is important to keep their mouth clean. 
• The client should brush their teeth at least twice daily with toothpaste and a soft brush. •
• Use a bought mouthwash or homemade salt solution (1 teaspoon salt added to 1 litre of water) as needed to freshen their mouth and breath.
• If the client has a dry mouth due to their treatment, use a salt solution mouthwash as bought mouthwashes containing alcohol can make the mouth dryer.
• If allowed, ice chips or sugarless gum can be used to prevent a dry mouth.
• Lip cream can prevent dry lips. Encourage the client not to lick their lips, as this will make them even dryer.
• Encourage the client to try to breathe through their nose.
• Report any bleeding or mouth problems 

• All workers and key managers must be aware of potential problems and appropriate corrective measures for clients receiving enteral tube feeding.
• Serious complications include tube dislodgement, septicaemia, nausea and vomiting, imbalanced nutrition, fluid and electrolyte imbalance, dehydration.
• Common problems include:
  • occlusion of feeding tubes (blockages)
  • vomiting and or aspiration—caused by improper tube placement, delayed gastric emptying, contamination of formula
  • diarrhoea—feeding too fast, lactose intolerance, contamination of formula
  • constipation—formula components, poor fluid intake, medication effect.
• Managing enteral tube feeding is complex care. 
  • Seek the advice of healthcare professionals if needed. 
  • Close consultation with nutritional support experts can address and resolve issues.

• Call the doctor if your client has any of these problems:
  • a dislodged tube
  • a blocked tube
  • any signs of infection (including redness, swelling, or warmth at the tube site; discharge that's yellow, green, or foul-smelling; fever)
  • excessive bleeding or drainage from the tube site
  • severe belly pain
  • vomiting or diarrhoea that keeps happening
  • trouble passing gas or having a bowel movement
  • pink-red tissue coming out from around the tube

• provide best practice guidelines for the management of clients receiving enteral feeding
• maintain both knowledge and problem-solving skills and a willingness to provide reassurance to clients and seek help when needed
• practice good hand hygiene and wear PPE as required
• accurate documenting including: 
  1. input and output
  2. formula/feed labelled with date and time opened
  3. baseline weight and weekly weight of the client
  4. condition of the skin around nasal cavity and lining for redness or maceration
  5. the due date for change of pump tubing (as per manufacturer's guidelines)
• ensure feeding tubes are kept clean and are flushed before and after feeding or medication
• confirm feeding tubes are in the correct place before any feed or medication is given
• feed clients according to their tube feeding management plan and the enteral tube feeding process
• promote healthy oral hygiene in clients with no oral intake
• maintain clean work surfaces and proper disposal of equipment and waste
• minimise complications with enteral tube feeding: 
  1. use liquid medications rather than pills
  2. dilute viscous liquid medications
  3. discard outdated formula
  4. follow general principles of tube feeding e.g. elevating the head of the bed and position the client comfortably
  5. flush feeding tubes regularly to maintain tube patency before and after bolus feeds, administration of medications
  6. assess regularly for complications e.g. aspiration, diarrhoea, constipation.

• Work with the health professionals to develop a feeding plan that fits in with their lifestyle.
• Ask questions 
• Talk to their health professionals about any concerns
• Keep this information handy: 
  • type and size of the feeding tube and the date it was inserted or last replaced
  • feeding plan
  • contact numbers for relevant health professionals

• ensure carers supporting clients with tube feeding are trained and confident to provide this support
• ensure clients are provided information about tubes, feeding, the purpose and possible complications so that they can make decisions based on correct information
• ensure workers' education and training covers: 
  1. positioning of the person
  2. medical administration
  3. infection control
  4. flushing of feeding tubes
  5. care of insertion site
• regularly audit enteral tube feeding management practices
• provide a template for recording data including specific medical orders
• provide information about complications of enteral feeding and escalation in an emergency