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National Clinical Guideline Centre (UK). Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2. London: Royal College of Physicians (UK); 2012 Mar. (NICE Clinical Guidelines, No. 139.)

Cover of Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care

Infection: Prevention and Control of Healthcare-Associated Infections in Primary and Community Care: Partial Update of NICE Clinical Guideline 2.

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11Enteral feeding

11.1. Introduction

The updated review questions in this chapter are:

Asepsis was considered as a priority to be included in this update as this area was not included in the previous guideline. The previous guideline did refer to aseptic techniques in the recommendations, but the terminology was considered to be incorrect or out-of-date by the scoping group. This area was also highlighted many times by various stakeholders during the scoping consultation as an area that should be included in the scope. The use of syringes (single-use syringes vs. single patient use (reusable) syringes) was also highlighted during the scoping phase as an area for update.

No new evidence was found, however changes were made to recommendations in section 11.4.2.3 and 11.5.2.4.

The evidence and text from the previous guideline that has been superseded by this update is included in Appendices D.6 and D.9.

No new review questions are included in this chapter.

The GDG recognised that hand decontamination is an important part of enteral feeding. See chapter 6 for further details.

Sections not updated in this chapter are:

  • preparation of storage feeds
  • administration of feeds
  • care of the insertion site.

In addition the GDG acknowledge that Medical Device Regulations169 implement the EC Medical Devices Directives into UK law. They place obligations on manufacturers to ensure that their devices are safe and fit for their intended purpose before they are CE marked and placed on the market in any EC member state. The GDG noted that guidance on the MHRA’s adverse incident reporting system is available for reporting adverse incidents involving medical devices.168

Once enteral feeding (EF) in hospital became common practice in the late 1980s, it was inevitable that those requiring prolonged feeding would continue this treatment at home. Enteral feeding is usually prescribed for patients in hospital requiring artificial nutrition support (ANS) for 7–10 days and long-term feeding/home enteral tube feeding (HETF) may be considered for patients needing ANS for more that 30 days.8 HETF has expanded rapidly and by the end of 2000, 11,817 adult patients receiving HETF were registered with the British Artificial Nutrition Survey (BANS).82 Of these, 46.5% were over 70 years of age. Over 60% of the patients were receiving tube feeds because of disorders of the central nervous system, of which cerebral vascular accident accounted for 34%. It was reported that over half the adult patients and virtually all children starting home enteral feeding lived in their own home and 40% of adults lived in nursing homes.

Nutrition Support Teams (NST) are recommended to support patients receiving artificial nutrition.82 However, only 22% of NST stated that they were responsible for HETF and 47% stated that they were never responsible.82 In addition, only one third felt that they had sufficient time to train patients on HETF prior to discharge from hospital. It is therefore not surprising that enteral feeding places a growing workload on community healthcare workers158 and an audit of patients on HETF highlighted a need for continuing support.142 Contamination of feeds is a key concern in HETF as it has been found that more than 30% of feeds in hospital and home are contaminated with a variety of microorganisms, largely due to the preparation or administration of feeds,10 and this has been linked to serious clinical infection.203 The rates of contamination are highest in home settings and reinforces the need for infection prevention guidelines.10

Despite searching for infection prevention measures associated with nasogastric and jejunostomy feeding, most of the evidence related to gastrostomy or percutaneous endoscopic gastrostomies (PEG feeds). Although these guidelines have been developed for gastrostomy feeding, the Guideline Development Group felt that most of these principles could also be applied to other feeding systems.

These guidelines apply to adults and children over 1 year old and should be read in conjunction with the guidance on Standard Principles. These recommendations are broad principles of best practice and are not detailed procedural protocols. They need to be adapted and incorporated into local practice guidelines. The recommendations are divided into four distinct interventions:

  1. Education of patients, their carers and healthcare workers
  2. Preparation and storage of feeds
  3. Administration of feeds
  4. Care of insertion site and enteral feeding tube.

11.2. Education of patients, carers and healthcare workers

Although not a specific question for our systematic review, it has become evident from our research that the responsibility for preparing and administering HETF lies usually with the patient, their carers and in some cases, community healthcare workers. An audit of the nursing knowledge of percutaneous endoscopic gastrostomy (PEG)126 of hospital nurses in a district general hospital identified gaps in their knowledge and management of enteral feeding systems and a similar situation was noted in the community.276 The BANS survey noted the less than optimum support people on HETF receive82 despite expert opinion stressing the need for education and training.2,166 Given that nutrition is a key Department of Health patient-focused benchmark for healthcare practitioners,63 it is of concern that this does not include those receiving artificial nutrition and consequently support and preparation for these patients is not widely available.

A system known as Hazard Analysis and Critical Control Point (HACCP) is employed widely in the food industry to highlight areas where food safety may be at risk. The Parenteral & Enteral Nutrition Group of the British Dietetic Association supports the use of HACCP in enteral feeding to increase safety and as an educational tool.9

11.2.1.1. Recommendations

59.

Patients and carers should be educated about, and trained in the techniques of hand decontamination, enteral feeding and the management of the administration system before being discharged from hospital. [2003]

60.

Healthcare workers should be trained in enteral feeding and management of the administration system. [2003]

61.

Follow-up training and ongoing support of patients and carers should be available for the duration of home enteral tube feeding. [2003]

11.3. Preparation and storage of feeds

11.3.1. Select the right system

Our systematic review identified two randomised controlled trials, which demonstrated that closed systems (i.e., sterile prefilled ready-to-use feeds that do not expose feed to the air during assembly) as available from all major manufacturers, have lower contamination rates than open systems.120,268

The design of the system is also important in order to minimise handling.22,161,275

11.3.1.1. Recommendations

62.

Wherever possible pre-packaged, ready-to-use feeds should be used in preference to feeds requiring decanting, reconstitution or dilution. [2003]

63.

The system selected should require minimal handling to assemble, and be compatible with the patient’s enteral feeding tube. [2003]

11.3.2. Hygienic preparation of feeds is essential

Hand hygiene is critical and hand decontamination is discussed more fully in Standard Principles (chapter 6). The International Scientific Forum on Home Hygiene has also published comprehensive guidance on food preparation and cleanliness in the home.235 Our systematic review identified three studies11,12,147 concerned with feed preparation. The evidence on the use of gloves is contradictory. Two studies11,12 suggested that gloves were preferable and one suggested bare hands if properly decontaminated were acceptable.147 However all three studies linked contamination to the amount of manipulation a system required and reinforces the guidance above.

Standard principles stress the importance of hand decontamination and expert opinion9,166,242 stresses the need to prepare the work surface and, where necessary the equipment for reconstituting or diluting the feed. Equipment used for either opening sterile feeds or preparing feeds should be dedicated for enteral feeding use only. It should be cleaned in a dishwasher or washed with hot soapy water, rinsed and then dried and stored covered until required. Cooled boiled water or freshly opened sterile water should be used to prepare feeds in the home.9,278

11.3.2.1. Recommendations

64.

Effective hand decontamination must be carried out before starting feed preparation. [2003]

65.

When decanting, reconstituting or diluting feeds, a clean working area should be prepared and equipment dedicated for enteral feed use only should be used. [2003]

66.

Feeds should be mixed using cooled boiled water or freshly opened sterile water and a no-touch technique. [2003]

11.3.3. Store feeds safely

Expert opinion242 and manufacturers5,91 advise that ready-to–use, prepackaged feeds should be stored in a clean environment, protected from extremes of temperature. Stock should be rotated to avoid feeds exceeding their best before date.

Where feeds need to be reconstituted or diluted they can be made up for 24 hours. All feeds not required for immediate use must be stored in a refrigerator at a temperature not exceeding 4 degrees Celsius and discarded after 24 hours.5,91

11.3.3.1. Recommendations

67.

Feeds should be stored according to manufacturer’s instructions and, where applicable, food hygiene legislation. [2003]

68.

Where ready-to-use feeds are not available, feeds may be prepared in advance, stored in a refrigerator, and used within 24 hours. [2003]

11.4. Administration of feeds

11.4.1. Minimal handling reduces risk

Four reports,108,147,160,197 which studied enteral feeds delivered in a variety of settings, demonstrated that the risk of contamination is related to the manipulation of the system and the system design. This reinforces earlier guidance about selecting a system that requires minimal handling.

When assembling the system, first assess the condition of the connection. A no-touch technique should be used to connect the feed container to the administration set using the minimum number of connectors possible. Contact with the patient’s clothes should be avoided when attaching the administration set to the enteral feeding tube.9

Administering feeds for the maximum time possible reduces handling to a minimum. Sterile ready-to-hang feeds can be left for a maximum time 24 hours and non-sterile (reconstituted) feeds for 4 hours.9,227 However even closed systems can become contaminated if hands are not adequately decontaminated.197

Bacterial contamination has been associated with the re-use of feed bags and administration sets.8 One study in a long-term care facility108 suggested that administration set changes could be left up to 72 hours but other studies83,136,227,232 suggested that 24 hours is the maximum time acceptable. Three experimental, in vitro studies13,109,244 considered the re-use of equipment but none identified a satisfactory system for disinfecting equipment that might be acceptable in practice. As evidence suggests re-use is not advisable, the administration system should be considered single-use only and discarded after each session.

Currently there appears to be a debate on the re-use of single-use syringes used to flush enteral feeding tubes. Our systematic review found no evidence to either support or refute the reuse of syringes. The Medicines and Healthcare Products Regulatory Agency’s current guidance is that medical devices labelled single-use must not be reused under any circumstances and the reuse of such medical devices has legal implications.167

11.4.2. Review question

The following question was asked to determine which technique should be used when handling PEGs as this was identified as an area where there is confusion in terminology. The GDG identified diarrhoea, vomiting, peritonitis and gastrostomy site infection as the primary outcomes of interest.

What is the most clinically and cost effective technique (such as aseptic technique, non-touch technique, aseptic non touch technique or a clean technique) when handling PEGs to reduce healthcare-associated infections?

11.4.2.1. Clinical evidence

No clinical evidence was identified in this update. No clinical evidence was identified in the previous 2003 guideline.

11.4.2.2. Cost-effectiveness evidence

No cost-effectiveness evidence was identified in this update. No cost-effectiveness evidence was identified in the previous 2003 guideline.

11.4.2.3. Recommendations

Recommendations
69.

Use minimal handling and an aseptic technique to connect the administration system to the enteral feeding tube. [new 2012]

Relative values of different outcomesThe GDG considered diarrhoea, vomiting, peritonitis and gastrostomy site infection the most important outcomes for this question. However, no evidence was identified which reported these outcomes.
Trade off between clinical benefits and harmsThe GDG recognised the potential for contamination when assembling a feeding system. Consequently adopting an aseptic technique, in which no key parts are touched, when assembling the equipment was considered the most important practice, regardless of how this is achieved. An example of this is that no open part of the enteral feeding delivery system, feed or enteral tube should be in contact with the hands, clothes, skin or other non-disinfected surface.
Economic considerationsThe GDG did not think that adopting an aseptic technique would be associated with any additional time or resource requirements.
Quality of evidenceNo clinical or economic evidence was identified.
Other considerationsA minor change was made during the update in that the term ‘no-touch’ was removed. The GDG noted that this terminology can cause confusion. The GDG chose the term ‘aseptic technique’ as its preferred option for describing this approach. It was acknowledged that connecting the administration system to the enteral feeding tube is a procedure that should be carried out in a manner that maintains and promotes the principles of asepsis.
See also the sections on asepsis discussed in LTC (section 10.6) and VAD (section 12.3) chapters.
70.

Ready-to-use feeds can be given for a whole administration session, up to a maximum of 24 hours. Reconstituted feeds should be administered over a maximum 4-hour period. [2003]

71.

Administration sets and feed container are for single use and must be discarded after each feeding session. [2003]

11.5. Care of insertion site and enteral feeding tube

11.5.1. Keep the tube clear

Our systematic review searched for evidence regarding the stoma site as a source of infection. Although some evidence related to infection immediately after insertion of the first tube, we have found no evidence relating to infections in a healed stoma.137,253 However, after the stoma site has healed, usually 10–12 days after placement, no dressings are necessary. Instead the site should be inspected and cleaned daily, and dried thoroughly. The tube should be rotated 360 degrees regularly to avoid infections related to ‘buried bumper syndrome’.242

11.5.1.1. Recommendations

72.

The stoma should be washed daily with water and dried thoroughly. [2003]

11.5.2. Review question

The following recommendation was prioritised for update to determine the most suitable type of syringe for flushing enteral tubes. The GDG identified the most important outcomes for the question as the number of blockages/tube occlusions and fungal colonisation.

What is the clinical and cost effectiveness of single vs. reusable syringes used to flush percutaneous endoscopic gastrostomy tubes on reduction of tube blockages, diarrhoea, fungal colonisation, gastrostomy site infection, peritonitis and vomiting?

11.5.2.1. Clinical evidence

No clinical evidence was identified in this update. No clinical evidence was identified in the previous 2003 guideline.

11.5.2.2. Cost-effectiveness evidence

No cost-effectiveness evidence was identified in this update. No cost-effectiveness evidence was identified in the previous 2003 guideline.

In the absence of any published cost-effectiveness analyses, current UK syringe and infection-related costs were presented to the GDG to inform decision making.

Table 76Cost of single use and single patient use (reusable) enteral syringes

Healthcare professionalCost per syringe (£)Approximate cost per week (£)(a)
Single patient use (reusable) syringe0.220.22
Single-use syringe0.165.60
a

Estimate only - based on the assumption that each reusable syringe is used for up to one week and five single use syringes are used per day.

Source: Based on average 2010 NHS Drug Tariff186 prices.

Possible infections arising from PEG tubes include: fungal colonisation, gastrostomy site infection, and peritonitis, with symptoms ranging from vomiting and diarrhoea to bloodstream infection and sepsis. Cost and quality of life implications are potentially large.

11.5.2.3. Evidence statements

ClinicalNo clinical studies were identified.
EconomicNo economic studies were identified.

11.5.2.4. Recommendations and link to evidence

Recommendation
73.

To prevent blockages, flush the enteral feeding tube before and after feeding or administering medications using single-use syringes or single patient use (reusable) syringes according to the manufacturer’s instructions. Use:

  • freshly drawn tap water for patients who are not immunosuppressed
  • either cooled freshly boiled water or sterile water from a freshly opened container for patients who are immunosuppressed. [new 2012]
Relative values of different outcomesThe number of blockages/tube occlusions and fungal colonisation were considered to be the key outcomes. Diarrhoea, vomiting, peritonitis and gastrostomy site infection were also considered to be important outcomes by the GDG.
Trade off between clinical benefits and harmsSingle-use syringes and single patient use syringes are both deemed feasible to use in primary and community care, provided use is in accordance with manufacturer’s instructions. Although the use of oral/enteral syringes is associated with a risk of infection, the GDG did not consider there to be a greater risk associated with one type of syringe compared to the other. In order to address concerns over immunosuppresed patients, the GDG decided to highlight the importance of using cooled freshly boiled water or sterile water from a freshly opened container to reduce the risk of infection in this highly susceptible group.
Economic considerationsThe GDG considered the difference in cost between single-use syringes and single patient use (reusable) syringes. The cost and quality of life associated with acquiring an infection was also considered. Because there is an absence of evidence related to the infection rate associated with each type of oral/enteral syringe, it is not possible to evaluate which type of syringe is most cost effective. If both are equally effective, then the question becomes one of cost minimisation and the least costly option should be chosen.
Quality of evidenceNo clinical or economic evidence was identified. The recommendation was formulated using GDG expert opinion.
Other considerationsSince March 2007 the National Patient Safety Agency (NPSA)184 has advised the use of clearly labelled ‘oral/enteral syringes’ (popularly known as purple syringes due to their purple coloured plungers or syringe barrels) for the oral/enteral administration of liquids to reduce the risk of accidental parenteral administration. Oral/enteral syringes can be sterile or non sterile devices and may be for single-use or single patient use.
In the absence of evidence for any of the outcomes for the use of single and single patient use oral/enteral syringes, the GDG felt that individual patient characteristics would play a role in this decision and that the choice of syringe should be assessed on an individual basis taking into account susceptibility to infection and patient care setting.
The GDG did not think that the type of solution that the tubes were flushed with should change from the recommendation in the previous guideline.
The GDG considered the wording of the recommendation in the previous infection control guideline and felt that restructuring the recommendation would make the advice for immunosuppressed patients clearer.
The GDG considered that the term ‘immunosuppressed’ included people with a jejunostomy as the natural protective effect of gastric acid is bypassed when administering feeds or medication.

11.6. Areas for Further Research

In developing the recommendations we identified several areas that were inadequately addressed in the literature. The following recommendations for research are therefore made.

Although comprehensive data is available on the use of HETF in the United Kingdom, very little information is documented about enteral feeding practices. Anecdotal reports suggest a wide variation in practice that may or may not be safe. The use of risk assessment, including HACCP has been reported as a means of reducing risks but little is known about healthcare workers’ knowledge and use of risk assessment tools.

Descriptive studies of enteral feeding practices in a range of primary care trusts. This should include healthcare workers, patients and carers, their preparation to undertake enteral feeding and ongoing support, availability and use of equipment. Data should also be collected on the incidence of stoma site infections.

A qualitative study of healthcare practitioners’ understanding and use of risk assessment in practice. Ideally this should be a series of interviews with a range of healthcare workers about their knowledge of risk assessment and the tools they use. This could be applied to other areas where risk assessment is used.

Randomised controlled trials to assess the effectiveness of HACCP in reducing the incidence of enteral feeding related infection. These should focus on HETF in a variety of settings and involving a range of patients and healthcare workers.

11.6.1. Preparation and storage of feeds

Epidemiological studies of the incidence of clinical infection associated with reconstituting enteral feeds for different populations and in different care settings. These should at least encompass the predominant populations - older people and those with neurological deficits in both institutional and domiciliary settings and children. There needs to be clear definition of the ‘cases’ and the populations from which they are drawn.

11.6.2. Administration of feeds

Randomised controlled trials of single-use, single patient use and reusable syringes. Outcome measures need to include rates of clinical infection, patient/carer satisfaction and cost effectiveness.

Randomised controlled trial comparing the use of cooled boiled water versus sterile water to flush enteral feeding tubes. Outcome measures need to include rates of clinical infection; patient/carer satisfaction, and cost effectiveness.

Copyright © 2012, National Clinical Guideline Centre.

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Bookshelf ID: NBK115259

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