percutaneous endoscopic gastrostomy guideline - …

WAHT-NUT-004 This guideline has been printed from the Worcestershire Acute Hospitals NHS Trust intranet on

25/03/2013,14:58 It is the responsibility of every individual to check that this is the latest version/copy of this document.

Percutaneous endoscopic gastrostomy guideline - Adults

WAHT-NUT-004 of 26 Version 2.3

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY GUIDELINE - ADULTS

This guidance does not override the individual responsibility of health professionals to make appropriate decision according to the circumstances of the individual patient in

consultation with the patient and /or carer. Health care professionals must be prepared to justify any deviation from this guidance.

INTRODUCTION This guideline covers the care of the patient prior to PEG placement, immediate post endoscopy care, longer term nursing care and care of the patient going home with a PEG. Adherence to these guidelines should ensure comprehensive care for all patients with a PEG, thus ensuring optimal nutrition support with reduced risk of complications.

THIS GUIDELINE IS FOR USE BY THE FOLLOWING STAFF GROUPS: Doctors, Nurses ,Healthcare Assistants, Dietitians, Speech & Language Therapists and other AHPs, Pharmacists

Lead Clinician(s)

Sue Dickinson

Chief Dietitian

Approved at Nutrition Steering Committee Approved with slight amendments

8th April 2008 13th July 2010

Approved by Medicines Safety Committee on : 20th May 2008

This guideline should not be used after end of: 31st May 2013

Key amendments to this guideline

Date Amendment By:

May 2010 Changes to Introduction and competencies

Changes to STAGE 1 Pre PEG assessment and Stage 2 - preinsertion

Information added to complications post procedure section

Changes to dietetic referral form appendix 6

Changes to nursing care plan : PEG feeding (adults) appendix 8

Sue Dickinson

20/09/2012 Guideline expiry extended whilst under review Sarah Trenbirth

December 2012 Guideline expiry extended whilst under review Nalinee Owen

January 2013 Guideline expiry extended whilst under review Sarah Trenbirth





PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) GUIDELINE

INTRODUCTION Percutaneous endoscopic gastrostomy (PEG) is a method of artificial enteral nutrition. Enteral nutrition is defined by the British Association of Parenteral and Enteral Nutrition (BAPEN) (1999) as,

“The provision of part or all of a patient’s nutritional requirements by administration of nutrients into the gastrointestinal tract directly (e.g. oral), or indirectly (by placement of a tube)”.

Gastrostomy feeding involves the creation of a tract between the stomach and the surface of the abdomen. Gastrostomy tubes may be placed endoscopically (PEG), surgically or radiologically. The PEG tubes of choice at Worcestershire Acute Hospitals NHS Trust are the Fresenius kabi PEG tube FG15 (WRH/KH) (please see diagram below), and Nutricia Flocare PEG tube CH10 (Alex). These tubes are placed endoscopically.

Both PEG tubes are made from polyurethane and are designed for long term feeding. For Head and Neck cancer patients with a Freka tube, it may be removed using the Cut and Push technique Ref WHAT guideline. For other patients, the tubes can only be removed via endoscopy. The internal fixator acts as an internal retention device holding the tube in place. The outer tube has an adjustable fixation plate/triangle and a safety clamp. At the end of both the Fresenius and Flocare external tube there is a luer fitting which fits directly onto the feed giving set or a female luer syringe. This guideline covers the care of the patient prior to PEG placement, immediate post endoscopy care, longer term nursing care and care of the patient going home with a PEG. Adherence to these guidelines should ensure comprehensive care for all patients with a PEG, thus ensuring optimal nutrition support with reduced risk of complications.

External fixation triangle

Internal fixator

End adaptor for giving set and funnel adaptor

Fresenius kabi 1998





PERCUTANEOUS ENDOSCOPIC GASTROSTOMY GUIDELINE The guideline covers the different stages for the patient from referral to discharge: Stage 1 Referral and Assessment Stage 2 PEG insertion Stage 3 Starting the feed regimen Stage 4 Planning the patient’s discharge COMPETENCIES REQUIRED Setting up and monitoring of the enteral feeding system, flushing the PEG tube, administration of medications down the tube and initial cleansing of the PEG site post insertion must only be carried out by a Registered Nurse. Cleansing of the PEG site once the stoma site is healed may be carried out by Healthcare Assistants with permission and instruction from the Registered Nurse responsible for the patients care. Training on PEG care for patients/carers may be obtained from the Ward Nurse or Homeward nurse. Use of the Infinity Flocare feed pump requires competency based training for both the nurse and the end user. STAGE 1 Pre PEG assessment Scoping our practice NCEPOD 2004 recommended that the multidisciplinary team should discuss the value of PEG feeding for a patient prior to PEG insertion. Patients who are being considered for a PEG should be referred by the medical team for an assessment by the Speech & Language Therapist (SLT) who will check whether it is safe for a patient to swallow if required. ENT endoscopic examination and milk swallow test can give further information. Detailed and informed discussion should take place with the family and carers, including risks and benefits. Patients with a poor quality of life/advanced dementia are unlikely to benefit from PEG placement. When selecting patients for PEG insertion the following criteria should be considered:

Risk of significant malnutrition and /or delayed recovery

Unable to use naso-gastric feeding to achieve nutritional intake.

Upper gastro-intestinal tract dysfunction

Functional status of gastro-intestinal tract

Enteral tube feeding is likely to be needed for more than 4 weeks Acceptability of the PEG to the patient

Contraindications or medical risks for PEG with presence of conditions such as:

Ascities

Bleeding disorders, anti coagulation therapy

Liver disease

Gastro-oesophageal reflux with risk of aspiration

Morbid obesity

Previous upper GI surgery

Crohn’s disease

MI in past 6 weeks

Peritoneal dialysis

Assessment of the patients long term prognosis





Availability of future care facilities

Availability of health care personnel experienced in the technique of PEG insertion and management

Availability of approved equipment and training to patient/carers on the use of equipment.

BAPEN, 1996 The PEG referral form (Appendix 6 should be completed by the GP or Consultant and forwarded to SLT if needed and Dietitian. Dietitian will to calculate the patient’s nutritional requirements and to check if there are alternative ways of giving nutrients. The following should be documented on the PEG referral form to ensure all involved in patients care are clear on the aim of PEG insertion:

whether PEG is being placed to provide nutrition support in the future or for immediate use

whether PEG will be used to provide complete nutrition& fluid, or for supplementary intake or for fluid only.

Once the Dietitian has completed their assessment the form is returned to Endoscopy who will arrange a date for PEG placement. Stage 2: PEG INSERTION: Pre and post insertion EDUCATION AND COUNSELLING PRIOR TO P.E.G. PLACEMENT Ensure patient/carers have received adequate education and counselling, informing them of

the potential impact on their lifestyle and body image, thus enabling them to make an informed decision about proposed PEG placement. The PEG referral form is in Appendix 6.

PRE-INSERTION The Nurse should ensure that: Patient is Nil By Mouth for 6 hours pre procedure for food, 2 hours for clear fluids eg water. Oral care is carried out Patient is aware of what the procedure entails Consent for treatment has been gained from patient INR screen is complete prior to patient going to Endoscopy Unit For those patients who have had poor nutritional intake for 5 days or more by day of PEG

insertion, blood tests for serum Potassium, Phosphate and Magnesium should be taken on the day of insertion as these need to be checked before PEG feeding can be safely started (refer to Out of hours emergency Enteral Feed Regimen (WAHT- NUT- 008) if Dietitian unavailable & Refeeding guidelines (WAHT- NUT- 006)

Patient has had shower/bath prior to PEG placement. Need to advise for Day case patients too Patient is wearing theatre gown Endoscopy Unit are aware if patient is wearing dentures Baseline observations have been carried out and documented Prophylactic antibiotic dose given to reduce risk of peristomal infection STOMA SITE CARE AND POST-INSERTION CARE On returning to the ward patient should have PEG pack containing Nursing Care Plan, Patient Carer Booklet, end of bed checklist & discharge checklist.





The following care should be carried out:

Half hourly observations to include PARS and assessment of stoma site for at least 2 hours until stable, patient alert, orientated and haemodynamically stable. Observe for excessive bleeding, drop in blood pressure and raised pulse (hypovolaemic or septic shock). Once stable continue with four hourly observations.

Observe patient for signs of pain and administer analgesia as required The patient will arrive from Endoscopy Unit without a dressing. A dressing is not usually

required over the stoma site unless clinically indicated, e.g. excessive exudate. Please check there is no abdominal pain, pyrexia or tachycardia prior to administering

water down the PEG tube. Do not release the external fixation triangle for the first 72 hours after placement, but

ensure cleansing and drying takes place daily. After 72 hours begin to release external fixation triangle on a daily basis to allow thorough

cleaning of the stoma site. Replace fixation triangle back into original position, approximately 0.5 cm from the skin. If discharged to be done by district nurse.

STAGE 3 STARTING THE PEG FEED 4 hours post insertion begin to flush PEG tube with 50ml of sterile water, continue flushing

as per PEG Starter Regimen. (See Appendix 1) If patient is being discharged on the same day as PEG placement ensure Dietitian has

arranged Homeward follow up visit and the patient has been given appropriate discharge literature and equipment (see page 8 for list and refer to Appendix 5)

After flushing, PEG feed regimen can be commenced as per Dietitian’s instructions. Ensure patient is sitting at 45o /semi-recumbent position where possible to avoid aspiration

of feeds. Patient should remain upright for at least 1 hour after feed has finished. If nausea or abdominal distension occurs stop the feed and seek medical review. If symptoms are severe or there is pain on feeding stop feed altogether and seek senior

medical review urgently. Sterile packs of enteral feed should be used as per Dietitian’s instructions. Feed should be

hung for no longer than 24 hours and giving sets should be changed every 24 hours. Any handling of the feeding system should be carried out using aseptic technique.

PREVENTION OF STOMA SITE INFECTION

If stoma site infection is suspected, send a swab of the site to Microbiology for culture and sensitivity and inform Infection Control Team as soon as possible.

If dressing is required due to excessive exudates, the choice of dressing will be dependent on stoma site assessment and referral to Trust Wound Dressing Guidelines.

If there is any external leakage of gastric contents or fresh bleeding stop feed/medication delivery immediately and obtain senior advice urgently.

If MRSA is identified see appendix 2





COMPLICATIONS POST PROCEDURE Complications most likely to result in serious illness or death in the immediate period after gastrostomy insertion based on Potack and Chokhavatia’s literature review include the following Aspiration pneumonia Colonic perforation Haemorrhage Wound infection Peritonitis These complications are rare BUT when they have occurred, the “red flag” symptoms have often been evident within the first 72hours. These symptoms are: Pain on feeding Prolonged or severe pain post procedure Fresh bleeding External leakage of gastric contents. At all times all staff should be aware of these symptoms. Feed and medication delivery should be stopped immediately. Senior medical advice should be obtained urgently . CARE OF SITE 10 DAYS POST PLACEMENT When the stoma site has healed it may be cleansed with unperfumed soap and water, rinsed

and dried thoroughly Begin to rotate the PEG tube 360o daily

Fresenius kabi (2002)

PREVENTION OF TUBE BLOCKAGE Tube blockage will be prevented by regular flushing (minimum once a day if PEG tube not in

use) For inpatients Sterile water is used for flushing For patients at home cooled boiled water is

used instead of sterile water. Use a 50or 60ml enteral syringe. The P.E.G. tube should be flushed with 30-50 mls of sterile water before starting a feed

1. Open the fixation catch

2. Detach tube from groove in fixation plate

3. Move plate away from skin. Clean tube and stoma area and the underside of the plate then dry. Push 2-3 cms of the tube into the stomach, rotate, then gently pull back the tube until resistance is felt

4, Place the fixation plate back to its original position. Reinsert the tube into the groove.

5. Close the fixation catch.





and when feed is stopped .

The P.E.G. tube should be flushed with 30-50 mls of sterile water prior to administering medications and once medication is given.

A 10 ml flush of sterile water should be given in between medications; medications must never be mixed, see below for further information on medicine administration

Infection Control and Safety

Wash hands and wear gloves.

All syringes used are single use only in hospital.

Sterile Water - Flushes may be decanted from a one litre bottle of sterile water, however the bottle must be labelled with patient name, must not be shared with other patients and must be discarded after 24 hours. Do not draw up water directly from a one litre bottle as this will lead to contamination of the water.

Keep exposure to medicine powder to a minimum. ADMINISTRATION OF MEDICINES (also see poster Appendix 7) Patients who need to have medicines administered via PEG tube should have their

prescriptions reviewed and their regime simplified where possible. Consideration should be given to using other routes and/or once-daily regimes where possible. The pharmacist may suggest alternative medicines/routes if there is doubt about the suitability of a medicine to be given via a PEG tube

Accountability – the prescriber must change the route on the prescription chart to make it clear that the medicines are to be given in this way

Where possible all medicines should be prescribed in liquid or soluble tablet form to avoid blockage of tube. Some tablets that are not marketed as soluble will nevertheless disperse in water

Discuss any medicine which does not come in liquid or soluble form with the medical team and the pharmacist.

Some liquid medicine preparations can be very thick and should be diluted with an equal volume of water before administration

Crushed tablets or opened capsules should be avoided if possible as particles may adhere to the sides of the tube and there is some exposure to the powder. There are also some tablets/capsules that must not be crushed or opened.

Medicines that must not be crushed or opened

Type of Medication

Example Reason

Enteric Coated Tablets

Diclofenac, Sodium Valproate Medicine designed not to be released in stomach.

Slow Release Preparations

Diltiazem, Nifedipine, Verapamil,

Medicine designed to be released over prolonged period,

Cytotoxics Methotrexate Risk to practitioner

Anitibiotics Flucloxacillin Risk to practitioner

Prostaglandin Analogues

Misoprostol Risk to practitioner

Hormone Cyproterone Risk to practitioner





Preparations

National Patient Safety Agency Patient Safety Alert no. 19 (March 2007) Promoting safer measurement and administration of liquid medicines via oral and enteral routes This Patient Safety Alert requires the Trust to ensure that only oral syringes (that cannot be connected to intravenous catheters or ports) to measure and administer oral liquid medicines The Trust Medicines Policy MedPolSOP11 ‘Administration of Oral and Enteral Liquid Medicines’ must be followed For an adapted version of a flowchart from BAPEN on administering medicines please see Appendix 7. Use a 50/60ml purple female luer syringe for flushing and an appropriate size for medications. Do not use IV Syringes . If unsure about any aspect of medicine administration via PEG – please contact the ward pharmacist, or Medicines Information (ext 30235 Trustwide Service) THE TUBE BECOMES BLOCKED Check that the clamp is open Attach an 50/60ml purple empty female luer syringe and pull the plunger back to try and

unblock the tube Massage the tube by rolling it gently between your fingers using small movements only. Start

from the end furthest away from the body and work towards the abdomen Try flushing with 30 mls of warm water, wait 30 minutes then try again. (If this does not work

repeat procedure using carbonated soda water) Do not use too much force and do not use any sharp objects to try and unblock tube If tube will not unblock inform Medical Team ENSURE CORRECT MONITORING OF NUTRITIONAL STATUS

Give feed as prescribed by Dietitian and record on fluid balance chart. Record patient’s weight

weekly If patient is eating ensure food texture is in accordance with instructions from Speech and

Language Therapist and is regularly reviewed Keep a record of food eaten and refer to dietitian to be reassessed if food intake varies. Swallowing should be re-checked by Speech and Language Therapist as appropriate

Monitor bloods regularly. If at risk of re-feeding syndrome monitor bloods daily during first week, ( Urea& Electrolytes, Phosphate & Magnesium ) For further details on re-feeding syndrome see WHAT-NUT-006

MAINTENANCE OF ORAL HYGIENE Please ensure that regular oral hygiene is carried out according to trust mouth care guidelines

PREVENTION OF HYPERGLYCAEMIA

Regular monitoring of blood glucose should be carried out for patients with diabetes





It is good practice to monitor every patient’s blood glucose level in the initial stages of enteral feeding.

Refer to Guideline for enteral Tube feeding (Nasogastric or PEG) in patients with Diabetes mellitus treated with insulin.

Rationale for care stated may be found in nursing care plan (appendix 8)

PROCEDURE FOR PATIENT BEING DISCHARGED WITH A PEG TUBE

The nurse must inform the Dietitian and pharmacist of discharge date 5 weekdays prior to patient discharge. This is to ensure that the Dietitian has time to arrange a Homeward delivery, contact the GP re feed prescriptions and arrange pump training for patient/carers and the pharmacist to organise the appropriate medicines and medication leaflet. Prior to discharge the nurse must ensure that the patient has:

7 day supply of purple female luer enteral syringes (provided by the ward unless patient has

had a Homeward delivery prior to discharge) 7 day supply of giving sets (provided by the Dietitian or Homeward) TTOs have been ordered and that a 7 day supply of feed is sent home Enteral feeding pump and stand (supplied by the Dietitian or Homeward) DO NOT SEND WARD PUMP

User guide instructions for Infinity Flocare feed pump, cleaning and maintenance guidelines ( supplied with pump)

Contact details for assistance with pump including out of hours. Enteral feed regimen (supplied by the Dietitian) PEG Patient/Carer booklet (supplied by Endoscopy).This includes contact number in event of

complications. Medications Leaflet (supplied by Pharmacy) Check with Dietitian that plans are in place for ongoing supplies of syringes and giving sets for

the patient in the Community Please ensure discharge checklist is fully completed and GP is aware of patient’s needs. Contact District Nursing team. Send nursing care plan with patient on discharge. This includes information and action to take

in the event of any complications.





MONITORING TOOL To be done by Dietitians with assistance from Clinical Governance. To be audited every 2 years via medical and nursing notes and questionnaire. Standards % Clinical exceptions All patients will have a PEG 100 Nil Referral form completed prior to PEG insertion Medical & nursing staff should 100 Nil be aware of the red flag symptoms And action taken as appropriate All medicines via PEG should be 100 NIL Administered as per Appendix 7 Of this guideline

REFERENCES Arrowsmith, H. (1993) Nursing Management of patients receiving naso-gastric feed. British Journal of Nursing Vol.2 No 21 Arrowsmith, H. (1996) Nursing management of patients receiving gastostomy feeding. British journal of Nursing Vol. 5 No 5 Anderton, A. (1995) Reducing bacterial contamination in enteral tube feeds. British Journal of Nursing Vol. 4 No 7 Ayliffe, G.A.J., Babb, J.R., Taylor, J.L. (1999) Hospital Acquired Infection Principles and Prevention. Pg 93

BAPEN 1999 www.bapen.org.uk BAPEN. 2003 Administering drugs via enteral feeding tubes. A Practical Guide. www.bapen.org.uk

Brandimarte, G., Turisi, A. (1999) American Journal of Gastroenterology; 94:4,1107. Early feeding after Percutaneous Endoscopic Gastrostomy: just do it. British Society of Gastroenterology (2001) Antibiotic prophylaxis in gastrointestinal Endoscopy www.bsg.org.uk Choudhry, U., Barde, C.J., Market, R. & Golpalswamy, N. (1996) Percutaneous endoscopic gastrostomy: a randomised prospective comparison of early and delayed feeding. Gastrointestinal Endoscopy Vol. 44 No 2 164-167

Howell, M. (2002) Do nurses know enough about percutaneous endoscopic gastrostomy. Nursing Times Vol. 98 No 17 40-42 Fresenius Kabi (2003) Gastrostomy Aftercare Booklet for Patients and Carers. F. Kabi Ltd

http://www.bapen.org.uk/

http://www.bapen.org.uk/





Kazi, N., Mobarhan, S., (1996) Enteral Feeding Associated Gastro-oesophageal Reflux and Aspiration: common pneumonia: A Review. Nutrition Reviews Vol. 54 No 10 Leder SB Serial fiberoptic endoscopic swallowing evaluations in the management of patients with dysphagia. Arch Phy Med Rehabil. 1998 Oct; 79 (10) : 1264-9 Leder SB, Sasaki CT, Burrell MI Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia 1998 Winter; 13(1) : 19-21 Lourenco, R. (2001) Enteral Feeding: Drug / nutrient interaction. Clinical Nutrition Vol. 20 No 2 187-193 National Confidential Enquiry into Patient Outcome and Death. Scoping our practice NCEPOD 2004

McCarter TL, Condon SC, AguilarRC, Gibson DJ, Chen YK. American J Gastroenterol. 1999 Apr;(4):1107-8 Randomized prospective trial of early versus delayed feeding after percutaneous endoscopic gasrostomy placement. National Patient Safety Alert 19 (2007) Promoting safer measurement & administration of liquid medications via oral and other enteral routes. Scoping our Practice NCEPOD 2004 NICE Clinical Guideline 32 Nutrition Support in adults February 2006 Oral Feeding difficulties and dilemmas January 2010 RCP/BSG Rapid Response Report NPSA/2010/RRR010 Early detection of complications after gastrostomy March 2010

Rickman, J. (1998) Percutaneous endoscopic gastostomy: psychological effects. British Journal of Nursing Vol.7 No 12 Sizer, T. (1996) Standards and Guidelines for Nutritional Support of Patients in Hospitals. British Association of Parenteral and Enteral Nutrition Srinivasan, R. & Fisher, R.S. (2000) Early Initiation of post-PEG feeding: do published recommendations affect clinical practice? Dig Dis Sci Vol. 45 No 10 2065-2068 WAHT-NUT-006 Guideline for re-feeding syndrome WAHT-NUT-008 Out of Hours Emergency Feeding starter regimen WAHT- END- Guideline for Enteral Tube feeding ( nasogastric or PEG) in patients with Diabetes Mellitus treated with insulin. WAHT-NUT- Cut and push technique for removal of PEG (number to be advised) White, S. (1998) Percutaneous endoscopic gastrostomy (PEG) [RCN Continuing Education] Nursing Standard Vol. 12 No 28 41-47





If patient tolerates this flush and there are no signs of leakage around PEG site. Indication of patient tolerance:

No abdominal pain

No distension

No vomiting

No leakage from PEG site

APPENDIX 1

PEG STARTER REGIMEN

Nil by P.E.G. for the first 4 hours to reduce risk of peritonitis

4 hours post insertion of PEG, if the abdomen is soft & there is no discomfort; flush tube with 50 ml sterile water.

The Doctors should prescribe Pabrinex or thiamine for those patients who are at high risk of refeeding syndrome. Give 30 mins before starting feed. Commence feed as per Dietitians regimen. If no regimen available but patient is to use PEG for feeding: start sterile water at 50mls/hr x 10hr or flush with 50ml sterile water every hour x 10 hrs unless able to take fluids orally. Contact Dietitian for regimen

If patient is not using PEG straight away, nurse to teach patient to flush tube daily with 50ml cooled boiled water.

If patient experiences problems, wait 3 hours and then flush with 50 mls of sterile water. Repeat as necessary. If patient has severe pain post procedure, pain on flushing tube, fresh bleeding or external leakage of gastric contents seek urgent medical advice.





APPENDIX 2 PEG tube carriage

PEG tube carriage

Chlorhexidine powder for 10 days

Stop for at least 2 days *

Await results

Full body re-screen as per schedule

NEGATIVE

(1st)

Multiple sites now positive

POSITIVE PEG tube carriage

only

Instigate source isolation

Commence Staph Pack

Continue to treat wound carriage

Re-treat with Chlorhexidine powder

for further 10 days

* When a Staph Pack is in use

it may be necessary to wait more than 2 days to re-screen to synchronise the next body screen with Staph Pack use

Discuss the need for subsequent body screening with

Infection Control team for patients on systemic antibiotics

Full body re-screen after 2 days as per schedule

Await results

NEGATIVE

(2nd

)



only

Instigate source isolation

Commence Staph Pack

Continue to treat wound carriage

Discuss with Infection Control Team (ICT) &

Tissue Viability Nurse (TVN)

Stop for 2 days

Full body re-screen after 2 days as per schedule

Await results

NEGATIVE

(3rd

)



only









APPENDIX 3

Send PEG referral form to

S.A.L.T.

Dietitian If not already done

Reason

Diagnosis / prognosis

S.A.L.T. assessment

Dietetic assessment

Medical assessment

Social assessment/discharge plans

Patient / carer expectations of procedure (including fitness for Endoscopy)

Results of assessments to surgeon/GI consultant

Assessment of discharge point

Letter to Gp

or Consultant (if inpatient) stating reasons for not placing

P.E.G. Dr

Referral and Assessment

For PEG

Plan when P.E.G. to go in

Assess suitability for day case or overnight stay

Gain patient consent for procedure

Education of patient/carers

Begin plan for discharge

Decision to

place PEG

Dr

Y N

For Day case/overnight stay

Inform GP / District Nurse and Dietitian of planned date for PEG placement

Advise a visit following discharge of patient For inpatient

Inform Dietitian and ward of date

Decision to refer for

PEG





APPENDIX 4

Insertion of PEG

Patient to have received PEG Information Pack from Endoscopy which includes list of “red flag” symptoms of complications needing medical attention.

Insertion of PEG according to local

policy/procedure

Education and Counselling for patients/carers about PEG and its potential

impact on lifestyle and body image to enable them to make an informed decision about

proposed PEG placement.

Pre insertion

Nil by mouth 6 hours food, 2hours water.

Oral care carried out

Consent obtained

INR screen completed before going to Endoscopy

Baseline blood tests done for those at risk of Refeeding Syndrome (refer to Refeeding Syndrome Guideline)

Patient has had shower or bath

Patient wearing theatre gown

Endoscopy aware if patient wearing dentures

Baseline observations carried out and documented

Prophylaxis antibiotic dose given.





APPENDIX 5

PEG Discharge plan

IN-PATIENT

Inform Dietitian in order to arrange equipment supplies and organise training for patient/carers (see Discharge Checklist)

Is patient going to

nursing home

or own home

DAY CASE/OVERNIGHT STAY Dietitian needs to know date Dietitian will need 7 working days notice

before day case PEG placed if feeding to start straight away. This is to organise Homeward delivery and GP prescription for feed.

If pre- surgery PEG may only need flushes prior to admission for surgery.

OWN HOME Dietitian to:-

Check GP is Worcestershire PCT

Register patient on Homeward

Train carers – liaise with Homeward Nurse who will train carers

Contact GP for feed prescription

Liaise with District Nurses if appropriate

Organise equipment and 7 day feed

Provide feed regime and contact numbers

NURSING HOME Dietitian to:-

Check GP is Worcestershire PCT

Identify Nursing Home

Confirm patient’s GP and contact GP for feed prescription

Register patient on Homeward

Organise training (if necessary) via Homeward Nurse

Organise equipment and 7 day feed

Provide feed regime and contact numbers

If not Worcestershire PCT pt, Dietitian to discuss with Dietitian

in appropriate area

Nurse / Dr to inform Dietitian which Nursing home and GP. If discharged within 72hrsof PEG placement Nurse/Dr to

inform GP of “red flag” symptoms to action.

Follow-up of patient post PEG insertion





APPENDIX 6

Dietetic Referral Form Pre-Insertion Percutaneous Endoscopic Gastrostomy (PEG HOSPITAL: WRH / AH / KH / ECH - Medical team to post completed form to Dietetic Department

If referral is URGENT please ring Dietitian and Fax this form (both Sides)

WRH FAX NO: 01905 760168 EXT: 33691 AH FAX NO: 01527 512043 WRH TEL. NO: 01905 760 696 EXT: 33695 AH TEL NO: 01527 512 043

For In patient/Out-patient Affix Patient Label

IN PATIENT/ OUT- PATIENT CLINIC

COMMUNITY PATIENT

Consultant:

Name of General Practitioner:

Ward: Or OPD Clinic:

General Practice:

Requesting Doctor:

Community Patient Surname: Forename: DOB: Address: Post Code:

Contact Bleep No: Telephone Number:

Date Requested:

Date Requested:

Is an assessment required by a Consultant Gastroenterologist / Consultant Surgeon prior to PEG insertion? Eg If patient had partial gastrectomy or significant abdominal surgery or needs a jejunostomy? NO YES Date referred: …………………….. Dietitian will check with the Gastroenterologist Consultant the outcome of the assessment.

The decision to insert a PEG should be made by the Consultant or GP and the MDT team in charge of the patient’s care in conjunction with the patient, family / carers. Referral to a Speech and Language Therapist (SLT) is required if swallow is unsafe. This referral form should be sent to the Dietitian prior to a date being booked in Endoscopy. Each case should be discussed individually and should take into account patient’s wishes and their welfare. The aim of the PEG is to improve or maintain quality of life and the potential benefits should outweigh the long term consequences. Please refer to guideline WAHT-NUT-004 Percutaneous Endoscopic Gastrostomy Guideline for adults available on the Intranet.

Please state reasons for PEG insertion

CVA Poor nutritional status

Multiple Sclerosis Dysphagia

Motor Neurone Disease Pre- radiotherapy / Pre-surgery

Trauma Learning Difficulties

Head and Neck Cancer PEG to be used at a later date (e.g. in MND)

Dementia – consider alternative support Other – specify ………………………………..

Please state extent of nutritional support via PEG at time of placement:

Patient’s Weight: …………… Height: …………….. BMI: ………… Weight Loss: ………………..

□ For complete nutrition

□ For partial nutrition e.g. overnight feed

□ For water only i.e. patient can manage solids but not fluids





□ For use at a later date- patient needs to keep tube patent by regular flushing

PATHWAY

Medical decision made to insert PEG

Referral to SLT: Does patient need a swallow assessment? YES □ NO □ If YES, date of referral to SLT: ………………………….. SLT to communicate to Medical team and Dietitian the outcome of the assessment.

INPATIENTS: Refer to Refeeding Syndrome Guideline To consider naso gastric tube feed if appropriate whilst awaiting assessment. Medical team to check bloods for Re-Feeding syndrome i.e. (U and Es, Phosphate, Magnesium) and refer patient to Dietitian. COMMUNITY PATIENTS: Those who have swallowing problems, GP to refer to Medical team for further assessment.

FOR IN PATIENTS / OUT-PATIENTS/ COMMUNITY PATIENTS

Are there any medical risks or contra-indication for PEG insertion? E.g. Ascites, gastric disease, abdominal surgery, anticoagulation therapy, peritoneal dialysis, recent MI (within past 6 weeks).

NO □

YES □

Has Medical team informed patient/carer about the reason for a gastrostomy? YES □ NO □

Has Medical team informed patient/carer of long term implications of PEG feeding? YES □ NO □

Has Medical team explained to patient/carer how nutrition will be given via PEG tube? YES □ NO □

Has Medical team explained that the dietitian will contact the patient? YES □ NO □

Is patient/carer agreeable to be contacted by telephone? YES □ NO □

Name and contact No. of main carer: ………………………… Only refer to Dietitian if all boxes in shaded section are ticked

Please post form to the Dietetic Department or if URGENT Fax both sides of form. WRH Fax No: 01905 760 168 EXT: 33691 AH Fax No: 01527 512 043

Dietetic Assessment: Date form received: Will an Inpatient episode be required? YES NO If YES, please state reason:





Date Dietitian sent referral form to relevant Endoscopy Unit: ……………………… Date booked by Endoscopy Unit for PEG insertion: ………………………… Date Dietitian informed by Endoscopy Unit: …………………………….

On the day of the procedure, a copy of the Endoscopy Report to be faxed to Dietitian. WR1559 June2009

APPENDIX 7





APPENDIX 8 NURSING CARE PLAN: PEG FEEDING (ADULTS)

PROBLEM/NEED EXPECTED OUTCOME

Stoma site care, post-insertion care and Prevention of stoma site infection

Complications after gastrostomy are detected early. “Red flag” symptoms:

pain on feeding or prolonged or severe pain post procedure, or fresh bleeding or external leakage of gastric contents. Feed/medication delivery stopped immediately and senior medical advice sought urgently.

Any pain is relieved

The stoma site heals without infection

Infection is detected and treated

NURSING CARE/INTERVENTIONS

Post insertion record observations including PARS half hourly for 2 hours or until stable, patient alert & orientated and heamodynamically stable, then 4 hourly observation. Monitor patient for signs of hypovolaemic or septic shock

Ask patient and observe for signs of pain at or leakage or bleeding around stoma site, give analgesia as prescribed

If there is prolonged or severe pain post procedure: stop any feed/medication delivery and seek senior medical advice urgently.

Dressing not normally required unless clinically indicated, eg excessive exudates (See Stoma Site Infection)

Flush PEG with 50ml sterile water 4 hours post insertion

Leave the external fixation triangle fastened for the first 72 hours after placement, but ensure cleansing and drying takes places daily.

After 72 hours the external fixation triangle may be released on a daily basis to allow thorough cleaning of the stoma site, replace the fixation triangle back in its original position (approx 0.5cm from the skin)

Clean the stoma site daily using sterile saline and aseptic technique for the first 10 days or until stoma site has healed. NB do not use talcum powder.

If there is any fresh bleeding or leakage of gastric contents stop feed/medication delivery immediately and seek senior medical advice urgently.

During first 7 – 10 days, cover stoma with waterproof dressing during a bath/shower. After 7 – 10 days stoma can be cleaned with unperfumed soap and water and left exposed.

Ensure the end adaptor is cleaned and dried thoroughly using soapy water followed by swabbing with 70% isopropyl alcohol eg steret.

Observe stoma site for signs of infection eg inflammation and pus. Send swab to microbiology for culture and sensitivity and inform Infection Control as appropriate

If exudate is present, a suitable dressing may be required. Selection of dressing will be dependent on stoma site assessment and referral to Trust Wound Dressing Guidelines.

SIGNATURE/DATE/TIME REVIEW DATE

Please attach patient sticker here or record:

Name:………………………………….

NHS No:

Hosp No:

D.O.B: ………………………………...

Male Female

Consultant: ……………... Ward: …………..





10 days post PEG insertion begin to rotate the tube 360 degrees daily.

PROBLEM/NEED EXPECTED OUTCOME Ensure correct monitoring of nutritional state The patient’s nutritional state is maintained or

improved as indicated by the Dietitian

Pain on feeding is recognised early as a “red flag” symptom. Feed/medication delivery stopped immediately and senior medical advice obtained urgently.

NURSING CARE/INTERVENTIONS SIGNATURE/DATE/TIME REVIEW DATE

Ensure feed and flush are given as prescribed by

the Dietitian and record on fluid balance chart

If there is pain on feeding stop feed/medication delivery immediately and seek senior medical advice urgently

Weigh once weekly & document

Volume of water for each flush may vary according to patient’s requirements. Dietitian will advise

Further swallowing assessments as appropriate If eating to maintain a food chart so feed can be

reviewed by the dietitian


Maintenance of Oral Hygiene

Oral hygiene is maintained and oral infection prevented


Carry out or encourage regular oral hygiene, including regular tooth brushing/denture cleaning, moistening the mouth with water and application of moisture cream/white soft paraffin to the lips

See Trust policy for oral care


Prevention of aspiration of the feed Gravitation drainage of feed from the stomach is


Name:………………………………….

NHS No:

Hosp No:

D.O.B: ………………………………...

Male Female






facilitated and risk of aspiration reduced


Head and shoulders should be elevated at least 45 degrees/semi recumbent position during feeding and for at least 1 hour afterwards


Medicine administration Medicine administration does not cause tube blockage

Medicine-feed interactions are prevented

To ensure correct absorption and prevent gastric irritation NURSING CARE/INTERVENTIONS SIGNATURE/DATE/TIME REVIEW DATE

Refer to trust guidelines re medicine admin

When administering medicines via the tube flush with water before and after each medicine and with a minimum of 10ml between medicines if more than one medicine should be used when possible. Consult the pharmacist for advice regarding medicine presentation and medicine-feed interactions.

Enteric- coated, slow release, cytotoxic and hormone preparations must NEVER be crushed and put down a PEG tube


Prevention of Tube Blockage

Tube blockage is prevented


Flushing: use sterile water

Using a 50/60ml purple female luer syringe flush the tube with 50ml sterile water before starting a feed and when a feed is stopped.

The volume of water to be used for a flush may vary depending on patients fluid requirement so check feeding regimen


The tube becomes blocked

PEG tube is unblocked


Check the clamp is open

Attach an empty 50/60ml syringe and pull the plunger back to try and unblock the tube

Massage the tube by rolling it gently between your fingers, using small movements only. Start from the end furthest away from the body and


Name:………………………………….

NHS No:

Hosp No:

D.O.B: ………………………………...

Male Female






work towards the abdomen

Try flushing with 30mls of warm water, waiting 30 minutes and trying again. If this does not work, repeat the procedure using carbonated soda water.

Do not use too much force and do not use a sharp object to try to unblock the tube

If the tube will not unblock inform local endoscopy unit who will advise on local contact person


Prevention of contamination of the feeding system

Infection via the feeding system is prevented


Wash hands before handling any part of the feeding system

The feed container/sterile feed pack should be connected directly onto a compatible giving set wearing a new pair of disposable procedure gloves (single use only)

If giving additional water via the pump sterile bags (currently supplied by Nutricia) should be used

Giving sets should be changed every 24 hours and syringes only used once only as specified by the manufacturer. (some areas may be BAXA re-useable syringes so use as specified by the manufacturer)

Sterile feeds can be hung for a maximum of 24 hours


The patient develops nausea and vomiting

Nausea and bloating are prevented

Aspiration of feed is prevented


When starting a feed gradually increase the rate and volume as prescribed by the dietitian

If bloating and nausea occurs, reduce the feed rate until symptoms subside. If the patient is vomiting, the feed should be stopped and the cause of vomiting investigated. Ensure fluid


Name:………………………………….

NHS No:

Hosp No:

D.O.B: ………………………………...

Male Female






requirements are met via the IV route until feeding is re-established.

Report any changes in feed rate to the Dietitian

Ensure patient is sitting at 45 degrees where possible.


The patient develops diarrhoea (refer to Trust Infection Control Manual)

The cause of diarrhoea is established

There are minimal interruptions to the feed regimen

To reduce risk of cross infection NURSING CARE/INTERVENTIONS SIGNATURE/DATE/TIME REVIEW DATE

If diarrhoea occurs, record on the Stool chart and send specimen to microbiology. Note patient’s normal bowel habit. Inform Infection Control.

Note any clinical cause of diarrhoea eg inflammatory bowel disease or faecal impaction ( overflow diarrhoea)

Slow feed rate and report to Dietitian

Ensure fluid requirements are met via the oral or IV route as appropriate until feed is re-established.

Ensure hand hygiene policy adhered to.

Ensure maintenance of asepsis during feed handling


Prevention of hypoglycaemia Any glucose intolerance is detected and treated, enabling maximum utilisation of nutrients in feed


Check blood glucose as per usual routine for diabetic patients

PROBLEM/NEED

EXPECTED OUTCOME

Altered body image due to the PEG Patient and/or carer take on care of PEG with a degree of acceptance of body image


Name:………………………………….

NHS No:

Hosp No:

D.O.B: ………………………………...

Male Female







Observe patient for signs of depression due to the loss of normal eating patterns

Involve patient carer in care of PEG at all stages where possible

Ensure dignity and privacy

Updated May 2010





CONTRIBUTION LIST

Key individuals involved in developing & updating the document

Name Designation

Sue Dickinson Chief Dietitian

Jo Brown Senior Dietitian

Dr D Aldulaimi Consultant Gastroenterologist AH

Mr M Wadley Consultant Upper GI Surgeon WRH

Mary Jones Speech and language

Caroline Gibson Clinical Lead Pharmacist AH

Keith Hinton Clinical Lead Pharmacist WRH

Helen Livett Nurse Endoscopist

Heather Gentry Infection Control

Alison Smith Principal Pharmacist Medicines Safety

Circulated to the following individuals for comments

Name Designation

Sarah Pritchard Senior Dietitian Head and Neck Cancer WRH

Sarah Rosser Macmillan Dietitian Head and Neck Cancer

Zakia Naz Senior Dietitian WRH

Emma Richardson Senior Dietitian AH

Rob Cronin Dietitian AH

Mr A Wetherall Consultant Surgeon Redditch

Mr S Lake Consultant Surgeon Worcester

Dr Sanmaganathan Consultant Physician Worcester

Dr Asokan Consultant Physician Redditch

Dr Mildner Consultant Physician Redditch

Helene Fletcher-Byers Medical DevicesTraining Manager

Sarah Sykes Endoscopy Manager

Mary Jordan Stroke Liaison Nurse Redditch

Louise Pearson Specialist Nurse Head and Neck

Karen Goode Sister Cookley Rehabilitation Ward

Judith Butcher Endoscopy Sister Kidderminster

Beverley Johnson Endoscopy Nurse

Elaine Stratford Stroke Liaison Nurse Worcester

Lynne Mazzocchi Matron, Surgery Worcester

Anne Marie Lewis Matron, Redditch

Circulated To The Following CD’s/ Heads Of Dept For Comments From Their Directorates / Departments

Name Directorate / Department

Nalinee Owen Nutrition & Dietetics

Circulated to the chair of the following committee’s / groups for comments

Name Committee / group

percutaneous endoscopic gastrostomy guideline - …

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