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SWMNN Tubefeeding Approved

SOUTHERN WEST MIDLANDS NEWBORN NETWORK

Hereford, Worcester, Birmingham, Sandwell & Solihull

1.0 Introduction : Some infants are unable to orally feed or complete the required volume of feed due to prematurity or disease4. In these circumstances feeding via a nasogastric (NGT) or orgogastric (OG) tube may be a desirable alternative.3,4,8,9,17,19,223 2.0 Purpose: The purpose of this guideline is to ensure patient safety and enable Health Care Professionals to follow a clinical procedure to insert and confirm the position of a nasogastric tube and administer a feed safely. Staff should only undertake this procedure if they are appropriately trained and must be either;

• Registered Adult Nurse, Children’s Nurse, Midwife or Health Visitor

• Registered Medical Staff

• Nurses/medical staff in training and nursery nurses, being supervised by one of the above professionals.

• Parents, Relatives, Carers who have undergone specific training for insertion of nasogastric tubes and have been deemed competent by an appropriately trained practitioner from the above list.

All practitioners are responsible to update their knowledge and practice to maintain their competency and skill6,18,.. All practitioners accept accountability for their practice.16,18 3.0 Indications

• To decompress and aspirate the stomach when an infant is not to be enterally fed.1,19

• To administer feed when full oral feeding is not possible.3,4,13,14,2223

• A nasogastric tube is preferred over an orogastric tube with a few exceptions, such as a structural abnormality (e.g. choanal atresia , cleft lip and palate) and some respiratory distress. It may still be possible to use a nasogastric tube if the infant is receiving nasal / mask CPAP or nasal prong oxygen7,14 714. An orogastric tube may irritate the uvula and cause a gag reflex resulting in negative oral stimulus that may affect later feeding development. Additionally, orogastric tubes are difficult to secure in situ.1515

Title Nasogastric Tube Feeding for Neonates

Author SWMNN Nutrition Group

Person Responsible for Review Jackie Stretton / Louise Hirons

Date Guideline Agreed: May 2011

Date of review: May 2014

Version no. Approved v1

Related guidelines/policies: Enteral Feeding of preterm infant, Breast feeding , Bottle feeding

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4.0 Equipment

• An NPSA compliant tube should be selected.1415,1616

• The smallest French gauge tube should be selected to ensure the infants comfort and reduce the risk of nasal abrasions (4FG or 5FG).1 Some feeds may be thickened in which case a larger sized tube may be preferred (size 5 FG or 6FG) 1. The only exceptions would be a surgical patient in specific clinical circumstances (refer to the appropriate surgical guidelines).

• Enteral syringe (Refer to manufacturers guidelines). Only enteral syringes should be used for aspirating, flushing nasogastric tubes. NEVER use IV compatible devices / syringes/connectors.15 (see NPSA alert 19) 15

• Duoderm, Soft adhesive tape e.g. Hypafix /Tegaderm/ Mefix/

• pH indicator sticks or pH paper 5.0 Insertion of a Nasogastric and Orogastric Tube - Procedure

ACTION RATIONALE

Discuss procedure with parents / carer where possible.

To ensure carer/ parent understanding, co-operation.

6,18 To obtain consent for procedure from parent / carer2425.

Pass tube before a feed To avoid the risk of causing vomiting and potential aspiration1,15

Wash hands and prepare equipment To minimize the risk of cross contamination2526

Select appropriate care strategy to ensure the infant’s comfort throughout the procedure (e.g. swaddling, containment holding, parent or care giver holding). Consider non-nutritive sucking and / or sucrose prior to the procedure. [ link to sucrose guideline ]

To minimize stress to infant during this invasive procedure23.24

Prepare equipment away from the infant, keeping noise to a minimum.

To avoid undue disturbance.

Duoderm or extra thin hydrocolloid dressing, may be positioned to the face either before or immediately after the tube has been passed.

To provide a barrier on which to secure the adhesive tape and maintain skin integrity.

Measure nasogastric tube, (xiphisternum to tip of nose and then from the nose to the ear lobe

To ensure the proximal end of the nasogastric tube rests in the stomach. 1,15

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For Orogastric tube measure from xiphisternum to tip of nose then nose to ear lobe. The appropriate length is 1 – 2 cms less than this measurement.

To ensure the proximal end of the orogastric tube rests in the stomach. 1,1515

Nasogastric placement. Insert the proximal end of the tube into the nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx.

Following normal anatomical structures.

Orogastric placement. Insert the proximal end of the tube into the mouth and slide it backwards and inwards along the tongue to the oropharynx.

Following normal anatomical structures.

If any obstruction is felt withdraw and try a different angle or nostril. Abandon procedure if resistance is felt, do not force the tube.

To avoid causing perforation of the oropharynyx , pneumothorax or damage delicate mucosa15

The use of a dummy (with parents permission) may help the passage of the tube24. 23

Swallowing closes the epiglottis enabling the tube to pass into the oesophagus.

Observe for signs of distress (change in colour, cyanosis, apnoea, bradycardia) throughout the procedure. Abandon procedure and remove the tube immediately if any of the above signs are detected.

The procedure may cause, pain, severe stress, injury or respiratory arrest15.15

Advance the tube until the pre measured (cm marking) has been met.

To ensure tube is in the desired position in the stomach. 1,15115

Aspirate the tube using an appropriate sized enteral syringe to obtain a small volume of aspirate sufficient to apply to pH indicator.

To ensure that the tube is in the stomach before anything is administered and avoid accidental infiltration of the respiratory tract, peritoneum or ‘other’ body cavity.1415

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If pH 0-5.5 is obtained it is deemed safe to commence feed.

pH must be documented (refer to Fig. 1)

The NPSA recommend that pHs of 5.5 or below are acceptable for confirmation of gastric placement15.15

If pH 6 or above is obtained it is deemed not safe to commence feed. Repeat aspiration and retest. DO NOT FEED if the repeated test is 6 or above, seek advise from a senior clinician and undertake a Risk assessment following the NPSA algorithm (Fig 1 a and b) - Review the NG position on a recent CXR or consider taking a one. The decision made and rationale should be documented by both parties.

First aspirate may reflect milk remaining in the tube from previous feed that has not come into contact with the stomach.

Some medications (i.e. ranitidine, omeprazole, domperidone, gaviscon) may produce a neutral or alkaline aspirate.

Tube may be positioned in the jejunum or duodenum.

Tube may be positioned in the lungs.1515

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If no aspirate is obtained it is deemed not safe to commence feed. Follow the procedure outlined in NPSA guideline ( Fig. 1 a and b)

Tube may be malpositioned or within the stomach but;

• In contact with the gastric mucosa

• Resting above the fluid level within the stomach

• Have advanced too far / coiled within the stomach

• Have doubled back to exit the stomach

• Tube could be kinked (obstructed). [ Figure 2– reasons for malposition of tube]

When the position has been confirmed, secure the nasogastric tube over the duoderm /or hydrocolloid dressing, using tape (e.g.mefix / hypafix)

If an endotrachaeal tube (ETT) is in situ the nasogastric tube may be secured to the plastic flange of the ETT fixture.

To secure the tube position To ensure patient comfort Avoiding direct contact of tape to the skin where ever this can be avoided, to maintain the integrity of the skin and reduce infection risks. 2324

When procedure has been completed specific details must be documented:

• type of tube (French gauge and cms)

• nostril

• markings to nostril

• the pH date passed / due for changing

To provide ongoing communication and in accordance of record keeping and documentation1,1818 A baseline mark will provide a benchmark for the risk assessment of tube position and movement. 15 15

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Figure 1 a

The Recommended Procedure for Checking The Position Of The Naso And Orogastric Feeding Tube In Babies Under The Care Of Neonatal Units. Patient Safety Alert 09. Reducing the harm

caused by misplaced gastric feeding tubes in babies under the care of neonatal units. NPSA 0223JUN0518.08.05 p3

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Figure 1 b

The Recommended Procedure for Checking The Position Of The Naso And Orogastric Feeding Tube In Babies Under The Care Of Neonatal Units. Patient Safety Alert 09. Reducing the harm

caused by misplaced gastric feeding tubes in babies under the care of neonatal units. NPSA 0223JUN05.18.08.05 p4

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Figure 2

Malposition of naso / orogastric tubes. Corflo Fine Bore Feeding Tubes Placement Guidelines (replicated with permission).

Inject 0.5 – 1 ml of air down the tube then aspirate

This is not a ‘Whoosh Test’ -

just a way to move the tip away from the wall

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6.0 Removal and replacement of naso or orogastric tube - Procedure

ACTION RATIONALE

Discuss procedure with parents / carer where possible.

To ensure carer/ parent understanding, and co-operation 66,18 To obtain consent for procedure from parent/ carer2524

Remove or replace tube before a feed

To avoid the risk of causing vomiting and potential aspiration11,1515

Wash hands and prepare equipment

To minimize the risk of cross contamination2526

Select appropriate care strategy to ensure the infant’s comfort throughout the procedure (e.g. swaddling, containment holding, parent or care giver holding). Consider non-nutritive sucking and / or sucrose prior to the procedure. [ link to sucrose guideline ]

To minimize stress to infant during this invasive procedure23.24

Prepare equipment away from the infant, keeping noise to a minimum.

To avoid undue disturbance23

Ensure the safe and gentle removal of tape using water, applied with a cotton bud, to soften adhesive tape. Never be tempted to rip tape directly from the skin.

To maintain the integrity of the skin, minimizing the risk of infection. Removing tape in this way can remove a layer (or layers) of the epidermis causing pain and damaging barriers to infection.

Once the tube is no longer secured ensure its gentle removal by pulling slowly and steadily. Observe the infant throughout the procedure.

To minimize potential discomfort and distress.

The tube should then be discarded safely as per local refuse disposal policy. (tubes are for single use only)

To minimize the risk of infection and cross contamination.

Cleanse and dry the skin surrounding the nostril and upper lip if necessary

Some secretions and residue from the tube may leak onto the skin during the removal process.

Document removal in medical records.

To provide ongoing communication and in accordance with record keeping and documentation1,6,1818

For tube replacement follow the steps above (‘inserting naso / orogastric tube) ensuring that, in the case of NGT, the alternative nostril is selected

( to avoid / reduce the effects of potential erosion or pressure injury to the delicate mucosa of the nostril)

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7.0 Nasogastric Tube Feeding - Procedure Feeding regimes should be determined according to the infant’s medical condition and the infant’s developmental cues42,4,8,9,10,19,21 When making the transition from nasogastric tube feeding to oral feeding adopt the general principle of cue based regimes22,4,10,21,23 i.e. offer an oral feed if the infant is awake and showing signs of rooting. Complete the feed via the nasogastric tube when the infant starts to tire1023 This may be at every feeding interval, avoid rigid feeding patterns (e.g. 1 Bottle / 2 tube, alternate bottle / tube etc.)24 Refer also to ‘guidelines for transition from tube to breast feeding’. Insert link For infants with specific feeding difficulties due to their medical condition, ensure that the advice of a speech and language therapist is sought to determine their feeding pattern. Encourage parents to take part in feeding to give parents the opportunity to actively participate in their infant’s care. The safety of the infant during the procedure is paramount therefore ensure that appropriate systems are in place to train and supervise parents undertaking the procedure6. (Refer to section 2.8) 6

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ACTION RATIONALE

This is a clean procedure, wash hands before gathering appropriate equipment.

• feed

• pH indicator

• enteral syringe

To minimize the risk of cross contamination and avoid interruptions during the procedure.

Select the feed type according to the individual infant’s prescription. Check feed type, expiry date / time, volume required. Check infants name / hospital number with feed label.

To avoid incorrect or out of date feed administration. 1616

Warm milk to body temperature before feeding if possible, according to local facilities.

This may be more comfortable and easier to digest than refrigerated milk.

Wash hands again before commencing the feed.

To minimize the risk of cross contamination.

The infant does not need to be lying down for the tube feed. Continue to feed even if infant is receiving kangaroo care or if positioned in an infant chair. If the infant is lying flat in a cot, elevate the cot to 30% prior to feeding. Return the baby to a flat position within an hour.

To promote an experience closer to ‘normal’ as opposed to a clinical procedure23

To reduce the effects of oesophageal reflux and minimize the risk of aspiration1.1

Aspirate the tube using an appropriate sized enteral syringe to obtain a small volume of aspirate sufficient to apply to pH indicator.

To ensure the tube is correctly positioned in the stomach reducing the risk of aspiration.15

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If pH 0-5.5 is obtained it is deemed safe to commence feed. pH must be documented (refer to Fig. 1a and b)

The NPSA recommend that pHs of 5.5 or below are acceptable for confirmation of gastric placement15.15

If pH 6 or above is obtained it is deemed not safe to commence feed. Repeat aspiration and retest. If the repeated test is 6 or above, seek advise from a senior clinician and undertake a Risk assessment following the NPSA algorithm (Fig 1). The decision made and rationale should be documented by both parties.

First aspirate may reflect milk remaining in the tube from previous feed that has not come into contact with the stomach. Some medications (i.e. ranitidine, omeprazole, domperidone, gaviscon) may produce a neutral or alkaline aspirate. Tube may be positioned in the jejunum or duodenum. Tube may be positioned in the lungs.

If no aspirate is obtained it is deemed not safe to commence feed. Follow the procedure outlined in NPSA guideline ( Fig. 1 )

Tube may be malpositioned or within the stomach but;

• In contact with the gastric mucosa

• Resting above the fluid level within the stomach

• Have advanced too far / coiled within the stomach

• Have doubled back to exit the stomach

• Tube could be kinked (obstructed). [ refer to previous illustrations]

Ensure that the pH is checked before every feed.

This could be considered the most crucial stage of the procedure with high risks to the infant if incorrectly implemented15.15 The nasogastric tube may have altered position since it was passed or since the last feed therefore it would not be considered safe practice to assume it is still in the correct position.

Start to administer the feed by gravity feeding technique. (Remove plunger from syringe, connect to tube, pour a small volume of the feed into the barrel, raise the level of the barrel above stomach level, control the speed of administration by raising or lowering the barrel.)

This technique provides a steady flow of milk more consistent with the normal feeding experience1,5. It avoids fast delivery of milk in short bursts that could induce hiccupping or vomiting or exaggerate gastro-oesophageal reflux.

Plunge feeding should be avoided if possible however for extremely small volumes of milk or thickened feeds the technique may be chosen. Ensure that the feed is administered steadily and slowly.

Avoids fast delivery of feed.

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The feed (using both gravity or plunge feeding techniques) should take approximately 20 minutes1,19 (This will be less for extremely small volumes)

Avoid fast delivery of milk in short bursts that could induce hiccupping or vomiting or exaggerate gastro-oesophageal reflux3,4

Observe the infant throughout the feed for signs of deterioration or distress. (change in colour, cyanosis, apnoea, bradycardia, vomiting, straining, squirming, grimacing and other avoidance behaviours.) Observe for abdominal distension following a feed1.1

Adverse behaviours and symptoms could indicate poor tolerance for feeding44

According to the infants developmental stage and capabilities an infant may be offered small drops of milk to the mouth to taste. Avoid this practice with infants with no swallow mechanisms. Consider offering the infant mothers breast for nuzzling during the tube feed. A dummy may be offered during the tube feed if the infant is awake.

To initiate physiological responses and stimulate taste2423

To encourage the infant to associate sucking and stomach filling sensation.

On completion of the feed instil a small amount of air (0.5 – 1ml) into the tube.

To clear any residual feed., avoid tube blockages11

Document feed details:

• pH

• Type

• Volume

• Time

• Behaviour / response during feed

• Adverse reactions (vomiting etc.)

To provide ongoing communication and in accordance of record keeping and documentation. 1,6,181618

7.1 Special Considerations If resistance or obstruction is found and the nasogastric tube cannot be advanced the practitioner must not have more than 3 attempts to insert the tube. If resistance and obstruction continues the practitioner must stop and seek advice from a senior clinician, Nutrition Support Team (according to local availability ).15 If the patient shows any sign of respiratory distress during or post insertion the tube must be withdrawn immediately. Prolonged respiratory distress and/or abnormal vital signs Medical Staff must be informed immediately.

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8.0 Ongoing Care - General principles

ACTION RATIONALE

Tubes used for short term should be PVC or Polyurethane Tubes should be changed every 7 days. If long term placement is required use a Polyurethanetube which may remain in situ for up to 28 days.

To minimize the risk of infection, damage or erosion of nasal / orogastric muscosa. Consistent with manufacturers guidelines.

Dry and cleanse the face surrounding the tube placement and fixture. Observe the skin frequently and respond appropriately to any redness, inflammation or injury. Record any interventions applied. (Refer to local skin care guidelines.)

Minimize the risk of iatrogenic disease.

Reduce the risk of injuries caused by pressure:

• Take care when positioning the infant to ensure that they are not lying on the plastic top.

• Ensure that there is no tension on tube leading to distortion of the nostril

• Ensure tape is not so tight as to apply undue pressure to face or nostril.

Observe for signs of pressure injury and respond appropriately, seeking specialist advice where appropriate. Accurately record injuries and interventions.

Minimize the risk of iatrogenic injury.

The NGT / OGT provides a direct route to the stomach. Ensure that clean procedure techniques are applied when handling tubes and pay careful attention to feed preparation and administration. Refer to appropriate feed preparation guidelines

Minimize the risk of infection and cross contamination.

Remove milk from fridge prior to instilling via NGT or OGT enabling the milk to reach room temperature. Never deliver fridge cold milk directly via the tube. Refer to appropriate feed preparation guidelines

The tube is a direct route into the stomach. Instilling cold liquid directly is unpleasant and could stress the infant2423 In addition, cold fluids internally will detrimentally affect temperature stability. Warm milk is more readily digested.

Ensure that a tube feed takes approximately the same time as a suckling feed. e.g. 20 minutes for the full feed volume requirement, 10 minutes 50% volume 5 minutes 25% volume

Mirror normal physiological behaviour and stomach filling,

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9.0 Education / Training

Staff / parents / carers undertaking these procedures MUST have received appropriate education and training from a recognised trainer.

Staff are required to update their skills on a bi-annual basis by undertaking training6,18.

Staff trainers for NGT updates must have undertaken a ‘train the trainer’ course appropriate for this procedure.

10.0 Local Additions

The value ranges for pH testing may vary according to the equipment used locally (i.e. some indicator papers use increments of 0.5 others increase in whole figures.) 5.5 or below is an acceptable measure for gastric feed. 11.0 Related Patient Information

Local Trust parent booklets SWMNN (2009) Parent Information Leaflet: Providing Milk Supplements for your Breastfed Baby: Cups, Bottles & Feeding Tubes BLISS – Parent Information Guide 5, Feeding. Available from BLISS website. 12.0 Categories of Evidence

Research : RCTs, systematic reviews, cohort studies NPSA Patient Safety Alerts. Professional consensus Cochrane protocol 13.0 Audit

• Monitor training

• Observation of practice

• Parent satisfaction survey

• Relevant reported incidents

• Documentation

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14.0 References

1. Bowling T Ed.( 2004) Nutritional Support for adults and children. A Handbook for hospital practice. Radcliffe Medical press. Oxford.

2. CollinsCT,MakridesM,McPhee AJ. (2003) Early discharge with home support of gavage feeding for stable preterm

infants who have not established full oral feeds.Cochrane Database of SystematicReviews 2003, Issue

4.Art.No.:CD003743.DOI: 10.1002/14651858.CD003743.

3. CollinsCT,MakridesM,Gillis J,McPhee AJ. (2005) Avoidance of bottles during the establishment of breast feeds in preterminfants. (Protocol) Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD005252. DOI:

10.1002/14651858.CD005252.

4. Crowe LM, Chang AM,Wallace KL.(2006) Instruments for assessing readiness to commence suck feeds in preterm infants: effects on time to establish full oral feeding and duration of hospitalisation. (Protocol) Cochrane Database of Systematic Reviews, Issue 1. Art. No.:CD005586. DOI: 10.1002/14651858.CD005586.

5. Dawson J, Summan R, Badawi N. (2005) Push versus gravity for intermittent bolus gavage tube feeding of

premature and low birth weight infants. (Protocol) Cochrane Database of Systematic Reviews, Issue 2. Art.No.:

CD005249. DOI: 10.1002/14651858.CD005249.

6. General Medical Council (2006) Good Medical Practice, GMC. GMC/GMP/0910.

7. Howe, Tsu-Hsin; Howe THF; Sheu, Ching-Fan; Sheu CFF; Holzman, Ian R; Holzman IR (2007 ) Bottle-feeding behaviours in preterm infants with and without bronchopulmonary dysplasia. The American journal of occupational therapy. : official publication of the American Occupational Therapy Association v.61; no.4; Jul-Aug; pp.378-383

8. Flint A, New K, Davies MW. (2007) Cup feeding versus other forms of supplemental enteral feeding for newborn

infants unable to fully breastfeed. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD005092. DOI: 10.1002/14651858.CD005092.pub2.

9. Kennedy KA, Tyson JE. (2000) Early versus delayed initiation of progressive enteral feedings for parenterally fed low birth weight or preterm infants. Cochrane Database of Systematic Reviews , Issue 1. Art. No.: CD001970. DOI: 10.1002/14651858.CD001970.

10. Law-Morstatt, Leslie; Law-Morstatt LF; Judd, Debra M; Judd DMF; Snyder, Patricia; Snyder PF

Baier, R John; Baier RJF; Dhanireddy, Ramasubbareddy; Dhanireddy R (2003 ) Pacing as a treatment technique for transitional sucking patterns. Journal Of Perinatology : Official Journal Of The California Perinatal Association v.23; no.6; September; pp.483-488

11. Medicines and Healthcare Products Regulatory Agency (2004) Medical Advice Alert- enteral feeding tubes.

12. Methany, N.A., Clouse,R.E.,Clarke,J.M.,Reed,L.,Wehrie,M.A., Wiersma,L.(1994) pH testing of feeding tube

aspirates to determine placement. Nutr.Clin.Prac. 9:185-190.

13. McGuire W, McEwan P. (2007) Transpyloric versus gastric tube feeding for preterm infants. Cochrane Database of Systematic Reviews Issue 3. Art. No.: CD003487. DOI: 10.1002/14651858.CD003487.pub2.

14. National Nutrition Nurses Group (2004) Guidelines for confirming correct positioning of nasogastric feeding tubes. 15. National Patient Safety Agency (2005) Reducing the harm caused by misplaced naso and orogastric feeding

tubes in babies under the care of neonatal units - Patient Safety Alert - 2005-09-18 - V1

16. National Patient Safety Agency (2007) Promoting safer measurement and administration of oral liquid medicines

2007-03-28 - V1 – CY

17. Ng E, Shah V. (2001) Erythromycin for feeding intolerance in preterm infants. Cochrane Database of Systematic

Reviews 2001, Issue 2. Art. No.: CD001815. DOI: 10.1002/14651858.CD001815.

18. Nursing and Midwifery Council (2008) Code of Professional Conduct: Standards for conduct, performance and

ethics for nurses and midwives.

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19. Premji S, Chessell L. (2002) Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams. Cochrane Database of Systematic Reviews Issue 4. Art. No.:

CD001819. DOI: 10.1002/14651858.CD001819.

20. Royal College of Physicians and The British Society of Gastroenterology ‘Oral feeding difficulties and dilemmas: A guide to practical care, particularly towards the end of life.’Working Party Report. January 2010

21. SWMNN (2009) Parent Information Leaflet: Providing Milk Supplements for your Breastfed Baby: Cups, Bottles &

Feeding Tubes

22. Tosh K, McGuire W. (2006) Ad libitum or demand/semi-demand feeding versus scheduled interval feeding for preterm infants. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD005255. DOI: 10.1002/14651858.CD005255.pub2.

23. Tyson JE, Kennedy KA. (2005) Trophic feedings for parenterally fed infants. Cochrane Database of Systematic

Reviews 2005, Issue 3. Art. No.:CD000504. DOI: 10.1002/14651858.CD000504.pub2.

24. Warren I, Bond C (2010) Tube Feeding. A Guide To Infant Development In The Newborn Nursery. 6.6., p324-326. Unpublished.

25. BAPM (2004) Consent for common neonatal investigations, interventions and treatments. Consent in neonatal clinical care: Good practice framework BAPM.

http://www.bapm.org/media/documents/publications/procedures.pdf

26. Health Protection Agency (2005) Health Protection in the 21st Century. Understanding the Burden of Disease; preparing for the future. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947403055

Additional sources

British Association of Entreral and Parenteral Nutrition – ( BAPEN ) Heart Of England Foundation Trust (HEFT) 2010 Consent to Examination and Treatment. HEFT (2010) Enteral Feeding Guidelines. HEFT (2010) Hand Decontamination Policy. HEFT (2010) Infection Control Policy. HEFT (2010) Risk Management Policy. HEFT (2010)Record Keeping in Health Care Records Policy. HEFT (2010) Standard Precautions Policy.

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