Enteral Feeding
Enteral tube feeding (ETF) is considered 'routine' by many health care professionals involved with it, but can still be a daunting thought for patients and caregivers. Careful consideration should be given to pre-discharge planning and training.
Enteral feeding literally means using the gastrointestinal tract for the delivery of nutrients, which includes eating food, consuming oral supplements and all types of tube feeding. The routes of ETF most often used are Naso Gastric Tubes (NGT) and Percutaneous Endoscopic Gastrostomy (PEG) tubes. Other routes that are increasingly being used include Naso-Jejunal (NJ) and jejunostomy feeding, which may be the only feasible route if it is not appropriate to feed via the stomach.
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Growth of home care enteral feeding
Enteral tube feeding as home health care has increased considerably in the last few years. Recent figures show a 26% growth in adults in the community on home ETF (HETF) from 1998 to 1999. The average growth rate prior to 1998 has been estimated at 20-25% per year. This includes patients in residential and nursing homes on home enteral tube feeding. ETF Figures from 1999 show 37.4% adults with HETF reside in nursing homes and 2.3% in residential care. At any one time it is estimated that over 10,000 patients receive enteral tube feeding as home health care, more than twice that in hospital.
There are several reasons that have contributed to the fast growth of home enteral tube feeding including reduction in the number of hospital beds, developments in artificial enteral nutrition, higher proportion of elderly subjects in the population, marketing and promotion of HETF by commercial companies and increased awareness of therapeutic nutrition.
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Starting home care enteral feeding
Dysphagia is the most common primary reason for initiating ETF commonly as a result of cerebrovascular accident, multiple sclerosis, motor neurone disease and cerebral trauma Other common reasons for ETF include aiming to improve or maintain nutritional status, malabsorption and anorexia.
More commonly, ETF is initiated in hospital and the patient is subsequently discharged into the community. However, more GPs are now referring electively for HETF and patients are having PEG tubes sited as day-patients. A number of complications post PEG insertions have been recently identified, so overnight admission is recommended.
Gastrostomy feeding tubes
In home health care, PEG tubes are the most common and easiest to manage. Gastric tubes are placed usually under local anaesthetic, with a small incision made in the abdominal wall, and the tube is inserted with the help of an endoscope. Gastric tubes vary in size from 9-28FG, and normally last for 18 months to 2 years when it may be advisable to replace them by repeat endoscopy. When gastric tubes are no longer required, they may be removed by traction, repeat endoscopy or they can be cut and allowed to pass naturally, although this remains controversial.
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It is important that a patient's tube is correctly identified in respect of type, size and manufacturer by the staff caring for the patient. This allows the proper replacement parts to be provided when required. However, from experience of the past, information about feeding tubes is frequently not handed over when a patient transfers districts. Gastrostomy ends many times break or lost, and spares of the right end should be easily accessible.
One of the most important things caregivers and patients need to be taught when starting to use enteral feeding sets for home health care, is caring for the feeding tube correctly. This includes flushing the feeding tube with water immediately after any feed or medication has been administered via it. The most common cause of blocked feeding tubes is leaving too long a time between feeding and flushing. Should a tube block, there are a variety of different tactics which may help unblock it including flushing with fizzy drinks, pineapple juice or sodium bicarbonate, whilst manipulating the tube between the fingers. There are also enzyme preparations which can be used in extreme cases. Inserting a sharp object down the tube to remove a blockage is discouraged.
The external fixation plate on a gastrostomy prevents the feeding tube from being drawn into the gastro-intestinal tract by peristalsis. It should not be removed, and replaced if faulty. It needs to be turned 90° daily to allow the site to be inspected and cleaned. The feeding tube should also be rotated and pushed slightly to prevent it from becoming adherent to the gastric mucosa of the abdominal wall and epithelialised, which is known as bumper syndrome.
Balloon retained gastrostomy tubes are increasingly becoming the choice of feeding for long term community feeders, as they can be replaced more easily and by the patient or caregiver. Generally, these are only sited when a stoma has already been formed by prior PEG insertion. A balloon inflated by sterile water holds the tube in place, which needs re-inflating about once a week; although some more modern tubes may be checked less frequently. Balloon gastrostomy tubes need replacing every 2-3 months and arrangements should be made for further supplies of spares. Prompt replacement is crucial to avoid closure of the stoma. Balloon gastrostomy tubes are particularly favorable in those home enteral tube feeding patients for whom the endoscopy procedure is traumatic or the practicality of transporting the patient to hospital is hard.
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There are complications associated with tube feeding: Soreness at the stoma site is not uncommon, and this may involve redness, inflammation and sometimes smelly discharge. Some neurological patients have reported feeling very poorly for a few days following the procedure, which may be a consequence of the anaesthetic. Blocked feeding tubes are a common problem, though good practice of caring for the tube should prevent this; unfortunately in the nursing home environment, with frequently changing staff and bank nurses, the incidence of blocked feeding tubes is quite high. Intolerance of feed may be reported, which may be iatogenic or pathogenic in origin, or may be helped by changing the feed, on which the dietitian will advise.
Home care enteral tube feeding
By the time of discharge, patients and caregivers should have been adequately trained on the various aspects of the home enteral tube feeding system, to ensure safe and effective enteral feeding at home. The British Association for Parenteral and Enteral Nutrition (BAPEN) has set standards for practice for home enteral tube feeding; this includes providing information so patients and caregivers can feel confident, emergency contact names and telephone numbers and addresses of support groups such as patients on Intravenous and Naso gastric feeding.
The team who monitor home enteral tube feeding patients should include a dietitian, speech and language therapist (for swallowing assessments), nutrition specialist nurse, GP and possibly district nurse. The hospital nutrition team may also be involved. In the community, GPs are primarily responsible for the patient's care, so close liaison with them is important.
Follow up monitoring by health professionals could be by telephone or home visits. Some hospitals hold multi-disciplinary PEG review clinics. These are consultant led and involve all members of the HETF team. For patients to attend, the GP's permission has to be sought. The advantage of these clinics is that a lot of time can be devoted to each patient, and professionals can discuss any problems, concerns or progress with patients and caregivers, and liaise as to the best course of action. Audits of practice have shown that patients who have attended such clinics have found this form of contact to be beneficial, and in some cases patients have been able to move onto full oral feeding and have their tubes removed.
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The commercial companies who manufacture enteral feeds and equipment, are increasingly playing a large role in this highly competitive and rapidly growing market. Companies tender for community contracts on the basis of range of feed and equipment, service and price of equipment and ancillaries. GPs will then prescribe the contractor's feed, as a company's feed is only compatible with their feeding system. Most companies now have their own home delivery service, an invaluable aid to patients and caregivers. This involves regular, usually monthly, deliveries of all feed and equipment required, assessed by regular stock checks. The GP prescribes the feed on FP10, endorsing ACBS, and, as equipment is not prescribable, it will either be funded by the care health home, hospital dietetic department, community nursing budget or directly by the local Health Authority. The contractors will usually loan enteral feeding sets free of charge.
The companies may also help in advising patients and caregivers on basic aspects of home health care and often play a key role in training. Continued liaison between health professionals, patient/careers and the home delivery company is essential for a smooth running service.
Patients and caregivers are encouraged to deal with simple problems themselves, e.g. blocked feeding tubes and minor pump problems, and should be trained accordingly. However, they should not hesitate to seek advice on any matter that concerns them, and should be aware of whom to contact in times of such crises. All too often, GPs and accident and emergency departments are contacted during out of hours times, which do not have adequate expertise in this area. Systems to deal with emergencies should be put into place before a patient commences home care enteral feeding.
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