Enteral Feeding - An Overview - part 2

By James Collier BSc (Hons) - Consultant in Nutrition and Moderator of Dietetics.co.uk

Treatment in the community
By the time of discharge, patients and carers should have been adequately trained on the various aspects of the HETF system, to ensure safe and effective feeding at home. The British Association for Parenteral and Enteral Nutrition (BAPEN) has set standards for practice for HETF (Elia 2000), this includes providing information so patients and carers can feel confident, emergency contact names and telephone numbers and addresses of support groups such as Patients on Intravenous and Naso-gastric Nutrition Therapy (PINNT).

The team who monitor HETF 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 (Parker, et al 1996). 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 (White 2000). 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/carers, 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 (Collier 1999), and in some cases patients have been able to move onto full oral feeding and have their tubes removed.

The commercial companies who manufacture enteral feeds and equipment, are increasingly playing a large role in this highly competitive and rapidly growing market (Elia 1998). 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 carers. 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 home, hospital dietetic department, community nursing budget or directly by the local Health Authority. The contractors will usually loan enteral feeding pumps free of charge.

The companies may also help in advising patients/carers on basic aspects of 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/carers are encouraged to deal with simple problems themselves, e.g. blocked 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 HETF.

Feeding regimens
Feeding regimens will be devised by the dietitian, using the most appropriate feed for the patient's medical condition. The aim is to get the patient established on the feed they will require at home, prior to discharge, so any difficulties can be dealt with in hospital.

There are a variety of different types of feed which the dietitian may opt to use. Standard feeds are generally 1kcal/ml, with higher energy alternatives (1.2 or 1.5kcal/ml) for patients who need more calories in a shorter period of time, or who do not tolerate large volumes. There are also fibre-containing feeds which help both diarrhoea and constipation. In rarer cases, a more specialist feed may be the choice.

There are three main methods of ETF:
1. Pump feeding: this is where an electronic feeding pump delivers feed, via a giving set, at a set rate per hour over a pre set dose or time period
2. Bolus feeding: this is where feed is administered directly into the feeding tube via a syringe
3. Gravity feeding: this is rarely used these days, and involves the feed bag attached, through a giving set, to the enteral feeding tube and feed drips in via gravity

Patients on HETF may be nil by mouth, in which case they rely solely on the artificial feed. Some patients will be allowed to eat but are unable to eat adequate amounts to improve or maintain their nutritional status, and the enteral feeding tube is used as a back up to ensure nutritional requirements are met.

In some cases a combination of pump feeding and bolus feeding may be the regimen of choice. This may be in order to reach the appropriate energy requirements, to minimise wastage or to be more convenient for the patient's daily routine. The bolus may also mimic a meal and help satiety during the day. We have to remember, for many ETF patients, one of life's pleasures has been taken away from them, i.e. eating.

The dietitian is likely to change the regimen as the patient's circumstances change. For example, the patient may be gaining too much weight and may require less feed, they may start eating so the feed needs to be reduced, or there may be problems tolerating the feed.

Problems in tolerating enteral tube feeding
A number of problems have been noted in respect of tolerating ETF, most commonly diarrhoea or constipation. Before the type of feed or regimen is altered, it is important to rule out side effects of any medication or pathogenic cause. Stool samples may highlight any bacterial infections. If no other cause can be identified, the dietitian may suggest a different type of feed, e.g. fibre-containing or semi-elemental.

Abdominal bloating, nausea and vomiting can be common side effects, in which case the rate or method of administration need to be reviewed. Some patients fail to tolerate large volumes at one time, in which case the pump rate may need to be slowed, a higher energy feed used or frequent rest periods may be advised to allow gastric emptying.

Discharge planning
Planning for discharge on HETF should begin at the earliest opportunity and involve all the relevant health care professionals and community staff (Mensforth and Spalding 1998), whilst discussing with the patient and carers what to expect on a daily basis when administering HETF (Goff 1998). In practice, to ensure smooth running, it often takes five working days to properly plan a discharge. Early and inadequately planned discharges may cause anxiety with the patient/carer and are potentially unsafe. However, with hospital bed crises and consultants eager for a quick discharge, HETF is often actioned prematurely.

Other than the practicalities of the feeding regimen, patients and carers need to be trained on caring for the tube, hygiene issues, safety and basic problem solving, and must be clear regarding arrangements for supply of feed and equipment.

Conclusion
ETF is becoming more and more widely used, and patients are being discharged from hospital sooner for their feeding to be managed in their own homes or in care homes. Improved systems need to be put into place to ensure patients/carers are adequately trained and aware of where to get help after discharge. All healthcare professionals, both pre- and post-discharge, have a role in this process, and it must be recognised that care does not end once the patient leaves the hospital.

REFERENCES
1. Collier J (1999) An Audit of Home Enteral Feeding in South Northamptonshire. Unpublished.
2. Elia M, et al (1994) Enteral and Parenteral Nutrition in the Community. A report by a working party of the British Association of Parenteral and Enteral Nutrition (BAPEN). BAPEN.
3. Elia M (1998) Trends in HETF. Clinical Nutrition Update 3(2): 5-7.
4. Elia M, et al (2000) Trends in Home Artificial Nutrition Support in the UK during 1996 - 1999. A Report by the British Artificial Nutrition Survey (BANS) a committee of BAPEN. BAPEN.
5. Elia M (2000) Guidelines for the Detection and Management of Malnutrition. A report by the Malnutrition Advisory Group - a committee of BAPEN. BAPEN.
6. Goff K (1998) Enteral and Parenteral Nutrition - Transitioning from Hospital to Home. Nursing Care Management 3(2): 67-74
7. Mensforth A, Spalding D (1998) Discharge Planning for Home Enteral Tube Feeding. Clinical Nutrition Update 3(2): 8-10.
8. Parker T, Neale G, Cottee S, et al (1996) Management of Artificial Nutrition in East Anglia: a community study. J R Coll Physicians Lond 30(1): 27-32.
9. Rollins H (1998) Managing Enteral Feeding Tubes at Home. Clinical Nutrition Update 3(2): 3-4.
10. White S (2000) A Multidisciplinary PEG Service and the Nurse Specialist. NTPlus 96(49): 6-9.

Key Points

There are a range of different routes and types of tubes by which patients may be enterally fed
The use of enteral tube feeding is increasing in both hospital and the community setting
Feeding regimens need to be devised and reviewed by the dietitian to take into account nutritional requirements, patient tolerance and convenience
Commercial companies with a range of enteral feeds, equipment and delivery systems are available, and play a vital role in ensuring a smooth running system
Multidisciplinary teams of health care professionals need to be available to ensure effective follow up of community fed patients
There needs to be adequate training education and support for those providing care to enterally fed patients in the community

Enteral Feeding - An Overview (part 1)