Leigh House Guidelines

1.0Introduction

In exceptional circumstances during the care and treatment of young people with Anorexia Nervosa it may be necessary to instigate a period of enteral feeding by nasogastric tube to prevent extreme weight loss and cardiovascular collapse. Also, young people receiving treatment for other diagnoses may, on rare occasions, have difficulty eating. Circumstances may dictate that a period of enteral feeding by nasogastric tube is necessary for example with diagnoses of Obsessive Compulsive Disorder, Psychosis and Severe Depression. A nasogastric (NG) tube is a flexible tube passed through the nose and into the stomach through which liquid feed is given. NG feeding is relatively safe method of providing nutrition when a young person cannot or will not feed her/ himself. It can be used flexibly, can provide bolus or continuous feeds, allows young people to continue to take oral feeds and does not require an anaesthetic.

2.0Purpose of the guidelines

The purpose of this guideline is to develop clear advice for the nasogastric (NG) feeding of a patient who is unable to eat or drink. The aim of the guideline is to ensure safe practice whilst respecting the young person’s dignity and working in accordance with high ethical standards and within the law. It will include clear limits to the use of these guidelines in practice and directions to alternative services when these limits are reached. The guide will also provide referenced background information and practical tools to improve practice and expand other guidelines relevant to the feeding of young patients who are refusing or unable to maintain adequate hydration and nutrition.

3.0Scope of the guideline

This guideline applies to the following people:-

  • young patients and their families
  • nursing staff
  • medical staff including on-call medical staff
  • pharmacy staff

4.0Definitions

Enteral tube feeding: / nasoenteric, gastrostomy (PEG) feeding:
Bolus feed: / administering a volume a feed via a syringe and tube at regular intervals
Intermittent feeding: / this involves gravity feeding or feeding with a pump with breaks between feeds to suit patient needs.
Continuous feeding: / may be appropriate for patients who cannot tolerate large volumes of feed.
Nutritional supplements: / - not requiring a prescription eg. Complain, Build Up
- requiring a prescription eg. Fortisip, Ensure Plus
- multivitamin and mineral tablets

5.0Examples

About 50% (n=10) of the inpatients in Leigh House at any one time have severe eating difficulties, usually associated with a diagnosis of Anorexia Nervosa. These young people have varying degrees of eating difficulty.

  • Some young people arrive with a nasogastric tube and enteral feeding regime in place and need to continue being fed by this method either totally or partially.
  • Some will be willing to have the nasogastric tube removed and to eat with the support of the eating programme.
  • Of those on the eating programme, some make steady progress with intensive support.
  • Some struggle and at times come close to requiring nasogastric feeds but in response to the interventions of the team manage to progress enough to avoid nasogastric feeding.
  • Some require intermittent nasogastric feeds to make up for meals missed on the programme but otherwise manage to keep up with the group.
  • Of the group who cannot make progress with the support of the eating programme some passively accept nasogastric feeding.
  • Others refuse and resist, fighting the team by preventing the insertion or pulling out the nasogastric tubes.

Some young patients with other diagnoses such as depression or psychosis develop associated eating difficulties which may be severe.

There are occasions when, despite full nursing and medical support, a young person refuses most food and fluids for 24 – 48 hours and becomes close to physical collapse. In order to prevent such deterioration and cardiovascular complications a decision is needed about re-establishing nutritional support using prepared feeds passed through a nasogastric tube. Such support will be necessary until the young person is able to resume eating and drinking sufficiently to sustain their physical recovery.

In view of the fact that young people have shown varying degrees of acceptance or resistance to this method of nutritional support, the team needs guidance on the safe limits of such an intervention, outlining at what point it is more harmful than beneficial to intervene in this way and what degree of coercion is within safe, legal and ethical practice.

6.0Criteria for use of Nasogastric (NG) Feeding

What are the criteria which should be met before attempts are made to pass an NG tube at Leigh House?

  • Creative use of the Leigh House eating programme has been exhausted
  • Every effort has been made to encourage normal eating including involvement of family if appropriate
  • Restriction of activity in place
  • Level of supervision has been increased
  • There has been close monitoring of fluid and food over previous 24 hours using fluid charts to measure input and output
  • The patient has refused food and liquid nutrition for a period of time up to 48 hours
  • Nursing staff confirm that no food or fluids have been taken in 48 hours
  • The patient is at risk of serious physical compromise with evidence of weight loss plus any of the following:-
  1. dehydration
  2. biochemical imbalance (rising Urea)
  3. postural hypotension or low blood pressure
  4. tachycardia
  5. bradycardia
  6. oedema
  7. dizzy on standing
  8. loss of skin turgor

The details of the assessment and the reasons for and against nasogastric feeding must be recorded in the patient’s medical notes prior to the commencement of feed.

7.0Risk Assessment

A full risk assessment must be undertaken by two competent health care professionals including the senior doctor responsible for the patient’s care. This assessment must include discussion with patient, family and members of the MDT. This must include consideration of the risks and benefits of staying at Leigh House over transfer to general hospital. See below 9.0. The risk assessment of the benefits and the risks of introducing a nasogastric tube must be documented, signed, dated and timed.

Consideration of the following risks will be necessary if treatment is to continue a Leigh House:-

  • Environment and capacity of the unit/
  • Staffing levels.
  • Availability of staff with the necessary skills in the short and longer term to support the correct insertion and accurate confirmation of placement of the tube.
  • The risk to the physical health of the young person if the intervention is not carried out.
  • The risk to the young person if the intervention is carried out.
  • The risk to the patient’s dignity in any event.
  • If the patient is already of low weight because of a diagnosis of Anorexia Nervosa s/he would have to be physically well enough to withstand the procedure and any level of restraint that might be required.
  • If the patient has unusual or altered anatomy, a senior clinician should be contacted and nasogastric tube insertion attempted only under fluoroscopic control.

All efforts to manage the situation without recourse to NG feeding and NG feeding under restraint must have been exhausted.

8.0Criteria for Referral to Paediatric Ward

  • If there is any medical or nursing doubt about the physical health of the patient.
  • If a young patient looks as if s/he is on the verge of collapse.
  • If the young person cannot get up from crouching without support.
  • If there is evidence of very significant cardiovascular instability, such as:-

-Hypotension BP < 80 / 50

-Arrhythmia: irregular pulse

-Bradycardia < 40

  • Vigorous resistance by the patient seems likely to persist despite all efforts at de-escalation.
  • The likelihood of a significant negative impact on the capacity of the nursing team to sustain the intervention and maintain the care of the other patients.
  • Need for sedation because of vigorous resistance.
  • Consideration to be given to the possibility of young person (who is vigorously resisting in Leigh House) accepting nutrition in the general hospital setting.

9.0 Management of Resistance

The following bullet points suggest techniques to build up the young person’s motivation to collaborate with the nursing team allowing some negotiation.

Assessment of likely resistance:

  • Review the history of resistance
  • How does the young person understand her/ his options?
  • What does the young person think might help to move things forward?
  • What is important to young person at present and can this be used to motivate the young person or provide an incentive to collaborate?

Encouragement to accept the process of feeding in any form:-

  • Acknowledge with the young person that members of staff are in charge of the young person’s health and therefore the decision that feeding (one way or another) must go ahead is not a choice the young person needs to make.
  • Within this ‘no choice situation’ provide a limited range of options e.g. offer oral nutrition / fortisipetc but offered with a time limit.
  • Discuss incentives eg free time when procedure finished, offer of an appropriate activity etc
  • Discuss short term goals eg activities, home leave, trips out etc.
  • Show empathy with difficulty faced, whilst remaining clear that feeding must go ahead.

Discuss possible physical consequences of refusal:-

  • The need to cease all activities
  • The need for constant rest
  • Signs of Hypotension
  • Weakness
  • Depression
  • Clouded thinking
  • Heart failure
  • Chest pain

10.0Once the clinical decision has been made to proceed with nasogastric feeding, if the patient is collaborative and consenting

  • The procedure must take place in the treatment room.
  • The passing of an NG tube must be undertaken only by members of the nursing or medical team with experience in passing NG tubes.
  • The availability of such staff in the week ahead must be assessed before the decision to use NG feeding is made to ensure that the treatment can be implemented and sustained in the event of tube being pulled out.
  • Ensure the availability of NG tubes (process of stock)
  • Nasogastric tubes used for the purpose of feeding must be radio-opaque throughout their length and have externally visible length markings.
  • Ensure the availability of NG feed
  1. A prescription must be written by the medical team for the required feed and fluid.
  1. This prescription must be discussed with dietician as soon as possible.
  1. Laboratory request forms for blood investigations must be completed.

These tests to include:-

  1. Urea and Electrolytes,
  2. Liver function Tests
  3. Renal function Tests
  4. Phosphate and Calcium
  5. Magnesium
  • Oral feed available and re-offered in final attempts to avoid need for NG feeding
  • but with agreed time limits on such negotiation.
  • REFER TO PARAGRAPH 15.00: GUIDELINES FOR PLACING THE NASOGASTRIC TUBE

11.0 If the patient is not consenting and resisting and nasogastric feeding is to go ahead under parental consent, Mental Capacity Act of Mental Health Act 1983:

More often than not the young person is experiencing intermittent impulses to pull at the tube in contrast to a prolonged struggle throughout the process therefore the necessary restraint is most likely to be one of holding the arms to help the patient inhibit these impulses.

  • The procedure must take place in the High Care Area.
  • Alert paediatricians and discuss the possibility of transfer to Paediatric ward if unsuccessful.
  • Only proceed to initiate NG feeding if a doctor on site in addition to an experienced nurse to pass the tube.

12.0 The procedure for safe holding during the insertion of and feeding via an NG tube in accordance with the guidelines for placing and feeding via an NG tube in para 15.00

  • The team must use only the techniques outlined in PRISS (Proactively Reducing Incidents for Safer Services).
  • The minimum number of people involved in restraint, whilst passing the NG tube is three. However, if initially more than three people are required to hold the young person safely, then try to de-escalate and sit to de-escalate for a further period until it is safe to hold with only three people.
  • All nurses involved in restraint must have up to datePRISS training
  • Persuade young person to go to HCA for feed
  • Sit to de-escalate
  • Once settled on settee – a nurse must sit either side of young person
  • The nurse who will be passing the NG tube should be ready and prepared to pass the NG tube as outlined below. (see preparation of NG Tube):
  • In order to hold the patient safely, s/he should be held and supported by one nurse to each arm and one supporting the head, plus one free to fetch and carry.
  • Young person sitting on settee with two staff, head co-ordinator doing the talking.
  • Define the point when negotiations will stop and insertion of NG tube to proceed
  • Head co-ordinator cups the head as in safe holding guidelines:-
  • Going with the movement
  • Not resisting any movement
  • Nurse would proceed with the NG tube
  • No attempt should be made to lock the head of the young person
  • If tube cannot be passed in these circumstances:
  • Sit to de-escalate for a further period
  • Try again

In the event of strong resistance and difficulty taking the young person to the High Care Area.

  • Re-evaluate
  • Re-offer oral feed
  • Review medication and if appropriate consider light sedation such as anxiolytics, eg Oral Diazepam / Lorazepam
  • Reconsider paediatric referral