ClinicalPracticeGuidelines

HomeEnteralNutritioninAustralia

AdocumentpreparedbytheAustralasianSocietyofParenteraland
EnteralNutrition

AuSPENClinicalPracticeGuidelinesforHomeEnteralNutrition
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Introduction:
Theaimoftheseguidelinesistoachievebetterhealthoutcomesbyimprovingthe
practiceofhealthprofessionalsinvolvedinthecareofpatientsrequiringhomeenteral
nutrition(HEN).

Multidisciplinarynutritionteams:
Nutritionsupportteamsoperatingwithinhospitalshavedemonstratedthattheir
involvementimprovesstandardsofcareandincreasescosteffectivenessofartificial
nutritionsupport.

ThebestcareofthepatientreceivingHENwilloccurwhentheprimarycarephysician
workingwithanutritionsupportteam(comprisingmedicalpractitioner,nurse,
dietitian,stomaltherapist)takesresponsibilityfortheinitialandongoingcareofthe
patientreceivingHEN.

AllmembersoftheteamhavespecialisedknowledgeandexperienceinHEN.The
teamfamiliarwithHENliaiseswithallotherhealthprofessionalsinvolvedwithother
aspectsofclinicalcare.Theteammakesajointdecisionregardingpatientselectionand
ongoingmanagement.

Theteamapproachcan:
improvestandardofcare
increasecosteffectiveness
ensureappropriatetrainingandcounselingofpatient/orcarer
reducecomplicationrates

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Indications:
HomeEnteralNutritioncanbeconsideredinthemanagementofthefollowing
conditions,including:

1. Impairedabilitytoingestnutrients: 3. Miscellaneous
Oropharyngeal,oesophageal Chronicpulmonarydiseaseeg
tumours CysticFibrosis
Neurologicaldisorderse.g. Chronicrenalfailure
cerebrovascularaccident,multiple Anorexianervosa
sclerosis,motorneuronedisease, Congestivecardiacfailure
trauma HIV/AIDS

2. Impairedabsorptionofnutrients 4. Paediatricindications
Surgicalresection/bypasse.g. Neurologicaldisorderseg.Cerebral
gastrectomy,smallbowelresection Palsy
MalignancyofGITe.g.Ca Failuretothrive
pancreas Shortbowelsyndrome
Inflammatorydisorderse.g.Crohn's Chronicpulmonarydiseaseeg.
disease CysticFibrosis
Shortbowelsyndrome Inflammatoryboweldisease
Gastrointestinalfistulae Gastrooesophagealreflux
Radiationenteritis Metabolicdisorders
Chronicrenalfailure
Malignancy

Contraindications
Patient/carernotmotivatedorabletomaintainthedisciplineinvolvedindelivering
HEN

SelectionofpatientsforHEN
Inabilitytomeetnutritionalrequirementsbyoralintakeasdocumentedby
dietitian'snutritionhistory.
Clinicalstatusisstableandallowsdischargetothehome.
Qualityoflifewillbemaintained/improvedbynutritionsupport.

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 Patienthastheabilitytocomplywithandtoleratethenutritiontherapy.
Thepatientandthecarerareabletocopewithchangesinlifestyleanddemonstrate
abilitytoperformprocedurestoacceptablestandards.
Thehomeenvironmentisappropriateforthesafeandeffectiveuseofnutrition
support.
Thepatientandcarerunderstandthecostofnutritionsupportandareawareof
financialresponsibilities.

Assessment
1. ClinicalHistory circumferenceinyoungchildren
Thefollowingclinicaldatawillbe andinfants.
assessed: Ifbodyweightcannotbemeasured,
underlyingdisease anestimationofbodyweight
age shouldbeobtainedfromfamilyor
metabolicdemandsincluding carer.
growthrequirements
fluidrequirements 5. Biochemicaldata
Thefollowingbiochemicaldatawillbe
2. Medicationsandsupplements assessed:
Considerationwillbegiventothe Liverfunction,renalfunction
methodofdeliveryofmedicationsand Serumelectrolytes,glucose,
supplements. phosphateandcalcium

3. Nutritionhistory 6. Socialconsiderations
Thedietitian,throughappropriate Thehomeenvironmentandthe
dietarymethodology,willassessthe patient/carer'sabilitytocopewiththe
nutrientintakeoftheclient. necessaryproceduresshallbeassessed.

4. Anthropometry 7. Activitypatternandlifestyle
Thefollowinganthropometric Therecreationalandrelaxation
measureswillbeassessed: activitiesoftheclientwillbe
Weight,height,BMI consideredincludinghowthesewill
Weighthistory impactonhomefeedingregimen.
Inchildren,includepercentile
growthdataandhead

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Planning
Acareplanwillbebasedontheresultsoftheassessment,andshouldincludethe
following:

SelectionofmostappropriaterouteofadministrationforHEN
TheselectionofthemostappropriaterouteofadministrationforHENwilltakeinto
accounttheexpecteddurationofsupport,theconsciousstateandclinicalconditionof
thepatient.
Possibleroutesinclude:
Nasogastric jejunostomy
gastrostomy nasojejunal
nasoduodenal

MethodsofdeliveryofHEN
ThesafestandmostefficientmethodofdeliveryofHENmustbedeterminedclinically
foreachpatient.Enteralfeedsmaybedeliveredbyintermittentbolus,gravityinfusion
orpumpcontrolledtechniques.

SelectionofformulaandtimingoffeedsforHEN
Theselectionofformulawillbebasedonabalancebetweentheclinical
requirements,modeofdeliverytolerance,longtermcostandavailability.
Theformulaewillbeappropriateforthediseaseprocessandbeadjustedaccording
tometabolicrequirements.
Formulaewillmeetestimatednutritionalandfluidrequirements,withconsideration
forothersourcesoffluid/restrictions
Thecostimplicationsoftypeandquantityoffeedsandtheavailabilityof
governmentsubsidiesforHENshouldbeconsideredintheselectionprocess.
Rateandtimingofadministrationofsolutionsshallbebasedonpatienttolerance
andhomeroutine.

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Implementation
Thereshallbewrittenguidelines(aninstructionmanual)fortheeducationof
patient/carer.

Upondischargefromhospital,thepatient/carerwillknow:

HowthefunctionofGIThas
changedandthereasonforenteral
nutrition
Howtochangemalfunctioning
partsofthetube.
Howtomanagethedelivery
system:pumporgravitydripor
syringe
Storage,hangtime,andmeansof
provisionoffeeds.
Theprinciplesofhygiene
Howtopreventandrecognise
complicationssuchasinfection,
aspiration,andmechanical
complicationssuchasocclusionor
misplacementofthetube.
Namesofpersonneltocontact24
hrs/day
Followuparrangements
Howtoirrigateablockedtube

Thepatient/carerwillbeableto:
Checktubeposition Connectfeedtofeedtube
Administerabolusfeeddownthe Disconnectfeedandflushwater
tube downthetube
Preparefeedreadyfor Programfeedingpump
administration
Administermedicationdownthe
tube

Documentation
1. Therewillbeawrittenstaffprotocolforinitiating,monitoringandterminating
HEN.

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2. Thenutritionsupportteamwilldocumentinmedicalhistoryallrelevantaspectsof
assessmentandmanagementofHEN,andsendinformationtoallinvolvedhealth
professionalsupondischarge.

Inthemedicalhistory,thefollowingwillbedocumented:
Nutritioncareplanincluding
Initialassessment:
anthropometry,biochemistry,nutrientrequirements.
routeandmethodofadministrationofHEN
deliverytimesordurationoffeedingperiod
formula
nutrientandfluidcomposition
3. Therewillbeapatient/carerinstructionmanualforHEN,whichisregularly
updatedinordertoreflectdevelopmentsandinnovationsintubefeeding,access,
nutrientsanddeliverysystems.
4. Therewillbeawrittenprescriptionfortheenteralfeed,andotherprescribable
items.
5. Therewillbealistoftherequiredequipmenteg.syringes,pump,dripstand.
6. Therewillbewrittenpatient/carerlearninggoalsforHEN.

Monitoring
Protocol shallbedevelopedfortheperiodicreviewofthepatient'sclinicaland
biochemicalstatus,andqualityoflife.
Thereisanagreedtimeframeforfollowupandreassessmentbythenutrition
supportteam.
PatientsreceivingHENfeedingshallbereviewedbythenutritionsupportteam
afterthefirst3monthsofinitialoftreatment.Afterthisreviewatnolongerthan6
monthlyintervals.

Thepatientwillbemonitoredfor:
effectivenessoftherapy,
adverseeffects,
clinicalchanges.

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Routinemonitoringshouldinclude:
ContinuedneedforHEN Therewillbeanoncallsystemfor
Adjustmenttotherapy providingexpertmedicaladvice
Nutrientintake andsupporttothepatient/carerby
Psychosocialproblems telephone24hoursaday.

Reviewofcurrentmedications Weightchanges

Changesinhomeenvironment Biochemical,haematological

Signsofintolerancetofeeds

Termination
Protocolswillexistwhichindicatewhenfeedingshouldbestopped,andwhat
alternativeactionshouldbetaken.
Enteralnutritionshouldbestoppedwhenthenutritionsupportteamand
patient/carerjudgethatthepatientnolongerbenefitsfromthetherapy.

Transitionalfeeding
Ifthepatientischangingovertooralintake,theymustbeseentobeachieving
adequatenutritionbythismethodbeforeHENisstopped.
Closedieteticinvolvementisimportanttoensureadequatenutrientintake.
Anintermediateperiodofincreasingoralintakeanddecreasingenteralfeedingwill
oftenbenecessarytoassessthis.
Ifswallowingdifficultiesarepresent,aspeechpathologistwillberequiredtoassistin
transitionfromenteralfeedingtooralintake,andtominimiseaspirationrisk

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References:

AmericanGastroenterologicalAssociationTechnicalReviewonTubeFeedingfor
EnteralNutrition.Gastroenterology1995108:323.

WolfeBM,MathiesenBS.Clinicalpracticeguidelinesinnutritionsupport:cantheybe
basedonrandomizedclinicaltrials?JPEN199721:16.

EliaM.Aninternationalperspectiveonartificialnutritionalsupportinthecommunity.
Lancet1995345:13459.

EliaM.Enteralandparenteralnutritioninthecommunity:areportbyaworkingparty
oftheBritishAssociationforParenteralandEnteralNutrition(BAPEN).M.Elia,ed.
Maidenhead,Berks:BAPEN,1994.

AmericanSocietyforParenteralandEnteralNutrition.Standardsforhomenutrition
support.NutrClinPractice19927:659.

DaveyMcCraeJA,HallNH.CurrentPracticesforHomeEnteralNutrition.JADA
198989(2):23340.

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