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