Improve & Standardise Tube Feeding

Process

Presented By:
Elimar Siriban
Senior Staff Nurse
QI Project: Improve & Standardise Tube
Feeding Process

Organised by: AIC

Participants: The Lentor Residence

SWAMI
Lee Ah Mooi
(3/10/2017 - 6/10/2017—training)

Project Period: Oct 2017-March 2018

Background
 Residents in nursing homes are often unable to ingest food via
oral intake. Enteral nutrition is the preferred feeding method for those
residents with functioning gastrointestinal tracts but with inability to
ingest nutrients by mouth.

 Nasogastric Tube (NGT) feeding is a common practice in the

nursing home and requires proper handling during preparation of
milk, feeding and cleaning feeding equipment. This process may be
accompanied by risks such as aspiration pneumonia, diarrhoea,
infection, as well as have a negative impact on resident’s well being.
Objectives
 The aim of this project is to bring together nursing homes to
standardise and streamline the process for tube feeding so as to
reduce residents’ risk of complication as a result of tube feeding. The
objectives are:

 Achieve percentage of Tube Feeding Residents admitted hospital

due to tube feeding related diagnoses to ≤14% (Ave. 4% per week).

 Reduce the no. of incidence of high (≥50ml) aspiration volume by

10% in 6 months.

 Reduce the time for preparing and cleaning by 10% in 6 months.

Scope
 End-to-end process from preparing milk feed, feeding, medication, to
cleaning feeding equipment

 Powdered milk and Canned milk

 Manual feeding and pump assisted feeding

OUT Of Scope
 Changing of Tubes

 Residents on PEG

 Residents on Transitional Feeding

Pre-Project State Mapping

Check dietitian’s
KEY NOTES:
order High aspirate volume
>50ml:Delay feeding for 30
mins and check again later

ph >5 or 6: inform doctor and

check medications and
aspiration content

Aspirate vol. < 50ml and pH

of <5 :proceed with feeing
Pre-Project Data
Lentor 60 Day Data

Objective: Maintain the percentage of Tube Feeding Residents admitted

hospital due to tube feeding related diagnoses at ≤14% (Ave. 4% per week)
 50ml pre workshop >50 % of the previous feed post workshop

Objective: Reduce the no. of incidence of high aspiration volume by 10% in 6 months.
 Pre-Workshop Data (Sep)

Clean Milk Total Time

No. of Tube Feeding Prepare Milk Ave. Time Taken to
Preparation Taken per
Residents Feed Prepare 1 resident
Equipment Day
10 43 mins 35 mins 78 mins 1.33 mins

Difference of 0.67min
/ patient = -13%
60 Day Data (Dec)
No. of Tube Feeding Clean Milk Total Time
Ave. Time Taken to
Residents for Time Prepare Milk Feed Preparation Taken per
Prepare 1 resident
Motion Equipment Day
3 11 mins 11 mins 22 mins 1.50 mins

Actual: 21
residents

Objective: Reduce the time for preparing and cleaning by 10% in 6 months
TARGET (QUALITY)
 To achieve percentage of Tube Feeding Residents admitted hospital
due to tube feeding related diagnoses to ≤14% (Ave. 4% per week).

 To reduce the no. of incidence of high (≥50ml) aspiration volume by

10% in 6 months.

 Reduce the time for preparing and cleaning by 10% in 6 months.

Root Cause Analysis
PROBLEM SOLUTION
1. Water for NGT feeding milk preparation is used 1. Mark water jar, for NGT ONLY.
for other purpose.

2. Quite a number of PH paper is wasted due to 2. Change to 4 coloured PH indicator

accidentally wet

3. Unnecessary use of Gloves 3. Use gloves only when necessary.

(when you have cuts/open wound and patient has a
lot of secretions ).

4. CURA system breakdown when key-in the data. 4. Use group chat to pass info and update. Keep
hard copy to key in later.

5. Nurse take the feeding regime file from nurse 5. Feeding regime is posted on the Preparatory
station to pantry area to prepare milk. Then go area
back to station to return the file. Individual shaker/feeding jug is labelled with feeding
regime.
PRIORITISING SOLUTION
• To purchase shaker
• To purchase 4 colour PH indicator
• To pack feeding box with 50cc syringe, Alcohol Swab, cup for aspiration, and PH indicator
• Label cup with room number, resident’s name and NRIC
• Posting of updated feeding regime
• Training for new NGT update
• Update SOP on NGT Feeding
• Dry run on NGT feeding project

• To inform management in regards to purchasing shakers and PH indicators

• To set a training to update staff on the new NGT update

• To discuss with management in regards to purchasing shakers and PH indicators

• No more soaking of feeding cups and syringes using precept

• Use of gloves only when necessary.
WORK INSTRUCTIONS
Preparing of Milk using
Shaker
 THINGS TO PREPARE (REQUISITES)
• Formula Feed(powder)
• Feeding Regime
• Feeding Jar/Jug
• 50ml Syringe
• Shaker
• pH Indicator
• Kidney Dish
• Alcohol Wipes/Pad
• Gloves(optional)
NGT FEEDING INSTRUCTIONS
 21 residents at one time
Preparation of milk feed for ____
S/N Main Steps Key Points Reasons for Key Points

Take note of Feeding Regime by

1 Check Dietician's Order Insert photo here Prevent errors in feeding the resident
Dietician (5R's)

Prevent contamination as well as a means for

2 Clean Feeding Trolley Insert photo here Use alcohol wipes for cleaning
infection control

Individualise cups with hardcopy

labels containing the vital
information of the patient: Prevent errors during the distribution of the
3 Prepare feeding cups/shaker Insert photo here
- Name milk feed
- Room Number
- Bed number

Go through all 7 steps of hand

To ensure any infection is controled with
4 Execute hand hygiene Insert photo here washing for a thorough hand
minimal chances of cross contamination
hygiene
 21 residents at one time
Preparation of milk feed for ____
S/N Main Steps Key Points Reasons for Key Points

1) To prevent alterations in the milk's

Ensure lukewarm water is used: nutrients
Pour lukewarm water into the shaker one at
5 Insert photo here - check water volume at eye level 2) To prevent resident's discomfort
a time
- Test the temperature of water 3) For accurate measurement of the water
volume

Add required scoops of milk formula as per Refer to dietician's list and check 1) To reduce error in preparing the milk
6 dietician's order. Add supplements as need Insert photo here the expiry date on the tin as well 2) To ensure residents receive sufficient
(eg. Propass, Myotein) as the tin's intactness nutrition

1) Ensure shaker cover is covered

Shake mixture for 10 - 15 seconds in one 1) Prevent spillage of milk while shaking
7 Insert photo here tightly
direction 2) Prevent the forming of bubbles
2) Shake in one direction only

Pour the prepared mixture into the feeding Ensure pouring is done at eye
8 Insert photo here To ensure accurate measurement
cups accordingly level

1) To prevent contamination (Infection

9 Cover cup with stainless steel/plastic cover Insert photo here Ensure cover is clean Control)
2) Keep milk at room temperature

Termination Phase: (1) Wash, clean and dry the utensils (2) Keep milk formula in proper place
WORK INSTRUCTIONS

Milk Feeding Procedure

 21
Preparation of milk feed for ____ residents at one time
S/N Main Steps Key Points Reasons for Key Points

Distribute the milk to the resident's I nsert photo

1
bedside here

Place screen/curtain in front of the I nsert photo Ensure resident is not visible
2 Privacy of the resident
door here from the outside

I nsert photo Ensure 7 steps of hand

3 Perform hand rub Prevent from cross contamination
here hygiene is performed

I nsert photo Ensure resident is placed at a

4 Position the residents for feeding Prevent residents from regurgitating
here 30 - 45 degree angle

Wipe from the lid

Wipe the connecting port of NGT with I nsert photo
5 downwards in a circular Prevent from cross contamination
alcohol swab here
motion

Check the following:

1) pH level
Kink and attach the 50ml syringe I nsert photo To ensure the proper placement of
6 2) Aspirate volume
Thereafter, aspirate gastric content here NGT & R/T
3) colour
4) consistency
Kink and attach the syringe
Thereafter, flush 10ml of water,
I nsert photo Prevent air from entering the
7 followed with feeding the medicine Kink tubing
here stomach
At the end, flush with another 10ml
of water
 21 residents at one time
Preparation of milk feed for ____
S/N Main Steps Key Points Reasons for Key Points
1) Observe any discomfort
(i.e. coughing, DOB, etc.)
Insert photo 2) Ensure the tip of the Prevent further complications (i.e.
8 Introduce milk feeds
here syringe is placed at the ASP, pneumonia, etc.)
forehead level of the
resident
Flush with the remaining water,
1) Check for any excess milk 1) Prevent clogging of the tube
spigot, followed by keeping the Insert photo
9 2) Ensure that no water is 2) Prevent residents from
position of the residents for 30 - 45 here
left in the tube regurgitating
minutes

Insert photo From lid downwards in a

10 Swab port Prevent contamination
here ciruclar motion

Insert photo Ensure 7 steps of hand

11 Perform Handrub Prevent from cross contamination
here hygiene is performed

1) Aspiration to be disposed
Discard aspiration and collect feeding Insert photo in the pail with a trash bag
12 Prevent contamination
items here 2) Used feeding items to be
placed in the other pail
Indicate the following:
1) pH level 1) Proper documentation for easier
Insert photo 2) Aspirate volume handovers
13 Documentation
here 2) Colour, consistency, etc. 2) Record in notebook to ensure no
Document in notebook accidental loss of updates
should NHELP be
Termination Phase: Resident at 30 - 45 degree incline position
WORK INSTRUCTIONS

Cleaning Up after Milk

feeding
Work Instructions Location: Pantry Revised Date: 6th Oct 2017
Process Title: Cleaning up after Milk Feeding Revised By:
Estimated Process Time:
Things to Prepare (Requisites)

1) Sponge and brush Insert photo here 2) Washing detegent Insert photo here 2) Alcohol wipes Insert photo here

3) Tray Insert photo here 5) IT System for documentation Insert photo here Insert photo here
 21 residents at one time
Preparation of milk feed for ____
S/N Main Steps Key Points Reasons for Key Points

Leaving the room 1) Residents comfort

1 Insert photo here Turn off lights
- fix curtain 2) Save electricity

2 Remove feeding items from trolley Insert photo here

3 Disinfect trolley Insert photo here Wipe trolley in one direction Prevent from cross contamination

Change syringe twice a week

1) Use soap and rinse, soaking
Start washing of measuring jugs, feeding is not required
4 Insert photo here
cups, syringes 2) Wash all items using sponge
and brush
(Wednesdays and Sundays)
- LAM - PM Shift (done by feeding nurse)
- SWAMI - PM Shift (done by feeding
nurse)
- Lentor - Night Shift

Air dry measuring jugs, feeding cups and Wipe from the lid downwards in
5 Insert photo here Label syringe with number and gender
syringes a circular motion
 21 residents at one time
Preparation of milk feed for ____
S/N Main Steps Key Points Reasons for Key Points

Indicate the following:

Documentation in IT system
1) pH level Evidence collection for potential issues
6 - NHELP Insert photo here
2) Aspirate volume that may arise
- CURA
2) Colour, consistency, etc.

Ensure items are placed at their

Put back the syringes, aspiration cups to
7 Insert photo here proper place at the right Easy access for subsequent feeds
NGT box at bedside
resident

8 Clean NGT box Insert photo here For infection control

9 Check residents after 30mins to 1hr Insert photo here Observe any discomfort

Termination Phase: Return residents to original position

Standard Work (Checking Aspirate and pH)

Key notes:
• pH of 5&<50%
of the previous
feeding –
proceed with
feeding
• pH >6&>50% of
the previous
feeding-Discard
and inform
SN/EN,IC,
then documents,
30 mins ,check
again.
 Any Changes to
inform and
update
DR./Dietitian
Future State Process Map for Powdered Milk

New:
Flush-
medicine-
Flush-Milk-
Flush the
remaining
water
Future State Process Map for Canned Milk

New: Use
of Dish
Washing
machine
IN-HOUSE TRAINING REGARDING NEW UPDATES ON NGT FEEDING

Demonstration on how to shake

the prepared milk formula with
Shaker
Sharing of ideas on NGT Feeding

Gathering feedback on the

Implementation of NGT Project
 KEY CHANGES AND BENEFITS
S/N Key Changes Benefits
1 Use gloves ONLY when necessary. • Saves cost
• Shortens processing time
2 • Use only 50ml syringe • Increase hygiene levels
• No soaking of syringes • Saves time and cost
• Change syringes twice a week
3 Align key NGT steps across nursing homes and • Ensure safety
standardise aspiration workflow • Avoid confusion
• Promote confident at work
4 Introduce new methods to prepare milk: • Milk powder is dissolve better.
- Shaker • Save time.
• Less chance for contamination.
5 Use 4-coloured pH paper Increases accuracy of results

6 Use of Alcohol swab For infection control