Presentation on theme: "Nutrition Support Specialist Dietitian"— Presentation transcript:
1 Nutrition Support Specialist Dietitian National Patient Safety Agency (NPSA) – a Dietitians guide OR ‘The return of the syringe’Ann AshworthNutrition Support Specialist DietitianTorbay HospitalTorquayTQ2 7AA2nd August 2006Thank you for asking me to present this afternoon.During this session, I will give you the knowledge and confidence to implement an important new Patient Safety Alert about to be issued from the National Patient safety agency (NPSA) which involves enteral feeding.
2 Aims Identify risks involved NPSA Alert Effect on practice Formulate an action planQuestions/discussionAs dietitians specialising in nutritional support, we need to communicate effectively with our colleagues on this Patient Safety Alert. To do this, we need to understand the potential risks involved in enteral feeding systems. So, I am going to briefly describe a case study, which happened to be one of my patients on HEF. I am then going to ask you to do some work, to identify the risks involved in enteral feeding systems.I will then cover the main points of the Alert and some possible effects on practice on the wards and in the community.You may well be asked to be involved in an Action Plan to implement the Alert, so I will present some ideas on how to go about this.There will be some time for some questions and discussion at the end.
3 Case study CVA patient Admitted PEG removal and supra-pubic catheter Perforation – laparotomyICU - triple lumen lineClinical incident: Oral Verapamil given via central lineFirst I need a volunteer to be an 80 year old lady who has had a stroke. She had done well since her discharge home on a PEG feed. Her dysphagia was resolving and she was managing to eat and drink well. She was cared for at home by her husband. She was admitted for the removal of her PEG and insertion of a supra pubic catheter (at the local private hospital). Things did not go well and she was admitted to Dstrict General Hospital with vomiting. She was NBM and had an NG tube placed.She was found to have perforated small bowel, which unfortunately had occurred during the insertion of the catheter. She had an emergency laparotomy and small bowel resection. She subsequently went to ICU and had a triple lumen line inserted. At this stage she was on medications both IV and PO (i.e. NG). A week later, she was better, alert and talking to husband. A drug called verapamil was mistakenly given down the central line instead of NG and she became very unwell. Subsequently had PEG reinserted and discharged to nursing home, where she died about 18 months after discharge.This type of incident has caused the NPSA to issue its Alert.
4 Identify risksWith a partner try and list the number of connectors and ports in an Enteral Feeding System, from feed reservoir to patientconnector = ‘thing that connects’anywhere the system can be accessed (not pump insert)Identify if male/female luer connectors as appropriate.
5 This diagram shows a giving set This diagram shows a giving set. British Standards exist for the end of the giving set, which must be a female luer but not the drug port, which is used by nursing staff to give meds.
6 This shows a PEG tube – again the end is covered by a BS, and must be a male end, but not the side port. Here it is being flushed by a catheter tip syringe.
7 However, here the syringe adaptor at the end of the side port has been inserted, so that tube is being flushed by a luer tip syringe, which is compatible with IV lines
8 This slide shows a low profile device with a balloon This slide shows a low profile device with a balloon. The balloon is inflated with water and he valve on the side of the tube is designed to take a luer slip syringe
9 Identify risks What is an See handout for NPSA draft glossary Oral syringe?Enteral syringe?Catheter tip syringe?Luer syringe? (lock/slip?)See handout for NPSA draft glossaryI am going to pass around some examples of syringes
10 NPSA Alert‘Preventing wrong route errors with oral/enteral medicines, feeds and flushes’Patient safety alert ‘requires prompt action to address high risk safety problems’
11 NPSA Alert– health professionals current projects – Medication Practice – NPSA stakeholder consultation - preventing wrong route errors
12 NPSA AlertOnly oral, enteral or catheter tip syringes…. must be used to administer oral/enteral medicines, feeds and flushes to patients
13 NPSA AlertPorts on nasogastric and enteral feeding tubes….must be male luer, catheter or other non-female luer in design
14 NPSA AlertAdmin and extension sets must not contain any in-line female luer portsUse of three way taps not recommendedAdaptors that convert syringes to connect with IV must not be used
15 NPSA Alert No final dates for publication – due in Autumn Use oral/enteral syringes in all clinical areas by 31st December 2006All other recommendations 30th September 2007e.g. NHS should not buy devices which do not comply
16 Effect on practice??No longer use IV (male luer) syringes or three way taps for medications/flushingUntil side ports changed, meds/flushes have to be given via feeding tubeMultiple breaks in system – microbiological issue?
17 Effect on practice?? Design and sizes of syringes Patients/carers need consistent adviceTrust policy on enteral feeding and/or single use syringes will need re-writing
18 Action plan – Risk assessment Read NPSA documentDiscuss with colleagues to determine which equipment/practice does not complyForm multidisciplinary group to write action plan (e.g. Chief Pharmacist, Nutrition nurses, Clinical Governance, Director of Nursing)
19 Summary Enteral feeding connectors Aware of risks Aware of Alert from NPSA and timelineIdeas for an action planQuestions?