1. Nutrition Support Specialist Dietitian
National Patient Safety Agency (NPSA) – a Dietitians guide OR ‘The return of the syringe’
Ann Ashworth
Nutrition Support Specialist Dietitian
Torbay Hospital
Torquay
TQ2 7AA
2nd August 2006
Thank 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 plan
Questions/discussion
As 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 – laparotomy
ICU - triple lumen line
Clinical incident: Oral Verapamil given via central line
First 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 risks
With a partner try and list the number of connectors and ports in an Enteral Feeding System, from feed reservoir to patient
connector = ‘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 glossary
I 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 Alert
Only oral, enteral or catheter tip syringes…. must be used to administer oral/enteral medicines, feeds and flushes to patients

13. NPSA Alert
Ports on nasogastric and enteral feeding tubes….must be male luer, catheter or other non-female luer in design

14. NPSA Alert
Admin and extension sets must not contain any in-line female luer ports
Use of three way taps not recommended
Adaptors 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 2006
All other recommendations 30th September 2007
e.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/flushing
Until side ports changed, meds/flushes have to be given via feeding tube
Multiple breaks in system – microbiological issue?

17. Effect on practice?? Design and sizes of syringes
Patients/carers need consistent advice
Trust policy on enteral feeding and/or single use syringes will need re-writing

18. Action plan – Risk assessment
Read NPSA document
Discuss with colleagues to determine which equipment/practice does not comply
Form 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 timeline
Ideas for an action plan
Questions?