VOL: 98, ISSUE: 17, PAGE NO: 40
Mandy Howell, BSc, RGN, OND, DPSN, DMS, is senior clinical nurse, Sunderland Royal Hospital
Percutaneous endoscopic gastrostomy (PEG) is a common procedure that provides enteral access for the administration of tube feeding in patients who are unable to obtain adequate nutrition by mouth.
However, Shaw (1994) claims that such patients may be at risk from a lack of knowledge about tube feeding on the part of nurses. Clinical governance requires up-to-date systematic evidence of what is being done in practice. For this study, an audit was conducted to assess nurses’ knowledge of the management of patients with PEGs at a district general hospital
A multiple-choice questionnaire was designed. The questions were reviewed for validity and ambiguous items were revised. The survey was given to 60 nurses from 13 wards, which was a representative sample of the skill mix of the nurses on duty on an average shift. A 100% response rate was achieved.
Results and discussion
PEG has been an established procedure for more than 20 years (Gauderer et al, 1980) and PEG management is part of nursing care in most gastroenterology and general medical settings. However, only 62% of the nurses surveyed correctly identified what the acronym PEG stood for.
Staff were asked multiple-choice questions to identify which groups of patients they considered to be most suitable for PEG feeding (see box). The procedure is contraindicated in patients with ascites, marked obesity, marked hepatomegaly, subtotal gastrectomy and gastrointestinal obstruction (Platt and Roe, 2000), as it is not possible to adequately bring the anterior gastric wall in apposition to the anterior abdominal wall.
The department under review has no guidelines for PEG tube placement and any decision to use the procedure focuses on a patient’s ability to take food by mouth. It is often made by the consultant alone. Rabeneck et al (1997) concluded that if an intervention was likely to have a physiological effect but no positive effect on quality of life, the physician should recommend against it
The patient is required to fast before PEG insertion. As there are no guidelines on the length of fasting time, this is based on individual ward/consultant preferences. Responses to the question on the length of fasting varied, with 37% of nurses recommending six to eight hours. Fawcett (1990) states that a six-hour fast is necessary, whereas White (1998) suggests a four-hour fast before endoscopy to prevent aspiration.
All wards had received the same written advice that feeding may be initiated six to 12 hours after PEG placement, starting with water. Again the responses varied widely, with 23% of nurses stating that patients should wait 24 hours before feeding.
Early enteral feeding can enhance wound healing and decrease the hypermetabolic response (Loan et al, 1998). When compared with parenteral nutrition, enteral feeding provides more nutrition per volume, causes fewer infection complications and costs less. Despite this, clinicians often withhold or delay enteral feeding.
PEG feeding within three hours of tube placement has been documented (McCarter et al, 1998; Brandimarte and Tursi, 1999). However, a study of gastroenterologists showed that although 81% were aware that they could do this, only 11% initiated feeding in less than three hours (Srinivasan and Fisher, 2000). Although bowel sounds should be audible before enteral feeding is initiated or continued (Fawcett, 1990), Loan et al (1998) suggest that these are an indication of gastrointestinal motility rather than absorption, and even when bowel sounds are absent the small bowel may be capable of absorbing nutrients. Our current hospital advice - to keep patients nil by mouth six hours after the procedure - should be reconsidered on the basis of the evidence.
Administering food directly into the gastrointestinal tract means the body receives nutrients to help fend off infection, heal wounds, and sustain organ function (Bliss and Lehmann, 1999). Nurses were asked how they would maintain a patent, clean tube before and after feeds or the administration of medication via a PEG, and what they would use as a regular flush.
According to hospital guidelines, the tube should be flushed with 25-30ml of lukewarm water before and after feeds and medication, yet only 8% of the respondents chose this amount. While a patient is in hospital, the guidelines recommend the use of sterile water after a new insertion but not the reinsertion of a tube. It is practice for the dietitian to write advice regarding water flushes on patient’s feeding plans, which may account for the larger volume chosen by 92% of staff. Mateo (1996) confirms that irrigating tubes before and after the administration of medication results in fewer becoming occluded.
Loose watery stools, or diarrhoea, are a common occurrence among tube-fed patients. This can occur because of enteral feeding but may also be a side-effect of medication. Nurses were asked to identify the most common causes of diarrhoea, and 63% identified a rapid infusion and high osmolality feed or lactose intolerance.
Antibiotics, laxatives, H2 receptor blockers and antacids with magnesium that stimulate gastrointestinal motility can all cause stools to become watery (Bliss and Lehmann, 1999). Diarrhoea may occur secondary to enteric pathogens or because of a predisposing illness, such as cancer, diabetes or Crohn’s disease. The improper administration of the feed or a lack of fibre can also cause watery stools.
When the feed is given by bolus, rapid gastric emptying and transition through the small bowel will result in diarrhoea; a continuous infusion will reduce the likelihood of diarrhoea as it delays gastric emptying (Shaw, 1994).
Daily checks of the stoma site are recommended for the first 10 days. Staff were asked to identify what to look out for during these checks (see box). Gastrostomy feeding has been associated with a 30% incidence of late complications (Kaw and Sekas, 1994; Wijdicks and McMahon, 1999), including accidental removal, blockage and wound infection, which occur in up to 5% of patients receiving enteral feeding (Platt and Roe, 2000). Daily checks include observing the stoma site for signs of leakage, redness, swelling and irritation, skin breakdown, soreness or excessive movement of the tube (more than 6mm) in or out of the patient’s stomach.
Staff were asked what cleaning practices they used (see box). Fawcett (1990) suggests cleaning the stoma site with sterile water and using an iodine dressing every day. If a keyhole dressing is applied, this should be removed after 24 hours. No further dressing is necessary. From day one to 28, the stoma site should be cleaned daily with ordinary soap and water, and the tube should be rotated 360° every day to prevent the formation of scar tissue. Patients are advised to shower rather than bath as the stoma site should not be immersed in water until it is fully healed.
The nurses were asked which dressings should be routinely used for PEG sites. After cleaning, the stoma site should be left to dry naturally. Dressings are not necessary as they precipitate moisture and irritate the surrounding skin and tissue. Eighty per cent of the nurses questioned agreed with this. Mackie (2001) says that the daily management of a PEG may be the main requirement for acceptance of the gastrostomy and for progressive improvement in the quality of life of the patient and carer.
The final questions focused on first-line action for blocked PEG tubes and PEG displacement. An occluded tube may cause patients to miss a dose of medication or fall behind in their fluid and nutritional requirements. If the occlusion cannot be cleared the patient may require a replacement tube.
The methods used to dissolve clotted feeds include the use of cranberry juice, carbonated beverages, meat tenderisers and enzymatic solutions (Metheny et al, 1988; Marcuard and Stegall, 1990). Regular flushing with water is the simplest way to prevent the tube from clogging but this is often neglected (Krupp and Heximer, 1998). Flushing enteral tubes with irrigants has been found to prevent occlusion and to restore the patency of partially obstructed tubes (Mateo, 1996).
Ward guidance prepared according to consultant preference and experience advises the following: first, flush with 25-30ml warm water, wait 30 minutes; if this fails, flush with 25-30ml soda water, wait 30 minutes; if this fails, flush with 25-30ml cola, wait 30 minutes; if this fails, flush with 25-30ml pineapple juice, which contains a digestive enzyme that may dissolve a blockage. When asked about the first-line management of blockages, 45% of the respondents suggested flushing with pineapple juice or cola.
Most PEGs need to be replaced because of tube breakage, deterioration, occlusion or dislodgement (Heiser and Malaty, 2001). A more serious complication is premature removal of the gastrostomy tube (Pofahl and Ringold, 1999).
Nurses were asked to describe how the removal of a tube should be managed (see box). When a tube is pulled out, a replacement should be inserted through the existing stoma tract immediately as this will start to close within an hour or two. A doctor or specialist nurse should be informed.
The potential complications associated with PEG placement include bleeding from the incision in the abdominal wall or the passage of the catheter into the patient’s stomach, perforation, aspiration and the PEG being pulled out of the stomach (Patrick et al, 1996). Replacing tubes carries risks such as PEG-tube complications (Heiser and Malaty, 2001) and death (Platt and Roe, 2000) owing to peritonitis caused by the incorrect positioning of a replacement.
The results of the audit are disappointing, but not entirely unexpected. Only 67% of nurses knew what PEG stood for and knowledge on which patients can be offered this type of nutritional support varied. So do patients and carers receive varying choice and support? This audit measured practice in the light of trust policies and procedures rather than nationally agreed guidelines. The gastroenterology service’s lack of clear guidance on fasting times and postprocedural feeding adds to confusion over PEG management and may result in conflicting advice being given, depending on the ward the patient is on and a consultant’s preferences.
Nurses working with PEG feeding tubes should know the causes of diarrhoea in patients receiving enteral feeding to ensure that effective action is taken, rather than simply stopping a feeding regimen or antibiotics.
In spite of individual care plans for patients with PEGs, the nurses failed to identify the correct care and daily checks for the first 10 days after PEG insertion in line with the written advice provided to wards. Practising safely is central to a nurse’s professional accountability. Effective management of PEG displacement or blockage is about doing the right thing, the right way, at the right time for patients. This audit shows that not all nurses take the most appropriate action and that this may indicate a lack of confidence rather than lack of ability.
Clinical governance provides opportunities to develop and change practice. This audit shows that standards need to be brought into line with the most up-to-date research to ensure the desired outcomes. With the appointment of a PEG nurse specialist we hope to improve these results by:
- Introducing criteria to improve patient selection before PEG insertion;
- Revisiting protocols/procedures for preinsertion and postinsertion management;
- Educating staff, including a planned programme of training and update sessions;
- Updating resource files in wards and departments;
- Updating core care plans for PEG management;
- Conducting regular audits to monitor and examine practice continuously.