The nutrition nurse team for adults with learning disabilities in Birmingham Community Healthcare NHS Foundation Trust is a unique dedicated community service caring for adults who have an enteral feeding tube.
Having an enteral tube placed is daunting for any adult, but for someone with a learning disability it is even more so, and the experience of hospital admission can be particularly challenging. Being in an unfamiliar environment such as a hospital, surrounded by unfamiliar faces and routines, encountering different ways of delivering care by hospital staff who may lack understanding of how to approach and deliver care to people with learning disabilities, can be frightening.
We initiated a project to improve the care of patients with learning disabilities who have a gastrostomy tube to help avoid unnecessary hospital admission following initial tube placement. The project involved introducing the use of a small piece of equipment to avoid hospital admission for our patient group—adults patients with learning disabilities who have a gastrostomy tube living in the community.
Rationale
ENPLUGs are silicone plugs inserted into the gastrostomy tract to prevent it from closing when a tube comes out unexpectedly. They are multicoloured, according to French gauge (10-20 Fr) and shaft length (4 cm or 7 cm). We decided to introduce the use of ENPLUGs for adults with learning disabilities in patients' homes, day centres, colleges and respite units, the rationale being that they could help:
To address these issues a training programme was devised by the nutrition nurse team, which consists of one full-time band 7 nurse and one part-time band 6 nurse (the authors), with a shared caseload of over 100 patients. Discussions took place with the care providers and colleagues from the multidisciplinary team to identify possible barriers that could prevent the project being successful due to the fact that the main target audience were carers with little or no healthcare training. The following barriers were identified:
‘They [ENPLUGs] are marvellous and effective—it buys us time because the tract can be kept open’
Patient suitability
Initially, the team looked at the caseload and identified patients for whom placing an ENPLUG would be appropriate if their tube came out. Most of those identified had a balloon-retained gastrostomy tube, a low-profile (button) tube or a flange-retained gastrostomy tube.
Next, the patients' locations of care in the community were mapped and the organisations providing care identified and contacted. This included Trust premises, colleges, day centres (local authority and third-party organisations) and respite centres. Face-to-face discussions took place with the relevant managers to explain the project and ensure that their agreement for staff training did not conflict with their own internal policies and procedures.
At this point, the potential barriers identified were discussed. With the exception of one local authority day centre all agreed for staff to be trained. Awareness training about ENPLUGs was agreed for all staff, with a core group being trained on their actual use—usually the managers or senior carers.
A risk assessment was devised and undertaken by the nutrition nurses for every patient deemed suitable for ENPLUG use. In addition to demographic details the assessment highlighted consent issues, the type of tube currently in use, and any insertion problems. It also detailed:
An individualised care plan for insertion of ENPLUGs was written for each patient, together with a personalised letter addressed to medical staff at any hospital emergency department (ED) in the event the patient had to attend out-of-hours care to explain use of the ENPLUG. Because this is a new specialised piece of equipment it was doubtful that ED staff would be familiar with them.
Staff training
The pack provided during training included a pictorial guide to ENPLUG colours and their corresponding sizes, as well as a written competency for their use. An ENPLUG box was also provided for each care location containing ENPLUGs, lubricating gel, dressings and tape, and copies of the pictorial guide to ENPLUG sizes. Contact details for the nutrition nurse team were included with each pack.
The first wave of training involved two day centres, two colleges, three Trust respite homes, and four non-NHS homes, as well as one patient's home. At the time of the project, these settings cared for up to 26 patients with balloon-retained gastrostomy or low-profile (button) tubes. The training consisted of:
In total, 70 carers received awareness training, 20 of whom went on to achieve competency in ENPLUG insertion across the stated locations.
During the project period, between June 2017 and February 2018, 12 admissions to hospital were avoided due to the use of ENPLUGs, with an estimated saving of £18 000 to the Trust. Of these 12 patients, 11 did not have to attend hospital because the nutrition nurses were able to respond to replace the balloon-retained gastrostomy following insertion of the ENPLUG. One patient did attend hospital but this was because the problem arose at the weekend. However, the patient did not require admission because the ENPLUG had preserved the tract and the ED staff were able to replace the low profile device the care staff had brought with them.
Feedback was collected from the carers involved in placing the ENPLUGs. Typical feedback included comments from one carer, who reported feeling ‘empowered’ because placing the ENPLUG had meant the patient had not needed to go to hospital. She was able to tell her colleagues how easy it was to place the ENPLUG.
One registered nurse in a Trust community home for people with learning disabilities commented: ‘They are marvellous and effective—it buys us time because the tract can be kept open.’
All the feedback received was positive, which has led to the use of ENPLUGs and training in their placement being offered and introduced in all locations attended by our patients. In the Trust in general they are now being used within the Adults and Community division and are being looked at within the children's nursing service.