Note: This article is intended for NDIS workers and providers. For a more clinically-focused article on enteral feeding, see Caring for Enteral Tubes.

This article has been updated in response to the release of Version 3 of the NDIS Practice Standards: High Intensity Support Skills Descriptors (HISSD), which came into effect on 1 February 2023.

Workers employed by National Disability Insurance Scheme (NDIS) providers, who deliver supports to NDIS participants with an enteral (feeding) tube in place, must be able to provide appropriate support.

What is Enteral Feeding?

Enteral feeding is the delivery of liquid nutritional support through a tube inserted into the gastrointestinal tract. It is used for people who are unable to meet their nutritional requirements through oral intake. This may be because:

• Their oral intake is inadequate (e.g. poor appetite), or
• They are physically unable to intake orally in a safe way (e.g. dysphagia, reduced level of consciousness).

(DAA 2019)

Enteral feeding may complement oral intake or be used completely in place of oral intake (Dix 2018).

Enteral Feeding Support in the NDIS Practice Standards

Enteral (Naso-Gastric Tube - Jejunum or Duodenum) Feeding and Management is set out in the NDIS Practice Standards under the High Intensity Daily Personal Activities Module.

This Practice Standard aims to ensure that NDIS participants who require enteral feeding and management receive nutrition, fluids and medicines that are appropriate, relevant and proportionate to their individual needs (NDIS 2021a).

Under these standards, NDIS providers must meet the following quality indicators:

• Participants are enabled to participate in the assessment and development of an enteral feeding and management plan. This plan identifies possible risks, incidents and emergencies, and what actions need to be taken to manage these situations, including the escalation of care, if necessary. The participant’s health status is reviewed regularly (with their consent)
• Workers providing enteral feeding support are informed by appropriate policies, procedures and training plans
• Workers providing enteral feeding support have received all necessary training from a qualified health practitioner or another appropriately qualified individual.

(NDIS 2021)

In order to recieve enteral feeding support under the NDIS, a participant must have an enteral feeding and management support plan in place. This support plan should be developed in consultation with a health practitioner and may also involve other healthcare professionals such as dieticians, speech therapists or occupational therapists (NDIS 2022).

If the participant is to receive medications through an enteral feeding tube, they should also have a medication plan that outlines this (NDIS 2022).

The participant’s support plan may outline support needs such as:

• The type of enteral feed required
• The feeding delivery mechanism
• Techniques for mealtime assistance
• Stoma care
• Issues to look out for
• Required actions to take in response to risks, incidents and emergencies.

(NDIS 2022)

Enteral Feeding Support Skills Descriptors and Knowledge

The NDIS high intensity support skills descriptors are additional guidance specifically for NDIS workers who are supporting participants with high intensity daily personal activities (HIDPA). Many of these HIDPAs are high-risk and/or intimate care areas that require a high level of care, competency and communication. The high intensity support skills descriptors set out the skills and knowledge required for NDIS workers to effectively and safely support participants with HIDPAs (NDIS 2022).

The high intensity support skills descriptors have been updated as of 1 February 2023 in order to:

• Ensure they reflect contemporary practice and expert advice
• Align their format and language more closely to the NDIS Workforce Capability Framework.

(NDIS 2023)

Skills Required for Enteral Feeding Support

Workers providing enteral feeding support under the NDIS should be able to:

• Understand and follow the participant’s support plan
• Ask the participant about their expectations, capacity and preferences for being involved in the delivery of their care
• Ask the participant about their communication preferences, and communicate in their preferred way
• Follow hygiene and infection control principles, including hand hygiene, disinfecting the environment and wearing gloves
• Ensure required equipment and consumables are available and prepared for use
• Support the participant to explore different timings, frequencies, environments and company for feeding in order to make the experience more enjoyable
• Provide support in the least intrusive and restrictive way practicable, in alignment with the participant’s daily routine and preferences
• Support the participant to position themselves for feeding and confirm they are ready for their meal
• Set up the water flush, assemble the feed, position the tube and introduce food to the tube
• Monitor the rate, flow and volume of feeding, and adjust this if necessary
• Identify feeding equipment alarms or malfunctions and take appropriate action in response to this
• Identify and immediately escalate issues, such as a broken or displaced feeding tube, or indicators of complications, to an appropriate health practitioner
• Assist the participant to maintain oral health
• Document required information and observations in the participant’s support plan
• Assist the participant to keep the stoma healthy and clean
• Work collaboratively with other members of the care team
• Discuss any changes needed to bowel care support with the participant
• Identify, document and report if the participant’s support plan is not meeting their needs
• Support the participant to provide feedback or request changes to their support plan.

(NDIS 2022)

Workers supporting a participant with a gastrostomy should be able to:

• Assist the participant to keep the stoma site healthy and clean
• Recognise and take immediate action in response to a dislodged PEG tube.

(NDIS 2022)

Workers supporting a participant to administer medication through an enteral tube should be able to:

• Understand and check the type of medication, dosage, delivery procedure and timing required by referring to the participant’s support plan
• Prepare the medication, in accordance with the participant's support plan
• Administer and flush the feeding tube with water, in accordance with the participant's support plan
• Prepare and introduce the medication into the feeding tube, in accordance with the participant's support plan
• Identify risk indicators such as adverse reactions or overdose and immediately escalate care to an appropriate health practitioner
• Appropriately handle and dispose of sharps and other consumables.

(NDIS 2022)

Knowledge Required for Enteral Feeding Support

NDIS Code of Conduct and Practice Standards

Read: The NDIS Practice Standards Explained

The NDIS Practice Standards establish the benchmark of performance, quality and safety that NDIS providers should meet in their delivery of supports and services (NDIS 2021b).

The Standards work alongside the NDIS Code of Conduct to inform NDIS participants about the quality they should be expecting from the supports and services they receive (NDIS 2021b).

The NDIS Code of Conduct sets out expectations for the behaviour of both NDIS workers and participants in order to promote safe and ethical service delivery. For more information of the NDIS Code of Conduct, see https://www.ndiscommission.gov.au/about/ndis-code-conduct.

The Importance of Good Enteral Feeding Support

Enteral support has a variety of benefits for people who would otherwise be unable to safely or adequately meet their nutritional requirements. These include reversing or preventing malnourishment, improving recovery from illness or surgery, and helping to optimise a person’s quality of life by ensuring they are nutritionally fulfilled, even without oral intake (WACHS 2019).

Therefore, appropriate and competent enteral feeding support is crucial for these participants.

Communication Supports

Participants may have a variety of communication needs and preferences, such as the use of communication aids or devices, or access to resources in another language (NDIS 2022). Remember to individualise communication to ensure each participant’s needs and preferences are met.

For more information on communication supports, see the following Ausmed resources:

• Communicating Effectively With People With Disability
• Communication Skills
• Communication for Quality Care

Infection Prevention and Control

It’s essential to be aware of and follow infection control principles, including PPE, handwashing and disinfecting (NDIS 2022).

For more information on infection control, see Ausmed’s Training Module on Infection Prevention and Control.

Scope of Practice

Always work within your scope of practice and your role’s responsibilities. Refer to your manager and/or local policies and procedures for more clarity on your specific role and responsibilities if you are unsure.

Also see Ausmed’s Training Module on Scope of Practice: Care Workers.

Types of Enteral Feeding

There are three sites on the body where an enteral feeding tube can be inserted, and different route options for each site. The chosen site and route will depend on:

• The intended duration of the nutritional support
• The participant’s condition
• Whether there is any trauma or obstruction that would impede access to a certain site.

(DAA 2018)

The three sites on the body where an enteral feeding tube can be inserted are:

1. Gastric (stomach)
2. Duodenum (small intestine)
3. Jejunum (small intestine).

(WACHS 2019)

The different kinds of tubes that can be used to access each of these sites are:

• Percutaneous endoscopic gastrostomy (PEG) tubes, which are inserted into the stomach via a surgical incision in the abdomen
• Nasogastric (NG) tubes, which are inserted through the nose, down the throat and into the stomach.

(Ausmed 2021; Cancer Research UK 2020)

As a general rule, NG tubes are usually more appropriate for shorter durations of time, while PEG tubes can stay in situ for longer periods (Schwartz 2014).

Methods of Tube Feeding

Feed can be administered using one of the following types of equipment:

• A pump is used continuously or intermittently where feed neads to be administered non-stop for periods of 8 to 24 hours.
• A gravity drip allows greater quantities of feed to be administered in shorter periods of time. It generally needs to be used four to six times per day.
• A syringe is the fastest way of administering feed and allows large amounts of formula to be administered at once.

(Queensland Health 2011)

Types of Enteral Feeding Formulas

Enteral feeding formulas contain a mixture of protein, fat, carbohydrate, fluid, vitamins and minerals, prescribed based on the the participant’s nutritional requirements (Queensland Health 2011).

Formulas can come in either a ready-to-use liquid form, or as a powder that needs to be mixed with fluid (Queensland Health 2011).

Preparing Formula

Powder formula:

1. Perform hand hygiene.
2. Ensure equipment is clean.
3. Follow the directions on the packaging.
4. Measure the required amounts of powder and fluid.
5. Mix the powder into the fluid thoroughly, ensuring there are no lumps.

(Queensland Health 2011)

Ready-to-use formula:

1. The formula should be removed from the fridge 30 minutes before use (as it needs to be administered at room temperature).
2. Perform hand hygiene.
3. Ensure equipment is clean.
4. Shake the bottle well.
5. Attach the formula to the feeding equipment.

(WACHS 2019; Queensland Health 2011)

Storing Formula

1. Formula should be stored in a cool, dark area
2. Formula that has already been prepared or opened (but not used) should be kept in the fridge
3. Prepared or opened formula that has not been used in 24 hours should be thrown away
4. Formula should never be heated up.

(Queensland Health 2011)

Equipment and Consumables Required for Enteral Feeding

• Prescribed formula
• Feed container and giving set
• An IV pole for hanging the feed container or a syringe (depending on the method of administering)
• Tap water
• Measuring cups
• Feeding tubes
• Skin sealants.

(Queensland Health 2011; WACHS 2019; NDIS 2022)

Positioning Participants for Enteral Feeding

Participants should be positioned sitting up in a chair or lying down with their head raised to at least 30 degrees. They should never lie flat on their back (Queensland Health 2011).

After feeding, the participant should remain in an elevated position for 30 to 60 minutes (Queensland Health 2011).

Feeding Pump Alarms, Errors and Maintenance

Enteral feeding devices use alarms to alert to issues such as:

• No more feed to administer
• Kinked or dislodged tube
• Feed obstructing the tube
• Incorrect body position
• Low battery
• Air in the tube.

(Queensland Health 2011)

Alarms and methods for deactivating them will differ depending on the model of device being used. Always refer to the manufacturer’s directions.

If in your scope of practice, you may need to fix blocked or dislodged tubes. Refer to your organisation’s policies and procedures and your position description for more information.

Maintaining Tube Integrity

In order to prevent blockage, tubes should be flushed:

• Before, between and after administering medications
• Every four hours during the day, and every eight hours overnight
• Before and after each feed.

(Queensland Health 2011)

Risks and Complications

The potential complications of enteral feeding include:

• Aspiration
• Tube blockage
• Misplaced or dislodged tube
• Infection
• Constipation
• Dehydration
• Delayed gastric emptying
• Diarrhoea
• Fluid overload
• Nausea and vomiting
• Ileus
• Decreased gut mobility
• Abnormal biochemistry
• Allergic reaction
• Mouth discomfort
• Abdominal pain or distension
• Reflux
• Mouth discomfort or infection.

(WACHS 2019; Bapen 2016; CDHB 2022)

These complications can cause significant discomfort to participants and may develop into more serious concerns - for example, aspiration can lead to pneumonia (Mcilvoy 2019).

High Risk Indicators

The following signs may be indicative of an issue:

• Coughing (especially a wet cough)
• Vomiting
• Changed bowel habits
• Unplanned weight gain or loss
• Dehydration
• Allergic reaction
• Diarrhoea
• Constipation.

(NDIS 2022)

Oral Health

People receiving enteral nutrition with little or no oral intake are at risk of issues such as dry mouth, oral infection and mouth discomfort. Therefore, maintaining good oral hygiene is essential in minimising the risk of these problems and optimising participants’ comfort (Bapen 2016).

Management

You may have specific documentation and reporting responsibilities, such as handover, observations and incident reporting (NDIS 2022). Refer to your organisation’s policies and procedures for further information on what is required.

You should also be aware of the process for requesting a review of a participant’s care (NDIS 2022). Refer to your organisation’s policies and procedures for further information.

When to Escalate Care

A participant should be referred to your manager or an appropriately qualified healthcare practitioner (refer to your organisation’s policies and procedures) if they are experiencing any of the following complications:

• Broken or dislodged feeding tube
• High risk indicators or signs of health-related complications.

(NDIS 2022)

Additional Support

Medication Support

Workers supporting a participant to administer medication through an enteral tube are required to also have knowledge on:

• Methods, equipment and consumables used to administer medication through an enteral tube
• The purpose of the medications being administered to the participant
• Medication storage requirements
• Factors that may affect the administration of medication through an enteral tube
• Signs and symptoms of adverse reactions to medications and dosage errors.

(NDIS 2022)

Gastrostomy Support

Workers supporting a participant with a gastrostomy are required to also have knowledge on:

• How to maintain different types of stomas, including:
  • Cleaning the stoma
  • Protecting the skin around the stoma site
  • Checking and refilling the balloon
• What a healthy stoma should look like
• Signs of an issue at the stoma site, e.g. wetness, infection or inflammation - and what actions are required to manage these
• Their documentation responsibilities.

(NDIS 2022)

Conclusion

NDIS providers should ensure that staff supporting participants with enteral feeding have the skills and knowledge outlined by the Skills Descriptors, and are reviewed annually for competency (NDIS 2022).