NUH Medicines Policy: Code of Practice

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST NUH Medicines Policy: Code of Practice THE USE OF SYRINGES TO ADMINISTER FLUSHES, FEEDS AND MEDICATION VIA THE ORAL AND ENTERAL ROUTES POLICY Reference CL/MM/037 Approving Body Senior Management Team Date Approved 23 November 2016 Implementation Date 23 November 2016 Version 1 (supersedes version 3 of CL/CGP/016 and version 2 of CL/CGP/069) Summary of Changes from Change to make reference to new ISO Previous Version connector (ISO 80369-3 ENFit) for enteral feeding tubes. Change to specify the use of ENFit compatible equipment including bottle adaptors to withdraw liquid medicines from medicine bottles. Change to use bottle adaptor /enteral syringe system to measure all doses of liquid medicines. Amalgamation of 2 previous policies, and move to include this policy as part of the overall NUH medicines policy Supersedes CL/CGP/016 version 3: The Use Of Syringes To Administer Flushes, Feeds And Medication Via The Oral And Enteral Routes In Adults Policy Consultation Undertaken CL/CGP/069 version 2: The Use of Syringes to Administer Flushes, Feeds and Medication via the Oral and Enteral Routes in Children/ Young People And Neonates Policy Adult Nutrition Nurse Specialist Children s gastrostomy and stoma Nurse Digestive Diseases & Thoracics Lead The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 1

Pharmacist Paediatric Pharmacist Neonatal Pharmacist Paediatric Dietitian Practice Development Matron Children s Services Children s Nurse Specialist Neonatal Nurse Critical Care Governance Matron Clinical Procurement Matron Medical Devices Clinical Lead Medicines Safety Group (Sept 2016) Medicines Management Committee (Oct 16) Medical Devices Safety Officer (Sept 2016) Dietetics Medicines Safety Officer Date of Completion of Equality Impact Assessment Date of Completion of We Are Here for You Assessment Date of Environmental Impact Assessment (if applicable) Legal and/or Accreditation Implications 02/10/16 02/10/16 02/10/16 This policy must be in place to fulfil requirements of NPSA alert no 19 Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, 28 th March 2007 and to prevent wrong route Never Events. The Department of Health Never Events list includes: Wrong route administration of medication; Oral/enteral medication or feed/flush administered by any parenteral route Target Audience All NUH staff who prescribe, supply and administer oral liquid medicines. All NUH staff involved in the process of The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 2

prescribing, supply and administration of feeds and flushes by the enteral route. Review Date Nov 2019 Lead Director Medical Director Author/Lead Manager Further Guidance/Information Rachel Medcalf Medicines Safety Officer Ext 59374 Medicines Management Committee secretary Ext 59374 Adult Nutrition Nurse Specialist (NCH) Ext 56754 Digestive Diseases & Thoracics Lead Pharmacist Pharmacist, Ext 59374 Bleep 780 5985 Children s Gastrostomy Nurse, Ext 63536 Paediatric Lead pharmacist, Ext 64410 Bleep 780-6072 Children s Dietitian, Ext 62081 Neonatal Clinical Development Nurse, Ext 69028 Clinical Procurement Specialist (QMC) Ext 59909 Medicines Safety officer ext 59374 The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 3

CONTENTS Paragraph Title Page 1. Introduction 5 2. Executive Summary 5 3. Policy Statement 6 4. Definitions (including Glossary as needed) 7 5. Roles and Responsibilities 8 6. Policy and/or Procedural Requirements 9 7. Training, Implementation and Resources 11 8. Impact Assessments 13 9. Monitoring Matrix 14 10. Relevant Legislation, National Guidance 16 and Associated NUH Documents 11. References 17 Appendix 1 Procedure for the use of ENFit compatible enteral syringes to administer liquid medicines via the ORAL route IN ADULTS 18 Appendix 2 Appendix 3 Procedure for the use of ENFit compatible syringes to measure and administer feeds, flushes and liquid medicines via the ENTERAL route IN ADULTS Procedure for the use of oral / enteral ENFit syringes to administer liquid medicines or feeds via the ORAL/ENTERAL ROUTE in CHILDREN 27 41 Appendix 4 Equality Impact Assessment 64 Appendix 5 Environmental Impact Assessment 67 Appendix 6 Here For You Assessment 69 Appendix 7 Certification Of Employee Awareness 71 The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 4

1.0 Introduction 1.1 Wrong route administration of oral medicines, flushes or enteral feeds can cause serious patient harm and may even be fatal. This policy states the practice required at NUH to reduce the risks of wrong route administration associated with the use of syringes for the administration of medication, feeds and flushes via the oral or enteral routes at NUH. 2.0 Executive Summary 2.1 In 2007 the National Patient Safety Agency issued a patient safety alert; Promoting safer measurement and administration of liquid medicines via oral and other enteral routes (1).The alert aimed to reduce the risk of wrong route administration errors with oral medicines and enteral feeds. The alert stated a requirement for the use of oral/enteral syringes and specified the design of enteral feeding systems to prevent wrong route errors. In 2012 the Department of Health issued a list of Never Events. Never Events are serious incidents that are wholly preventable, as guidance or safety recommendations that provide strong systemic protective barriers, are available at a national level and should have been implemented by all healthcare providers (2). Administration of oral medicines or feeds/flushes by the parenteral route is a Never Event. There have been wrong route Never Events at NUH due to parenteral administration of medication intended for oral or enteral administration (3). This policy incorporates the requirements of the legacy NPSA alert, the current NHS England Never Events List and the recommendations from the NUH serious incident investigations. It sets out the actions required to reduce the risks of wrong route administration of oral medicines and enteral feeds/flushes at NUH. Oral and enteral ENFit compatible syringes must be used to measure liquid medicines, feeds and enteral flushes. Parenteral (Hypodermic) syringes must NEVER be used for this purpose. ENFit compatible bottle adaptors or ENFit compatible straws The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 5

must be used with an ENFit compatible oral/enteral syringe to withdraw liquid medicines from medicine bottles. 3 way taps must not be used for enteral feeding systems. Adaptors which enable oral/enteral syringes to fit intravenous ports must not be used. Enteral feeding tubes and administration/extension sets must not contain ports nor have end connectors that can be connected to intravenous syringes or parenteral lines. Medication prescribed for enteral administration must be rationalised to the least number without compromising patient care. Preparation and administration via the enteral or oral route should be separated from any parenteral route preparation or administration. ENFit oral/enteral syringes used for oral administration or measuring liquid medicines for enteral administration must be single use only. Large ENFit enteral syringes used for enteral administration must be single use per patient episode of care. The nurse who prepares the medication must be the nurse who administers the medication to the patient. All enteral feeding sets and syringes must be clearly labelled enteral. 3.0 Policy Statement 3.1 The Trust supports the use of ENFit compatible syringes and enteral feeding systems to reduce the risk of wrong route administration of oral medicines, feeds and enteral flushes. This policy and the associated standard operating procedures, apply to all practitioners working at NUH or working in affiliated hospitals or in the community on behalf of NUH, who are involved in prescribing, supply and administering oral liquid medicines. This policy and the associated standard operating procedures, apply to all practitioners working at NUH or working in affiliated hospitals or in the community on behalf of NUH, who are involved in prescribing, supply and administering feeds and flushes by the enteral route. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 6

When practitioners employed by other Trusts or private companies are contracted to practice in NUH they must comply with all NUH policies, procedures and guidelines for medicines. 4.0 Definitions 4.1 ISO: The International Standards Organisation ENFit: a global connector design that complies with ISO 80369-3 while also defining the orientation of the connectors within the enteral feeding system (female on the administration device and male on the receiving device). Oral administration: administered via the mouth Enteral administration: method of delivery where fluid is administered directly into the gastrointestinal tract Enteral/ oral syringe: An ISO 80369-3 ENFit compatible syringe, labelled ENTERAL with purple plunger, used to administer medication via the mouth OR administer medication, feeds or flushes via an Enteral Feeding Device. Enteral Feeding Device: Naso-gastric tube Naso-jejunal tube Gastrostomy tubes (PEG, RIG, Balloon) Gastrostomy button Replacement gastrostomy tube Gastro-Jejunal tubes(pegj, PEJ) Jejunal tubes Jejunostomy tube Malecot catheter & Foley catheter (Neonates only) Single Use: Use once and dispose of immediately Patient episode of care: a set of drug or feed administrations & The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 7

flushes at a given administration time for an individual patient. Bottle Adaptor: a plastic insert which fits within the neck of a medicine bottle to prevent drawing up of liquid medicine into any syringe other than an ENFit compatible enteral/oral Syringe. Filter straw: an ENFit compatible filter straw to allow drawing up of medicines into an ENFIT compatible enteral/oral syringe. Blunt needle: an ENFit compatible blunt needle. 5.0 Roles and Responsibilities 5.1 Committees 5.1.1 The Medicines Management Committee (MMC) is responsible for maintaining this policy. 5.1.2 The NUH Medicines Safety Group (MSG) is responsible for overseeing the Trust wide risk assessment on wrong route administration of oral medicines, feeds and flushes and informing MMC of any revision to this policy to mitigate new risks identified, or due to changes in national guidance or legislation. 5.2 Individual Officers 5.2.1 The Clinical Procurement Matron working with Ward and Clinical Managers is responsible for ensuring that the correct equipment is available in the Trust to support the implementation of this policy. 5.2.2 All health professionals involved in the prescribing, supply or administration of flushes, feeds or medication via the oral or enteral routes have a responsibility to adhere to this policy and associated procedures. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 8

6.0 Policy and/or Procedural Requirements 6.1 Equipment Requirements 6.1.1 Purple ENFit compatible oral/enteral syringes must be used for measurement and administration of medicines via the oral and enteral routes, and for the administration of feeds and flushes via the enteral route. 6.1.2 ENFit compatible bottle adaptors or ENFit compatible Straws must be used with an ENFit compatible oral/enteral syringe to withdraw liquid medicines from medicine bottles. 6.1.3 Intravenous or parenteral (hypodermic) syringes must never be used for the purpose of administering liquid medicines, feeds or flushes via the oral and enteral routes (1). 6.1.4 Intravenous 3-way taps must not be used for enteral feeding Systems (1). 6.1.5 Adaptors which enable oral/enteral syringes to fit intravenous ports must not be used (1). 6.1.6 Enteral feeding tubes and enteral feed administration and extension sets used at NUH must not contain any ports that can be connected to intravenous syringes or have end connectors that can be connected to intravenous or other parenteral lines (1). All enteral tubes and enteral equipment must have an ENFit end that connects to an ENFit enteral syringe only. During the transition to ENFit enteral feeding tubes, adaptors must be used for any patients who have not yet had their existing enteral feeding tube replaced. The exception to this is the use of Foley or Malecot urinary catheters which may be used as a gastrostomy tube in neonates and children. In these patients an enteral male adaptor must be connected to the urinary catheter to enable use of an oral / enteral syringe. 6.2 Labelling requirements 6.2.1 Enteral feed administration sets and syringes used in NUH must be clearly labelled enteral. (1) The ward nurse must label the feed administration set with an ENTERAL label each time the feed administration set is changed. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 9

6.3 Administration Process 6.3.1 Medication prescribed for patients with enteral feeding tubes must be rationalised to the least number of administration episodes possible without compromising patient care. 6.3.2 The process of preparation and administration of medication via the oral or enteral route must be separated in time from the process of preparation and administration of medication via the parenteral route i.e. intravenous, subcutaneous, intramuscular. 6.3.3 For inpatients, ENFit oral/enteral syringes used for oral administration or measuring liquid medicines for enteral administration must be single use only (4, 5). i.e. use for one drug for one patient for one administration episode and dispose of immediately. However one large ENFit enteral syringe can be used for a set of enteral administrations during a single patient episode of care. i.e. can be re-used for the same patient during a set of drug or feed administrations & flushes at a given administration time. The enteral syringe must be disposed of immediately after the set of drug or feed administrations are complete. 6.3.4 Medication drawn up into oral/enteral syringes must be administered immediately. 6.3.5 The nurse who prepares the medication must be the nurse who administers the medication to the patient 6.3.6 All used oral and enteral syringes must be treated as pharmaceutically contaminated waste and disposed of according to the Trust waste handling and management policy HS/EI/017. 6.4 Self-administration 6.4.1 As stated in the NUH Medicines Policy CL/MM/005 Selfadministration of medicines by patients, parents or carers policy, a patient or carer may administer medicines where selfadministration procedures are in place and where they have been assessed as competent by a nurse. On children s wards patients and carers may participate in medicine administration where the ward staff consider them competent to do so. A parent or carer may administer feeds or flushes via the enteral route once they have been taught the procedure and assessed competent by a trained nurse. A competency tick list will be completed as proof of competence and a copy stored in the child s The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 10

medical notes. 6.5 Legislation /National Guidance The Medicines Act 1968 governs the supply and administration of all medicines in the UK. The majority of medicines prescribed in the UK are licensed under this Act. To remain licensed the medicine must be given in a licensed form, within a licensed dose range, by a licensed route and only for conditions where the manufacturer has tested the medicine for safety. The administration of medication via enteral feeding tubes is likely to be outside of the licensed indications and route of administration included in the product s Summary of Product Characteristics (6). The dispersing and crushing of tablets and opening of capsules will also place the medicine outside of its product licence (7). Under an exemption within the Medicines Act, Medical Practitioners (doctors and dentists) and Independent Prescribers may use licensed medicines for indications, doses or routes outside of the terms of the product licence (6, 7). In addition the regulations permit these medicines so prescribed to be dispensed by pharmacists and administered by nurses and midwives. Refer to Trust Policy for the Procurement and Use of Medicines without UK Marketing Authorisation and Medicines Used Outside of their UK Marketing Authorisation (CL/MM/010) (7). 7.0 Training and Implementation 7.1 Training This is an established policy however the change to the new ENFit equipment will require training. Nursing The Adult Nutrition Nurse Specialist will deliver a training session at the adult nutrition link nurse meetings for both campuses. Training will be provided via the Paediatric nutrition link nurses. The Ward Manager will be responsible for ensuring the training of all The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 11

staff on their ward involved in the administration of medicines feeds and flushes via the enteral route. The Ward Manager must keep a record of staff training and copy to the individual members of staff for their own records. The Ward Manager is responsible for identifying any gaps in training for their staff and facilitating further training through the Nutrition link Nurse for their area. Pharmacy The Lead Pharmacist for Paediatrics and Digestive Diseases & Thoracics Lead Pharmacist will provide training for Pharmacy staff. Dietetics Senior Dietitians will provide training sessions for Dietetic staff on the issues covered in this policy and keep a record of these activities. Dietitians will be responsible for providing compliant equipment for home discharge. 7.2 Implementation The Clinical Procurement Team will ensure ENFit compatible equipment is available on all wards and departments prior to implementation of this policy. Ward Managers are responsible for maintaining adequate stocks of ENFit compatible enteral syringes and ENFit bottle adaptors on their ward through liaison with clinical procurement or the material management assistant for their area. Training for relevant professional groups will be delivered in advance of the implementation of the policy. NUH COMMS will be used to communicate the new equipment and change in procedures. Divisional Governance Leads are responsible for distributing and implementing this policy within their Division. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 12

The Medicines Safety Group will manage the risk assessment for wrong route administration of oral medicines, feeds and flushes and will facilitate audit of adherence to this policy. 7.3 Resources Enteral syringes and bottle adaptors and straws are already in use across the Trust. The design of the equipment is changing to ENFit. There may be an increase in use of equipment due to the requirement to use an enteral syringe/bottle adaptor system for the measurement of all liquid medicines. This policy will require delivery of training via Nutrition Link Nurse meetings. 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 13

9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Trustwide risk assessment on wrong route administration of oral liquids, feeds and flushes Trustwide risk assessment on wrong route administration of oral liquids, feeds and flushes Responsible individual/ group/ committee Medicines Safety Group Nursing Pharmacy Dietetics Process for monitoring e.g. audit Review of incidents and review of risk assessment Frequency of monitoring as incidents arise and as part of Trustwide biannual incident review. Annual formal review of risk assessment Responsible individual/ group/ committee for review of results Medicines Safety Group reporting to Medicines Governance Committee Audit of policy annual Medicines Safety Group Responsible individual/ group/ committee for development of action plan Medicines Safety Group for Trust wide actions, Divisional Governance Groups for local actions Divisional Governance Groups for local actions Responsible individual/ group/ committee for monitoring of action plan Medicines Safety Group Medicines Safety Group The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 14

Divisional risk assessment on wrong route administration of oral liquids, feeds and flushes Divisional Governance Group Review of incidents and review of risk assessment At least annual Divisional Governance Group & share results with Medicines Safety Group. Divisional Governance Group Divisional Governance Group The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 15

10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 1. Legislation: N/A 2. National Guidance: NPSA alert 2007, Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, 28 th March 2007 NHS England Revised Never Events Policy and Framework, March 2015 3. Associated NUH Documents: NUH Medicines Policy CL/MM/005 Self-administration of medicines by patients, parents or carers policy NUH Medicines Policy CL/MM/010 for the Procurement and Use of Medicines without UK Marketing Authorisation and Medicines Used Outside of their UK Marketing Authorisation NUH Medicines Policy CL/MM/008- Drug administration Procedure for administration of medicines- paediatrics Procedure for the use of oral / enteral syringes to administer liquid medicines or feeds via the ORAL/ENTERAL ROUTE in children/ young people and neonates Procedure for the use of ENFit enteral syringes to administer liquid medicines via the ORAL route IN ADULTS Procedure for the use of syringes to measure and administer feeds, flushes and liquid medicines via the ENTERAL route IN ADULTS Working In New Ways Expanding The Scope Of Professional Practice Passing Fine Bore Nasogastric Tubes (For Adults And Paediatrics) Version 4 March 2012 NUH Guideline Enteral Feeding in adults The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 16

11.0 References 1. NPSA alert 2007, Promoting safer measurement and administration of liquid medicines via oral and other enteral routes, 28th March 2007 2. NHS England Revised Never Events Policy and Framework, March 2015 3. NUH Serious Incident investigations NUHWEB116897 and NUHWEB124058 4. Advice from NUH Infection Control Team (original policy CL/CGP/016 and CL/CGP/069) 5. NUH Single Use Policy 6. The NEWT Guidelines for the administration of medication to patients with Enteral feeding tubes or swallowing difficulties, accessed 02/11/2016 7. NUH Medicines Policy for Procurement and Use of Medicines without UK Marketing Authorisation and Medicines Used Outside of their UK Marketing Authorisation CL/MM/010 The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 17

APPENDIX 1 Procedure for the use of ENFit enteral syringes to administer liquid medicines via the ORAL route IN ADULTS 1. Definition For the purpose of this procedure a liquid medicine for administration via the oral route will be termed an oral liquid medicine. Such products include: A commercially available liquid medicine formulation Soluble tablets A specially manufactured liquid medicine Tablets crushed and mixed in water Tablets dispersed in water Capsules opened and mixed in water Injections administered orally 2. Patient group This procedure applies to all adults receiving oral liquid medicine via the oral route. 3. Syringes All ENFit compatible enteral syringes for use with this policy and procedure must be sterile (1). An ENFit compatible enteral syringe must be used to administer oral liquids via the oral route. 3.1 When to use an ENFit compatible enteral syringe An ENFit compatible enteral syringe should be used for the measurement and administration of oral liquid medicine doses for: All adult patients even if the dose is a multiple of 5ml All controlled drug liquids for accuracy reasons (also see controlled drugs policy CL/MM/012) The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 18

There will be exceptions where an ENFit compatible enteral syringe can not be used to measure the liquid e.g. if a bottle adaptor can not fit on to the liquid bottle. In this case the dose can be measured by pouring the liquid medicine into a graduated medicine pot if it is a multiple of 5ml. If it is not a multiple of 5ml then the correct amount can be drawn up using an ENFit compatible Straw. 3.2 Selection of oral syringe ENFit compatible enteral syringes are available in a range of sizes. To maintain accuracy, the smallest syringe for measuring the dose must be used. Syringes supplied with oral liquid medicines by manufacturers must not be used because they may not be just oral syringes i.e. may be syringes with luer locks which could connect to an intravenous line. There are exceptions, notably ciclosporin liquid which is incompatible with standard oral syringes, and the Epistatus brand of midazolam buccal liquid. If in doubt, advice must be sought from a Pharmacist or Medicines Information. 3.3 Re-use of ENFit compatible enteral syringes Within the NUH premises, syringes must be single use only in line with the Trust s Single Use Policy. i.e. use for one drug for one patient for one administration episode and dispose of immediately. Under no circumstances should the syringe be washed and re-used within the hospital environment 4 Selection of water to mix with tablets /capsules 4.1 Type of water to use The type of water used will depend on the patient group. Table 1 Patient group Immunocompromised patients Recommended Water to use with medication (1) Sterile water should be considered for all immunocompromised patients The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 19

All other patients at NUH (see local protocols) Freshly drawn drinking tap water (This is different to tap water see section 4- Definitions) Sterile water should be taken from a bottle of Sterile water. A new bottle must be used for each episode of care (1). 4.2 Volume of water to use The volume of water used will depend on the individual patient and their fluid requirements. The volume of water used during administration of medicines must be recorded on the patient s fluid balance chart. If the volume of fluid is not a concern, a minimum of 10-15ml water should be used to disperse each tablet /mix with crushed tablet or powder from capsules (2). 5 Measurement of commercial and manufactured liquid medicine doses 5.1 Use of Bottle Adaptors with an ENFit compatible enteral syringe A sterile ENFit compatible bottle adaptor MUST be inserted into the neck of the medicine bottle when it is first opened. An ENFit compatible enteral syringe is the only syringe which will connect to the ENFit bottle adaptor. An ENFit enteral syringe should be used to measure all liquid medication. The ENFit compatible bottle adaptor must remain in situ whilst the medicine is in regular use. If it falls onto the floor or is removed for any other reason it must be disposed of and replaced with a new one. Bottle adaptors are single use and must not be washed and re-used. An ENFit compatible bottle adaptor will be supplied from inpatient pharmacy with all non-stock liquid medication. The nurse responsible for that patient will be responsible for inserting the bottle adaptor into the liquid medication upon first opening. Stock bottles of liquid medication which is dispensed from pharmacy stores will not have a bottle adaptor supplied with it. The nurse opening the stock The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 20

liquid medication for the first time will be responsible for inserting the ENFit compatible bottle adaptor into the bottle. ENFit compatible bottle adaptors of various sizes will be available on the ward. All controlled drug liquids MUST have an ENFit compatible bottle adaptor inserted for accurate measurement. 5.1.1 Measurement of doses using an ENFit compatible bottle adaptor Select the oral liquid medicine to be administered. Shake the bottle if necessary. Insert an ENFit compatible bottle adaptor if it does not already have one in place. Insert the ENFit compatible syringe into the ENFit compatible bottle adaptor. Invert the bottle and withdraw the required volume for the dose prescribed. Multiple drugs must not be withdrawn into the same syringe. The original cap of the liquid medication should be replaced with the bottle adaptor in situ. 5.2 Straws Straws must only be used when the neck of the medicine bottle is too large/small for the bottle adaptor to fit. Straws are single use only and must not be left in the bottle or washed and re-used. 5.2.1. Measurement of doses using an ENFit compatible Straw Select the oral liquid medicine to be administered. Shake the bottle if necessary. Attach an ENFit compatible syringe onto the end of the ENFit compatible straw. Insert ENFit compatible straw into the bottle The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 21

Withdraw the required volume for the dose prescribed. Dispose of the ENFit compatible straw and replace the lid on the bottle. 6. Preparation of drugs which are not commercially available as an oral liquid formulation If a patient is unable to swallow the medication they are prescribed as a tablet or capsule, due to their age or swallowing difficulties, then the Ward Pharmacist or Medicines Information department must be contacted for advice. The alteration of medical formulations e.g. crushing tablets or opening capsules is outside of the product licence of the drug (3) and may alter the patients handling of the drug. Some drugs are not suitable for crushing. (Table 2) Table 2 Formulation /class of drug Enteric coated tablets (EC) Modified release (MR) /Sustained release (SR) Possible problem from crushing tablets The coating may protect the stomach from damage from the drug e.g. aspirin, and may cause gastrointestinal side effects. The coating may protect the drug from the acid in the stomach. (3) Crushing these drugs may result in abrupt high or low peaks of the drug which can be dangerous to the patient, especially if the drug has a narrow therapeutic range (3) Chewable tablets Designed to be partially absorbed in the mouth, not all the drug will be absorbed if they are crushed (3) The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 22

Cytotoxics & hormones Potential risk of toxicity to the staff handling the drug (3) The pharmacist must review the patient s prescription and discuss with the Prescriber whether alternative licensed liquid medicine formulations are available within the same class of drug or whether the drug prescribed could be given by an alternative route. Alternative routes of administration include: Rectal route Transdermal route Buccal route Sublingual route Parenteral route (intravenous, subcutaneous, intramuscular) If a licensed preparation or route is not available or appropriate for the patient, then the pharmacist may recommend crushing or dispersing tablets, opening capsules or manufacturing a suspension for the individual patient. This should be endorsed onto the drug chart. 6.1 Dispersing tablets in water It is not necessary to use an oral syringe. Place the tablet(s) into a medicine pot of water. Wait for the tablet to disperse / effervescent reaction to be complete. This may take a few minutes. Give the patient the solution to drink. Rinse the medicine pot with more water and give this to the patient to drink. 6.2 Crushing tablets A ceramic pestle and mortar or tablet crusher must be used. Place the required tablet(s) in the mortar or tablet crusher and crush to a powder. Mix the powder with an appropriate volume of water in a medicine pot (see section 4). Draw up the solution into an oral syringe. Administer the dose to the patient (see section 7) Rinse out the mortar / tablet crusher with water and administer the rinsings to the patient. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 23

The pestle and mortar or tablet crusher must be cleaned thoroughly with a detergent and water after each use and dried thoroughly using a paper towel. 6.3 Opening capsules Open the capsule and tip the powder into a medicine pot. Mix the powder with an appropriate volume of water (see section 4). Draw up the solution into an ENFit compatible enteral syringe. Administer the solution to the patient (see section 7). Rinse the medicine pot and administer the rinsings to the patient. 6.4 Cytotoxics A ready-made liquid should be used wherever possible. Ask pharmacy for advice. For cytotoxic drugs the ENFit compatible syringe must be disposed of in a cytotoxic waste disposal container. 6.5 Preparation of injections for oral use Consult pharmacy for advice on which injectable preparations are suitable for oral/enteral administration and directions for preparation. If not already in solution, reconstitute the injection following the manufacturer s information or directions from pharmacy as appropriate. Draw up the required dose using an ENFit compatible syringe connected to an: o ENFit compatible blunt needle for vials o ENFit compatible filter straw for glass ampoules Remove ENFit compatible needle or ENFit compatible straw before administration. 6.5.1 Vancomycin Vancomycin injection is licensed for administration via the oral route for the treatment of Clostridium difficile. The injection must be reconstituted following the manufacturer s information using the method described in 6.4. Remove ENFit compatible needle before administration. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 24

7 Administration of oral liquid medicines Check the inpatient prescription chart. Select the appropriate size ENFit compatible enteral syringes for the doses prescribed. Use the methods described in section 5 and 6 to prepare the oral liquid medicine doses. Prepare and administer one drug at a time. Complete the usual drug administration checks in the NUH Medicines Code of Practice. Insert the ENFit compatible enteral syringe into the inside of the patient s cheek and slowly depress the plunger asking the patient to swallow as is comfortable for them. Dispose of the used syringe into a sharps container as per the Trust policy for disposal of pharmaceutically contaminated products. Sign the inpatient medication chart to record administration of the drug immediately after it has been given. Repeat the above steps for each medication prescribed. The nurse who prepares the medication must be the nurse who administers the medication to the patient. If the administration process is interrupted at the point of administration, and medication has been left unattended drawn up in an unlabelled oral syringe, then the medication must be discarded. If there is any doubt over which medication has been administered, then the doctor must be informed immediately and a decision made whether to omit the medication until the next administration time. If the patient finds it difficult or uncomfortable to take the medication via the syringe then it can be transferred into a medicine pot and given to the patient to drink. Smaller doses may need diluting with water. If necessary seek advice from pharmacy. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 25

8 Discharge & Outpatient supply of medication For all adults prescribed oral liquid medicines via the oral route on discharge or as an outpatient, Pharmacy will supply one multi-use ENFit compatible syringe for each newly supplied oral liquid medication and an ENFit compatible bottle adaptor. Syringe size will be appropriate to the volume of medication required. 9 Responsibilities Ward managers are responsible for maintaining adequate stocks of ENFit compatible syringes, ENFit compatible bottle adaptors, ENFit compatible Straws and ENFit compatible blunt needles on their ward through liaison with the Clinical Procurement team. Senior Managers (Pharmacists, Dietitians, Nurses, Prescribers) are responsible for ensuring that all their staff are aware of this procedure and comply with it. 10. References 1. Advice from NUH Infection Control Team (original policies CL/CGP/016 and CL/CGP/069 now superseded- available from Medicine Management Committee) 2. www.bapen.org.uk BAPEN guideline: Administering Drugs via Enteral Feeding Tubes. A Practical Guide published 2003 updated 2004. Accessed 02/11/2016 3. The NEWT Guidelines for the administration of medication to patients with Enteral feeding tubes or swallowing difficulties, accessed 02/11/2016 The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 26

APPENDIX 2 Procedure for the use of ENFit compatible syringes to measure and administer feeds, flushes and liquid medicines via the Enteral route IN ADULTS 1. Unlicensed route of administration Administration of medication via the enteral route is usually unlicensed. The prescriber and practitioner accept liability for any adverse effects resulting from this route of administration (1). Refer to NUH Medicines Policy for Procurement and Use of Medicines without UK Marketing Authorisation and Medicines Used Outside of their UK Marketing Authorisation CL/MM/010. If the prescription does not clearly specify the route as enteral, the drugs must not be administered until the prescriber has been contacted and confirmed the route. 2. Definition For the purpose of this procedure an oral liquid medicine is one which is intended to be administered normally via the mouth but for clinical reasons needs to be administered via the enteral route. Such products include: A commercially available liquid medicine formulation Soluble tablets A specially manufactured liquid medicine Tablets crushed and mixed in water Tablets dispersed in water Capsules opened and mixed in water Injections administered orally 3. Patient group This procedure applies to all adults receiving oral liquid medication, feeds or flushes via the enteral route. 4. Syringes 4.1 Selection of ENFit compatible enteral syringe for administration via enteral tube or enteral feed administration set If an enteral feed administration set is in use at the time medication is due then the medication must be administered via the medicines administration The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 27

port. The enteral feed administration set must not be disconnected to allow administration directly into the enteral tube and then reconnected. There are different sizes of ENFit compatible enteral syringes available. All Enteral compatible syringes supplied for this purpose are sterile. Only purple 60ml ENFit compatible enteral syringes marked ENTERAL must be used for the administration of medication, feeds or flushes via the enteral route. Parenteral (Intravenous), syringes must never be used. 4.2 Selection of ENFit compatible enteral syringe to measure drug doses All ENFit compatible enteral syringes for use with this policy and procedure must be sterile (2). ENFit compatible enteral syringes are available in a range of sizes. To maintain accuracy, the smallest syringe for measuring the dose must be used. Syringes supplied with oral liquid medicines by manufacturers must not be used because they may not be just oral syringes i.e. may be syringes with luer locks which could connect to an intravenous line. There are exceptions, notably ciclosporin liquid which is incompatible with standard oral syringes. If in doubt, advice must be sought from the Pharmacist or Medicines Information 4.3 Re-use of syringes Within the NUH premises, ENFit compatible enteral syringes for oral administration must be single use only (3) in line with the Trust s Single Use Policy. i.e. use for one drug for one patient for one administration episode and dispose of immediately Large ENFit compatible enteral syringes must be one syringe per patient episode of care. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 28

5 Water i.e. can be re-used for the same patient during a set of drug administrations & flushes at a given administration time. Each drug should be flushed through with water after it has been administered (see section 8).The syringe must be disposed of immediately after the set of drug administrations and flushes are complete. 5.1 Type of water to mix with tablets /capsules /flush enteral tubes The type of water used will depend on the patient group and type of enteral tube. Sterile water should be taken from a bottle of sterile water. A new bottle should be used for each patient episode of care (2). Table 1 Patient group Enteral Tube Recommended water for flushes /mixing with tablets or capsules (2) Immunocompromised patients Enteral tubes feeding into the stomach Sterile water should be considered for all immunocompromised patients at NUH (see local protocols) All other patients Enteral tubes feeding in to the jejunum Enteral tubes feeding in to the stomach Enteral tubes feeding in to the jejunum Sterile water Freshly drawn drinking tap water (this is different to tap water see section 4 definitions) Sterile water 5.2 Volume of water to use The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 29

The volume of water used will depend on the individual patient and their fluid requirements but should be sufficient to flush the drug out of the delivery system. The volume of water used during administration of medicines should be recorded on the patient s fluid balance chart. 5.2.1 Dispersing tablets or mixing with crushed tablets or opened capsules If the volume of fluid is not a concern, a minimum of 10-15ml water should be used to disperse each tablet / mix with crushed tablet or powder from capsules (1). 5.2.2 Flushes Water should be used to flush the enteral feeding system. Follow instructions from the dietitian. 6 Measurement of commercial and manufactured liquid medicine doses 6.1 An ENFit compatible enteral syringe must be used to measure all controlled drug liquids and all liquid medication even if it is a multiples of 5ml. The dose must then be transferred into the barrel of a 60ml syringe prior to administration via the enteral route (see section 8). 6.1.1 Use of Bottle Adaptors with an ENFit enteral syringe A sterile ENFit compatible bottle adaptor must be inserted into the neck of the medicine bottle when it is first opened. The bottle adaptor must remain in situ whilst the medicine is in regular use. If it falls onto the floor or is removed for any other reason it must be disposed of. Bottle adaptors must not be washed and re-used. 6.1.1.1 Measurement of doses using a bottle adaptor Select the oral liquid medicine to be administered. Shake the bottle if necessary. Insert an ENFit compatible bottle adaptor if it does not already have one in place. Insert the ENFit compatible syringe into the ENFit compatible bottle adaptor Invert the bottle and withdraw the required volume for the dose prescribed. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 30

Multiple drugs must not be withdrawn into the same syringe. The original cap of the liquid medication must be replaced with the bottle adaptor in situ. 6.1.2 Straws Straws must only be used when the neck of the medicine bottle is too large/small for the bottle adaptor to fit. Straws are single use only and must not be left in the bottle or washed and re-used. 6.1.2.1. Measurement of doses using an ENFit compatible Straw Select the oral liquid medicine to be administered. Shake the bottle if necessary. Attach an ENFit compatible syringe onto the end of the ENFit compatible straw. Insert ENFit compatible straw into the bottle Withdraw the required volume for the dose prescribed. Dispose of the ENFit compatible straw and replace the lid on the bottle. 6.2 Doses which are multiples of 5ml Doses which are a multiple of 5ml should be drawn up using an ENFit compatible enteral syringe for accuracy of measurement and transferred to a 60ml syringe. All Controlled Drugs MUST be measured using an ENFit enteral syringe. 6.2.1 Measurement of doses using a medicine pot and ENFit compatible enteral syringe A medicine pot should only be used if an ENFit compatible bottle adaptor can not fit on to the bottle neck of the liquid medication. Select the oral liquid medicine to be administered Shake the bottle if necessary Measure the dose required into a graduated medicine pot The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 31

Select the 60ml ENFit compatible syringe required for enteral administration Draw up the oral liquid medicine from the medicine pot into the enteral syringe and give as per section 8 Prepare and administer each drug as an individual process. Each drug should be flushed through with water after administration and the same enteral syringe may be re-used for administration of flushes and subsequent drugs required within the individual patient s episode of care. Liquid medication that is not a multiple of 5ml can be drawn up using a straw and correct size ENFit compatible enteral syringe and transferred to a 60ml syringe for enteral administration. 7 Preparation of oral drugs which are not commercially available as a liquid formulation The alteration of medical formulations for administration via enteral tubes e.g. crushing tablets or opening capsules, is usually outside of the product licence of the drug (1) and may alter the handling of the drug. Some drugs are not suitable for crushing. (Table 2) Table 2 Formulation /class of drug Enteric coated tablets (EC) Modified release (MR) /Sustained release (SR) Buccal /sublingual comments If crushed enteric coated tablets break up into small pieces that clump together when moistened and can clog the feeding tube (1) Crushing these drugs may result in abrupt high or low peaks of the drug which can be dangerous to the patient, especially if the drug has a narrow therapeutic range (1) Designed to avoid the GI tract and first pass metabolism. The doses tend to be low and maybe insufficient if given via an enteral tube (1) The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 32

Chewable tablets Cytotoxics & hormones Designed to be partially absorbed in the mouth, not all the drug will be absorbed if they are crushed (1) Potential risk to staff from aerolisation of particles (1) The pharmacist must review the patient s prescription and discuss with the Prescriber whether alternative licensed liquid medicine formulations are available within the same class of drug or whether the drug prescribed could be given by an alternative route. Alternative routes of administration include: Rectal route Transdermal route Buccal route Sublingual route Parenteral (intravenous, subcutaneous, intramuscular) If a licensed preparation or route is not available or appropriate for the patient, then the pharmacist may recommend crushing or dispersing tablets, opening capsules or manufacturing a suspension for the individual patient. 7.1 Dispersing tablets in water (4) Place the tablet in a medicine pot and disperse in 10mls of water Use a 60ml ENFit compatible enteral syringe to draw up the dispersed solution from the medicines pot Administer the solution Rinse the syringe with more water and administer the rinsings 7.2 Crushing tablets (4) A tablet crusher must be used Place the required tablet in the tablet crusher and crush to a powder. Mix the powder with an appropriate volume of water (see section 5). The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 33

Draw up the solution into a 60ml ENFit compatible enteral syringe Administer the dose to the patient (see section 8) Rinse out the tablet crusher with water, draw up into the ENFit compatible enteral syringe and administer this to the patient The tablet crusher must be cleaned thoroughly with a detergent and water after each use and dried thoroughly using a paper towel. 7.3 Opening capsules(4) Open the capsule and tip the powder into a medicine pot Mix the powder with an appropriate volume of water (see section 5) Draw up the solution into a 60ml ENFit compatible enteral syringe Administer the solution to the patient (see section 8 ) Rinse the medicine pot, draw up into the ENFit compatible enteral syringe and administer this to the patient. 7.4 Cytotoxics A ready-made liquid should be used wherever possible. Ask pharmacy for advice. For cytotoxic drugs the ENFit compatible syringe must be disposed of in a cytotoxic waste disposal container. 7.5 Preparation of injections for enteral administration consult pharmacy for advice on which injectable preparations are suitable for oral/enteral administration and directions for preparation. If not already in solution, reconstitute the injection following the manufacturer s information or directions from pharmacy as appropriate. Draw up the required dose using an ENFit compatible syringe connected to a: ENFit compatible blunt needle for vials ENFit compatible filter straw for glass ampoules The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 34

Remove ENFit compatible needle or ENFit compatible straw before administration 7.5.1 Vancomycin Vancomycin injection is licensed for administration via the oral route for the treatment of Clostridium difficile. The injection must be reconstituted following the manufacturer s information using the method described in 7.4. Remove ENFit compatible needle before administration The solution must be administered to the patient (see section 8) 8 Administration of oral liquid medicine formulations via the enteral route Review the inpatient prescription chart to identify the drugs and doses to be administered via the enteral route for this administration episode. Select the appropriate type of 60ml ENFit compatible enteral syringe for administration of the oral liquid medicine to the patient (section 4 and Appendix 1) Select the appropriate type of water for the patient (section 5 Table 1) Proceed to the patient. Follow all the administration steps described in NUH medicines Code of Practice Check the patient s identity. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 35

Check the position of the enteral tube following the appropriate Nursing guideline for the type of enteral tube in place. Check the enteral tube or feed administration set back to the patient to confirm the route and check that the feed administration set is labelled enteral. Stop the feed if there is a feed in progress. Flush the enteral tube with an appropriate volume of water for the individual patient (see section 5). Prepare the first dose required using the methods described in section 6 & 7 If the dose has been prepared in a smaller ENFit compatible enteral syringe, the medication must be transferred to the 60ml enteral syringe before it can be administered. Attach the 60ml ENFit compatible enteral syringe to the enteral tube or enteral feed administration port as appropriate. Remove the plunger of the 60ml enteral syringe. Eject the contents of the liquid medication into the barrel of the 60ml ENFit compatible enteral syringe. If the medication has been dispersed in a medicine pot draw the contents in the pot into a 60ml enteral syringe. This should then be gravity fed to administer it to the patient if attached directly to the enteral tube, or using the plunger if administration is via the enteral feed administration set. Sign the inpatient medication chart to record administration of the drug immediately after it has been given. Repeat the above steps for each medication prescribed. The same ENFit compatible enteral syringe can be used throughout the patient episode of care. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 36

If more than one medicine is to be administered, the enteral tube must be flushed with at least 10ml water in between each medicine unless another volume is specified by the Dietitian. After the last medicine has been administered, the enteral tube must be flushed with 30ml water unless another volume is appropriate and specified by the Dietitian. Restart the feed, if it has been stopped. Dispose of the used syringe into a sharps container as per the Trust policy for disposal of pharmaceutically contaminated products. The nurse who prepares the medication must be the nurse who administers the medication to the patient. If the administration process is interrupted at the point of administration, and medication has been left unattended drawn up in an ENFit compatible enteral syringe, then the medication must be discarded. If there is any doubt over which medication has been administered then the doctor must be informed immediately and a decision made whether to omit the medication until the next administration time. 9 Administration of Bolus Enteral Feeds Bolus enteral feeds must be administered using a 60ml ENFit compatible enteral Syringe. Refer to the appropriate enteral feeding guideline. 10 Aspiration of Gastric Contents to check tube position ENFit compatible enteral syringes must be used for aspirating all enteral tubes. 11 Discharge Ward nursing staff are responsible for ensuring parents/carers can safely prepare and administer the medicines via the enteral tube prior to discharge. The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 37

Ward nursing staff are responsible for notifying the Dietitian and the Pharmacist in a timely fashion when the discharge is planned. The prescriber must specify the route of administration on the discharge prescription. For all adults prescribed oral liquid medicines via the enteral route on discharge or as an outpatient, Pharmacy will supply one multi-use ENFit compatible syringe for each newly supplied oral liquid medication and an ENFit compatible bottle adaptor. Syringe size will be appropriate to the volume of medication required. Dietitians will provide an appropriate supply of ENFit syringes for feeds at discharge for use in the community. Multi-use ENFit compatible syringes can be washed and re-used at home in accordance with the manufacturer s instructions. 12 Responsibilities Ward managers are responsible for maintaining adequate stocks of ENFit compatible syringes, ENFit compatible bottle adaptors, ENFit compatible Straws and ENFit compatible blunt needles on their ward through liaison with the Clinical Procurement team. Senior Managers (Pharmacists, Dietitians, Nurses, Prescribers) are responsible for ensuring that all their staff are aware of this procedure and comply with it. 10. References 1. The NEWT Guidelines for the administration of medication to patients with Enteral feeding tubes or swallowing difficulties, accessed 02/11/2016 2. Advice from NUH Infection Control Team (original policy CL/CGP/016 and CL/CGP/069) 3. NUH Single Use Policy 4. www.bapen.org.uk BAPEN guideline: Administering Drugs via Enteral Feeding Tubes. A Practical Guide published 2003 updated 2004. Accessed 02/11/2016 The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 38

BAPEN Administering Drugs via Enteral Feeding Tubes A Practical Guide (www.bapen.org.uk) The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 39

The use of syringes to administer flushes, feeds and medication via the oral and enteral routes policy CL/MM/037 version 1, November 2016 40