Safe Practice Guidelines for the Insertion and Care of Nasal Retaining Loops to Secure Naso-Enteral tubes- Adult Patients

• Summary
• Scope
• Definitions
• Aims
• Background
• What are nasal retention loops (NRLs)?
• Duties and responsibilities
• Competence and training requirements
• Consent
• Diagnosis
• Investigation
• Treatment / Management
• Insertion of CORGRIP NRL
• Insertion of AMT BRIDLE NRL
• Frequently asked questions
• Appendix 1: CORGRIP PICTURES
• Appendix 2: AMT BRIDLE PICTURES
• Appendix 3: Nasal Retaining Loop Assessment Tool 
• Appendix 4: Competency Documentation 
• Appendix 5: Information Sheet for patients 
• Appendix 6: Information Sheet for carers 
• Appendix 7: Procurement information
• Appendix 8: Ethical considerations

Summary

Naso-enteral nutrition is an essential part of patient care which is used when patients are unable to meet their nutritional requirements via the oral route and have a functioning gastrointestinal tract.

Naso-enteral feeding tubes can frequently become dislodged or removed which is a major limitation, leading to loss of feeding hours, uncomfortable reinsertion procedures and exposure to radiation if an X-ray is used to confirm tube position, as well as significant cost implications in terms of health care practitioners’ time, cost of X-rays and tube usage (Popovich, M (1996)).

The nasal retaining loop (NRL, bridle or Corgrip) consists of a piece of umbilical tape that is looped around the vomer bone at the rear of the septum and attached with a specially designed clip to the enteral feeding tube, making tube placement very secure. It is inserted using two catheter mounted magnets, each of which is introduced into a separate nostril so that the magnets connect at the nasopharyngeal space, allowing umbilical tape to be fed around the nasal septum, leaving tape exiting from both nostrils, which is then attached to the feeding tube (pictures in Appendix 1).

Patients who repeatedly remove Nasoenteral Tubes (NETs – these include both nasogastric (NG) tubes and nasojejunal (NJ) tubes) or other indwelling devices such as catheters or cannulas, despite other measures should be assessed for a nasal retaining loop (NRL). This assessment should be made by suitably qualified staff

NRLs are usually simple to place and optimise the ability of the feeding tube to meet nutritional requirements by reducing accidental removal. A NRL is suitable for bed side placement by trained practitioners in both NG and NRL placement.

Consent is a difficult but important issue. Informed verbal consent should be obtained prior to NRL insertion whenever possible and must be documented in patients’ notes. See the section on consent.

This guideline should be used in conjunction with the enteral feeding policy and nasoenteral tube insertion guidelines.

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Scope

All aspects of decision making, placement technique and aftercare will be addressed in the guideline.

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Definitions

Nasal Retaining Loop (NRL): A piece of equipment which reduces the chance of inadvertent displacement or removal of fine-bore NETs in patients requiring enteral administration of feed, fluid or medication. Tape is fed round the nasopharynx and out through each nostril and then clamped to the NET, holding it in place.

Corgrip: Preferred nasal retaining loop device used within the trust provided by Halyard Health.

AMT Bridle: Alternative nasal retaining loop device (which may be found on wards as stocks are used up) used within the trust provided by GBUK.

Fine bore naso-enteral feeding tube: -
Defined as between a 6fg - 8fg tube. The length of the tube is measured in cms starting at the distal tip. Measurements are seen along the length of the tube, but the tube length will vary depending on manufacturer. The tube is made of silicone or polyurethane which is passed through the nostril via the naso-pharynx into the oesophagus, then stomach (NG tubes) or through the stomach and duodenum, sitting in the jejunum (NJ tubes).An 8fg NET needs to be in situ to place a NRL, although smaller NRLs can be ordered via materials management if necessary.(i.e if a patient has a smaller bore NET in situ). The NET and NRL MUST be the same size.

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Aims

• To provide guidelines to facilitate correct and timely patient selection.
• To provide guidelines for the safe, effective and comfortable placement of a nasal bridle.

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Background

• The use of NETs is a common procedure across many different specialties. This procedure is documented in the LTHT Policy for Insertion and Ongoing care of Fine Bore Feeding Tubes in Adults.
• Naso-enteral tubes become displaced for a variety of reasons and a small group of patients appear to be particularly intolerant of the tube and require repeated reinsertions. This can be distressing for the patient and their family and detrimental to their recovery as it means missing feed and medication due to delays until the tube is replaced.
• An alternative fixing device has been developed called the Nasal Retaining Loop. This provides a means of securing the NET to prevent accidental or intentional tube removal by the patient. The NRLs used within the trust are Corgrip or Bridle
• This guideline has been written to enable suitably trained practitioners to follow an agreed decision making, assessment and procedural process.

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What are nasal retention loops (NRLs)?

• See pictures in appendix 1 and appendix 2
• The main purpose of NRLs are to ensure the provision of feed, fluid and medication via NETs by reducing the chance of dislodgement.
• They are a gauze loop fed around the nasopharynx and fixed to an external clamp attached to the NET.
• They can still be dislodged and may cause discomfort or nasal erosion and bleeding, especially in confused or agitated patients.

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Duties and responsibilities

Doctors: It is a medical decision to commence enteral feeding and decide on the appropriateness of the NRL after consultation with the patient, carers and multidisciplinary team (MDT). See Appendix 3.

Registered Nurse: it is the nurse’s responsibility to care for the NET and NRL as per Trust Policy/Guideline

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Competence and training requirements

A registered practitioner is needed who has completed relevant education and training in the insertion of nasal Corgrips or AMT bridles.
A NRL should only be placed by a trained practitioner. If a trained practitioner is not available on your ward please contact the Enteral feeding nurses.

Training for insertion of NRLs should be limited to practitioners working within areas of high usage to gain competence and experience such as the stroke unit, neurosciences, intensive care, liver unit and the enteral feeding nurse team.

All staff who insert NRLs must have completed the ward based training and competency assessment (see appendix 4). Training sessions can be arranged by contacting the Enteral Feeding Clinical Nurse Specialist (bleep 80-4727, tel. 0113 2068690). It is recommended that in all areas of high usage, arrangements are made to keep a record of trained staff. For doctors in training, competency may be documented on their e-portfolio.

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Consent

• There are various options to facilitate NET feeding which include forms of restraint (the use of mittens for example) and, as such, are ethically sensitive and fraught with emotion for the patient, their family and for staff. Such tensions have to be managed alongside the need to provide optimal treatment. It is important to remember that a nasal retaining loop is best thought of as a retaining device, rather than a restraining device.
• Staff are required to be skilled in the consent process. They need to consider the patient’s capacity to be involved in the decision-making process. Where possible they should gain the patient’s consent, or alternatively, the assent of a person close to the patient. Guidelines for obtaining patients’ consent are to be found inThe Mental Capacity Act 2005 Procedure
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• If, after using the two stage process for determining mental capacity, detailed in the procedure above, it is determined the patient has capacity to make the decision, it is very important to acknowledge that they have the legal right to decide. When a person has the mental capacity to decide, they must be given all the necessary information to enable them to make their decision, including pros, cons and likely outcomes.
• If the two stage capacity test shows that a patient lacks the capacity to decide on this issue, their best interests are taken into account given all the circumstances.
• The least restrictive method of restraint, with the lowest risk and discomfort, should be used at any point.

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Diagnosis

Identifying appropriate patients (refer to Appendix 3)
Suitable patients are:

• Those with documented evidence of inadvertent displacement of the NG/NJ tube on more than two occasions.
• Those with enteral feeding tubes placed peri-operatively and where enteral access will no longer be available if the tube becomes misplaced or removed.
• Patients who are pulling at other devices such as urinary catheters and intravenous cannulas, and who require an enteral tube for feeding or medication.
• Patients who demonstrate skin irritation from tape secured to the nose.
• Patients discharged to the community on long term NG feeding.
• Those who have elective nasogastric or nasojejunal tubes when replacement is of high risk or technically difficult.
• NRLs are used following careful assessment in patients who have removed two or more NETs and in whom other methods of restraint such as better fixation, distraction and mittens have failed. In some cases, reducing time attached to a pump with fast rates of feeding may be a better solution in agitated and confused patients, as in these patients the NRL may cause nasal trauma if the patient mobilises whilst attached to the pump".

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Investigation

Relative contraindications for bridle placement:

• Patient with deranged clotting (consider risks vs. benefits if INR/platelets abnormal)
• Extremely confused/agitated patients who may continue to pull at the NG tube and cause trauma to the nasal septum.
• Patients with grossly deviated nasal septum or other anatomical challenge such as nasal polyps, or any structural deformity of the nose or nasopharynx.
• Patients with facial or cranial trauma.
• Patients that are unable to demonstrate appropriate response to painful stimuli: e.g some head injury patients, advanced dementia.
• Patients who would be likely to dislodge gastric or jejunal tubes because of frequent coughing, retching or vomiting.
• History of epistaxis.

Absolute contraindications for NRL placement

• Patients who are competent and refuse treatment.
• Patients for whom nasal tubes are contra-indicated, for example those with basal skull fracture or nasal obstruction.
• Patients judged to have an excessive local bleeding risk
• Excessive agitation
• Grossly deviated nasal septum
• Mechanical obstruction-i.e nasopharyngeal airway in situ

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Treatment / Management

1. Assess the patient for appropriateness for nasal loop insertion.(Appendix 3)

2. If the patient has capacity the procedure should be explained to gain verbal consent. If the patient is deemed to lack capacity, then a best interests decision should be made and documented in the medical notes. A check should be made to determine whether anyone has ‘Lasting power of attorney’ or whether a valid ‘Advance decision to refuse treatment’ exists. The options should be discussed with any people close to the patient who are available and this discussion should also be recorded. The procedure should be explained and an information leaflet provided. (see appendix 8 for ethical overview)

• The purpose of the NRL and procedure for insertion should be explained to the patient, or people close to the patient if they lack capacity to decide on the issue. The information sheets should be provided (see appendix 5/6)
• Verbal consent or assent should be obtained and recorded in the medical notes/PPM+ (appendix 3).

3. The patient should be positioned upright and be alert, to enable ease of placement.

5. Check nose for any signs of obstruction and that the nose is clean as this may impede insertion.

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Insertion of AMT BRIDLE NRL

6b It is generally better to have the NET in place before the bridle as occasionally the NET will not pass and so the bridle is not needed. See Appendix 1 – Picture 1. 7b. Lubricate rigid blue probe and insert into the nostril following the anatomy of the nose. If NET in situ insert rigid blue probe into the NET nostril. Advance up to the 2nd groove on the probe and maintain probe position. If blue probe will not advance try the other nostril (as patient may have deviated nasal septum or obstruction in that nostril) See Appendix 2 – Picture 1. When rigid blue probe is in situ-insert the flexible white probe (with tape) into the opposite nostril and withdraw the guidewire 1-2 cms. See Appendix 2 – Picture 2. This allows flexibility of the white probe and easier connection with the magnet of the rigid blue probe. Some manipulation of the flexible white probe may be required until the magnets from both the rigid blue probe and the flexible white probe unite within the nasopharynx. OR Fully insert the flexible white probe and completely remove the guidewire, very gently withdraw the rigid blue probe until taped white probe and magnets unite. If the magnets have joined then the flexible white probe will be able to be pulled through by the rigid blue probe. (May also hear a click or feel the magnets joining) See Appendix 2- Picture 3 8b. When confirmed that the magnets are joined- remove guidewire from flexible white probe (if still in situ) prior to pulling through nostril. 9b. Slowly withdraw the rigid blue probe from one nostril- pulling the flexible white probe with attached tape up from the other nostril and over the nasal septum. Pull all the way out until only the tape is visible protruding from both nostrils. See Appendix 2 - Picture 4 10b. Using scissors cut the flexible white probe from the tape leaving only the tape in the nose. Insert NET if not already in situ. The assistant is responsible for ensuring the nasal retaining loop remains insitu. 11b. If inserting NET at time of nasal retaining loop placement-check NET position as per Trust Policy prior to securing the clamp from the nasal retaining loop to the NET. If there is a delay in confirming correct position, knot tapes securely under the nose but do not clamp. Once correct position confirmed , place NET in the groove in the clamp near to the nose. See Appendix 2 – Picture 5. 12b. Put one of the tapes in the clamp with the NET and fold the two halves of the clamp together and press firmly to secure the NET in the clamp. 13b. After the clamp has been closed – verify that it will not slip or re-open. Knot the tapes together under the clamp and trim excess tape. See Appendix 2 – Picture 6. 14b. Document procedure with outcome in medical notes/PPM+ leaving clear instructions re ongoing management for nursing staff. Need to include: reason for insertion and who decided it was required (appendix 3), that no contraindications present, patient gave verbal consent or assent received from carers and whether there were any complications. ONGOING CARE OF PATIENT WITH NASAL RETAINING LOOP. Check the nasal loop tapes and clip are secure. Ensure the tapes are not over-tight. Check that the clip is not causing any pressure to under-lying skin. Inspect the skin around the nostrils for any signs of soreness/pressure necrosis. Clean around nostrils to prevent build-up of any crusting and reduce the risk of skin becoming sore. Apply skin barrier as required. Ensure the NRL is recorded in the pressure ulcer prevention documentation to ensure thorough regular inspection as described above If the strings become dirty the clip can be removed and the strings cleaned with warm soapy water. Then the clip can be reattached. NASAL RETAINING LOOP REMOVAL. If the patient becomes very agitated and is pulling aggressively at the NET you may have to remove the NRL to prevent damage to the nasal septum. Please alert medical staff on the ward to assess. Out of hours ward staff can remove the NRL if it becomes absolutely necessary, but please consider: Other methods of maintaining the NRL e.g. mittens. How will the patient receive nutrition if the NRL and/or NET are removed? How To Remove NRL: With scissors cut the white tape here. Pull the NET (with clamp and tape attached) from the opposite nostril until the whole tube is removed. Alternatively, the NRL clamp can be unclipped allowing removal of the NRL whilst retaining the NET.

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Frequently asked questions

Will a patient still be able to remove a NET whilst a NRL is in-situ?

Yes, it is still possible for a NET to become displaced, despite a NRL securing the tube. Patients may vomit the tube out of their mouth, or they may pull the tube out of their nostril by accessing the tube above the clip. This is why it is important to ensure good placement of the clip outside the nostril.

What if a patient vomits the NET out of their mouth whilst secured to a NRL?

Do not cut the NRL to release the NGT, use a plectrum, (they come in the NRL packs) to open the clip and release the NGT. Tape the strings to the side of the patient’s face. Then an assessment about reinserting a feeding tube with a NRL in-situ can be made by the medical team.

Do I still need to check the position of the feeding tube if the patient has a NRL attached?

Yes, the position of the nasojejunal or nasogastric tube still needs to be confirmed by checking the pH of gastric aspirate and/or external length as per LTHT guidelines.

The external length should also be checked before and after any manipulation of the NRL clip to confirm there has been no movement in the position of the tube.

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APPENDIX 1: CORGRIP PICTURES 

Picture 1

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APPENDIX 2: AMT BRIDLE PICTURES

Picture 1

Picture 2	Picture 3	Picture 4

Picture 5	Picture 6

Appendix 3

Appendix 3: Nasal Retaining Loop Assessment Tool 

Appendix 4

Appendix 4: Competency Documentation 

Appendix 5

Appendix 5: Information Sheet for patients 

Appendix 6

Appendix 6: Information Sheet for carers 

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Appendix 7: Procurement information

Supplier AMT Bridle :
GBUK Healthcare
Blackwood Hall Business Park
North Duffield
Selby
North Yorks
Tel no. 01757 288587

Corgrip (Halyard Health)

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APPENDIX 8

Ethical considerations

According to the Mental Capacity Act, when a decision-maker for someone who lacks mental capacity is working out what is in that person's best interests, they should consult the following people 'where it is practical and appropriate to do so':

• anyone the person has previously named as someone they want to be consulted
• anyone involved in caring for the person
• anyone interested in their welfare (for example, family carers, other close relatives,
  or an advocate already working with the person)
• an attorney appointed by the person under a Lasting Power of Attorney, and
• a deputy appointed for that person by the Court of Protection.

The role of those who are consulted is to give their opinion about what is in the patient's best interests. They are not really being asked to either consent or assent, but they are able to provide information that supports a broader interpretation of best interests than a purely clinical one.
The exception to the very limited role of family and friends in the consent process is the more authoritative one of attorneys holding a 'Lasting Power of Attorney' for health and welfare decisions.  They must be consulted and formal consent obtained.
Also check if the patient has completed an Advance Decision to Refuse treatment in relation to restraint for NG feeding as this should be respected if applicable to the clinical situation.

The MCA doesn't refer to relatives as 'next of kin' as they may not be the people who are closest to the patient. The MCA prefers to use the term 'people close to a person who lacks capacity.'

The MCA Code of Practice describes the use of restraint: 
Using restraint
Any action intended to restrain a person who lacks capacity will not attract protection from liability unless the following two conditions are met:

• the person taking action must reasonably believe that restraint is necessary to prevent harm to the person who lacks capacity, and
• the amount or type of restraint used and the amount of time it lasts must be a proportionate response to the likelihood and seriousness of harm.

When might restraint be ‘necessary’?
Anybody considering using restraint must have objective reasons to justify that restraint is necessary. They must be able to show that the person being cared for is likely to suffer harm unless proportionate restraint is used. A carer or professional must not use restraint just so that they can do something more easily. If restraint is necessary to prevent harm to the person who lacks capacity, it must be the minimum amount of force for the shortest time possible.

What is a ‘proportionate response’?
A ‘proportionate response’ means using the least intrusive type and minimum amount of restraint to achieve a specific outcome in the best interests of the person who lacks capacity. On occasions when the use of force may be necessary, carers and healthcare and social care staff should use the minimum amount of force for the shortest possible time.