Tube-fed people are cared for in many settings other than their own home. Providing blended diet in each of them is a common challenge.
Good examples exist where blended diet has been successfully prepared and provided on site in education, care respite and acute hospital settings.
Where these settings provide blends, tube-fed people have the same choice away from home as they have at home.
Obstacles are generally organisational rather than clinical, and a service that works through them can usually resolve them.
Any food can be blended, including in restaurants and on holiday (point 8).
1. Consider all settings in which the person is fed
At the point the decision is made, establish where blends will be given (Part 2).
Notify those settings, and send a letter confirming the decision, which reassures staff that the choice has health professional support (Appendix 4).
It is easiest to establish blended diet at home first, so that it is clear whether blends will continue before time is invested in training a setting. Developing guidance and training staff takes time, so engage early.
2. In-house provision as a choice should be considered the gold standard
Working models exist in which catering staff cook and blend on site for the tube-fed person.
It gives the tube-fed person the same access and the same level of support an oral eater receives.
School meals are the clearest example: a tube-fed pupil eligible for free school meals is entitled to the same meal. School kitchens already plan menus to meet national school food standards.
Where blends are prepared on site, reassure the setting that the food hygiene and health and safety assessments it already applies to catering for oral eaters apply equally to a blend.
Working models exist in adult residential and supported living settings too (Part 12).
3. The tube-fed person should be able to choose to bring in their own food prepared at home
Where there are no catering facilities or the person prefers it, blends prepared at home should be accepted.
A school already accepts food prepared at home for children who eat orally, by the same parent in the same kitchen. A school trained to give a commercial enteral formula through the same tube is already trained on the medical task.
Agree labelling, with a name, the date made, a use-by date and the ingredients, and how the blend is transported and stored on arrival (Part 7).
No reheating of blends sent in from home is required, unless the blend contains chilled ready-to-eat food and the pupil is in one of the groups more vulnerable to foodborne illness (Part 7).
What matters most is keeping the time the blend spends at ambient temperature under two hours (Part 7).
Dedicated fridge space is useful. Where it is not available, a cool bag with ice packs can be used.
Agree an alternative for a day when a blend is spilt, spoilt or cannot be given for any reason.
4. Work across agencies, around the needs of the tube-fed person
Bring healthcare staff, the setting’s staff and the tube-fed person together to build a plan around the facilities available.
The example care plan can be adapted to the setting’s own procedures, though every circumstance will differ (Appendix 7). Appendix 8 sets out what a local policy should define.
Families need to trust that a setting will prepare and handle blends to the standard they keep at home.
Involving them from the outset, and keeping communication open between the family, the setting and healthcare staff, helps build that trust.
5. Agree who trains staff and keep a record
Responsibility for training staff in education, respite and social care is not consistently agreed, so record locally which service trains and which holds the records.
Describe the training as enteral tube feeding and blended diet together, rather than as blended diet training on its own.
Much of it is the tube feeding the setting may already do, and separating the two is what leads settings to treat blends as a new competency to be built from nothing.
Involve whoever prepares and administers the blend: a joint visit in which staff observe preparation and administration is the most effective method described, and they can advise on the signs of intolerance specific to the person.
Staff turnover is the main threat to consistency, so build training into induction and mandatory updates, keep a register, provide written procedures, and name a lead in the setting.
Where a setting uses competency assessment, it covers the enteral tube feeding task rather than the blend, which varies from meal to meal.
Either way it is not a precondition the person must satisfy (Part 12).
6. Plan ahead for transitions and transfers
Starting school, moving between settings, and transfer from paediatric to adult services are all foreseeable. Each is a point at which provision can break down if the receiving setting has not been prepared.
Make contact before the move, so that guidance, training and equipment are in place when the person arrives.
Pay particular attention to transfer from paediatric to adult services, where models of care, funding and levels of support may differ significantly (Part 12).
7. Blended diet should continue on admission to hospital
Where a person is established on blended diet at home, the default position on admission should be that it continues, with any change agreed with them, not imposed by the admission.
Recognised clinical exceptions are critical care, significant immunocompromise, a change to post-pyloric feeding, biochemical instability, and a clinical need for continuous feeding.
Several UK hospitals now provide blended diet to inpatients, so where provision is not yet in place, services should look to those examples.
A working group of dietetics, catering, nursing and infection prevention can agree who is responsible for each step, how contamination is minimised, how ward-level equipment is cleaned and what training is needed.
Developing an inpatient blended diet service is described in the case studies.
8. Plan for travel, holidays and eating out
Travel, holidays and eating out are all possible using a blended diet but may need more planning and preparation.
Time spent travelling counts as part of the storage period, so a cool bag with ice packs is needed where a blend will be out of the refrigerator for any length of time (Part 7).
Shop-bought alternatives such as ambient pouches, smoothies or commercial enteral formula containing real food ingredients can cover occasions when a blend cannot be prepared or stored safely.
PINNT has prepared a comprehensive guide to travelling with blended food (Appendix 10).