Problems with use of a Foley

catheter in enteral tube feeding

Omorogieva Ojo

that the three main types of gastrostomy tubes

include PEG, RIG and the balloon gastrostomy
Abstract tube. Although balloon gastrostomy tubes
This article discusses the unlicensed use of a Foley catheter in home enteral tube
are placed mainly in existing tracts, there is
feeding in the community. It is now clear that patients on long-term enteral
evidence that some gastroenterologist now
feeding in the community may require replacement of their feeding tubes due
place them as a primary tube of choice in new
to deterioration, damage or tube dislodgment. Often, these conventional feeding
stoma sites (Ojo, 2011). The delivery of post-
tubes such as percutaneous endoscopic gastrostomy and radiologically inserted
pyloric feeding is through the use of naso-
gastrostomy tubes are replaced with similar tubes or with balloon gastrostomy
jejunal tubes and percutaneous endoscopic
tubes. However, the use of a Foley catheter in place of conventional feeding tubes
jejunostomy (Wright, 2004).
as replacement tube has been observed in a number of patients in practice and
The enteral feeding tubes used for
documented in literature.
these procedures will normally meet the
The Foley catheter is significantly less expensive and easily accessible than
requirements of the product licence (Griffith
conventional feeding tubes or balloon gastrostomy tubes. However, its use as an
and Tengnah, 2011). In addition, the
enteral feeding tube has implications for practice in terms of its use as unlicensed
conventional enteral feeding tubes such as
product, consent, ethics and professional responsibilities. Issues relating to body
PEG or RIG may require replacement due
image and quality of life are also discussed.
to deterioration, malfunctioning or accidental
Key words: Enteral nutrition ■ Foley catheter ■ Unlicensed product dislodgement such as when a confused patient
■ Consent ■ Community ■ Professional responsibility pulls on the tube. Therefore, a replacement
either with the same type of tube or with

T
his article aims to explore the use of
a Foley catheter in home enteral tube
feeding and in the administration
of medication in the community.
Although limited in scope, the use of Foley
catheters to deliver enteral nutrition has been
observed in practice and documented in some
studies (Pereira and Mersich, 1991; Kadakia et
al, 1994). Therefore, a review of this subject
will enable a greater understanding of the
reasons for placing this tube in patients. In
addition, it will ensure an understanding of the
issues associated with this procedure including
body image, ethics, consent, professional
responsibilities and cost compared with
conventional feeding tubes.
The prevalence of patients on enteral feeding
in the UK is on the increase (Ojo, 2010). With
respect to the community, the increase in the
number of these patients can be linked to the
Omorogieva Ojo is Senior Lecturer in Primary Care,
Department of Acute and Continuing Care, School
growth in scientific knowledge, technological
advances and the drive by government to move
patients from acute hospitals to community
settings (Madigan, 2003; Ojo, 2012).
Fogg (2007) suggested that nutritional
support should be provided to patients who
are malnourished or at the risk of malnutrition
including those with neurological disorders
and cancers of the upper gastrointestinal
tract. However, it is now established that
individuals who are unable to meet their
nutritional requirements through oral intake
and have functional guts often need enteral
nutritional support in order to meet their daily
requirements for energy, protein, vitamins
and minerals (Fletcher, 2011; Ojo, 2011).
Enteral nutrition in these individuals is
primarily delivered by means of conventional
feeding tubes including percutaneous
endoscopic gastrostomy (PEG), naso-gastric
tube, radiologically inserted gastrostomy
(RIG), PEG with jejunal extension, direct
jejunostomy and naso-jejunal tubes (Ojo,
2011). According to Madigan et al (2002),
balloon gastrostomy tubes will be required.
For example, Fogg (2007) observed that RIG
tubes were being replaced electively after 3-6
months of placement with balloon gastrostomy
tubes in order to reduce the risk of accidental
dislodgement. However, some patients with
dislodged PEG, RIG or balloon gastrostomy
tubes are now being provided with Foley
catheters in place of balloon gastrostomy
tubes. Sometimes, these patients do not have
a replacement balloon gastrostomy tube and
one possible way of ensuring that the stoma
is patent and patients have access to fluid, feed
and medication is the placement of a Foley
catheter. However, the use of Foley catheters
for enteral feeding and medication does not
meet the requirements of the product licence.
Sometimes, gastroenterologists may prefer the
use of Foley catheters (Figure 1) in place of
conventional enteral feeding tubes or balloon
gastrostomy tubes (Figure 2) because the
Foley catheter is cheaper and easily accessible
(Kadakia et al, 1994).
While Foley catheters are used routinely for
urinary bladder catheterisation, complications
© 2014 MA Healthcare Ltd

of Health and Social Care, University of Greenwich,

Avery Hill Campus, London 88.5% of patients receiving enteral feeding have been reported when they are used as
in the community have PEG tubes compared enteral feeding tube either as replacement
Accepted for publication: March 2014 with 7.5% who have naso-gastric tubes and tubes for conventional feeding tubes or as
4% fed via jejunum. Wright (2004) also noted primary tube of choice (Kadakia et al, 1994;

360 British Journal of Nursing, 2014, Vol 23, No 7


Date et al, 2002). Incidents of surgically placed
Foley catheters may include balloon rupture
and distal migration resulting in small bowel
obstruction by the inflated balloon. Other
complications in the use of Foley catheter
in enteral tube feeding may include tube
dislodgement. According to the Medicines
and Healthcare Products Regulatory
Agency (MHRA, 2010), manufacturers
employ different controls on the design and
manufacture of devices, and assess the level
of safety and performance of the device
in its intended use. However, devices that
are used off-label (e.g. Foley catheters as
enteral feeding tubes) will not have undergone
this level of scrutiny. Examples of potential
dangers include, adverse reactions, inadequate
sterilisation, insufficient mechanical strength
and/or structural integrity, insufficient
durability, and misuse due to lack of adequate
training for the device (MHRA, 2010).
The National Institute for Health and Care
Excellence (NICE) guideline on prevention
and control of healthcare associated infections
in primary and secondary care clearly outlines
strategies for managing long-term urinary
catheters (NICE, 2012). While the focus of the
NICE guideline is on educating the patients,
their carers and healthcare workers; assessing
the need for catheterisation; catheter drainage
options; and catheter insertion and maintenance,
the use of Foley catheters in enteral feeding is
not included in NICE guidelines.
Therefore, healthcare professionals who
insert and maintain Foley catheters for the
purpose of enteral nutrition have to develop
their own local guidelines for these procedures,
relying on a range of evidence. In particular, it
has to be borne in mind that while a urinary
catheter is placed primarily for the purpose of
draining urine from the bladder, the reverse
is the case when they are placed for the
purpose of enteral nutrition. In this latter
case, Foley catheters actually deliver enteral
feed to the stomach. This has implications for
practice in terms of ethics, consent, clinical
and professional responsibilities.
Conventional enteral feeding tubes
PEG tubes are usually placed endoscopically
in patients with a functional stomach and
mainly for long-term tube feeding while
naso-gastric tubes are often placed in patients
requiring short-term feeding through a fine-
bore tube (Fletcher, 2011).
© 2014 MA Healthcare Ltd
In patients with oesophageal obstruction or
fistula where endoscopic procedure may be
difficult or where there is a risk of malignant
cell translocation, the use of RIG to deliver
British Journal of Nursing, 2014, Vol 23, No 7
Figure 1. A 3-way urinary catheter
long-term enteral feed has been reported (Ojo,
2011). In addition, patients with complete or
partial gastrectomy, may benefit from the use
of jejunostomy tube while patients with PEG
in-situ may be provided with jejunal extension
when there is increased risk of nausea and
aspiration (Ojo, 2010).
It is essential to emphasise that the use of
each of these conventional enteral feeding
tubes has their merits and demerits. In
addition, there are complications including
gastrointestinal, stoma-site complications and
pump or mechanical problems associated with
the use of all enteral feeding tubes (Madigan
et al, 2002; Fletcher, 2011).
Foley catheter
The Foley catheter was first introduced in
the 1930s by the American urologist, Dr
Fedrick Foley, for the purpose of urinary
catheterisation (Knoll et al, 2011). However,
there is now evidence of its use in a range
of clinical settings including enteral tube
feeding in the community. For example, in
difficult cases following postoperative bowel
preparation, Foley catheter enterostomy can
be used to control bowel effleunts when it is
impossible to have stoma formation (Tøttrup,
2010). Its use in the management of epistaxis
or acute nasal hemorrhage has also been
reported (Pellard et al, 2005).
With respect to enteral tube feeding,
many commercial replacement gastrostomy
tubes such as balloon gastrostomy tubes are
significantly more expensive than standard
Foley catheters. Therefore, it is possible that
the increased use of Foley catheter by various
agencies may be partly due to its reduced
cost although most are unsure of its safety
including risks of complications.
In a randomised controlled trial by Kadakia
et al (1994), 46 patients with established and
mature tract who required replacement of
their PEG tube or a standard commercial
replacement tube for various reasons were
randomly selected for the study. While 24 of
the patients had a 20 French Foley catheter
as replacement tubes, the remaining 22
patients had a 20 French Flexiflo replacement
gastrostomy.
clinical focus
Catheter-tip feed port
Luer-lock
balloon port
External
retention
ring
Graduated cm Track
markings
Internal
retention
balloon
Figure 2. A balloon gastrostomy tube
It was clear from the results of the study
that the use of Foley catheter as a replacement
gastrostomy tube functioned as well as the
commercial replacement gastrostomy (Flexiflo).
The study also found low incidence of balloon
rupture and absence of distal migration of
the Foley catheter although the incidence of
balloon ruptures has been reported in Foley
catheters used as replacement feeding tubes
(Date et al, 2002).
Costs
Kadakia et al (1994) argued that the Foley
catheter was much cheaper than conventional
gastrostomy tubes used in enteral tube feeding.
For example, while the Flexiflo Stomate had
a list price of $97.90, the Flexiflo replacement
gastrostomy tube had a list price of $36.04
and the all-silicone Foley catheter a list price
of $5.80 (Kadakia et al, 1994). A recent price
listing for the UK quoted £15.54 for a pack
of 5 Bard Medical 2-Way Female Latex 12 Ch
361
Foley Catheter with 10ml balloon (OnCall
Medical Supplies, 2014). It has also been
reported that the cost of a balloon gastrostomy
tube with a long shaft could range from £30
to £70.55 compared with Corflo Cubby
(Button) the cost of which could be as high as
£146.47 (Ojo, 2011; Nutricia, 2009).
In general, the Foley catheter is 4 to 5
times less expensive than the commercial
replacement gastrostomy tube and 12 times
less expensive than the commercial skin-level
gastrostomy device (Kadakia et al, 1994).
Body image and quality of life
The presence of a Foley catheter, whether
in the urinary tract or stoma site as an
enteral feeding tube, brings with it physical,
psychological and body image challenges that
would require life changes and adjustments
(De Jaeger, 2011). According to De Jaeger
(2011), this adjustment can take up to 1 year
and thus patients having long-term Foley
catheters in place may require a programme
of psychological support. The use of a Foley
catheter, which is primarily designed for the
purpose of draining urine, as a tube for enteral
feeding raises issues concerning body image
for the patient. In addition, dressing the stoma
site, protecting it, planning for it and the
stigma of having a Foley catheter in situ are
some of the problems that the patients might
face (De Jaeger, 2011). Problems relating to
patient’s sexuality, especially patients who are
single, have also been reported when a Foley
catheter is used as a feeding tube.
It is possible that the low quality of life
(QoL) scores in patients on enteral feeding
tubes may be related to the complications
with this method of feeding including wound
infections and accidental dislodgement
(Crosby and Duerksen, 2005).
Consent and ethical issues
Oral intake of food is a natural process of
maintaining nutritional balance and brings
with it the taste and enjoyment of food
(McMahon et al, 2005). However, gastrostomy
tubes are commonly used in patients who
are unable to maintain their nutritional status
orally but who have a functional gastrointestinal
tract (Crosby and Duerksen, 2005). While the
process of oral food intake is often seen by
patients and members of their family as being
related to good health, the use of artificial
nutrition is often equated with ill health and
limits the emotional relevance of oral nutrition
(McMahon et al, 2005). The widespread use of
the Foley catheter is because it is cheap, well
known, easy and readily available (Pellard et
362
al, 2005). However, MHRA recognises the
off-label use of medical devices but outlines
the need to ensure users are aware of the risks
associated with and, where possible, avoid
the off-label use of medical devices (MHRA,
2010).
When using devices or products such as
Foley catheter, it is important to check the
summaries of product characteristics (SPCs).
The SPCs are the principal source of product
information including indications, cautions,
contra-indications, and side effects (Joint
Formulary Committee, 2013). However, the
British National Formulary includes unlicensed
use of medicines when the clinical need
cannot be met by licensed medicines,
although it is emphasised that such action
should be supported by appropriate evidence
and experience (Joint Formulary Committee,
2013).
According to Pellard et al (2005), it is
essential that consent should be obtained by
health professionals from each patient before
using medications or devices outside their
product license. This process should include
informing the patient;
■■ That the product or device was being used
outside its license
■■ About the side effects of the device
■■ The risks/benefits of all available alternatives
■■ The reasons why it was in the patient’s best
interest (Pellard et al, 2005; Nursing and
Midwifery Council (NMC), 2006).
The liability of complications resulting from
defective products which are used within
the terms of their licence rests with the
producer (Pellard et al, 2005). In contrast,
when devices are used outside the terms of
the product licence, the health professional
and their employer may be liable if there are
complications arising from their use (Pellard
et al, 2005).
Professional responsibilities
The NHS regulations 2006 allow independent
nurse prescribers to supply licensed medicines
off-label (Griffith and Tengnah, 2011). Off-
Key points
n Patients on long-term enteral feeding in the community may require tube replacement due
to deterioration or tube dislodgment
n Foley catheters are sometimes used for enteral feeding and for administering medication
because they are cheap and easily accessible although this is outside the terms of the
product licence
n The use of Foley catheters for enteral feeding and medication has implications for practice as
it relates to the use of an unlicensed product, consent and professional responsibilities
label use occurs where a licensed medicine
is used for a purpose or class of patient
that is outside its product licence (NMC,
2006; Griffith and Tengnah, 2011). The NMC
(2010) describes an unlicensed medicine as
the term used to refer to a medicine that
has no marketing authorisation. It is possible
that many healthcare professionals who are
using Foley catheters for the delivery of
enteral feed, hydration and medications do
not know that the product is not licensed
for these procedures (Pellard et al, 2005).
Also, the medications are not licensed to be
administered through the catheter. This can
create a professional dilemma for the nutrition
nurse specialist or the community nurse who
often administers medications to these patients
in the community. In such circumstance, the
use of informed consent is very important
in order to reduce the risk of legal action or
litigation. According to the NMC (2010):
‘A registrant may administer an
unlicensed medicinal product with
the patient’s informed consent
against a patient specific direction
but not against a patient group
direction’.
The exceptional cases under which medicines
that are licensed but used outside their licensed
indications may be used under a patient group
direction has to be justified by best practice
and the status of the product clearly described
(NMC, 2010).
The NMC (2010) stated further that:
‘As a registrant, you should be
satisfied that you have sufficient
information to administer an
unlicensed or off-label drug safely
and, wherever possible, that there
is acceptable published evidence
for the use of that product for the
intended indication’.
Although the NMC (2010) outlined
these standards for administering unlicensed
medicines, the principles of the standards can
© 2014 MA Healthcare Ltd
British Journal of Nursing, 2014, Vol 23, No 7
also be applied to the use of Foley catheters in
enteral tube feeding.
Therefore, it is essential to establish who
takes responsibility when Foley catheters are
placed for the purpose of enteral feeding and
for administering medication. For instance,
it will be useful to know the professional
responsibility of the doctor who placed
the Foley catheter to be used for enteral
nutrition, the dietitian that outlines the
feeding regimen, the nurse who administers
the feed, water and medication and the
hospital or community trust where the enteral
feeding provisions sit (Howard and Bowen,
2001). It has to be clarified whether there is
professional indemnity that has been provided
by the professional bodies or employing
trusts to cover healthcare professionals who
are involved in the use of Foley catheters
in enteral feeding in case of litigation that
may arise from potential adverse reactions or
complications (Howard and Bowen, 2001).
According to the NMC (2010),
‘Liability for prescribing an off-label
product sits with the prescriber and
the dispenser or supplier’.
It is also useful to ensure that patient
safety is taken into consideration when Foley
catheters are used for enteral feeding and for
administering medication in the community
(NMC, 2006). This could include ensuring
that nutrition nurse specialists and community
nurses are aware of the unusual type of feeding
tube and have been provided the required
training to remove or replace these tubes
when required (Howard and Bowen, 2001).
364
Conclusion
Long-term use of enteral feeding tubes
may lead to tube damage and dislodgment
requiring tube replacement. While the use of
balloon gastrostomy tubes as a replacement
for damaged conventional tubes such as PEG
and RIG tubes is common, the use of a Foley
catheter as a replacement tube has also been
observed in practice and evidence from studies
has been reported.
Foley catheters are considerably cheaper
than balloon gastrostomy tubes. While patients
on enteral feeding tubes have lower QoL scores
than the general population, the implications
of using a Foley catheter for enteral feeding
and medication can be profound in terms
of issues relating to the use of unlicensed
products, consent, ethics and professional
responsibilities. BJN
Acknowledgment:The author wishes to acknowledge
Vygon (UK) for providing the photograph of a
balloon gastrostomy tube.
Conflict of interest: none
Crosby J, Duerksen D (2005) A retrospective survey of tube
related complications in patients receving long term home
enteral nutrition. Dig Dis Sci 50 (9): 1712-7
Date RS, Das N, Bateson PG (2002) Unusual complications
of ballooned feeding tubes. Ir Med J 95(6): 181-2
De Jaeger (2011) Exploring urinary catheters: the perspectives
of patients and nurses. Br J Nurs 20(7): 400-8
Fletcher J (2011) Nutrition: safe practice in adult enteral tube
feeding. Br J Nurs 20(19): 1234-9
Fogg L (2007) Home Enteral feeding part 1: an overview. Br
J Community Nurs 12(6): 246–52
Griffith R, Tengah C (2011) Prescription of controlled drugs
by non medical prescribers. Br J Community Nurs 16(11):
558-62
Howard P, Bowen N (2001) The challenges of innovation in
the organization of home enteral tube feeding. J Hum Nutr
Diet 14: 3-11
Joint Formulary Committee (2013) British National Formulary
66. September. BMJ Group and Pharmaceutical Press.
Kadakia SC, Cassaday M, Shaffer RT (1994) Comparison
of Foley catheter as a replacement gastrostomy tube with
commercial replacement gastrostomy tube: a prospective
randomised trial. Gastrointest Endosc 40(2 part 1):188–93
Knoll BM, Wright D, Ellingson L et al (2011) Reduction
of inappropriate urinary catheter use at a veterans affairs
hospital through a multifaceted quality improvement
project. Clin Infect Dis 52(11): 1283-90 doi: 10.1093/cid/
cir188
Madigan SM (2003) Home enteral-tube feeding: The
changing role of the dietitian. Proc Nutr Soc 62: 761-3
Madigan SM, O’Neill S, Clarke J, L’Estrange F, MacAuley
DC (2002) Assessing the dietetic needs of different patient
groups receiving enteral tube feeding in primary care. J
Hum Nutr Diet 15(3): 179–84
McMahon MM, Hurley DL, Kamath PS, Mueller PS (2005)
Medical and ethical aspects of long term enteral tube
feeding. Mayo Clin Proc 80(11): 1461-76
Medicines and Healthcare Product Regulatory Agency
(2010) Medical Device Alert Ref: MDA/2010/001. 4
January. http://tinyurl.com/oneuy7p (accessed 25 March
2014)
National Institute for Health and Clinical Excellence (2012)
Clinical Guideline 139. Infection: Prevention and control
of healthcare associated infections (HCAIs) in primary and
community care. NICE, London
Nursing and Midwifery Council (2006) Standards of Proficiency
for Nurse and Midwife Prescribers. http://tinyurl.com/ojoj446
(accessed 25 March 2014)
Nursing and Midwifery Council (2010) Standards for Medicines
Management. http://tinyurl.com/ck8fk4z (accessed 25
March 2014)
Nutricia (2009) Ancillary Price list. Nutricia, Trowbridge
Ojo O (2010) Managing patients on enteral feeding tubes
in the community. Br J Community Nurs 15(Suppl): S6-13
Ojo O (2011) Balloon gastrostomy tubes for long-term
feeding in the community. Br J Nurs 20: 34–8
Ojo O (2012) The impact of changes in health and social
care on enteral feeding in the community. Nutrients 4(11):
1709-22 doi: 10.3390/nu4111709.
Oncall Medical Supplies (2014) Price listing for Bard Medical
female Foley catheters pack of 5. http://tinyurl.com/
oy7q68k (accessed 1 April 2014)
Pellard S, Boyce J, Ingrams DR (2005) Consent and the use of
Foley catheters in epistaxis. J Laryngol Otol 119(10): 822–24
Pereira MC, Mersich K (1991) Foley catheter gastrostomy
tube migration: small bowel obstruction relieved by
percutaneous balloon aspiration. Gastrointest Endosc 37:
372–4
Tøttrup A (2010) Foley catheter enterostomy for postoperative
bowel perforation: An effective source control. World J Surg
34(11): 2752-4 doi: 10.1007/s00268-010-0741-8.
Wright C (2004) Home enteral nutrition. Journal of
Community Nursing 18 (2): 8–13
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British Journal of Nursing, 2014, Vol 23, No 7