One of our columns that surprisingly is near the top of our “hit” list was our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?”. In that column we noted that nasogastric tube (NG tube) insertion is so common that we tend to forget its risks. But if you’ve ever seen a patient die because their enteral feeds were inadvertently given into their lungs or develop meningitis because the NG tube went through a basal skull fracture, you won’t take this cavalier attitude toward NG tubes. We noted 3 Patient Safety Alerts from the UK’s NPSA (NPSA 2005a, NPSA 2005b, NPSA 2011) that reported numerous incidents, including deaths and other bad outcomes related to misplaced NG tubes.
Feeding tube misplacement is an issue not just in the UK. The American Association of Critical-Care Nurses issued a press release (AACN 2016) on September 15, 2016 calling attention to their practice alert “Initial and Ongoing Verification of Feeding Tube Placement in Adults” issued earlier this year. According to that new guideline, the expected practice during the insertion procedure is to use a combination of two or more of the following bedside methods to predict tube location:
Confirmation by radiography is still the most important element but results of the above elements can be used to determine when it is time to use radiography to confirm tube location and they may also be able to reduce the number of confirming radiographs to one.
Just as important, the alert discusses methods of tube location that should not be used. It stresses that nurses should not use the auscultatory (air bolus) or water bubbling method (holding tube under water) to determine tube location.
It also has important considerations for the radiologic confirmation of tube location. Correct placement of a blindly inserted small-bore or large-bore tube should be confirmed with a radiograph that visualizes the entire course of the tube prior to its initial use for feedings or medication administration. Once correct tube placement is confirmed, the exit site from the patient’s nose or mouth should be immediately marked and documented to assist in subsequent determinations of tube location. After feedings are started, tube location should be checked at four-hour intervals.
The practice alert is well-referenced, both in terms of citing the literature on adverse effects of tube misplacement and the supporting evidence for the recommended best practices.
We refer you back to our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?” for other lessons learned and other issues regarding NG and other feeding tubes. Pay particular attention to the section on radiologic confirmation. First, the x-ray requisition should clearly state the x-ray is for determination of tube placement. All too often we still see x-ray requisitions filled out with something like the admission diagnosis rather than the real reason for the x-ray. And you need to make sure that the person doing the interpretation is appropriately credentialed to do so (for example, if someone other than the radiologist is doing the interpretation). And feeding should not be commenced via that tube until the radiologist (or appropriately credentialed person) has documented the tube is in the correct location.
AACN (American Association of Critical-Care Nurses). Feeding Tubes Require Initial and Ongoing Verification to Minimize Complications. American Association of Critical-Care Nurses updates Practice Alert on feeding tube placement. Press Release 15-Sep-2016
AACN (American Association of Critical-Care Nurses). AACN Practice Alert: Initial and Ongoing Verification of Feeding Tube Placement in Adults. CriticalCareNurse 2016; 36(2): e8-e13 April 2016