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A patient with difficulty swallowing had a nasogastric tube inserted for feeding (Kang-chun 2019). He pulled out his nasogastric tube. After the tube was reinserted, an X-ray examination was performed, and the patient’s gastric juices were also tested for acidity in accordance with the prevailing protocol at the hospital. “No abnormalities were detected,” said the hospital spokeswoman. Nasogastric tube feeding was restarted on the same night and in the early hours of the next morning. But the patent subsequently developed cardiac arrest and had to be sent to the intensive care unit after resuscitation by clinical staff. It was at this stage that the earlier X-ray results were reviewed, and it was found that the nasogastric tube was inserted into the patient’s left lung. The patient’s condition deteriorated and he died.
In our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?” we noted numerous reports from the UK’s NPSA of incidents and bad outcomes related to NG (nasogastric) tubes and we mentioned some of our own observations. NG tube insertion is viewed by many as a simple and routine procedure. But we have seen NG tubes in patient’s lungs, the pleural space, and even in a cerebral ventricle! So, we have a great respect for proper NG tube insertion.
Then, our October 2016 What's New in the Patient Safety World column “AACN Alert on Feeding Tube Placement” discussed American Association of Critical-Care Nurses practice alert “Initial and Ongoing Verification of Feeding Tube Placement in Adults”. And our June 2019 What's New in the Patient Safety World column “Guidelines for NG Tube Placement” discussed a new systematic review (Metheny 2019) of guidelines and recommendations to distinguish between gastric and pulmonary placement of nasogastric tubes.
We’ve stressed that particular attention be paid to the x-ray requisition, which 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. We’ve also noted that 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.
A hospital trust in the UK undertook a performance improvement project after it had 2 incidents of NG tube misplacement (Earley 2019). They first performed a gap analysis and found nursing and medical staff sometimes worked in silos without necessarily understanding each others’ responsibilities. There was a lack of standardized documentation. There was no formally agreed dataset to audit compliance with practice. They also found that 90% of advanced nurses and doctors who were involved in confirming the NG tube position on X-ray had received no specific training. They also noted lack of an escalation process for challenging decisions.
After the gaps were identified, they took a multicomponent implementation approach that included education and training, development of a new e-learning tool designed to educate staff and assess their competence, standardization in the approach to care for patients with an NG tube, and monitoring and reporting systems to assure the trust’s board. One of their educational strategies is our old favorite – stories, not statistics. They included the story from relatives of a deceased patient who had experienced a never event.
But one interesting approach they took was development and use of a novel mnemonic to make things easier and more memorable for staff, The mnemonic was “NEX, 2C’s and 2D’s” to highlight the required areas to review on chest X-ray:
NEX = Nose to Ear to Xyphoid process measurement
2C’s = anatomical landmarks Carina, Clavicle
2D’s = Diaphragm and Deviation
Documentation of these findings was standardized, first as a sticker in the notes and later digitally as part of the electronic patient record.
Several parameters of the training improved after implementation, and satisfaction with the e-learning tool was high. They also implemented rigorous monitoring and reporting. The e-learning tool has subsequently been adopted by several other trusts in the National Health Service.
Obviously, a culture change and staff buy-in were key elements of success.
It’s too bad when it takes a “never event” related to NG tube insertion and placement to get the attention of a hospital’s staff. Use of NG tubes is ubiquitous in most hospital settings, yet you’d be surprised at how often we see lack of knowledge, training, and standardization regarding NG tube insertion and verification of accurate placement. Do you know what gaps exist in your organization?
See our prior columns on NG tube placement and positioning:
November 1, 2011 “So What’s the Big Deal About Inserting an NG Tube?”
October 2016 “AACN Alert on Feeding Tube Placement”
June 2019 “Guidelines for NG Tube Placement”
Kang-chun N. Patient in Hong Kong hospital dies after medical tube wrongly inserted into his lung. South China Morning Post 2019; November 27, 2019
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
Metheny NA, Krieger MM, Healey F, Meert KL. A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes. Heart & Lung 2019; 48(3): 226-235
Earley T. Improving safety with nasogastric tubes: a whole-system approach. Nursing Times 2019 [online]; 115: 12, 50-51 December 2019
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