Jacob Lopez

and 13 more

Executive Summary ChecklistSuccessful implementation of NG tube safe practices includes a commitment from hospital governance and senior administrative leadership to Identify and maintain awareness of performance gaps within their organization.Institutional procedures guiding NGT insertion and placement verification should be evidence-based and should provide guidance to staff on when a patient is considered high risk for misplacementAll NGTs should be radio-opaque throughout their length with external centimeter length markings to be used to detect post-insertion tube movement.All staff who place NGTs should be specifically trained in this procedureAccurate measurement prior to insertion should utilize the NEMU (Nose→Earlobe→Mid-Umbilicus)pH of gastric aspirate should be used to confirm NG placement prior to initial use with pH in desired range of 1.0 to 5.0.  If unable to obtain a gastric aspirate within the required pH range, confirm NG placement with a radiograph.All staff who read radiographs should be specifically trained in reading the radiograph using the following four criteria:  Does the tube path follow the esophagus/avoid contours of the bronchi?Does the tube clearly bisect the carina or the bronchi?Does the tube cross the diaphragm in the midline?Is the tip clearly visible below the left hemi-diaphragm?Confirmation of NG tube should be documented in the EMR and method of confirmation (ph or radiograph).  Tubes should be secured to the patient after confirmation in such a way that the centimeter mark is visible at the nare.  This mark should be documented in the medical record and used as a point of reference for other caregivers to gauge movement of the tube.Observe for signs of respiratory distress or gagging/vomiting and remove tube if these signs are present as NG tube may have been dislodged into the airway or lungs.A mandatory reporting system should be developed to track nasogastric feeding tube misplacements as a percentage of all tubes placed. The Performance GapNasogastric tubes (NGTs) are a commonly used intervention in clinical practice for decompression or for administration of enteral nutrition, fluids and medications.  In a neonatal and pediatric one day prevalence study of 63 institutions, 24% of hospitalized infants and children required an orgastric (OG), nasogastric (NG), or transpyloric tube \cite{Lyman_2015}.  Of those patients, 61% were located in a neonatal intensive care unit (NICU). A National Patient Safety Alert (NPSA) issued by the National Health Service (NHS) documented over 3 million NG or OG tubes were used from 2011-2016 in the United Kingdom (UK) \cite{parker2016}. These tubes are inserted using blind placement technique, so called because the person doing the procedure cannot discern where the tube is going in the body as it is being advanced.  As a consequence, complications can occur if the NG or OG is misplaced into the esophagus, duodenum or pulmonary tree.  Serious patient harm and deaths have occurred when tube misplacement is not detected prior to use.Studies of adult patients report NGT misplacement with serious harm to patients in 1.3 to 3.2% of tubes placed\cite{Gilbertson2011,Bourgault2009}. A study of neonates documented an incidence of 59% NGT misplacements with the majority of tubes being in the esophagus\cite{October2009}.  The Pennsylvania Patient Safety Authority documented 44 NGT misplacements into the lung from 2011-2013\cite{Powers2013}. Of these events, 24 were classified as serious patient harm.  Case reports in the literature describe such injuries as pneumothorax, enteral formula administration into the lung, esophageal perforation, and even death \cite{Gilbertson_2011,Bourgault_2009}. Failure to detect misplaced NGTs are attributed to: use of non-evidence based methods to confirm initial placement (auscultation or aspiration), failure to recognize when an NGT has changed position, failure to properly read an abdominal radiograph, failure to accurately interpret an electromagnetic device screen \cite{October_2009,Powers_2013}.