Patient safety matters: reducing the risks of nasogastric tubes

Abstract

-Nasogastric tube insertion is a common clinical procedure carried out by doctors and nurses in NHS hospitals daily. For the last 30 years, there have been reports in the medical literature of deaths and other harm resulting from misplaced nasogastric tubes, most commonly associated with feed entering the pulmonary system. In 2005 the National Patient Safety Agency in England assembled reports of 11 deaths and one incident of serious harm from wrong insertion of nasogastric tubes over a two-year period. The agency issued a safety alert setting out evidence-based practice for checking tube placement. In the two and a half years following this alert the problem persisted with a further five deaths and six instances of serious harm due to nasogastric tube misplacement. This is a potentially preventable error but safety alerts advocating best practice do not appear to reliably reduce risk. Alternative solutions, such as standardising procedures, may be more effective.KEY WORDS: nasogastric tube, patient safety, safety alert IntroductionPhysicians have been intubating the gastrointestinal tract to allow artificial feeding since ancient times. 1 Today over 275,000 nasogastric tubes are supplied to the NHS annually (personal communication, NHS Supply Chain, May 2009). As with most medical procedures, there are risks to the use of these tubes. Some complications (eg epistaxis) are common and minor, others (eg oesophageal perforation and pneumothorax) are rare but serious.In recent years patient safety has emerged as a major issue of concern to healthcare providers. 2 Various approaches to improving safety have been used, including attempts to apply the experience of safety experts from other industries to hospital care. Over time, understanding of what approaches have most impact on reducing medical errors has grown. In this paper, the nature and scale of the problem of nasogastric tubes in England is reviewed. The limited impact of a safety alert is highlighted and the issue of nasogastric tube safety is used to illustrate other approaches to improving patient safety. Problems of nasogastric tubes in the NHSIn April 2004, an inquest was held into the unexpected death of an eight-year-old girl in an NHS hospital in England. She had required intubation and ventilation due to respiratory failure and was temporarily unable to eat or drink. A nasogastric tube was passed to administer enteral feed. The position of the tube was checked with the whoosh test (auscultating the epigastrium for bubbling as air is injected down the tube) and litmus testing of the aspirate. The whoosh test was positive while the aspirate from the tube turned blue litmus paper pink, suggesting gastric acidity. The tip had in fact punctured the pleura to lie in the pleural cavity. When enteral feed was administered through the tube her respiratory function worsened. The whoosh and litmus paper test were repeated. Again, they appeared to confirm the positioning of the tube in the stomach. Feeding continued and the girl died. At post mortem a l...

Examining the Evidence to Guide Practice: Challenging Practice Habits

“…The nurse should feel confident with the result of the verification methods that the tip of the tube is in the stomach. Numerous case reports of tubes verified as being in correct place by auscultation, later found to be malpositioned 97,100,101,115 Cutoff values for capnography not established Colorimetric device may detect respiratory placement 120 but does not allow distinction between esophageal, gastric, and intestinal placement Conflicting evidence that the cutoff of 5 mg/dL allows distinction between gastric and intestinal placement 89,124,125 No bedside test Values highly variable during first year of life [126][127][128] Conflicting evidence regarding predictive value 124,129 No bedside test Values <50 μg/mL may be associated with gastric placement, but values ≥50 μg/mL may not be associated with intestinal placement 129 No bedside test pH values ≤5 good predictor of gastric placement 89,124 ; however, values >5.0 are not as helpful at identifying tubes that are not in the stomach 89 Does not allow distinction between respiratory and intestinal placement Most useful if used in conjunction with aspirate color 102,105,129,130 Subjective May not allow distinction between respiratory, esophageal, and gastric placement Most useful if used in conjunction with pH 102,105,129,130 limitations associated with various methods of verifying tube placement. Radiography remains the only single method by which feeding tube placement can be reliably determined.…”

“…94,95 Reported complications of malpositioned feeding tubes in infants and children include pneumothorax, 96 hydropneumothorax, 97 esophageal perforation, 98,99 urinary bladder perforation, 99 and death. 100,101 Ensuring safe and effective feeding via nasogastric tubes requires the nurse to initially insert the tube to the correct place and periodically confirm that the tube remains in the intended location. Even if a nasogastric tube is positioned correctly upon insertion and secured, the distal tip can migrate forward or backward from its original position.…”

The Real Risks of Nasogastric Tubes: "Nutrothorax" Complicating a Misplaced Nasogastric Feeding

“…Plain radiography and chest CT are sufficient for a proper diagnosis of this serious complication, although sometimes laryngoscopy can be used to visualize the localization of the tube. Thoracic drainage is the technique of choice, nevertheless sometimes an isolated drainage is not sufficient and placement of additional chest tubes can be required or even performing a bronchoscopy to aspirate the feeding contents [7,8]. …”

False-positive pH aspirates after nasogastric tube insertion in head and neck tumour: Figure 1

“…Our case also adds particular interest because the correct national guidelines were followed and yet false-positive aspirates were gained, perhaps due to altered anatomy of the pharynx, and chronic aspiration in head and neck cancer patients. Lessons can be learnt from this case, and the local trust guidelines are undergoing review with the potential for specific guidelines for NG-tube insertion in the head and neck cancer cohort 1 2…”