Misplaced nasogastric tubes: a fast tracked solution Trisha Bain, BSc', PhD Patient Safety Manager w

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Misplaced nasogastric tubes a fast tracked
solutionTrisha Bain, BSc., PhDPatient Safety
Managerwww.npsa.nhs.uk
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What is a nasogastric tube?

• Fine bore tube that is inserted down the
  oesaphagus into the stomach
• Enteral feed is run through the tube either at
  regular intervals or continuously
• Allows patients who can not swallow or who have
  gag reflex to receive nutrition

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(No Transcript)
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Tests for placement

• Tests
• Blue Litmus paper
• pH indicator paper
• Whoosh test
• X-ray
• Developments
• Capnometry (Burns 2001,Kindop 2001,Araujo-Preza
  2002)
• Testing for presence of gastric enzymes (Metheny)
• Use of ECG changes (Diaz-Rodriguez 2004, Keidan
  2000)
• Use of magnets (Gabriel 1997)
• Bedside videoscopic placement (Grathwohl 1997)

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Background

• Coroners inquest (April 2004) into death of a
  child,
• NPSA informed via Patient Safety Manager
• Report to the Chief Medical Officer by coroner

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Coroners Recommendations

• Alert Trusts about risks associated with litmus
  paper
• whoosh test to be withdrawn from use
• A review of the next edition of the Marsden
  Manual to ensure that the most up to date
  evidence based advice was inserted,
• Feed manufacturers to be required to show the pH
  level of their food
• Tube manufacturers to include advice on
  appropriate tests for placement
• Consideration of a scheme for reporting adverse
  events and lessons learnt nationally National
  Reporting and Learning System (NPSA)

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Alert June 2004

• Medicines and Healthcare Regulatory Authority
  issued an alert replace blue litmus with pH
  indicator paper
• No advice given as to checking process or pH cut
  off points for feeding
• Neonatal professions unwilling to change practice

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NPSA involvement

• CMO request to take work forward with MHRA
• Coroners recommendations based on one case
• Patient Safety Managers identified 10 more deaths
  due to misplaced tubes
• Literature review, No test perfect, pH and x-ray
  most reliable
• Limited studies in UK, specifically in relation
  to neonates
• NRLS not in operation at the time
• Difficulty in pinpointing the incidence of
  mis-placed naso-gastric tubes limited reporting
• Range of 0.3 - 20 reported in literature
• Potential for aggregate Root
  Cause Analysis

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Root Cause

• A Root Cause is a fundamental cause which if
  resolved will eradicate, or significantly
  contribute to the resolution, of the identified
  problem.
• Root Cause Analysis (RCA) is a structured
  investigation that aims to identify the true
  cause(s) of a problem and the actions necessary
  to eliminate it (Anderson Fagerhaug 2000)
• There is often more than one root cause

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Aggregate RCA

• Powerful method of determining underlying causes
  across a number of incidents
• Originally developed in high hazard industries
• Veterans Association 11 step process
• Advantage - actions taken to improve care are
  based on information from a number of events and
  so are more likely to address common problems.
• Not been done before in UK

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Steven step process

• Step 1 Identifying the cases (age range, pubic
• domain, within same timeframe)
• Step 2 Review the literature and other sources
  of information
• Step 3 Develop team, organise and develop
• programme
• Step 4 Conduct event
• Step 5 Determine actions
• Step 6 Write and disseminate report
• Step 7 Set up systems and processes to
  implement and
• evaluate actions

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Workshop August 2004

• One day event, five cases, pre-event preparation
• Multi-disciplinary small group work
• Sensitive handling of cases and groups
• Facilitated sessions
• Identified care and service delivery problems,
  contributory factors and root causes
• Determine next steps local to national action

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Root Causes

• Use of unreliable bedside tests
• Limited awareness of risks
• Lack of decision tree
• Lack of competency based training
• solution fast tracked

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Fast track process

• Review of NRLS and literature
• Development of advice by National Nursing
  Nutrition Group, expert panel
• Workshop December 2004
• Advice further developed and agreed by expert
  panel Jan 2005
• Consultation and testing process Jan 2005
• Alert disseminated February 2005
• 1-2 year process into 6 months

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NG Alert and Carer Briefing
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Issues for neonates

• Rationale for not changing
• Limited evidence and/or reporting for neonate
  population
• No evidence of any deaths
• NPSA rational for changing
• Problems with blue litmus still applicable
• Risks of misinterpretation of whoosh test
  potentially higher
• Consistency of approach across all healthcare
  settings
• Waiting for evidence abdication of
  responsibility

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Communication and negotiation

• Workshop March 2005
• Ongoing discussions with professional body
• Wider consultation and testing through neonatal
  units
• Agreement May 2005
• Delays gateway process disseminated Aug 05

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Fast tracked processImplementing and developing

• Feedback from service, issues adult intensive
  care units, antacid medication (PPIs)
• Research programme, systematic reviews,
• exploring other methods
• Design of tubes
• pH paper improvements
• labelling of feeds

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Change management in the NHS

• Training and education programmes, NHS
  infrastructure
• Understanding of risk assessment
• Ownership of the issue by all clinicians
• Eliminating out of date advice
• Purchasing for safety, cost vs effectiveness
• Availability of pH paper e.g. community setting
• Reporting incidents

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Thankyou

• ANY QUESTIONS