CrossHospital Audit: Nasogastric Tubes

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Cross-Hospital Audit Nasogastric Tubes

• Suzanne Metcalf
• SDE Clinical Audit
• Royal Perth Hospital

2
Rationale

• 2004 the Medicines and Healthcare products
  Regulatory Agency (MHRA) in the UK
• pH strips or paper
• February 2005 the NHS National Patient Safety
  Agency released the Patient Safety Alert
  Reducing the harm caused by misplaced
  nasogastric feeding tubes
• X-Ray recommended as gold standard for Adults
  (but should not be used routinely)
• Measuring the pH of aspirate using pH indicator
  strips/paper is recommended

3
Patient Safety Alert

• Testing methods not to be used
• The Whoosh Test
• Blue Litmus paper
• The Bubble Test
• Observing the visual appearance of aspirate

4
Patient Safety Alert

• Testing methods not to be used
• The Whoosh Test
• Blue Litmus paper
• The Bubble Test
• Observing the visual appearance of aspirate

5
Rationale continued

• RPH established a working party to develop
  metro-wide standards to guide nursing practice in
  the management of patients with enteral tubes.
• RPH established an additional working party in
  March 2006 to develop and coordinate an audit
  focussing on tube placement checking to collect
  base line data prior to the implementation of the
  Metro-wide guidelines.

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Seven Hospitals included

• Royal Perth Hospital
• Sir Charles Gairdner Hospital
• Princess Margaret Hospital
• Fremantle Kaleeya Hospitals
• Armadale Health Service
• Osborne Park Hospital
• Swan Kalamunda Health Service

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Audit

• A point prevalence study to determine compliance
  with recommended best practice guidelines for the
  correct positioning of nasogastric feeding tubes
  throughout Seven Perth Hospitals
• Aim of the audit
• To increase patient safety and minimise the risk
  associated with incorrect positioning of
  nasogastric feeding tubes.

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Objectives

• To ensure
• - safe and effective management of nasogastric
  tubes (NGT).
• - appropriate actions are taken to determine
  correct placement of tube prior to feeding /
  administering medications.
• - nursing staff are aware of and complying with
  the hospital standards for the management of NG
  tubes and associated documentation.

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• Inclusion Criteria
• All adult and paediatric patients in general
  wards, ICU and Emergency Departments with NG
  tubes insitu on the 12th July 2006 (data
  collection).
• Exclusion Criteria
• Patients with NG tubes insitu for drainage /
  decompression or lavage, but not for feeding or
  administration of medications.
• Neonates

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Data Collection

• Two phases
• Retrospective review of documentation relating to
  insertion placement checking
• Nurse Interview to establish any deficits in
  nursing knowledge to guide further educational
  support

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Pilot Study undertaken

• Four hospitals
• Royal Perth Hospital
• Sir Charles Gairdner Hospital
• Princess Margaret Hospital
• Fremantle Hospital
• Both Phases piloted
• Data collection tool
• Nurse interview

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Hospital that met inclusion criteria on 12th July
2006

• Undertook both components of the audit
• Royal Perth Hospital
• Fremantle Hospital
• Sir Charles Gairdner Hospital
• Princess Margaret Hospital

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Assessment of Nurses Knowledge only

• Osborne Park Hospital
• Armadale Health Service
• Swan Kalamunda Health Service

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Results

• Demographic data
• 79 patients included in the audit
• 70.9 (n56) adult patients
• 29.1 (n23) paediatric patients
• 53.6 (n30) of adult patients from one of three
  ICU
• No paediatric ICU patients

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Demographic data continued

• 100 of NGT were secured appropriately according
  to the patients condition
• 98.7 were radiopaque
• 67.1 (n53) prescribed acid inhibiting
  medication
• 88.7 (n47) adult patients
• 11.3 (n6) paediatric patients

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Demographic data continued

• 44.3 (n35) were receiving continuous feeds
• 71.4 (n25) were prescribed acid inhibiting
  medication.
• 41.8 (n33) were receiving intermittent feeds
• 57.6 (n19) on acid inhibiting medication

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Demographic data continued

• 81.8 (n9) of the eleven adult patients
  prescribed medication via the NGT were on acid
  inhibiting medication
• 100 of patients at RPH (n29) were prescribed
  acid inhibiting medication

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Nurse Interviews
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Nurse Interviews
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Documentation on Insertion

• Date of Insertion
• Reason for insertion
• Nasogastric Tube length (cm)
• Nasogastric Tube diameter (French Gauge)
• Type of feed regime
• Method used to confirm placement
• Confirmation tube is in correct position
• External length (nare to tip) following
  confirmation

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Documention - Date of insertion
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Documentation - Reason For Insertion
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Documentation - Tube Length
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Documentation - Tube Gauge
25
Documentation - Type of feed or Medication
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Documentation - Method used to assess placement
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Documentation - Confirmation NGT in correct
position
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Documentation - External Length (Nare to tip)
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Other Documentation indicated by those interviewed

• 21.2 (n22) information relating to the aspirate
  including colour, amount and pH
• 14.4 (n15) their assessment of the insertion
  process including trauma, nostril patency,
  complications or ease of insertion
• 17.3 (n18) nare the NGT was inserted

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Placement checking for enteral feeding and
medication administration

• Following initial confirmation of NGT placement
  tubes should be checked
• Prior to all bolus or intermittent feeds
• Prior to commencing continuous feed (minimum
  daily)
• Prior to administration of medications (NG route)

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Documentation - confirming placement checks
(intermittent)
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Documentation - confirming placement checks
(continuous)
Hospital
70.0
Fremantle Hospital
Princess Margaret
Hospital
Royal Perth Hospital
60.0
Sir Charles Gairdner
Hospital
50.0
40.0
30.0
20.0
10.0
0.0
Not applicable
Tube placement checks
Tube placement checks
documented
not documented
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Documentation - confirming placement checks
(medication)
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Documented - Method used
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Gastric pH

• 66.6 (n63) indicated a pH lt5.5
• 12.5 (n8) nurses reporting the pH 6 or above
• 12.5 (n8) not reporting a figure.

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Risk assessment process

• Medication (PPI, H2 antagonists)
• Visual checks
• Well secured
• Signs of migration (curling)
• External markings
• Length from nare to tips
• pH test of aspirate with pH indicator strips

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Prior to aspirating

• 18.2 (n18) would confirm if patients on acid
  inhibiting medication
• 58.6 (n61) confirm tube securely anchored
• 36.5 (n38) Visual check for migration
• 23.1 (n24) Check external markings
• 30 (n31) Check external length (nare to tip)

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Methods employed to aid aspiration

• 47.1 (n49) Turn patient on their side
• 32.7 (n34) Inject air gently into tube
• 32.7 (n34) Advance / withdraw tube then try to
  aspirate again

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Number of attempts to aspirate
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Recommendations

• The General Surgical Supplies tender ensure the
  following criteria are met for NGTs
• Radiopaque
• Have multiple ports (air port) to aid aspiration
• Have clear centimetre line markers
• Are made of suitable / choice of materials
• Have caps attached to close ports when not in use
• Are available in a number of lengths
• Are available in a number of sizes

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Recommendations cont

• The Metro Wide NPS group to develop a suitable
  form for nursing staff to document assessment of
  placement checks with MR number assigned, (follow
  local policy for MR numbers at all sites).

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Recommendations cont

• Continuous feeding regime to follow the NICE
  Guidelines for nutrition support in adults
  (enteral feeding)
• ie dieticians to prescribe feeding regime over
  16 24 hours thus allowing a feed free break to
  allow the stomach to empty and enabling pH
  measurements to be taken.
• The DON at each site to write to the chief
  dietician to recommend changes following
  implementation of NPS.

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Recommendations cont

• The NPS to state required information for
  documentation following NGT insertion in-patients
  integrated notes.

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Recommendations cont

• NPS group to develop a NGT competency as part of
  the nursing practice standard. The competency to
  be developed using the RPH template.
• NPS to ensure process highlighted in Nursing
  Practice Standard to document / report incidents
  relating to NGT insertion, misplacement and
  removal on AIMS. Incident reporting should also
  include all near miss incidents.

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Recommendations cont

• All hospital to ensure there is a process in
  place which allows appropriate clinical nurse
  specialists / consultants or Nurse Practitioner
  involvement in product evaluation / review during
  all relevant tender contract renewals.
• Approved recommendations to be reflected in EBP
  NPS

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Recommendations cont

• Education program to be developed to coincide
  with the implementation of EBP NPS. Education to
  include but not limited to
• Background to NPS
• Physiology
• Types of tube
• Patient assessment (NGT or PEG)
• Placement checking (risk assessment)
• Documentation

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Recommendations cont

• Copy of report has been distributed to team
  members, and NPS group.
• Copy of report distributed within hospital sites
  to appropriate Governance Committees / Councils.
• Reaudit of NGT documentation to be undertaken in
  August 2007 (invitation will be sent to other
  hospital to participate).

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Conclusion

• First for Western Australia
• Real time benchmarking
• Hospitals involved have reviewed current practice
• Review bedside placement checking of NGTs
• Whoosh test, Litmus paper and Bubble tests banned
• Introduction of pH indicator strips
• Need for specific documentation form