“In 2003, I was holding the bleep for my hospital, and woke to an early morning call from night staff explaining that during the attempted resuscitation of a patient they had realised he had been fed through a misplaced nasogastric tube. I drove through empty streets, and undertook the painful tasks of contacting the patient’s family and breaking the news to the devastated doctor who had misinterpreted the x-ray. Those of you who’ve been in the same position may recognise how very heavy a phone feels in those circumstances, and the effort of will it takes to press dial, knowing neither the family nor the staff member’s life will ever be quite the same.”
Dr Frances Healey RN, RN-MH, PhD wrote the above in a forward to an UK NHS Improvement Resource Set. called Initial placement checks for nasogastric and orogastric tubes, about a patient incident that may have been preventable with proper care and diligence.
No nurse would ever want to find themselves in that position.
The paper has an analysis of 95 incidents that occurred because of misplaced nasogastric tubes. Almost all the incidents occurred with adults in an acute hospital setting, where most nasogastric tube use occurs.
45 of the incidents related to the use of x-ray misinterpretation. This occurred because the staff (junior doctors to consultants) had not received competency-based training in checking nasogastric placement on x-ray.
A further 23 incidents related to the use of pH tests. 15 of the 23 incidents found a pH in the safe range even though the nasogastric tube was found to be in the respiratory tract.
A review of these incidents showed that there were systematic gaps in the provision of competency-based training in checking nasogastric tube placement as only 1 of the 23 incidents describes a staff member who had received competency based training.
Of the remaining 27 incidents, 9 occurred because
- there was miscommunication and the tube placement was not checked at all.
- dislodgement of the tube after correct initial placement, and
- the use of a ‘whoosh’ test that is not recommended.
There was no clear description of the checking method in 14 incidents and 4 incidents related to the use of electromagnetic devices.
Most research related to nasogastric tube placement checks is not recent.
One paper in the International Journal of Nursing Studies recommended the cessation in nursing of the practice of measuring the appropriate length of the nasogastric tube placement in adults via the nose to ear to xiphisternum method.
This was because the method lead to the tube being positioned incorrectly.
The tube was found to either ending
- in the oesophagus, or
- in the stomach but too close to the oesophagus, or
- too far into the stomach or duodenum.
The NHS Improvement Resource Set recommends the following for confirming initial nasogastric placement.
DO NOT use the ‘whoosh test’ or ‘bubble test’
DO NOT test aspirate using blue litmus paper (As it not sufficiently sensitive to distinguish between brachial or gastric secretions.)
DO NOT interpret absence of respiratory distress or the appearance of aspirate as an indicator of correct positioning.
pH in the ‘safe range’ of 1 to 5.5 can be used as the first line test to exclude placement in the respiratory tract.
Nasogastric tubes are not flushed, nor are guidewires pre-lubricated, nor is anything introduced though the tube until initial placement has been confirmed
Each pH test (including failure to obtain aspirate) and test result is documented. (As well as checking that the pH test strips are intended to test human gastric aspirate.)
Radiology (x-ray) can be used to confirm placement but should not be used routinely for all patients
Any unused tubes identified in the lung are removed immediately, whether in the x-ray department or clinical area
pH in the ‘safe range’ or x- ray are the only acceptable methods of confirming initial placement of a nasogastric tube.
To learn more about nasogastric tube placement:
de Oliveira Santos, Sandra Cristina Veiga, et al. “Methods to determine the internal length of nasogastric feeding tubes: An integrative review.” International Journal of Nursing Studies 61 (2016): 95-103.