Evaluating unintentional nasogastric tube displacement in critically ill patients
Helen Prescott on behalf of the “Better NUHCC” Collaboration1
Queen’s Medical Centre, Nottingham University Hospitals NHS Trust
The use of nasogastric tubes (NGTs) in critical care is routine. However, their dislodgement is not uncommon and risks patient harm. Adverse outcomes include: interruptions in nutritional support; delay in medication administration; increased aspiration risk; increased radiographic exposure; and increased patient distress with repeated insertions.2-4
NGTs can be secured using adhesive dressings, nasal clips or looped systems, such as magnetic bridles or in-house slings fashioned from suction catheters. Looped systems can reduce the the incidence of unintentional NGT displacement (UND) but the need for device specific training, administration of sedation for sling insertion and concern about potential complications means they are not often used first line.3&4
Within Nottingham University Hospitals Critical Care (NUHCC) department there has been concern about the frequency of UND yet there is no consensus as to the best method for securing NGTs. A recent retrospective review of chest x-ray requests suggested patients may be requiring multiple NGTs. However, this data does not discriminate between those requiring repeat x-rays due to malposition or insertion of a new NGT. We therefore sought to capture UND events in real time and to look further at the governance and management of NGTs within our critical care areas. Alongside this study there was ongoing promotion within the department of looped-systems for patients deemed at risk of UND.
1.Determine the percentage of critical care patients requiring NGTs and the proportion of these that suffer UND.
2.Investigate how often looped securing systems are used in our department and promote awareness amongst nursing colleagues of the types of patients that may benefit from these devices.
3.Examine the effect of promoting looped-securing systems on the incidence of UND.
4.Evaluate the efficiency of the Trust’s electronic incident reporting system at capturing UND events compared to our manual data collection method.
•Data collection was undertaken over a 15 week period by a rotating team of student doctors attached to NUHCC.
•Patients on Adult Intensive Care (AICU) and Surgical High Dependency (SHDU) were reviewed at multiple time points (typically 3 times per week) and the following recorded: presence or absence of a NGT; method for securing NGT; incidence of UND during preceding 48 hours; nasal pressure damage; completion of NGT care plan.
•For 6 weeks of the study, at the same time as data collection, nursing staff were questioned about the types of patients that may benefit from a looped-securing system.
•The number of UND events and nasal pressure damage captured by our study was compared with the Trust’s electronic incident reporting system.
31 (15%) of patients suffered at least one episode of UND. 12 of these patients (38%) suffered more than one episode of UND.
36 patients (17%) had a looped securing system in situ for at least part of their critical care admission and 3 of these patients (8%) suffered UND whilst the loop was in-situ. In a further 3 cases it was unclear from the records if a looped system had been in place at the time of the UND or not.
The number of NGT care plans completed in full varied throughout the data collection period (mean 73%, range 17-100%). The adult intensive care unit tended to perform better than its high dependency counter part. On only 6 occasions on each unit was the local target of 90% achieved. E-mails to remind staff to complete the plans appeared to have little effect.
Knowledge amongst nursing colleagues improved over a two month period. Interventions included regular e-mail reminders and reinforcement at the time of questioning. However, despite this the use of looped-systems did not increase over the study period nor did the rate of UND decline.
Across all months bar January , manual data collection captured more UND events than the electronic reporting system making manual collection the more reliable of the two methods. In contrast the electronic system captured more episodes of NGT related pressured damage.
•NGTs are commonly used in our critical care areas. On average, at any one time point, two thirds of our patients will have an NGT in-situ.
•At least 15% of patients with NGTs suffer one or more UNDs whilst in a critical care area.
•38% of patients suffering one UND went onto suffer a further episode, demonstrating that one episode of UND is a risk factor for a further event.
•Looped-securing systems were used in 17% of patients. The incidence of UND in this group appears lower but the numbers are small.
•Knowledge amongst nursing colleagues of “at risk” patients improved during the study period with only bedside and e-mail reminders as education tools.
•The use of looped-systems did not increase over the study period despite interventions promoting their use.
•There is scope to improve NGT governance. Currently, just 73% of NGT care plans are routinely completed and not all UND events are being logged on the Trust’s electronic incident reporting system.
•Disseminate these results within the department to raise awareness of UND and promote discussion about ways to reduce the incidence of UND within critical care areas.
•Implement interventions to encourage staff to record UND events on the electronic reporting system. If used reliably the electronic system could be a valuable audit tool.
•Specifically investigate the use of looped NGT securing systems within NUHCC to determine if there is a difference in adverse NGT events when using these systems (e.g. sling and bridle).
1.NUHCC Collaboration including: Hayley Prior; Alexander Sykes; Eloise Shaw; Tom Beadman; Cara Valente; Gareth Gibbon
2.Morton B et al. Nasogastric tube dislodgement: A problem on our ICU. Critical Care. Conference: 33rd International Symposium on Intensive Care and Emergency Medicine Brussels Belgium. 2013. Conference Publication: (var.pagings). 17 (pp S90).
3.Leong SC, Mahanata V. Securing the nasogastric tube in head and neck cancer patients. Laryngoscope. 2006;116(11):2089-2091.
4.Beavan J et al. Does looped nasogastric tube feeding improve nutritional delivery for patients with dysphagia after acute stroke? A randomised controlled trial. Age and Aging. 2010;39(5):624-630.