January 2013 Volume 2, Issue 1
UMMC Nursing Newsletter New Enteral Feeding Policy Enhances Patient Safety Over the past year, multiple incidents have occurred where the placement of blindly inserted NG tubes has caused patient harm. At Clinical Practice Council (CPC) meetings, the subject of malpositioned feeding tubes has been discussed several times. AACN Guidelines recommend that feeding tubes have placement confirmed by xray. Data was collected on all tubes placed over a 2 week period. (See Table). This data revealed that 53% of the NG tubes placed for feeding had been x-rayed. Of that 53%, 11% were found to be in a less than optimal position. ENTERAL FEEDING TUBE PLACEMENT DATA Data collected by Clinical Nutrition Staff: n = 95 total feeding tubes placed Corflo = post-pyloric tubes
Gastric = nasogastric tubes
59/95 tubes placed were post-pyloric
36/95 tubes were blindly placed gastric tubes
(58/59) 98% of Corflos were xrayed
(19/36) only 53% of gastric tubes
(50/58) 86% were in good position
(17/19) 89.5% were in good position
1 Corflo tube was not xrayed
17/36 47% of gastric tubes were not xrayed
The data also showed that:
ο 48/54 or 89% of Corflo tubes placed in ICUs were in good position ο 3/5 or 60% of Corflo tubes placed on the floor (outside of an ICU) were in good position ο 15/22 Corflo tubes required repositioning due to improper placement Feeding tube placement is a commonly performed and necessary procedure to promote optimal nutrition and healing in our patients. The standard of auscultation for placement verification, as many of us were taught, is now thought to be ineffective. Evidence shows that radiologic confirmation of feeding tubes is the most effective method to determine safe placement prior to the initiation of feeding or delivery of medications. Numerous challenges were identified with radiologic confirmation standards for gastric tube insertion at the organizational level and how this standard would impact patient care and providers including: ο Requirement for providers to order and document placement of tube tip ο Increased workload for radiology staff due to increased volumes of films and readings ο Nursing impact of additional time to verify orders and awaiting verification ο The potential patient impact of additional exposure to x-rays required, and potential delays in feeding and medication administration while awaiting tube confirmation ο The potential system impact of additional charges for radiology films ο IT implications for changing order sets for new standard ο Pharmacy review of medication administration components, and recommendations regarding the use of methylene blue. The group worked through these challenges to create a new standard. The enteral tube management policy is expected to be finalized in the next few weeks. We expect that our new standard will include x ray confirmation of tube placement to protect our patients from unintentional harm. 1