Download Management of gastric and jejunal feeding tubes policy

Management of Feeding Tubes Policy
Developed in response to NPSA Patient Safety Alert on Reducing the Harm of misplaced nasogastric
feeding tubes in adults, children and infants (2011),
Supporting the NPSA Patient Safety Alert on ‘ ‘Reducing the Harm caused by misplaced nasogastric
feeding tubes’ (2011) and Rapid Response Report :Harm from flushing of nasogastric tubes before
confirmation of placement’ (2012),
LEAD EXECUTIVE DIRECTOR: Liz Morgan, Chief Nurse
POLICY APPROVED BY: Quality and safety Committee
DATE POLICY APPROVED: July 2012
IMPLEMENTATION DATE: March 2013
REVIEW DATE: March 2015
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Document Control Sheet
Policy Title
Management of Feeding Tubes Policy
Purpose of Policy/
Assurance Statement
The policy sets out the safe practice that must
be followed in regard to feeding tube
management at GOSH, including assessment,
insertion and management.
Target Audience
(Policy relevant to)
All clinical staff involved in the insertion,
assessment and management of feeding tubes
Lead Executive Director
Liz Morgan, Chief Nurse
Name of Originator/ author
and job title
Version (state if final or
draft)
Date reviewed
(Previous review dates)
Sue Chapman, Nurse Consultant
1.1
July 2012
July 2011
Circulated for Consultation Quality and Safety Committee; Clinical Unit Leads, Heads of
to
Nursing, Ward Sisters/Charge Nurses, Practice Educators,
Head of Dietetics, Head of Radiology, Deputy Head of QST,
Assistant Chief Nurses
Amendments:
Recognition of jejunal tube management within this policy.
Additional guidance as directed by NPSA alert
Links to other policies or
relevant documentation
CPC guidelines on nasogastric and nasojejunal feeding
Medications policy
If draft
[only complete remaining boxes]
Draft Number
Comments to
By
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Table of contents
1.Introduction .......... ............... ............... ...................................................................... .......................................
2.Aims and objectives ............. ............... ...................................................................... .......................................
3.Definitions ............ ............... ............... ...................................................................... .......................................
4.Duties and responsibilities.... ............... ...................................................................... .......................................
5.Assessment of the need for a feeding tube ................................................................. .......................................
6.Insertion of feeding tubes ..... ............... ...................................................................... .......................................
7.Confirming feeding tube position: Principles ................................................................ .......................................
8.Confirming feeding tube position by pH testing ........................................................... .......................................
9.Confirming feeding tube position by x-ray ................................................................... .......................................
11.Feeding tube placement – techniques that must NEVER be used ............................. .......................................
12.Managing blocked feeding tubes ........ ...................................................................... .......................................
13.Administering feeds/fluid via a feeding tube .............................................................. .......................................
14.Administering medications via a feeding tube............................................................ .......................................
15.Documentation of feeding tube care ... ...................................................................... .......................................
16.Discharging a patient with a feeding tube .................................................................. .......................................
17.Process for implementation ............... ...................................................................... .......................................
18.Monitoring arrangements ... ............... ...................................................................... .......................................
19.Equality impact statement .. ............... ...................................................................... .......................................
20.Training and Competence .. ............... ...................................................................... .......................................
21.Other policies of relevance . ............... ...................................................................... .......................................
22.References......... ............... ............... ...................................................................... .......................................
23.Appendices ........ ............... ............... ...................................................................... .......................................
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1. Introduction
The placement of enteral feeding tubes is a common procedure in hospitalised children, however they
carry risks which can lead to significant patient harm and even death if principles of good, safe
practice are not followed. This policy sets out safe practice that must be followed in regard to feeding
tube management at GOSH. In this policy, feeding tubes are considered as nasal or oral tubes
passed into the gastro-intestinal tract to facilitate feeding, administration of medicines and/or other
liquids. It does not apply to tubes which are passed for other purposes such as decompressing the
stomach during anaesthesia.
The UK National Reporting and Learning System (NRLS) has previously identified a significant
number of deaths and harm events associated with nasogastric tubes (NGT) and issued an alert in
2005 (National Patient Safety Agency (NPSA) 2005). This highlighted safe practice with regards to
testing and confirming the position of NGT’s by pH testing and x-ray.
Despite this alert, there have since been a further 21 deaths and 79 cases of harm nationally due to
feeding into the lungs through misplaced NGT’s. The main contributing factor was misinterpretation of
x-rays (12 deaths, 45 incidents of patient harm). This prompted a further updated alert (NPSA 2011)
was which highlights safe practice, particularly around x-ray interpretation. Other causes of harm
relate to the failure of professionals to follow the NPSA 2005 guidance and include feeding despite
obtaining aspirate with a pH of 6-8 (7 incidents including 2 deaths), instilling water down the tube
before obtaining aspirate (2 incidents), no checking of tube placement by any method (9 incidents
including 1 death). A repeated finding in local investigations was that no written record was made of
pH obtained or of x-ray interpretation before feeding commenced. Despite all this work, there has
been 2 further deaths reported since march 2011 related to flushing feeding tubes prompting a further
NPSA Rapid Response Report in 2012.
Although Great Ormond Street Hospital (GOSH) has previous highlighted NGT management as a
Clinical Practice Guideline (CPC), the testing and confirmation of NGT’s is now being issued as a
policy, as the risks to patients are significant if staff do not comply fully with the national guidance.
Guidelines on naso- and oro-gastric and naso-and oro-jejunal tube insertion will remain as a CPC.
Similar risks exist for naso-jejunal tubes (NJT) and although no specific guidance has been issued by
the NPSA, GOSH has decided to include guidance on jejunal tube management within this policy in
response to a never event experience at GOSH in 2012 which involved a patient with both a NGT and
NJT.
The principles outlined below are based on the NPSA alerts of 2005 and 2011 and the Rapid
Response Report in 2012. The 2011 alert is attached as Appendix A.
2. Aims and objectives
The policy sets out the safe practice that must be followed in regard to feeding tube management at
GOSH, including the assessment, insertion and management of nasogastric, orogastric, naso-jejunal
and oro-jejunal tubes.
3. Definitions
3.1. Glossary of Terms
 Feeding tubes –
3.2. For the purposes of this policy nasogastric, orogastric, nasojejunal and orojejunal tubes
inserted to facilitate feeding, administration of medicines and/or other liquids will be
collectively referred to as feeding tubes
3.3.
Abbreviations
 NPSA – national patient safety agency

HCP – Health Care Professional

CSP – Clinical Site Practitioners. The senior nursing team available to support
clinical staff with any aspects of this policy. Available 24 hours/day on bleep 0313.
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
NGT - Nasogastric tube

OGT – Orogastric tube

NJT – Naso jejunal tube

OJT– Oro-jejunal tube
4. Duties and responsibilities
4.1. Ward Sisters: are responsible for ensuring that all nursing staff (including non-registered
staff) are aware of this policy and follow the safe practice within it.
4.2. Consultant staff: are responsible for ensuring that medical staff are aware of this policy
and follow the safe practice within it, particularly around ordering and interpreting x-rays.
4.3. Radiographers are responsible for ensuring that the feeding tube can be clearly seen on
this x-ray if a check for feeding tube position check is requested.
4.4. All clinical staff: are responsible for following this policy and reporting any adverse events
via Datix. Staff who assess the position of feeding tubes radiologically must undertake the
mandatory training outlined in section 9
4.5. The Compliance and Governance Manager: Is responsible for uploading all policies and
strategies approved by the Policy Approval Group.
5. Assessment of the need for a feeding tube
Before a decision is made to insert a feeding tube, an assessment must be made to identify if gastric
or jejunal feeding is appropriate for this individual patient.
The assessment must also include whether sufficiently experienced staff are available to undertake
the procedure and to then assess the correct placement of the tube. The procedure must be delayed
if sufficiently experienced staff are not available. The CSP team can advise and support any clinical
staff with these decisions out of hours.
The rationale for all these decisions must be recorded in the patients’ healthcare records.
6. Insertion of feeding tubes
All feeding tubes must be radio-opaque throughout their length and have externally visible markings.
Tubes obtained through GOSH supplies will conform to these standards, but those which are in-situ
before a child is transferred may not. If in doubt, remove the tube and re-insert with a new tube
obtained through GOSH.
Feeding tubes may be inserted by
 a HCP who has undergone appropriate training and is deemed competent in the skill

HCP in training who is fully supervised by a competent professional

A parent/carer who has been trained in the skill and deemed competent
If both a gastric and a jejunal tube are inserted each tube must be clearly identified and documented
to prevent inadvertent management (i.e. mixing up the jejunal with the gastric tube). The length of
each tube should be clearly documented, including the landmark which this is assessed against (e.g.
15cms to the right nostril). Testing of each tube should be documented on the appropriate testing
charts (gastric or jejunal).
A nasal feeding tube (NGT, NJT) rather than an oral feeding tube (OGT, OJT) should always be
inserted unless there is a documented contraindication to this procedure, as the risks of the tube
migrating are reduced. The clinical practice guideline on gastric tube insertion or jejunal tube insertion
should be followed.
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7. Confirming feeding tube position: Principles
The NPSA decision tree for NGT placement checks must be followed (Appendix B). Although these
principles relate to gastric tube naso-gastric tube feeding, most aspects are relevant to jejunal tube
placement EXCEPT for the ‘safe’ pH range which should be 6-8 for jejunal tubes.
The position of all feeding tubes must be checked:
 After insertion

Before any liquid, feed or medications is introduced via the tube

At the change of feed if the child is receiving continuous tube feeding (this will be 4 hourly for
EBM and 6 hourly for all other feeds )
8. Confirming feeding tube position by pH testing
pH testing using pH indicator paper must be the first line method of checking the tube position:
 Aspirate a small amount of stomach/jejunal contents using a 20ml or 50ml syringe (except
neonates)

Test the aspirate on CE marked pH indicator paper intended by the manufacturer to test
human gastric aspirates

For gastric tubes (NGT/OGT) the safe pH range is between 1 and 5.5

For jejunal tubes (NJT/OJT) the safe pH range is between 6 and 8

Each test and test results must be documented on the NGT or NJT testing chart as
appropriate (Appendix C) and must be kept at the child’s bedside
If no aspirate can be obtained OR if the aspirate is NOT between 1-5.5 for gastric tubes or 6-8 for
jejunal tubes:
 Change the child’s position and try to aspirate again

Inject 1-5ml air into the tube

Wait for 15-30 minutes and aspirate again

Advance or withdraw the tube by 1-2cm

Give mouthcare to patients who are nil by mouth (this stimulates gastric secretions of acid)

NEVER use water to flush the tube before confirming the position
If no aspirate is then obtained or the aspirate is still outside of the safe range (gastric tubes 1 - 5.5,
jejunal tubes 6-8), the tube position must be checked by x-ray (second line testing)
Further guidance on gastric or jejunal tube insertion can be found in the relevant CPC.
9. Confirming feeding tube position by x-ray
The confirmation of feeding tube position by x-ray is a second-line intervention and should only be
used when pH testing of feeding aspirates has failed.
The x-ray request form must clearly state that the purpose of the x-ray is to establish the position of a
gastric or jejunal tube for the purposes of feeding or medication administration. The radiographer
must take responsibility for ensuring that the feeding tube can be clearly seen on this x-ray.
The x-ray must be interpreted by clinicians who have been deemed competent in assessing the
position of feeding tubes by x-ray. This includes:
 All radiologist, as this is a core part of their training and role
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
Medical staff who have been assessed as competent by completing the trust e-learning
module or, if this is not possible, by a consultant radiologist

Nurses and Allied Health Care Professionals who have undertaken an advanced practice
programme at masters level AND have completed the trust e-learning module
The assessment of feeding tube placement must be documented in the patients’ healthcare record.
Documentation must include:
 Confirmation that the x-ray viewed was the most recent for that patient

How the placement was interpreted

Clear instructions as to any required actions

The length of the feeding tube at the nostrils or mouth at the time of x-ray

If the x-ray been formally reported upon, a clinician must write in the healthcare record that
they have viewed the radiologists report and that the feeding tube position is confirmed as
satisfactory.
HCP who rely on x-ray confirmation of the feeding tube’s position should confirm before feeding:
 that the entry in the patients’ healthcare record is the most recent one

that the tube has not become significantly dislodged by cross-checking the length of the tube
at the nostril or mouth with the entry confirming correct tube placement
Any tubes identified to be in the lung are to be removed immediately, whether in the x-ray department
or the clinical area.
10. Specific Guidance for neonates:
Neonates differ physiologically to children and the NPSA (2005) has recommended the following:
 None of the existing methods for checking feeding tube position is totally reliable Their advice
is based on the premise that it is better to base clinical decisions on one reliable test (pH
indicator paper or radiography) than a combination of tests with varying reliability.
 Small bore feeding tubes are particularly difficult to gain aspirate from
 Tube markings should be used for all babies to enable accurate measurement of depth and
length and the position of the tube documented.
 Although radiography is the most reliable indicator of feeding tube position, x-rays should not
be ‘routinely’ used. However if the baby is going to have an x-ray as part of their clinical care,
the feeding tube should be placed beforehand and checked for positioning.
 The NPSA flowsheet should be used to guide practitioners (Appendix D)
If the pH is outside the safe range AND a x-ray is not planned as part of routine care, a risk
assessment should be performed and the following factors which may contribute to high pH
considered:
 the presence of amniotic fluid in a baby under 48 hours old
 milk in the baby’s stomach, particularly if they are on one to two hourly feeds
 use of medication to reduce stomach acid
11. Feeding tube placement – techniques that must NEVER be used
The following are considered by the NPSA to be ‘never events’ and should not be used, no matter
what the circumstances:
 The ‘whoosh test’ – injecting air into the tube and auscultating the stomach

Acid/alkaline tests of gastric aspirates using litmus paper

Interpretation based on the appearance of the aspirates alone

Inject water into a feeding tube to confirm its position

Internal guidewires/stylets should NOT be lubricated before feeding tube position has been
confirmed
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
Confirmation of feeding tube position based on x-ray alone by staff who have not been
deemed competent to perform this assessment by this trust (either by successful completion
of the e-learning or are deemed as competent by a consultant radiologist).
Additional advice for neonates (NPSA 2005):

DO NOT interpret the absence of respiratory distress as an indicator of safe positioning

DO NOT test correct tube positioning by monitoring for bubbling at the end of the tube

Radiography should NOT be used ‘routinely’ but can be used if the baby is being x-rayed
for another reason. Tube markings should be used for all babies to enable accurate
measurement of depth and length and the position of the tube documented
12. Managing blocked feeding tubes
The same safety principles apply to managing blocked tubes:

If aspirate cannot be obtained because the tube is blocked, fluid SHOULD NEVER be
injected into the tube to unblock it

If a tube is blocked, remove it immediately and re-insert a new tube.
Follow the principle of confirming tube placement outlined above
13. Administering feeds/fluid via a feeding tube
Key principles:
 This is a clean procedure, requiring a hygienic hand-wash, apron and gloves

The position of the feeding tube should be confirmed immediately prior to administering an
enteral feed

Do not heat enteral feeds prior to administration

Wipe the top of the feeding bottle with an alcohol impregnated wipe.

Do not touch the key parts, such as the inner part of the spike set

Flush the feeding tube with 3-5ml water after confirming correct position and following
administration of the feed.

Never top-up enteral feeds into the reservoir of feeding systems

Never decant feeds from bottles into bed sets on the ward
14. Administering medications via a feeding tube
Key principles:
 This is a clean procedure, requiring a hygienic hand-wash, apron and gloves

The position of the feeding tube should be confirmed immediately prior to administering the
medication

Follow the principles outlined in the medications policy

The majority of medicines prescribed enterally can be administered via the gastric or the
jejunal route. The risks and benefits of this should be discussed within the multi-professional
team, but considerations include:

o
Evidence of interference with the drugs efficacy if given via the jejunal route rather than
the gastric route
o
Risk of aspiration if drugs are given via the gastric rather than jejunal route
Use syringes designed for administering medications via an feeding tube, never use
intravenous syringes
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
Use liquid preparations where possible. If the preparation is very thick and may block the tube,
consult the pharmacist for advice.

Soluble, dispersible and crushed tablets may need to be administered, but ensure that the
pharmacist is aware that administration is via a feeding tube. Certain preparations (e.g. enteric
coated medications) are not suitable for crushing.

Flush the feeding tube with 3-5ml water after confirming correct position and after
administering the drug. If more than one drug is being administered, the tube should be
flushed between each drug. Document the amount of fluid on the fluid chart.
15. Documentation of feeding tube care
Documentation must happen at key points in the patient’s care. This includes:

The decision-making and rationale behind the initial assessment that placement of a feeding
tube is required for feeding or medications

Insertion of feeding tube – date, time, type and size of tube inserted, length of tube at nostrils
or mouth, method of confirming tube position, whether the tube is gastric or jejunal

Each pH test and the result on the NGT testing chart, even if the pH is outside the safe level.

Each attempt to confirm tube position which has failed because no aspirate was obtained

Any interventions performed to gain aspirate as outlined on the decision tree for children
(Appendix B) or neonates (Appendix D)

Confirmation of feeding tube position using x-ray as outline above

Whether parents and/or patients are involved in the insertion and/or checking of feeding tube
position and administration of feeds and medications.
Date and time of feeding tube removal and the reason why this was undertaken

16. Discharging a patient with a feeding tube
A full multiprofessional supported risk assessment must be made before a child with a feeding tube is
discharged into the community. The child’s community team must be consulted/informed about the
decision before the child is discharged.
This must be fully documented in the patient’s healthcare record.
17. Process for implementation
17.1. This policy has been implemented in response to the NPSA rapid alert. Key factors to note are
 All doctors are required to complete the e-learning training and assessment as part of their
induction
 Senior Nurses in advanced practice roles are required to complete the e-learning as part of
their development programme
 Nurses who insert and manage feeding tubes are trained in the procedure pre-registration and
are assessed and updated through the preceptorship programme.
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18. Monitoring arrangements
18.1. Summary of Monitoring
Element to
be monitored
Lead
Tool
Frequency
Reporting arrangements
Acting on
recommendations
and Lead(s)
Change in practice and
lessons to be shared
Compliance
with elearning on
radiological
assessment
of feeding
tubes
Head of PGME
and Medical
Education Lead
Assessment of elearning
6 monthly, coinciding with
change of junior medical
staff
Results will be reported to
the Quality and Safety
Committee
Head of PGME and
Medical Education
Lead
Disseminated via Quality
and Safety Committee
Audit of
compliance
with feeding
tube testing
Deputy Chief
Nurse
Compliance with
feeding tube
testing audit
Yearly audit of all wards
(5 wards per quarter)
Results will be reported to
the Quality and Safety
Committee
Deputy Chief
Nurse
Disseminated via Quality
and Safety Committee
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19. Equality impact statement
This policy has been assessed for its impact on equality and will not have an impact on the protected groups
below:









Age
Disability (including learning disability)
Gender reassignment
Marriage or Civil partnership
Pregnancy and maternity
Race
Religion or belief
Sex
Sexual orientation
All patients will be assessed on the basis of clinical need. The safe practice outlined in this policy is
applicable to all children and young people.
20. Training and Competence

All staff who insert, maintain or use feeding tube’s should be assessed as competent through
theoretical and practical training. For nurses this is generally achieved through pre-registration
training, and confirmed during the preceptorship period. For medical staff, this is achieved through
pre-registration training and post-registration experience.

It is the responsibility of the individual clinician to identify to their manager if they are not competent in
the insertion, maintenance (including confirming safe feeding tube position) and use of feeding tubes
AND this skills is required within their role.

Parents should undergo training and assessment of competence before they are allowed to insert or
administer feeds or medications via a feeding tube. The same principles apply to patients who selfinsert feeding tubes. If training and assessment has been undertaken on a previous occasion, this
should be confirmed when the child is readmitted. This must be documented in the child’s medical
record

All clinical staff who assess the position of a feeding tube by x-ray are required to undergo specific
training and assessment of their competence. This applies even if individuals have previously
undertaken this role here or in another trust. The only exceptions are radiologists, as this is a core
part of their role. Assessment is via e-learning on Gold.
Education and training will maintain a list of individuals who have achieved the necessary competence to
assess the position of a feeding tube by x-ray.
21. Other policies of relevance
21.1. Clinical Practice Guidelines on gastric and jejunal feeding
21.2. Medications Policy
22. References
NPSA (2012) Rapid Response report: Harm from flushing of nasogastric tubes before confirmation of
placement. National Patient Safety Agency, London
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NPSA (2005) Patient safety Alert NPSA/2011/PSA002 Reducing the harm caused by misplaced
nasogastric feeding tubes in adults, children and infants. National Patient Safety Agency, London
NPSA (2005) Patient safety Alert 09: Reducing the harm caused by misplaced naso and orogastric
feeding tubes in babies under the care of neonatal units. National Patient Safety Agency, London
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23. Appendices
23.1. Appendix A- NPSA Guidance 2011
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23.2.
Appendix B-NGT decision tree (NPSA 2011)
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23.3.
Appendix C-NGT and NJT Testing chart
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Page 16 of 20
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Appendix D
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Appendix D continued:
Page 19 of 20
Appendix E- Equality Analysis Form
TITLE OF DOCUMENT
Management of nasogastric, orogastric and jejunal feeding tubes
COMPLETED BY
Sue Chapman]
DATE COMPLETED
27th June 2012
SUMMARY OF STAKEHOLDER FEEDBACK
Nil
POTENTIAL EQUALITY IMPACTS AND ISSUES IDENTIFIED
Protected
group
Potential issues
identified
Actions to mitigate/Opportunities to
promote
Age
Nil
Nil
Disability
(including
learning
disability)
Nil
Nil
Gender reassignment
Nil
Nil
Marriage or
civil
partnership
Nil
Nil
Pregnancy
and maternity
Nil
Nil
Race
Nil
Nil
Religion or
belief
Nil
Nil
Sex
Nil
Nil
Sexual
orientation
Nil
Nil
ASSESSMENT OF EQUALITY IMPACT
All patients will be assessed on the basis of clinical need. The safe practice outlined in this policy is
applicable to all children and young people.
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