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Nasogastric Feeding Tube Insertion and Management in Adults Type: Clinical Guideline Register No: 05102 Status: Public Developed in response to: Best practice NPSA guidance 4 and 5 Contributes to CQC Outcome: Consulted With Dr A Lwin Pauline Bird Andrea Francis Sarah Ridgwell Angela Wade Professionally Approved By Dr R. Fenton, Post/Committee/Group Consultant, ITU Nutrition Steering Group Nutrition & Dietetic Service Manager Clinical Lead Radiology Advanced Practitioner Radiographer Practice Development Nurse Medical Director Version Number Issuing Directorate Ratified by: Ratified on: Trust Executive Sign Off Date Implementation Date Next Review Date Author/Contact for Information Policy to be followed by (target staff) Distribution Method Related Trust Policies (to be read in conjunction with) Date October 2014 October 2012 October 2014 October 2014 October 2014 November 2014 3.1 Medicine DRAG Chairmans Action 14th November 2014 December 2014 20th November 2014 November 2017 Dr L Westcott, S. Maponga (Nutrition CNS) All clinical staff Intranet, Website Incident Policy Consent Policy Mental Capacity Act Policy Infection and Prevention Policies Guideline for Passing a Naso/orogastric tube and intermittent tube feeding for Children(10days-16yrs) Document Review History Version No 1.1 2. 3. 3.1 Reviewed by Angela Wade, Rachael Frost, Cathy Powis Dr L Westcott, Dr R Dobson Sibo Maponga (Nutrition CNS) Sibo Maponga (Nutrition CNS) Active Date 26 September 2005 28th April 2011 November 2014 15 April 2015 1 Index 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0 15.0 16.0 17.0 18.0 19.0 20.0 21.0 22.0 23.0 24.0 Purpose Scope Risks of NG Tubes Advantages and Disadvantages of NG Tubes Definitions Roles and Responsibilities Decision making Consent Equipment Insertion Procedure Ventilated Patients Checking tube position First Line Test Method: pH Testing Second Line Test Method: Radiography Methods that must not be used On-going management of Nasogastric tubes in situ Feeding Transfer into the community setting Education and Training Breaches of Policy Audit and Monitoring Communication and Implementation Review References Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5a Appendix 5b Decision tree for NG tube placement checks in adults (NPSA) Recommended Procedure for checking the position of NG feeding tubes (NPSA) Additional Guidelines for Nasogastric Tube Placement Nurse Competency Form NG Tube Insertion & Management form NG Tube Position Check Record 2 1.0 Purpose 1.1 To promote a clear, consistent and evidenced based approach to the insertion, care and management of NGs (nasogastric tubes). 1.2 To promote the safety and well-being of all patients who require an NG. 1.3 To provide guidance regarding scope of professional practice, level of competence and accountability in nasogastric tube insertion, care and management. 1.4 To provide a framework for roles and responsibilities in nasogastric tube insertion and care thereafter. 1.5 This policy reflects all the NPSA Alerts and Recommendations. 2.0 Scope 2.1 This guideline applies to the insertion and management of NG feeding tubes in adult patients. 2.2 All clinical staff involved in the placement and ongoing management of NG feeding tubes must adhere to the principles described in this guideline. 2.3 Indications for Use See Appendix 1 for Flow chart to guide decision making for tube feeding route Nasogastric feeding is the most common method of providing short-term artificial nutritional support in the acute setting. Decision to feed with a nasogastric tube should be a multidisciplinary approach. NG tube feeding should be considered for patients who: Are malnourished. Have a functioning gastrointestinal (GI) tract. Require short-term tube feeding (up to 4-6 weeks). Require long-term tube feeding (if an alternative route is inappropriate or not possible i.e. Percutaneous Endoscopic Gastrostomy (PEG) Radiologically Inserted Gastrostomy (RIG) or Parenteral Nutrition (PN) Are unable to fulfil their nutritional requirements with normal /modified diet nutritional supplements. Are not predicted to fulfil their nutritional requirements with normal / modified diet nutritional supplements. Have increased nutritional requirements e.g. sepsis, trauma, post-op stress & burns. • • • • • • • 2.4 Contraindications 2.4.1 Absolute Contraindications are: • • • Non-functioning GI tract e.g. ileus. Obstructive pathology in oropharynx or oesophagus preventing passage of the tube e.g. stricture, tumour, pharyngeal pouch. Large gastric aspirate and/or high risk of aspiration. 3 • • Intractable vomiting not resolved by anti-emetics Basal skull fracture, as the tube may enter the brain if incorrectly positioned (orogastric positioning may be appropriate). 2.4.2 Relative Contraindications: NG Tube placement is not an absolute “no” for these patients but it will be dependent on how each patient with these symptoms presents and the medical team will make the final decision on whether NG tube placement is possible. • • • • • Oesophageal varices Mucositis Vomiting responding to anti-emetics Recent radiotherapy to head and neck Advanced neurological impairment 3.0 Risks with NG Tubes 3.1 Feeding through a tube misplaced into the lungs instead of the stomach can be fatal. This guideline has been developed to support clinical staff in the correct insertion of both wide and fine bore nasogastric (NG) feeding tubes and in the confirmation of tube placement to reduce risk to patients in line with current best practice and Clinical Governance. 3.2 Nasogastric feeding can be vital to the survival and recovery of patients who are unable to eat normally. An estimated 271,000 nasogastric (NG) tubes are supplied to the NHS annually (NHS Supply Chain 2008). However, nasogastric feeding, as with any clinical treatment, carries risks. 3.3 In February 2005, the National Patient Safety Agency (NPSA) issued a Patient Safety Alert, Reducing the harm caused by misplaced NG feeding tubes. This alert provides guidance on checking and confirming that an NG Tube has been inserted into the right place. This alert followed reports to the NPSA’s National Reporting and Learning System (NRLS) of patient deaths as a result of feeding into the lungs through misplaced nasogastric tubes. This Alert provides guidance on checking and confirming that a nasogastric tube has been inserted into the right place, i.e. the stomach. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59794 3.4 Since the 2005 Alert’s completion date (1 September 2005), the NRLS received reports of a further 21 deaths and 79 cases of harm due to feeding into the lungs through misplaced nasogastric tubes. The main cause was misinterpretation of xrays, found in 45 incidents, 12 of which resulted in patient death. Guidance was reviewed and updated and in March 2011 a new Patient Safety Alert was issued: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. The focus of this Alert supports safe x-ray interpretation. • pH checking should be used as the First line test method • X-ray should only be used as the Second line test when no aspirate could be obtained or pH indicator paper has failed to confirm the position of the nasogastric tube. http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=129640 4 3.5 In 2009 feeding into the lungs from a misplaced nasogastric tube became a Never Event: a serious, largely preventable patient safety incident that should not occur if the available preventable measures have been implemented. http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf. Never Event #19 3.6 2 further deaths due to NG Tubes flushed with water prior initial placement were reported and in March 2012 a Rapid Response Report was issued -: Harm from flushing of nasogastric tubes before confirmation of placement. The focus of this Alert was to remind all staff responsible for checking initial placement of nasogastric tubes that Nothing should be introduced down the tube before gastric placement has been confirmed; that the tube should not be flushed before gastric placement has been confirmed and that Internal guidewires/stylets should NOT be lubricated before gastric placement has been confirmed. http://www.nrls.npsa.nhs.uk/resources/?EntryId45=133441 4.0 Advantages and Disadvantages of NG Tubes Advantages • • • • • Disadvantages Readily available Easily inserted Easily reversed Rapid start of enteral feeds Few contraindications to placement 5.0 Definitions 5.1 Nasogastric (NG) tube • • • Easily dislodged Uncomfortable Aesthetically displeasing Common complications • • • • Pulmonary intubation Pulmonary aspiration Reflux Nasal and mucosal ulceration Rarer complications • • • • Epistaxis Gastrointestinal bleeding Oesophageal gastric and duodenal perforation Pneumothorax 5.1.1 A Nasogastric (NG) tube is a flexible tube that can be inserted Trans nasally into the stomach. It is commonly used for delivery of feed, fluids, medication, or drainage of gastric contents. 5.1.2 NG Tubes are usually made of polyurethane; should be radio-opaque throughout their length; should have external visible length markings and will often have a guidewire throughout their length to aid insertion. These should be the tubes of choice particularly if feeding is likely to be for longer than 14 days. These tubes should be changed in line with the manufacturer’s guidelines (usually every 30-90 days). 5.2 Wide Bore tubes or Gastric Drainage tubes (Ryles) Non-feeding nasogastric tubes (e.g. Ryles tubes), usually made of PVC and used for a maximum of 7-10 days (as per manufacturers’ instructions), are not recommended for feeding as they are not NPSA compliant. This is due to the link between the leaching of plasticisers from PVC tubes when in contact with fats in 5 nutrition formulas (MHRA 2007). However, they may be used for administration of essential drugs and initial feeding in the critical care setting. If a PVC/Ryles tube is used for feeding it must be NPSA compliant and it must be replaced with a finebore NG Tube as soon as it is not required for drainage. 5.3 CE Marked pH paper pH indicator paper is CE marked and intended by the manufacturer to test gastric aspirate. pH paper is more sensitive than litmus paper and must be used for confirming the position of the NG tube (NPSA 2005). 5.4 Blue Litmus paper – do not use for checking gastric aspirate Litmus paper is paper which has been treated with a natural dye which can be used as a pH indicator. Blue litmus paper turns red under acidic conditions (pH below 4.5). However it is not sensitive enough to reliably distinguish between gastric acid (pH 3-5) and bronchial secretions (pH >6) (NPSA 2005, MHRA 2004, Rollins 1997). Litmus paper must therefore not be used in checking NG tube position. 6.0 Roles and Responsibilities 6.1 Chief Executive The Chief Executive is responsible for ensuring that systems are in place to ensure the safe and effective placement and management of NG tubes. This responsibility is delegated to the Medical Director. 6.2 Medical Director The Medical Director is responsible for ensuring compliance with systems in place to ensure the safe and effective placement and management of NG tubes. 6.3 Clinical / Educational Supervisors Clinical and or Educational Supervisors should ensure that Foundation doctors have completed the NHS e-Learning training module “Reducing the Risk of Feeding through Misplaced NG Tube” and they should also complete a Direct Observation of Procedural Skills (DOPS) form to assess competency in NG feeding tube insertion and placement checks. 6.4 Nutrition Nurse • To provide training for all staff involved in the placement and management of enteral feed tubes/equipment. • Where trained medical or nursing staff are unavailable to site enteral feeding tubes, or tube placement is complex, the Nutrition Nurses will place the tube if appropriate. • Ensure that all policies and procedures for the placement and management of enteral feed equipment are up to date and evidence based. 6 6.5 Dietitians All NG tube fed patients should be referred to the Dietitians immediately. The dietitians have the responsibility of: 6.6 • Ensuring that each patient receives adequate and appropriate nutritional support. • Drawing up the feeding regime for the patient according to each patient’s need. • Ensuring that the NG tube guidelines are up to date and adhered to in accordance with national guidelines to ensure best practice. Registered Nurses (And other Healthcare Professionals, as appropriate) • To complete the clinical skills training for Passing a Fine Bore Feeding Tube for Enteral Feeding and be assessed as competent. • All healthcare professionals must adhere to the principles described in this policy. • A decision to insert a Nasogastric tube for the purpose of feeding must be made and documented by a senior member of the medical team responsible for the patient’s care. This decision should only be made following careful assessment of the risks and benefits. • Only staff with the relevant skills and expertise should insert and confirm the placement of NG tubes. • Only staff with the relevant skills and expertise should undertake placement checks prior to commencing feeding or administration of medication. • When there are continuous difficulties obtaining an aspirate with a pH less than 5.5 seek advice from senior medical staff. • Assess patient comfort and safety through regular observation. An incident report must be completed where an incident related to the placement of NG tube occurs 6.7 Lead Nurse/Ward Sister • Identify which members of staff are required to undertake various aspects of feeding and management of nasogastric feeding tubes. • Ensure training and assessment of competence is undertaken and documented. • Monitor standards of practice in their environment in relation to feeding and management of nasogastric feeding tubes. 6.8 Radiographer • It is the radiographer’s responsibility to provide an image to clearly demonstrate the presence and position of the NG tube. 7 • Every effort must be made to ensure that the patient is not rotated. • The cassette/detector should be positioned so as to obtain a 'low chest' i.e. skimming the apices to demonstrate more of the abdomen below the diaphragm. • If there is difficulty in interpreting whether the tube is correctly placed on the subsequent chest x-ray, advice should be sought from the Duty Radiologist in the first instance. If the Duty Radiologist is unavailable, and the x-ray is not technically adequate, a repeat should be considered after discussion with the radiographer. 7.0 Decision Making 7.1 A decision to insert a Nasogastric tube for the purpose of feeding must be made by a senior doctor responsible for the patient’s care. 7.2 This decision should only be made following careful assessment of the risks and benefits. 7.3 This entry in the medical notes must be signed, dated and timed. 7.4 Prior to insertion the rationale for insertion of an NG tube must be considered and responses to the following documented on the NG Tube Insertion & Management form (Appendix 5a): Is Nasogastric tube feeding the right decision for this patient? Is this the right time to place the NG tube and is appropriate equipment available? Is there sufficient expertise available at this time to test for safe placement? • • • 7.6 Nasogastric tubes should only be placed when there is experienced support available for NG Tube insertion and for confirming the NG tube position. If there is no sufficient, experienced support available (for example at night) then, unless clinically urgent, placement should be delayed until that support is available. Rationale for any decisions made should be recorded in the patient’s medical notes. Where longer term enteral feeding is required (> 4 – 6 Weeks) consideration should be given to PEG placement. 7.5 8.0 Consent 8.1 Informed verbal consent must be sought prior to the insertion of the NG tube. A clear explanation of the procedure should be given and verbal consent gained. 8.2 If the patient is unable to respond verbally, other means of communication should be sought. 8.3 If the patient is unable to communicate or lacks mental capacity, staff should refer to the Trust’s Consent Policy and Mental Capacity Act Policy. An MCA2 form should be completed in full and a copy submitted to the adult safeguarding team. 9.0 Equipment • Plastic apron and gloves; • Radio-opaque NG tube with externally visible length markings; 8 • CE marked pH indicator strips/paper with a range of 0 to 6 and 0.5 gradations; • Lubricating jelly; • Freshly drawn water to flush the tube once NG Tube position has been confirmed • Purple Enteral Syringe; • Receiver • Glass of water/coloured fluid and a straw (only if the patient has a safe swallow reflex) • Nasal/cheek dressing to secure tube (included in some packs) • NG Tube Insertion and Management Form 10.0 Insertion Procedure Action Prior to the procedure, check the medical and nursing notes for complications, e.g. anatomical variations due to surgery or cancer. Assess the patient’s requirements. Explain the procedure to the patient (even if the patient appears not to understand). Arrange a signal so that the patient can communicate with the nurse during the procedure e.g. raise a hand. Wash hands and put on non-sterile gloves and an apron. Assist the patient in a semi-upright position. Support the head in a slightly forward position. Rationale These may affect the procedure and result in further complications. Patients with head injury or facial trauma may have the feeding tube passed through the mouth and down into the stomach to bypass nasal damage and cerebral oedema. To ensure the appropriate tube is inserted to meet the patient’s needs and clinical condition and that the tube is acceptable and comfortable. To ensure that the patient understands and is able to give consent and cooperate with the procedure. Helps to alleviate fear as the patient has some control over the procedure. Minimises cross infection Assists swallowing and helps prevent tracheal placement if the swallow is compromised. Helps identify potential obstruction. Check that the nostrils are patent by asking the patient to sniff with one nostril closed. Repeat with the Prevents nasal irritation and potential ulceration. other side. Alternate nostrils if replacing a tube. Action Rational Prevents the tube from coiling back on Unpack the tube, close the end connectors. If the tube has a guide wire, gently push it into the tube until itself during insertion. it is fixed. Check tube’s not kinked. 9 Place the tip of the tube (the distal opening, if the tube is weighted) at the xiphisternum and measure up to the tip of the nose and then to an ear lobe (NEX measurement). Note the measurement on the tube. Lubricate the tube. Use a thin coating of water based jelly. If the tube is hydrophilic e.g. Corpak Corflo, immerse the distal end of the tube in water to activate the lubricant. Insert the tip of the tube into the chosen nostril, advancing it horizontally and gently along the floor of the nostril; parallel to the nasal septum, to the nasopharynx and then oropharynx. The patient may sneeze. Reassure. If resistance is met, withdraw slightly and alter the angle of insertion, otherwise try the other nostril. If the patient is able to swallow small sips should be taken at this stage. An assistant may be required to help give the fluids if the patient is unable to take them themself. If the patient is NBM, sometimes placing a cold spoon on the tongue may initiate a swallowing reflex Advance the tube down the oesophagus with successive swallows until the correct measurement or mark is seen at the nostril. Check the position by testing the aspirate pH (should be between 1 and 5.5). If unable to obtain aspirate or if the pH is more than 5.5, position should be checked via x-ray NB Do not flush the tube before gastric placement has been confirmed. Internal guidewires/stylets should not be lubricated before gastric placement has been confirmed. Fix the tube in position. Ensures that the correct length of tube is placed in the stomach. Facilitates easy passage of the tube. Follow the natural anatomy of the nose. The swallowing action places the epiglottis over the trachea allowing the tube to enter the oesophagus. Also it gives the patient something else to focus on. If the tip of the tube is in the oesophagus there is a high risk of aspiration. If too much tube is inserted it might kink in the stomach, or pass through the pylorus into the duodenum. To verify position in the stomach Water activation of the lubricant may give an inaccurate low pH result. Helps prevent dislodgement. Document in the NG Tube Insertion & Management Form (Appendix 4) • • • Type of tube, size and lot number Name of person inserting the tube, date and time The cm measurement on the tube at the exit point from the nostril. The pH value (if gastric aspirate obtained) • Which nostril • The Doctor reading the X-ray should record the result on the Insertion Form or in the patient’s • • • • • • • Tracking and traceability For audit and training requirements Allows the user to assess whether the tube has changed position. Allows staff to compare with previous readings Prevents trauma caused by using the same nostril being used repeatedly To identify whether the tube is 10 Medical notes. • 11.0 Ease of insertion • safe for use and for tracking and accountability Useful information for other healthcare professionals inserting subsequent tubes. Ventilated Patients Ventilated patients may have the NG tube inserted under direct laryngoscopy. 12.0 Checking Tube Position 12.1 The ideal position for the NG tube is in the stomach below the diaphragm. The position of the NG tube must be checked to confirm it is in the stomach. The procedure is summarised in the flow charts and guidance on pH testing in Appendix 1 and Appendix 2. Further information is available in the NPSA Supporting information document. 12.2 Nasogastric tubes must not be flushed or liquid/feed introduced through the tube following initial placement, until the tube tip is confirmed to be in the stomach by pH testing or x-ray. 13.0 First Line Test Method: ph Testing 13.1 Aspirate 2ml of stomach content using a sterile syringe and test using CE marked pH paper. A pH of less than 5.5 is unlikely to be of pulmonary origin and can be considered gastric in origin. 13.2 Only if a pH of between 1 and 5.5 has been obtained and documented or the correct placement confirmed and documented by a competent person through x-ray can an NG Tube be used. 13.3 NG Tube position should be checked in the following circumstances: • • • • • • Following initial insertion Before administration of medication or commencement of feed At least once a day if the patient is on continuous feed (stop the feed for an hour, flush with water and then check the pH before restarting the feed). Following episodes of vomiting, retching or coughing spasms (note that the absence of coughing does not rule out misplacement or migration) When there is suggestion of tube displacement (for example, loose tape or portion of visible tube appears longer) in the presence of any new or unexplained respiratory symptoms or reduction in oxygen saturation 13.4 Initial and on-going pH checks must be documented on the Trust NG Tube Insertion & Management form (Appendix 5b) which should be kept at the patient’s bedside. 13.5 pH readings should be between 1 and 5.5 for feeding to commence safely. However, the NPSA has identified the potential difficulty experienced by some staff in differentiating pH readings using currently available pH indicator paper between pH 5 and 6. It is therefore recommended that two competent members of staff 11 check any readings that fall within the pH range of 5 to 6. The second check should be undertaken by a registered nurse, who has completed their competency assessment. 13.6 Consideration should be given to the impact of medication such as antacids and the frequency of feeds on stomach pH. 13.7 If a member of staff has difficulty obtaining an aspirate an alternative method is being able to aspirate a coloured fluid that has been drunk. If the patient is alert, has intact swallow and is perhaps only on supplementary feeding and is thus eating and drinking during the day, staff should ask them to sip a coloured drink and then aspirate the tube. If a coloured fluid is obtained then the tube is in the stomach. 13.8 Refer to Appendixes 1, 2 & 3 for further advice on attempting to gain aspirate 13.9 Any staff still having difficulty obtaining an aspirate must request help from a more experienced member of staff or the Nutrition CNS. 14.0 Second Line Test Method: Radiography 14.1 If staff are unable to obtain aspirate or pH indicator paper failed to confirm the location of the NG tube in the stomach, then a request for an x-ray of the upper abdomen and chest should be made. 14.2 The request form must clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube for the purpose of feeding and which type of feeding tube was inserted. If a fine bore tube is used, the guide wire must be left in place until after imaging and interpretation of the resultant image. 14.3 Chest x-rays should be obtained using the technique described in 5.8 14.4 X-rays must only be interpreted and nasogastric tube position confirmed by a doctor assessed as competent to do so. 14.5 If there is any difficulty in interpretation, the advice of a radiologist should be sought. The radiologist should document the position of the NG tube and tip and whether it is safe to proceed with administration of liquids. 14.6 If the tube is not in the correct position, it must be removed immediately whether in the x-ray department or clinical area. 14.7 If there is any relevant past medical history such as Hiatus Hernia or previous gastric surgery, staff should consider using x-ray after discussion with the senior medical team. 15.0 Methods that must not be used • Auscultation of air insufflated through the tube (‘whoosh test’) • Testing aspirate with Blue Litmus paper • Interpreting absence of respiratory distress as indicator of correct positioning; • Monitoring bubbling at the end of the tube • Observing the appearance of the aspirate 12 16.0 On-going Management of NG Tubes in situ 16.1 Prior to use of an NG tube the healthcare professional must re-assess the risk to the patient. 16.2 pH of aspirate and length of tube must always be checked to confirm position using methods explained in sections 12-14: • Once daily during continuous (pump) feeds; at the end of the rest period before reconnecting the feed • Before administration of medication when the patient is not currently receiving continuous feed • Before administering each bolus feed • Following episodes of vomiting/retching/coughing • If the patient complains of a change in level of discomfort • If the patient develops difficulty in breathing during administration of feeds or medicines • Following any evidence of tube displacement 16.3 Where feed/medication has already passed through the tube, a minimum of an hour delay, without any further feeding, should be instigated prior to testing of gastric aspirate using the correct pH paper wherever aspirate can be obtained. However, in some situations, such as when patients are fed continuously, when they are treated with acid-reducing medication and when medications are frequently given down nasogastric tubes, it may not be possible to obtain aspirate with a pH between 1 and 5.5, and daily x-rays are not practical or safe. 16.4 Therefore, in circumstances where the initial placement was appropriately confirmed, and there is no reason to suspect displacement since (i.e. no vomiting, retching or coughing spasms and no unexplained respiratory symptoms) the only practical method of determining if the tube remains correctly placed prior to each administration of medications or feed may be through external observation of the tube. This should include confirmation that the length of the external tube remains identical to that recorded initially in the patient’s notes, and that fixation tapes or plasters have not moved or worked loose. 16.5 Tube length should be recorded on a daily basis and prior to administration of any liquid via the nasogastric tube on the bedside chart Appendix 5b. If there is any indication that the length has changed, appropriate action should be taken to assess tube tip position prior to using the nasogastric tube. 16.6 If there is evidence that the tube has become displaced, for whatever reason, then only checking the position at the nose would be inappropriate as it could be coiled in the back of the mouth, so in this circumstance second line testing through x-ray, or removal of the tube if seen to be coiled in the mouth, is appropriate. 13 16.7 • • Flushing Tubes should be flushed with 30ml water before and after the administration of each drug. If more than one medicine is to be administered, flush between drugs with at least 10 ml of water to ensure that the drug is cleared from the tube. • Flush the tube with at least 30 ml water following the administration of the last drug. • NG fed patients should have their medication in liquid or dispersible form; liaise with the Pharmacist re. Medication. The pharmacist will advise on how to administer drugs that only come in tablet form and has to be crushed • If the patient is on a fluid restriction or for a paediatric patient, consult the dietitian and pharmacist about the quantity of water to be given before and after medication. • Tubes should be flushed with at least 30ml water at the start and finish of the administration of each feeding period. • All fluid given as a flush must be clearly documented on the patient’s fluid balance chart each day. 16.8 Blocked NG Tube Possible causes Not flushing or inadequate flushing after feed and medication. Unsuitable medicine preparations for giving via a tube, e.g. large particles, viscous liquids. Multiple medications being given together without a flush in between each drug. Kinked tube 16.9 Intervention Flush with 30-50ml water before and after feed or medication Review medication and consider alternative medication. All medication given via NG tube should be in either liquid or dissolvable form if possible. Liaise with pharmacist. All medications should be given separately, flushing about 10ml of water in between each medication. NG tube may be kinked in the stomach, pull back slightly and retry. Guidelines for unblocking the tube Flushing with water can shift most blockages (Check length marking to confirm NG tube position has not shifted before flushing with any fluid to unblock the tube) • Use a 60ml oral/enteral syringe with a plunger • Prime with 20-30mls Warm water or Carbonated (sparkling) water or Soda water (do not use Coca-Cola/Lucozade/Pineapple juice or anything other than warm water, carbonated water or soda water) • Flush by using a pumping action • Squeeze along the tube, and then retry flushing. 14 • Once cleared, flush thoroughly. • If unsuccessful: Try using a smaller syringe, 20mls then 10mls then 5mls. Caution: This will exert greater pressure and may split the tube. Check the tube for leakage after the blockage has been cleared. • If all fails remove NG Tube and insert a new one. 17.0 Feeding 17.1 The dietitian will calculate the patient’s requirements and device an appropriate regimen to meet these requirements. The regimen will be provided in a written format and discussed with the nursing staff and where possible, the patient. The Emergency Feeding Regime (available on the intranet under Nutrition and Dietetic Service) may be used over weekends or bank holidays or until the dietetics service is available for advice. 17.2 If the patient is at risk of Refeeding syndrome, feeding must not be started until the appropriate vitamins have been prescribed and administered as described in Guidelines for the Management of Refeeding Syndrome (Adults), Refeeding Flow Chart for Enteral Nutrition (Mid Essex Formulary). 17.3 Administration of the feed should be recorded on the patient’s fluid chart, detailing both the volume and name of the feed. Volume of water flushes should also be recorded on the fluid chart. 17.4 The dietitian will monitor tolerance of the feed together with the patient’s condition and adjust the regimen appropriately. 18.0 Transfer of care to the community setting 18.1 A full multidisciplinary supported risk assessment involving the Dietetic Services should be made and documented, before a patient with a Nasogastric tube is discharged from the Trust into the community. 19.0 Education and Training 19.1 Only staff trained and assessed as competent to insert or check the position of an NG tube should attempt these procedures. 19.2 Nurses may only insert an NG tube following completion of training and competency sign off (Appendix 4). 19.3 All junior Doctors may only insert NG tubes if they have been trained to do so and should attend the relevant session within their training programme to ensure they are competent to interpret chest x-rays undertaken to confirm the position of the tube. Clinical and or Educational Supervisors should ensure that Foundation doctors have completed the NHS E-learning training module “Reducing the Risk of Feeding through Misplaced NG Tube” and they should also complete a Direct Observation of Procedural Skills (DOPS) form to assess competency in NG feeding tube insertion and placement checks. 19.4 15 20.0 Breaches of Policy 22.1 Any incidents related to misplaced NG tubes must be reported as a Serious Incident in accordance with the Trust Incident Policy and Serious Incident Policy. 21.0 Audit and Monitoring 21.1 An annual audit of compliance with this policy will be undertaken by Intensive Care Team, Corporate Nursing and the Dietetic Service with the support of Clinical Audit. Findings of the audit will be reviewed by the Nutrition Steering Group and where deficiencies are identified, actions will be developed and their implementation monitored by this Group. 22.0 Communication & Implementation 22.1 The policy will be available to staff and the public on the Trust’s intranet site and website. 22.2 The policy will be sent to all Clinical Directors and Corporate Nursing for information and dissemination amongst their teams by the author. 23.0 References Royal Marsden Online procedures MEHT guidelines for passing naso/orogastric tube and intermittent feeding for children (10days to 16 yrs). 2009 NPSA/2012/RRR001, Rapid Response Report: Harm from flushing of nasogastric tubes before confirmation of placement. March 2012 NPSA / 2011 / PSA 002. Patient safety alert: Reducing the harm caused by misplaced Nasogastric feeding tubes in adults, children and infants. March 2011 NPSA 2005. How to confirm the correct position of nasogastric feeding tubes in infants, children and adults, February 2005 Rajaraman D 2009 Nasogastric tubes 1: Insertion technique and confirming the correct position. Nursing Times Vol. 105, Iss. 16, 2009 16 Appendix1 17 Appendix 2 Recommended procedure for checking the position of NG feeding tubes Action Rationale Check whether the patient is on medication that may increase the pH level of gastric contents Medications that could elevate the pH level of gastric contents are; antacids, H2 antagonists and proton pump inhibitors. For those patients who are regularly on antacids, the initial risk assessment needs to identify actions that staff should take in this scenario, and document them in the care plan. The initial pH of the aspirate should also be documented in the case notes. Documenting the external length of the tube initially and checking external markings prior to feeding will help to determine if the tube has moved. The documentation will also assist radiographers if an x-ray is needed. 0.5 to 1ml of aspirate will cover an adequate area on the single, double or triple reagent panels of pH testing strips/paper. Allow ten seconds for any colour change to occur. Commence feed. There are no known reports of pulmonary aspirates at or below this figure. The range of pH 0 to 5.5 balances the risk between increasing the potential problems for clinical staff e.g. removing tubes that are actually in the stomach, increased use of x-ray, with the as yet, unreported possibility of feeding at pH 5.5 when the tube is in the respiratory tract. DO NOT FEED. Possible bronchial secretion; leave up to one hour and try again. The initial risk assessment should identify actions for staff to take in this scenario for each patient. The actions should be documented in the care plan and/or in local policies. If there is ANY doubt about the position and/or the clarity of the colour change on the pH indicator strip/paper, particularly between the ranges pH 5 and 6, then feeding should NOT commence – seek advice. The most likely reason for failure to obtain gastric aspirate below pH of 5.5 is the dilution of gastric acid by enteral feed. Waiting for up to an hour will allow time for the stomach to empty and the pH to fall. The time interval will depend on the clinical need of the patient and whether or not they are on continuous or bolus feeds. Check for signs of tube displacement Sufficient aspirate (0.5 to 1ml) obtained Aspirate is pH 5.5 or below Aspirate is pH 6 or above Wait up to one hour before reaspirating to check pH level Problems obtaining spirate? Turn patient onto their side Inject air (1-5ml for infants and children, 10-20ml for adults) using a 20ml or 50ml syringe. Wait for 15-30 minutes and try again This is NOT a testing procedure: DO NOT carry out auscultation of air (‘whoosh’ test) to test tube position Advance the tube by 1-2cm for infants and children or 1020cm for adults Consider x-ray All radiographs should be read by appropriately trained staff Additional tip This will allow the tip of the NG tube to enter the gastric fluid pool. Injecting air through the tube will dispel any residual fluid (feed, water or medicine) and may also dislodge the exit-port of the NG feeding tube from the gastric mucosa. Using a large syringe allows gentle pressure and suction; smaller syringes may produce too much pressure and split the tube (check manufacturers guidelines). Polyurethane syringes are preferable to other syringes. It is safe practice to use NG tubes and enteral syringes that have non luer connectors (Building a Safer NHS for Patients: Improving Medication Safety published 22/01/2004 available at www.dh.gov.uk) Advancing the tube may allow it to pass into the stomach if it is in the oesophagus. X-ray should not be used routinely. The radiographer will need to know that this advice has been followed, what the problem has been and the reason for the request. The radiographer should document this. Fully radio-opaque tubes with markings to enable measurement, identification and documentation of their external length should be used. If the patient is alert, has intact swallow and is perhaps only on supplementary feeding and is thus eating and drinking during the day, ask them to sip a coloured drink and aspirate the tube. If you get the coloured fluid back then you know the tube is in the stomach. 18 Appendix 3 Additional Guidelines for Nasogastric Tube Placement 19 Competency for Nasogastric Tube (NG) Insertion and Management (Competency training should include theoretical and practical learning (NPSA/2011/PSA002) Name Ward This competency document is designed to be used in conjunction with the generic core competency document. Nasogastric tube insertion and management Initial Self/mentor Assessment Level self Discusses and demonstrates understanding of indications for nasogastric (NG) tube placement Discusses and demonstrates understanding of contraindications for NG tube placement Understands the differences and indications for fine bore feeding tubes or wide bore NG tubes e.g. for drainage/aspirate Abides by and understands the NPSA directives (2011, 2012) and Trust Policy for the insertion and management of fine bore NG feeding tubes Demonstrates the correct procedure for NG tube placement including all aspects of health & safety. Maintains patient comfort throughout Demonstrates competency in checking position of NGT immediately after insertion using 1st line pH testing (aspirate ≤ 5.5) and only using the 2nd line testing (x-ray) when appropriate i.e. If no aspirate is obtained or if aspirate is >5.5 Articulates knowledge of when / how often NGT should be checked for correct position post insertion. Demonstrates knowledge of what action to take if: • Unable to obtain aspirate • pH > 5.5 / patient receiving PPI mentor Date of initial self/mentor assessment Date of Review Date Final Level achieved Final Level Achieved mentor Comments/Action Plan Signature of preceptor/ Mentor Can provide care for a patient with a NG tube including changing NG tapes, checking skin, providing mouth care Correctly documents insertion, care of, and position checks of NG tubes according to Trust policy and using Trust documentation. Can provide enteral feeding according to prescription and feeding regime and correctly documents the feed according to the Trust policy. Understands the indications for and can implement the Emergency Standard Enteral Feeding Regime in the absence of dietetic assessment 21 NG Tube Insertion & Management To be filed in patient’s medical record Please affix patient demographics label or complete the following details Surname: First Name DOB: Ward: NHS Number: Hospital Number: Reason for NG Tube insertion: Identify the senior doctor responsible for the patient’s care who has agreed to the NG tube insertion: Is Nasogastric tube feeding the right decision for this patient? Yes / No Is this the right time to place the NG tube and is appropriate equipment available? Yes / No Is there sufficient expertise available at this time to test for safe placement? Yes / No Has verbal consent been given by the patient? Yes / No / NA If NA, please give details: NG Tube Type: _______________ Size: ______ Length: ----------------- Date: __ / __ / __ Time: __:__ Inserted by: __________________ Signature: _________________ Designation: _______________ Was aspirate obtained: Yes / No Date: __ / __ / __ Time: __ : __ Please note length marking: Placement check: First line test method Aspirate checked using pH indicator paper that is CE marked Yes / No Is it confirmed as safe to Initial pH test result: _______ administer feed / medication Yes / No Safe range for feeding is 1 to 5.5 Checked by: Signature: Designation: _______________ If pH between 5 and 6, signature & designation of second competent person checking result: Please confirm that the tube was not flushed prior to the placement check by ticking this box Second line check Interpretation of x-ray: Position of tube confirmed on: ___ / ___ / ___ Time: ___ : ____ X-ray authorised by: Name: Signature: Plan: Was the x-ray reviewed the most current available? Yes / No If tube placed in lung was the NG tube removed immediately? Yes / No Designation: NG Tube Position Check Record (Check prior to commencing feed or giving drugs) pH of NG Aspirate pH 1 to 5 proceed to feed or use tube pH between 5 and 6; second checker to confirm reading Confirmed pH 5.5 or less proceed to feed or use tube pH > 5.5 additional checks or action required Patient Surname: _____________________ First Name _________________________ NHS / Hospital Number ________________ Initial tube length on insertion_________ Date / time Name of person checking NGT (print) Signature Tapes intact Y/N Tube length (daily / prior to feed) Aspirate obtained Y/N pH before feed / drugs Name of 2nd checker (competent RN) if pH between 5 and 6 (Print name) Signature Agreed pH Outcome e.g. proceed to feed; record additional checks carried out; escalate to medical team (record name and grade of Dr) 23