10
Winter 2013
Interprofessional Task Force Uses A Collaborative Approach For Enteral Feeding Tube Management Christine Provance, MS, RN, Clinical Education Coordinator, Neurocare Acute and IMC Allison Murter, MSN, RN, Professional Development Coordinator, Clinical Practice and Professional Development
The placement of nasogastric (NG) feeding tubes is a common practice for patients who are unable to take oral feedings or medications. This skill is a component of basic nursing education and a required competency for the successful completion of new graduate orientation. The methods that were taught to many nurses to confirm the blind placement of NG tubes have recently been deemed ineffective. The auscultation method has shown to be unreliable in distinguishing between respiratory and gastric placement. NG feeding tubes are malpositioned in 1.3% to 3.2% of all insertions, and 28% of tube malpositions result in pneumonia or pneumothorax.1 Over the past year at the Medical Center, multiple incidents have occurred where the placement of blindly inserted NG tubes has caused patient harm. During Clinical Practice Council (CPC) meetings, the subject of malpositioned feeding tubes has been discussed several times, with the subsequent identification of inconsistencies in verification practices among nursing units. The review of the literature revealed that the American Association of Critical Care Nurses (AACN) guidelines recommend radiographic confirmation of NG (enteral) tube placement prior to initial use for feedings or medication administration as a best practice.2 With this knowledge and the potential impact of changing institutional practice, registered dietitians from CPC volunteered to collaborate with nursing by collecting data on enteral tube insertion and verification practices throughout the Medical Center. Nurses and dietitians created a data collection tool to track all enteral feeding tube placements over a two week period. The results are shown in Table 1. This data revealed that only 53% of the NG tubes placed for feeding had been X-rayed. Of that 53%, 11% of tubes that had been X-rayed were found to be in a less than optimal position, and those patients were being fed via the NG tube. Table 1
Enteral Feeding Tube Placement Data (N = 95) Criteria
CorFlo Post-Pyloric Tubes
Nasogastric Tubes
Number placed
59/95 total tubes
36/95 total tubes
Placement X-ray done
(58/59) 98%
(19/36) 53%
% of X-rayed tubes in correct position
(50/58) 86%
(17/19) 89.5%
Tubes not X-rayed
(1/59) 2%
(17/36) 47 %
CorFlo* tubes in correct position
(48/54) 89% placed in ICU in correct position (3/5) 60% placed in acute care in correct position
*Used by ICUs 98% of the time
The Director of Clinical Nutrition presented this data to CPC, and a riveting discussion ensued. There was concern on many levels that the number of tubes not confirmed by X-ray posed a significant risk to our patients. The group recognized the implications of a proposed practice change to require radiologic confirmation of all enteral feeding tubes. This included clinical and financial resources as well as provider support. Numerous council members volunteered to participate in a task force to develop a proposal for improving the safety of enteral tube insertion and placement verification. The task force included nursing, radiology, clinical nutrition, risk management, and nursing governance council leadership. The task force began with a review of the current Medical Center enteral feeding guidelines, located in the Clinical Practice Manual. In accordance with the CPC standard for policy revision, the task force also reviewed the Lippincott Nursing Practice Manual 3 and performed additional literature searches for best practice recommendations. This information provided compelling evidence to support the standard for radiologic confirmation after initial insertion of an enteral feeding tube.4 It required the revision of the current guidelines into a formal hospital policy to reinforce best practice among all disciplines. Over a two month period, the group met on a weekly basis to resolve issues and incorporate evidence-based standards in a new hospital policy for enteral tube management. Numerous challenges at the organizational level were identified as a consequence of establishing a standard of radiologic confirmation after initial insertion of an enteral feeding tube. Such a standard could potentially impact patient care and providers in numerous ways and included: ◗◗ The patient impact of additional exposure to radiation and delay in feeding and medication administration while awaiting placement confirmation. ◗◗ The additional requirement for providers to order and document placement of enteral tubes. ◗◗ An increased workload for radiology staff due to higher volumes of films and readings. ◗◗ The additional time required for nurses to verify orders and await placement confirmation. ◗◗ The system impact of additional charges for radiology films. ◗◗ IT implications for changing order sets to match the new standard of care. ◗◗ Pharmacy review of medication administration components and recommendations regarding the use of methylene blue. continued on page 11.