In this article, Dr Natasha Coen, Senior Clinical Risk Manager, discusses the risks associated with the placement of nasogastric tubes, and how those risks can be mitigated.
Nasogastric (NG) tubes are used to provide liquid nutrition, fluids and medication to service users who require short-term nutritional support. They can also be used for the removal of gastric contents. Placement of NG tubes is a common procedure and many are placed daily without incident. However, the fact that they are used frequently, and that the procedure may be seen as simple, should not negate the potentially serious consequences if they are misplaced in the lungs or dislodged from the stomach.
Some examples of incidents related to NG tube misplacement reported on NIMS, the National Incident Management System, include:
- misplacement of the NG tube in the lung
- failure to check the position of the NG tube either radiologically or by checking the pH of the gastric aspirate
- accidental dislodgment due to traction on the NG tube.
That the procedure may be seen as simple, should not negate the potentially serious consequences if they are misplaced in the lungs or dislodged from the stomach.Dr Natasha Coen State Claims Agency
Risk factors for the displacement of NG tubes or associated complications include:
- Failure to check the position of the NG tube either by measuring the pH of gastric aspirate or radiological imaging
- Misreading of imaging when checking NG tube placement
- Failure to record the NG tube tip position in the service user’s healthcare record
- Complexity of the service user’s condition, e.g. stroke, making dislodgement more likely
- Lack of appropriate supervision of less experienced staff placing NG tubes
- Lack of availability or awareness of guidelines and procedures for NG tube insertion
Minimising the risks
Health and social care services should ensure local procedures / guidelines for assessing NG tube placement are in line with best practice standards and should ensure that healthcare professionals are familiar with them. The procedure should only be undertaken by appropriately trained staff.1
When inserting a NG tube:
- Explain the risks associated with insertion and placement to the service user2
- Once gastric position is confirmed, secure the NG tube on the nostril or cheek2 with hypoallergenic tape and check skin integrity around nasal pressure areas regularly
- Document the date and time of tube insertion; the size, type, length and position of tube inserted; the date the tube is due for a change / removal2
- Follow local procedures to ensure correct placement of the NG tube, which may include:
- Use of automated pH readers to reduce observer error in pH reading1
- Radiological imaging for complex cases, with confirmation of position by competent personnel1
- The length of tube at the nostril should be marked, checked, and documented at least daily2
- Aspirate NG tube at least once daily when in use - pH of gastric aspirate must be 5.5 or below1
- If the pH is above 5.5 do not use; promptly seek assistance and advice3
- Exercise caution when a service user is on proton pump inhibitors as they may alter the pH of the gastric aspirate3
References available on request.
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Clinical Risk Insights
View more articles from the latest edition of Clinical Risk Insights by the State Claims Agency.