1. Misplaced Nasogastric Tube: A Serious Preventable Error By Daniel Haslam, Dr Michael Parris, Nutritional Team

2. Content Problem Quantifying the problem Addressing issues Discussion

3. Problem Increasing use of chest radiograph as first line check for NG tube position [2]. Implications include: - unnecessary radiation exposure - unnecessary expenditure - risk of interpretation errors - Treatment delays 2005-2010: 21 deaths, 79 causes of harm due to feeding into the lungs [1]. Feeding from a misplaced nasogastric tube is a Never Event [1].

4. Problem Training varies between Trusts – A National audit suggests only 31% junior doctors receive training on use of chest radiograph for interpreting NG tube position [3].

5. Case Studies Patient requiring NG feeding. NG tube resited through night. Portable chest x ray was viewed by nightshift ITU CT2 who then advised the nurses to commence feeding. Patient was fed for approximately 1.5 hours giving 200 ml of feed. 0850: patient became very distressed, hypertensive, desaturating and coughed up NG feed into ventilator tubing. The NG feed was stopped. Duty ITU doctors were alerted to the problem and patient was reviewed. The CXR was reviewed and the NG tube was found to be positioned in the left lung.

6. Case Studies The NPSA is aware of two patient deaths since March 2011 where staff had flushed nasogastric tubes with water before initial placement had been confirmed [4]. – Staff then aspirated back the water (including the lubricant within the tube). – The mix of water and the lubricant gave a pH reading below 5.5, and assumed it was in correct position, although the tube was actually in the patient’s lung.

7. Design Questionnaire – Assessed level of training and knowledge 1 st and 2 nd line methods of confirming NG placement Three landmarks on a chest radiograph confirming NG placement Bisects Carina Crosses hemi- diaphragm NG tube deviates left Quiz Assessed clinical judgement of 7 random chest radiographs of NG tube placement [5] 2 NG tube in correct position 5 NG tube not in correct position

8. Baseline measurements (1) 61.7% [29/47] response rate. - 13.8% [4/29] were aware of the National Patient Safety Agency (NPSA) guidelines - 6.9% [2/29] received training, both informally.

9. Baseline measurement (2) 1 st line check for NGT placement

10. 2 nd line check for NGT placement Baseline measurement (3)

11. Baseline measurement (4) Percentage of foundation Doctors that identified the landmarks of NGT placement on chest radiographs

12. Baseline measurement (5) 6.9% [2/29] answered the correct pH cut off of NG aspirates (pH 5.5). 3.4% [1/29] would correctly ‘wait and aspirate later’ if the pH aspirate was outside the range.

13. Baseline measurement (6) 59.6% [28/47] responded – 7 radiographs 2 correctly placed NG tubes (89.3% - 50/56 potential correct answers) 5 incorrectly placed NG tubes (75% - 105/140) – 3 F1s answer all questions correctly – Out of the incorrect answers 83% [34/41] commence feeding when not suitable 17% [7/41] would not commence feeding when suitable

14. Intervention (1) 1.Educating junior doctors through a formal lecture – Including 8 chest radiographs from PACS system. 2.Introduction of a compulsory electronic- module [6]

15. Intervention (2) 3.Poster presentation 4. Engaging with nursing team – Electronic-module available for nurses – Additional comments in competency Framework

16. Remember to … C heck Ng position p H sensitive paper Ch E st radiograph W ait if unsure … your food!

17. Results (1) The response rate 57.4% [27/47] was similar to that of baseline measurements. 100% rating of ‘training was beneficial’.

18. Results (2) Percentage of F1’s who could correctly identify the first line check for NG tube placement

19. Results (3) Percentage of F1’s who could correctly identify the landmarks on chest radiographs

20. Results (4) 48.15% [13/27] answered the correct pH cut off of NG aspirates. 40.7% (11/27) would correctly ‘wait and aspirate later’ if the pH aspirate was outside the range.

21. Key points There is large discrepancy in the knowledge on the guidance NG tube placement Highlights the importance of continuous training amongst health professionals Simple, cost-effective, reproducible, modifiable interventions

22. Discussion Should there be universal training across all Trust Sites? If so, in what training format? Should the training be aimed at grade-specific doctors?

23. References 1.Patient Safety Alert NPSA/2011/PSA002: Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. 2011. http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 (accessed 22.01.2014). http://www.nrls.npsa.nhs.uk/alerts/?entryid45=129640 2.Nasogastric feeding tube placement: changing culture. www.nursingtimes.net/Journals/2011/10/17/j/u/c/Innov-ng-tubes.pdf (accessed on the 10/05/14) www.nursingtimes.net/Journals/2011/10/17/j/u/c/Innov-ng-tubes.pdf 3.National Patient Safety Agency. Nasogastric tubes audit. Available online at: www.nrls.npsa.nhs.uk/resources/?entryid45=66675 4.Harm from flushing of nasogastric tubes before confirmation of placement. http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 (accessed on the 10.03.2015) http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=133441 5.http://www.trainingngt.co.uk/site/home.aspx (accessed on the 23.01.2014)http://www.trainingngt.co.uk/site/home.aspx 6.http://asph.trainingtracker.co.uk/training-slides.asp?5C1B4B404F4141 (accessed on the 25/04/2014http://asph.trainingtracker.co.uk/training-slides.asp?5C1B4B404F4141

24. Thank you for listening. Questions?