Primary Author:	Diane Baker, EdD, APN-BC
Co-Principal Investigators/Collaborators:	Robert Parker, MSN, Carla Lane, MSN, Lisa Young, MSN, Cindy Wooten, MSN
Organization	System Nursing, BMHCC

 

 

 

Abstract

Purpose

Establish gastrointestinal tube confirmation of placement best practice guidelines for adults in a 14 Hospital System with 4400 registered nurses.

Background

Auscultation is no longer an acceptable practice for confirmation of gastrointestinal tube placement in adults. The changing landscape of managing the functions (lavage and gavage) of placement has increased in complexity related to patient safety. Radiologic confirmation remains the Gold Standard. The functions continue as foci of gastrointestinal tube studies.

Materials & Methods

Integration of the Iowa model of evidence-based practice/research (the adopted model for the system) for best practice guidelines development occurred. PICO question drafted by Medical Surgical Unit(s) RN’s: What method of confirming nasogastric or enteral feeding tube placement is the most accurate for adult acute care hospital inpatients? A comprehensive literature review was conducted. Collaboration was a second methodology. Collaborating disciplines included radiology; nutrition services; laboratory; nursing practice, education, and informatics (manual and electronic documentation). The nursing practice and nursing education disciplines participated in drafting the guidelines. The other disciplines acted as reviewers.

The best practice guidelines are comprised of assessments (nare measurement, oral coiling, positioning, presence of radiologic confirmation on chart) interventions (NEX tube measurements, oral hygiene, positioning, residual gastrointestinal contents volume measurement), and documentation (all assessments and interventions). A Soft Chalk program is available. Simulation activity templates also are available. Executive summaries to the 14 hospital entities, affiliating schools of nursing, and medical staff complete the results. Chief Nursing Officers, hospital entity Nursing Staff development staff, and Nursing Research Council members share accountability for dissemination. Nursing Informatics provided EHR support during the documentation dissemination process. A plan to study the 4400 nurse’s response to the auscultation change is underway.

 

Conclusion

Best practice guideline development for confirmation of gastrointestinal tube placement in adults was challenging to all disciplines involved. Patient safety was the driver.

Bibliography

American Association of Critical-Care Nurses. (2005). Practice alert: Verification of feeding tube placement . Retrieved from internet

Araujo-Preza, Melhad, F. J., Gutierrez, T., Maniatis, M. A., & Castellanot, M. A. (2002). Use of capnography to verify feeding tube placement . Critical Care Medicine, 30(10). 2255-2259.

Burns, S.M., Carpenter, R., Blevins, C., Bragg, S., Marshall, M. et. al. (2006, March). Detection of inadvertent airway intubation during gastric tube insertion: Capnography versus a colorimetric carbon dioxide detector. American Journal of Critical Care, 15(2), 188-192.

Burns, S.M., & Carpenter, J., & Truwit, J. D. (2001). Report on the development of a procedure to prevent placement of feeding tubes into the lungs using end-tidal CO2 measurement. Critical Care Medicine 2001, 29(5). 936-939.

Dulak, S. B. (2006, August). Inserting an nasogastric tube. Healthcare Traveler, 36-41.

Ellett, M.L.C. (2004). What is known about methods of correctly placing gastric tubes in adults and children. Gastroenterologic Nursing, 27(6), 253-259.

Farrington, M., Lang, S., Cullen, L. &, Stewart, S. (2009 January-February). Nasogastric tube placement verification in pediatric and neonatal patients. Pediatric Nursing,35(1), 17-24.

Goodwin, R.S. (1996). Prevention of aspiration pneumonia: A research-based protocol. Dimensions of Critical Care Nursing, 15(22), 58-71.

Jacobson, G., Brokish, P. A., & Wrenn, K. (2009). Percutaneous feeding tube replacement in the ED – are confirmatory x-rays necessary? American Journal of Emergency Medicine, 27, 519-524.

Kunis, C. (2007). Confirmation of nasogastric tube placement. American Journal of Critical Care 16(1), 17-19.

Marks, D.J. B., Cox, A., Proodromou, A., Gadelrab, R., Pakzad, F., & Harrison, R. A. (2009). Fatal consequences of nasogastric intubation: A clinical reminder. Journal of the Royal Society of Medicine, 102, 157-159.

May. S. (2007). Testing nasogastric tube positioning in the critically ill, exploring the evidence. British Journal of Nursing, 16(7), 414-418.

Metheny, N. A., & Ignatavicius, D.L. (1998). Detection of improperly positioned feeding tubes. Journal of Healthcare Risk Management, 18(3), 37-48.

Metheny, N. A., & Stewart, B. J. (2002, November). Testing feeding tube placement during continuous tube feedings. Applied Nursing Research, 15(4), 254-258.

Metheny, N. A. (2002). Case report: Inadvertent intracranial nasogastric tube placement. American Journal of Nursing, 102(8), 25-27.

Metheny, N. A., & Meert, K. (2004, October). Monitoring feeding tube placement. Nutrition in Clinical Practice, 19, 487-495.

Munera-Seeley, V. Ocha, J. B., Brown, N., Bayless, A., Isabel, M., Cori, T. D., et al (2008, June). Use of a colorimetric carbon dioxide sensor for nasoenteric feeding tube placement in critical care patients compared clinical methods and radiography. Nutrition in Clinical Practice, 23(3),, 318-321.

Peter, S. & Gill, F. (2009, January). Development of a clinical practice guideline for testing nasogastric tube placement. JSPN, 14(10), 3-11.

Pillai, J. B., Vegas, A., & Brister, S. (2005). Thoracic complications of nasogastric tube: Review of safe practice. Intreractive Cardiovascular and Thoracic Surgery, 4, 429-433.

Preetha, K. C. (2009, May). Effectiveness of auscultation and testing pH for assessing the placement of feeding tube. The Nursing Journal of India, 100(5), 112-114.

Rauen, C. A., Chulay, M., Bridges, E., Vollman, K. M., & Arbour, R. (2008, April). Seven evidence-based practice habits: Putting some sacred cows out to pasture. Critical Care Nurse, 20(2), 98-123.

Sanko, J. S. (2004). Aspiration assessment and prevention in critically ill enterally fed patients: Evidence-based recommendations for practice. Gastroenterology Nursing, 27(6), 279-285.

Thomson, M. A., Lawson, L., & Shaw, M. (2007, November). Best practice with regard to confirmation of nasogastric tube placement. Proceedings of the Nutrition Society.

Zaloga, G. P. (1991, December). Bedside method for placing small bowel feeding tubes in critically ill patients. Chest, 100(6), 1643-1646.
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The ISRN published this as received and with permission from the author(s).