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Taylor SJ, Karpasiti T, Milne D. Safety of blind versus guided feeding tube placement: Misplacement and pneumothorax risk. Intensive Crit Care Nurs 2023; 76:103387. [PMID: 36657250 DOI: 10.1016/j.iccn.2023.103387] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/04/2023] [Accepted: 01/07/2023] [Indexed: 01/19/2023]
Abstract
Most intensive care unit patients require a feeding tube, but misplacement risk is high due to the presence of artificial airways and because unconsciousness reduces clinical warnings. Predominantly, tubes are placed 'blindly', where position is not known throughout placement. The result is that 1.6% enter the lung, 0.5% cause pneumothorax and potentially 5% are left in the oesophagus. Guided placement, by identifying tube position in real time, may prevent these problems, but undetected misplacements still occur. We review the safety of guided methods of confirming tube position, including rates of pneumothorax, in the context of current unguided methods. During blind tube placement, tube position can only be tracked intermittently. Excepting X-ray and ultra-sound, most methods of checking position are simple. Conversely, guided tube placement can track tube position from the nose to small intestine (IRIS®), or oesophagus to jejunum (Cortrak™, ENvue®). However, this requires expertise. Overall, guided placement is associated with lower rates of pneumothorax. Unfortunately, for Cortrak, low-use centres have higher rates of undetected misplacement compared with blind placement whereas Cortrak use in high-use centres had lower risk compared with blind placement and low use centres. Because guided placement requires high-level expertise manufacturer training packages have been developed but currently appear insufficient. Specifically, Cortrak's package is less accurate in determining tube position compared to the 'gastrointestinal flexure' system. Validation of an evidence-based guide for IRIS placement is underway. Recommendations are made regarding the training of new operators, including minimum numbers of placements required to achieve expertise.
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Affiliation(s)
- Stephen J Taylor
- Department of Nutrition & Dietetics, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, United Kingdom.
| | - Terpsi Karpasiti
- Department of Nutrition & Dietetics, Royal Brompton and Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, SW3 6NP, United Kingdom
| | - Danielle Milne
- Department of Nutrition & Dietetics, Southmead Hospital, North Bristol NHS Trust, BS10 5NB, United Kingdom
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Bloom L, Seckel MA. Placement of Nasogastric Feeding Tube and Postinsertion Care Review. AACN Adv Crit Care 2022; 33:68-84. [PMID: 35259226 DOI: 10.4037/aacnacc2022306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.
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Affiliation(s)
- Lindsey Bloom
- Lindsey Bloom is Critical Care Clinical Practice Specialist, Adventist Health, One Adventist Health Way, Roseville, CA 95661
| | - Maureen A Seckel
- Maureen A. Seckel is Critical Care Clinical Nurse Specialist and Sepsis Coordinator, ChristianaCare, Newark, Delaware
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Bourgault AM, Upvall MJ, Nicastro S, Powers J. Challenges of de-implementing feeding tube auscultation: A qualitative study. Int J Nurs Pract 2021; 28:e13026. [PMID: 34664768 DOI: 10.1111/ijn.13026] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 06/25/2021] [Accepted: 09/25/2021] [Indexed: 11/30/2022]
Abstract
AIM This qualitative study explored de-implementation of feeding tube auscultation practice in adult patients by critical care nurses. BACKGROUND Despite years of evidence suggesting inaccuracy and harm, auscultation (air bolus method) continues to be used by the majority of critical care nurses to verify small-bore feeding tube placement in adults. DESIGN This descriptive qualitative study used thematic analysis with telephone interview data. METHODS Fourteen critical care nurses from four stratified groups within the United States (by hospital type and auscultation practice) participated in telephone interviews. RESULTS Two major themes of individual influence and organizational leadership emerged from the data. Categories identified key components required for auscultation de-implementation. CONCLUSIONS Nurses feel obligated to follow hospital policies and expressed less accountability for their own practice. Organizational leadership involvement is recommended to facilitate de-implementation of this tradition-based, low-value practice and mitigate harm events.
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Affiliation(s)
- Annette M Bourgault
- College of Nursing, University of Central Florida, Orlando, Florida, USA.,Orlando Health, Orlando, Florida, USA
| | - Michele J Upvall
- College of Nursing, University of Central Florida, Orlando, Florida, USA
| | - Samantha Nicastro
- College of Nursing, University of Central Florida, Orlando, Florida, USA
| | - Jan Powers
- Parkview Health System, Fort Wayne, Indiana, USA
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Powers J, Brown B, Lyman B, Escuro AA, Linford L, Gorsuch K, Mogensen KM, Engelbrecht J, Chaney A, McGinnis C, Quatrara BA, Leonard J, Guenter P. Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients. Nutr Clin Pract 2021; 36:517-533. [PMID: 34021623 DOI: 10.1002/ncp.10671] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/04/2021] [Indexed: 01/15/2023] Open
Abstract
Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.
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Affiliation(s)
- Jan Powers
- Parkview Health System, Fort Wayne, Indiana, USA
| | - Britta Brown
- Nutrition Services Hennepin Healthcare Minneapolis, Minneapolis, Minnesota, USA
| | - Beth Lyman
- Nutrition Support Consultant, Smithville, Missouri, USA
| | - Arlene A Escuro
- Center for Human Nutrition, Digestive Disease and Surgery Institute Cleveland Clinic, Cleveland, Ohio, USA
| | - Lorraine Linford
- Nutrition Support/Vascular Team, Intermountain Healthcare Medical Center Murray, Salt Lake City, Utah, USA
| | - Kim Gorsuch
- Interventional GI and Pulmonology, Gastroenterology and Nutrition Support Clinic, Comprehensive Care and Research Center, Chicago, Zion, Illinois, USA
| | - Kris M Mogensen
- Department of Nutrition, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Amanda Chaney
- Department of Transplant, College of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Carol McGinnis
- Sanford USD Medical Center, Sioux Falls, South Dakota, USA
| | - Beth A Quatrara
- Center of Interprofessional Collaborations School of Nursing, University of Virginia Charlottesville, Charlottesville, Virginia, USA
| | - Jennifer Leonard
- Department of Surgery, Washington University School of Medicine, St Louis, Missouri, USA
| | - Peggi Guenter
- Clinical Practice, Quality, and Advocacy, American Society for Parenteral and Enteral Nutrition, Silver Spring, Maryland, USA
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Bourgault AM, Powers J, Aguirre L, Hines R. Migration of Feeding Tubes Assessed by Using an Electromagnetic Device: A Cohort Study. Am J Crit Care 2020; 29:439-447. [PMID: 33130862 DOI: 10.4037/ajcc2020744] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Bedside methods to verify placement of a feeding tube are not accurate for detecting placement within the gastrointestinal tract, increasing risk of pulmonary aspiration. Current guidelines recommend verifying placement every 4 hours, yet the rationale for this recommendation is unknown. OBJECTIVE To assess spontaneous migration of small-bore feeding tubes in critically ill adults. METHODS A prospective, repeated-measures cohort study was performed in 2 intensive care units. An electromagnetic placement device was used to assess distal feeding tube location every 24 hours for 7 days. Tube migration between zones-esophageal, gastric, and postpyloric- was considered clinically significant. RESULTS Feeding tubes were analyzed in 20 patients. Interrater agreement was substantial for round 2 of a blinded analysis of insertion tracings (g = 0.78); 100% agreement was achieved after unblinding. Among 62 outcomes (migration assessments), 4 feeding tubes migrated 8 times (3 forward and 5 retrograde). All migrations occurred in the postpyloric zone and none were clinically significant. Within 24 hours of insertion, 50% of feeding tubes had migrated forward. Repeated-measures analysis showed a greater likelihood of migration in patients with an endotracheal tube (relative risk, 3.46 [95% CI, 1.14-10.53]; P = .03). CONCLUSIONS No tubes migrated retrograde into the stomach or esophagus, challenging the practice of verifying placement every 4 hours. Verification every 24 hours may be adequate if migration is not suspected. Also, lack of visible anatomical structures on insertion tracings from an electromagnetic placement device make subtle changes in postpyloric placement difficult to identify accurately.
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Affiliation(s)
- Annette M. Bourgault
- Annette M. Bourgault is an associate professor, University of Central Florida College of Nursing, and a nurse scientist, Orlando Health, Orlando, Florida
| | - Jan Powers
- Jan Powers is the director of nursing research and professional practice, Parkview Health System, Fort Wayne, Indiana
| | - Lillian Aguirre
- Lillian Aguirre is a clinical nurse specialist in trauma/burn critical care services, Orlando Regional Medical Center (a part of Orlando Health), Orlando, Florida
| | - Robert Hines
- Robert Hines is an associate professor, University of Central Florida College of Medicine, Orlando, Florida
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Campos Y, Kerin C, Reyes R. Complications of small-bore feeding tubes: is newer technology necessarily better? Trauma Surg Acute Care Open 2020; 5:e000572. [PMID: 32923683 PMCID: PMC7462156 DOI: 10.1136/tsaco-2020-000572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/10/2020] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yesica Campos
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Claire Kerin
- Department of Neuroscience ICU, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ranier Reyes
- Department of Neurology, The University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Department of Neurosurgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
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