When patients can't eat because of illness, swallowing difficulties, declining hunger, or other feeding disorders, they may receive nutrition through an enteral feeding tube. An enteral feeding tube can be placed through the nose or mouth or directly into the gastrointestinal tract (percutaneous placement)—into the stomach, duodenum, or jejunum.
The American Society for Parenteral and Enteral Nutrition recommends that selection of an enteral-access device be based on evaluation of the patient's disease state; gastrointestinal anatomy, taking into account past surgery; gastric and intestinal motility and function; and the estimated length of therapy.1
Studies suggest that more than 1.2 million small-bore feeding tubes are placed annually in the United States, and placement is often considered a harmless practice. However, statistics show that complications can occur.2-6 During blind placement, for instance, feeding tubes are placed without visualization of the access route, which can lead to serious and even fatal complications. Chest X-ray is considered the gold standard for confirmation of correct nasogastric feeding tube placement.7
In one study, data gathered from more than 25 years of blind placement showed that 1% to 2% of small-bore feeding tubes were accidentally placed in the lungs and that pulmonary injury occurred in 0.3% to 1.2% of patients.6 Other reports suggest that 0.1% to 0.5% of all patients who have blindly placed small-bore feeding tubes die as a result of bronchopulmonary injury from misplaced tubes.2-6
Analysts observed an increase in misplacements of small-bore feeding tubes in Pennsylvania hospitals in 2013, compared with the previous two years, after reviewing event reports submitted to the Pennsylvania Patient Safety Authority through its Pennsylvania Patient Safety Reporting System (PA-PSRS). The analysts studied the report descriptions, interviewed hospital personnel who reported misplacements of the feeding tubes, and conducted a literature search, all in hopes of determining possible causes of the increase in such events.
PENNSYLVANIA EVENT REPORTS
There was a 58% increase in reports of small-bore nasogastric feeding tube misplacements in 2013, compared with the previous two years. Analysis of events reported through PA-PSRS during that span revealed 49 reports describing placement of small-bore nasogastric feeding tubes in the lung.
Adverse events that occurred as a result of the misplacements (confirmed by X-ray) included placement in the lung, pneumothorax, and lung puncture. Of the 49 reports, 13 events occurred in 2011, six occurred in 2012, and 30 occurred in 2013. (An earlier version of this article, published by the Pennsylvania Patient Safety Authority, reported numbers from only the first 10 months of 2013.) More than half of the events (n = 28) were classified as serious (adverse events resulting in harm to patients). Of those, a total of 12 occurred in 2011 and 2012, whereas 16 occurred in 2013.
EXAMPLES OF EVENT REPORTS
The following are examples of events related to misplacements of feeding tubes reported to PA-PSRS in 2013.
- [A weighted feeding tube] was used, and the correct procedure was followed. The [weighted feeding tube] had coursed to wrong destination (bronchus) instead of the intended (stomach–pylorus), as noted during confirmation by chest X-ray. Patient was on close monitor… without resultant complication from the [weighted feeding tube] misplacement. However, we have noted unusual events of [weighted feeding tube] misplacement since introduction of this model.
- A pneumothorax was noted [after weighted feeding] tube placement. The patient was closely monitored, and a surgical consult was obtained. The patient stabilized without the need for invasive treatment.
- The nurse inserted a small-bore feeding tube for enteral nutrition. Upon [X-ray to confirm correct placement], tube placement was noted to be in the left pleural space. Small-bore feeding tube was removed, and a repeat X-ray was taken. Repeat X-ray showed a left pneumothorax, which required insertion of a chest tube.
Patient safety officers (PSOs) at some of the facilities that reported events in 2013 were asked whether they could provide possible explanations for the event increase, and the PSOs suggested that a change in device was the culprit. Abbott Laboratories had announced in October 2012 that it would cease the manufacture, leasing, and sale of all enteral device products (pumps, disposable sets, feeding tubes, kits, and related device accessories) in the United States as of April 30, 2013. As a result, facilities that owned or leased Abbott's enteral feeding–delivery system had to find and convert to an alternative system in a relatively short time frame.
A new brand was introduced, and it was assumed that using the new system would be similar to using the Abbott system. However, according to the nurses who inserted the tubes, there were differences in lubrication and pliability, causing the new tubes to have less resistance during insertion. Staff were not consistently trained by the manufacturer or the health care facility in the use of new feeding tubes. The PSOs reported that
- the events occurred within a month of switching to the different system.
- staff members who misplaced the tubes typically had several years of experience in tube placement.
- the misplaced tubes were weighted, small-bore (8-French) nasogastric feeding tubes—the same size and type as the tubes used before switching to a different manufacturer.
- the facilities used blind placement followed by radiographic confirmation.
- staff were not consistently trained by the manufacturer or the health care facility in the use of the new feeding tubes.
One PSO stated that staff described the integral lubrication on the new small-bore feeding tubes as “slicker” than that of the previous brand of feeding tubes. Staff believed that this may have caused the new tubes to have less resistance than the Abbott tubes as the tubes were advanced during placement. Staff also stated that the new feeding tubes seemed to be less pliable than the previous feeding tubes. The PSO said that she thought this problem wasn't widely understood and had gone underreported. Her facility was taking steps to improve patient safety by using published data and reviewing alternatives to nurses blindly placing small-bore feeding tubes.
The PSOs listed several actions that were taken to minimize the risk of incorrect feeding tube placement:
- testing and evaluating other enteral feeding systems
- reviewing literature on feeding tube placement to determine evidence-based placement procedures
- using a simulation laboratory to practice feeding tube placement
- redefining which staff and what kind of training are appropriate to perform feeding tube insertion
- restructuring vendor communication processes and creating steering committees that include senior leadership and clinical stakeholders
- including nursing leaders, managers, and educators in assessing newly acquired equipment and determining whether staff training is needed before institutional rollout
WHAT YOU CAN DO
Although the literature doesn't specifically address training requirements or other safety precautions when a facility is switching to a different manufacturer's enteral feeding–delivery system, there is endorsement of a variety of methods of verifying placement of feeding tubes by institutions such as the American Association of Critical-Care Nurses, the American Society for Parenteral and Enteral Nutrition, the Joanna Briggs Institute, and the National Patient Safety Agency. One facility developed a feeding tube placement algorithm, adapted from an algorithm created at Brigham and Women's Hospital in Boston; it's available online at (http://bit.ly/1CJxaoK).
Although the gold standard for confirming nasogastric feeding tube placement is radiographic confirmation with a chest X-ray, there is no consensus on a particular combination of practices for checking placement during insertion. A search of the literature finds support for the following methods5, 8, 9:
Capnography. The measurement of carbon dioxide (CO2) in expired air directly reveals changes in the elimination of CO2 from the lungs.
Colorimetric capnometry. A CO2 detector incorporates a colorimetric paper technology engineered to display a change in color from purple to yellow within seconds when the presence of CO2 is detected.
Measuring the pH of aspirate. This practice determines the pH of the fluid aspirated from the feeding tube. Gastric fluid is usually acidic, with a pH less than or equal to 5.5. Respiratory secretions are almost always alkaline, with a pH greater than or equal to 7. Measurement of pH aspirate may not be possible with a feeding tube inserted to 35 cm because fluid may not be available to sample from that anatomic position.
Electromagnetic visualization. A transmitter is used in the tip of the feeding tube stylet. An external receiver is placed over the xiphoid process, and a monitor displays the tube position in both anterior and cross-sectional views in real time.
Radiographic confirmation. After insertion, a radiograph captures the entire course of the feeding tube in the gastrointestinal tract, and the X-ray is then read by a radiologist, which helps prevent errors in interpretation.7, 10, 11
1. Andris D, Krzywda EA, eds. The A.S.P.E.N. nutrition support patient education manual
. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.); 2007.
2. Sorokin R, Gottlieb JE. Enhancing patient safety during feeding-tube insertion: a review of more than 2,000 insertions JPEN J Parenter Enteral Nutr. 2006;30(5):440–5
3. Giantsou E, Gunning KJ. Blindly inserted nasogastric feeding tubes and thoracic complications in intensive care Health. 2010;2(10):1135–41
4. Koopmann MC, et al. A team-based protocol and electromagnetic technology eliminate feeding tube placement complications Ann Surg. 2011;253(2):287–302
5. Krenitsky J. Blind bedside placement of feeding tubes: treatment or threat? Practical Gastroenterology. 2011;35(3):32–42
6. Merrel P. Prevention of NG tube misplacement: nursing practices. Perspectives: recovery strategies from the OR to home
8. Joanna Briggs Institute. Methods for determining the correct nasogastric tube placement after insertion in adults
. Adelaide, SA, Australia. Best practice: evidence-based information sheets for health professionals. 2010;14(1):1-4.
9. Chau JP, et al. Use of end-tidal carbon dioxide detection to determine correct placement of nasogastric tube: a meta-analysis Int J Nurs Stud. 2011;48(4):513–21
11. Bankhead R, et al. Enteral nutrition practice recommendations JPEN J Parenter Enteral Nutr. 2009;33(2):122–67