DO NOT interpret absence of respiratory distress or the appearance of aspirate as an indicator of correct positioning Observing for respiratory distress is ineffective in detecting misplaced nasogastric tubes as nasogastric tubes can enter the respiratory tract without causing any symptoms. There is no absolute distinction that can be made in the appearance of gastric, respiratory and pleural secretions that can easily be described and applied to normal variation in healthy people and to patients with a wide range of gastric and respiratory conditions No local or national clinical guidance should amend this requirement. Observing for respiratory distress include within revised policy.
Nasogastric tubes are not flushed, nor are guidewires pre-lubricated, nor is anything introduced though the tube until initial placement has been confirmed Any flush could cause aspiration pneumonia if the tube is misplaced in the lungs. pH testing for gastric placement relies on collecting aspirate via the tube; anything introduced down the tube will contaminate this aspirate, potentially leading to false positive pH readings. No local or national clinical guidance should amend this requirement. Purchasing policies are revised and old stock systematically removed to ensure all pH test strips are CE and intended by the manufacturer to test human gastric aspirate Some pH papers are designed specifically for laboratory testing and so not appropriate for testing human gastric aspirate. No local or national clinical guidance should amend this requirement, although the reference to requirements of pH test strips may be extended to alternative technology that has met relevant regulatory requirements and is CE marked and intended by the manufacturer to test human gastric aspirate (eg pH meters). Each pH test (including failure to obtain aspirate) and test result To allow for an ongoing record of a patient’s normal range. To assist in investigation in the event of respiratory feeding following initial placement. No local or national clinical guidance should amend this requirement. Recording sheets in place
Purchasing policies are revised and old stock systematically removed to ensure all nasogastric tubes used for the purpose of feeding are radio-opaque throughout their length and have externally visible length markings Tubes that are clearly visible on x-ray through radio-opaque materials throughout their length (rather than solely at the tip) are critical to being able to carry out the ‘four criteria’ for x-ray interpretation. Externally visible length-markings enable accurate measurement for insertion and identification of any subsequent tube displacement. Purchasing policies and stock control are required to ensure no unintended reversion to unsafe supplies. No local or national clinical guidance should amend this requirement. X-ray request forms clearly state that the purpose of the x-ray is to establish the position of the nasogastric tube for the purpose of feeding or the administration of medica To ensure the radiographer provides an x-ray that allows for the interpretation of the four criteria for gastric placement described below. To ensure the radiologist’s report gives a definitive view on the position of the nasogastric tube for this purpose. No local or national clinical guidance should amend this requirement Staff have access to a validated report within the PACS system (the IT system which sits behind Radiography). There will be a validated report within the PACS system for sign off by medical staff. It is suggested that this could be
Staff training, competency frameworks and supervision are reviewed to ensure that all healthcare professionals involved with nasogastric tube position checks have been assessed as competent. Competency training should include theoretical and practical learning. A National Patient Safety Agency audit of 166 junior doctors identified that only 31% had received training or formal guidance on the use of x-ray for checking nasogastric tube placements. The Review of incidents in this resource set suggests that x-ray checks or pH testing appear to have been carried out by staff who had not received competency-based training, and therefore did not follow the safety-critical requirements. Elearning is available for some aspects of confirming nasogastric tube placement, but uptake of this via NHS elearning platforms is very low.11 This requirement can be linked to the structured documentation required above by including in that a requirement to note that competency has been assesse No local or national clinical guidance should allow staff who have not been assessed as competent to confirm nasogastric tube placement. In policy and competency checklist. Staff training is annual as a minimum. HCAs are trained in CCN teams to manage and check nasogastric tubes.
Nasogastric tubes should only be placed when senior support for placement and placement confirmation is readily available Earlier NPSA advice referred to avoiding placement ‘out-of-hours’. The rationale for this was the greater risk of error by junior and less experienced staff confirming nasogastric tube placement in evenings and at night. The rationale of not placing tubes except where there is relevant senior and experienced support (nursing, medical and radiology) remains, but it is recognised availability of senior staff will vary between organisations and services and so cannot be defined as simply as within or outside ‘normal hours No local or national clinical guidance should allow nasogastric tubes to be placed at times when staff cannot access relevant senior support for placement confirmation Unless there are essential drugs required then nasogastric tubes should not be inserted out of normal working hours. Parents are advised to contact the OUH if they are unsure. Health staff would only do this between 8-8 when there would be senior staff around and to go to the local general hospital out of hours. Clinical policies, protocols and patient documentation (whether paper or electronic patient records) are designed to help staff comply with these safety Structured documentation reinforces training and protocols and helps staff carrying out nasogastric tube placement checks to remember and follow the appropriate steps. Structured documentation helps the rest of the clinical team identify key safety information. No local or national clinical guidance should amend this requirement. Forms are uploaded
critical requirement Clinical policies, protocols and patient documentation (whether paper or electronic patient records) are designed to help staff comply with these safety critical requirements Structured documentation reinforces training and protocols and helps staff carrying out nasogastric tube placement checks to remember and follow the appropriate steps. Structured documentation helps the rest of the clinical team identify key safety information. No local or national clinical guidance should amend this requirement. Revised policy An ongoing audit programme is put in place to monitor compliance and act on any identified gap Reliable implementation of safety-critical requirements can only be achieved if compliance is routinely monitor No local or national clinical guidance should amend this requirement. Audit to be completed in 6 months (by nominated lead in each service) - end July/August 2016
in use in different clinical departments in an organisation. Are you confident nasogastric tubes or pH paper not meeting these safety-critical requirements have been removed from all areas? Competency-based training Training needs to reflect all the requirements summarised in this resource set. Not all trusts appear to have created training programmes, or levels of training completion had not been routinely monitored and had lapsed. Some incident investigations suggested that trusts had seen training as unnecessary for experienced or senior nursing staff, but the risks of them continuing to use incorrect techniques that predated the NPSA and NHS England alerts may be greater. In some trusts there seemed to be an assumption that consultants did not require training in x-ray interpretation, but investigations have demonstrated that errors are made by consultants and not just junior staff. Some trusts appeared to assume that newly registered nursing staff or junior doctors must already have had these competencies assessed in their training; this is not necessarily so. Some training programmes appeared theoretical rather than assessing competency. Organisations had not recognised that having an up-to-date register of staff who have the appropriate competencies is key to ensuring nursing staff avoid asking doctors not ‘on the list’ to confirm nasogastric tube placement. Investigation reports describe medical staff using the unsafe and outmoded ‘whoosh test’ or giving incorrect advice to nursing staff in relation to obtaining and Are you confident the content of your local training programme accurately reflects all the safety critical requirements summarised in this resource? Are you confident that all clinical staff (regardless of profession or level of seniority) who confirm nasogastric tube placement by pH or x-ray have been assessed as competent through theoretical and practical learning? Are you confident there is a process to monitor and review competency? Can frontline staff easily identify staff who have (and who have not) been assessed as competent in the interpretation of x-rays for confirming nasogastric tube placement? Only radiologist from acute hospital critical