Nasogastric Tube Insertion for Eternal Feeding in Babies and Infants - Assignment Example

 Skill Development Assignment: Nasogastric Tube Insertion For Enteral Feeding In Babies And Infants Nasogastric (NG) tubes are mainly used for feeding, deflation and drainage. The placement of NG tubes in infants is a common practice undertaken by nurses and increasingly by cares. It is often the responsibility of the paediatric nurse to ensure that a NG tube is properly sited. The prevalence of tube errors is not easy to ascertain because of the differing descriptions across the reported studies. However Ellett and Beckstrand (1999) reported tube error rates in infants as high as 43.5 per cent. Verifying the placement of a NG tube is not only vital on insertion but also on subsequent use. Coughing, sneezing and vomiting are all common causes of tube displacement in infants (Guenter and Silkroski 2001). NG tubes can easily be displaced on placing or after placement has been confirmed and often with no accompanying clinical signs (Metheny et al 1986). Even though displaced NG tubes carry associated morbidity and mortality, many nurses continue to be uninformed of the potential risks associated with their insertion and subsequent management (Cannaby et al 2002). If insertion of the NG tube cannot be confirmed it should be removed and repositioned. There can be a reluctance to replace a NG tube because of the known distress caused to infants, staff (Holden et al 1997). Additional time and resources are essential for the necessary psychological preparation of the child. In addition, any vagueness in tube placement may lead to inadvertent removal of a correctly positioned tube, with unpleasant consequences for the infant. In the event that prompted this review, two experienced nurses had followed recommended practice but a nasogastric tube was displaced in a conscious young person, resulting in pneumonitis. When not capable to obtain aspirate, the nurses used auscultation and confirmed the presence of a 'whoosh' of air. They proceeded to use the nasogastric tube to administer drugs and the child remained asymptomatic during and for a substantial period following the course of action. Making a culture that helps institutions to learn from mistakes and embed lessons into practice is essential to clinical governance. The local clinical governance group understood the severity of this incident and, following an extensive review, developed an evidence-based algorithm for the management of nasogastric tubes in infants. Consequently, the National Patient Safety Agency (NPSA) published an alert containing similar guidance (NPSA 2005). But, there remains no dependable 'bedside' method to ultimately determine the position of nasogastric tubes; there remains the potential that the tube will be displaced in some infants. This piece of writing reviews the assumptions surrounding nasogastric tube feeding in infants and describes the development of the algorithm and its subsequent implementation within clinical practice. Techniques for determining placement A number of evidence-based and ritualistic techniques co-exist throughout clinical practice to confirm tube placement. Radiography is the recommended method but financial costs, radiation risks and potential delays limit its use (Metheny et al 1997). Radiography only verifies tube positioning at the exact time of X-ray; it does not allow for any displacement that may occur subsequently. With growing numbers of infants being tube fed at home and in school (Sidey and Torbet 1995) radiography is impractical (Puntis 2001). The practice of auscultation (listening for a 'whoosh' when air is insufflated down the tube) has been resolutely embedded into nursing culture. Auscultation is undependable because bowel and chest sounds can be easily confused (Colagiovanni 1999). The dependability of this method is not influenced by the practitioner's level of experience: when Metheny et al (1990) tested experienced nurses' capability to predict tube placement using auscultation their predictions were no more accurate than chance. Other unverified methods to determine NG tube placement include inspection of the type and quantity of aspirate obtained. It can be wrongly assumed, if feed is aspirated, that the NG tube is correctly located in the stomach. However, the aspirated feed could be the remnants of an earlier administration down a displaced tube. Assuming the NG tube is properly positioned if the tape fixings are intact is not safe practice because NG tubes can migrate from the stomach without disturbing the tape (Metheny et al 1986). In addition, the tube may have been displaced on insertion. Placing the end of the NG tube in water to examine for the bubbling of air from the respiratory tract is unproven and can place the child at risk of aspiration (Rakel et al 1994). NG tubes can be displaced with no accompanying clinical signs (Metheny et al 1986), therefore relying on deterioration in the infant's condition is unreliable. In spite of this evidence some paediatric nurses continue to depend upon their intuition or experience, a practice that is arguably no safer than guesswork. pH testing There is substantial support for pH testing to find out NG tube placement in adults (Metheny and Titler 2001, Colagiovanni 1999). The pH level is obtained by placing aspirate onto pH paper and comparing the resulting colour change against a chart. Blue litmus paper is a common alternative that turns pink on contact with acidic solutions. Blue litmus paper involves no comparisons of colour charts or risks of discrepancies in readings as can occur in pH paper. Most users prefer litmus paper and find its potential inexactness difficult to accept (Cannaby et al 2002). Characteristically, gastric aspirate should have a lower pH than intestinal or respiratory secretions. Reviewing pH levels across a range of studies reveals that gastric position can safely be presumed with pH values of 5.5 or less (Metheny et al 1999). However, the pH technique is less useful to distinguish pulmonary from intestinal placement because both samples show pH levels higher than 5.5 (Metheny et al 1999). There are limitations with pH testing when the pH levels fall outside expected norms. Metheny et al (1993) found gastric pH fell outside expected norms in 18 per cent of adult aspirates tested. The use of pH testing in infants is contentious as gastric acidity may not be at the same level as in adults (Koren 1997). Prominently, the effects of gastro-oesophageal reflux on gastric and respiratory pH in infants are not yet determined. Gastrooesophageal reflux is common in babies, neonates and neurologically impaired children. It can cause chronic aspiration, oesophagitis, gastritis and can affect feeding (Hockenberry et al 2002). Associated conditions of gastro-oesophageal reflux such as gastritis, differing feeding formulas and drugs such as acid inhibitors and H2 receptor blockers used in the treatment of reflux, are known to influence gastric pH (Metheny and Titler 200l). Research in adults recommend waiting one hour post dose or feed before testing pH, but this may not be enough time in infants because their absorption rates can differ (Hockenberry et al 2002). pH testing is at present the recommended bedside method to determine NG tube placement in infants (NPSA 2005). While pH testing is valuable for infants in whom gastric pH falls within normal limits, the numbers of infants in whom this applies is unknown. Change in methods The children's services practice group (CSPG) a local, multidisciplinary group used the 'Five whys tool' (Senge et al 1994) to examine this reported incident. This simple tool involves asking, 'Why the incident occurred?' and with each answer, asking 'why?' again. The procedure is repeated five times thus enabling a comprehensive root cause analysis of the incident. The results of the analysis highlighted the following vulnerabilities in the existing methods for testing placement of NG tubes: – lear guidelines were not available – practice had been built upon cultural routines and assumptions rather than best evidence – a lack of awareness existed across the multidisciplinary team of the risks associated with NG tube management. There was evidently the potential for a number of infants and young people being put at risk. A stakeholder group was created across the trust, the local primary care trust, the university, and users. This group first 'process mapped' the issues surrounding NG tubes in infants. An evaluation of the literature confirmed that studies into NG tube placement were pioneered by the work of Norma Metheny in the late 80s. There is limited new information and these studies have not been replicated in infants, probably due to the associated ethical issues. A symposium of key professionals and user representatives was held, and experience, skills and judgments were used along with the best available evidence to develop an algorithm on the management of NG tubes in infants. Best practice statements were developed using the Essence of Care model (DH 2001) and the group benchmarked current practice within and outside of the trust. This baseline evaluation highlighted the gaps between the existing practice and benchmarked best practice, and enabled effective planning of resources to initiate change. The dealing with NG tubes is not limited to nursing staff but also involves parents, respite carers, community and school nurses. Practice in all these groups required change and standardisation. Implementation was progressive across the NHS and primary care trusts. Practical exhibitions challenged firmly embedded assumptions. Potential risks Full transparency of local and national unpleasant incidents helped raise awareness of potential risks and encouraged staff involvement early in the change process. However, powerful assumptions and ritualistic practices surrounded the management of NG tubes in infants. The assumptions were gathered together by the working group and termed the 'Rock of Assumptions'. These included: – litmus paper is preferred – auscultation is effective – type and quantity of aspirate identifies placement – NG is correct if tape undisturbed – X-ray is useful – experience and intuition count – misplacement is rare – high pressure associated with larger syringes – can't aspirate small bore tube – clinical signs are apparent. The analogy was to chip away at the 'rock' piece by piece. Evidence and rationale were offered to contest each assumption, allowing practice to change and develop. Syringe pressures are an example of an assumption. The algorithm supports the use of larger bore syringes (minimum 30ml) with NG tubes. High pressures were wrongly associated with larger syringes instead of smaller ones. The excess pressure exerted by smaller syringes can collapse the NG tube making aspiration difficult, while small-bore tubes (such as those used in paediatrics) have been known to burst with excessive pressure (Rollins 1997). A neonatal consultant designed a practical device to illustrate pressures exerted by various sized syringes in an effort to change these convictions. In the same way, before the introduction of the algorithm it was usually considered difficult to aspirate from small-bore tubes. The success rate within studies varies but Metheny et al (1999) reported a success rate of 93.8 per cent. Although the suggested methods for improving aspirate collection are valid (Huband and Trigg 2000) lack of evidence-based guidelines means that the appropriate action to take when unable to aspirate remains unclear. This can lead to the use of variable, unproven practice or unnecessary replacement of the NG tube. Evidence-based instructions are included within the algorithm and subsequently difficulties with obtaining aspirate have become less frequent. Risk assessments in infants The project was assessed at three and six months post implementation using benchmarking of primary care areas against the baseline best practice statements. An audit of risk assessments in infants, a staff questionnaire and a review of reported adverse incidents were also undertaken. At the three month evaluation, there was recognition of increasing numbers of children with pH levels between 6 and 6.5. At this pH level, gastric placement cannot be confirmed. Waiting one hour post feed or medication appeared to make no change to the pH values in some infants, similarly with those infants on continuous or frequent feeds. Radiography was rapidly discounted as a feasible option because of the anticipated frequency of use. X-raying at intervals to check position of the tube would be unhelpful because of the risk of displacement between X-rays. A risk evaluation is recommended in such circumstances. This involves identifying associated risks and benefits of each situation and balancing them against one another, allowing the safest or most desirable route to be taken. In the case of a child requiring NG feeds the benefits of having the NG feed are compared to the risk of likely displacement of the tube. Risk assessment should be performed collaboratively with the multi-disciplinary team, carers and the infant. Informed consent is essential to the process. Although risk assessment cannot establish NG tube positioning it offers individualised assessment and allows the decision-making processes to be recorded. Eliminating risks The use of the algorithm efficiently does not eliminate the risk of the NG tube being inadvertently displaced, consequently its effectiveness may be challenged. However, its use contributes to patient safety by increasing confidence and awareness of the issues surrounding the safe placement of NG tubes in infants. Risk assessment facilitates informed decision making and advocates infant and parent involvement. Since introduction of the algorithm a greater emphasis has been placed on education. A tradition of respect has been cultivated. Increased teamwork between professionals has positively impacted on other aspects of the infant's care. Staff and users are recognising the benefits of risk assessment in strengthening decision-making procedures. The algorithm is not solely based on published studies, but also on the precious experiences and judgments of its stakeholders, generating a sense of ownership and resulting in enhanced compliance. Despite this, paediatric nurses have found it difficult to abandon old and trusted ways. Methods that were previously taught and shared with others are now deemed unsafe. Conclusion Even though pH testing can be a precious method for determining tube placement in some groups of infants, for others the risk of unintentional displacement still exists. 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