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Nasogastric Tube

Placement Verification
Continuing
Nursing
In Pediatric and Neonatal
Education
Series
Patients
Michele Farrington Laura Cullen
Sheryl Lang Stephanie Stewart

This article reports an evidence-based practice project using the Iowa Model of Evidence-Based Practice to
Promote Quality Care for a common nursing procedure, nasogastric tube placement verification in children.
Little research exists regarding the care of nasogastric tubes in children, and traditional verification methods
prevail. Auscultation of air insufflation over the abdomen is still used to check placement in many settings,
despite research dating back to the 1980s questioning this approach. X-ray remains the only certain way to
verify placement, but getting an X-ray before each feeding would be costly and impractical. Additional bedside
methods are needed. Project results demonstrate a decrease (93.3% to 46.2%) in the use of auscultation and
improved use of other, more reliable methods to determine nasogastric tube placement. Changing practice can
be challenging. However, with persistence and re-infusion, this project provides an important example of how
the evidence-based practice process leads to excellence and improves patient care.

ediatric nurses have always based on the strongest research evi- minimize the risk of incorrectly placed

P been strong advocates of pro-


viding high-quality patient care.
The evidence-based practice
process offers an opportunity to
support updating nursing practice
dence available, in combination with
patient and family values and sound
clinical judgment (Sackett, Straus,
Richardson, Rosenberg, & Haynes,
2000). Using the evidence-based
NG tubes. The Iowa Model of Evidence-
Based Practice to Promote Quality
Care (Titler et al., 2001) provided a
guide for completing the project, and
support was provided through the
practice process results in improved Evidence-Based Practice Staff Nurse
patient outcomes, often while reduc- Internship (Cullen & Titler, 2004).
Michele Farrington, BSN, RN, is a Staff
ing costs, and provides an opportuni-
Nurse, Department of Nursing Services and Evidence-Based Practice
Patient Care, University of Iowa Hospitals ty for bedside clinicians to demon-
and Clinics, Iowa City, IA. strate an important impact on health Process
care. Traditional nursing practices The Iowa Model of Evidence-
Sheryl Lang, MA, RN, CPNP, CNA-BC, is a
provide a wonderful opportunity to Based Practice to Promote Quality
Nurse Manager, Department of Nursing
Services and Patient Care, University of question practice and potentially Care successfully promotes the inte-
Iowa Hospitals and Clinics, Iowa City, IA. improve patient care, which can be gration of evidence into practice. The
very empowering for staff nurses. model shown in Figure 1 outlines the
Laura Cullen, MA, RN, FAAN, is an
Nasogastric (NG) tube placement process for developing an evidence-
Evidence-Based Practice Coordinator,
Department of Nursing Services and is a routine procedure used for pedi- based practice project. Identifying a
Patient Care, University of Iowa Hospitals atric and neonatal patients. However, practice problem or new knowledge
and Clinics, Iowa City, IA. little research exists regarding the ver- triggers the evidence-based practice
ification of NG tubes in children. process. Leaders in the health care
Stephanie Stewart, MSN, RNC, is an
Advanced Practice Nurse, Department of Several clinical studies and anecdotal facility or on the nursing unit prioritize
Nursing Services and Patient Care, reports questioning the use of auscul- issues to be addressed and then
University of Iowa Hospitals and Clinics, tation to verify NG tube placement assemble a team. The team selects,
Iowa City, IA. have been reported, some dating back reviews, critiques, and synthesizes
Statements of Disclosure: The authors more than 20 years (Ghahremani & evidence in the literature. If the
reported no actual or potential conflict of Gould, 1986). However, the vast research evidence is sufficient, the
interest in relation to this continuing nursing majority of nurses continue to check team initiates change. If the evidence
education series. NG tube placement by auscultation of is insufficient, the team reviews other
All Pediatric Nursing Editorial Board mem- air insufflation over the abdomen. evidence or suggests more research.
bers reported no actual or potential conflict The team then pilots and evaluates
of interest in relation to this continuing nurs- Purpose the practice change to determine if the
ing education series. The purpose of this evidence-based change worked or whether revisions
practice project was to improve and are needed before integrating and
standardize NG tube placement verifi- applying the change in other clinical
cation practices used throughout a areas. Additional evaluation and dis-
Objectives and the Midwestern children’s hospital. An evi- semination of results is essential to
CNE posttest can be dence-based practice approach was fully integrate the change into practice.
found on pages 25-26. used to outline nursing practice and to This project began as a knowledge

PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1 17


Figure 1.
The Iowa Model of Evidence-Based Practice to Promote Quality Care

Problem Focused Triggers Knowledge Focused Triggers


1. Risk Management Data 1. New Research or Other Literature
2. Process Improvement Data 2. National Agencies or Organizational
3. Internal/External Benchmarking Data Standards & Guidelines
4. Financial Data 3. Philosophies of Care
5. Identification of Clinical Problem 4. Questions from Institutional Standards Committee

Is this Topic
Consider No a Priority
Other
For the
Triggers
Organization?

Yes

Form a Team

Assemble Relevant Research & Related Literature

Critique & Synthesize Research for Use in Practice

Is There
Yes a Sufficient No
Research
Base?

Pilot the Change in Practice


1. Select Outcomes to be Achieved
2. Collect Baseline Data Base Practice on Other Types of Evidence: Conduct
3. Design Evidence-Based 1. Case Reports Research
Practice (EBP) Guideline(s) 2. Expert Opinion
4. Implement EBP on Pilot Units 3. Scientific Principles
5. Evaluate Process & Outcomes 4. Theory
6. Modify the Practice Guideline

Is Change
Continue to Evaluate Quality No Appropriate for Yes
Institute the Change in Practice
of Care and New Knowledge Adoption in
Practice?

Monitor and Analyze Structure,


Process, and Outcome Data
Disseminate Results
• Environment
• Staff
• Cost
• Patient and Family

DO NOT REPRODUCE WITHOUT PERMISSION


= a decision point
REQUESTS TO:
Department of Nursing
Reference The University of Iowa Hospitals and Clinics
Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, B.A., Budreau, G., Everett, L.Q., Buckwalter, K.C., Iowa City, IA 52242-1009
Tripp-Reimer, T., & Goode C. (2001).The Iowa Model of Evidence-Based Practice to Promote Quality
Care. Critical Care Nursing Clinics of North America, 13(4), 497-509. Revised April 1998 © UIHC

Copyright © 2001. University of Iowa Hospitals and Clinics and Marita Titler. Reproduced with permission from Marita G. Titler, PhD,
RN, FAAN. For permission to use or reproduce the model, please contact the University of Iowa Hospitals and Clinics, Department
of Nursing, at 319-384-9098.

18 PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1


Nasogastric Tube Placement Verification in Pediatric and Neonatal Patients

focus trigger with new information (Wilkes-Holmes, 2006). Expanded Titler, 2001; Swiech et al., 1994).
suggesting use of a patient’s height search strategies included personally However, studies have shown that the
and a graph (graphic method) as a contacting experts about their work expected pulmonary symptoms may
better method for determining depth regarding NG tubes in pediatric not be present to indicate there is a
of NG tube insertion in children patients (J. Beckstrand, personal problem until shortly after the feeding
(Klasner, Luke, & Scalzo, 2002). The communication, April 12, 2003; A.E. has been initiated, as evidenced by
team was developed to support the Klasner, personal communication, symptoms such as shortness of
staff nurse as the project director April 2, 2003 and April 3, 2003; N.A. breath, fever, and even respiratory
through the Evidence-Based Practice Metheny, personal communication, arrest (Swiech et al., 1994). It is also
Staff Nurse Internship. An extensive April 2, 2003). important to remember that these
literature review was conducted, cur- In adult patients, the rate of NG signs may be absent in either uncon-
rent practice was evaluated, and prac- tube misplacement ranges from 1.3% scious patients or those with a poor
tice changes were implemented utiliz- to 89.5% (McWey et al., 1988; Niv & gag reflex (Colagiovanni, 1999).
ing a variety of strategies. This change Abu-Avid, 1988), depending on how Soft, small-bore NG tubes are less
was evaluated at multiple points fol- the error is defined, and averages likely to cause complications and also
lowing implementation. This article about 4% (Ghahremani & Gould, reduce the risk of aspiration because
reports some of the more interesting 1986; Kearns, 1997). The prevalence the lower esophageal sphincter is less
results and processes used to imple- of NG tube placement errors in chil- compromised, decreasing the risk of
ment this change. dren is difficult to determine because reflux (Boyes & Kruse, 1992;
of the differing definitions across stud- Metheny, 1988), but they may migrate
Synthesis of Evidence ies; however, rates of misplacement in out of position, knot, occlude, or rup-
The project began in 2003, with lit- children have been reported at 21% to ture (Williams & Leslie, 2004).
tle evidence supporting use of height 43.5% (Ellett & Beckstrand, 1999; Negative pressure generated when
and the graphic method to determine Ellett et al., 2005; Ellett, Maahs, & attempting to aspirate fluid can cause
proper insertion depth for NG tubes. Forsee, 1998), which is concerning these flexible NG tubes to collapse.
Therefore, the project focus changed for these vulnerable infants and chil- Certain types of NG tubes are report-
from measuring for tube insertion to dren (Crisp, 2006). Poor reporting of ed to collapse in 50% of aspiration
using other evidence-based methods tube misplacement has hindered the attempts (Gharib et al., 1996; Rakel,
to ensure NG tube placement verifica- adoption of effective protocols to pre- 2004). In these cases, nurses are
tion. vent such errors (Metheny et al., unable to use aspiration of gastric
The traditional method of assess- 2007). In children, several risk factors contents as a method to verify NG
ing NG tube placement has been aus- have been identified for initial tube tube placement (Ellett & Beckstrand,
cultation over the abdomen after air misplacement or subsequent dis- 1999; May, 2007; Metheny et al.,
insufflation because it is a simple and lodgement, including age (younger), 1986; Metheny, Stewart et al., 1999).
low-cost method (Eisenberg, 1994), is level of consciousness (comatose or In some situations, even if fluid is not
easy to perform (Metheny, Wehrle, semicomatose), abdominal distention, obtained with aspiration, the NG tube
Wiersema, & Clark, 1998), and was vomiting, and dysphagia (Ellett & is later found to be properly positioned
taught for years in nursing schools. Beckstrand, 1999; Ellett et al., 1998). by another verification method, usual-
Although this is a frequently used Although NG tubes are identified ly X-ray (Swiech et al., 1994).
method in the clinical setting, research as being misplaced infrequently, sig- However, aspiration of fluid alone is no
literature does not support the reliabil- nificant adverse outcomes can result, guarantee that the NG tube is correct-
ity of this method (Ellett, 2004; Ellett, such as aspiration pneumonia or ly placed in the stomach (Widmann,
Croffie, Cohen, & Perkins, 2005; pneumothorax (Burns, Carpenter, & 1985).
Metheny, Aud, & Ignatavicius, 1998; Truwit, 2001). Tube misplacement Ellett (2004) published the follow-
Metheny, Meert, & Clouse, 2007; into the lungs is most common and ing information regarding methods to
Swiech, Lancaster, & Sheehan, 1994; is estimated to occur in 5% of all NG determine NG tube placement that
Winterholler & Erbguth, 2002), and tube insertions (Ellett, 2004), and have been studied in adults: aspirating
malpractice cases have been based on feeding through an NG tube mis- gastric contents and measuring the
this research (McWey, Curry, Schabal, placed into the airway will result in pH; measuring bilirubin, pepsin, and
& Reines, 1988; Metheny, Wehrle et al., pulmonary aspiration (Ellett et al., trypsin levels; examining the visual
1998). The primary problem with aus- 1998). Even when the NG tube characteristics of the aspirate; placing
cultation is that sounds can be trans- remains taped in place, the tube’s the proximal end of the tube under
mitted to the epigastrium regardless of distal tip could spontaneously shift water and observing for bubbles with
whether the NG tube is placed in the upward or downward from its origi- expiration; measuring the carbon
lung, esophagus, stomach, duode- nal position (Huffman, Pieper, dioxide (CO2) level at the proximal
num, or proximal jejunum (Cannaby, Jarczyk, Bayne, & O’Brien, 2004; end of the NG tube; auscultating for a
Evans, & Freeman, 2002; Eisenberg, Metheny, Spies, & Eisenberg, 1986; gurgling sound over the abdomen;
1994; Ellett & Beckstrand, 1999; Richardson, Branowicki, Zeidman- and measuring the length from the
Gharib, Stern, Sherbin, & Rohrmann, Rogers, Mahoney, & MacPhee, nose to the proximal end of the tube.
1996; Metheny, McSweeney, Wehrle, & 2006), something that is even more In the end, the conclusion for adult
Wiersema, 1990; Metheny, Wehrle et likely with the soft, small-bore NG patients was that only pH and bilirubin
al., 1998). tubes (Sanko, 2004). When placing of aspirates have proven to be reliable,
The majority of research or evi- NG tubes, it is common to observe for inexpensive bedside tests. Aspiration
dence regarding the use of NG tubes is coughing or cyanosis because they of gastric contents and pH measure-
in adult patients and was pioneered by may indicate respiratory placement ments are both simple and cost-effec-
Norma Metheny in the late 1980s with (Boyes & Kruse, 1992; Chen, Paxton, tive ways to determine NG tube place-
scant evidence for pediatric patients, & Williams-Burgess, 1996; Metheny, ment (Chen et al., 1996; Westhus,
possibly due to ethical considerations Smith, & Stewart, 2000; Metheny & 2004). Based on the work completed

PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1 19


for adult patients (Rakel, 2004; Rakel Table 1.
et al., 1994), the pH of an aspirate Pediatric Nasogastric Tube Standard of Practice
obtained from the stomach would
range from 1 to 4, unless the patient is 1. Verification of NG tube placement is required at the following times:
receiving an H2 receptor antagonist, a a. After initial tube insertion.
proton pump inhibitor, antacids, or b. Before each intermittent feeding.
tube feedings, any of which would c. Before medication administration.
falsely increase the pH of the aspirate d. Once a shift (or every 8 hours) with continuous feedings.
and make pH analysis less reliable
(May, 2007). For both adults and chil- 2. Verification methods
dren, use of pH testing as the only ver- a. Upon initial NG tube placement, an X-ray is recommended to confirm prop-
ification method is inadequate er placement before initiation of feedings or medication administration. X-ray
because of overlap in pH among sites is required in PICU (American Association of Critical-Care Nurses, 2005).
(Ellett & Beckstrand, 1999; Metheny, b. If an X-ray was not obtained, verify NG tube placement by two of the follow-
Stewart et al., 1999). The pH method ing methods:
is usually effective in differentiating i. Confirm the mark on the tube is at the point it exits the nare. (Remove
between gastric and respiratory or and replace the NG tube if it is not marked and will be used for feedings
gastric and intestinal placement of an and/or medication administration.)
NG tube because gastric fluid typical- ii. Aspirate small amount of gastric contents and evaluate color (clear, light
ly has a much lower pH than either yellow, or light green).
intestinal or respiratory fluid (Chen et iii. Test aspirate pH (unless patient is receiving an H2 receptor antagonist or
al., 1996; Metheny et al., 1990). proton pump inhibitor) using pH paper (on units with competencies main-
However, the pH method is less effec- tained for pH testing at the point of care) or laboratory analysis (stomach
tive in distinguishing between intestin- placement: pH 1-4).
al and respiratory fluids because both
have higher pH values (Metheny et al.,
2000). Another method for bedside
verification of NG tube placement is Kearns, 1997; Metheny, 1988; child or neonate (Ellett & Beckstrand,
by aspiration of gastric contents and Metheny, Stewart et al., 1999), and it 1999; Kearns, 1997; Metheny, 1988;
assessing color (clear, light yellow, or only confirms tube positioning at the Metheny, Eikov, Rountree, & Lengettie,
light green) (Freer & Lyon, 2005; exact time of the X-ray (Wilkes- 1999; Richardson, et al., 2006). There
Weibley, Adamson, Clinkscales, Holmes, 2006). The use of X-rays to are some new non-invasive magnetic
Curran, & Bramson, 1987). A third verify NG tube placement at the imaging techniques being studied for
bedside verification method is con- beginning of every feed or simply as a visualizing the placement of NG tubes,
firming the tube is secured and verify- means to ensure correct NG tube so X-rays would not be needed.
ing the mark on the tube is at the point placement is not practical, could be However, more research is necessary
it exits the nare (Freer & Lyon, 2005; inappropriate, dangerous, and costly before practice changes to these tech-
Metheny, 2006; Metheny et al., 2007; (Christiansen, 2001; Ellett, 2004; niques (Bercik et al., 2005). In addition
Metheny & Stewart, 2002; Metheny & May, 2007; Metheny, 1988; Metheny to new imaging techniques, use of
Titler, 2001; Viall, 1996; Weibley et al., et al., 1993). X-rays are not only height as a parameter for insertion
1987). expensive and expose patients to radi- length (Beckstrand, Ellett, & McDaniel,
Using more than one bedside ation, a greater concern in young chil- 2007) offers some promise, but more
assessment method to verify NG tube dren than in adults (Premji, 2005), but research is needed, particularly for
placement is superior to any single also require licensed independent ongoing placement verification. The
placement-verification method used practitioner interpretation and usually literature also suggests verifying NG
alone (Arbogast, 2002; Bockus, 1993; cannot be done in outpatient settings tube placement following initial tube
Ellett & Beckstrand, 1999; Metheny & (Bercik et al., 2005; Eisenberg, insertion, at least once per shift with
Meert, 2004; Metheny, Reed, Berglund, 1994). However, periodic chest or continuous feedings, before each
& Wehrle, 1994). If there is ever a abdominal X-rays may be helpful for intermittent feeding, and before med-
doubt regarding NG tube placement NG tubes used for a longer length of ication administration (Bockus, 1993;
following completion of bedside time in order to help detect tube mis- Bowers, 2002; Colagiovanni, 1999;
placement verification methods, the placement, knot formation, or clinical- Eisenberg, 1994; Metheny, 1988;
licensed independent practitioner ly silent aspiration (Ellett et al., 1998; Metheny, Clouse et al., 1994;
should be consulted about obtaining Ellett et al., 2005; Gharib, et al., 1996; Metheny, Reed et al., 1994; Metheny
an X-ray (Ellett, 2004; Grant & Martin, Metheny et al., 1986). Sometimes et al., 1993; Metheny & Titler, 2001;
2000; May, 2007; Metheny & Titler, patients have chest or abdominal X- Viall, 1996).
2001; Sanko, 2004; Williams & Leslie, rays taken for other reasons, which
2005), or the NG tube should be might also reference correct NG tube Practice Change: Hospital Policy
removed and a new one placed placement, and should be taken Based on the evidence in the liter-
(Wilkes-Holmes, 2006). advantage of when available (Metheny ature, the pediatric standard of prac-
X-ray remains the only 100% reli- & Titler, 2001). tice, briefly described in Table 1, was
able method to document NG tube Given the reported frequency of updated and will continue to be
placement (Ellett, 2004; Ellett, et al., NG tube misplacement found in the reviewed at least every three years per
2005; Marderstein, Simmons, & Ochoa, literature for pediatric patients, the hospital policy. When an aspirate can-
2004; Metheny et al., 2007), but it value of obtaining X-ray verification of not be obtained from an NG tube,
must show the full course of the tube NG tube placement upon insertion nurses can use any or all of the strate-
and where the tip and ports are locat- may outweigh the expense and radia- gies listed in Table 2 (Metheny, Wehrle
ed (Ellett & Beckstrand, 1999; tion exposure an X-ray would cause a et al., 1998) to help facilitate obtain-

20 PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1


Nasogastric Tube Placement Verification in Pediatric and Neonatal Patients

Table 2. The questionnaire addressed both


Strategies to Help Facilitate Obtaining an Aspirate nursing knowledge and nursing pro-
cess. Nursing knowledge about signs
1. Use a larger-sized syringe (to decrease the pressure created by the plunger). and symptoms of NG tube misplace-
ment was evaluated. Pediatric nurses
2. Reposition the patient (to move the NG tube away from the stomach wall).
were knowledgeable about signs and
3. Instill a small amount of air (to move the NG tube away from the stomach wall). symptoms of NG tube misplacement
If instillation of air is unsuccessful, the NG tube may be kinked or dislodged and both before and after implementation
should be removed and replaced. of the practice change, but knowledge
4. Wait 5 to 30 minutes before trying again to obtain an aspirate. was determined to be somewhat high-
er in the post-questionnaire (correctly
answered items regarding various
signs and symptoms of aspiration,
Table 3. 87.6% pre: n = 312/356 to 94.4%
Project Timeline post: n = 272/288).
Nursing care of pediatric patients
February 2003: Project Initiation
with an NG tube was assessed through
February 2003-December 2003: Literature Review and Synthesis a nursing process questionnaire. A
large number of nurses (n = 83/89;
October 2003: Pre-Survey
93.3%) on the pre-questionnaire
November 2003-February 2004: Revise Pediatric NG Tube Standard of Practice responded that they check NG tube
placement by auscultation of air insuf-
March 2004: Post-Survey
flation over the abdomen. The same
January 2007: Follow-Up Survey was true on the initial post-question-
naire (n = 69/72; 95.8%); however,
there was also a demonstrated
increase in the number of nurses
ing an aspirate to verify NG tube rent practices, knowledge, and report- checking NG tube placement through
placement. ed complications related to NG tube three additional measures: verifying
Occasionally, an aspirate cannot cares. It was evident that practice was that the measured mark is aligned at
be obtained. If all bedside methods are neither standardized nor evidence- the nare, aspirating gastric contents,
tried and found to be unsuccessful in based as demonstrated in Figures 2 and measuring the pH of the aspirate
verifying NG tube placement, a nurse and 3. using evidence-based approaches.
may instill 1 to 2cc of sterile water and Education was provided to the These numbers are similar to the 86%
observe the patient for symptoms of nurses by sharing existing evidence of nurses who regularly use ausculta-
aspiration (such as apnea, bradycar- using a PowerPoint™ presentation, a tion to check NG tube placement
dia, coughing, decreased oxygen satu- one-page flier, and a poster that was reported by Persenius, Larsson, and
rations, shortness of breath, cyanosis, displayed to highlight policy changes Hall-Lord (2006). On the most recent
or discolored sputum) (Freer & Lyon, and clarifications. Each unit identified follow-up questionnaire, only 46.2%
2005). If no symptoms of aspiration a “change champion” to educate col- (n = 48/104) of nurses responded that
are observed, the nurse may proceed leagues about the practice changes. they use auscultation to check NG
with the feeding while continually The unit change champions were sent tube placement. These numbers
observing the patient for symptoms of reminders and updates via e-mail and demonstrate that ongoing re-infusion
aspiration. Water is not instilled in periodically attended team meetings. is helpful and continues to be neces-
patients in the neonatal intensive care After the NG tube policy revisions sary for practice changes to be inte-
unit (NICU) because fluid intake and were approved, the online documen- grated in the daily actions of nurses
output need to be very closely con- tation system was updated to reflect working at the bedside.
trolled (Verklan & Walden, 2004). If the new policy. The updated docu- Overall, questionnaire results indi-
there is a doubt regarding NG tube mentation system also provides a cated improvement in nurses utilizing
placement following completion of reminder for nurses about frequency evidence-based verification methods
bedside placement verification meth- of cares related to NG tubes. Moving (see Figure 2). Adverse outcomes
ods, the licensed independent practi- the policy change through to integra- related to NG tube misplacement are
tioner should be consulted about tion is one challenge of implementing difficult to track due to the low inci-
obtaining an X-ray. evidence-based practice changes. To dence of aspiration pneumonia related
accomplish this goal, education con- to NG tube misplacement in children.
Implementation Strategies tinues at the unit level through various No incidents of aspiration pneumonia
Implementing practice changes strategies, including yearly competen- were reported from the pediatric units
can be difficult and requires multiple cies (written or demonstration), orien- within the children’s hospital before or
reinforcing and interactive strategies tation for new nurses, and NG tube after the project was implemented.
to be effective (Greenhalgh, Robert, practice quality improvement moni- Staff nurses in the NICU had the
MacFarlane, Bate, & Kyriakidou, tors. most difficulty adopting the practice
2005; Rogers, 2003; Titler, 2008; change. These nurses had not yet
Titler & Everett, 2001; van Achterberg, Evaluation transitioned away from using auscul-
Schoonhoven, & Grol, 2008). This Project evaluation compared base- tation of air insufflation over the
project was no exception; the timeline line data with post-implementation abdomen as a way to verify NG tube
is outlined in Table 3. Nurses through- data. After implementing the practice placement. Barriers to change includ-
out the pediatric division completed a change, nurses were given a question- ed the financial cost and physiological
baseline questionnaire to assess cur- naire to re-assess NG tube practices. stress of obtaining an X-ray prior to

PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1 21


Figure 2. from the previous feeding (Arbogast,
Methods Used to Verify NG Tube Placement 2002). Nurses were reminded of the
methods that could be used to assist
in obtaining an aspirate (see Table 2).
Out of 232 feedings, an inability to
100% 95.8%
93.3% obtain an aspirate occurred only five
88.9%90.4%
90% times; 97% of the feedings had an
aspirate obtained on the first attempt,
80% while 98% of feedings had an aspirate
72.1%
66.3% 66.7%
70% obtained by the second attempt after
some manipulation, numbers similar
60% to those reported by Metheny et al.
Percent

52.8% 50.6% (1989). When an aspirate could not


50% 46.2%
be obtained, NICU nurses were taught
37.5% 41.3%
40% to observe the patient carefully during
29.8% the feeding for signs and symptoms of
30% aspiration (Freer & Lyon, 2005).
21.3% 18.0%
20% After sharing the results of these
quality improvement data and after
10% providing additional education to the
NICU staff, an audit assessed compli-
0
X-Ray Marked at Nare Auscultation pH Aspirate GI ance with this procedure. To verify
Contents that nurses were marking the tube, the
NG tube at the bedside was reviewed
Pre (Oct 2003) Post (Mar 2004) Follow-Up (Jan 2007) to see if a mark was present. After six
months, 86% of NICU patients with
NG tubes had their tubes marked
appropriately. Audits continue on a
monthly basis, with the most recent
Figure 3. audit showing 98% compliance with
Times When NG Tube Placement is Checked marking the tube.

Challenges with Outcome


Measures
100% 93.3%
95.8% 94.2% 95.8%
93.3% 94.4% 98.6% 94.2% Patients with an incorrectly placed
88.8% 87.5%
90% NG tube are at high risk of aspiration
83.1% 83.7%
(Chen et al., 1996). However, there
80% appears to be a lower incidence of
70% aspiration pneumonias in pediatric
patients compared to adult patients,
60% possibly due to sampling limitations
Percent

with quality improvement and the fact


50% that there has been less research con-
40% ducted in the vulnerable pediatric
patient population. Lack of data
30% demonstrating a problem with aspira-
20% tion pneumonia made project imple-
mentation and evaluation more diffi-
10% cult.
0% Next Steps
After insertion Before Medications Before Before Continuous
Bolus Feedings Feedings This evidence-based practice proj-
ect has identified additional areas for
Pre (Oct 2003) Post (Mar 2004) Follow-Up (Jan 2007) practice improvement. NG tube place-
ment is known to be a painful and dis-
tressing procedure. Despite knowing
that NG tube placement is uncomfort-
able, it is usually done without analge-
sia or anesthesia. Currently, informa-
each intermittent feeding (often 8 likely to collapse (Ellett, 2004). The tion is being gathered about the
times per day), and a concern about smaller gastric fluid volumes of amount of pain and distress pediatric
the ability to obtain an aspirate in neonates may also cause difficulty patients experience during NG tube
neonatal patients. Theoretically, the when trying to obtain an aspirate in insertion. The information will be
inability to aspirate fluid is expected to children (Khair, 2005). shared with a multidisciplinary com-
be more likely to occur in children In the NICU, a quality improve- mittee to improve pain management.
because the tubes used for children ment project assessed the ability to The amount of research regarding
are smaller in diameter than those obtain an aspirate, which may include NG tubes in children has been
used for adults, and therefore, more a scant amount of residual formula increasing over recent years, but prac-

22 PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1


Nasogastric Tube Placement Verification in Pediatric and Neonatal Patients

tice changes adopting use of this evi- Colagiovanni, L. (1999). Nutrition: Taking the tutional protocols on adverse events
dence have not occurred at the same tube. Nursing Times, 95(21), 63-64, 67, related to feeding tube placement in the
rate. Despite the fact that auscultation 71. critically ill. Journal of the American
is ineffective, changing long-standing Crisp, C.L. (2006). Esophageal nasogastric College of Surgeons, 199(1), 39-47.
tube misplacement in an infant following May, S. (2007). Critical care. Testing nasogas-
traditional nursing care practices can laser supraglottoplasty. Journal of tric tube positioning in the critically ill:
be difficult. This project demonstrated Pediatric Nursing, 21(6), 454-455. Exploring the evidence. British Journal
that verification of NG tube placement Cullen, L., & Titler, M.G. (2004). Promoting of Nursing, 16(7), 414-418.
in children and neonates is a complex evidence-based practice: An internship McWey, R.E., Curry, N.S., Schabal, S.I., &
patient care issue, and that more for staff nurses. Worldviews on Reines, H.D. (1988). Complications of
research is needed to support many Evidence-Based Nursing, 1(4), 215- nasoenteric feeding tubes. American
pediatric nursing practices. Despite 223. Journal of Surgery, 155(2), 253-257.
the challenges, basing practice on the Eisenberg, P.G. (1994). Nasoenteral tubes. Metheny, N. (1988). Measures to test place-
best available evidence will improve RN, 57(10), 62-70. ment of nasogastric and nasointestinal
Ellett, M.L. (2004). What is known about feeding tubes: A review. Nursing
patient care. The key to evidence- methods of correctly placing gastric Research, 37(6), 324-329.
based practice is involving the staff tubes in adults and children. Gastro- Metheny, N.A. (2006). Preventing respiratory
who “do the work” to ensure their enterology Nursing, 27(6), 253-261. complications of tube feedings:
input in problem-solving and process Ellett, M.L.C., & Beckstrand, J. (1999). Evidence-based practice. American
changes, closing the gap between Examination of gavage tube placement Journal of Critical Care, 15(4), 360-369.
research and practice. in children. Journal of the Society of Metheny, N.A., Aud, M.A., & Ignatavicius,
Pediatric Nurses, 4(2), 51-60. D.D. (1998). Detection of improperly
Ellett, M.L.C., Croffie, J.M.B., Cohen, M.D., & positioned feeding tubes. Journal of
References Perkins, S.M. (2005). Gastric tube Healthcare Risk Management, 18(3),
Arbogast, D. (2002). Enteral feedings with placement in young children. Clinical 37-48.
comfort and safety. Clinical Journal of Nursing Research, 14(3), 238-252. Metheny, N.A., Clouse, R.E., Clark, J.M.,
Oncology Nursing, 6(5), 275-283. Ellett, M.L.C., Maahs, J., & Forsee, S. (1998). Reed, L., Wehrle, M.A., & Wiersema, L.
American Association of Critical-Care Prevalence of feeding tube placement (1994). pH testing of feeding-tube aspi-
Nurses. (2005). Practice alert: Verifi- errors and associated risk factors in rates to determine placement. Nutrition
cation of feeding tube placement. Re- children. MCN: The American Journal of in Clinical Practice, 9(5), 185-190.
trieved December 30, 2008, from Maternal/Child Nursing, 23(5), 234-239. Metheny, N.A., Eikov, R., Rountree, V., &
http://classic.aacn.org/AACN/practiceAl Freer, Y., & Lyon, A. (2005). Nasogastric tube Lengettie, E. (1999). Indicators of feed-
ert.nsf/Files/VOFTP/$file/Verification%2 aspirate pH values associated with typi- ing tube placement in neonates.
0 o f % 2 0 F e e d i n g % 2 0 Tu b e % 2 0 cal enteral feeding patterns in infants Nutrition in Clinical Practice, 14(6), 307-
Place ment%2005-2005.pdf admitted to an NICU. Journal of 314.
Beckstrand, J., Ellett, M.L.C., & McDaniel, A. Neonatal Nursing, 11(3), 106-109. Metheny, N.A., McSweeney, M., Wehrle,
(2007). Predicting internal distance to Ghahremani, G.G., & Gould, R.J. (1986). M.A., & Wiersema, L. (1990). Effective-
the stomach for positioning nasogastric Nasoenteric feeding tubes: Radio- ness of the auscultatory method in pre-
and orogastric feeding tubes in children. graphic detection of complications. dicting feeding tube location. Nursing
Journal of Advanced Nursing, 59(3), Digestive Diseases and Sciences, Research, 39(5), 262-267.
274-289. 31(6), 574-585. Metheny, N.A., & Meert, K.L. (2004).
Bercik, P., Schlageter, V., Mauro, M., Gharib, A.M., Stern, E.J., Sherbin, V.L., & Monitoring feeding tube placement: A
Rawlinson, J., Kucera, P., & Armstrong, Rohrmann, C.A. (1996). Nasogastric review. Nutrition in Clinical Practice,
D. (2005). Noninvasive verification of and feeding tubes: The importance of 19(5), 487-495.
nasogastric tube placement using a proper placement. Postgraduate Metheny, N.A., Meert, K.L., & Clouse, R.E.
Magnet-tracking system: A pilot study in Medicine, 99(5), 165-168, 174-176. (2007). Complications related to feeding
healthy subjects. Journal of Parenteral Grant, M.J.C., & Martin, S. (2000). Delivery of tube placement. Current Opinion in
and Enteral Nutrition, 29(4), 305-310. enteral nutrition. AACN Clinical Issues: Gastroenterology, 23(2), 178-182.
Bockus, S. (1993). When your patient needs Advanced Practice in Acute and Critical Metheny, N.A., Reed, L., Berglund, B., &
tube feedings: Making the right deci- Care, 11(4), 507-516. Wehrle, A. (1994). Visual characteristics
sions. Nursing, 23(7), 34-42. Greenhalgh, T., Robert, G., MacFarlane, F., of aspirates from feeding tubes as a
Bowers, S. (2002). All about tubes:Your guide Bate, P., & Kyriakidou, O. (2005). method of predicting tube location.
to enteral feeding devices. Nursing, Diffusion of innovations in health serv- Nursing Research, 43(5), 282-287.
30(12), 41-47. ice organisations: A systematic litera- Metheny, N.A., Reed, L., Wiersema, L.,
Boyes, R., & Kruse, J. (1992). Nasogastric ture review. Malden, MA: BMJ Book and McSweeney, M., Wehrle, M.A., & Clark,
and nasoenteric intubation. Critical Blackwell Publishing. J. (1993). Effectiveness of pH measure-
Care Clinics, 8(4), 865-878. Huffman, S., Pieper, P., Jarczyk, K.S., Bayne, ments in predicting feeding tube place-
Burns, S.M., Carpenter, R., & Truwit, J.D. A., & O’Brien, E. (2004). Methods to ment: An update. Nursing Research,
(2001). Report on the development of a confirm feeding tube placement: 42(6), 324-331.
procedure to prevent placement of feed- Application of research in practice. Metheny, N.A., Smith, L., & Stewart, B.J.
ing tubes into the lungs using end-tidal Pediatric Nursing, 30(1), 10-13. (2000). Development of a reliable and
CO2 measurements. Critical Care Kearns, P.J. (1997). Evaluation of diagnostic valid bedside test for bilirubin and its
Medicine, 29(5), 936-939. tests: Verification of feeding tube place- utility for improving prediction of feeding
Cannaby, A., Evans, L., & Freeman, A. ment using electromagnetic principles. tube location. Nursing Research, 49(6),
(2002). Nursing care of patients with Nutrition in Clinical Practice, 12(1, 302-309.
nasogastric feeding tubes. British Suppl), S61-S65. Metheny, N., Spies, M., & Eisenberg, P.
Journal of Nursing, 11(6), 366-372. Khair, J. (2005). Guidelines for testing the (1986). Frequency of nasoenteral tube
Chen, C.A., Paxton, P., & Williams-Burgess, placing of nasogastric tubes. Nursing displacement and associated risk fac-
C. (1996). Feeding tube placement veri- Times, 101(20), 26-27. tors. Research in Nursing & Health,
fication using gastric pH measurement. Klasner, A.E., Luke, D.A., & Scalzo, A.J. 9(3), 241-247.
Worldviews on Evidence-Based (2002). Pediatric orogastric and naso- Metheny, N., & Stewart, B.J. (2002). Testing
Nursing, 3(1), 79-85. gastric tubes: A new formula evaluated. feeding tube placement during continu-
Christensen, M. (2001). Bedside methods of Annals of Emergency Medicine, 39(3), ous tube feedings. Applied Nursing
determining nasogastric tube place- 268-272. Research, 15(4), 254-258.
ment: A literature review. Nursing in Marderstein, E.L., Simmons, R.L., & Ochoa, Metheny, N., Stewart, B.J., Smith, L., Yan, H.,
Critical Care, 6(4), 192-199. J.B. (2004). Patient safety: Effect of insti- Diebold, M., & Clouse, R.E. (1999). pH

PEDIATRIC NURSING/January-February 2009/Vol. 35/No. 1 23


and concentration of bilirubin in feeding Issues in Critical Care Nursing, 5(2), 194- ence: How evidence-based nursing
tube aspirates as predictors of tube 206, 218-219, 223. requires evidence-based implementa-
placement. Nursing Research, 48(4), Richardson, D.S., Branowicki, P.A., Zeidman- tion. Journal of Nursing Scholarship,
189-197. Rogers, L., Mahoney, J., & MacPhee, M. 40(4), 302-310.
Metheny, N.A., & Titler, M.G. (2001). (2006). An evidence-based approach to Verklan, M.T., & Walden, M. (Eds.). (2004).
Assessing placement of feeding tubes. nasogastric tube management: Special Core curriculum for neonatal intensive
American Journal of Nursing, 101(5), considerations. Journal of Pediatric care nursing (3rd ed.). Philadelphia:
36-45. Nursing, 21(5), 388-393. W.B. Saunders Publishing Company.
Metheny, N., Wehrle, M.A., Wiersema, L., & Rogers, E.M. (2003). Diffusion of innovations Viall, C.D. (1996). Location, location, loca-
Clark, J. (1998). Testing feeding tube (5th ed.). New York: Free Press. tion…NG tube placement. Nursing,
placement: Auscultation vs. pH method. Sackett, D.L., Straus, S.E., Richardson, W.S., 26(9), 43-45.
American Journal of Nursing, 98(5), 37- Rosenberg, W.M., & Haynes, R.B. (2000). Weibley, T. T., Adamson, M., Clinkscales, N.,
42. Evidence-based medicine: How to prac- Curran, J., & Bramson, R. (1987).
Metheny, N., Williams, P., Wiersema, L., tice and teach EBM (2nd ed.). Edinburgh: Gavage tube insertion in the premature
Wehrle, M.A., Eisenberg, P., & Churchill Livingstone. infant. Maternal Child Nursing, 12(1),
McSweeney, M. (1989). Effectiveness of Sanko, J.S. (2004). Aspiration assessment and 24-27.
pH measurements in predicting feeding prevention in critically ill enterally fed Westhus, N. (2004). Methods to test feeding
tube placement. Nursing Research, patients: Evidence-based recommenda- tube placement in children. MCN, The
38(5), 280-285. tions for practice. Gastroenterology American Journal of Maternal/Child
Niv, Y., & Abu-Avid, S. (1988). On the posi- Nursing, 27(6), 279-285. Nursing, 29(5), 282-287.
tioning of a nasogastric tube [Letter to Swiech, K., Lancaster, D.R., & Sheehan, R. Widmann, W. (1985). Complications of
the editor]. The American Journal of (1994). Use of a pressure gauge to differ- nasoenteric tubes [Letter to the editor].
Medicine, 84(3), 563-564. entiate gastric from pulmonary placement Journal of the American Medical
Persenius, M.W., Larsson, B.W., & Hall-Lord, of nasoenteral feeding tubes. Applied Association, 254(1), 54.
M.L. (2006). Enteral nutrition in intensive Nursing Research, 7(4), 183-189. Wilkes-Holmes, C. (2006). Safe placement of
care: Nurses’ perceptions and beside Titler, M.G. (2008). The evidence for evidence- nasogastric tubes in children. Paediatric
observations. Intensive and Critical based practice implementation. In, R.G. Nursing, 18(9), 14-17.
Care Nursing, 22(2), 82-94. Hughes (Ed), Patient safety and quality: Williams, T.A., & Leslie, G.D. (2004). A review
Premji, S.S. (2005). Enteral feeding for high- An evidence-based handbook for nurses. of the nursing care of enteral feeding
risk neonates: A digest for nurses into (AHRQ Publication No. 08-0043). tubes in critically ill adults: Part 1.
putative risk and benefits to ensure safe Retrieved January 22, 2009, from Intensive and Critical Care Nursing,
and comfortable care. Journal of http://www.ahrq.gov/qual/nurseshdbk/ 20(6), 330-343.
Perinatal & Neonatal Nursing, 19(1), 59- Titler, M.G., & Everett, L.Q. (2001). Translating Williams, T.A., & Leslie, G.D. (2005). A review
73. research into practice: Considerations for of the nursing care of enteral feeding
Rakel, B. (2004, September). Piloting the critical care investigators. Critical Care tubes in critically ill adults: Part 2.
practice changes. Paper presented at Nursing Clinics of North America, 13(4), Intensive and Critical Care Nursing,
the meeting of the 3rd Annual 587-604. 21(1), 5-15.
Advanced Practice Institute: Promoting Titler, M.G., Kleiber, C., Steelman, V.J., Rakel, Winterholler, M., & Erbguth, F.J. (2002).
Adoption of Evidence-Based Practice, B.A., Budreau, G., Everett, L.Q., et al. Accidental pneumothorax from a naso-
Iowa City, Iowa. (2001). The Iowa model of evidence- gastric tube in a patient with severe
Rakel, B.A., Titler, M., Goode, C., Barry- based practice to promote quality care. hemineglect: A case report. Archives of
Walker, J., Budreau, G., & Buckwalter, Critical Care Nursing Clinics of North Physical Medicine and Rehabilitation,
K.C. (1994). Nasogastric and nasoin- America, 13(4), 497-509. 83(8), 1173-1174.
testinal feeding tube placement: An inte- van Achterberg, T., Schoonhoven, L., & Grol,
grative review of research. AACN Clinical R. (2008). Nursing implementation sci-

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