HospitalInspections.org

Based on interview, a review of hospital policy instruction utilized for the insertion and placement checks of nasogastric tubes (NGT), and nursing competency expectations, it was determined that a disparity existed between policy and nursing competency validation regarding NGT placement checks. Further, interviews and document review validated that the hospital had failed to provide a definitive standard for checking placement of NGTs and failed to hold nurses accountable for using NGTs safely.

Background: A NGT is inserted via the nose into the stomach. There are two ways to utilize a NGT. One is for giving nutrition and delivery of medications, and the other is to drain gastric (stomach) contents. In the first instance, liquid nutrition and/or crushed medication is pushed into the stomach via the NGT. In the second instance, gastric contents are removed from the stomach by a suction pump or gravity drain attached to the NGT. While the first instance represents a risk of aspiration should the liquid nutrition or medications be placed inadvertently into the lungs, the second instance also carries risk of aspiration. Both instances require confirmation of placement in the stomach vs. the lungs immediately after the tube is placed and before feeding or suctioning procedures.

Interview with a Charge RN on 8/22 at approximately 1030, revealed that nurses check NGT for placement by various means. If the NGT is used for feeding and medications, the Charge RN stated she hoped an x-ray would always be done after placement. If the NGT is used for suction of gastric contents, the Charge RN stated that nurses would sometimes use x-ray, or check for gastric contents, or listen for an air bubble over the stomach.

A request for the hospital policy on nasogastric tube (NGT) placement checks revealed the response that nurses use "Lippincott Nursing Procedures," (7th Edition copyright 2016) for "Nasogastric Tube Insertion and Removal." A review of this procedure revealed instruction for multiple ways of checking placement of the NGT.

The instruction stated in part, " ...Use various beside methods to determine tube location during insertion, including watching for signs of respiratory distress ...using capnography, if available, to detect carbon dioxide, ...measuring the pH of aspirate from the tube ...however, this method isn't reliable enough to exclude the need for x-ray placement verification ...Anticipate an X-ray to verify placement ...before its initial use for feedings or medication administration ..." No specific guidance was given for suction.
Review of nursing competency information for "Inserting NGT" revealed in part, "Validates position by obtaining an order for CXR (chest x-ray); Initiates TF (tube feeding or connects to drainage as ordered ..." This competency calls for an x-ray following initial NGT insertion whether for nutrition and medications or for suction of gastric contents. Additionally, under "Maintaining NGT" the competency stated in part that the nurse, "Verifies position ..."

Review of patient #1's record revealed insertion of an NGT for gastric suction and medication administration which on placement in early February 2017 was checked by aspiration of gastric contents rather than x-ray. An order for x-ray confirmation must be obtained from a physician. No physician order for x-ray was found.

Twelve hours later, another NGT was placed in patient #1's right nostril. A determination of placement was made by the return of gastric contents rather than x-ray. An order for x-ray confirmation must be obtained from a physician. No physician order for x-ray was found.

Further review of the hospital competency under "Maintaining NGT," the competency stated in part that the nurse, "Verifies position ..." Reviews of maintenance documentation revealed few entries where nursing had checked placement during maintenance procedures.

Based on all information and other examples, the hospital failed to reconcile training and competencies given to nursing regarding NGT, and consequently, failed to make nursing accountable to competency and documentation standards set by the hospital.