Volume 3 Supplement 1

ESICM LIVES 2015

Open Access

Changing how we confirm ngt placement: impact on nutrition delivered

  • E Segaran1,
  • A Hartle1 and
  • R Leonard1
Intensive Care Medicine Experimental20153(Suppl 1):A288

DOI: 10.1186/2197-425X-3-S1-A288

Published: 1 October 2015

Introduction

Confirming the position of Nasogastric tubes (NGT) in critical care is a controversial area. The National Patient Safety Agency (NPSA) guidance [1] advocates pH testing although use is limited in ICU due to continuous enteral feeding and proton pump inhibitor therapy. Chest X-ray is therefore commonly used with trainee doctors often being responsible for confirming tube position. Following three incidents of undetected NGT misplacement (outside of our ICU), our trust stipulated a change in practice so that only radiologists or ICU consultants were allowed to confirm placement. We were concerned that this could negatively influence tube confirmation times and enteral nutrition (EN) provision. Cumulative calorie deficits contribute to malnutrition [2]. Under-nutrition in critically ill patients is associated with increased mortality, infections and length of stay [3].

Objectives

To determine if new guidance for NGT confirmation would influence time off EN and calories delivered.

Methods

Quality improvement project over two different 4 week time frames, before and after the change in NGT confirmation policy in a general/trauma ICU

Results

Data was collected on 32 patients, 16 at each data point. See table 1 for demographic details. The majority of NGT placements or replacements occurred in trauma patients. The change in NGT confirmation resulted in significantly longer time off EN and a significant decrease in EN provided (Table 2).
Table 1

Patient Demographics.

 

Data Point 1 Jan 2014

Data Point 2 Nov 2014

No of Patients

16

16

No of NGT confirmations

36

32

No. of confirmations per patient (median, IQR)

2 (1-3)

2 (1-2.8)

Type of patients n (%)

  

Trauma

12 (75)

11 (69)

Medical

3 (19)

5 (31)

Surgical

1 (6)

0

Days data collected (median, IQR)

11 (8-17)

11 (6-13)

Table 2

Nutritional data.

 

Data Point 1 Jan 2014 Median (IQR)

Data Point 2 Nov 2014 Median (IQR)

P

Hours off EN per episode of NGT (re)placement

5.3 (2-9)

10 (6-16)

0.028

Calorie deficit per episode of NGT (re)placment

402 (363-442)

768 (635-867)

0.04

Calorie deficit per patient for duration of EN received over study duration

2423 (1955-3452)

5660 (4299-7338)

0.00024

% of calories delivered vs. prescribed over study duration

84 (77-87)

71 (62-80)

0.018

Conclusions

All patients acquired a cumulative calorie deficit over the time they were studied (average of 11 days). The change in NGT confirmation practice had a detrimental effect on time off EN and amount of EN provided. The size of increase in calorie deficit between the two time periods is only partly attributable to the change in NGT confirmation. Other factors influenced EN delivery in our patients, between the two data points such as non-compliance with our fasting guidelines for surgery and airway procedures. We speculate that the change in NGT confirmation may have led to an excessively risk-averse approach in which the problems of cumulative calorie deficit were under-appreciated. The current NGT confirmation practice for ICUs in our organisation is being reviewed. It is proposed once again to permit ICU trainees who have successfully completed relevant competency training to confirm position of NGT on x-ray. We intend to repeat data collection once this change has been implemented.

Grant Acknowledgement

No external funding was sought for this project.

Authors’ Affiliations

(1)
Adult ICU, St Mary's Hospital

References

  1. National Patient Safety Agency. 2011Google Scholar
  2. Alberda C, et al: Intensive Care Medicine. 2009, 35 (10): 1728-37. 10.1007/s00134-009-1567-4.PubMedView ArticleGoogle Scholar
  3. Villet S, et al: Clinical Nutrition. 2005, 24 (4): 502-9. 10.1016/j.clnu.2005.03.006.PubMedView ArticleGoogle Scholar

Copyright

© Segaran et al.; 2015

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.