Evaluation of methods used to verify nasogastric feeding tube placement in hospitalized infants and children - A follow-up study.

BACKGROUND: Nasogastric (NG) feeding tubes are used to deliver nutrition, hydration, and medications to hospitalized infants and children but the ongoing use of non-evidence-based practice (EBP) methods to confirm NG tube (NGT) placement has been associated with adverse patient events. METHODS: A study was undertaken to ascertain if practice changes have occurred since findings from a previous study were published by the New Opportunities for Verification of Enteral tube Location (NOVEL) project. The NOVEL project was an initiative of the American Society of Parenteral and Enteral Nutrition (ASPEN). A survey was distributed to member organizations participating in the NOVEL project. Respondents were also asked if and when a change in practice occurred in the policy for NGT placement verification, if there was variation within the institutional units and if there were barriers to practice change. FINDINGS: Respondents were primarily nurses (205/245) from 166 institutions that provided care to combined adult/pediatric/neonatal (122/166) patients. Respondents indicated a radiograph (64%) or pH measurement (24%) were best practice but in actual practice 42% use pH measurement and 23% use a radiograph to verify NGT placement. There was variability within institutions, with the Neonatal Intensive Care Unit (NICU) most often using aspiration and direct eye visualization to verify placement and the other units within the institutions using EBP method(s). DISCUSSION: Comparing these results to previous work by the NOVEL project shows an increase toward the use of EBP method(s) to verify NGT placement verification. APPLICATION TO PRACTICE: This study demonstrates variation within units at the same facility using methods unsupported by the literature, demonstrating that many centers still rely on non-EBP methods of NG placement confirmation, despite cautions issued by many major healthcare organizations.

Development of a Competency Model for Placement and Verification of Nasogastric and Nasoenteric Feeding Tubes for Adult Hospitalized Patients.

Nasogastric/nasoenteric (NG/NE) feeding tube placements are associated with adverse events and, without proper training, can lead to devastating and significant patient harm related to misplacement. Safe feeding tube placement practices and verification are critical. There are many procedures and techniques for placement and verification; this paper provides an overview and update of techniques to guide practitioners in making clinical decisions. Regardless of placement technique and verification practices employed, it is essential that training and competency are maintained and documented for all clinicians placing NG/NE feeding tubes. This paper has been approved by the American Society for Parenteral and Enteral Nutrition (ASPEN) Board of Directors.

Acidity of Enteral Feeding Tube Aspirate in Neonates: Do pH Values Meet the Cutoff for Predicting Gastric Placement?

BACKGROUND: Enteral feeding tubes (EFTs) are commonly used in neonatal practice, but complications from tube misplacement remain a concern. Measuring the pH of EFT aspirate is a recommended method to evaluate EFT placement. A pH value of ≤5.5 is considered predictive of gastric placement. Using this method in infants has been questioned. It is unclear whether infants can produce adequate gastric acid to achieve a pH 5 or less and whether feedings and medications influence pH. PURPOSE: To report EFT aspirate pH values in infants and to evaluate factors potentially influencing pH values. METHODS: A retrospective descriptive study was conducted with 1024 infants with 6979 pH values. Demographic and clinical data were collected including type of EFT, pH of gastric aspirate, feeding method, time of last feeding, and administration of acid suppression medications. The frequency of measured pH values of 5 or less was calculated for each covariate. FINDINGS/RESULTS: The majority (97.51%) of pH values were 5 or less. Orogastric tubes, continuous feeding, a 4-hour or more feeding interval, exposure to medications (proton pump inhibitor, histamine-2 receptor antagonist, or multiple medications) were associated with an increased likelihood of pH values of more than 5. However, with each study variable the majority of pH values were 5 or less. IMPLICATIONS FOR PRACTICE: These findings suggest EFT pH, a recommended method to evaluate the likelihood of gastric placement, can be successfully used in the neonatal population. IMPLICATIONS FOR RESEARCH: Future research should prospectively evaluate EFT pH in infants when compared with clinically indicated radiographs. Other factors that might influence pH should be explored including severity of illness, feeding type, and other medications.

Pediatric Nasogastric Tube Placement and Verification: Best Practice Recommendations From the NOVEL Project.

The placement of a nasogastric tube (NGT) in a pediatric patient is a common practice that is generally perceived as a benign bedside procedure. There is potential risk for NGT misplacement with each insertion. A misplaced NGT compromises patient safety, increasing the risk for serious and even fatal complications. There is no standardized method for verification of the initial NGT placement or reverification assessment of NGT location prior to use. Measurement of the acidity or pH of the gastric aspirate is the most frequently used evidence-based method to verify NGT placement. The radiograph, when properly obtained and interpreted, is considered the gold standard to verify NGT location. However, the uncertainty regarding cumulative radiation exposure related to radiographs in pediatric patients is a concern. To minimize risk and improve patient safety, there is a need to identify best practice and to standardize care for initial and ongoing NGT location verification. This article provides consensus recommendations for best practice related to NGT location verification in pediatric patients. These consensus recommendations are not intended as absolute policy statements; instead, they are intended to supplement but not replace professional training and judgment. These consensus recommendations have been approved by the American Society for Parental and Enteral Nutrition (ASPEN) Board of Directors.

Pediatric Nasogastric Tubes in the Home: Recommendations for Practice.

One of the dilemmas facing home healthcare nurses is the placement of a nasogastric tube (NGT) in the home setting coupled with being assured and confident that the NGT tip is in the correct position, that is, the stomach. There are very limited data to address the issue of management of an NGT in the home care setting with even less guidance for the pediatric population. Therefore, home healthcare nurses must use agency policy and procedures coupled with their own education, knowledge, experience, and skills when performing this procedure. These may vary from agency to agency, thus providing inconsistencies in teaching and techniques.

Use of Nasogastric Feeding Tubes for Children at Home: A Template for Caregiver Education.

There is a lack of knowledge on the part of caregivers who need to place nasogastric (NG) tubes in children for enteral nutrition therapy. This article provides the rationale, best practices, and a template for caregiver education. Canadian and Australian programs have excellent patient education materials. They have shared these step-by-step procedures for healthcare professionals to provide to caregivers to whom they are teaching placement and care of NG tubes.

Enteral Feeding Set Handling Techniques.

BACKGROUND: Enteral nutrition therapy is common practice in pediatric clinical settings. Often patients will receive a pump-assisted bolus feeding over 30 minutes several times per day using the same enteral feeding set (EFS). This study aims to determine the safest and most efficacious way to handle the EFS between feedings. METHODS: Three EFS handling techniques were compared through simulation for bacterial growth, nursing time, and supply costs: (1) rinsing the EFS with sterile water after each feeding, (2) refrigerating the EFS between feedings, and (3) using a ready-to-hang (RTH) product maintained at room temperature. Cultures were obtained at baseline, hour 12, and hour 21 of the 24-hour cycle. A time-in-motion analysis was conducted and reported in average number of seconds to complete each procedure. Supply costs were inventoried for 1 month comparing the actual usage to our estimated usage. RESULTS: Of 1080 cultures obtained, the overall bacterial growth rate was 8.7%. The rinse and refrigeration techniques displayed similar bacterial growth (11.4% vs 10.3%, P = .63). The RTH technique displayed the least bacterial growth of any method (4.4%, P = .002). The time analysis in minutes showed the rinse method was the most time-consuming (44.8 ± 2.7) vs refrigeration (35.8 ± 2.6) and RTH (31.08 ± 0.6) ( P < .0001). CONCLUSIONS: All 3 EFS handling techniques displayed low bacterial growth. RTH was superior in bacterial growth, nursing time, and supply costs. Since not all pediatric formulas are available in RTH, we conclude that refrigerating the EFS between uses is the next most efficacious method for handling the EFS between bolus feeds.

Current Practices in Home Management of Nasogastric Tube Placement in Pediatric Patients: A Survey of Parents and Homecare Providers.

Enteral feeding tubes are used in pediatric patients to deliver nutrition, fluids or medications. The literature related to short-term feeding tube (nasogastric [NG], hereafter known as NGT, or orogastric [OGT],) use in pediatric homecare patients is sparse. This descriptive study sought to gather baseline information about these children and how their feeding tubes are managed at home. Specifically, we sought to better understand how the tubes are placed and the method(s) used for tube placement verification. Two surveys were distributed: one to parents and one to homecare providers who have direct patient contact. RESULTS: Responses were obtained from 144 parents and 66 homecare providers. Over half of the children were 12months of age or younger and had a 6 Fr feeding tube. Over 75% (108) had an NGT for 1year or less. Predominantly parents replaced the NGT but a few children self-inserted their tubes. Feeding tube placement was verified by auscultation (44%) or measurement of gastric pH (25%) in the parent's survey. Twenty-six percent of parents indicated they had misplaced an NGT at least once and 35 parents described symptoms of pulmonary misplacement. The homecare provider data indicated auscultation (39%) and pH measurement of gastric contents (28%) to verify NG tube placement location. Study results confirms a need for consistency of practice among health care professionals and in parent education for those children who require NGTs at home. It is troubling that auscultation is still widely used for NGT location confirmation despite practice alerts that warn against its use.

Enteral Feeding Set Handling Techniques: A Comparison of Bacterial Growth, Nursing Time, Labor, and Material Costs.

BACKGROUND: Enteral nutrition therapy is common practice in pediatric clinical settings. Often patients will receive a pump-assisted bolus feeding over 30 minutes several times per day using the same enteral feeding set (EFS). This study aims to determine the safest and most efficacious way to handle the EFS between feedings. METHODS: Three EFS handling techniques were compared through simulation for bacterial growth, nursing time, and supply costs: (1) rinsing the EFS with sterile water after each feeding, (2) refrigerating the EFS between feedings, and (3) using a ready-to-hang (RTH) product maintained at room temperature. Cultures were obtained at baseline, hour 12, and hour 21 of the 24-hour cycle. A time-in-motion analysis was conducted and reported in average number of seconds to complete each procedure. Supply costs were inventoried for 1 month comparing the actual usage to our estimated usage. RESULTS: Of 1080 cultures obtained, the overall bacterial growth rate was 8.7%. The rinse and refrigeration techniques displayed similar bacterial growth (11.4% vs 10.3%, P = .63). The RTH technique displayed the least bacterial growth of any method (4.4%, P = .002). The time analysis in minutes showed the rinse method was the most time-consuming (44.8 ± 2.7) vs refrigeration (35.8 ± 2.6) and RTH (31.08 ± 0.6) (P < .0001). CONCLUSIONS: All 3 EFS handling techniques displayed low bacterial growth. RTH was superior in bacterial growth, nursing time, and supply costs. Since not all pediatric formulas are available in RTH, we conclude that refrigerating the EFS between uses is the next most efficacious method for handling the EFS between bolus feeds.

Pediatric Enteral Access Device Management.

Enteral nutrition (EN) support has proven to be a nutrition intervention that can provide full or partial calories to promote growth and development in infants and children. To supply these nutrients, an enteral access device is required, and the use of these devices is growing. Placement of the proper device for the patient need, along with appropriate care and monitoring, is required for individualized patient management. When complications arise, early identification and management can prevent more serious morbidity. Complication management requires a tiered approach starting with staff nurses and ending with a physician expert. In addition to this, each institution needs to have an approach that is coordinated among disciplines and departments to promote consistency of practice. The formation of an enteral access team is a conduit for clinical experts to provide education to families, patients, and healthcare professionals while serving as a platform to address product and practice issues.

ENFit Enteral Nutrition Connectors.

New enteral connectors are now available based on the development of standards using the International Organization of Standardization process to prevent misconnections between systems that should not connect. Enteral devices with the new patient access connectors, called ENFit, are being now introduced for the purpose of improving patient safety. Transitioning to these new connectors poses benefits and challenges for facilities or agencies implementing these new devices. Information from appropriate resources should be sought by clinicians who need to partner with their suppliers and clinical organizations to see how best to meet these challenges.

Use of Temporary Enteral Access Devices in Hospitalized Neonatal and Pediatric Patients in the United States.

BACKGROUND: Temporary enteral access devices (EADs), such as nasogastric (NG), orogastric (OG), and postpyloric (PP), are used in pediatric and neonatal patients to administer nutrition, fluids, and medications. While the use of these temporary EADs is common in pediatric care, it is not known how often these devices are used, what inpatient locations have the highest usage, what size tube is used for a given weight or age of patient, and how placement is verified per hospital policy. MATERIALS AND METHODS: This was a multicenter 1-day prevalence study. Participating hospitals counted the number of NG, OG, and PP tubes present in their pediatric and neonatal inpatient population. Additional data collected included age, weight and location of the patient, type of hospital, census for that day, and the method(s) used to verify initial tube placement. RESULTS: Of the 63 participating hospitals, there was an overall prevalence of 1991 temporary EADs in a total pediatric and neonatal inpatient census of 8333 children (24% prevalence). There were 1316 NG (66%), 414 were OG (21%), and 261 PP (17%) EADs. The neonatal intensive care unit (NICU) had the highest prevalence (61%), followed by a medical/surgical unit (21%) and pediatric intensive care unit (18%). Verification of EAD placement was reported to be aspiration from the tube (n = 21), auscultation (n = 18), measurement (n = 8), pH (n = 10), and X-ray (n = 6). CONCLUSION: The use of temporary EADs is common in pediatric care. There is wide variation in how placement of these tubes is verified.

ENFit Enteral Nutrition Connectors: Benefits and Challenges.

New enteral connectors are now available based on the development of standards using the International Organization of Standardization process to prevent misconnections between systems that should not connect. Enteral devices with the new patient access connectors, called ENFit, are being now introduced for the purpose of improving patient safety. Transitioning to these new connectors poses benefits and challenges for facilities or agencies implementing these new devices. Information from appropriate resources should be sought by clinicians who need to partner with their suppliers and clinical organizations to see how best to meet these challenges.

Caring for Tube-Fed Children: A Review of Management, Tube Weaning, and Emotional Considerations.

Enteral nutrition is the practice of delivering nutrition to the gut either orally or through a tube or other device. Many children are reliant on enteral feedings to either supplement their nutrition or as a complete source of their nutrition. Managing children on tube feedings requires a team of providers to work through such dilemmas as feeding schedules, weaning from tube feeding, sensory implications of tube feeding, treatment of pain or nausea associated with eating, oral-motor issues, and behavioral issues in the child and family. The purpose of the current review is to summarize the multidisciplinary aspects of enteral feeding. The multidisciplinary team consists of a variable combination of an occupational therapist, speech-language pathologist, gastroenterologist, psychologist, nurse, pharmacist, and dietitian. Children who have minimal oral feeding experience and are fed via a nasogastric or gastrostomy tube often develop oral aversions. Limited data support that children with feeding disorders are more likely to have sensory impairment and that early life pain experiences contribute to feeding refusal. There are inpatient and outpatient programs for weaning patients from tube feeding to eating. The parent-child interaction is an important part of the assessment and treatment of the tube-fed child. This review also points out many information gaps, including data on feeding schedules, blenderized tube feedings, the best methods for weaning children off enteral feedings, the efficacy of chronic pain medications with tube-fed children, and, finally, the necessity of the assessment of parental stress among all parents of children who are tube fed.