Acurácia e custo de métodos utilizados por enfermeiros na confirmação do posicionamento de sondas nasoenterais recém inseridas às cegas à beira leito / Accuracy and cost of methods used by nurses in confirming the placement of recently inserted nasoenteral tubes at bedside

Os objetivos do estudo foram analisar a acurácia e os custos de métodos realizados à beira leito para confirmar a posição de sonda nasoenteral recém inserida às cegas à beira leito por enfermeiros. Tratou-se de estudo de acurácia diagnóstica de três métodos (ultrassonografia, ausculta epigástrica e medição do pH) utilizados na prática clínica por enfermeiros e compará-los com a radiografia, que é o padrão-ouro na confirmação do posicionamento de sondas nasoenterais. Os dados foram coletados nas enfermarias e unidades de cuidados críticos de um hospital universitário de grande porte do interior do estado de São Paulo. A amostra foi de conveniência e incluiu todos os pacientes que necessitaram de sonda nasoenteral durante a internação, no período de 19/11/2019 a 18/03/2020. Os métodos foram realizados na seguinte ordem: ultrassonografia, ausculta epigástrica e medição do pH (testes índice). Posteriormente, os resultados dos três métodos foram comparados com a radiografia (teste de referência). Também foram comparados os resultados provenientes da combinação entre ausculta epigástrica e medição do pH com a radiografia. Dados sociodemográficos, clínicos e terapêuticos foram obtidos do prontuário do paciente e registrados no formulário de coleta de dados eletrônico. Também foram mensurados os custos diretos de cada método utilizado para confirmar o posicionamento da sonda nasoenteral. Foram realizados 53 procedimentos de inserção de sonda nasoenteral em 41 pacientes adultos. Destes, 58,5% estavam posicionadas no estômago, 11,3% estavam posicionadas no esôfago ou pulmão, 11,3% no intestino, e em 18,9%, não foi possível definir se a ponta da sonda estava localizada no estômago ou no intestino na radiografia. Dentre os métodos utilizados neste estudo, a medição do pH foi o que apresentou maior sensibilidade (87,5%) e especificidade (100%). A sensibilidade do ultrassom foi de 76,6%. Ademais, quando combinados, a ausculta epigástrica e a mensuração do pH apresentaram sensibilidade, especificidade, valor preditivo positivo (VPP) e valor preditivo negativo (VPN) iguais a 100%. A medição do pH e o ultrassom apresentaram concordância considerável com a radiografia e, quando avaliado o método combinado, a concordância foi quase perfeita. Em média, a ausculta abdominal apresentou o menor custo (R$ 6,62) quando comparado aos demais métodos avaliados no presente estudo. Considerando as probabilidades de observação da posição da sonda pela ultrassonografia, o custo esperado foi de R$ 35,76, enquanto pelo método da mensuração do pH, o custo mínimo foi de R$ 8,49. Contudo, não foi possível obter o aspirado gástrico em 35,2% dos procedimentos realizados, apesar das intervenções. Nesses casos, o custo da mensuração do pH foi maior (R$ 43,38) quando comparado aos demais métodos. A ultrassonografia pode ser uma alternativa para situações em que a radiografia não esteja disponível. Entretanto, estudos futuros são necessários para avaliar a acurácia desse método em amostra maior de pacientes. Ademais, na impossibilidade de implementação de métodos radiológicos para confirmar o posicionamento das sondas, o enfermeiro deve considerar a associação de dois métodos não radiológicos, sendo eles a mensuração do pH e a ausculta epigástrica

The objectives of the study were to analyze the accuracy and the costs of methods performed at bedside to confirm the placement of the nasoenteral tube which were recently and blindly inserted at bedside by nurses. It was a diagnostic accuracy study of three diagnostic methods (ultrasonography, epigastric auscultation, and pH measurement) used in clinical practice by nurses and compare them to the radiography, which is the gold standard in confirming the placement of nasoenteral tubes. The data were collected in wards and critical care units of a large size university hospital in the countryside of São Paulo state. It was a convenience sample, and it comprised all the patients who needed nasoenteral feeding tube during their hospitalization, from 11/19/2019 to 03/18/2020. The methods were performed in the following order: ultrasonography, epigastric auscultation and pH measurement (index tests). Afterwards, the results of the three methods were compared to that of the radiography (reference test). The results from the combination of epigastric auscultation and pH measurement were also compared to the radiograph. Sociodemographic, clinical, and therapeutic data were obtained from the patient record and registered in an electronic data collection form. The direct costs of each method used to confirm the placement of nasoenteral feeding tube were also measured. Fifty-three (53) procedures for inserting the nasoenteral feeding tube were performed in 41 patients. Out of these, 58.5% were positioned in the stomach, 11.3% were positioned in the esophagus or lung, 11.3% in the intestine and, in 18.9% of them, it was not possible to define whether the tip of the tube was placed in the stomach or in the intestine in the radiograph. Among the methods used in this study, the pH measurement was the one which presented greater sensitivity (87.5%) and specificity (100%). The ultrasound sensitivity was 76.6%. Moreover, when combined, the epigastric auscultation and the pH measurement presented sensitivity, specificity, positive predictive value (PPV) and Negative Predictive Value (NPV) equal to 100%. The pH measurement and the ultrasound presented substantial match with the radiography and when the method was assessed in combination, the match was almost perfect. On average, the abdominal auscultation presented the lowest cost (R$ 6.62) if compared to the other methods assessed in this study. Considering the probability of the tube position observation by the ultrasonography, the expected cost was R$ 35.76, while the pH measurement method minimum cost was R$ 8.49. Nevertheless, it was not possible to obtain the gastric aspirator in 35.2% of the procedures carried out, despite the interventions. In these cases, the pH measurement cost was higher (R$ 43.38) when compared to other methods. The ultrasonography may be an alternative for situations where radiography is not available. Nevertheless, future studies are needed in order to assess the accuracy of this method in a greater sample of patients. Besides, in case of implementation impossibility of the radiologic methods to confirm the placement of the tubes, the nurse must consider the association of two non-radiologic methods, which are the pH measurement and epigastric auscultation

Development of a nomogram for predicting nasogastric tube-associated pressure injuries in intensive care unit patients.

Here, we aimed to build a nomogram model to estimate the probability of nasogastric tube-associated pressure injuries (NTAPIs) in intensive care unit(ICU)patients. This prospective cohort study included 219ICU patients with nasogastric tube between September 2019 and January 2020.Univariate and multivariate logistic regression analyses were used to develop the nomogram model. The resulting nomogram was tested for calibration, discrimination, and clinical usefulness. Of the included patients, 58 developed NTAPIs, representing an incidence rate of 26.5%. Binary logistic regression analysis revealed that the prediction nomogram included C-reactive protein, vasopressor use, albumin level, nasogastric tube duration, and Sequential Organ Failure Assessment score. The value of these predictors was again confirmed using theLasso regression analysis. Internal validation presented a good discrimination of the nomogram, with an area under the curve value of 0.850, and good calibration (Hosmer-Lemeshow test, P = 0.177). The decision curve analysis also demonstrated preferable net benefit along with the threshold probability in the prediction nomogram. The nomogram model can accurately predict the risk factors for NTAPIs, to formulate intervention strategies as early as possible to reduce NTAPI incidence.

Best Practices to Verify Ongoing Placement of NG or OG Tube After Initial X-ray Confirmation.

BACKGROUND: Many patients in intensive care units (ICU) require nasogastric (NG) or orogastric (OG) tubes. These patients often require a combination of sedatives that can alter level of consciousness and impair cough or gag reflexes. Such factors can lead to NG/OG tube displacement. Using a misplaced tube can lead to aspiration, lung injury, infection, and even death. AIMS: To standardize ongoing verification of NG tube placement practices in our 34-bed Medical-Surgical ICU. METHODS: The Johns Hopkins Nursing Model was utilized to guide this project. A literature review and critical appraisal were performed to establish NG/OG tube best practices. Best practices were implemented and assessed (via a survey and charting audits). RESULTS: Fifteen publications were identified and appraised as Level 4 and 5 sources. Best evidence supported that at the time of radiographic confirmation of the tube site, it should be marked with inedible ink or adhesive tape where it exits the nares; tube location should be checked at 4-hour intervals; and placement/patency should be checked in patients who complain of pain, vomiting, or coughing. Following the practice change, N = 40 nurses indicated improvement in verification of NG/OG tube knowledge, "OK to use" order was verified for 89% of patients, and 63% of tubes were marked with tape at the exit site. LINKING ACTION TO EVIDENCE: Adherence to current, evidence-based strategies for NG/OG tube verification promotes patient safety. Monitoring practice changes is critical to determine whether a best practice is sustained. Electronic health records must be current to guide and support evidence-based nursing practice.

Monitoring photographic proof of cecal intubation: A closed-loop audit of best practice colonoscopy.

Gold standard colonoscopy in the UK demands a 90% cecal intubation (CI) rate. Endoscopists must provide photographic evidence of CI, which can include images of the terminal ileum, appendix orifice, anastomosis or ileocecal valve. Whilst photographic proof of intubation should be obtained for all complete colonoscopies, this is not routinely audited. Three hundred and ninety-six complete colonoscopies were analyzed, 200 in an initial audit, and 196 in a second audit. Photos taken during colonoscopy were reviewed for evidence of successful CI, as well as whether these photographs had been marked as "proof of intubation" (POI). Results were shared at departmental governance meetings in order to assess any improvement in practice. Initial audit revealed 70% of colonoscopies had provided sufficient proof of CI but only 50% provided photographs that were described as such. Twenty percent of colonoscopies provided sufficient images, but these were not identified as POI. Thirty percent of all colonoscopies provided insufficient proof of CI. Upon repeat audit, 71% of colonoscopies met best practice standards, with the remaining 29% showing insufficient evidence of CI. In the modern era of digital technology, lack of photographic evidence should be seen as unacceptable and may raise important clinical and medicolegal concerns. We recommend that audits such as this become standard practice to ensure best practice.

Fecal Microbiota Transplantation (FMT) with Colonoscopy Is Superior to Enema and Nasogastric Tube While Comparable to Capsule for the Treatment of Recurrent Clostridioides difficile Infection: A Systematic Review and Meta-Analysis.

BACKGROUND: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules. AIM: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI. METHODS: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design. RESULTS: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I2 15.6%), capsule 92.1% (CI 88.6-95.0%; I2 7.1%), enema 87.2% (CI 83.4-90.5%; I2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%. CONCLUSION: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

Endoscopic Enteral Access.

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed.

Nasogastric tube utilization after esophagectomy: an unnecessary gesture? / Uso de sonda nasogástrica en pacientes sometidos a esofaguectomía: ¿Un gesto innecesario?

INTRODUCTION: Nasogastric decompressive tube utilization has been accepted as one of the basic perioperative care measures after esophageal resection surgery. However, with the development of multimodal rehabilitation programs and without clear evidence to support their use, the systematic indication of this measure may be controversial. MATERIAL AND METHODS: Retrospective, descriptive and comparative study of patients who had undergone Ivor-Lewis esophagectomy in our center -from January 2015 to December 2018- with placement (Group S), or without placement (Group N) of a decompressive tube in gastroplasty during postoperative period. Epidemiological variables and differences between groups in post-surgical morbidity and mortality, hospital stay, onset of oral tolerance and the need for nasogastric tube placement were evaluated. RESULTS: A total of 43 patients were included in this study, with a median age of 61 years, being 86% male. 46.5% were hypertensive, 25.5% had lung disease and 16.3% had diabetes mellitus. The median length of hospital stay was 9 days in group S versus 11.5 days in group N, with no differences in the onset of oral tolerance. Anastomotic dehiscence rate was 5% and 0% respectively. The overall mortality was 2.3% in the first 90 days, without differences between the groups. Placement of nasogastric tube during postoperative period was required only in 1 patient (4.3%) of the group N. CONCLUSIONS: Non-use of nasogastric tube during postoperative period of an Ivor-Lewis esophagectomy is a safe measure, as it is not associated with a higher rate of complications or hospital stay. This fact may be able to improve patients' comfort and postoperative recovery.

Report on the impact of a service improvement programme in a well-established radiologically inserted gastrostomy service.

BACKGROUND: The present study aimed to evaluate whether the implementation of a service improvement programme improved the occurrence of radiologically inserted gastrostomy (RIG) tube displacements, post-insertion. METHODS: A retrospective observational study of cancer patients was conducted over a 2-year period divided into two time points. Eighty-two RIG insertions were audited retrospectively; 42 in Time 1 and 40 in Time 2. RESULTS: Some 70% (n = 57) of patients had head and neck (H&N) malignancy, 24% (n = 20) had gastrointestinal cancer and 6% (n = 5) had a variety of other malignancies. Following the implementation of the service improvement programme, the number of RIG tube displacements almost halved from nine (21%) to five (12%). CONCLUSIONS: The present study offers persuasive evidence indicating that the implemented service improvement programme improved patient care; however, further research incorporating a more robust evaluation is necessary. People with advanced disease are living longer and so there is a need to maintain good nutritional support. This innovation offers the potential to enhance patients' quality of care and minimise complications.

Evaluation of a Nasoenteral Feeding Tube With Balloon to Facilitate Placement.

BACKGROUND: Enteral feeding is essential for critically ill, head trauma, and burn patients who are unable to swallow. OBJECTIVE: To evaluate a new nasoenteral feeding tube with distal tip balloon designed to facilitate post-pyloric migration and avoid misplacement in the trachea. METHODS: A case series was conducted in 50 critically ill patients aged 19 to 89 years receiving mechanical ventilation and requiring enteral nutrition in a teaching hospital. Patients received a soft, flexible, kink-resistant nasoenteral feeding tube with a balloon near the distal tip to enhance postpyloric migration by peristalsis. The feeding tube was inserted with a novel thread technique to reduce posterior nasopharyngeal trauma and tube misplacement. Pulse oximetry provided early detection of misplacement into the trachea. Placement was verified by abdominal radiography performed shortly after the procedure and repeated within 24 hours if needed. RESULTS: Postpyloric placement was achieved at 30 minutes in 24% of patients and by the following morning in 70% of patients. Tracheal intubation occurred in 1 patient but was recognized and corrected without injury. No tube occlusion from kinking occurred. CONCLUSIONS: Early gastric or postpyloric feeding can be provided with this novel feeding tube. Its use facilitates quick bedside recognition of accidental misplacement in the trachea, reducing the chance of pneumothorax. The tip balloon reduces deeper placement into a lung and promotes distal migration into the small intestine. The design prevents occlusion from kinking, which is common with conventional feeding tubes. Nurses easily adopted the tube and insertion technique.

Methods of Gastric Tube Placement Verification in Neonates, Infants, and Children: A Systematic Review and Meta-Analysis.

INTRODUCTION: The objective was to evaluate diagnostic performance of multiple methods used to assess gastric tube placement verification in neonates, infants, and children. METHODS: A systematic review using the methods outlined in the Cochrane Handbook for Reviews of Diagnostic Test Accuracy was conducted. Eight databases were searched. Studies on neonates, infants, and children in which researchers compared different methods for gastric tube placement verification with x-ray reference standard were eligible in the review. RESULTS: Eight studies involving 911 participants that evaluated 9 index tests for gastric tube placement verification were included. Most studies were of moderate methodological quality, and most index tests were assessed in small individual studies. pH testing with cutoff values ≤ 6 for gastric tube position confirmation was the only index test subjected to meta-analysis, with the summary sensitivity and specificity being 0.77 (95% confidence interval [CI] 0.56-0.90) and 0.42 (95% CI 0.16-0.73). Other tests for gastric tube placement verification showed great variations in sensitivities and specificities. DISCUSSION: pH ≤ 6 is not sufficiently accurate to be recommended for gastric tube placement verification in neonates, infants, and children. Diagnostic performance of pH ≤ 4 or 5 and other methods cannot be determined because of the paucity of data and methodological variations in studies. Clinical practice related to the diagnostic tests used will continue to be dictated by local preferences and cost factors, until stronger evidence becomes available.

Weight-Based Estimation of Insertion Length of the Nasogastric Tube in Extremely Low Birth-Weight Infants.

BACKGROUND: Nasogastric (NG) tubes are used in the neonatal intensive care unit (NICU) for various indications. However, evidence of the best practice for estimating the NG tube insertion length in extremely low birth-weight (ELBW) infants is limited. PURPOSE: To determine a weight-based estimation formula of NG tube length in ELBW infants. METHODS: This prospective study was performed at a single-center level III neonatal intensive care unit. Low birth-weight infants admitted between May 2009 and May 2010 who required radiography for clinical reasons were included. Radiographs of participants whose current body weights (BWs) were less than 2500 g were reviewed, and the appropriate ideal insertion length of the NG tube adjusted based on radiographs and the infant's current BW was assessed. A regression model was used to determine the ideal insertion length of the NG tube with respect to the current BW. RESULTS: Overall, 533 radiographs (152 patients weighing 422-2486 g) were analyzed. Among the patients, 246 had BWs less than 1000 g and 287 had BWs more than 1000 g. Formulas that predicted NG tube length (centimeters) were derived as follows: (5 × weight [kg] + 10 [BW < 1.0 kg]) or (3 × weight [kg] + 12.5 [1.0 < BW <2.5 kg]). IMPLICATIONS FOR PRACTICE: The application of the weight-based formula for estimating the NG tube length derived from the present study together with commonly used morphological methods may improve the accuracy of the NG tube insertion procedure in ELBW infants. IMPLICATIONS FOR RESEARCH: Further studies in other cohorts are needed.

Medication errors and drug knowledge gaps among critical-care nurses: a mixed multi-method study.

BACKGROUND: Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors. METHODS: This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3. RESULTS: The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate). CONCLUSIONS: Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.

Acceptability of a new practice development for radiographers focussed on reducing 'never events' related to nasogastric feeding tubes in adult patients.

INTRODUCTION: Ascertain if a new practice development designed to reduce 'never events' from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce. METHODS: Despite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of 'never events' still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system. RESULTS: There was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession. CONCLUSION: Evaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous 'never events'. Large scale implementation of this system across the NHS Radiography workforce should be considered.

Observation on the curative effect of long intestinal tube in the treatment of phytobezoar intestinal obstruction.

The aim of the study was to observe the curative effect of long intestinal tube (LT) in the treatment of phytobezoar intestinal obstruction.We performed a retrospective study of patients with phytobezoar intestinal obstruction who underwent decompression with different tube insertion method. A total of 80 patients were collected and divided into nasogastric tube (NGT) group (n = 36) and LT group (n = 44) between August 2015 and August 2018 at our hospital. Univariate analysis was used to assess the clinical efficacy of 2 groups of patients.There were no significant differences in the mean age, sex ratio, and previous surgical history between the 2 groups. There were statistically significant differences between the 2 groups in terms of improvement time of clinical indications (4.2 ±â€Š1.4 vs 2.5 ±â€Š0.6 days; P = .008), liquid decompression amount on the first day of catheterization (870.4 ±â€Š400.8 vs 1738.4 ±â€Š460.2 mL; P = .000), transit operation rate (4/36 vs 0/44; P = .023), clinical cure rate (25/36 vs 40/44; P = .014), total treatment efficiency (32/36 vs 44/44; P = .023), and total hospitalization cost (3.25 ±â€Š0.39 vs 2.07 ±â€Š0.41 ¥ ten thousand; P = .000).The curative effect of LT in the treatment of phytobezoar intestinal obstruction is accurate and reliable, which can effectively improve the clinical symptoms of patients, comprehensively improve the non-surgical rate of intestinal obstruction treatment, reduce the total cost of hospitalization, and is worthy of promotion in clinical application.

A review of guidelines to distinguish between gastric and pulmonary placement of nasogastric tubes.

The purpose of this review was to (1) identify areas of agreement and disagreement in guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tube and (2) summarize factors that affect choices made by clinicians regarding which method(s) to use in specific situations. Systematic searches were conducted in the PubMed, Scopus, and CINAHL Plus databases using a combination of keywords and data-specific subject headings. Searches were limited to guidelines/recommendations from national level specialty groups and governmental sources published in the English language between January 1, 2015 and September 20, 2018. Fourteen guidelines that described methods to distinguish between gastric and pulmonary placement of nasogastric tubes were identified from a variety of geographic locations. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation.

Nursing Care Guidelines for Reducing Hospital-Acquired Nasogastric Tube-Related Pressure Injuries.

BACKGROUND: Nurses certified in wound, ostomy, and continence monitored an increasing incidence of hospital-acquired pressure injury of the nares due to medical devices, specifically nasogastric tubes, in a metropolitan hospital. A majority of these pressure injuries occurred in patients in the intensive care unit. The organization lacked formal guidelines for preventing such injuries. OBJECTIVE: To decrease the incidence of nasogastric tube-related hospital-acquired pressure injury. METHODS: The organization's process improvement model, comprising steps to define, measure, analyze, improve, and control, guided the project. The incidence rate of nasogastric tube-related hospital-acquired pressure injury before the intervention was determined for calendar year 2015 and compared with data obtained after the intervention, for calendar year 2016. An interprofessional team created, implemented, and evaluated the effectiveness of evidence-based guidelines and surveillance strategies for preventing nasogastric tube-related hospital-acquired pressure injury. The team implemented guidelines using the simple mnemonic "CLEAN": correct tube position, stabilize tube, evaluate area under/near tube, alleviate pressure, note date and time. RESULTS: The incidence rate of nasogastric tube-related hospital-acquired pressure injury (0.13 per 1000 patient days in 2015) decreased 100% (0.0 per 1000 patient days in 2016) after the guidelines were implemented in the organization. This rate was sustained for a full year, after which it increased slightly because temporary and new staff lacked knowledge of the guidelines. CONCLUSIONS: The creation and implementation of clear and specific guidelines for assessing and securing nasogastric tubes successfully reduced nasogastric tube-related hospital-acquired pressure injury.