Nutritional support for children and young people: nasogastric tubes.

The need to offer nutritional support to children and young people is commonplace for health professionals. This article explores the use and indication of nasogastric tubes (NGT) in children and young people, before explaining the process of inserting NGTs and the ongoing management of this method of nutritional support.

Confirming nasogastric tube placement in adults.

Nurses are responsible for ensuring that short-term enteral feeding tubes are placed correctly before using them for gastric emptying, enteral nutrition, or medication administration. This article reviews evidence-based methods for assessing tube placement and discusses the limitations of each method with a focus on nasogastric tube placement.

Providing optimal nursing care for patients undergoing enteral feeding.

Enteral feeding is defined as the intake of food directly into the gastrointestinal (GI) tract. Enteral feeding tubes can also be used to administer medicines. Patients who may require enteral feeding include those who are unconscious, or those with neurological swallowing disorders, upper GI obstruction, GI dysfunction or malabsorption. There are several routes that can be used for enteral feeding including gastrostomy, post-pyloric, nasogastric, continuous pump and bolus feeding. When undertaking enteral feeding, nurses and other healthcare professionals should be aware of the potential complications such as tube blockage and infection. This article examines the various enteral feeding routes, discusses the administration of medicines, and details the common complications associated with enteral feeding.

Bedside Postpyloric Tube Placement and Enteral Nutrition Delivery in the Pediatric Intensive Care Unit.

BACKGROUND: Enteral nutrition (EN) delivery may be more effective via a postpyloric (PP) feeding tube in critically ill children, but tube placement can be challenging. We aimed to describe PP tube placement and EN practices in a multidisciplinary pediatric intensive care unit (PICU) after the implementation of a nurse-led bedside PP tube-placement program. METHODS: In a single-center retrospective study, we identified 100 consecutive patients admitted to the PICU for >48 hours and for whom PP tube placement was attempted. Demographics, clinical characteristics, and details of PP tube placement and EN delivery were examined. RESULTS: The study cohort had a median age (25th, 75th percentiles) of 3.89 years (0.55, 14.86); 66% were male. Respiratory illness was the primary diagnosis of admission (55%); 92% were on respiratory support. Risk of aspiration was the primary indication for PP tube placement (48%). Bedside placement was the initial technique for PP tube placement in 93% of patients (successful for 84.9%) and was not associated with serious complications. Eighty-seven patients with a PP tube started EN and received a median 73.9% (12.3%, 100%) of prescribed energy goal on day 3 after EN initiation. PP EN allowed 14 of 39 patients receiving parenteral nutrition (PN) to transition off PN 7 days after EN initiation. Thirty-five percent of EN interruptions were due to feeding-tube dysfunction. CONCLUSION: Bedside PP tube placement is safe and feasible and allows for effective EN delivery and decreased PN use when applicable. Interruptions in PP EN due to tube malfunction are prevalent.

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.

People with enteral tubes and their carers' views of living with a tube and managing associated problems: A qualitative interview study.

BACKGROUND: Nutrition by enteral tube is a complex therapy requiring significant management to ensure safe, timely delivery of nutrients and avoidance of complications. In the home setting, people with enteral tubes and their carers are required to self-manage the therapy, including the need to cope with problems that arise. Whilst previous studies have conveyed experiences of people with enteral tubes, few have described views on enteral tube problems. AIMS AND OBJECTIVES: Drawing on the findings of a previously reported study (Journal of Human Nutrition and Dietetics, 2019), this paper aims to describe in-depth the experiences of people with enteral tubes and their carers of living with the tube day to day and managing problems that arise. DESIGN: A qualitative descriptive design using semi-structured in-depth interviews was employed. METHODS: A purposive sample of 19 people with enteral tubes and 15 carers of people with tubes participated. Interviews were recorded and transcribed. Using a thematic analysis approach, codes were defined and applied; themes developed and refined. Five themes with associated subthemes were generated, of which one, "living with the tube," is reported in-depth. The COREQ checklist was used. RESULTS: Participants described the tube affecting both physical and psychosocial being and revealed it had resulted in significant changes to their daily living, necessitating adaptation to a new way of life. Participants reported spending much time and effort to manage tube problems, at times without support from healthcare practitioners knowledgeable in tube management. Discomfort associated with the tube was commonly described. CONCLUSIONS: Living with an enteral tube impacts significantly on daily life requiring adaptations to normal routine. People with tubes and their carers use a range of strategies to manage common complications. RELEVANCE TO CLINICAL PRACTICE: Knowledge and understanding of how people with enteral tubes live with their tube and manage issues as they arise will enable healthcare practitioners to provide better support.

Lose the Whoosh: An Evidence-Based Project to Improve NG Tube Placement Verification in Infants and Children in the Hospital Setting.

PURPOSE: The purpose of this EBP project was to align NG and OG tube placement and verification practices with evidence-based recommendations for children. PRACTICE CHANGE: An evidence-based NG/OG Tube Placement Algorithm was developed. The algorithm provided an individualized approach based on patient condition as well as a tiered approach that incorporated radiographs, tube measurement and marking, and pH testing. METHODS: A systematic appraisal of literature identified 40 studies supporting the development of the practice change. A 9-item questionnaire was administered to nurses across five pediatric units to assess current tube verification practices. Education was provided in participating units through a Competency Fair. Post-implementation evaluation included re-administering the practice survey and conducting a chart audit of NG/OG events occurring in the year following the practice change. RESULTS: Seventy-one nurses completed the pre-implementation survey; 64 nurses completed the post-implementation survey. Strategies for checking NG/OG placement varied across units prior to implementation; however, auscultation was the most likely to be used strategy and assessing pH was the least likely to be used strategy across units. Post-implementation, aspiration and checking pH were the most frequently endorsed assessment strategy, and auscultation was the least endorsed strategy. The post-implementation chart audit revealed that 73% of NG/OG tubes were checked for placement on insertion with radiograph or aspirate pH. CONCLUSIONS: Implementation of an NG/OG Tube Placement Algorithm standardized NG/OG care across five pediatric units. Additional efforts are underway to further improve adherence to protocol in order to ensure safe, evidence-based practice for children with NG/OG tubes.

Adherence to standard nursing protocols on nasogastric tube feeding in a secondary referral hospital in Ghana: comparing self-ratings by professional and auxiliary nurses.

BACKGROUND: Data on nurses' adherence to standard protocol on nasogastric (NG) tube feeding remain scanty in Ghana even though patients in critical medical conditions are routinely managed using this procedure. This study explored self-rated adherence to standard protocols on NG tube feeding among professional and auxiliary nurses and the perceived barriers impeding compliance to these standard protocols. METHODS: This is a descriptive analytical cross-sectional study among professional (n = 89) and auxiliary (n = 24) nurses in a major referral hospital in one of the ten administrative regions in Ghana. Four-point Likert scale was used to ascertain the level of adherence to standard guidelines on nasogastric tube, ranging from 4 "Very large extent" to 1 "Very little extent". Wilcoxon Mann-Whitney test and univariate ordered logistic regression tests (proportional odds models) were performed to determine the odds of higher self-ratings among professional and auxiliary nurses. RESULTS: Overall, the odds of higher self-ratings on adherence to standard nursing protocols on NG tube feeding was higher among auxiliary nurses than professional nurses (OR = 2.76, p = 0.031) after adjusting for age, gender, education and years of work experience. Key barriers to adherence to standard protocols on NG tube feeding were: limited opportunities for in-service trainings and insufficiency of NG tube feeding protocols on the wards. CONCLUSION: There is the need for more routine in-service trainings for nursing staff to update their knowledge on NG tube feeding. Hospital management should also make current nursing protocols available to nurses to guide their practice alongside routine onsite supervision of nurses.

The Feasibility Study of a Revised Standard Care Procedure on the Capacity of Nasogastric Tube Placement Verification Among Critical Care Nurses.

BACKGROUND: Evidence-based studies propose that the aspirate pH test may be easily and reliably conducted to verify the proper placement of nasogastric tubes (NGTs). Nurses rarely implement this procedure because of the lack of related knowledge. PURPOSE: The purpose of this study was to explore the feasibility of implementing a revised standard care procedure to enhance nurses' ability to verify placement of the NGT. METHODS: his study used a quasi-experimental, longitudinal research design. Nurses from two intensive care units were randomly assigned to the experimental group (n = 35) and the control group (n = 31). A revised standard-of-care procedure to confirm the proper placement of an NGT was incorporated into a slideshow presentation, a printed leaflet, and an audit checklist. The experimental group received continuous education and individual teaching on the revised standard-of-care procedure, whereas the control group did not receive additional education and continued to provide conventional care. The study gathered data using scales designed to address knowledge of and attitudes toward verification of NGT placement and the checklist for auditing the NGT care procedure. Scales were implemented before and after the practice program was conducted, in Months 1, 2, and 3, to evaluate the feasibility of the developed improvement measures. RESULTS: This study found significant improvements in the experimental group in terms of knowledge regarding NGT placement verification and the NGT care auditing procedure. The positive improvement of the intervention on the NGT care auditing procedure remained for at least 3 months after the end of the intervention. CONCLUSIONS: The findings suggest that using an aspirate pH test is a feasible approach to verify NGT placement in critical care units, a crucial aspect of care necessary to promote patient safety and quality of care.

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.

Elaboração de instrumento para conhecer o preparo e administração de medicamentos via sonda pela equipe de enfermagem / Instrumento de preparación para saber la preparación y administración de medicamentos a través de la sonda equipo de enfermería / Elaboration of instrument to know practice of preparation and administration of drugs enteral feeding tube by nursing professionals

Objective: to describe the scientific process of elaboration of an instrument in order to know the practice of preparation and administration of drugs via enteral feeding tube by nursing professionals in clinical adult inpatient units. Methods: Methodological study, the preparation of the instrument succeeded from the systematic and intentional search of texts in the Virtual Library in Health (BIREME) in April 2014. Results: Used seven studies from the literature review, resulting in an instrument with six questions about participants and 24 questions for the direct observation of the nursing team work. Conclusion: It is expected to contribute to the production of research on the administration of drugs via enteral feeding tube, which will serve to promote further discussions in health. In addition to these contributions, in the future, this study may help hospital institutions in developing guidelines and protocols, from the systematic observation of their workers.

Objetivo: descrever o processo científico de elaboração de um instrumento para conhecer a prática de preparo e administração de medicamentos via sonda por profissionais de enfermagem, em unidades de internação clínica adulto. Métodos: Estudo metodológico, cuja elaboração do instrumento ocorreu a partir da busca sistematizada e intencional de textos na Biblioteca Virtual em Saúde (BIREME), em abril de 2014. Resultados: Utilizaram-se sete estudos provenientes da revisão de literatura, obtendo-se um instrumento com seis questões de caracterização dos participantes e 24 questões para a observação direta do trabalho da equipe de enfermagem. Conclusão: Espera-se contribuir para a produção de pesquisas a respeito de administração de medicamentos via sonda, que servirão para fomentar novos debates no campo da saúde. Além dessas contribuições, os resultados desse estudo poderão ajudar instituições hospitalares no desenvolvimento de guias e protocolos, futuramente, a partir da observação sistemática dos seus trabalhadores.

Objetivo: describir el proceso científico de desarrollar una herramienta para conocer la práctica de la preparación y administración de medicamentos a través de la sonda por profesionales de enfermería en las unidades de hospitalización de adultos clínica. Métodos: Estudio metodológico, la redacción de los cuales era el instrumento de la búsqueda sistemática y deliberada de los textos en la Biblioteca Virtual en Salud (BIREME) en abril de 2014. Resultados: Se utilizaron siete estudios de la revisión de la literatura, la obtención de una instrumento con seis preguntas sobre los participantes y 24 preguntas para la observación directa del trabajo en equipo de enfermería. Conclusión: Se espera que contribuya a la producción de la investigación sobre la administración de fármacos a través de la sonda, que servirá para promover nuevos debates en el campo de la salud. Además de estas aportaciones, los resultados de este estudio pueden ayudar a los hospitales para desarrollar directrices y protocolos en el futuro, a partir de la observación sistemática de sus trabajadores.

Nasoenteric feeding discharge planning for cancer patients in a Brazilian teaching hospital: a best practice implementation project.

OBJECTIVES: The objective of this project was to improve local practice in nasoenteric feeding discharge planning for cancer patients in a cancer teaching hospital in São Paulo, Brazil. INTRODUCTION: Nasoenteric tubes are commonly used for enteral nutrition in patients with cancer for over seven days during their recovery and this may be continued at home, with clear benefits. RESULTS: Baseline audit results indicated poor compliance (between 0% and 22%) with the current evidence, although good compliance (100%) was observed for three audit criteria. Implementation of the strategies, including changes to achieve higher participation of caregivers, resulted in an improvement of the audited criteria (100% compliance was maintained for three criteria, compliance increased from 22% to 67% for a further three criteria, with 0% compliance for one criterion). CONCLUSIONS: Despite the short time frame of this study, an increase in compliance with best practices proposed by the Joanna Briggs Institute was observed. Implementing a multidisciplinary meeting before patient discharge remains a challenge.

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.

Nurse-Assisted Percutaneous Endoscopic Gastrostomy Tube Placement Is a Safe Procedure in Adult Patients.

The percutaneous endoscopic gastrostomy (PEG) procedure is normally carried out by two doctors. Preliminary experience has suggested that this procedure may be accomplished with the same safety level using one doctor and a specially trained endoscopy nurse. The aim of the study was to assess the immediate outcome and 30 days' procedure-related morbidity following nurse-assisted percutaneous endoscopic gastrostomy (NA-PEG) in an unselected population of adult patients. Retrospective, nonconsecutive analysis of NA-PEG procedures were registered between 2008 and 2014. Demographic data, indications, and early and late procedure complications were registered. During the study period, a total of 222 nonconsecutive adult patients had a NA-PEG placement. Neurologic (56%) and malignant diseases (35%) were the major indications for the PEG placement. The NA-PEGs were performed by six specially trained endoscopy nurses. NA-PEG-related overall morbidity was 24%, and all complications were minor. No procedure-related mortality occurred. When NA-PEG was compared with standard PEG placement literature, there was no increase in the number of complications, and the types of complications were similar. Despite being performed in patients with multiple co-morbid conditions, NA-PEG was a safe procedure with no mortality and minor complications. We suggest that NA-PEG should be used on a larger scale with the intention of saving time and medical costs.

Standardized Competencies for Parenteral Nutrition Administration: The ASPEN Model.

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document.

Improved Safety and Efficacy of Small-Bore Feeding Tube Confirmation Using an Electromagnetic Placement Device.

BACKGROUND: Early enteral nutrition has been shown to decrease complications and improve patient outcomes. Post pyloric feeding is recommended for patients with gastric intolerance or at high risk for aspiration. Feeding tube placement can be challenging and pose risk of pulmonary complications. Reliance on radiographic confirmation for feeding tube placement exposes the patient to radiation. Electromagnetic placement device (EMPD) may offer a method to minimize pulmonary complications, increase successful placement, and decrease radiation exposure to the patient. OBJECTIVE: The purpose of this study was to evaluate the safety and efficacy of using EMPD verification, instead of routine abdominal radiographic confirmation, for small-bore feeding tube placement. RESULTS: Variables evaluated were adverse events, utilization of radiographs for confirmation, and success rate of feeding tube placement in the ordered location. Two time frames were reviewed. In a 1-year period, 3754 small-bore feeding tubes were placed using EMPD, with zero adverse events noted. Radiographic confirmation was utilized in 0%-29.2% of the EMPD placed tubes. Successful placement of feeding tubes using EMPD ranged from 94%-99.6%. During a 5-year period, 7081 EMPD feeding tubes were evaluated. One adverse event, pneumothorax, occurred during the placement of these 7081 tubes, for a rate of 0.014%. CONCLUSION: Feeding tube placement confirmation is safe and efficacious via EMPD providing an effective method of feeding tube placement with a success rate >94% into the desired location. EMPD is an accurate verification method of distal tip location, eliminating the need for routine abdominal radiographic confirmation.