A prospective observational study of pH testing to confirm ongoing nasogastric tube position.

AIMS AND OBJECTIVES: To measure the reliability of pH testing to confirm ongoing nasogastric tube (NGT) position and to document associated complications. BACKGROUND: Confirming NGT position is essential, as use of an incorrectly positioned tube can cause harm. Substantial evidence examines initial confirmation of NGT position, yet limited evidence exists considers NGT displacement which is identified via ongoing NGT position tests. In the NHS, pH testing is recommended to confirm ongoing NGT position; however, there may be an association with excess X-rays and missed enteral nutrition and/or medications. DESIGN: Prospective observational study using STROBE checklist. METHODS: Data collected from medical records of 136 patients with NGTs in a London NHS Trust included pH tests, test results and complications related to ongoing pH tests which failed to confirm the tube was positioned in the stomach, that is, X-rays, and disruptions to enteral nutrition and medication. Cohen's Kappa determined pH test reliability. RESULTS: Of 1381 pH tests conducted to confirm NGT position, five (0.3%) correctly identified an NGT displacement, and one (0.07%) failed to identify displacement before use. The reliability of ongoing pH tests using Cohen's Kappa was minimal (0.29). Ongoing pH tests that failed to confirm a correctly positioned NGT led to 31 (22.8%) patients having X-rays, 24 (17.6%) missing >10% of prescribed enteral nutrition and 25 (18.4%) missing a critical medication. CONCLUSION: Ongoing NGT position testing using pH tests did not prevent the use of a displaced tube, and more than one-fifth of patients required X-rays to confirm a correctly position NGT, contributing to missed medications and enteral nutrition. RELEVANCE TO CLINICAL PRACTICE: Caution should be used when confirming ongoing NGT position with a pH test. Future guidelines should balance the risk of using a displaced tube with potential delays to nutrition and/or medication. More research is needed to explore alternative methods of ongoing NGT position testing.

Determinants and outcomes of bloodstream infections related to obesity.

Although obesity is a major healthcare problem that is increasing in many populations worldwide, there are limited studies that have examined its contribution to infectious diseases morbidity and mortality. The aim of this study was to examine the clinical determinants and outcomes of bloodstream infections among patients with obesity. All adults within the publicly funded healthcare system in Queensland, Australia, identified with a BSI during 2017-2019 were included and the presence of obesity was based on discharge International Classification of Diseases (ICD-10) codes. Clinical features, microbiology, and outcomes were compared among obese and non-obese subjects. A total of 24,602 incident BSI were identified among 21,613 Queensland residents; of which 4,579 (21.2%) and 17,034 (78.8%) were classified as obese or non-obese, respectively. Obese patients were less likely to have community associated infections and were more likely to be younger, female, have higher comorbidity scores, and have bone and joint or soft tissue infections as compared to non-obese subjects. Obese patients had a lower proportion of Escherichia coli BSI and higher proportions of b-haemolytic streptococci. Although obese patients had longer hospital admissions and more repeat incident BSI within 1 year, they had lower overall case fatality. In a logistic regression model, obesity was associated with a lower risk for 30-day case fatality (adjusted odds ratio 0.51, 95% confidence interval 0.45-0.58). Obesity is associated with significant differences in the determinants and outcome of BSI. Increasing rates of obesity is likely to influence the epidemiology of BSI in populations.

Use and safety of enteral nutrition protocols in acute care: A scoping review of literature and retrospective audit of practice.

AIM: Standardised enteral nutrition protocols are recommended in critical care, however their use and safety are not well described in other inpatient populations. This mixed methods study reports on the use and safety of enteral nutrition protocols for non-critically ill adults. METHODS: A scoping review of published literature was conducted. In addition a retrospective audit of practice at an Australian tertiary teaching hospital with an existing hospital-wide standardised enteral nutrition protocol was performed. Data on use, safety and adequacy of enteral nutrition prescription were collected from medical records for patients receiving enteral nutrition on acute wards (January-March 2020). RESULTS: Screening of 9298 records yielded six primary research articles. Studies were generally low quality. Published literature suggested that protocols may reduce time to enteral nutrition initiation and goal rate, and improve adequacy of nutrition provision. No adverse outcomes were reported. From the local audit of practice (105 admissions, 98 patients), enteral nutrition commencement was timely (median 0 (IQR 0-1) days from request; goal rate: median 1 (IQR 0-2) days from commencement and adequate (nil underfeeding), without prior dietitian review in 82% of cases. Enteral nutrition was commenced per protocol in 61% of instances. No adverse events, including refeeding syndrome, were observed. CONCLUSIONS: Most inpatients requiring enteral nutrition can be safely and adequately managed on enteral nutrition protocols. Evaluation of protocols outside of the critical care setting remains a gap in the literature. Standardised enteral nutrition protocols may improve delivery of nutrition to patients, whilst allowing dietitians to focus on those with specialised nutrition support needs.

Ongoing pH testing to confirm nasogastric tube position before feeding to reduce the risk of adverse outcomes in adult and paediatric patients: A systematic literature review.

BACKGROUND & AIMS: There is no agreed gold standard method to confirm nasogastric tube position before every use. However, many global guidelines recommend testing the pH of gastric aspirates obtained from an NGT before each use. This study aims to determine whether ongoing pH testing has been shown to reduce adverse events. Secondary aims are to determine how frequently aspirates can be obtained, and how often pH correctly confirms ongoing NGT tip position. METHODS: Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed and protocol was published on PROSPERO. Keywords were used to search PubMed, Embase, CENTRAL, CINAHL and MEDLINE. Article assessment for inclusion was completed by two independent authors and risk of bias was assessed using ROBINS-I. RESULTS: The systematic search and review methodology was followed due to wide variety and high risk of bias in the included studies. One full study and five abstracts met inclusion criteria for the primary aim. The full article contained one instance where pH testing and external NGT length together identified a misplaced NGT. The abstracts identified missed or delayed feeds and medications, and frequent unnecessary X-rays, as negative outcomes of ongoing pH testing. Ten full studies and one conference abstract addressed the secondary aims, but the studies varied widely which prevented meta-analysis and made it difficult to draw conclusions. CONCLUSIONS: This review confirmed that ongoing pH testing is based on expert opinion due to limited evidence. More primary research is required to determine the clinical impact of ongoing pH testing to confirm NGT position.

Exergaming: Feels good despite working harder.

Strategies to encourage exercise have led to research on cycle ergometer 'exergaming', as a means of enhancing exercise enjoyment. This research has typically prescribed the exercise intensity and used one exercise mode. The aim of this study was to compare self-selected exercise intensity on a cycle ergometer with and without exergaming modes activated. A total of 20 participants aged between 18-40 years (M = 24.2 ± 5.9) completed a sub-maximal exercise test. Participants returned two days later to complete one 45 minute session of self-selected exercise with 15 minutes in each of 'control' (standard ergometer), 'track', and 'game' modes, with order randomized. Heart rate, work rate, perceived exertion, and affective valence were recorded during exercise. Dissociation and enjoyment were recorded in the rest interval between each mode. Participants exercised above ventilatory threshold (VT) in all three modes (track, M = 9.5 ± 12%; game, M = 6.2 ± 12%; and control, M = 4.4 ± 14% above VT) and at higher work rates (P < 0.05) exergaming (track, M = 94.5 ± 27.9; game, M = 96.2 ± 32.8 watts) than control (M = 86.6 ± 26.5 watts). Despite exercising at a higher intensity, participants perceived exercise during the exergaming modes to be most pleasant (P < 0.01), with greater enjoyment (P < 0.01) and dissociation (P < 0.01) in the game than track mode, and both modes higher on these variables than the control mode. Findings support the use of exergaming as a strategy to encourage individuals to exercise, with participants choosing to work harder physiologically, but reporting more positive psychological responses during and following the exercise.