Originally published June 2013
Feeding and nasogastric tubes are commonly used peri-operatively and also to provide much needed nutrition and medication to patients, both in acute and chronic healthcare facilities.
Placing a feeding or nasogastric (ng) tube is often considered a routine procedure requiring minimal training, yet if inserted improperly, patients can suffer harm. Physicians can provide patients with safer medical care by knowing the clinical situations where there is a higher risk of misplacement.
The task of placing these tubes may be delegated to medical students, postgraduate trainees, and nursing staff, and other qualified healthcare providers. Formal training and protocols on inserting and verifying the placement may be lacking despite the existence of recognized guidelines.1 Common complications of tube misplacement include epistaxis, vomiting, aspiration, pneumonia, and gastric or esophageal perforation.
The potential for patients to be harmed by improper tube placement is recognized. Data voluntarily reported over a recent 5-year period to the United Kingdom National Reporting System revealed 21 deaths and 79 cases of harm related to feeding tube placement. In 2009 the National Patient Safety Agency in the UK designated the use of a misplaced feeding tube as a never event. Never events are defined as: "A serious, largely preventable patient safety incident that should not occur if the available preventative measures have been implemented by healthcare providers." 2
During the period from 2002 to 2012, the CMPA reviewed its medico-legal experience related to misplaced feeding tubes. The clinical situations associated with a higher risk of misplacement include: unsupervised placement by inexperienced staff; insertion in obtunded patients; difficulties in interpreting post-placement X-rays, particularly out of hours; and lack of timely communication between a radiologist and the most responsible practitioner or delegate.
Two CMPA cases clearly illustrate some of these high-risk circumstances.
Case 1: Tube reinsertion by unsupervised and less experienced staff
An elderly female was transferred to a medical ward after a lengthy intensive care unit (ICU) admission for pneumonia, adult respiratory distress syndrome (ARDS), and acute kidney injury requiring renal replacement therapy. While she was in the ICU, the patient had a feeding tube inserted.
On the same day of her transfer and after she returned from dialysis, it was noted that the patient's feeding tube had become dislodged. After reinsertion, her nurse ordered a portable chest X-ray to confirm the placement. Late in the afternoon, the study was completed and the nurse notified a postgraduate trainee that the X-ray had been done. The resident located the patient in the PACS system and, after confirming the patient's identity, reviewed the film, which showed the feeding tube in the correct position. On this basis, an order was given to renew tube feedings.
Later that evening, following the administration of a tube feed, the patient was noted to be coughing, hypoxic, and dyspneic. She subsequently arrested and could not be resuscitated. At post-mortem, the tip of the feeding tube was found to be in the right main stem bronchus. On investigation, it became apparent that the post-insertion film had been misfiled prior to being interpreted by a radiologist. The film the resident reviewed was from the previous day prior to the displacement and reinsertion of the tube.
As expert support could not be obtained for the care in this case, the CMPA, on behalf of the resident member, and the hospital, on behalf of the radiology clerical staff, shared in paying a settlement to the patient's estate.
Case 2: Difficulties in interpreting post-placement X-rays and lack of timely communication
Just prior to the December holidays, a premature infant with severe gastroesophageal reflux was admitted to the neonatal intensive care unit. To facilitate nutrition, a naso-jejunal feeding tube was inserted later that evening. The procedure was performed with some difficulty by a pediatric resident and an abdominal flat plate was ordered post-insertion. The procedure was not documented. The pediatric resident reviewed the film and felt that the tube was in the correct position and ordered resumption of feedings.
The following morning, the film was reviewed by a radiologist. The radiologist felt that the tube was probably in the duodenum, but a lateral view was needed for definitive confirmation. This recommendation was noted in the dictated report. Due to holidays, the report was not transcribed until early January and was not available until 8 days after the tube was placed. There was no direct communication between the radiologist and the care team about the immediate need for a lateral film.
Two days after the tube was placed, the infant became hypotensive, tachycardic, and hypoxic. A repeat abdominal film disclosed a pneumoperitoneum. At surgery a perforation of the proximal jejunum was noted as well as extravasated formula in the peritoneal cavity. Despite surgical correction, the child died several days later.
The CMPA, on behalf of the member radiologist and radiology resident, and the hospital, on behalf of the nursing and clerical staff, shared in paying a settlement to the infant's parents.
What the peer experts said
Peer experts reviewing these and other cases of nasogastric and feeding tube malposition made the following observations that may help physicians avoid risk and improve patient safety.
- Those responsible for inserting tubes and verifying their placement should be aware of any institution-specific protocols or guidelines.
- Tubes should not be flushed or used for feeding until the tube position is confirmed.
- Tubes should be radio opaque and have external length markings. It is advisable to pre-measure the tubes before inserting them.
- Traditional methods for verifying the position of tubes, such as epigastric auscultation and the absence of coughing may not be reliable.
- When an adequate volume of gastric aspirate can be obtained, pH testing using approved indicator paper is acceptable as first line confirmation, however the concomitant administration of proton pump or H2 inhibitors may elevate pH readings, making this an unacceptable confirmation of the tube placement.
- If the tube position cannot be confirmed with aspirate pH testing, then confirmation should be sought using plain X-rays.
- If possible, an experienced clinician should review any films when performed out of hours.
- If tube malposition is suspected by a radiologist, immediate notification of the ward or the most responsible physician is necessary.
- If there is a suspicion that the tube has been dislodged, it may be necessary to repeat the confirmation of the tube position.
The clinical benefits of feeding and nasogastric tubes make these indispensable for treating some patients. But, if inserted improperly, the tubes can also cause harm. By being aware of clinical situations where there is higher risk of misplacement of the tubes, physicians
- National Patient Safety Agency UK, Patient Safety Alert "Reducing the harm by misplaced nasogastric feeding tubes in adults, children and infants," March 2011. Retrieved on February 26 2013 from: http://www.nrls.npsa.nhs.uk/resources/?EntryId45=129640
- National Patient Safety Agency, Never events annual report 2009/2010, October 2010. Retrieved on March 14 2013 from: http://www.nrls.npsa.nhs.uk/resources/?entryid45=83319