Radiology Standard Operating Procedure

Transcription

1 Title Purpose Scope and responsibilities Owner(s) Authors Confirmation of site of Naso-Gastric Tube using Chest X-ray This SOP details the operating procedure for clinical staff when confirming by Chest X-ray the site of existing or recently placed Naso- Gastric (NG) tubes. Those deemed qualified to perform and report these X-rays have a responsibility to ensure that the standard procedure is adhered to. Includes: Radiologists, Radiographers and Assistant Practitioners On noting a discrepancy, all must inform their Line Managers; Assistant Head of Service Helen O Shea and/or Modality Manager Tracey Clegg. Tracey Clegg (PF Modality Manager); Helen O Shea Assistant Head of Service Teresa Burton Practice Development Radiographer Effective date 17/06/2015 Review date 17/06/2019 Electronic name file NGTubeConfirmProtocol- ChestXray_V1.0 ISAS standards met CL1 C3; CL1 C4; CL1 C5; CL1 C7; CL2 C5; SA1 C3 Ratified by Radiology Clinical Improvement Group Date ratified 17/06/2015 Version History Version Date issued Brief summary of change Owner(s) name V0.1 06/03/2015 Draft Tracey Clegg (PF Modality Manager); Helen O Shea (AHoS) V1.0 17/06/2015 Ratified by CIG Tracey Clegg (PF Modality Manager); V1.2 17/6/2016 Reviewed (exposure when no guidewire in fine bore tube added) Helen O Shea (AHoS) EB7C71C9.docx 1 of 9

2 Table of Contents 1. Purpose of SOP Dependencies Justification criteria fully met Request compliant with IR(ME)R etc Radiography protocol Health and Safety Relevant safety issues and guidance NICE Guidelines (CG32) Patient Safety Alert NG Check flowchart References... 9 EB7C71C9.docx 2 of 9

3 1. Purpose of SOP This SOP details the operating procedure for clinical staff when confirming by Chest X-ray the site of existing or recently placed Naso-Gastric (NG) tubes. This will ensure that the best model of practice is consistently performed. Following this procedure will ensure a standard method of working so that every patient is guaranteed a safe as well as high quality examination is completed 2. Dependencies 2.1 Justification criteria fully met PH test inconclusive/lack of aspirate Critical Care areas Guide-wire in situ, radio-opaque NG tube or Ryles tube used. Difficult tube insertion Atypical anatomy surgery, radiotherapy, hiatus hernia. Where the NG tube used is of the type where the guide-wire has to be removed to obtain aspirate and has no radio-opaque properties, a Chest x-ray should be performed so that a whole repeat procedure* is not inflicted on the patient should malplacement occur. Guide-wires should NOT be re-introduced (Trust Guidelines: Enteral Feeding in Adults 2013) NOTE: Inappropriate requests should be rejected on CRIS and the referrer informed by phone. This then needs to be documented on CRIS in the comments section. 2.2 Request compliant with IR(ME)R etc Request card must clearly state chest x-ray is required to establish the position of nasogastric tube for the purpose of feeding/medication administration State which type of tube used and whether aspirate test attempted Chest x-ray should be 2nd line test when aspirate inconclusive i.e. higher than 5.5 (on critical care due to proton pump inhibitor, it is their 1st line test) (NICE CG32) Where injection of contrast via NGT is requested, refer to Radiologist first. (Out-ofhours ) If sanctioned by Radiologist, 5-10ml Niopam 300 is appropriate. If contrast is provided by the department, please Debbie.donoghue@nuh.nhs.uk with Patient K No., Contrast provided, Ward/Dr., what examination undertaken, for internal recharge. The ward may be able to obtain contrast themselves through pharmacy stores. EB7C71C9.docx 3 of 9

4 3. Radiography protocol REQUESTS MUST BE TREATED AS HIGH PRIORITY - within 4 hours!! Radiographer is responsible for ensuring NG tube is visible on image. i.e. correct exposure factors and positioning to visualise distal end of NG tube (lower than usual) portrait orientation.(patient Safety Alert NSPA/2011/PSA002) *For fine bore tubes, without a guidewire, increased exposure may be required: e.g. 85kv/25mas + grid. It is the Radiographer s responsibility to ensure the exposure is appropriate, so that the patient does not have to undergo the procedure again unnecessarily* Check for coils of tube in throat when assessing patient alert clinician if found. Radiographer must ensure both hemi-diaphragms are visible on the image in the mid-line. Where multiple line/tube checks are required (e.g. AICU: ETT+NGT check), it is acceptable to take 2 images when necessary: chest x-ray to include lower neck + upper abdomen to include iliac crests up check with referrer after first image to determine whether further image required. Ensure time of exposure added to image. (More than one image is required in some instances) most current image should be interpreted by an assessed as competent individual. Radiographer is not responsible for final NGT position confirmation unless appropriately trained.(patient Safety Alert NSPA/2011/PSA002) If Radiographer identifies NGT is obviously misplaced, they should contact the referrer, ward or Radiologist so that confirmation is achieved and tube can be removed promptly (if in lungs) and re-sited or advanced/withdrawn and re-x-rayed whilst patient still in department (return to ward if clinicians unavailable to re-site) (Patient Safety Alert NSPA/2011/PSA002) Windowing/algorithm changes can be made to image to improve visualisation. Images of difficult interpretation should be referred to a Radiologist, use bleep OOH. ( ) 4. Health and Safety All equipment must be cleaned before and after use. Observe correct manual handling techniques when deploying cassette/detector on critical care areas (unconscious patient) EB7C71C9.docx 4 of 9

5 5. Relevant safety issues and guidance 5.1 NICE Guidelines (CG32) Management of tubes People requiring enteral tube feeding should have their tube inserted by healthcare professionals with the relevant skills and training The position of all nasogastric tubes should be confirmed after placement and before each use by aspiration and ph graded paper (with X-ray if necessary) as per the advice from the National Patient Safety Agency (NPSA 2005). Local protocols should address the clinical criteria that permit enteral tube feeding. These criteria include how to proceed when the ability to make repeat checks of the tube position is limited by the inability to aspirate the tube, or the checking of ph is invalid because of gastric acid suppression The initial placement of post-pyloric tubes should be confirmed with an abdominal X-ray (unless placed radiologically). Agreed protocols setting out the necessary clinical checks need to be in place before this procedure is carried out EB7C71C9.docx 5 of 9

6 5.2 Patient Safety Alert EB7C71C9.docx 6 of 9

7 Above Right diaphragm Left lower lobe Patient Safety Alert NSPA/2011/PSA002 10/03/2011 EB7C71C9.docx 7 of 9

8 5.3 NG Check flowchart NG REQUEST JUSTIFIED YES XRAY AS HIGH PRIORITY NO NG CHECK ONLY MULTIPLE CHECKS REJECT ON CRIS REASON RECORDED. REFERRER INFORMED PORTRAIT CXR PERFORMED 1-2 IMAGES AS REQUIRED DEPARTMENT PORTABLE SITE CORRECT -check with Spr- RETURN PATIENT TO WARD SITE INCORRECT - check with Spr - INFORM WARD, DOCUMENT ON CRIS (staff recorded) SITE INCORRECT - check with Spr - INFORM WARD/REFERRER Document on CRIS? RESITE & RE-X-RAY IN DEPARTMENT If unable to attend dept to resite, return patient to ward Remove NG Tube if in bronchus EB7C71C9.docx 8 of 9

9 6. References 1. NICE 2006 Nutrition Support for Adults Oral Nutrition Support, Enteral Tube feeding and Parenteral Nutrition (CG32) 2. NPSA (2011) NPSA (March 2011) Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants Nottingham University Hospital NHS Trust Clinical Guidelines: Enteral Feeding in Adults. P 19 EB7C71C9.docx 9 of 9