The alternatives: in defence of naso-gastric tubes Tracy Earley Consultant Nurse Lancashire Teaching Hospitals NHS Foundation Trust.
NGT s Friend Or Foe?
Indications for NGT Feeding For short to medium term feeding Decreased appetite Inability to feed Gastro-intestinal disease Increased nutritional requirements When PEG cannot be placed safely
Positive Aspects of NGT s Inexpensive Low risk of complications Can be used as a supplement to oral intake or to provide complete nutritional requirements Nasogastric tube insertion is a relatively simple and safe procedure
Contraindications Absolute and Relative Recent Nasal surgery or mid face trauma Fractured base of skull Oesophageal disease Varices Carcinomas Pouches Nasal Tumours Nasal septum deviation Congenital abnormalities to the nose Severe gastric reflux or vomiting
Negative Aspects of NGT s
Negative Aspects of NGT s Short to medium term usage only Can be displaced Can be prone to blockage Very Obvious Requires testing to confirm position each day prior to usage
Resource Implications for NGT s Time consuming to replace Difficult to keep secured in some patients Night time displacement a problem often! Traumatic to replace for patients (and staff sometimes!)
Successful NGT placement is an achievement which both patients and staff are relieved and elated by
Now we just need to ensure it doesn't come out!!!!!!!
What are the Options? Short term NGT Short term / Medium term + Community NGT / PEG Medium to Long term + Community PEG PEG is usually always preferable, however these options may not always be possible or practical
Patient Choice Severe contractures Gastric surgery Why PEG may not be Possible Short life expectancy (and patient choice to continue feeding)
The alternative LTHTR model : Offer Nasal Bridle to secure NGT in displaced tubes or short medium term patients in community. Training for nursing homes to re-pass their own tubes Rapid access nutrition nursing service service mon - fri
Nasal Bridle
What is it? It utilises magnets to connect 2-introducer rods behind the nasal septum and a piece of surgical tape to be pulled through. This tape is then secured to the feeding tube.
Introduction 1 st described in 1980 1 Safe & effective 2,3 Traditional uses Head & neck malignancy Critical care Paediatric intensive care 1. McGuirt WF, Strout JJ, Securing of Intermediate Duration Feeding Tubes Laryngoscope 1980; 90: 2046-48. 2.Levenson R, Dyson A, Turner W, Feeding tube anchor Nutr Support Serv 1985; 5: 40-42. 3.Barrocas A, Jastram C, St Romain C, The Bridle: increasing the use of nasoenteric feeding Nutr Support Serv 1982; 2: 8-10.
Patient Review with Nasal Bridle If In- Patient Review within two weeks of commencing feed to assess. PEG if appropriate If discharged with NGT / Bridle then Review by HEF dietitian in three months to assess if enteral route still required Return to Rapid access clinic for replacement of NGT / Bridle as needed. Continued regular review.
Benefits of NGT and Nasal Bridle Increased security of NGT Increased Comfort for Patients with NGT Able to enterally feed those patients who require short term feeding without having to resort to PEG. Able to enterally feed a large population who cannot have PEG placed.
NGT replacement in Community Targeted replacement in some nursing homes, but not yet nasal bridle Support from nutrition nursing team Initial trainee in nursing home selected and then competency assessed by Nutrition nurses They then become cascade trainers Rapid access nutrition nursing service mon fri for advice and support
Rapid Access Nutrition Nursing Service Based at Royal Preston Hospital site. Open week days except bank holidays Dedicated telephone helpline.
Service Now: Runs days mornings (sessions) per week based in Endoscopy Six slots per session (follow up / day case / new patient) Widened access gates existing patients with enteral / Parenteral feeding devices problems are referred via GP s, District Nurses, patients, carer s. New referrals for assessment of patient s suitability for feeding device, for paediatrics undergoing transition, or patients new to the area. Central telephone number for all referrals. Nurse led with wide skill set for assessing and treating patients Templated on Trust system so financial revenue as a result Protocols accepted by Trust for band 6 and 7 nutrition nurses Nurse led discharge Clinic letter given to patient / carer at the end of appointment Formal letters out to GP within 5 days
Benefits See > 500 patient episodes annually Patients seen by clinical specialists equipped to trouble shoot / replace their devices. Discharge >98% patients home the same day. Avoids hospital admissions Relieves pressure on IP / OP services Liaise directly with other colleagues should the need arise.
? Are NGT s + Bridles being used as a replacement for PEG?
1997-1999 44 Patients (1.57 patients p/m) 2003-2004 30 Patients (3.33 patients p/m) 2004 45 Patients (3.75 patients p/m) 2005-2006 55 Patients (4.58 patients p/m) 2006-2007 56 Patients (4.62 patients p/m) 2008 76 patient (6.2 patients p/m) 2009-94 patients (7.8 patients p/m) PEG AUDITS
30 Day PEG Mortality 30 25 20 % 15 10 5 0 1997-1999 2003-2004 Appt. of nutrition nurse 2004 2005-2006 Nasal Bridle 2006-2007 2008 2009
Audit: NGT / Nasal Bridle Outcome of Nasal Bridle Patients 1% 4% 0% RIP Discharge (+ bridle) 37% PEG 34% Discharge (no nut support) IP Not resited 2008 8% 16% N = 143 LTHTR 1000+ Nasal Bridles placed since 2007
Audit Results HEF Patients 250 200 150 100 Total PEG NGT + Bridle 50 0 HEF Patients 2010
Summary Where possible in medium long term patients who require enteral feeding place a PEG. However, NGT feeding in short to medium term needs NGT with Nasal Bridle can be successful with targeted training for community colleagues AND support of local hospital for trouble shooting. LTHTR model demonstrates that NGT+ bridle is NOT being used as a replacement for PEG. Simply able to feed more patients.