Policy No: RM82 Version: 1.0 Name of Policy: Paediatric Nasogastric Tube Policy Effective From: 25/07/2018 Date Ratified 07/06/2018 Ratified Paediatric SafeCare Review Date 01/06/2020 Sponsor Kathryn Brown Paediatric Clinical Lead Expiry Date 06/06/2021 Withdrawn Date Unless this copy has been taken directly from the Trust intranet site (Pandora) there is no assurance that this is the most up to date version This policy supersedes all previous issues
Version Control Version Release Author/Reviewer 1.0 25/07/2018 Laura Collins, Ward Manager, Paediatrics Ratified by/authorised by Paediatric SafeCare Date 07/06/2018 Changes (Please identify page no.) 2
Contents Section Page 1. Introduction... 4 2. Policy scope... 4 3. Aim of policy... 4 4. Duties (Roles and responsibilities)... 4 5. Definitions... 5 6. Main Body of the policy... 5 6.1 Background... 5 6.2 Contraindications or complications... 5 6.3 Decision to insert NG Tube... 6 6.4 Preparation of equipment... 6 6.5 Inserting the NG Tube... 6 6.6 Feeding tube placement- techniques that should never be used... 7 7. Giving Fluids and Medications via an NG Tube... 8 8. Training... 9 9. Equality and diversity... 10 10. Monitoring compliance with the policy... 10 11. Consultation and review... 10 12. Implementation of policy (including raising awareness)... 10 13. References... 10 Appendices Appendix 1 Paediatric Nasogastric Tube Position Chart... 11 3
Paediatric Nasogastric Tube Policy 1 Introduction Displacement of Nasogastric tubes (NG) can have serious implications if undetected. NG tubes can be misplaced into the lungs on insertion or displaced from the stomach into the oesophagus at a later stage. Incorrectly positioned tubes leave patients vulnerable to the risks of regurgitation and respiratory aspiration, which can cause serious harm and in some cases can be fatal (NPSA 2005). It is therefore vital to differentiate between gastric and respiratory placement on initial insertion to prevent potentially fatal complications. Medical and nursing staff who place these tubes need to be aware of the risks and receive the necessary training and support to ensure safety and best practice. 2 Policy scope This policy applies to all staff caring for paediatric patients requiring nasogastric tubes within Gateshead Health NHS Foundation Trust. 3 Aim of policy The aim of this policy is to standardise the care of patients with NG tubes to ensure that insertion and ongoing management is safe, effective and comfortable for the patient. The policy includes safe methods for checking the position of NG feeding tubes and advises on unsafe methods which should not be used. It does not include the use of NG tubes in the neonatal unit. 4 Duties (roles and responsibilities) Roles Responsibility Chief Executive Has the overall responsibility for the implementation of this policy; however the day to day accountability for the care and management of the patient with a NG tube is the sole responsibility of the individual practitioner. Executive Directors Are responsible for ensuring that the policy is adhered to within all clinical areas. Divisional Directors, Are responsible for the implementation of this policy Divisional Managers and and ensuring that adequate resources are available for heads of Service staff to deliver care to the appropriate standard. Dietitian Has a responsibility of ensuring that each patient receives adequate and appropriate nutritional support. Medical Staff Medical staff should consider patients who require short term feeding when there is an inadequacy in feeding e.g. bronchiolitis. Modern Matrons Are responsible for ensuring the implementation of this policy at ward level. Supporting Ward Managers/Departmental Managers to ensure that staff receive adequate training. 4
Ward/Departments Nursing Responsibilities Ensure they receive adequate training from a senior nurse of member of the medical team Ensure they stay up to date with current practice 5 Definitions Nasogastric Tube (NG Tube): A tube passed through the nose into the stomach used to deliver enteral feeds or medications. 6 Main Body of the policy 6.1 Background NG feeding tubes are tubes passed into the stomach via the nasopharynx for the purpose of providing nutrition. NG feeding is an active nutritional support commonly used to maintain or improve the nutritional status of patients who are unable to take sufficient nutrition orally (Stroud et al 2003). It is the commonest way of providing artificial nutritional support to patients in hospital. 6.2 Contraindications or Complications The following are relative contraindications for the insertion of a NG feeding tube Anatomical deformities Maxilla-facial surgery/trauma/disease Oral, nasal or esophageal tumours/surgery Basal skull fractures Severe gastro oesophageal reflux disease Mucositis Allergies- to NG tube or securing material These contraindications are not absolute, but in these patient groups the insertion of a nasogastric tube must be discussed with the medical team in charge of the patients care and specialist advice sought where appropriate. The decision and plan of care should be documented in the patient s medical notes. Complications: There are some potential complications to NG tube insertion that practitioners should be aware of in order to recognize and appropriately respond to these if and when they may occur. Fine bore tubes are preferred for gastric feeding as they are better tolerated by patients however accidental insertion can occur into the trachea and bronchi without any obvious signs of distress. If a misplaced tube is not spotted and feeding commenced the consequences can be serious. Such complications include: Pneumothorax Severe pneumonia Emphysema Pulmonary hemorrhage Death 5
6.3 Decision to Insert NG Tube The decision to insert an NG tube must be made by a senior nurse or medical staff. Decision must be documented in medical and nursing notes. Check there are no contra-indications. Inform family/child of procedure and reason for passing tube and obtain verbal consent. 6.4 Preparation of equipment Appropriate size/ type of tube Sterile water to lubricate tube ph indicator strips 20ml oral syringe Duoderm Mepital tape Gloves Blanket or sheet to wrap child 6.5 Inserting the NG Tube Wash and dry hands thoroughly, gathering together equipment listed above in a cleaned plastic tray. Position the child at a 45 degree angle either by elevating the head of the bed for an older child or tilting the cot. Wrapping infants and young children in a blanket or sheet can help to secure them. Ensure chosen nostril is clear of secretions. Older children can be asked which side they would prefer tube to be inserted on. Wash and dry hands thoroughly and put on apron and gloves. Place duoderm on chosen side of face to protect skin. Remove tube from package. Measure the length of the tube to be inserted. Measure on the child from the nose to the ear then to the xiphisternum or xiphisternum to nose then ear. Make note of the length from the number on the tube. Lubricate the end of the tube in sterile water. Gently pass the tube into the child s nostril, advancing it along the floor of the nasopharynx to the oropharynx. At this point ask an older child to swallow a little water and a younger child if they have one can be offered a dummy. This assists the passage of the tube down the oesophagus until the required length of tube has been inserted. Never advance the tube against resistance. 6
If the child shows signs of breathlessness or severe coughing remove the tube Secure the tube with tape over the duoderm or have assistant to hold in place until position has been checked. Check tube by withdrawing stomach contents using a 20ml or 60ml syringe; apply fluid to ph indicator strip and record ph reading which should be below 5. If no aspirate, reposition patient, i.e. on their side as this can affect the fluid level in the stomach and try again. If no aspirate can be obtained OR if the aspirate is NOT between 1-5.5 for gastric tubes: Change the child s position and try to aspirate again. Wait for 15-30 minutes and aspirate again. Advance or withdraw the tube by 1-2cm. Give mouth care to patients who are nil by mouth (this stimulates gastric secretions of acid). Give small oral feed to patients who are able to drink NEVER use water to flush the tube before confirming the position (Rationale 25). If no aspirate is then obtained or the aspirate is still outside of the safe range (gastric tubes 1-5.5) then discussion with senior medical staff must be had to determine the next course of action. 6.6 Feeding tube placement techniques that must NEVER be used The following are considered by the NPSA (2011) to be never events and should not be used, no matter what the circumstances: The whoosh test injecting air into the tube and auscultating the stomach. Acid/alkaline tests of gastric aspirates using litmus paper. Interpretation based on the appearance of the aspirates alone. Inject water into a feeding tube to confirm its position. Internal guide wires/stylets should NOT be lubricated before feeding tube position has been confirmed. Confirmation of feeding tube position based on x-ray alone by staff who have not been deemed competent to perform this assessment by this trust (either by successful completion of the e-learning or are deemed as competent by a consultant radiologist). Never flush the NG tube with any fluid prior to confirmation of the NG correct position. Certain factors affect PH levels: H 2 receptor blocking agents, e.g. ranitidine. Omeprazole blocks proton pump, inhibiting gastric acid secretion. Antacids temporarily reduce gastric acidity by neutralising hydrochloric acid. If the tube is advanced through the stomach into the intestine, the PH will increase to between 6 and 8. The aspirate will also change colour to 7
green/yellow, indicating the presence of bile. If this occurs withdraw the tube slightly and re-test. Note: If there is any doubt about the position of the tube, a chest X-ray must be requested, stating the reason for x-ray- to confirm position of NG tube for feeding. It is the responsibility of the radiographer to ensure that the NG tube can be clearly seen on the x-ray used to confirm the tubes position for feeding. ph reading and tube insertion length should be recorded in the nursing notes Tube position must be checked prior to every use and ph reading documented and a visual inspection also carried out to ensure tube remains at the same numerical position. 7 Giving fluids and Medications via an NG Tube Gloves and gowns should be worn as this is a clean procedure. Tube placement must be checked with ph indicator sticks prior to any medications or fluids being given. There should also be a visual check carried out to ensure tube has not shifted. If there is any doubt about the tube placement the tube should be removed and re-sited. To give a bolus feed using a syringe. Check tube placement as previously described. Remove plunger from the syringe and connect syringe to extension set. Connect extension set to NG tube. Holding the syringe straight pour required amount of feed into the syringe and let it flow through the tube. Pour small amount of water into syringe once milk feed complete and allow to flow through NGT to flush feeding tube appropriately. Feeds via a feeding pump. Some children who are admitted from the community may be receiving feeds using a feeding pump. Enteral feeding pumps are used to control the rate of delivery of feed. There are some ready to hang feeds available however some feeds will require the use of a flexitainer which should be changed FOUR hourly. The feeding regime will be prescribed by the dietitian; The giving set should be changed every 24 hours. ALWAYS use a new single use enteral enfit syringe each time the tube is handled, i.e. checking position by aspirate or administering medications Check tube placement as previously described 8
Position of patient Never feed patient lying flat. Feed sitting up or elevated to 45 during feed and for 60 minutes after. This angle does not prevent positional changes. On transferring a patient on to a trolley, the feed must have been turned off for at least 30 minutes Feeding equipment To comply with the National Patient Safety Alert No 19, dedicated clearly labelled, enteral/oral syringes MUST be used to flush enteral feeding tubes, administer enteral feed or administer enteral/oral medication. These syringes are not compatible with IV devices; therefore reducing the risk of incorrect intravenous administration of oral liquid medicines. The syringes identified for this use by the Trust will be GBUK purple female luer lock enfit syringes. These are sterile packed singly and are single use only. These syringes are all clearly labelled ENTERAL by the manufacturer in a large font. Giving sets used to deliver enteral feed via a feeding pump MUST not contain ports that can be connected to IV syringes. Three way taps with IV ports MUST not be used with any enteral feeding equipment. Enteral feeding pumps are to be used to control the rate of delivery of feed. The Trust uses Nutricia Infinity pumps and giving sets. Giving sets must be replaced every 24 hours. Each set has a stepped connector that may be needed to connect to some tubes. Feed, giving sets are obtained through the Nutrition and Dietetic Service. Nasogastric tubes for paediatrics are obtained on top up by pea pod/the ward. Pumps are obtained from the medical device library. Enteral enfit syringes are obtained at ward level via the supplies department. The hospital pumps are not to be sent home with a patient. They are the property of the Nutrition and Dietetic Service and are stored in the medical devices library. The Nutrition Nurses will provide a pump for home use from Homeward a home delivery service. If medications are required to be given via the NG tube liquid preparations should be used where possible. If liquid is not available or is thick and may block the tube please consult pharmacy for advice. Flush the tube with 5mls water after confirming the position of the tube and after each medication. 8 Training All staff must be observed and assisted by a senior member of medical or nursing staff until deemed competent to carry out the procedure unsupervised. 9
9 Equality and diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. 10 Monitoring compliance with the policy This policy will be monitored by the ward manager and charge nurse/sister for Paediatrics to ensure all staff are compliant with the policy. Datix s related to nasogastric tubes will be investigated and actioned by the Band 7 and 6 nurses and medical staff if required. 11 Consultation and review This policy will be reviewed every 2 years and consultation will involve, Nursing Staff, Consultants, Practice Development Nurses, dietitians and Safecare. 12 Implementation of policy (including raising awareness) The contents of this policy will be shared with the following: Nursing staff Consultants Medical Staff Modern Matron Children s Community Nursing Staff Dietitians Will be shared at team update sessions and ward meeting. To be presented at safecare. 13 References Royal Marsden (2011) Royal Marsden Hospital Manual of Clinical Nursing Procedures Eighth edition National Patient Safety Agency (NPSA) (2011) Patient Safety Alert NPSA/2011/PSA002 Reducing the harm caused by misplaced nasogastric feeding tubes in adults, children and infants. London. [Accessed 22 July 2014]. Knox, T. and Davie, J. (2009). Nasogastric tube feeding--which syringe size produces lower pressure and is safest to use? Nursing Times, 105 (27): 24-26. Durai, R. and Venkatraman, R. (2009) Nasogastric tubes 1: Insertion technique and confirming the correct position. Nursing Times, 105 (16): 12-13. Durai, R. and Venkatraman, R. (2009) Nasogastric tubes 2: Risks and guidance on avoiding and dealing with complications. Nursing times, 105 (17): 14-16. National Patient Safety Agency (NPSA) (2005) Patient Safety Alert 2005-02- 21. Reducing harm caused by the misplacement of nasogastric feeding tubes. London. 10
Appendix 1 Patient Details Name: Date of Birth Ward:.. PAEDIATRIC NASOGASTRIC TUBE POSITION CHART Hospital Number: Feeding tube insertion check of position Date of insertion:../../ External length of tube:.. cm Method used to confirm tube position on insertion of tube: PH testing of aspirate / chest xray (circle as appropriate) If no aspirate is obtained following insertion then a senior member of the medical team must be made aware. Checking of NG tube position: never flush Ng with any fluids until correct position is confirmed The position of the nasogastric feeding tube MUST be checked PRIOR TO COMMENCEING FEED OR GIVING OF MEDICINES Date/Time PH of aspirate: External length of tube (cm) Signature If unable to get aspirate or aspirate Ph > 5.0 then please consider the following- (please initial in each box and then sign at the bottom) Is external length of tube the same as when tube inserted? Is NG tube taped securely? Does aspirate look like gastric contents? Is the patient on any drugs that may affect ph eg. Ranitidine, omeprazole Signature If unable to confirm tube position contact SENIOR medical staff 11