It was a privilege to contribute to the National Nutritional Nurses Group April Newsletter article focusing on the recent BAPEN Nasogastric Tube Special Interest Group and NHS Innovations, Healthcare Services Investigation Branch reports into nasogastric tube safety.
Both reports identify a myriad of patient safety and human factors problems associated with current NGT confirmation methods, resulting in NHS Improvement (formerly National Patient Safety Agency) issuing six patient safety alerts between 2005 and 2016. Despite these reports and tremendous efforts by the clinical community in the UK, the number of Never Events associated with the use of misplaced nasogastric tubes continues to rise.
Our response to the article by Georgie Adams highlights the game-changing difference that NGPOD can make to patient safety in nasogastric tube confirmation by eliminating or significantly reducing most of the problems associated with current placement confirmation methods.
You can read the full article along with more industry news over at https://www.nnng.org.uk/2021/04/ngpod/
The HSIB report clarifies that current testing methods for NGT position are significant contributors to NGT Never Events, noting that;
“…both pH testing and use of X-ray are prone to error…”
“…using pH testing strips is potentially unreliable and its complexity underestimated…”
“The investigation also identified concerns about the reliability and usability of pH strips.”
“There is no standard process on how to read a pH strip.”
“In two of the Never Event reports, the nursing team was not able to get any aspirates for pH checks…These scenarios are common…”
“The environment within which pH testing strips are being interpreted can increase the risk of error. In the reference event, this was particularly noted with the poorly lit environment.”
“…causes included misinterpretation of pH testing of gastric aspirate, use of outdated checking methods use of outdated checking methods…”
“…incorrect X-ray confirmation and interpretation is the most common cause of NG tube incidents.”
“…misinterpretation of X-rays by medical staff was the most common cause of placement errors.”
NGPOD either overcomes or significantly reduces many of the factors identified as contributing to Never Events related to the use of misplaced NGTs
Provides a pH test result significantly more often than aspirate and pH strips
Gives a result more rapidly than aspirate and pH strips, reducing clinical staff time to complete the test and staff exposure time to patients
Gives a clear pH </= 5.5 Yes/No result with no need for user interpretation
Does not require aspirate to be obtained
Is very easy to learn to use
Reduces the need for x-rays reducing patient exposure, reduces the risk of misinterpretation of x-rays and resource demand in radiology
Reduces delays to patients receiving their prescribed nutrition, hydration and medication, which may improve recovery