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Nasogastric tube feeding is generally considered safe provided a nasogastric aspirate with a pH ≤5.5, which indicates that the end of tube is correctly located in the stomach, can be obtained. When this is not possible, hospital attendance or admission is usually required so that an X-ray can be undertaken to check the tube's position. This practice is based on an interpretation of the evidence that places undue importance on nasogastric aspirate pH testing before every use of a tube that is already in place, with potential negative consequences for children cared for in the community and their families. Following a re-examination of the evidence base, a revised approach is proposed in this article: when a child has a tube in place, provided its position has been confirmed as correct on initial placement using aspirate pH testing, nurses can use checks other than aspirate pH testing, alongside their clinical judgement, to determine whether it is safe and appropriate to use the tube. This proposed revised approach would reduce delayed or missed administration of fluids, feeds and medicines and enable more children to remain at home., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Introduction: Accurate determination of the internal length of nasogastric tubes is essential for the safe and effective completion of blind insertions, a routine nursing procedure. The widely used nose-earlobe-xiphoid distance lacks evidence and effectiveness. A recent randomized controlled trial proposed an alternative, the corrected nose-earlobe-xiphoid distance formula. However, its effectiveness in real-world clinical practice has not yet been studied., Objective: This study assessed the real-world clinical effectiveness of the corrected nose-earlobe-xiphoid distance formula for determining the internal nasogastric tube length in adult patients admitted to hospitalization or intensive care units., Design: A single-center retrospective clinical effectiveness study was conducted, utilizing routinely collected observational data., Setting and Main Outcome Measures: Between October 2020 and November 2022, 358 adult patients in a general hospital requiring a nasogastric feeding tube were included. The primary outcome involved assessing nasogastric tube tip positioning (>3 cm below the lower esophageal sphincter) by an advanced practice nurse through X-ray verification. Secondary outcomes, obtained from patient records for a random subgroup of 100 participants, were reporting clarity and evaluation of the tip position by reviewing radiologists., Results: Following evaluation by an advanced practice nurse, all nasogastric feeding tubes were determined to be correctly positioned. Among the subgroup of 100 tubes, X-ray protocols, as documented by the reviewing radiologists, showed varying levels of reporting clarity for the tube tip: 4.0 % lacked reporting, 33.0 % had ambiguous reporting and 63.0 % had unambiguous reporting., Conclusion: The corrected nose-earlobe-xiphoid distance formula demonstrates potential to emerge as a safer alternative to existing methods for determining the internal length of nasogastric tubes., Implications for Clinical Practice: In addition to healthcare provider education and training, a checklist-based framework is recommended for radiologists to unambiguously report nasogastric tube tip positions., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Many patients in intensive care units (ICU) require nasogastric (NG) or orogastric (OG) tubes. These patients often require a combination of sedatives that can alter level of consciousness and impair cough or gag reflexes. Such factors can lead to NG/OG tube displacement. Using a misplaced tube can lead to aspiration, lung injury, infection, and even death., Aims: To standardize ongoing verification of NG tube placement practices in our 34-bed Medical-Surgical ICU., Methods: The Johns Hopkins Nursing Model was utilized to guide this project. A literature review and critical appraisal were performed to establish NG/OG tube best practices. Best practices were implemented and assessed (via a survey and charting audits)., Results: Fifteen publications were identified and appraised as Level 4 and 5 sources. Best evidence supported that at the time of radiographic confirmation of the tube site, it should be marked with inedible ink or adhesive tape where it exits the nares; tube location should be checked at 4-hour intervals; and placement/patency should be checked in patients who complain of pain, vomiting, or coughing. Following the practice change, N = 40 nurses indicated improvement in verification of NG/OG tube knowledge, "OK to use" order was verified for 89% of patients, and 63% of tubes were marked with tape at the exit site., Linking Action to Evidence: Adherence to current, evidence-based strategies for NG/OG tube verification promotes patient safety. Monitoring practice changes is critical to determine whether a best practice is sustained. Electronic health records must be current to guide and support evidence-based nursing practice., (© 2021 Sigma Theta Tau International.)

Here, we aimed to build a nomogram model to estimate the probability of nasogastric tube-associated pressure injuries (NTAPIs) in intensive care unit(ICU)patients. This prospective cohort study included 219ICU patients with nasogastric tube between September 2019 and January 2020.Univariate and multivariate logistic regression analyses were used to develop the nomogram model. The resulting nomogram was tested for calibration, discrimination, and clinical usefulness. Of the included patients, 58 developed NTAPIs, representing an incidence rate of 26.5%. Binary logistic regression analysis revealed that the prediction nomogram included C-reactive protein, vasopressor use, albumin level, nasogastric tube duration, and Sequential Organ Failure Assessment score. The value of these predictors was again confirmed using theLasso regression analysis. Internal validation presented a good discrimination of the nomogram, with an area under the curve value of 0.850, and good calibration (Hosmer-Lemeshow test, P = 0.177). The decision curve analysis also demonstrated preferable net benefit along with the threshold probability in the prediction nomogram. The nomogram model can accurately predict the risk factors for NTAPIs, to formulate intervention strategies as early as possible to reduce NTAPI incidence., (Copyright © 2021 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.)

Background: Several routes of fecal microbiota transplantation (FMT) administration are available for treating recurrent Clostridioides difficile infections (CDI), the most recent of which are capsules., Aim: To assess the efficacy of colonoscopy, capsule, enema, and nasogastric tube (NGT) FMT for the treatment of recurrent CDI., Methods: We reported clinical outcomes of colonoscopy, capsule, enema, and NGT FMT for the treatment of recurrent CDI according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. During January 2000 to January 2018, three databases were searched: PubMed, EMBASE, and CINAHL. Primary outcome was overall cure rate which was assessed using a random effects model; secondary outcomes included adverse effects as well as subgroup analyses comparing donor relationship, sample preparation, and study design., Results: Twenty-six studies (1309 patients) were included in the study. FMT was administered using colonoscopy in 16 studies (483 patients), NGT in five studies (149 patients), enema in four studies (360 patients), and capsules in four studies (301 patients). The random effects of pooled FMT cure rates were colonoscopy 94.8% (CI 92.4-96.8%; I 2 15.6%), capsule 92.1% (CI 88.6-95.0%; I 2 7.1%), enema 87.2% (CI 83.4-90.5%; I 2 0%), and NGT/NDT 78.1% (CI 71.6-84.1%; I 2 0%). On subgroup analysis of colonoscopy FMT, sample preparation methods had comparable cure rates: fresh 94.9% compared to 94.5%. Similarly, cure rates were unaffected by donor relationship: mixed 94.5% compared to unrelated donor 95.7%., Conclusion: CDI cure rates with FMT performed with colonoscopy are superior to enema and NGT FMT, while those with FMT with colonoscopy and capsule are comparable.

Gold standard colonoscopy in the UK demands a 90% cecal intubation (CI) rate. Endoscopists must provide photographic evidence of CI, which can include images of the terminal ileum, appendix orifice, anastomosis or ileocecal valve. Whilst photographic proof of intubation should be obtained for all complete colonoscopies, this is not routinely audited. Three hundred and ninety-six complete colonoscopies were analyzed, 200 in an initial audit, and 196 in a second audit. Photos taken during colonoscopy were reviewed for evidence of successful CI, as well as whether these photographs had been marked as "proof of intubation" (POI). Results were shared at departmental governance meetings in order to assess any improvement in practice. Initial audit revealed 70% of colonoscopies had provided sufficient proof of CI but only 50% provided photographs that were described as such. Twenty percent of colonoscopies provided sufficient images, but these were not identified as POI. Thirty percent of all colonoscopies provided insufficient proof of CI. Upon repeat audit, 71% of colonoscopies met best practice standards, with the remaining 29% showing insufficient evidence of CI. In the modern era of digital technology, lack of photographic evidence should be seen as unacceptable and may raise important clinical and medicolegal concerns. We recommend that audits such as this become standard practice to ensure best practice.

Various approaches for enteral access exist, but because there is no single best approach it should be tailored to the needs of the patient. This article discusses the various enteral access techniques for nasoenteric tubes, gastrostomy, gastrojejunostomy, and direct jejunostomy as well as their indications, contraindications, and pitfalls. Also discussed is enteral access in altered anatomy. In addition, complications associated with these endoscopic techniques and how to either prevent or properly manage them are reviewed., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: Nasogastric decompressive tube utilization has been accepted as one of the basic perioperative care measures after esophageal resection surgery. However, with the development of multimodal rehabilitation programs and without clear evidence to support their use, the systematic indication of this measure may be controversial., Material and Methods: Retrospective, descriptive and comparative study of patients who had undergone Ivor-Lewis esophagectomy in our center -from January 2015 to December 2018- with placement (Group S), or without placement (Group N) of a decompressive tube in gastroplasty during postoperative period. Epidemiological variables and differences between groups in post-surgical morbidity and mortality, hospital stay, onset of oral tolerance and the need for nasogastric tube placement were evaluated., Results: A total of 43 patients were included in this study, with a median age of 61 years, being 86% male. 46.5% were hypertensive, 25.5% had lung disease and 16.3% had diabetes mellitus. The median length of hospital stay was 9 days in group S versus 11.5 days in group N, with no differences in the onset of oral tolerance. Anastomotic dehiscence rate was 5% and 0% respectively. The overall mortality was 2.3% in the first 90 days, without differences between the groups. Placement of nasogastric tube during postoperative period was required only in 1 patient (4.3%) of the group N., Conclusions: Non-use of nasogastric tube during postoperative period of an Ivor-Lewis esophagectomy is a safe measure, as it is not associated with a higher rate of complications or hospital stay. This fact may be able to improve patients' comfort and postoperative recovery., (Copyright © 2020 AEC. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: The present study aimed to evaluate whether the implementation of a service improvement programme improved the occurrence of radiologically inserted gastrostomy (RIG) tube displacements, post-insertion., Methods: A retrospective observational study of cancer patients was conducted over a 2-year period divided into two time points. Eighty-two RIG insertions were audited retrospectively; 42 in Time 1 and 40 in Time 2., Results: Some 70% (n = 57) of patients had head and neck (H&N) malignancy, 24% (n = 20) had gastrointestinal cancer and 6% (n = 5) had a variety of other malignancies. Following the implementation of the service improvement programme, the number of RIG tube displacements almost halved from nine (21%) to five (12%)., Conclusions: The present study offers persuasive evidence indicating that the implemented service improvement programme improved patient care; however, further research incorporating a more robust evaluation is necessary. People with advanced disease are living longer and so there is a need to maintain good nutritional support. This innovation offers the potential to enhance patients' quality of care and minimise complications., (© 2020 The British Dietetic Association Ltd.)

Introduction: The objective was to evaluate diagnostic performance of multiple methods used to assess gastric tube placement verification in neonates, infants, and children., Methods: A systematic review using the methods outlined in the Cochrane Handbook for Reviews of Diagnostic Test Accuracy was conducted. Eight databases were searched. Studies on neonates, infants, and children in which researchers compared different methods for gastric tube placement verification with x-ray reference standard were eligible in the review., Results: Eight studies involving 911 participants that evaluated 9 index tests for gastric tube placement verification were included. Most studies were of moderate methodological quality, and most index tests were assessed in small individual studies. pH testing with cutoff values ≤ 6 for gastric tube position confirmation was the only index test subjected to meta-analysis, with the summary sensitivity and specificity being 0.77 (95% confidence interval [CI] 0.56-0.90) and 0.42 (95% CI 0.16-0.73). Other tests for gastric tube placement verification showed great variations in sensitivities and specificities., Discussion: pH ≤ 6 is not sufficiently accurate to be recommended for gastric tube placement verification in neonates, infants, and children. Diagnostic performance of pH ≤ 4 or 5 and other methods cannot be determined because of the paucity of data and methodological variations in studies. Clinical practice related to the diagnostic tests used will continue to be dictated by local preferences and cost factors, until stronger evidence becomes available.

Background: Nasogastric (NG) tubes are used in the neonatal intensive care unit (NICU) for various indications. However, evidence of the best practice for estimating the NG tube insertion length in extremely low birth-weight (ELBW) infants is limited., Purpose: To determine a weight-based estimation formula of NG tube length in ELBW infants., Methods: This prospective study was performed at a single-center level III neonatal intensive care unit. Low birth-weight infants admitted between May 2009 and May 2010 who required radiography for clinical reasons were included. Radiographs of participants whose current body weights (BWs) were less than 2500 g were reviewed, and the appropriate ideal insertion length of the NG tube adjusted based on radiographs and the infant's current BW was assessed. A regression model was used to determine the ideal insertion length of the NG tube with respect to the current BW., Results: Overall, 533 radiographs (152 patients weighing 422-2486 g) were analyzed. Among the patients, 246 had BWs less than 1000 g and 287 had BWs more than 1000 g. Formulas that predicted NG tube length (centimeters) were derived as follows: (5 × weight [kg] + 10 [BW < 1.0 kg]) or (3 × weight [kg] + 12.5 [1.0 < BW <2.5 kg])., Implications for Practice: The application of the weight-based formula for estimating the NG tube length derived from the present study together with commonly used morphological methods may improve the accuracy of the NG tube insertion procedure in ELBW infants., Implications for Research: Further studies in other cohorts are needed.

Background: Enteral feeding is essential for critically ill, head trauma, and burn patients who are unable to swallow., Objective: To evaluate a new nasoenteral feeding tube with distal tip balloon designed to facilitate post-pyloric migration and avoid misplacement in the trachea., Methods: A case series was conducted in 50 critically ill patients aged 19 to 89 years receiving mechanical ventilation and requiring enteral nutrition in a teaching hospital. Patients received a soft, flexible, kink-resistant nasoenteral feeding tube with a balloon near the distal tip to enhance postpyloric migration by peristalsis. The feeding tube was inserted with a novel thread technique to reduce posterior nasopharyngeal trauma and tube misplacement. Pulse oximetry provided early detection of misplacement into the trachea. Placement was verified by abdominal radiography performed shortly after the procedure and repeated within 24 hours if needed., Results: Postpyloric placement was achieved at 30 minutes in 24% of patients and by the following morning in 70% of patients. Tracheal intubation occurred in 1 patient but was recognized and corrected without injury. No tube occlusion from kinking occurred., Conclusions: Early gastric or postpyloric feeding can be provided with this novel feeding tube. Its use facilitates quick bedside recognition of accidental misplacement in the trachea, reducing the chance of pneumothorax. The tip balloon reduces deeper placement into a lung and promotes distal migration into the small intestine. The design prevents occlusion from kinking, which is common with conventional feeding tubes. Nurses easily adopted the tube and insertion technique., (©2020 American Association of Critical-Care Nurses.)

Background: Nurses certified in wound, ostomy, and continence monitored an increasing incidence of hospital-acquired pressure injury of the nares due to medical devices, specifically nasogastric tubes, in a metropolitan hospital. A majority of these pressure injuries occurred in patients in the intensive care unit. The organization lacked formal guidelines for preventing such injuries., Objective: To decrease the incidence of nasogastric tube-related hospital-acquired pressure injury., Methods: The organization's process improvement model, comprising steps to define, measure, analyze, improve, and control, guided the project. The incidence rate of nasogastric tube-related hospital-acquired pressure injury before the intervention was determined for calendar year 2015 and compared with data obtained after the intervention, for calendar year 2016. An interprofessional team created, implemented, and evaluated the effectiveness of evidence-based guidelines and surveillance strategies for preventing nasogastric tube-related hospital-acquired pressure injury. The team implemented guidelines using the simple mnemonic "CLEAN": correct tube position, stabilize tube, evaluate area under/near tube, alleviate pressure, note date and time., Results: The incidence rate of nasogastric tube-related hospital-acquired pressure injury (0.13 per 1000 patient days in 2015) decreased 100% (0.0 per 1000 patient days in 2016) after the guidelines were implemented in the organization. This rate was sustained for a full year, after which it increased slightly because temporary and new staff lacked knowledge of the guidelines., Conclusions: The creation and implementation of clear and specific guidelines for assessing and securing nasogastric tubes successfully reduced nasogastric tube-related hospital-acquired pressure injury., (©2019 American Association of Critical-Care Nurses.)

Background: Medication errors are a serious and complex problem in clinical practice, especially in intensive care units whose patients can suffer potentially very serious consequences because of the critical nature of their diseases and the pharmacotherapy programs implemented in these patients. The origins of these errors discussed in the literature are wide-ranging, although far-reaching variables are of particular special interest to those involved in training nurses. The main objective of this research was to study if the level of knowledge that critical-care nurses have about the use and administration of medications is related to the most common medication errors., Methods: This was a mixed (multi-method) study with three phases that combined quantitative and qualitative techniques. In phase 1 patient medical records were reviewed; phase 2 consisted of an interview with a focus group; and an ad hoc questionnaire was carried out in phase 3., Results: The global medication error index was 1.93%. The main risk areas were errors in the interval of administration of antibiotics (8.15% error rate); high-risk medication dilution, concentration, and infusion-rate errors (2.94% error rate); and errors in the administration of medications via nasogastric tubes (11.16% error rate)., Conclusions: Nurses have a low level of knowledge of the drugs they use the most and with which a greater number of medication errors are committed in the ICU.

Introduction: Ascertain if a new practice development designed to reduce 'never events' from feeding through misplaced nasogastric tubes (NGT) in a large teaching hospital Trust was acceptable to a large radiography workforce., Methods: Despite National Patient Safety Agency guidance advising on safe practice for confirming position of NGTs a number of 'never events' still occur nationally due to misinterpretation of the check X-ray. A new practice development for radiographers included providing an immediate comment and removal of misplaced NGTs at the time of the check X-ray examination. Success of the new system was partly assessed using qualitative and quantitative measures of radiographer opinion of the training and different aspects of the system., Results: There was a significant improvement in radiographers' level of confidence in image interpretation after training (58/98 positive responses before, 89/98 positive after training) and after five months of experience at undertaking the role (96/98 positive) (p < 0.01). There was increased confidence in NGT removal post training and with five months of experience (16/95 positive before training, 67/96 positive after and 81/95 positive with five months of experience). 97/98 (99%) of radiographers agreed the new system benefits patients, 93/98 (95%) believed it a positive step for the radiography profession., Conclusion: Evaluation of this new practice development has shown it was embraced by radiographers and is a workable and potentially cost-effective solution in addressing real time image interpretation issues that were evident from previous 'never events'. Large scale implementation of this system across the NHS Radiography workforce should be considered., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

The purpose of this review was to (1) identify areas of agreement and disagreement in guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tube and (2) summarize factors that affect choices made by clinicians regarding which method(s) to use in specific situations. Systematic searches were conducted in the PubMed, Scopus, and CINAHL Plus databases using a combination of keywords and data-specific subject headings. Searches were limited to guidelines/recommendations from national level specialty groups and governmental sources published in the English language between January 1, 2015 and September 20, 2018. Fourteen guidelines that described methods to distinguish between gastric and pulmonary placement of nasogastric tubes were identified from a variety of geographic locations. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

The aim of the study was to observe the curative effect of long intestinal tube (LT) in the treatment of phytobezoar intestinal obstruction.We performed a retrospective study of patients with phytobezoar intestinal obstruction who underwent decompression with different tube insertion method. A total of 80 patients were collected and divided into nasogastric tube (NGT) group (n = 36) and LT group (n = 44) between August 2015 and August 2018 at our hospital. Univariate analysis was used to assess the clinical efficacy of 2 groups of patients.There were no significant differences in the mean age, sex ratio, and previous surgical history between the 2 groups. There were statistically significant differences between the 2 groups in terms of improvement time of clinical indications (4.2 ± 1.4 vs 2.5 ± 0.6 days; P = .008), liquid decompression amount on the first day of catheterization (870.4 ± 400.8 vs 1738.4 ± 460.2 mL; P = .000), transit operation rate (4/36 vs 0/44; P = .023), clinical cure rate (25/36 vs 40/44; P = .014), total treatment efficiency (32/36 vs 44/44; P = .023), and total hospitalization cost (3.25 ± 0.39 vs 2.07 ± 0.41 ¥ ten thousand; P = .000).The curative effect of LT in the treatment of phytobezoar intestinal obstruction is accurate and reliable, which can effectively improve the clinical symptoms of patients, comprehensively improve the non-surgical rate of intestinal obstruction treatment, reduce the total cost of hospitalization, and is worthy of promotion in clinical application.

Aims and Objectives: To observe the effects of bundle care on preventing unplanned extubation of nasobiliary drainage catheter after endoscopic retrograde cholangiopancreatography., Background: Preventing unplanned extubation has become a difficult problem for nursing staff because the catheter is stiff, fine and long., Design: A total of 114 cases that experienced nasobiliary drainage after endoscopic retrograde cholangiopancreatography for the first time in our hospital from April 2015-July 2016 were enrolled in this study. According to receiving routine nurse or bundle nurse, these cases were randomly divided into control (n = 56) and intervention (n = 58) group., Method: The unplanned extubation incidence, contact area between tape and catheter and tensile resistance were compared between the two groups., Results: The contact area was one square centimetre in the control group and 5 cm 2 in the intervention group. Tensile resistance was significantly higher in the intervention group than in the control (all p < .05). Unplanned extubation incidence was significantly lower in the intervention group (1.72%, 1/58) than in the control (12.5%, 7/56) (p = .0305)., Conclusion: Bundle care can effectively decrease unplanned extubation incidence after endoscopic retrograde cholangiopancreatography., Relevance to Clinical Practice: This study provides a basis for decreasing unplanned extubation incidence., (© 2017 John Wiley & Sons Ltd.)

Background: Medication administration via enteral tubes is a complex and key application for which nurses in intensive care units are responsible., Aim: The aim of this study was to evaluate drug administrations via enteral tubes by nurses in intensive care units., Methods: This research was conducted using a descriptive and cross-sectional research design. The study was conducted with 289 nurses at intensive care units in hospitals in İzmir, Turkey. The data of the study were collected with the 'Sociodemographic Information Form' and the 'Enteral Medication Administrations Questionnaire', which was designed in accordance with the literature and consists of questions on interventions before, during and following medication administrations via enteral tubes., Results: It was found that more than half the nurses (62.3%) use nasogastric tubes for medication administrations and that all of them use the enteral way for the administration of medications in the form of tablets, while 58.8% use this method to administer the medications in the form of enteric-coated tablets. It was determined that approximately half the nurses (52.6%) apply more than one medication separately, and a majority (84.1%) use tap water to wash the enteral tube., Conclusions: Enteral medication administration practices are inconsistent. Some nurses use unsafe practices and may therefore compromise patient care., Relevance to Clinical Practice: Conduction of education programmes on medication administration via enteral tubes for intensive care unit nurses is important in improving nurses' knowledge., (© 2018 British Association of Critical Care Nurses.)

Parenteral nutrition (PN) is a highly complex medication and its provision can be prone to a variety of errors. Safe administration of this therapy requires that the competency of clinicians, particularly nurses, be demonstrated using a standardized process. In this document, a standardized model for PN administration competency is proposed based on a competency framework, the ASPEN-published interdisciplinary core competencies, discipline-specific standards of practice, safe practice recommendations, and clinical guidelines. ASPEN recognizes that all healthcare institutions may not currently meet the aspirational goals of this document. This framework will guide institutions and agencies in developing tools and procedures and maintaining competency of staff members around safe PN administration. The ASPEN Board of Directors has approved this document., (© 2018 American Society for Parenteral and Enteral Nutrition.)

Nasogastric tubes (NGTs) are important for feeding, stenting and decompression after gastrointestinal surgeries, particularly in the upper gastrointestinal tract. Resistance in the removal of a NGT is a rare surgical complication and may be due to a knot in the tube or a stitch anchoring the tube to an anastomosis . We report a 41-year-old male patient who was admitted to the King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia, in 2015 with stomach cancer. He underwent a radical total gastrectomy with a Roux-en-Y oesophagojejunostomy. One week after the surgery, removal of the NGT was attempted; however, this was very difficult and the proximal end of the tube was cut off as a temporary measure. Six weeks later, an upper gastrointestinal tract endoscopy revealed that the distal end of the NGT had been accidentally stitched to the Roux-en-Y oesophagojejunostomy. The stitch was removed and the rest of the NGT was successfully extracted using a snare.

Enteral supplementation for nutritional support in pediatric oncology patients remains nonstandardized across institutions and between providers. Pediatric oncology patients frequently fail to meet their growth curve percentiles, lose weight, and/or are malnourished due to both the oncologic process as well as side effects from chemotherapy and radiation treatments. Methods of increasing weight include enteral feeding (nasogastric, nasoduodenal/jejunal, or gastrostomy), parenteral intravenous feeding, and oral supplementation. Indications for feeding and feeding protocols are highly variable, in part due to parental and familial choices, and in part due to the lack of guidelines available for providers. This article provides a comprehensive literature review of 8 published studies regarding the effectiveness and safety of enteral feeding in maintaining or increasing weight in pediatric oncology patients to help inform practice. The review concludes that enteral feeding in pediatric oncology patients is an effective and safe method to affect weight positively. However, further research is needed for developing treatment guidelines, including establishing a timeline for initiation of feeding, and determining which patients are most likely to benefit from enteral feeding.

Objectives: A cecal intubation rate (CIR) of >90% is a well-accepted quality indicator of colonoscopy and is consequently monitored within endoscopy units. Endoscopists' desire to meet this target may mean that incomplete colonoscopies are recorded as flexible sigmoidoscopies. The aim of this study was to examine whether the conversion of requested colonoscopies is a clinically significant phenomenon and whether this impacts upon the measurement of quality indicators., Methods: A retrospective review of all flexible sigmoidoscopies performed between 1 January 2015 and 31 December 2015 at Nottingham University Hospitals, Sheffield Teaching Hospitals, and Cambridge University Hospitals was performed. Where a colonoscopy was requested but a flexible sigmoidoscopy performed, the patient's records and endoscopy reports were reviewed to determine whether this conversion was decided before the start of the procedure and documented., Results: During the 12-month period, 6,839 flexible sigmoidoscopies were performed by 125 endoscopists. The original requests of 149 sigmoidoscopies could not be retrieved and were therefore excluded from this analysis. Of the 6,690 sigmoidoscopy requests reviewed, 2.8% (n=190) procedures were originally requested as a colonoscopy. On review of patient records, 85 conversions were appropriate according to pre-defined criteria. However, 105 conversions were deemed inappropriate, occurring in patients who had a valid documented indication for colonoscopy and had undergone full bowel preparation. The most common reasons cited included poor bowel preparation (n=37), technically challenging procedure (n=24), at the endoscopist's discretion based on clinical factors (n=21), and obstructing patology (n=8). A clear reason for conversion was not apparent in 11 cases. During the study period, 21,271 colonoscopies were performed and so conversions represent 0.45% of the total requests. When inappropriate conversions were included in individuals' performance data, 15 endoscopists fell to ≤90% target cecal intubation target., Conclusions: A small, but significant number of colonoscopies are converted to flexible sigmoidoscopies at the time of the procedure. This study demonstrates the conversion of colonoscopy to sigmoidoscopy as being a potential limitation of relying on CIR alone. Endoscopy units should consider monitoring the rate of inappropriate conversions to ensure quality.

Objective:: to investigate evidence in the literature on procedures for measuring gastric tube insertion in newborns and verifying its placement, using alternative procedures to radiological examination., Method:: an integrative review of the literature carried out in the Cochrane, LILACS, CINAHL, EMBASE, MEDLINE and Scopus databases using the descriptors "Intubation, gastrointestinal" and "newborns" in original articles., Results:: seventeen publications were included and categorized as "measuring method" or "technique for verifying placement". Regarding measuring methods, the measurements of two morphological distances and the application of two formulas, one based on weight and another based on height, were found. Regarding the techniques for assessing placement, the following were found: electromagnetic tracing, diaphragm electrical activity, CO2 detection, indigo carmine solution, epigastrium auscultation, gastric secretion aspiration, color inspection, and evaluation of pH, enzymes and bilirubin., Conclusion:: the measuring method using nose to earlobe to a point midway between the xiphoid process and the umbilicus measurement presents the best evidence. Equations based on weight and height need to be experimentally tested. The return of secretion into the tube aspiration, color assessment and secretion pH are reliable indicators to identify gastric tube placement, and are the currently indicated techniques., Objetivo:: investigar, na literatura, evidências sobre procedimentos de mensuração da sonda gástrica em recém-nascidos e de verificação do seu posicionamento, procedimentos alternativos ao exame radiológico., Método:: revisão integrativa da literatura nas bases Biblioteca Cochrane, LILACS, CINAHL, EMBASE, MEDLINE e Scopus, utilizando os descritores "intubação gastrointestinal" e "recém-nascido" em artigos originais., Resultados:: dezessete publicações foram incluídas e categorizadas em "método de mensuração" ou "técnica de verificação do posicionamento". Como métodos de mensuração, foram encontrados os de tomada de duas distâncias morfológicas e os de aplicação de duas fórmulas, uma baseada no peso e outra na altura. Para técnicas de verificação do posicionamento, encontrou-se traçado eletromagnético, atividade elétrica do diafragma, detecção de CO2, solução de índigo carmim, ausculta do epigástrio, aspiração de secreção gástrica, inspeção da cor, avaliação de pH, enzimas e bilirrubina., Conclusão:: o método de mensuração que utiliza as medidas do nariz ao lóbulo da orelha ao ponto médio entre apêndice xifoide e cicatriz umbilical apresenta melhores evidências. As equações baseadas em peso e altura necessitam ser testadas experimentalmente. O retorno de secreção na aspiração da sonda, avaliação da cor e do pH da secreção são indicadores confiáveis na identificação do posicionamento da sonda gástrica, e são as técnicas atualmente indicadas., Objetivo:: investigar, en la literatura, evidencias sobre procedimientos de medición de la sonda gástrica en recién nacidos y de verificación de su posicionamiento, procedimientos alternativos al examen radiológico., Método:: revisión integradora de la literatura en las bases Biblioteca Cochrane, LILACS, CINAHL, EMBASE, MEDLINE y Scopus, utilizando los descriptores "intubación gastrointestinal" y "recién nacido" en artículos originales., Resultados:: diecisiete publicaciones fueron incluidas y categorizadas en "método de medición" o "técnica de verificación del posicionamiento". Como métodos de medición, fueron encontrados los de medida de dos distancias morfológicas y los de aplicación de dos fórmulas (una basada en el peso y otra en la altura). Para las técnicas de verificación del posicionamiento, se encontró: trazado electromagnético, actividad eléctrica del diafragma, detección de CO2, solución de índigo carmín, auscultación del epigastrio, aspiración de secreción gástrica, inspección del color, evaluación de pH, enzimas y bilirrubina., Conclusión:: el método de medición que utiliza las medidas de la nariz al lóbulo de la oreja al punto medio entre apéndice xifoideo y cicatriz umbilical, presenta las mejores evidencias. Las ecuaciones basadas en peso y altura necesitan ser comprobadas experimentalmente. El retorno de secreción en la aspiración de la sonda, evaluación del color y del pH de la secreción son indicadores confiables en la identificación del posicionamiento de la sonda gástrica, y son las técnicas actualmente indicadas.

Objective: Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospitalisation. We aimed to assess whether intravenous hydration (IVH) was more cost-effective than nasogastric hydration (NGH) as a planned secondary economic analysis of a randomised trial involving 759 infants (aged 2-12 months) admitted to hospital with a clinical diagnosis of bronchiolitis and requiring non-oral hydration. No Australian cost data exist to aid clinicians in decision-making around interventions in bronchiolitis., Methods: Cost data collections included hospital and intervention-specific costs. The economic analysis was reduced to a cost-minimisation study, focusing on intervention-specific costs of IVH versus NGH, as length of stay was equal between groups. All analyses are reported as intention to treat., Results: Intervention costs were greater for IVH than NGH ($113 vs $74; cost difference of $39 per child). The intervention-specific cost advantage to NGH was robust to inter-site variation in unit prices and treatment activity., Conclusion: Intervention-specific costs account for <10% of total costs of bronchiolitis admissions, with NGH having a small cost saving across all sites., (© 2016 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.)

Objective: to know the time between indication and use of a nasoenteral tube (NET) and factors associated with delays., Method: A prospective cohort study that followed adults in a Brazilian emergency department, since the indication of the use of a NET, evaluating clinical variables and the work process. The Generalized Estimated Equations model was adopted to identify factors associated with the delays in each stage of the process., Results: the time between indication and use of NET was 573 (IQR: 3601,093) minutes, in 150 insertions of NET. Insertions in patients who previously did not use it; delays in the medical, nutrition, and nursing care routine; use of mechanical ventilation; noradrenaline; and fasting were factors for longer time before the use of the tube., Conclusion: the time between indication and use of NET was high, exceeding 10 hours in half of the cases. Factors related to the clinical condition of the patient and to the care management would contribute to delays.

Objectives: This present study was designed to determine the efficacy of the colorimetric capnometry method used to verify the correct placement of the nasogastric tube., Methods: The present study comprised forty patients who had a nasogastric tube inserted and were being monitored in the adult intensive care unit. After the insertion of the nasogastric tube, 40 colorimetric capnometry and 40 auscultation measurements were performed. Auscultation and colorimetric capnometry results were compared with tube placement results confirmed radiologically., Results: In the confirmation of the placement of the nasogastric tube, the consistency was 97.5% (p<0.05) between the colorimetric capnometry method and the radiological method, and 82.5% (p>0.05) between the auscultatory method and the radiological method. The oesophageal placement of the nasogastric tube was detected with the colorimetric capnometry method, but the gastric and duodenal insertions were not determined. While the sensitivity and specificity of the colorimetric capnometry method in determining the correct placement of the nasogastric tube were 1.00 and 0.667 respectively, those of the auscultatory method were 0.89 and 0.0 respectively., Conclusion: As a result, for the confirmation of the NGT placement, the colorimetric capnometry method is considered more reliable than the auscultatory method and is compatible with the radiological method. However, the colorimetric capnometry method is inadequate to distinguish between the gastric or duodenal insertion., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objectives: Previous studies have shown that ultrasonography (USG), as an alternative to radiography, has a good accuracy in confirming nasogastric tube (NGT) position. Color flow detection of air insufflation is a novel approach in verifying NGT position. In our study, we aimed at evaluating its sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy in confirming the NGT position, as compared with 2-dimensional (2D) USG., Methods: The study was conducted on adult patients over a period of 38months in an emergency department in Hong Kong. 2D USG and color flow Doppler imaging were conducted for each subject. Chest X-ray was used as the gold standard for NGT position confirmation., Results: 100 patients (59 males and 41 females) were recruited totally. Their mean age was 82. The sensitivity, specificity, PPV and NPV of 2D USG were 11.1% (95% CI 4.6%-17.6%), 100% (95% CI 100%-100%), 100% (95% CI 100%-100%), and 11.1% (95% CI 4.6%-17.6%) respectively. For color flow Doppler USG, the sensitivity, specificity, PPV and NPV were 90% (95% CI 83.7%-96.2%), 80% (95% CI 55.2%-100%), 97.6% (95% CI 94.3%-100%), and 47.1% (95% CI 23.3%-70.8%) respectively. The overall accuracy of color Doppler imaging was 89%, which was higher than that of 2D USG (20% only)., Conclusions: Color flow detection of air insufflation improves the diagnostic accuracy of ultrasound in verifying NGT position. It is a quick investigation such that fasting time of patients and their length of ED stay can be shortened., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Aim: The aim of this study was to evaluate the effectiveness of pH paper testing of aspirate and chest x-ray for determining nasogastric tube (NGT) placement in terms of cost and patient outcome., Background: Nasogastric tubes are frequently used in clinical practice, however during insertion the practitioner is blinded as to the precise final location. Despite robust checking procedures, recognized patient morbidity and mortality associated with this procedure have resulted in national safety alerts prompting the revision of all NGT care clinical guidelines., Design: Cost utility analysis using economic modelling., Methods: A decision tree was built and populated with effectiveness data gathered from a systematic search of the extant literature. Specificity, pooled sensitivity and event probabilities were calculated using statistical software. Patient outcome was measured in terms of quality of life. Health state utilities were gathered from a sample (n = 23) of adult surgical patients using a recognized instrument. Cost data were gathered using published sources. The study adopted a third party payer perspective in a Scottish context and was completed in June 2013., Results: The results confirm that the current UK algorithm advocated by the National Patient Safety Agency appears to offer the most cost effective approach to NGT confirmation in terms of cost and patient outcome. Sensitivity analyses indicate that these findings may be significantly altered by tube aspiration success and the rates of chest x-ray interpretation errors., Conclusion: The results confirm current UK recommendations and have wider policy implications for those areas, whereby chest x-ray is recommended as the first and only acceptable confirmation approach., (© 2016 John Wiley & Sons Ltd.)

A clinical case is presented that was communicated to Spanish Notification System on Safety in Anaesthesia and Recovery (SENSAR). Using this communication and its analysis, a strategy is obtained in order to reduce the risks associated with the insertion of a nasogastric tube (NST) for enteral nutrition in adult patients in the post-surgical recovery unit. A description of the incident is presented, an analysis of its causes, and the measures that were introduced in order to avoid similar incidents in the future, as well as to promote a safety culture in the organisation. A description of associated incidents registered in SENSAR is also given. The aim of this work is to describe, analyse and introduce safety measures arising from incidents notified to SENSAR, associated with the insertion and checking of the nutrition NST in adult patients in the post-surgical recovery unit., (Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.)

Problem: Significant deficiencies exist in the knowledge and skills of medical students and residents around health care quality and safety. The theory and practice of quality and safety should be embedded into undergraduate medical practice so that health care professionals are capable of developing interventions and innovations to effectively anticipate and mitigate errors., Approach: Since 2011, Leeds Medical School in the United Kingdom has used case study examples of nasogastric (NG) tube patient safety incidents within the undergraduate patient safety curriculum. In 2012, a medical undergraduate student approached a clinician with an innovative idea after undertaking an NG tubes root cause analysis case study. Simultaneously, a separate local project demonstrated low compliance (11.6%) with the United Kingdom's National Patient Safety Agency NG tubes guideline for use of the correct method to check tube position. These separate endeavors led to interdisciplinary collaboration between a medical student, health care professionals, researchers, and industry to develop the Initial Placement Nasogastric Tube Safety Pack., Outcomes: Human factors engineering was used to inform pack design to allow guideline recommendations to be accessible and easy to follow. A timeline of product development, mapped against key human factors and medical device design principles used throughout the process, is presented. The safety pack has since been launched in five UK National Health Service (NHS) hospitals, and the pack has been introduced into health care professional staff training for NG tubes., Next Steps: A mixed-methods evaluation is currently under way in five NHS organizations.

Purpose: Enteral nutrition (EN) is the preferred route of nutrient delivery in critically ill patients. Research has consistently described an incomplete delivery of EN in critically ill patients. The purpose of this study was to investigate barriers to reach and maintain >90% prescribed EN among critically ill medical intensive care unit (ICU) patients., Methods: We performed a retrospective cohort quality improvement study of patients ≥ 18 years of age admitted to a tertiary medical ICU and referred for EN from October 1-December 31, 2013. We excluded patients who received intermittent or bolus feeding. Demographic, clinical, and nutrition data were collected. Potential barriers to EN were categorized a priori., Results: Seventy-eight patients receiving 344 days of EN were included in the study. EN was initiated at a median of 32 hours (interquartile range, 18.5-75 hours) after ICU admission. Initiation and advancement of EN was identified as the most common reason for <90% prescribed intake. The top 5 interruption reasons were extubation, fasting for bedside procedure, loss of enteral access, gastric residual volume (0-499 mL), and radiology suite procedure., Conclusions: Suboptimal EN volume delivery continues to be an issue in critically ill patients. Our study identified initiation and advancement of EN as the most common reason for suboptimal EN volume delivery. Variation in practice was noted within several categories, and multiple reversible barriers to optimal EN delivery were identified. These data can serve as the impetus to modify practice models and workflow to optimize EN delivery among critically ill patients., (© 2015 American Society for Parenteral and Enteral Nutrition.)

Patient-centered care is an expectation in our current environment, yet it is only one of the six domains that the Institute of Medicine has described as critical in redesigning the architecture of a medical system. Patients requiring long-term feeding tube access represent a particularly complex group of patients who stress the mechanisms placed within a healthcare system to optimize quality and safety. We describe the implementation of a new approach to this patient population that serves as an example of redesigning a system of care to optimize safety using the principles of patient-centered care while delivering safe, effective, timely, efficient, and equitable care., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Enteral tube placement in hospitalized neonates and young children is a common occurrence. Accurate placement and verification are imperative for patient safety. However, despite many years of research that provides evidence for a select few methods and clearly discredits the safety of others, significant variation in clinical practice is still common. Universal adoption and implementation of evidence-based practices for enteral tube placement and verification are necessary to ensure consistency and safety of all patients. This integrative review synthesizes current and seminal literature regarding the most accurate enteral tube placement and verification methods and proposes clinical practice recommendations.

Purpose: We aimed to develop and evaluate an algorithm to facilitate drug switching between primary and tertiary care for patients with feeding tubes., Methods: An expert consortium developed an algorithm and applied it manually to 267 preadmission drugs of 46 patients admitted to a surgical ward of a tertiary care university hospital between June 12 and December 2, 2013, and requiring a feeding tube during their inpatient stay., Results: The new algorithm considered the following principles: Drugs should be ideally listed on the hospital drug formulary (HDF). Additionally, drugs should include the same ingredient instead of a therapeutic equivalent. Preferred dosage forms were appropriate liquids, followed by solid drugs with liquid administration form, and solid drugs that could be crushed and/or suspended. Of all evaluated drugs, 83.5% could be switched to suitable drugs listed on the HDF and another 6.0% to drugs available on the German drug market. Additionally, for 4.1% of the drugs, the integration of individual switching rules allowed the switch from enteric-coated to immediate-release drugs. Consequently, 6.4% of the drugs could not be automatically switched and required case-to-case decision by a clinical professional (e.g., from sustained-release to immediate-release)., Conclusions: The predefined principles were successfully integrated in the new algorithm. Thus, the algorithm switched more than 90% of the evaluated preadmission drugs to suitable drugs for inpatients with feeding tubes. This finding suggests that the algorithm can readily be transferred to an electronic format and integrated into a clinical decision support system.

Background: Blind placement of a nasogastric feeding tube is a common nursing procedure. Confirmation of the correct position in the stomach is warranted to avoid serious complications such as misplacement in the lung. Testing pH of aspirate from a tube is one of the techniques to confirm the tip position. The purpose of this study was to evaluate the auscultatory method and pH measurement with a pH cut-off point of 5.5 after tube insertion and to compare this with the 'gold standard': an abdominal X-ray. Also the feasibility of the pH method was evaluated., Materials and Methods: Large prospective observational study in a general hospital. In adult hospitalised patients, the positioning of 331 feeding tubes was tested using two different methods to predict tube position in the stomach., Results: In 98.9% (n=178) of aspirate samples with a pH ≤ 5.5, the tube was located in the stomach. If an aspirate could be obtained, the results of pH measurements showed a sensitivity of 78.4% and a specificity of 85.7%. Obtaining aspirate initially after placement was possible in approximately half of cases but after taking additional measures (including administration of air into the tube, side-positioning of the patient and re-aspiration after one hour) this increased to 81.6%. The sensitivity of the auscultatory method was 79% while the specificity was 61%., Conclusions: A pH of ≤ 5.5 from tube aspirate is adequate to check the position of the tube in the stomach. Additional measures improve the success to obtain an aspirate from the tube. The auscultatory method is unreliable., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Enteral access device malfunction and breakage results in significant morbidity and healthcare cost. In many healthcare systems, enteral nutrition care is fragmented and inefficient. We describe the development and validation of an enteral nutrition support clinic (NSC) with a focus on prevention of enteral access complications. A care protocol consisting of pre- and postplacement visits and subsequent weekly visits was developed. Competencies were established for dietitians to staff the NSC., Methods: A retrospective quality analysis was performed in patients before and after the implementation of an enteral NSC. Enteral access complications, emergency room visits, readmissions, unplanned physician visits, and tube replacements were recorded for 90 days after tube placement., Results: Thirty patients were evaluated in the NSC pilot and compared with 22 baseline patients with adequate follow-up. The NSC resulted in an 88.9% reduction in nutrition-related emergency room visits (P = .016) and 78.1% reduction in readmissions (P = .027). Estimated per-patient cost reductions amounted to $6831. Approximately 30% of patients were seen in the NSC at least once for a clogged tube and 43.3% for tube leakage. Only 1 NSC patient required a procedure for tube reinsertion., Conclusion: Implementation of a dietitian-led nutrition support clinic resulted in improved quality, as well as reductions in hospital readmissions, tube-related complications, and healthcare costs

Background: Early enteral nutrition is recommended for patients in intensive care units, but nutrition provision is often hindered by a variety of unit-specific problems., Objectives: To evaluate the impact of a nutrition support protocol on nutrition prescription and delivery in the intensive care unit., Methods: Nutrition-related data from 73 patients receiving mechanical ventilation who were treated in an adult medical intensive care unit before introduction of an enteral nutrition support protocol were retrospectively compared with data for 87 patients admitted after implementation of the protocol., Results: After implementation of the protocol, enteral nutrition was started significantly earlier (P = .007) and enteral feeding goals were reached significantly faster (6 vs 10 days, P < .001) than before. Prescription of enteral nutrition on the first day of invasive mechanical ventilation increased from 38% before to 54% after (P = .03) implementation of the protocol. Prescribed and delivered nutrition doses on the first 2 days of mechanical ventilation also increased significantly (P < .001) after the protocol was implemented. Nasojejunal feeding tubes were used in 52% of patients before and 56% of patients after protocol implementation P = .63). Jejunal tubes were placed earlier after the protocol was implemented than before (median 5 vs 6.5 days), and when a jejunal tube was in place, feeding goals were reached faster (median 2 vs 3 days, P = .002)., Conclusion: Implementing an enteral nutrition support protocol shortened the time to reach feeding goals. Jejunal feeding tubes were necessary in more than half of the patients, and with a jejunal feeding tube in place, feeding goals were reached rapidly., (©2014 American Association of Critical-Care Nurses.)

Aim: The aim of this study was to describe paediatric feeding-tube weaning practice in Australian children's hospitals and to compare this with practice in tube weaning programmes internationally., Methods: A literature review regarding tube weaning practices was conducted to inform questionnaire design. Six Australian children's hospitals and six international paediatric service providers completed a written questionnaire., Results: Four of six Australian children's hospitals surveyed reported that they have adopted informal paediatric tube weaning practices; four of six lacked clinical practice guidelines (CPGs), and five of six lacked a clearly defined case leadership. Practice varied substantially within and between these Australian feeding teams. By comparison, all six international feeding teams reported having developed formal CPGs. Five of six reported clearly defined case leadership with no more than three lead professionals overseeing cases and concordantly reported a high level of practice consistency within and between teams., Conclusions: The majority of Australian children's hospitals lack a formal CPG and clearly defined case leadership to guide tube weaning practices, and accordingly, there is considerable practice variation. This is in contrast to the situation in a select group of international centres. There is a need for further research to define best practice models and for Australian CPGs., (© 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)