Executive Summary Checklist

The Performance Gap

Nasogastric tubes (NGTs) are a commonly used intervention in clinical practice for decompression or for administration of enteral nutrition, fluids and medications.  In a neonatal and pediatric one day prevalence study of 63 institutions, 24% of hospitalized infants and children required an orgastric (OG), nasogastric (NG), or transpyloric tube \cite{Lyman_2015}.  Of those patients, 61% were located in a neonatal intensive care unit (NICU). A National Patient Safety Alert (NPSA) issued by the National Health Service (NHS) documented over 3 million NG or OG tubes were used from 2011-2016 in the United Kingdom (UK) \cite{parker2016}. These tubes are inserted using blind placement technique, so called because the person doing the procedure cannot discern where the tube is going in the body as it is being advanced.  As a consequence, complications can occur if the NG or OG is misplaced into the esophagus, duodenum or pulmonary tree.  Serious patient harm and deaths have occurred when tube misplacement is not detected prior to use.
Studies of adult patients report NGT misplacement with serious harm to patients in 1.3 to 3.2% of tubes placed\cite{Gilbertson2011,Bourgault2009}. A study of neonates documented an incidence of 59% NGT misplacements with the majority of tubes being in the esophagus\cite{October2009}.  The Pennsylvania Patient Safety Authority documented 44 NGT misplacements into the lung from 2011-2013\cite{Powers2013}. Of these events, 24 were classified as serious patient harm.  Case reports in the literature describe such injuries as pneumothorax, enteral formula administration into the lung, esophageal perforation, and even death \cite{Gilbertson_2011,Bourgault_2009}. Failure to detect misplaced NGTs are attributed to: use of non-evidence based methods to confirm initial placement (auscultation or aspiration), failure to recognize when an NGT has changed position, failure to properly read an abdominal radiograph, failure to accurately interpret an electromagnetic device screen \cite{October_2009,Powers_2013}.