Safety of Nasogastric Tube Insertion

This research focuses on the safety of nasogastric tube insertion and explores the benefits and risks associated with the procedure. It discusses different insertion techniques, evidence-based practices, and the role of nurses in assisting doctors. The research also identifies gaps in evidence-based practice and provides recommendations for improving safety.

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Safety of nasogastric tube insertion

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Abstract
The research based discourse is focussed over the aspect of nasogastric tube insertion as far
as the implication of the feasibility in terms of food intake for patients is concerned taking
account of the disciplines of clinical studies. Relevant literature is discussed with regard to
the application of the methodology of the research taking account of the aspect of PICO
(Population, Intervention, Comparison and Outcome) with regard to nasogastric tube
insertion along with the addressing of the relevant research question.

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Table of Contents
Introduction................................................................................................................................3
Research Question......................................................................................................................3
Methodology..............................................................................................................................4
Literature review....................................................................................................................4
Different NG tube insertion techniques.................................................................................5
Best approach evidence to use the technique.........................................................................6
Role of nurses in the evidence based practice........................................................................6
Risks associated with NG tube insertion................................................................................6
Research strategy.......................................................................................................................7
Quality appraisal tool.................................................................................................................8
Summary....................................................................................................................................8
Issues of implementation............................................................................................................9
Conclusion................................................................................................................................10
Reference List..........................................................................................................................11
Appendix..................................................................................................................................13

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Introduction
Nasogastric tubes are used as medical equipment to deliver food to patients or for removing
gastric contents. The tube is made of plastic that can be inserted into nostrils due to its
flexibility down the nasalparings into the stomach.in a healthcare setting there are patients
who have undergone some surgery or affected with some medical some medical condition
that restricts the patient from consuming solid food.The NG tubes are flexible and more
narrower wither a smaller opening at the ends.. The aim of this project is to make a critical
appraisal of the safety of nasogastric tubes and find a method to improve safety while still
maintaining patient care. The research project investigates the safety practices that should be
implemented by the health professionals. The research project also identifies the gap in
evidence based practice related to NG tube insertion.
Research Question
The main question for the research is “What are the benefits of nasogastric tube insertion in
terms of safety as far as the addressing of the issues related to health are concerned in
comparison to methods such as x-ray? Such a question has been formulated due to the fact
that there is not enough existing literature with regard to the comprehensive results pertaining
to research on such aspect (Lim et al., 2019). Furthermore, the aspect related to the treatment
of issues of the stomach is also imperative from the fact that nasogastric tube insertion
facilitates the ease of the decompression of stomach to a large extent. The question has been
formulated by the virtue of the observances made in terms of the access which can be paved
as a result of the insertion of the nasogastric tube. Additionally, the passage of food is also
feasible by the virtue of the insertion of nasogastric tube (Eriksen and Frandsen, 2018).
Taking account of PICO, the relevant literature implies the Population targeted being patients
which imply the number of patients benefitted as a result of the nasogastric tube insertion.
The aspect of Intervention implies the usage of pH strips with regard to the determination of
the placement of the nasogastric tube for the purpose of feeding. Intervention would also be
inclusive of the application of the techniques relted to chest radiography as far as the
identification of the correctness involved in the placement of nasogastric tube is concerned.
The aspect of Comparison would involve the comparative analysis to be made with methods
such as x-ray as implied by the research question accordingly. The aspect of Outcome would
imply the health complications such as dizziness involved. The aims and objectives of the

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research involve the analysis in terms of the usage of the nasogastric tubes and their usage
accordingly (Bear et al., 2016).
Methodology
In order to search the evidence based practice of the safe insertion of NG tube, research was
carried out online secondary sources. There are many research papers available in the internet
authored by renowned researchers. Hence the resources have helped to get a wide exposure to
the healthcare practices for nasal gastro insertion patients. However in order to get authentic
evidences, inclusion criteria included research journals published within the last five years
are taken into account. The papers which lacked the authenticity or availed for paid service
were excluded from the research. The literature review is written after referring peer viewed
journals collected from various database such as Google scholar, Pub Med. PRISA and
Caldwell.The literature review will through light on the collected evidences and it will also
illustrate the best approach of interventions. The literature review section also throws light of
comparison between different NG tube insertions practices are also made in order to get a
generalized view of the process. The methodology section brings number of keyword
searches associated with the topic. The search terms used for conducting the literature review
is Naso-gastro insertion, patient intubation, endotracheal technique, and laryngoscope and so
on
The search strategy will brief all the researched evidences and represent them in a tabular
form.
Literature review
In order to identify the gaps and limitation of the process, it is very important to know the
background of the technique. Hence the literature review section will analyse the utility of the
process and its associated risks. According to Irvinget al. (2016) there requires sufficient
literature to educate the healthcare professionals about the standardizing procedures for
performing NG tube insertion preventing risk. The treatment process can be improved in a
cost effective manner if the junior doctors or anesthesist are separately trained for performing
the technique (Niet al. 2017). As discussed before the NG tube is used to feed patients
surviving under vegetative state or they have gone some kind of surgery that makes them
difficult in swallowing things. Thus the naso gastric tube is used to deliver essential food
supplements or nutrients to patient in a fluid base. Despite there are medical advantages of

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feeding through NG tubes there are much risk involved while using it. For instance, in young
patients there are frequent tube pull out and needs to reinsert properly (Borsciet al. 2017).
The patient families find it very confusing while using it for the first time. Also for adult
patients who are using it for prolonged period, tend to face gastro esophageal reflux resulting
in leakage of food.
Different NG tube insertion techniques
According to Rowatet al(2018) there are multiple modes of insertion of NG tube that includes
using intubation stylet, endoscopy, technique associated with endotracheal tube, using frozen
NG tube, peel away split tracheal tube, esophageal guide wire technique and so on. As opined
byChavdaet al. (2017) the success rate of intubation is also dependent on the nature of
technique chosen. The above listed techniques are more advanced than the conventional
intubation technique performed during the abdominal surgery. A few of the popular
techniques are discussed below.
Conventional technique: Anesthetist insert the NG tube gently through a nostril. The head
of the patient is maintained at a nutral position without any help of instrument.
Lateral position: in this technique the patient head is maintained in a lateral position.
Without any neck maneuvers, the NG tube is inserted through a selected nostril (Gray and
Smith, 2019).
Endotracheal tube assisted technique: The patient mouth is opened with the help of two
fingers for about 80 cm. the endotracheal tube should have 7.5mm internal diameter
splitlongitudinally with sterile scissors. The split ET is now attached with the NG tube
followed by advancing into the oral cavity (Tierneyet al. 2017).
As recorded by Irvinget al. (2018) laryngoscopy confirms success rate of all the listed
techniques. There were less mucosal bleeding in the mentioned techniques. However,
successful insertion is confirmed by the auscultation sound while air injecting out through the
NG tube. If the healthcare professional failed during the first attempt, the NG tube was
completely withdrawn, cleared and re lubricated followed by repetition of the same
procedures. On failure of two consecutive attempts, the particular technique was eliminated
and the other one was chosen.

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Best approach evidence to use the technique
Lateral positioning technique:After gathering several sources from the available resources
it is noted that positioning the patient in appropriate manner is first step of the process (Roeet
al. 2017). The patient sits up with head tilted slightly to lateral position. The doctorchoses
appropriate size tube and lubricate it to place in the wider nostril. The tube is fixed in the
nose with tapes.The pH test and X ray confirms the tube’s placement within patient.
This particular technique has proved to be more effective because the NG tube tip travels a
lateral border when the head is turned. Thus it helps the tube to move smoothly into the
esophagus advancing into the stomach(Tierneyet al. 2017). This approach also prevents tube
coiling inside laryngopharynx. Turing patient head to one side aids tube passage to glide
smoothly. The other advantage of the technique is that it helps in decompressing stomach by
releasing any contents avoiding the risk of aspirating the stomach contents. The technique is
useful for patients suffering from dysphagia or has undergone tracheostomy.
Role of nurses in the evidence based practice
The available resources failed to establish the basic standardization process to perform the
technique. The research journals mostly elaborated the success rate of the different insertion
modes applied on the patients and has less focused on the role of nurses in assisting junior
doctors in the process. As opined by Irvinget al. (2016) most of the cases the nurses do not
explain the process to the patient before implementing the technique as a result the patients
are traumatized that makes the insertion more difficult. The view is confirmed by Borsciet al.
(2017)that says nurses play a significant role in assisting the junior doctors since the set up iv
line for patients examine the nostrils before tube insertion. These are the major interventions
associated with the process. Apart from this nursesanso encounter the patient for collecting
information regarding and allergic prone or any secondary condition.
Role nurses to encounter the intubated patient involve attending the seminars to know Care
evidence based strategies on NG tubation. They should also upgrade their skills with more
knowledge and evidences from medical articles available from internet and hospital
libraryIrvinget al. (2016).
Risks associated with NG tube insertion
NG tube insertion is a mandatory process for abdominal surgery or laparoscopic process. As
stated above improper insertion technique might channel the food particles in the pulmonary
system resulting in blockage of air passage (Tierneyet al. 2017). While making the insertion

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by the anesthesiologists, the gastric tube sometimes becomes tightly coiled in its bucal cavity
and the patient experience accumulation of inflated cuff in his trachea making him unable to
swallow. The tube flexibility makes it coiled after entering the oral canal making it an
unsuccessful positioning. Opening of the pipe near the tip might provoke kinking of the tube.
As opined by (Borsciet al. 2017) there is a very low success rate for the anesthetists in their
first attempt. Other complications can also include for instance there is lot of bleeding and
kinking in laryngoscopy NG insertion.
Research strategy
The concept of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-
Analyses) has been followed in order to formulate and implement the effective strategy for
the research in a proper and appropriate manner. In this aspect a research question has been
formulated for the research taking into consideration the tool related to PICO (Population,
Intervention, Comparison and Outcome) with regard to nasogastric tube insertion. The
sources in the form of electronic books and online journal articles have been identified
determined as a result of the various key words which mainly include stomach, nasogastric
tube, health, safety, treatment, medicine, pH and food. As a result, such terms used for
searching of the relevant literature have comprehensively helped in the carrying out of the
research and analysis in an effective and efficient manner as far as the findings are concerned.
The rationale behind the posing of the research question along with the aims and objectives
of the research has also been taken into account as far as the approach of PRISMA is
concerned (Gerritsen et al., 2015). The sources have been screened and filtered thereby being
included for a systematic review in order to imply the desired results in a comprehensive
manner. Such comprehensive results imply the usage of nasogastric tube in a proper and
appropriate manner as far as the intake of food for patients is concerned thereby implying the
findings of the research by the virtue of PRISMA. The data has been collected in secondary
form in the form of electronic books and online journal articles along with the usage of
certain keywords in the form of search terms as aforesaid. The limitations of the research as
per the strategy imply the constraints in the form of time and budget to a huge level. An
abstract has also been taken into consideration.

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Quality appraisal tool
The appraisal tool with regard to the effectiveness of the quality of the research that has been
taken into account is Caldwell. Such a framework has been formulated by Kay Caldwell
along with Lynn Henshaw and Georgina Taylor accordingly. In order to imply the validation
of the research, the articles were verified in terms of being peer reviewed in a proper and
appropriate manner. The credibility of the authors of the books and articles has also been
taken into consideration in an effective and efficient manner as far as the verification of the
research is concerned. The benefits of nasogastric tube insertion has been emphasised to a
large extent as far as the incredibility of the quality of the research in the desired manner is
concerned. As a result, the credibility of the research has been taken into consideration with
regard to the relevant qualitative data thereby providing the scope for the critical appraisal of
the research in the desired manner (Caldwell, Henshaw and Taylor, 2011). It is to be ensured
that the guidelines for the research are to be followed by the health professionals in question
which imply the analysis of the relevant medical journals for the research. In this regard, such
kinds of journals have been taken into account for the research as aforesaid. The framework
of Caldwell pertaining to the research also implies that the basic ethics to be followed while
conducting research based on the disciplines of health and medicine. In this matter, the
approval of the ethics committee for the research has been obtained in the desired manner
with regard to the conducting of the research. The various kinds of concepts have been
applied with regard to the conducting and undertakings of the research as far as the obtaining
of the favourable results are concerned.
Summary
The main observances made from the literature of the research imply the aspect of the
nasogastric tube insertion as far as the providing of a pathway for food intake is concerned in
terms of treatment in a proper and appropriate manner. In relation to the research questions,
such observances imply the advantages of nasogastric tube insertion in comparison to x-ray
thereby implying that the approach related to x-ray would involve time consumption as far as
checking is concerned. As a result, it is imperative that nasogastric tube insertion by the
virtue of PICO would imply the placement of the tube in the desired manner by the virtue of
pH testing which is more convenient to chest radiography accordingly as far as the derivation
of the results in a timely manner is concerned (McFarland, 2017). The themes of the research
as per the analysis of the relevant sources imply the concept of health and safety as far as the

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overall well being of the patients is concerned in terms of the relevant data collected and
applied for the research study. The area of focus of the research is the benefits of the
nasogastric tube insertion as far as the intake of food is concerned in terms of the disciplines
pertaining to the health of the patients. As a result, the relevant data has been relied upon by
the virtue of the tools of PRISMA and Caldwell as far as the determination and identification
of the research is concerned regarding the findings and appraisal of the research in the desired
manner. It is also observed that the health and safety guidelines are to be followed with
regard to nasogastric tube insertion in a proper and appropriate manner. The frameworks and
policies of the National Health Service ids also of great help in terms of nasogastric tube
insertion.
Issues of implementation
Despite the benefits of the nasogastric tube insertion as mentioned earlier, there are certain
issues in the implementation of the aspects related to nasogastric tube insertion. The PARIHS
framework is to be applied in this regard which implies the Promotion of the Action involved
in the Implementation of the Research in an effective and efficient. It further implies that the
credible evidence is to be analysed for the research related to the viabilities involved in the
nasogastric tube insertion thereby resulting in the effective outcomes. The norms and
standards related to health safety in terms of nasogastric tube insertion would play an
extremely vital role in the benefits of the patients as far as their addressing of the health
issues is concerned. The pH strips are to be taken into account with reference to the
determination of the appropriate placement of the nasogastric tube for the patient as far as
intake of food is concerned (Chavda et al., 2017). Extra care and attention is to be considered
with regard to the nasogastric tube insertion for sensitive and critical patients as far as the
standards of healthcare are concerned. The issues also involve the non-compliance of the
basic medical ethics thereby leading to ill-effects of patients as a result of nasogastric tube
insertion. As a result, such issiues would be resolved by the virtue of the stringent action to
be undertaken against the ones involved in the unethical activities regarding nasogastric tube
insertion. In the recent past, there has been advancement in technologies with regard to the
improvements on the nasogastric tube insertion for feeding patients in a proper and
appropriate manner thereby implying incredible results (Cole, 2015).

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Conclusion
There is some safety process that needs to be followed while inserting a nasal gastric tube for
instance a feeding NG tube should be labeled. Junior doctors or anesthetist use NG tube to
feed patients having swallowing difficulties or are at unconscious state to have meal. During
such situation healthcare professionals provide essential supplements to the patient with the
help of this tube. Unfortunately research studies conducted by the National Patient Safety
Agency in England reveal that there are reported cased for patient death arising from
improper NG tube insertion. Some junior doctors or anesthesist and healthcare professionals
are hardly aware of the safety practices hence the food gets stuck in the pulmonary system
resulting in blockage of air passage. Despite of governmental support for issuing safety alert,
the number of deaths is not abolished completely. So the healthcare professionals should
learn the appropriate process before implementing them practically. They should have an
wide idea before choosing the correct insertion technique for individual patient.

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Reference List
Bear, D.E., Champion, A., Lei, K., Smith, J., Beale, R., Camporota, L. and Barrett, N.A.,
2016. Use of an electromagnetic device compared with chest X-ray to confirm nasogastric
feeding tube position in critical care. Journal of Parenteral and Enteral Nutrition, 40(4),
pp.581-586.
Borsci, S., Buckle, P., Huddy, J., Alaestante, Z., Ni, Z. and Hanna, G.B., 2017. Usability
study of pH strips for nasogastric tube placement. PloS one, 12(11), p.e0189013.
Caldwell, K., Henshaw, L. and Taylor, G., 2011. Developing a framework for critiquing
health research: an early evaluation. Nurse education today, 31(8), pp.e1-e7.
Cason, M.L., Gilbert, G.E., Schmoll, H.H., Dolinar, S.M., Anderson, J., Nickles, B.M.,
Pufpaff, L.A., Henderson, R., Lee, F.W. and Schaefer, J.J., 2015. Cooperative learning using
simulation to achieve mastery of nasogastric tube insertion. Journal of Nursing
Education, 54(3), pp.S47-S51.
Chavda, V., Alhammali, T., Farrant, J., Naidu, L. and El-Rabaa, S., 2017. Nasogastric tube
knotting: a rare and potentially overlooked complication among healthcare
professionals. Case Reports, 2017, pp.bcr-2017.
Cole, E., 2015. Improving the documentation of nasogastric tube insertion and adherence to
local enteral nutrition guidelines. BMJ Open Quality, 4(1), pp.u203207-w1513.
Eriksen, M.B. and Frandsen, T.F., 2018. The impact of patient, intervention, comparison,
outcome (PICO) as a search strategy tool on literature search quality: a systematic
review. Journal of the Medical Library Association: JMLA, 106(4), p.420.
Gerritsen, A., Van Der Poel, M.J., De Rooij, T., Molenaar, I.Q., Bergman, J.J., Busch, O.R.,
Mathus-Vliegen, E.M. and Besselink, M.G., 2015. Systematic review on bedside
electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding
tubes. Gastrointestinal endoscopy, 81(4), pp.836-847.
Gray, A. and Smith, J.L., 2019. Does Everyone with a Small Bowel Obstruction Need a
Nasogastric Tube? What Is the Safest Way to Place It?.In Gastrointestinal Emergencies (pp.
177-178).Springer, Cham.

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Irving, S.Y., Crawford, J.E., Goldberg, E., Mohan, A., Ford, N. and Davis, D.H., 2016.
Practice Change for Patients with Nasogastric/Orogastric Enteral Tubes: Safety Improvement
Initiative.
Irving, S.Y., Rempel, G., Lyman, B., Sevilla, W.M.A., Northington, L., Guenter, P. and
American Society for Parenteral and Enteral Nutrition, 2018. Pediatric nasogastric tube
placement and verification: Best practice recommendations from the NOVEL
Project. Nutrition in Clinical Practice, 33(6), pp.921-927.
Lim, J.Y., Yong, E., Aneez, D.B.A. and Tham, C.H., 2019. A simple procedure gone wrong:
pneumothorax after inadvertent transbronchial nasogastric tube insertion necessitating
operative management. Journal of Surgical Case Reports, 2019(6), p.rjz186.
McFarland, A., 2017. A cost utility analysis of the clinical algorithm for nasogastric tube
placement confirmation in adult hospital patients. Journal of advanced nursing, 73(1),
pp.201-216.
Ni, M.Z., Huddy, J.R., Priest, O.H., Olsen, S., Phillips, L.D., Bossuyt, P.M. and Hanna, G.B.,
2017. Selecting pH cut-offs for the safe verification of nasogastric feeding tube placement: a
decision analytical modelling approach. BMJ open, 7(11), p.e018128.
Roe, G., Harris, K.M., Lambie, H. and Tolan, D.J.M., 2017. Radiographer workforce role
expansion to improve patient safety related to nasogastric tube placement for feeding in
adults. Clinical radiology, 72(6), pp.518-e1.
Rowat, A.M., Graham, C. and Dennis, M., 2018. Diagnostic accuracy of a pH stick, modified
to detect gastric lipase, to confirm the correct placement of nasogastric tubes. BMJ open
gastroenterology, 5(1), p.e000218.
Tierney, M., Sibley, C., Leach, Z., Rutter, C., Pither, C. and Smith, T., 2017. PTU-117 Chest
xray interpretation of nasogastric tube placement by medical registrars: how safe is it?.

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Appendix
Strategy and appraisal Tools
PARIHS
PRISMA
Caldwell
Relevancy
Validity
Reliability