Safety in nutrition nursing—a need to protect patients and professionals

We have been busy in the National Nurses Nutrition Group (NNNG) networking, supporting and showcasing many nasogastric (NG) tube initiatives, safety concerns and national recommendations. The administration of feeds or medicines via a misplaced NG tube remains a Never Event, and during the year April 2020 to March 2021 there were 34 events reported to NHS England/NHS Improvement (Table 1):

Despite a patient safety alert issued in 2016 with recommendations for all professionals to attend training and be competency assessed (NHS Improvement, 2016), mistakes are still occurring. New innovations are now appearing on the market to help minimise these risks. As a subgroup of BAPEN, the Nasogastric Special Interest Group (NGSIG) aims to provide a multiprofessional forum enabling discussion on best practice between those health professionals in the UK who provide NG therapy (for the purpose of feeding, fluids or medication) to adults and children. NGSIG is proposing to look at new techniques, considering the safety aspect, evidence/research and link this to the BAPEN position paper on nasogastric tube safety (NGSIG, 2020), and the recent report from the Healthcare Safety Investigation Branch (HSIB) (2020). New techniques that possibly will be critiqued are: NGPod, IRIS (Integrated Real-time Imaging System), Cortrak magnetic induction, lipase testing, the Avanos app for NG placement, pH readers, and combined pH and CO2 technique. Additional information will be available on the BAPEN and NNNG websites.

Considering safety issues

The HSIB report undertook a detailed investigation focusing on NG tubes that are used to enterally feed patients and the two methods used for confirmation of NG tube tip position: pH testing and interpretation of chest X-rays. For anyone who is involved with insertion and management of NG tubes it is a very detailed review of the subject and an interesting read (even those not in a nutrition-specific role). The investigation used a human factors approach in reviewing the multifactorial elements with regard to the insertion and management of NG tubes—from education and training, policies and procedures to staffing factors and procurement.

Five safety recommendations and seven safety observations were made, identifying that a more cohesive approach to management of NG tubes should involve Heath Education England, NHS England/NHS Improvement, NHS Supply Chain and the British Standards Institution, the Medicines and Healthcare Products Regulatory Agency, the Society of Radiographers/College of Radiographers, and the British Society of Gastrointestinal and Abdominal Radiologists, in addition to the Department of Health and Social Care. Within the safety observations, the report identifies that following Brexit, the UK may need to consider how patient safety incident data is shared with the EU.

The variability of the skill and knowledge level of staff members involved with the insertion, care and management of NG tubes are documented. One of the risks highlighted is that without specific oversight of what skills were taught on a ‘train the trainer’ cascade approach, incorrect information could be distributed among team members.

There is also the acknowledgement that ‘learning from seniors’ may be a reason why learning from previous alerts or safety incidents is not always embedded in clinical practice. In addition to this, the report mentions that some respondents admitted to using methods of checking position that are not included in nationally agreed standards, such as the ‘whoosh test’. After reviewing this element to the report, it is important for all clinicians managing NG tubes to be aware that with an increased number of staff from outside the UK and EU now working within the NHS, individuals may be using methods that have not been used in the UK for some time. This could present an additional risk if staff members are not confident in using the pH method or know to refer/request an X-ray when necessary.

COVID-19 concerns

The HSIB report also touches on the impact that COVID has had regarding NG tube management and the impact that nursing patients in the prone position (commonly adopted for patients with severe COVID symptoms) may have in terms of confirming correct tip position. There is an increased risk of aspiration of gastric contents into the lungs and this presents challenges to reliability if using pH as the first line measure of confirming tip position.

COVID-19 has also brought into focus the safety of staff members when undertaking the procedure of inserting a NG tube. Nationally, the AGP Alliance (2020) has been busy pushing forward on the safety of all front line staff in relation to aerosol-generating procedures (AGPs). In November 2020, Dr Barry Jones (Chair of AGP Alliance) and Suzy Cole (NNNG committee member), presented on the NNNG webinar about staff safety and AGPs relating to NG tube placement. The latest statement from the AGP Alliance (2021) raises a new urgency in relation to the Delta variant of COVID-19 and government guidance for healthcare workers. A meeting was held on 3 June 2021 between DHSC and the AGP Alliance—with representation from 20 healthcare organisations. The purpose was to press the government to change its infection prevention and control guidance to reflect the short and long-term range of airborne transmission of COVID-19 and to provide all frontline healthcare workers with enhanced personal protective equipment (PPE). The Government has proposed further stakeholder meetings, but unfortunately did not find the scientific evidence compelling or the guidance in both Europe and the USA to be strong enough reason to change the guidance for England at this time. The alliance still believes that immediate changes to the guidance are essential for staff safety.