Welcome to the latest Nutrition Supplement. The updated National Nurses Nutrition Group (NNNG) Nasogastric Tube Guidance (2023) was launched at the BAPEN annual conference in November, where the authors presented the main changes. The guidance can be downloaded from the NNNG website and is free to members.
Let's go over what we already know. The whoosh test or bubble test should NEVER be used to check position. We all know that one practitioner who listens for the whoosh ‘just to see’. This does not reflect evidence-based care and keeps the embers burning of poor practice; inadvertently these actions can and do influence others. It is imperative that we provide evidence-based care to our patients, and act as a role model to our colleagues.
What we already know:
- Blue litmus paper is open to misinterpretation. Always use pH strips that are designed for human aspirate and are CE marked. The absence of respiratory distress or the appearance of aspirate is not an indication of correct placement
- Tubes should never be placed without senior support being available. This is easier within core working hours. Nothing should be introduced through the tube until placement is confirmed
- Never Events are events that should not happen. Investigations appear to show that many Never Events happen due to failure to follow guidance.
The following information forms the main updates in the latest NNNG guidance:
- Practitioner experience: it counts, it makes a difference. Your patients will feel more comfortable if you feel confident in your abilities
- Clinical setting: it is generally safer for a tube to be placed in the acute setting, but only if staff in the area have experience of using nasogastric tubes (NGT) with access to senior support and radiology. Community settings – with the correct experience, support and pathways – are also safe
- Keep patients, carers and relatives informed: if confirmation of tube placement is delayed, ensure everyone knows what is happening
- Accurate documentation: 25% of all NGT-related Never Events in 2022/23 were related to placement checks not described or documented clearly (NHS England, 2023)
- NEX+10 cm: adding 10 cm to the NEX measurement (the distance from nose to earlobe to xiphisternum) can reduce oesophageal placement. It is to be used in conjunction with local policy and professional judgement. Misplaced NGTs can cause pneumothorax. Oesophageal placement can be a cause of aspiration pneumonia. The focus should be on minimising as many risks as possible
- Secure to the cheek not to the forehead or nose: keep it out of the patient's eyeline. Secure with a dressing across the cheek and regularly check pressure areas for signs of damage
- Repeat checks AFTER initial placement has been confirmed: in certain circumstances it may not be possible to obtain aspirate below a pH value of 5.5. Where local guidance exists then external observation of the tube may be used
- Training: staff must be competency assessed and maintain competence. They must be aware of risks and know how to mitigate them
- Blocked NGTs: the safest action is to remove and insert a new NGT. An exception may be considered for those tubes that are difficult to place or require radiological guidance to place. In these circumstances, local guidance should be followed, including ensuring that initial placement has been appropriately confirmed, and there is no reason to suspect displacement
- Novel technology: this comes at a price and requires training. Current national guidance remains that pH testing and chest X-ray are the methods to use to check tube position.
We must not lose momentum for trying to reduce the number of Never Events, reduce risks and protect our patients.