Sage Journals: Discover world-class research

Abstract

Background: An intervention to reduce complications from insertion of small-bore nasogastric feeding tubes was performed. Methods: This was a Performance Improvement project with the Plan, Do, Study, Act (PDSA) format; interventions occurred in July 2003. Electronic searches of risk management and radiology databases identified feeding-tube malpositions and complications from January 1, 2001, through December 31, 2004. Chart abstraction and a pre- and postintervention comparison were performed. Interventions were adoption of a more compliant feeding tube, direct supervision of residents, technology-guided insertion, and implementation of explicit policies and procedures. Results: Of all small-bore nasogastric feeding-tube placements, 1.3%–2.4% resulted in 50 documented cases of feeding-tube malpositions during 4 years. Over half of the 50 patients were mechanically ventilated, and only 2 had a normal mental status. There were 13 complications (26% of malpositions), including 2 deaths, which were directly attributed to the feeding-tube malposition. Only 2 of the 13 complications and none of the misplacements had been recorded in the risk management database; most cases were identified from the search of radiology reports. In the 15-month postintervention period, no complications were identified. The control chart showed that after the intervention, there was a significant increase in the “number between” tube insertions without complications, confirming the effectiveness of the performance improvement (PI) project. Conclusions: Unassisted feeding tube insertion carries significant risk in vulnerable patients, which can be mitigated. Voluntary reporting appears inadequate to capture complications from feeding tube insertion.

A performance improvement project led to a change in feeding tubes and in insertion procedures. Two electronic data base searches identified 50 complications in 4 years. After the interventions, complications and malpositions declined and the “number between” complications increased, suggesting an improved process.

Get full access to this article

View all access options for this article.

References

Leape LL. Error in medicine. JAMA. 1994 ;272:1851– 1857.

Joint Commission on Accreditation of Health Care Organizations. An introduction to FMEA. Using failure mode effects analysis to meet JCAHO's proactive risk assessment requirement. Failure modes effect analysis.Health Devices. 2002;31:223– 226.

Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA. 2005 ;293:2384– 2390.

Kohn LT, Corrigan JM, Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

Pauker SG, Zane EM, Salem DN. Creating a safer health care system: finding the constraint. JAMA. 2005 ;294:2906– 2908.

Deming WE. Quality, Production and Competitive Position. Cambridge, MA: MIT Center for Advanced Engineering Study;1982 .

Batalden PB, Stoltz PK. A framework for the continual improvement of health care: building and applying professional and improvement knowledge to test changes in daily work. Jt Comm J Qual Improv. 1993 ;19:424– 447.

Berwick DM. Continuous improvement as an ideal in health care.N Engl J Med. 1989;320:53– 56.

McWey RE, Curry NS, Schabel SI, Reines HD. Complications of nasoenteric feeding tubes. Am J Surg. 1988 ;155:253– 257.

10.

Ghahremani GG, Gould RJ. Nasoenteric feeding tubes: radiographic detection of complications. Dig Dis Sci. 1986 ;31:574– 585.

11.

Harris MR, Huseby JS. Pulmonary complications from nasoenteral feeding tube insertion in an intensive care unit: incidence and prevention.Crit Care Med. 1989;17:917– 919.

12.

Hendry PJ, Akyurekli Y, McIntyre R, Quarrington A, Keon WJ. Bronchopleural complications of nasogastric feeding tubes. Crit Care Med. 1986;14:892– 894.

13.

Mardenstein EL, Simmons RL, Ochoa JB. Patient safety: effect of institutional protocols on adverse events related to the feeding tube placement in the critically ill. J Am Coll Surg. 2004 ;199:39– 50.

14.

Roubenoff R, Ravich WJ. Pneumothorax due to nasogastric feeding tubes: report of four cases, review of the literature, and recommendations for prevention. Arch Intern Med. 1989 ;149:184– 188.

15.

Scholten DJ, Wood TL, Thompson DR. Pneumothorax from nasoenteric feeding tube insertion: a report of five cases. Am Surg. 1986 ;52:381– 385.

16.

Rassias AJ, Ball PA, Corwin HL. A prospective study of tracheopulmonary complications associated with the placement of narrow-bore enteral feeding tubes. Crit Care Forum. 1998;2:25–29. Available at: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=28998. Accessed June 30, 2006.

17.

Bankier AA, Weismayr MN, Henk C, et al. Radiographic detection of intrabronchial malpositions of nasogastric tubes and subsequent complications in intensive care unit patients. Intensive Care Med. 1997 ;23:406– 410.

18.

Apkon M, Leonard J, Probst L, DeLizio L, Vitale R. Design a safer approach to intravenous drug infusions: failure mode effects analysis.Qual Saf Health Care. 2004 ;13:265– 271.

19.

Montgomery DC. Introduction to Statistical Control. 3^rd ed. New York, NY: John Wiley & Sons, Inc;1997 .

20.

Benneyan JC. Number-between g-type statistical quality control charts for monitoring adverse events. Health Care Manag Sci. 2001 ;4:305– 318.

21.

Odocha O, Lowery RC, Mezghebe HM, Siram SM, Warner OG. Tracheopleuropulmonary injuries following enteral tube insertion. J Natl Med Assoc. 1989;81:275– 281.

22.

Jackson RH, Payne DK, Bacon BR. Esophageal perforation due to nasogastric intubation. Am J Gastroenterol. 1990 ;85:439– 442.

23.

Powers J, Chance R, Bortenschlager L, et al. Bedside placement of small bore feeding tubes in the intensive care unit. Crit Care Nurse. 2003;23:17– 24.

24.

Welsh CH, Perdot R, Anderson RJ. Use of morning report to enhance adverse event detection. J Gen Intern Med. 1996 ;11:454– 460.

25.

Cullen DJ, Bates DW, Small CD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995 ;21:548– 552.

26.

Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study 1. N Engl J Med. 1991 ;324:370– 376.

27.

Steel K, Gertman PM, Crescenzi C, Anderson J. Iatrogenic illness on a general medical service at a university hospital. N Engl J Med. 1981;304:638– 642.

Enhancing Patient Safety During Feeding-Tube Insertion: A Review of More Than 2000 Insertions

Abstract

Get full access to this article

References