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

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.

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