Nasogastric tube (NGT) placement checks before first use in critical care settings during the COVID-19 response (May 2020)

Summary

If a nasogastric tube (NGT) has been misplaced into the respiratory tract and this is not detected before fluids, feed or medication are given, death or severe harm can be caused. The consequences are even more likely to be fatal for patients who are already critically ill. Most nasogastric ‘Never Events’ of feeding into the respiratory tract through a misplaced tube continue to arise from misinterpretation of x-rays by staff who had not been given training in the ‘four criteria’ technique and were unaware that relying on the position of the tube tip alone on a radiograph can be a fatal error. 

Content

This easy reference guide has been produced because:

• Some aspects of COVID-19 presentation and treatment present special challenges for safely confirming nasogastric tube position. The dense ground-glass x-ray images can make x-ray interpretation more difficult, and the increasing use of proning manoeuvres in conscious patients increases the risk of regurgitation of gastric contents into the oesophagus and aspiration into the lungs which will render pH checks less reliable.
• This aide-memoire is not designed to replace existing, established, NHSI compliant practice of NG confirmation. If a critical care provider is in the fortunate situation of having nursing and medical staff who have all completed local competency-based training in nasogastric tube placement confirmation aligned to local policy, they would be able to continue more complex local policies. Such policies might include specific advice indicating which critical care patients could have pH checks for initial placement confirmation, and which require x-tray confirmation, and how second-line checks should be used if first-line checks are inconclusive.

However, staff returning to practice, or redeployed to critical care environments, including in Nightingale hospitals, will be helped by reminders of established safety steps in a form that can be used for all critical care patients, rather than requiring different processes for different patients.

This is version 2 of the aide memoire, which includes additional advice on situations where providers can continue to safely use more complex local polices. Other changes were minor refinements of language and use of capital letters to emphasise application to checks before first use.