A position paper on nasogastric tube safety: “Time to put patient safety first” (September 2020)

Summary

This position paper was prepared by the Nasogastric Tube Special Interest Group of BAPEN.

Dr Trevor Smith, BAPEN President commented: 

“It is essential that patient safety is at the top of the agenda of every NHS Trust and Health Board. Nobody in need of artificial nutrition should be at risk of a Never Event, so we endorse the special NGT placement training for a select group of staff in every hospital. Our mission is to ensure everybody receives optimal nutritional care, but it is also important to us to protect frontline healthcare professionals from the risk of avoidable and incredibly distressing mistakes. We hope this paper goes some way to encouraging Trusts and Health Boards to move towards far safer practices.”

Content

Key points include:

• Misplacement and use of nasogastric feeding tubes leads to ongoing avoidable complications and deaths classified as Never Events despite multiple NHS Alerts since 2005. The most common cause relates to use of X-rays to confirm intragastric placement, followed by poor adherence to guidance on use of gastric aspirate pH, although the vast majority of nasogastric feeding tubes in the UK are passed safely and have their position confirmed using pH checks without issue.
• The root cause of these problems is a failure by Hospital Trusts and Health Boards to implement guidelines through rigorous clinical governance over many years.
• The perception of nasogastric feeding tube insertion as a “simple” procedure must be changed to that of a “complex” and dangerous procedure and limited to properly trained and competent healthcare professionals.
• The ongoing incidence of nasogastric Never Events is symptomatic of a wider failure of NHS governance procedures centrally and at senior Trust level.
• It must be accepted that this method of feeding is associated with a risk of complications and death which requires new strategies to mitigate these risks and to place patient safety at the top of the agenda.