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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.

BAPEN recognises that resources will be limited and often patchy depending on availability of appropriately trained staff – doctors, nurses, dietitians and pharmacists. The demands posed by large numbers of COVID -19 patients with pneumonia, especially on CPAP or ventilators in critical care and intensive care settings will test the capacity of all involved. It follows that special care still needs to be taken to ensure nutritional support is given where indicated whilst avoiding complications associated with tube misplacement in the lungs or oesophagus followed by infusion of nutrients, drugs or water – so called “Never Events”. BAPEN has provided the following advice: An overview of opinions on nasogastric tubes as aerosol generating procedures during the Covid-19 crisis COVID-19 & enteral tube feeding safety

During my many years of working in operating theatres, I observed that hydrogen peroxide was adopted by surgeons as a ritual for washing out wounds and deep cavities. An entire bottle of 200 ml hydrogen peroxide was mixed with 200 ml of normal saline. It seems this ritual was passed down from consultant to trainee and it then became a habit. In a recent post on the hub, I mentioned that women in 1920 were given Lysol as a disinfectant to preserve their feminity and maritial bliss! Lysol contains hydrogen peroxide, so women were daily irrigating their vaginas with a harmful solution of fizz, unaware of the hazards. I believe it is still being used to colour hair, remove blood stains, as a mouthwash gargle and also to whiten teeth. Then suddenly a breakthrough! In 2014, in my email inbox, a yellow sticker warning appeared from the Medicines and Healthcare products Regulatory Agency (MHRA) regarding the use of hydrogen peroxide in deep cavities. So why did the MHRA ban the use of hydrogen peroxide in deep cavities? Hydrogen peroxide is contraindicated for use in closed body cavities or on deep or large wounds due to the risk of gas embolism. Hydrogen peroxide breaks down rapidly to water and oxygen on contact with tissues. If this reaction occurs in an enclosed space, the large amount of oxygen produced can cause gas embolism.[1] There has been several case reports that have been published from around the world of life threatening or fatal gas embolism with use of hydrogen peroxide in surgery, of which five were from the UK. Most of the global reports describe cardiorespiratory collapse occurring within seconds to minutes of instillation of hydrogen peroxide as wound irrigation or when used to soak swabs for wound packing. This was sometimes accompanied by features associated with excess gas generation such as surgical emphysema, pneumocephalus, aspiration of gas from central venous lines, or the presence of gas bubbles on transoesophageal echocardiography. Non-fatal events were sometimes associated with permanent neurological damage such as neuro-vegetative state and hypoxic encephalopathy.[1] As the Practice Development Lead for the theatre department where I worked it was my role to pass on and act on the information received from the MHRA, so I discussed it with my very supportive theatre manager and then escalated to the theatre staff. But some consultants still ask for it today; it is always refused. So why do consultants request it when they are aware of the hazards? One theatre never event describes a syringe of hydrogen peroxide given to a consultant and injected into a joint instead of the required local anaesthetic![2] The patient survived but required care in the intensive care unit. As a scrub nurse practitioner this scares me. What about you? Would you now research this yellow sticker alert further, implement best practice and speak up, or would you just keep quiet and go "with the flow?" We all make mistakes, but learning from our errors will always be the ultimate key to improvement in healthcare and best practice and safety for our patients. References 1. Medicines and Healthcare products Regulatory Agency. Hydrogen peroxide: reminder of risk of gas embolism when used in surgery. 19 December 2014. 2. Chung J and Jeong M. Oxygen embolism caused by accidental subcutaneous injection of hydrogen peroxide during orthopedic surgery. A case report. Medicine (Baltimore) 2017; 96(43): e8342.

The patient was a 62-year-old man who underwent hip replacement surgery. During his surgery, incompatible prostheses made by different manufacturers were used. The error was identified when data from the procedure was recorded in the National Joint Registry several days later. The investigation centred on how the error occurred and what safety recommendations we could make to reduce the risk of a similar event happening again. The investigation focuses on hip replacement surgery but the findings are applicable to all orthopaedic joint replacements.

Key findings The study findings suggest that the designation of a NE as a NE is dependent on the individual/type of NE and that NEs were reportedly rare. Although GPs were more likely to disagree with the NE label for the more frequently occurring NEs, this was not in proportion to their increased frequency of occurrence. Most GPs remained unconvinced that the risk can be eliminated for any of the NEs. GPs do, however, seem to take the actual and potential occurrence of such events seriously given that 99% stated an intention to undertake a significant event analysis after a NE. Opinions varied widely with some GPs commenting that the risk of serious harm was extremely low, whereas other GPs suggested that the NE should be more stringent. Some GPs felt that the NE description was placing a burden of responsibility on them that was not intended by the description of the NE; for example, that they should be responsible for the actions of a laboratory or the ambulance service. There were differences in opinion about the level of responsibility a GP should take for the actions of non-medical staff.

The study achieved its aim of beginning a consensus building process to develop and validate a preliminary list of candidate never events for primary care dentistry. Consensus was achieved on a list of nine candidate never events covering a range of potentially serious system wide issues, most of which relate to patient safety checking procedures. At the time of publication, this was one of a small number of dental studies with an explicit focus in terms of developing a tool to help improve patient safety related work practices and performance in this setting, potentially reducing risks to practitioners and practices alike.

For fires to occur, heat, fuel and oxygen must be present. Oxygen was a factor in half of the surgical fire cases reviewed, usually when the concentration of oxygen being delivered for ventilation wasn’t reduced sufficiently during electro- or laser surgery on the head, neck or upper chest. Most of the burns that weren’t caused by fire involved heat from equipment. These cases included surgeons using the wrong device or settings, as well as issues with the maintenance, malfunction or positioning of devices. Cases involving fuel were usually caused by the unsafe use of alcohol-based antiseptics, including allowing it to pool under patients, using the wrong concentration, or failing to let it dry before placing drapes. To reduce the risk of fires and burns, CMPA recommends that surgical teams “identify, separate and manage the elements of the fire triangle” before procedures. This involves ensuring that “ignition sources should not come into contact with fuels, and oxygen should be reduced to the minimum required concentration.” The association also recommends that surgical teams ensure that antiseptic has time to dry and doesn’t pool, follow device instructions, and run simulations to practice responding to fires.