Feature

Methods Used by Critical

Care Nurses to Verify
Feeding Tube Placement
in Clinical Practice
ANNETTE M. BOURGAULT, RN, PhD, CNL
JANIE HEATH, PhD, APRN-BC
VALLIRE HOOPER, RN, PhD, CPAN
MARY LOU SOLE, RN, PhD, CCNS
ELIZABETH G. NeSMITH, PhD, APRN-BC

BACKGROUND The American Association of Critical-Care Nurses practice alert on verification of feeding tube
placement makes evidence-based practice recommendations to guide nursing management of adult patients
with blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improper
positioning of a feeding tube within the gastrointestinal tract, thereby increasing aspiration risk.
OBJECTIVES To determine how the expected practices from the American Association of Critical-Care Nurses
practice alert were implemented by critical care nurses.
METHODS This study was part of a larger national, online survey that was completed by 370 critical care nurses.
Descriptive statistics were used to analyze the data.
RESULTS Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes,
although 14% were unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy of
auscultation methods, only 12% of nurses avoided this practice all of the time.
CONCLUSIONS Implementation of expected clinical practices from this guideline varied. Nurses are encouraged
to implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient
harm. (Critical Care Nurse. 2015;35[1]:e1-e7)

T
he findings presented here are a subset of results from a larger study that examined critical
care nurses’ adoption of the American Association of Critical-Care Nurses (AACN) practice
alert on feeding tube placement and the clinical practices recommended therein.1 Insertion
of feeding tubes to deliver enteral nutrition is a common intervention in critically ill patients; however,
the methods used for feeding tube verification and the frequency of their use vary widely.2 Two verifica-
tion methods that are not supported by research evidence, auscultation (air bolus)2 and water bubbling
(no published evidence found), continue to be used. Unfortunately, adverse outcomes such as pneumo-
nia, pneumothorax, and death have been associated with inconsistent practices for verifying feeding

©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015984

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tube placement.3-5 The most common complication of
blindly inserted feeding tubes is improper placement in
the esophagus (21% of cases) or pulmonary system (4% of
cases).3,6 Case studies7,8 of feeding tubes placed in the brain
and spinal column also have been published. Incorrect
placement of a feeding tube may be difficult for clinicians
to assess at the bedside, because the patient can be asymp-
tomatic initially.9,10 Because of this, radiographic confirma-
tion is considered the gold standard for initial verification
of placement of all blindly inserted feeding tubes.11-14
Clinical practice guidelines such as the AACN practice
alerts contain recommendations for practice that are
evidence-based.15 Guidelines synthesize available evidence
to assist clinicians in translating research findings into
clinical practice.16 AACN’s practice alert on verification
of feeding tube placement was originally published in
2005, revised in 2009, and is available on the AACN web-
site (www.aacn.org).17 Several clinical practice guidelines
supporting practices for verifying feeding tube placement
have been published by other organizations, including
the American Association of Parenteral and Enteral
Nutrition, the American Gastroenterological Associa-
tion, and England’s National Health Service.11,12,14
Objectives
Previously published data from our larger study
examined the influence of Rogers’ diffusion of innova-
tion variables on critical care nurses’ adoption of the
AACN practice alert on feeding tube placement and its
Authors
Annette M. Bourgault is an assistant professor and interim assistant
dean for assessment and development at Georgia Regents University,
College of Nursing, in Augusta.
Janie Heath is dean of the College of Nursing at University of Kentucky
in Lexington.
Vallire Hooper is the manager of nursing research at Mission Hospital
in Asheville, North Carolina.
Mary Lou Sole is the Orlando Health Distinguished Professor at
University of Central Florida, College of Nursing, in Orlando.
Elizabeth G. NeSmith is an associate professor and chair of the Depart-
ment of Physiological and Technological Nursing at Georgia Regents
University, College of Nursing, in Augusta.
Corresponding author: Annette M. Bourgault, Georgia Regents University, College of
Nursing, EC-4350, 987 St. Sebastian Way, Augusta, GA, 30912 (e-mail: abourgault
@gru.edu).
To purchase electronic or print reprints, contact the American Association of Critical-
Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)
362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.
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Table 1 American Association of Critical-Care Nurses
practice alert on verification of feeding tube placement:
expected practices
1. Use a variety of bedside methods to predict tube
location during the insertion procedure.
• Observe for signs of respiratory distress.
• Use capnography if available.
• Measure pH of aspirate from tube if pH strips are available.
• Observe visual characteristics of aspirate from the tube.
• Recognize that auscultatory (air bolus) and water bubbling
methods are unreliable.
2. Obtain radiographic confirmation of correct
placement of any blindly inserted tube before its
initial use for feedings or medication administration.
3. Check tube location at 4-hour intervals after
feedings are started.
• Observe for a change in length of the external portion of
the feeding tube.
• Review routine chest and abdominal radiography reports
to look for notations about tube location.
• Observe changes in volume of aspirate from feeding tube.
• If pH strips are available, measure pH of feeding tube aspi-
rates if feedings are interrupted for more than a few hours.
• Observe the appearance of feeding tube aspirates if feedings
are interrupted for more than a few hours.
• Obtain a radiograph to confirm tube position if the tube’s
location is in doubt.
recommended clinical practices in adult patients with
feeding tubes.1 The term adoption is commonly used to
describe the processes of accepting and implementing an
innovation such as the AACN practice alert.18 Implemen-
tation is a term commonly used in nursing practice and
refers to the action of using an innovation. For the pur-
pose of this article, the terms adoption and implementa-
tion will be used in reference to the use of a clinical
practice unless otherwise stated.
Whereas our first article1 reported on factors that
increased the likelihood of adoption of the practice alert,
this article explores how the recommendations in the
AACN practice alert were used by critical care nurses to
verify feeding tube placement in clinical practice. No
unique findings regarding radiographic confirmation
are reported here.
The AACN practice alert on verification of feeding
tube placement for blindly inserted tubes contains 3
major recommendations under the heading Expected
Practice17 (Table 1). The practice alert identifies the unre-
liable auscultatory (air bolus) method as a subset of the
first recommendation. Because auscultation is reported
as a method commonly used by nurses to verify feeding
tube location, we decided to measure auscultation practice
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separately from the 3 major practices recommended in
the practice alert.
Methods
Design
This study had a cross-sectional, exploratory design
that used survey methods. The online survey was hosted
by the University of Georgia Survey Research Center.
Study approval was provided by the institutional review
board at Georgia Health Sciences University (now Georgia
Regents University), and data collection occurred during
September and October 2011.
Instrument
The survey tool consisted of 86 categorical and Likert-
style questions that measured adoption of the AACN
practice alert, adoption of the practice alert’s recommended
clinical practices, perceived guideline characteristics,
personal innovativeness, communication behaviors, and
collaboration. Only data from the Nursing Practice Ques-
tionnaire (NPQ ),19 a subscale that measured clinical
practices related to the practice alert, are reported here.
NPQ items received minor customization to capture
recommended practices from the practice alert. Our NPQ
scale had an internal reliability coefficient (Cronbach a)
of 0.82. The NPQ consisted of 8 items for each individual
practice and required mostly yes/no categorical answers.
Respondents were asked to indicate whether they use a
practice: yes, sometimes; yes, always; no, not aware of
practice; or no, aware of practice. No definition was
provided for performing a practice “yes, sometimes,”
and thus selection of a response was left to the interpre-
tation of the participant.
For questions about specific verification methods,
only methods recommended by the practice alert were
included as survey options. Therefore, auscultation and
water bubbling methods were not included as survey
options because these methods are not empirically based.
All items were related to the care of blindly inserted
nasogastric or feeding tubes. A blindly inserted tube was
defined as a feeding tube that is inserted without imaging
guidance such as fluoroscopy, endoscopy, or sonography.
No distinction was made between small-bore (styleted)
and large-bore (nonstyleted) feeding tubes.
Original wording in the practice alert under the head-
ing of Expected Practice states “Obtain radiographic
confirmation . . .” Radiographic confirmation is not an
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Table 2 Characteristics of 370 nurses in sample
Characteristic Valuea
Age, mean (SD), years 42.5 (10.9)
Sex
Female 334 (90.3)
Male 36 (9.7)
Years worked in critical care, mean (SD) 12.8 (7.9)
Nursing certification 278 (75.1)
CCRN 187 (50.5)
AACN Beacon unit 50 (13.5)
a Values represent number (percentage) unless otherwise indicated.
independent practice for generalist nurses, so we revised
the language in our survey and asked if nurses recom-
mend/encourage radiographic confirmation. Survey
questions were reviewed by expert nurses for face validity,
and a pilot test of the online survey was performed by
27 AACN members.
Recruitment
Invitations to participate were included in AACN’s
Critical Care Newsline for 4 consecutive weeks. Detailed
recruitment methods have been described previously.1
Results
Sample
Descriptive statistics were used to present demograph-
ics and clinical practice data. The final sample consisted
of 370 critical care nurses (Table 2). A complete descrip-
tion of the sample was previously published.1 Participants
were 23 to 65
years old (mean, Initial feeding tube placement should
43 years) and be verified by using multiple methods.
had 1 to 40 years
(mean, 13 years) of critical care nursing experience.
About 83% were AACN members, 51% were CCRN certi-
fied, and 14% worked in a Beacon unit. Baccalaureate or
higher nursing degrees were held by 74% of the nurses.
Use a Variety of Methods To Predict
Initial Location of Feeding Tube
Seventy-eight percent of participants (n=287) used
a variety of methods to verify initial feeding tube place-
ment all of the time, and 12% (n=45) implemented this
practice only some of the time. Ten percent of nurses
(n =38) were unaware of this practice recommendation.
CriticalCareNurse Vol 35, No. 1, FEBRUARY 2015 e3
 100 100
90 90
80 80
70 70
Percentage

Percentage
60 60
50 50
40 40
30 30
20 20
10 10
0 0
ss y ure te ite gth e e e rt h
tre raph as spira xits n r anc lum a sur epo rap
yd
is
pn
og me fa ee b e le p e a
t e v o m e
h y r
d i og
r pH no tub Tu ap a pH rap ra
ato Ca ate pir ed
esp
ir
rvatio Ma
rk
pir As adi
og
tain
r b
R
O bse A s
we
d O
e vie
R
Never Sometimes Always
Never Sometimes Always
Figure 1 Methods used to verify feeding tube location during Figure 2 Methods used to verify feeding tube location at
insertion procedure (n = 332). 4-hour intervals (n = 309).

A total of 332 respondents answered the question about

the specific methods that were used to verify tube place- 100
ment. Verification methods reported to be used all of the 90
time included observing for signs of respiratory distress 80

(95%, n=315/332), observing feeding tube aspirate (82%, 70

Percentage

60
n=272/332), and marking the feeding tube at the exit
50
site (72%, n=239/332; Figure 1). Capnography and pH
40
measures were used less frequently (8%, n=26/332 and
30
9%, n=30/332, respectively). In the open comment field,
20
participants identified the use of 2 additional methods
10
for verification of initial tube placement: auscultation
0
(20%, n=67/332) and the water bubbling technique Always Sometimes Never
(0.6%, n=2/332).
Figure 3 Used auscultatory (air bolus) method to verify
feeding tube location (n = 370).
Check Feeding Tube Location at
4-Hour Intervals
Fourteen percent (n=50) of nurses were unaware Avoid Auscultatory (Air Bolus) Method
that feeding tube location should be reassessed every 4 Twelve percent (n=46) of participants indicated that
hours. A total of 309 respondents answered questions they avoided using the auscultatory (air bolus) method
about the specific methods they used to reassess tube all of the time. Ten percent (n=38) avoided auscultation
position at 4-hour intervals. Methods always used included some of the time, and 77% (n=286) never avoided using
observing change in aspirate volume (89%, n=276/309), the auscultatory (air bolus) method to verify feeding
observing the appearance of feeding tube aspirate (81%, tube location (Figure 3). Forty percent of nurses (n=149)
n=251/309), observing change in external length of the were unaware that the auscultatory method is consid-
feeding tube (80%, n=248/309), obtaining a radiograph ered unreliable.
(66%, n = 203/309), reviewing the radiography report
(52%, n=162/309), and pH measurement (7%, n=21/309; Discussion
Figure 2). Five percent (n = 16/309) of nurses reported Fifty-five percent of participants (n=203) were aware
in an open comment field that they also used auscultation of the practice alert, yet only 45% (n=167) indicated that
for ongoing verification of feeding tube location. they had used the practice alert when caring for a patient

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receiving enteral feeding.1 The methods used by nurses
with CCRN certification or who were employed in a unit
with Beacon award status did not differ from the meth-
ods used by other nurses. CCRN is an acute/critical
care specialty certification through AACN.20 The Beacon
award for excellence is presented by AACN to units that
meet rigorous criteria related to patients’ outcomes and
work environment.21
The main goal when inserting feeding tubes blindly
is to place the tube within the gastrointestinal tract, in
either the stomach or the small bowel, and avoid inser-
tion of the tube into the pulmonary system or other
inappropriate locations. One of the challenges of feed-
ing tube verification at the bedside is that none of the
nonradiographic verification methods identifies incorrect
positioning of the feeding tube within the gastrointestinal
tract, such as tubes placed in the esophagus or the gas-
troesophageal junction.22 Administration of formula or
medications through a feeding tube with ports positioned
above the lower esophageal sphincter (esophageal or
gastroesophageal placement) may place the patient at
higher risk for aspiration of gastric fluid, medications,
and/or formula into the pulmonary system.12,23,24 Because
other methods do not allow identification of the exact
tube position within the gastrointestinal tract, radiogra-
phy is considered the gold standard for verification of
blindly inserted feeding tubes before administration
of formula or medications.11,12 Electromagnetic placement
devices have been suggested as a replacement for radi-
ographic confirmation of feeding tube placement at the
bedside, although adverse outcomes have been reported,
implying that a high level of user expertise may be nec-
essary to obtain consistently positive results.25
The 2 verification methods used most often by critical
care nurses for initial verification of feeding tube place-
ment in our study were observation for signs of respira-
tory distress and visual observation of aspirate from the
feeding tube. These 2 methods are less reliable than
capnography and pH methods. Although signs of respi-
ratory distress such as decreased oxygen saturation,
coughing, and dyspnea have been reported, pulmonary
placement has occurred without any signs of respiratory
distress.4 Critical care nurses should also be aware that
cuffs from endotracheal and tracheostomy tubes do not
prevent pulmonary placement of feeding tubes.3 Visual
observation of the color and consistency of gastric aspi-
rate has also been used to verify feeding tube placement.
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Fluid from gastric placement has been reported as green,
tan, off-white and cloudy, or brown or bloody.26 Aspirates
from tubes with pulmonary placement are yellow and
serous or off-white/tan and mucous.26 In 1 study,26 aspi-
rate from a number of feeding tubes with pulmonary
placement resembled the color and consistency of gas-
tric aspirate, and nurses accurately identified tubes with
pulmonary placement only 57% of the time.
In our study, capnography and pH measures were
infrequently used for initial verification of feeding tube
placement, a finding similar to results of another national
US study of critical care nurses.2 Although these 2 meth-
ods can be performed independently by nurses, barriers
that may inhibit use of either technique include the need
for additional supplies, equipment, and training.2 Addi-
tional barriers to the use of pH methods for ongoing tube
verification include the use of formula or medications
that lower gastric acid, such as H2 blockers and proton
pump inhibitors.27-30 Owing to the effects of medications
and formula on
pH measures, Feeding tubes misplaced in the
using the pH pulmonary system do not always
method to verify result in signs of respiratory distress.
tube placement
after feeding has been started requires that formula be
withheld.30 The optimal length of time that feeding
should be suspended for accurate pH measurement was
suggested as “more than a few hours” in the practice
alert, although in 1 research protocol, pH measures were
delayed for only 1 hour after medication administration
or formula being stopped.30 Researchers have also reported
difficulty obtaining gastric aspirate from feeding tubes,
which may pose an additional challenge to pH measure-
ments.29 In 1 study,30 researchers recommended that 30
mL of air be instilled into the feeding tube via a syringe
to clear the tube of formula before aspirating fluid.
As previously mentioned, methods such as capnogra-
phy and pH do not allow users to discriminate between
different tube positions within the gastrointestinal tract.24,31
These methods are sensitive to differentiating between
the pulmonary and gastrointestinal systems,27,32 which
may reduce risk of pulmonary placement. For example,
a pH less than 5.0 typically indicates gastric placement,
and a pH greater than 6.0 indicates intestinal or pul-
monary placement.30,33-35 Unfortunately, feeding tube
placement in the esophagus or gastroesophageal junc-
tion cannot be confirmed, making pH and capnography
CriticalCareNurse Vol 35, No. 1, FEBRUARY 2015 e5
 methods inconclusive for initial verification of feeding
tube placement.24,31,36
The location of the feeding tube should be verified
every 4 hours once feeding has been established to assess
for change in tube position.2,12,17 Methods for ongoing
verification may include monitoring the length of the
externally marked feeding tube from the exit site (nare
or lip)12,37,38 or monitoring gastric residual volumes for
changes.17 Nurses are encouraged to inspect the external
tube mark at
Nurses are encouraged to use
4-hour intervals
evidence-based, peer-reviewed
to check for a
practice alerts.
change in length
of the external portion of the tube. Although this method
is not empirically based, the premise is that an increase
in external length of the tube may prompt the nurse to
perform additional verification methods such as radi-
ographic confirmation to assess for a change in tube
position.2,38 Moreover, radiographic confirmation is rec-
ommended any time that improper placement of a feed-
ing tube is suspected.12
Only 12% of nurses avoided using auscultation all of the
time when verifying feeding tube placement, suggesting
that 88% of nurses continued to use auscultation for feed-
ing tube verification (all or some of the time), even though
accuracy of this method is disputed.39 Our results are in
agreement with other studies that reported auscultation
was used by 73% to 93% of critical care nurses to verify ini-
tial feeding tube placement.2,40,41 Of the practices examined
in our survey, auscultation required the least amount of
specialized equipment or supplies, which may be one
of the reasons this practice continues to be widely used.2
It is disconcerting that auscultation continues to be
one of the most commonly used methods for feeding tube
verification. More than 20 years ago, Metheny et al42
reported that auscultation methods were only 34% accurate,
a message that was repeated by Rauen et al.4. Use of auscul-
tation may compromise patient safety by failure to distin-
guish feeding tube locations both within and outside of
the gastrointestinal tract.11,12,14,17 Nurses should replace
auscultation practice with evidence-based methods for
feeding tube verification.
Nursing Implications for
Practice and Policy
Nurses can also play a role in increasing their knowl-
edge of practices for verifying feeding tube location by
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reviewing AACN’s practice alert, presentation, and audit
tool (www.aacn.org). At the unit level, audits are recom-
mended to increase awareness of local practices for veri-
fying feeding tube location so that a practice improvement
plan can be implemented if necessary. To support local
practices, institutional practice policies should be evidence-
based and developed by an interdisciplinary team.44
On the basis of our findings, we recommend 3 revi-
sions of the practice alert under the headings of Expected
Practice and Actions for Nursing Practice. A variety of
methods are recommended for initial confirmation of
feeding tube location, yet the exact number is not explic-
itly identified. It would be helpful to confirm the expected
number of methods/techniques to be used, by including
a statement such as “2 or more.” The current practice
alert states that auscultation is unreliable, but it does not
include an action statement for nursing practice. Because
a majority of the nurses in our sample continue to use
auscultation in their practice, a bold action statement
should be added, such as “Do not use unreliable meth-
ods such as auscultation and water bubbling. Evidence
does not support these methods and suggests risk for
patient harm if used.” The third recommendation is to
modify the language used for radiographic confirmation.
Instead of “obtain radiographic confirmation,” a revised
statement such as “encourage or recommend radiographic
confirmation” would be actionable by all nurses because
it is within the scope of practice for a generalist registered
nurse. It is important to note that the current practice
alert suggests that nurses work with an interdisciplinary
team to obtain radiographic confirmation.
Limitations
Limitations of this study have been previously
reported.1
Conclusions
This study is the first to explore one of the AACN
practice alerts in detail to determine how practice rec-
ommendations are being followed by critical care nurses.
Although the majority of critical care nurses in our sam-
ple were aware of the practice alert on verification of
feeding tube placement, implementation of the expected
clinical practices from this guideline varied. We encour-
age nurses to become familiar with AACN’s practice alerts.
Practice alerts are evidence-based, peer-reviewed clinical
practice guidelines that are developed by content experts.
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Implementing expected practices from this practice alert
will bring research evidence to the bedside and minimize
risk for patient harm. CCN
Acknowledgments
The authors thank the critical care nurses who participated in this study. Their
assistance was instrumental to the success of this project.
Financial Disclosures
This study was supported by a grant from Sigma Theta Tau, Beta Omicron
Chapter.
Now that you’ve read the article, create or contribute to an online discussion
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“Responses” in the middle column and then “Submit a response.”
To learn more about caring for patients with feeding tubes, read
“Effectiveness of an Electromagnetic Feeding Tube Placement
Device in Detecting Inadvertent Respiratory Placement” by
Metheny and Meert in the American Journal of Critical Care, May
2014;23:240-248. Available at www.ajcconline.org.
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CriticalCareNurse Vol 35, No. 1, FEBRUARY 2015 e7
Methods Used by Critical Care Nurses to Verify Feeding Tube Placement in Clinical
Practice
Annette M. Bourgault, Janie Heath, Vallire Hooper, Mary Lou Sole and Elizabeth G. Nesmith
Crit Care Nurse 2015;35 e1-e7 10.4037/ccn2015984
©2015 American Association of Critical-Care Nurses
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