NG Tube

Verification
Methods
By Paige Billadeau, Sarah
Lagge, & David Sexton

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 Introduction
• Nasogastric feeding tube insertions are a simple
procedure with the potential for great harm when
they are misplaced

• Imagine going through the trauma of getting an

NG tube inserted, and then suddenly you start
gasping for air!

• We will outline existing policy, history, and

clinical significance and then present our change

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 History
• Use of feeding tubes first described in 1921

• Complications from improper placement

• Confusion around which method to use

• “The Whoosh”

• Other methods of confirmation

https://www.sciencedirect.com/science/article/pii/S2214751920305831
 Hospital 1 (no true pediatric policy):
Local Hospital Policy • Before placement measure from nose to ear to
xiphoid process

• NICU: x-ray confirmation as ordered, adult

require x-ray confirmation prior to use

Hospital 2:

• Same way of measurement as hospital 1

• Pediatric policy stating initial x-ray confirmation

is done before use

• NICU only does auscultation method of

confirmation for placement

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Clinical Significance
• As the person inserting the tube, you can be liable for
Significance in complications if incorrect verification methods were used to
Nursing confirm placement

• Seen frequently in NICU or pediatric population

NGT placements are • Many different reasons for having an NG tube placed
very common • Nutrition, decompression, lavage

This change needs to • decrease risk of patient harm and complications

be made to:
 Is X-ray confirmation of a nasogastric
tube placement the best confirmation
tool while the patient is in the hospital?
P I O C T

Most
Inpatient accurately
All forms of While in
(Pediatric X-Ray identify NG
confirmation hospital
focus) tube
placement
Comparison of electromagnetic guided imagery to standard confirmatory
methods for ascertaining nasogastric tube placement in children
(Wathen, Peyton, Thomas, Fidanza, Neu, McNeely, Pan, Callahan, & Brown, 2021)

Aim: Review accuracy of an electromagnetic device (EMD) guided NGT placement compared to a standard
confirmation method with hopes to avoid pulmonary placement complications

Sample: 45 PICU patients with NGT order that are ages 1-18, allowed use of 8 French

Findings: There was a 58% agreement between EMD and pH testing (p=0.0029)
-when compared with x-ray pH had a 32% detection rate, and EMD had an 85% detection rate (p=0.0.8)

Conclusions: EMD was more accurate than pH testing when compared with x-ray confirmation
The effectiveness of auscultatory, colorimetric capnometry and pH
measurement methods to confirm placement of nasogastric tubes: A
methodological study
(Taskiran & Sari, 2022)

Aim: Determine if auscultatory, colorimetric capnometry and pH measurement methods are better ways
to confirm a nasogastric tube is correctly placed.

Sample: 88 patients in an inpatient setting that are critically ill, and18+ years old

Findings: Auscultation: 95.4% confirmed in stomach (p=0.002); pH: 63.6% confirmed in stomach
(p=0.789); Colorimetric capnometry: 83% confirmed in stomach (p=1.000)
When those findings were compared with x-ray, all had a successful placement rate of 82.9%

Conclusions: the 3 methods tested proved ineffective and unreliable at confirming NG tube placement
Point-of-Care Ultrasound for confirmation of nasogastric and orogastric tube
placement in pediatric patients
(Claiborne, Gross, McGreevy, Riemann, Temkit, & Augenstein, 2021)

Aim: Determine if ultrasound can identify correct placement of NGT/OGT

Sample: Convenient sample of 26 pediatric patients seen in Phoenix Children’s

Hospital’s ED

Findings: Ultrasound correctly identified placement 88% of the time. Xray

correctly identified placement 100% of the time.

Conclusion: Feasible for pediatric patients

Does bedside sonography effectively identify nasogastric tube
placement in pediatric critical care patients?
(Atalay, Aydin, Ertugrual, Gul, Polat, & Paksu, 2016)

Aim: Determine efficiency of ultrasound compared

Sample: Convenient sample of 21 pediatric patients seen at Ondokuz Mayis

University Children’s Hospital

Findings: Ultrasound verified correct placement in 100% of patients

Conclusion: Ultrasound could be used as a verification method

Testing placement of gastric feeding tubes in infants
(Metheny, Pawluszka, Lulic, Hinyard, & Meert, 2017)

Aim: To determine the utility of four different pH cut points for NG tube placement
under a series of different treatment conditions.

Sample: 212 critically ill infants with a nasogastric or orogastric feeding tube who
were receiving mechanical ventilation.

Findings: Across the different population categories, at a cutoff of 5.5 pH the PPV
ranged from 85-98.4%, and the NPV ranged from 95.2-100%.

Conclusion: A cutoff point of 5.5 provides reasonable certainty of proper placement,

but it is not 100% accurate when compared to an X-Ray.
A cost utility analysis of the clinical algorithm for nasogastric tube placement
confirmation in adult hospital patients
(McFarland, 2017)

Aim: Determine if the benefit of X-Ray for NG tube placement

weighed against pH testing.

Sample: Adult patients, with short term NG tube placement in the

hospital setting receiving general care.

Findings: Chest X-Ray produced a slightly higher QALY of 0.12

with a higher ICER of 1322.

Conclusion: While more expensive, X-Ray confirmation had

improved patient outcomes over pH testing.
 Synthesis of Evidence
X-ray is proven to be the most accurate verification method
of NGT placement

X-ray is more accurate than colorimetric capnometry,

auscultation, pH, electromagnetic imagery, ultrasound
(Atalay et al., 2016; Claiborne et al., 2021; McFarland, 2019; Metheny et al., 2017; Wathen et al.,
2021; Taskiran & Sari, 2022)

pH testing is a less reliable method then perceived

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 Recommendation:
New Documentation
1. Physician order for NGT placed

2. Radiology technician notified via new order alert

3. NGT scanned for placement

4. Notification of order being in progress

5. NGT placement charted

6. Notification of order of complete and ready for Xray

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Lewin’s Stages of Change

Unfreeze Stage: Complications of incorrect placement, Xray is standard of practice,

identify stakeholders, & recognize benefits of change

Change Stage: Implementation to NICU, EMR updates, EMR training, education modules,
& data collection

Refreeze Stage: 90% compliance in 6 months, monthly compliance check, open

communication, focus groups, report of success, education included in onboarding, &
including incentives
 Conclusion
• NG tubes have a strong potential for harm

• Significance to nursing

• Our findings have shown that X ray is best

Our recommendations improve patient safety

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References
Atalay, Y. O., Aydin, R., Ertugrul, O., Gul, S. B., Polat, A. V., & Paksu, M. S. (2016). Does bedside sonography effectively identify nasogastric tube placements in pediatric critical care patients? Nutrition in Clinical Practice, 31(6), 805-809.

http://doi.org/10.1177/0884533616639401

Claiborne, M. K., Gross, T., McGreevy, J., Riemann, M., Temkit, M., & Augenstein, J. (2021). Point-of-Care Ultrasound for confirmation of nasogastric and orogastric tube placement in pediatric patients. Pediatric Emergency Care, 37(12).

https://doi.org/10.1097/pec.0000000000002134

Kisting, M. A., Korcal, L., & Schutte, D. L. (2019). Lose the Whoosh: An Evidence-Based Project to Improve NG Tube Placement Verification in Infants and Children in the Hospital Setting. Journal of Pediatric Nursing, 46, 1–5.

https://doi.org/10.1016/j.pedn.2019.01.011

McFarland A. (2017). A cost utility analysis of the clinical algorithm for nasogastric tube placement confirmation in adult hospital patients. Journal of advanced nursing, 73(1), 201–216. https://doi.org/10.1111/jan.13103

Metheny, N. A., Pawluszka, A., Lulic, M., Hinyard, L. J., Meert, K. L. (2017). Testing Placement of Gastric Feeding Tubes in Infants. American Journal of Critical Care, 26(6), 466–473. https://doi.org/10.4037/ajcc2017378

Wathen, B., McNeely, H. L., Peyton, C., Pan, Z., Thomas, R., Callahan, C., Fidanza, S., Brown, J., & Neu, M. (2021). Comparison of electromagnetic guided imagery to standard confirmatory methods for ascertaining nasogastric tube placement in children. Journal for

Specialists in Pediatric Nursing, 26(4), 1–9. https://doi-org.ezproxy.umary.edu/10.1111/jspn.12338

Taskiran, N., & Sari, D. (2022). The effectiveness of auscultatory, colorimetric capnometry and pH measurement methods to confirm placement of nasogastric tubes: A methodological study. International Journal of Nursing Practice (John Wiley & Sons, Inc.), 28(2),

1–10. https://doi-org.ezproxy.umary.edu/10.1111/ijn.13049

Simon, D. S., & An, J. (2022, October 31). Nasogastric tube. National Library of Medicine. Retrieved April 20, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK556063/