NPSA Alert: Nasogastric Tubes
Update – July 2017
The following update is provided courtesy of the National Patient Safety Agency (NPSA).
Introduction
Nasogastric tube (NGT) feeding is common practice and thousands of tubes are inserted daily
without incident. However, there is a risk that the tube can become misplaced into the lungs during
insertion, or move out of the stomach at a later stage.
In February 2005, following reports of patient death and harm caused by misplaced nasogastric
feeding tubes, the National Patient Safety Agency (NPSA) issued a Patient Safety Alert. Between
September 2005 and March 2010 there were a further 21 deaths and 79 cases of harm, related to
feeding through misplaced nasogastric tubes, reported to the National Reporting and Learning
System (NRLS) (see Appendix 1). We have therefore updated our original Alert to provide
organisations with strengthened guidance based on the learning from these reports. In 2009 feeding
into the lung from a misplaced nasogastric tube became a Never Event in England.
During 2009/10, there were 41 Never Events reported to the NPSA where a misplaced naso or
orogastric tube was not detected prior to use. Evidence from the Never Event reports suggests there
are issues with x-ray interpretation at all times, and there may be increased risks from nasogastric
placement or x-ray checking at night.
Scope
This Supporting Information and the Alert it accompanies does not relate to nasogastric feeding in
neonates. Patient Safety Alert 09; Reducing the harm caused by misplaced naso and orogastric
feeding tubes in babies under the care of neonatal units, issued in August 2005 can be found at:
www.nrls.npsa.nhs.uk/resources/type/alerts/
This information is not intended to replace clinical judgement. Local policies may vary but must not
fall below the standards set out in this document.
In a small number of cases a nasogastric tube has been placed under direct vision by an anaesthetist
and/or surgeon. As long as this confirmation of position is properly documented it may be
acceptable to forgo other tests. For example it may be considered that the risk of irradiation
outweighs the benefit of radiograph confirmation.
Transanastamotic nasogastric tubes require special consideration and are not within the scope of
this Alert.
Existing non-feeding tubes (for example drainage tubes) are not recommended for feeding. All
nasogastric tubes used for feeding must be radio-opaque throughout their length and have
externally visible length markings.
Clinical actions
This section of the document elaborates on the clinical actions required within this revised Alert
based on the following questions:
1. Is nasogastric tube feeding the right decision for this patient?
2. Is this the right time to place the nasogastric tube and is the appropriate equipment
available?
3. Is there sufficient knowledge/expertise available at this time to test for safe placement of
the nasogastric tube?
1. Is nasogastric tube feeding the right decision for this patient?
a) Before a decision is made to insert a nasogastric tube, an assessment is undertaken to identify if
nasogastric feeding is appropriate for the patient, and the rationale for any decision is recorded in
the patient’s medical notes.
A decision must be made that balances the risks with the need to feed or administer medications.
Patients who are comatose or semi-comatose, have swallowing dysfunction or recurrent retching or
vomiting, have a higher risk of placement error or migration of the tube, whereas patients on
antacid medication are more likely to have pH levels of 6 and above, making confirmation of tube
position more difficult. Actions to reduce all identified risks and the rationale behind these actions
should be documented prior to insertion of a nasogastric tube for the purpose of feeding, as follows:
The details of the assessment must be recorded in the patient’s medical notes prior to
commencement of feed.
The decision to insert a nasogastric tube for the purpose of feeding must be made following careful
assessment of the risks and benefits by at least two competent health care professionals including
the senior doctor responsible for the patient’s care.
As a minimum, documentation should include signed, dated and timed entry, of the process of initial
risk assessment that evaluates the benefits against the risks of introducing a nasogastric tube for the
purpose of feeding. For example:
“Mr xxx has been nil by mouth for the last 24 hours due to having an unsafe swallow following a CVA.
An assessment has been made by SALT that it is unsafe for Mr xxx to take diet, fluids and medication
orally and recommended NG tube placement to maintain adequate nutrition and hydration.
Reassessment of swallow function to take place on 01/01/11..."
Nasogastric tube insertion can be dangerous as well as difficult in patients with altered anatomy, for
example oesophageal fistula or pharyngeal pouch or in certain clinical conditions, such as basal skull
fracture. In these situations, or if these are suspected, senior clinical help should be sought and
nasogastric tube insertion should only be attempted under fluoroscopic control.
2. Is this the right time to place the nasogastric tube and is the appropriate equipment available?
The NPSA is concerned about the number of errors reported as a result of staff confirming tube
position out of hours.
It is also a concern that whilst nasogastric feeding and administration of medication via the
nasogastric tube can be crucial in the treatment of certain patients, the benefits of this are not
always balanced against the risks of tube insertion and enteral feeding.
b) If there is not sufficient experienced support available to accurately confirm nasogastric tube
placement (for example at night) then, unless clinically urgent, placement should be delayed until
that support is available, and that the rationale for any decisions made is recorded in the patient’s
medical notes.
Placement of nasogastric tubes should not occur at times when there is insufficient support available
to accurately confirm placement (insufficient support may not be available at night or out of hours).
Initial confirmation of nasogastric tube position should also be made at times when there is
sufficient support available to accurately confirm placement, should any ambiguity arise.
Where an urgent situation might reasonably be expected to arise, for example in intensive/critical
care units, the clinical service should produce locally approved guidance for staff to define when
nasogastric tubes should be placed for feeding. Guidance should consider the increased risk
attached to commencing feeding when the confirmation of the correct placement of a nasogastric
tube would be dependent on a doctor in training. The guidance should also cover the
documentation required around confirmation of tube placement. This allows each service to decide
on the safest course of action after considering the risks and benefits for its own patients.
If the risk of delay in feeding or administering medication to an acutely unwell patient is considered
by the senior team member responsible for that patient to outweigh the risk of interpretation of
tube position and commencing feeding at night, then this decision and its rationale must be clearly
documented in the patient’s medical notes.
c) Nasogastric tubes used for the purpose of feeding must be radio-opaque throughout their length
and have externally visible length markings.
The tube length should be estimated before insertion using the NEX measurement (place exit port of
tube at tip of nose. Extend tube to earlobe, and then to xiphisternum - this is known as the NEX
measurement). Once inserted, the external tube length should be recorded and confirmed before
each feed.
d) pH indicator paper must be CE marked and intended by the manufacturer to test human gastric
aspirate.
3. Is there sufficient knowledge/expertise available at this time to test for safe placement of the
nasogastric tube?
In the following circumstances, patients should NOT be fed unless a pH of between 1 and 5.5 has
been obtained and documented OR correct tube placement has been confirmed by a competent
person through x-ray and documented:
following initial insertion;
following episodes of vomiting, retching or coughing spasms (note that the absence of
coughing does not rule out misplacement or migration);
when there is suggestion of tube displacement (for example, loose tape or portion of visible
tube appears longer);
in the presence of any new or unexplained respiratory symptoms or reduction in oxygen
saturation.
While none of the existing bedside methods for testing the position of nasogastric feeding tubes is
totally reliable there is evidence to suggest that a pH reading of between 1 and 5.5, can reliably
exclude pulmonary placement of the nasogastric tube. However, a pH between 1 and 5.5 does not
necessarily confirm gastric placement of the nasogastric tube, and there is a small possibility that
the tube is sitting in the oesophagus, which carries a higher risk of aspiration.
The NPSA consulted widely with stakeholders on reducing the pH threshold during summer 2010.
There was little support for this. Stakeholders, including professional bodies and a sample of local
hospitals in England and Wales, noted the impact in terms of increased x-rays (costs, radiation
exposure and risks of misinterpretation) and likely delays for patients needing urgent feeding. There
were also implications for access to X-rays for patients in the community. These disadvantages
appeared to outweigh the benefits of reducing risks of misplacement in the oesophagus.
Following insertion, the tube type, size and external length once secured, should be documented by
the person who passed the tube. The method of testing the tube position must be documented.
Each test and test result should be documented on a chart kept at the patient’s bedside.
e) Nasogastric tubes are not flushed, nor any liquid/feed introduced through the tube following
initial placement, until the tube tip is confirmed by pH testing or x-ray, to be in the stomach.
It is essential to ensure that the nasogastric tube is in the stomach to prevent any complications.
Some reports to the NRLS suggested staff believed it was acceptable to insert water or other fluid to
‘flush out some aspirate’. This is never safe to do.
First Line test method: pH paper
f) pH testing is used as the first line test method, with pH between 1 and 5.5 as the safe range, and
that each test and test result is documented on a chart kept at the patient’s bedside
pH readings should be between 1 and 5.5 for feeding to commence safely. However, the NPSA is
aware of the potential difficulty experienced by some staff in differentiating pH readings using
currently available pH indicator paper between pH 5 and 6. It is therefore recommended that a
second competent person checks any readings that fall within the pH range of 5 to 6.
All areas where nasogastric feeding tube placement is likely to occur must have access to pH
indicator paper that is CE marked and manufactured to test human gastric aspirate.
All pH tests and test results must be recorded on a chart kept at the patient’s bedside.
Documentation following pH testing should include:
whether aspirate was obtained;
what the aspirate pH was;
who checked the aspirate pH;
when it was confirmed to be safe to administer feed and/or medication (i.e. gastric pH
between 1 and 5.5).
Second line test method: X-ray confirmation
g) X-ray is used only as a second line test when no aspirate could be obtained or pH indicator paper
has failed to confirm the location of the nasogastric tube and that:
I. The request form must clearly state that the purpose of the x-ray is to establish the position
of the nasogastric tube for the purpose of feeding.
II. It is the radiographer’s responsibility to ensure that the nasogastric tube can be clearly seen
on the x-ray to be used to confirm tube position.
III. X-rays must only be interpreted and nasogastric tube position confirmed by someone
assessed as competent to do so.
Healthcare professionals are reminded that PACS windows can be manipulated to improve contrast
and visualisation.
If there is any difficulty in interpretation the advice of a radiologist should be sought.
Any nasogastric tubes identified to be in the lung should immediately be removed whether in the x-
ray department or clinical area.
Documentation following X-ray should include:
who authorised the x-ray;
who confirmed the position of the nasogastric tube. This person must be evidenced as
competent to do so;
confirmation that any x-ray viewed was the most current x-ray for the correct patient.
the rationale for the confirmation of position of the nasogastric tube, i.e. how placement
was interpreted, and clear instructions as to required actions. For example:
- 19 January 2011, 10:30 – Dr A. Smith – core surgical trainee
- X-ray taken at 10:15 today
- NG tube passed down midline, past level of diaphragm and deviates to left
- Tip is seen in stomach
- Plan: NG tube safe to use for feeding
Dr A. Smith
Radiographer’s responsibilities
The radiographer must ensure that exposure of the x-ray is adjusted to allow the nasogastric tube to
be visible to the bottom of the film.
The radiographer must ensure the film is centred lower than would normally be appropriate for a
chest x-ray so that it shows the abdomen as far as possible below the diaphragm.
The x-ray film must show the bottom of both hemi-diaphragms in the midline.
X-rays that are not as described above will not allow accurate interpretation of nasogastric tube
placement and should not be allowed out of the x-ray department.
Radiologist’s responsibility
When the radiologist reports the placement film, he or she must document not only the position of
the nasogastric tube and tip, but whether it is safe to proceed with the administration of any liquids
via the tube.
Repeat checks AFTER initially correct placement has been confirmed
As stated above, after initial insertion and after circumstances, signs or symptoms that indicate the
tube could have been displaced, only a pH between 1 and 5.5 or x-ray confirmation is an acceptable
checking method.
It is recognised that despite correct confirmation of nasogastric tube position prior to
commencement of feed, it is still possible for the tube to migrate or be dislodged away from the
stomach and into the oesophagus or into the lungs where feeding could prove fatal.
Because of this, British Association of Parenteral and Enteral Nutrition (BAPEN) recommends repeat
placement checks are made as follows:
before administering each feed;
before giving medication (see BAPEN guidance at www.bapen.org.uk/res_drugs.html);
at least once daily.
Where feed/medication has already passed through the tube, a minimum of an hour delay, without
any further feeding, should be instigated prior to testing of gastric aspirate using the correct pH
paper wherever aspirate can be obtained. However, in some situations, such as when patients are
fed continuously, when they are treated with acid-reducing medication, and when medications are
frequently given down nasogastric tubes, it may not be possible to obtain aspirate with a pH
between 1 and 5.5, and daily x-rays are not practical or safe.
Therefore, in circumstances where the initial placement was appropriately confirmed, and there is
no reason to suspect displacement since (i.e. no vomiting, retching or coughing spasms and no
unexplained respiratory symptoms) the only practical method of determining if the tube remains
correctly placed prior to each administration of medications or feed may be through external
observation of the tube. Where local guidance permits this, this should include confirmation that the
length of the external tube remains identical to that recorded initially in the patient’s notes, and that
fixation tapes or plasters have not moved or worked loose.
Tube length should be recorded on a daily basis and prior to administration of any liquid via the
nasogastric tube on the bedside chart. If there is any indication that the length has changed,
appropriate action should be taken to assess tube tip position prior to using the nasogastric tube.
If there is evidence that the tube has become displaced, for whatever reason, then only checking the
position at the nose would be inappropriate as it could be coiled in the back of the mouth, so in this
circumstance (which should be defined in local guidance) second line testing through x-ray, or
removal of the tube if seen to be coiled in the mouth, would be appropriate.
Electromagnetic bedside feeding devices are being used in a number of units and may increasingly
have a place as a second line testing method.
Competency
h) Healthcare professionals should ensure that if involved with nasogastric tube position checks
they have been assessed as competent through theoretical and practical training
A useful training resource on x-ray interpretation of nasogastric tube position is available at
www.trainingngt.co.uk.
An NPSA audit of 166 junior doctors across five sites highlighted that only 31 per cent of junior
doctors have any formal guidance or training on the use of x-ray for checking nasogastric tube
positioning. We have therefore provided an x-ray interpretation aid with our Alert, for distribution
across relevant clinical areas. The aid is not meant as a replacement for clinical judgement and it
should only be used to assist x-ray interpretation in conjunction with formal competency training of
all clinical staff responsible for the care of patients receiving nasogastric tube feeding. Minimising
the number of x-rays is important in order to avoid increased exposure to radiation, loss of feeding
time and increased handling of seriously ill patients.
Whoosh tests, acid/alkaline test using litmus paper, or interpretation of the appearance of aspirate
are never used to confirm nasogastric tube position as these are not reliable.
Transfer of care to community settings
Outside the acute care setting access to radiology can be difficult, particularly if the patient requires
transportation from the community.
j) A full multidisciplinary supported risk assessment should be made and documented, before a
patient with a nasogastric tube is discharged from acute care to the community.
Guidance on ongoing confirmation of nasogastric tube placement by community staff should be
provided and communicated with this risk assessment.
Learning from errors
Feeding into the lung, through a misplaced nasogastric tube is now a Never Event in England. All
misplacement incidents must be reported locally as well as nationally to the NRLS.
Organisations are required to ensure that staff report incidents of misplaced nasogastric feeding
tubes through their local risk management system, for uploading to the NRLS. This will enable both
local and national monitoring of misplaced nasogastric feeding tubes and further understanding of
the issue.
Appendix 1
Summary of reported incidents relating to misplaced nasogastric feeding tubes between issue of
the NPSA Alert between 2005 and 31 March 2010
Since the September 2005 NPSA Alert, Reducing the harm caused by misplaced nasogastric
feeding tubes, the NPSA has become aware of 21 deaths and 79 other cases of harm due to
feeding into the respiratory tract through misplaced nasogastric tubes. In 45 per cent of cases the
harm was due to misinterpreted x-rays.
Table 1: Summary of all reported incidents relating to misplaced nasogastric feeding tubes
between September 2005 and 31 March 2010
Checking method where error occurred: Total number of Number of reported deaths
reported incidents (out of total)
X-ray misinterpretation 45 12
Fed despite aspirate tested as pH 6-8 7 2
(i.e. existing advice ignored)
Fed after apparently obtaining pH 1-5.5* 9 1
Water instilled down nasogastric tube 2 0
before testing pH (i.e. existing advice
ignored)
Not checked at all 9 1
Apparent migration after initially correct 8 1
placement (e.g. after suction)
No information obtained on checking 17 4
method used
Other
Placed under endoscopic guidance 1 0
Visual appearance of aspirate 1 0
Bubble test 1 0
TOTAL 100 21
