Nasogastric Feeding Tube Insertion and Type: Clinical Guideline

Management in Adults Register No: 05102

Status: Public

Developed in response to: Best practice

NPSA guidance
Contributes to CQC Outcome: 4 and 5

Consulted With Post/Committee/Group Date

Dr A Lwin Consultant, ITU October 2014
Nutrition Steering Group October 2012
Pauline Bird Nutrition & Dietetic Service October 2014
Manager
Andrea Francis Clinical Lead Radiology October 2014
Sarah Ridgwell Advanced Practitioner
Radiographer
Angela Wade Practice Development Nurse October 2014
Professionally Approved By Medical Director November 2014
Dr R. Fenton,

Version Number 3.1

Issuing Directorate Medicine
Ratified by: DRAG Chairmans Action
Ratified on: 14th November 2014
Trust Executive Sign Off Date December 2014
Implementation Date 20th November 2014
Next Review Date November 2017
Author/Contact for Information Dr L Westcott, S. Maponga (Nutrition
CNS)
Policy to be followed by (target staff) All clinical staff
Distribution Method Intranet, Website
Related Trust Policies (to be read in Incident Policy
conjunction with) Consent Policy
Mental Capacity Act Policy
Infection and Prevention Policies
Guideline for Passing a Naso/oro-
gastric tube and intermittent tube
feeding for Children(10days-16yrs)

Document Review History

Version No Reviewed by Active Date
1.1 Angela Wade, Rachael Frost, Cathy Powis 26 September 2005
2. Dr L Westcott, Dr R Dobson 28th April 2011
3. Sibo Maponga (Nutrition CNS) November 2014
3.1 Sibo Maponga (Nutrition CNS) 15 April 2015

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 Index

1.0 Purpose
2.0 Scope
3.0 Risks of NG Tubes
4.0 Advantages and Disadvantages of NG Tubes
5.0 Definitions
6.0 Roles and Responsibilities
7.0 Decision making
8.0 Consent
9.0 Equipment
10.0 Insertion Procedure
11.0 Ventilated Patients
12.0 Checking tube position
13.0 First Line Test Method: pH Testing
14.0 Second Line Test Method: Radiography
15.0 Methods that must not be used
16.0 On-going management of Nasogastric tubes in situ
17.0 Feeding
18.0 Transfer into the community setting
19.0 Education and Training
20.0 Breaches of Policy
21.0 Audit and Monitoring
22.0 Communication and Implementation
23.0 Review
24.0 References

Appendix 1 Decision tree for NG tube placement checks in adults (NPSA)

Appendix 2 Recommended Procedure for checking the position of NG feeding
tubes (NPSA)
Appendix 3 Additional Guidelines for Nasogastric Tube Placement
Appendix 4 Nurse Competency Form
Appendix 5a NG Tube Insertion & Management form
Appendix 5b NG Tube Position Check Record

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1.0 Purpose

1.1 To promote a clear, consistent and evidenced based approach to the insertion, care
and management of NGs (nasogastric tubes).

1.2 To promote the safety and well-being of all patients who require an NG.

1.3 To provide guidance regarding scope of professional practice, level of competence

and accountability in nasogastric tube insertion, care and management.

1.4 To provide a framework for roles and responsibilities in nasogastric tube insertion
and care thereafter.

1.5 This policy reflects all the NPSA Alerts and Recommendations.

2.0 Scope

2.1 This guideline applies to the insertion and management of NG feeding tubes in
adult patients.

2.2 All clinical staff involved in the placement and ongoing management of NG feeding
tubes must adhere to the principles described in this guideline.

2.3 Indications for Use

See Appendix 1 for Flow chart to guide decision making for tube
feeding route
Nasogastric feeding is the most common method of providing short-term artificial
nutritional support in the acute setting. Decision to feed with a nasogastric tube
should be a multidisciplinary approach. NG tube feeding should be considered for
patients who: -
• Are malnourished.
• Have a functioning gastrointestinal (GI) tract.
• Require short-term tube feeding (up to 4-6 weeks).
• Require long-term tube feeding (if an alternative route is inappropriate or not
possible i.e. Percutaneous Endoscopic Gastrostomy (PEG) Radiologically Inserted
Gastrostomy (RIG) or Parenteral Nutrition (PN)
• Are unable to fulfil their nutritional requirements with normal /modified diet
nutritional supplements.
• Are not predicted to fulfil their nutritional requirements with normal / modified diet
nutritional supplements.
• Have increased nutritional requirements e.g. sepsis, trauma, post-op stress &
burns.

2.4 Contraindications

2.4.1 Absolute Contraindications are:

• Non-functioning GI tract e.g. ileus.

• Obstructive pathology in oropharynx or oesophagus preventing passage of the tube
e.g. stricture, tumour, pharyngeal pouch.
• Large gastric aspirate and/or high risk of aspiration.
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 • Intractable vomiting not resolved by anti-emetics
• Basal skull fracture, as the tube may enter the brain if incorrectly positioned (oro-
gastric positioning may be appropriate).

2.4.2 Relative Contraindications:

NG Tube placement is not an absolute “no” for these patients but it will be
dependent on how each patient with these symptoms presents and the medical
team will make the final decision on whether NG tube placement is possible.

• Oesophageal varices
• Mucositis
• Vomiting responding to anti-emetics
• Recent radiotherapy to head and neck
• Advanced neurological impairment

3.0 Risks with NG Tubes

3.1 Feeding through a tube misplaced into the lungs instead of the stomach can be
fatal. This guideline has been developed to support clinical staff in the correct
insertion of both wide and fine bore nasogastric (NG) feeding tubes and in the
confirmation of tube placement to reduce risk to patients in line with current best
practice and Clinical Governance.
3.2 Nasogastric feeding can be vital to the survival and recovery of patients who are
unable to eat normally. An estimated 271,000 nasogastric (NG) tubes are supplied
to the NHS annually (NHS Supply Chain 2008). However, nasogastric feeding, as
with any clinical treatment, carries risks.

3.3 In February 2005, the National Patient Safety Agency (NPSA) issued a Patient
Safety Alert, Reducing the harm caused by misplaced NG feeding tubes. This alert
provides guidance on checking and confirming that an NG Tube has been inserted
into the right place. This alert followed reports to the NPSA’s National Reporting
and Learning System (NRLS) of patient deaths as a result of feeding into the lungs
through misplaced nasogastric tubes. This Alert provides guidance on checking
and confirming that a nasogastric tube has been inserted into the right place, i.e.
the stomach.
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59794

3.4 Since the 2005 Alert’s completion date (1 September 2005), the NRLS received
reports of a further 21 deaths and 79 cases of harm due to feeding into the lungs
through misplaced nasogastric tubes. The main cause was misinterpretation of x-
rays, found in 45 incidents, 12 of which resulted in patient death. Guidance was
reviewed and updated and in March 2011 a new Patient Safety Alert was issued:
Reducing the harm caused by misplaced nasogastric feeding tubes in adults,
children and infants. The focus of this Alert supports safe x-ray interpretation.

• pH checking should be used as the First line test method

• X-ray should only be used as the Second line test when no aspirate could be
obtained or pH indicator paper has failed to confirm the position of the nasogastric
tube. http://www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45=129640

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3.5 In 2009 feeding into the lungs from a misplaced nasogastric tube became a Never
Event: a serious, largely preventable patient safety incident that should not occur if
the available preventable measures have been implemented.
http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf.
Never Event #19
3.6 2 further deaths due to NG Tubes flushed with water prior initial placement were
reported and in March 2012 a Rapid Response Report was issued -: Harm from
flushing of nasogastric tubes before confirmation of placement. The focus of this
Alert was to remind all staff responsible for checking initial placement of nasogastric
tubes that Nothing should be introduced down the tube before gastric placement
has been confirmed; that the tube should not be flushed before gastric
placement has been confirmed and that Internal guidewires/stylets should NOT be
lubricated before gastric placement has been confirmed.
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=133441

4.0 Advantages and Disadvantages of NG Tubes

Advantages Disadvantages Common Rarer

complications complications

• Readily available • Easily • Pulmonary • Epistaxis

• Easily inserted dislodged intubation • Gastrointestinal
• Easily reversed • Uncomfortable • Pulmonary bleeding
• Rapid start of • Aesthetically aspiration • Oesophageal
enteral feeds displeasing • Reflux gastric and
• Few • Nasal and duodenal
contraindications to mucosal perforation
placement ulceration • Pneumothorax

5.0 Definitions

5.1 Nasogastric (NG) tube

5.1.1 A Nasogastric (NG) tube is a flexible tube that can be inserted Trans nasally into
the stomach. It is commonly used for delivery of feed, fluids, medication, or
drainage of gastric contents.

5.1.2 NG Tubes are usually made of polyurethane; should be radio-opaque throughout

their length; should have external visible length markings and will often have a
guidewire throughout their length to aid insertion. These should be the tubes of
choice particularly if feeding is likely to be for longer than 14 days. These tubes
should be changed in line with the manufacturer’s guidelines (usually every 30-90
days).

5.2 Wide Bore tubes or Gastric Drainage tubes (Ryles)

Non-feeding nasogastric tubes (e.g. Ryles tubes), usually made of PVC and used
for a maximum of 7-10 days (as per manufacturers’ instructions), are not
recommended for feeding as they are not NPSA compliant. This is due to the link
between the leaching of plasticisers from PVC tubes when in contact with fats in
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 nutrition formulas (MHRA 2007). However, they may be used for administration of
essential drugs and initial feeding in the critical care setting. If a PVC/Ryles tube is
used for feeding it must be NPSA compliant and it must be replaced with a finebore
NG Tube as soon as it is not required for drainage.

5.3 CE Marked pH paper

pH indicator paper is CE marked and intended by the manufacturer to test gastric

aspirate. pH paper is more sensitive than litmus paper and must be used for
confirming the position of the NG tube (NPSA 2005).

5.4 Blue Litmus paper – do not use for checking gastric aspirate

Litmus paper is paper which has been treated with a natural dye which can be used
as a pH indicator. Blue litmus paper turns red under acidic conditions (pH below
4.5). However it is not sensitive enough to reliably distinguish between gastric
acid (pH 3-5) and bronchial secretions (pH >6) (NPSA 2005, MHRA
2004, Rollins 1997). Litmus paper must therefore not be used in checking NG tube
position.

6.0 Roles and Responsibilities

6.1 Chief Executive

The Chief Executive is responsible for ensuring that systems are in place to ensure
the safe and effective placement and management of NG tubes. This responsibility
is delegated to the Medical Director.

6.2 Medical Director

The Medical Director is responsible for ensuring compliance with systems in place
to ensure the safe and effective placement and management of NG tubes.

6.3 Clinical / Educational Supervisors

Clinical and or Educational Supervisors should ensure that Foundation doctors

have completed the NHS e-Learning training module “Reducing the Risk of Feeding
through Misplaced NG Tube” and they should also complete a Direct Observation of
Procedural Skills (DOPS) form to assess competency in NG feeding tube insertion
and placement checks.

6.4 Nutrition Nurse

• To provide training for all staff involved in the placement and management of
enteral feed tubes/equipment.

• Where trained medical or nursing staff are unavailable to site enteral feeding tubes,
or tube placement is complex, the Nutrition Nurses will place the tube if appropriate.

• Ensure that all policies and procedures for the placement and management of
enteral feed equipment are up to date and evidence based.

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6.5 Dietitians

All NG tube fed patients should be referred to the Dietitians immediately. The
dietitians have the responsibility of:

• Ensuring that each patient receives adequate and appropriate nutritional

support.

• Drawing up the feeding regime for the patient according to each patient’s need.

• Ensuring that the NG tube guidelines are up to date and adhered to in

accordance with national guidelines to ensure best practice.

6.6 Registered Nurses (And other Healthcare Professionals, as appropriate)

• To complete the clinical skills training for Passing a Fine Bore

Feeding Tube for Enteral Feeding and be assessed as competent.

• All healthcare professionals must adhere to the principles described in this policy.

• A decision to insert a Nasogastric tube for the purpose of feeding must be made
and documented by a senior member of the medical team responsible for the
patient’s care. This decision should only be made following careful assessment of
the risks and benefits.

• Only staff with the relevant skills and expertise should insert and confirm the
placement of NG tubes.

• Only staff with the relevant skills and expertise should undertake placement checks
prior to commencing feeding or administration of medication.

• When there are continuous difficulties obtaining an aspirate with a pH less

than 5.5 seek advice from senior medical staff.

• Assess patient comfort and safety through regular observation. An incident report
must be completed where an incident related to the placement of NG tube occurs
6.7 Lead Nurse/Ward Sister

• Identify which members of staff are required to undertake various aspects of

feeding and management of nasogastric feeding tubes.

• Ensure training and assessment of competence is undertaken and

documented.

• Monitor standards of practice in their environment in relation to feeding and

management of nasogastric feeding tubes.

6.8 Radiographer

• It is the radiographer’s responsibility to provide an image to clearly demonstrate the

presence and position of the NG tube.

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 • Every effort must be made to ensure that the patient is not rotated.
• The cassette/detector should be positioned so as to obtain a 'low chest' i.e.
skimming the apices to demonstrate more of the abdomen below the diaphragm.

• If there is difficulty in interpreting whether the tube is correctly placed on the

subsequent chest x-ray, advice should be sought from the Duty Radiologist in the
first instance. If the Duty Radiologist is unavailable, and the x-ray is not technically
adequate, a repeat should be considered after discussion with the radiographer.

7.0 Decision Making

7.1 A decision to insert a Nasogastric tube for the purpose of feeding must be made by
a senior doctor responsible for the patient’s care.

7.2 This decision should only be made following careful assessment of the risks and
benefits.

7.3 This entry in the medical notes must be signed, dated and timed.

7.4 Prior to insertion the rationale for insertion of an NG tube must be considered and
responses to the following documented on the NG Tube Insertion & Management
form (Appendix 5a):
• Is Nasogastric tube feeding the right decision for this patient?
• Is this the right time to place the NG tube and is appropriate equipment available?
• Is there sufficient expertise available at this time to test for safe placement?

7.6 Nasogastric tubes should only be placed when there is experienced support
available for NG Tube insertion and for confirming the NG tube position. If there is
no sufficient, experienced support available (for example at night) then, unless
clinically urgent, placement should be delayed until that support is available.
Rationale for any decisions made should be recorded in the patient’s medical notes.
7.5 Where longer term enteral feeding is required (> 4 – 6 Weeks) consideration should
be given to PEG placement.

8.0 Consent

8.1 Informed verbal consent must be sought prior to the insertion of the NG tube. A
clear explanation of the procedure should be given and verbal consent gained.

8.2 If the patient is unable to respond verbally, other means of communication should
be sought.

8.3 If the patient is unable to communicate or lacks mental capacity, staff should refer
to the Trust’s Consent Policy and Mental Capacity Act Policy. An MCA2 form should
be completed in full and a copy submitted to the adult safeguarding team.

9.0 Equipment

• Plastic apron and gloves;

• Radio-opaque NG tube with externally visible length markings;

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 • CE marked pH indicator strips/paper with a range of 0 to 6 and 0.5 gradations;

• Lubricating jelly;

• Freshly drawn water to flush the tube once NG Tube position has been confirmed

• Purple Enteral Syringe;

• Receiver

• Glass of water/coloured fluid and a straw (only if the patient has a safe swallow
reflex)

• Nasal/cheek dressing to secure tube (included in some packs)

• NG Tube Insertion and Management Form

10.0 Insertion Procedure

Action
Prior to the procedure, check the medical and nursing
notes for complications, e.g. anatomical variations
due to surgery or cancer.
Assess the patient’s requirements.
Explain the procedure to the patient (even if the
patient appears not to understand).
Arrange a signal so that the patient can communicate
with the nurse during the procedure e.g. raise a hand.
Wash hands and put on non-sterile gloves and an
apron.
Assist the patient in a semi-upright position. Support
the head in a slightly forward position.
Check that the nostrils are patent by asking the
patient to sniff with one nostril closed. Repeat with the Prevents nasal irritation and potential
other side. Alternate nostrils if replacing a tube.
Action
Unpack the tube, close the end connectors. If the
tube has a guide wire, gently push it into the tube until itself during insertion.
it is fixed. Check tube’s not kinked.
Rationale
These may affect the procedure and
result in further complications.
Patients with head injury or facial
trauma may have the feeding tube
passed through the mouth and down
into the stomach to bypass nasal
damage and cerebral oedema.
To ensure the appropriate tube is
inserted to meet the patient’s needs
and clinical condition and that the tube
is acceptable and comfortable.
To ensure that the patient understands
and is able to give consent and co-
operate with the procedure.
Helps to alleviate fear as the patient
has some control over the procedure.
Minimises cross infection
Assists swallowing and helps prevent
tracheal placement if the swallow is
compromised.
Helps identify potential obstruction.
ulceration.
Rational
Prevents the tube from coiling back on

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 Place the tip of the tube (the distal opening, if the tube Ensures that the correct length of tube
is weighted) at the xiphisternum and measure up to is placed in the stomach.
the tip of the nose and then to an ear lobe (NEX
measurement). Note the measurement on the tube.
Lubricate the tube. Use a thin coating of water based Facilitates easy passage of the tube.
jelly. If the tube is hydrophilic e.g. Corpak Corflo,
immerse the distal end of the tube in water to activate
the lubricant.
Insert the tip of the tube into the chosen nostril, Follow the natural anatomy of the
advancing it horizontally and gently along the floor of nose.
the nostril; parallel to the nasal septum, to the
nasopharynx and then oropharynx. The patient may
sneeze. Reassure. If resistance is met, withdraw
slightly and alter the angle of insertion, otherwise try
the other nostril.
If the patient is able to swallow small sips should be The swallowing action places the
taken at this stage. An assistant may be required to epiglottis over the trachea allowing the
help give the fluids if the patient is unable to take tube to enter the oesophagus. Also it
them themself. If the patient is NBM, sometimes gives the patient something else to
placing a cold spoon on the tongue may initiate a focus on.
swallowing reflex
Advance the tube down the oesophagus with If the tip of the tube is in the
successive swallows until the correct measurement or oesophagus there is a high risk of
mark is seen at the nostril. aspiration. If too much tube is inserted
it might kink in the stomach, or pass
through the pylorus into the duodenum.
Check the position by testing the aspirate pH (should To verify position in the stomach
be between 1 and 5.5). If unable to obtain aspirate or
if the pH is more than 5.5, position should be checked
via x-ray
NB Do not flush the tube before gastric placement Water activation of the lubricant may
has been confirmed. give an inaccurate low pH result.
Internal guidewires/stylets should not be lubricated
before gastric placement has been confirmed.
Fix the tube in position. Helps prevent dislodgement.
Document in the NG Tube Insertion &
Management Form (Appendix 4)

• Type of tube, size and lot number • Tracking and traceability

• Name of person inserting the tube, date and • For audit and training
time requirements
• The cm measurement on the tube at the exit • Allows the user to assess
point from the nostril. whether the tube has changed
• The pH value (if gastric aspirate obtained) position.
• Allows staff to compare with
• Which nostril previous readings
• Prevents trauma caused by
using the same nostril being
• The Doctor reading the X-ray should record the used repeatedly
result on the Insertion Form or in the patient’s • To identify whether the tube is
  10
 Medical notes. safe for use and for tracking and
accountability
• Ease of insertion • Useful information for other
healthcare professionals
inserting subsequent tubes.

11.0 Ventilated Patients

Ventilated patients may have the NG tube inserted under direct laryngoscopy.

12.0 Checking Tube Position

12.1 The ideal position for the NG tube is in the stomach below the diaphragm. The
position of the NG tube must be checked to confirm it is in the stomach. The
procedure is summarised in the flow charts and guidance on pH testing in Appendix
1 and Appendix 2. Further information is available in the NPSA Supporting
information document.

12.2 Nasogastric tubes must not be flushed or liquid/feed introduced through the tube
following initial placement, until the tube tip is confirmed to be in the stomach by pH
testing or x-ray.

13.0 First Line Test Method: ph Testing

13.1 Aspirate 2ml of stomach content using a sterile syringe and test using CE marked
pH paper. A pH of less than 5.5 is unlikely to be of pulmonary origin and can be
considered gastric in origin.
13.2 Only if a pH of between 1 and 5.5 has been obtained and documented or the
correct placement confirmed and documented by a competent person through x-ray
can an NG Tube be used.
13.3 NG Tube position should be checked in the following circumstances:

• Following initial insertion

• Before administration of medication or commencement of feed
• At least once a day if the patient is on continuous feed (stop the feed for an hour,
flush with water and then check the pH before restarting the feed).
• 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

13.4 Initial and on-going pH checks must be documented on the Trust NG Tube Insertion
& Management form (Appendix 5b) which should be kept at the patient’s bedside.
13.5 pH readings should be between 1 and 5.5 for feeding to commence safely.
However, the NPSA has identified 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 two competent members of staff
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 check any readings that fall within the pH range of 5 to 6. The second check should
be undertaken by a registered nurse, who has completed their competency
assessment.
13.6 Consideration should be given to the impact of medication such as antacids and the
frequency of feeds on stomach pH.
13.7 If a member of staff has difficulty obtaining an aspirate an alternative method is
being able to aspirate a coloured fluid that has been drunk. If the patient is alert,
has intact swallow and is perhaps only on supplementary feeding and is thus eating
and drinking during the day, staff should ask them to sip a coloured drink and then
aspirate the tube. If a coloured fluid is obtained then the tube is in the stomach.
13.8 Refer to Appendixes 1, 2 & 3 for further advice on attempting to gain aspirate
13.9 Any staff still having difficulty obtaining an aspirate must request help from a
more experienced member of staff or the Nutrition CNS.
14.0 Second Line Test Method: Radiography

14.1 If staff are unable to obtain aspirate or pH indicator paper failed to confirm the
location of the NG tube in the stomach, then a request for an x-ray of the upper
abdomen and chest should be made.
14.2 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 and which type of feeding
tube was inserted. If a fine bore tube is used, the guide wire must be left in place
until after imaging and interpretation of the resultant image.
14.3 Chest x-rays should be obtained using the technique described in 5.8
14.4 X-rays must only be interpreted and nasogastric tube position confirmed by a doctor
assessed as competent to do so.
14.5 If there is any difficulty in interpretation, the advice of a radiologist should be sought.
The radiologist should document the position of the NG tube and tip and whether it
is safe to proceed with administration of liquids.
14.6 If the tube is not in the correct position, it must be removed immediately whether in
the x-ray department or clinical area.
14.7 If there is any relevant past medical history such as Hiatus Hernia or previous
gastric surgery, staff should consider using x-ray after discussion with the senior
medical team.
15.0 Methods that must not be used

• Auscultation of air insufflated through the tube (‘whoosh test’)

• Testing aspirate with Blue Litmus paper

• Interpreting absence of respiratory distress as indicator of correct positioning;

• Monitoring bubbling at the end of the tube

• Observing the appearance of the aspirate

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16.0 On-going Management of NG Tubes in situ

16.1 Prior to use of an NG tube the healthcare professional must re-assess the risk to
the patient.

16.2 pH of aspirate and length of tube must always be checked to confirm position
using methods explained in sections 12-14:

• Once daily during continuous (pump) feeds; at the end of the rest period before re-
connecting the feed

• Before administration of medication when the patient is not currently receiving

continuous feed

• Before administering each bolus feed

• Following episodes of vomiting/retching/coughing

• If the patient complains of a change in level of discomfort

• If the patient develops difficulty in breathing during administration of feeds or

medicines

• Following any evidence of tube displacement

16.3 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.

16.4 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. 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.

16.5 Tube length should be recorded on a daily basis and prior to administration of any
liquid via the nasogastric tube on the bedside chart Appendix 5b. 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.

16.6 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 second line testing through x-ray,
or removal of the tube if seen to be coiled in the mouth, is appropriate.

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16.7 Flushing

• Tubes should be flushed with 30ml water before and after the administration of
each drug.
• If more than one medicine is to be administered, flush between drugs with at least
10 ml of water to ensure that the drug is cleared from the tube.

• Flush the tube with at least 30 ml water following the administration of the last drug.

• NG fed patients should have their medication in liquid or dispersible form; liaise with
the Pharmacist re. Medication. The pharmacist will advise on how to administer
drugs that only come in tablet form and has to be crushed

• If the patient is on a fluid restriction or for a paediatric patient, consult the dietitian
and pharmacist about the quantity of water to be given before and after medication.

• Tubes should be flushed with at least 30ml water at the start and finish of the
administration of each feeding period.

• All fluid given as a flush must be clearly documented on the patient’s fluid balance
chart each day.
16.8 Blocked NG Tube

Possible causes Intervention

Not flushing or inadequate
flushing after feed and
medication.
Unsuitable medicine
preparations for giving via a
tube, e.g. large particles,
viscous liquids.
Multiple medications being
given together without a flush in
between each drug.
Kinked tube
Flush with 30-50ml water before and after feed or
medication
Review medication and consider alternative medication.
All medication given via NG tube should be in either liquid
or dissolvable form if possible. Liaise with pharmacist.
All medications should be given separately, flushing
about 10ml of water in between each medication.
NG tube may be kinked in the stomach, pull back slightly
and retry.

16.9 Guidelines for unblocking the tube

Flushing with water can shift most blockages (Check length marking to confirm NG
tube position has not shifted before flushing with any fluid to unblock the tube)

• Use a 60ml oral/enteral syringe with a plunger

• Prime with 20-30mls Warm water or Carbonated (sparkling) water or Soda water
(do not use Coca-Cola/Lucozade/Pineapple juice or anything other than warm
water, carbonated water or soda water)

• Flush by using a pumping action

• Squeeze along the tube, and then retry flushing.

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 • Once cleared, flush thoroughly.
• If unsuccessful: Try using a smaller syringe, 20mls then 10mls then 5mls.
Caution: This will exert greater pressure and may split the tube. Check the tube for
leakage after the blockage has been cleared.
• If all fails remove NG Tube and insert a new one.
17.0 Feeding

17.1 The dietitian will calculate the patient’s requirements and device an appropriate
regimen to meet these requirements. The regimen will be provided in a written
format and discussed with the nursing staff and where possible, the patient. The
Emergency Feeding Regime (available on the intranet under Nutrition and Dietetic
Service) may be used over weekends or bank holidays or until the dietetics service
is available for advice.

17.2 If the patient is at risk of Refeeding syndrome, feeding must not be started until the
appropriate vitamins have been prescribed and administered as described in
Guidelines for the Management of Refeeding Syndrome (Adults), Refeeding Flow
Chart for Enteral Nutrition (Mid Essex Formulary).

17.3 Administration of the feed should be recorded on the patient’s fluid chart, detailing
both the volume and name of the feed. Volume of water flushes should also be
recorded on the fluid chart.

17.4 The dietitian will monitor tolerance of the feed together with the patient’s condition
and adjust the regimen appropriately.

18.0 Transfer of care to the community setting

18.1 A full multidisciplinary supported risk assessment involving the Dietetic Services
should be made and documented, before a patient with a Nasogastric tube is
discharged from the Trust into the community.

19.0 Education and Training

19.1 Only staff trained and assessed as competent to insert or check the position of an
NG tube should attempt these procedures.

19.2 Nurses may only insert an NG tube following completion of training and competency
sign off (Appendix 4).

19.3 All junior Doctors may only insert NG tubes if they have been trained to do so and
should attend the relevant session within their training programme to ensure they
are competent to interpret chest x-rays undertaken to confirm the position of the
tube.
19.4 Clinical and or Educational Supervisors should ensure that Foundation doctors
have completed the NHS E-learning training module “Reducing the Risk of Feeding
through Misplaced NG Tube” and they should also complete a Direct Observation of
Procedural Skills (DOPS) form to assess competency in NG feeding tube insertion
and placement checks.

  15
20.0 Breaches of Policy

22.1 Any incidents related to misplaced NG tubes must be reported as a Serious Incident
in accordance with the Trust Incident Policy and Serious Incident Policy.

21.0 Audit and Monitoring

21.1 An annual audit of compliance with this policy will be undertaken by Intensive Care
Team, Corporate Nursing and the Dietetic Service with the support of Clinical Audit.
Findings of the audit will be reviewed by the Nutrition Steering Group and where
deficiencies are identified, actions will be developed and their implementation
monitored by this Group.

22.0 Communication & Implementation

22.1 The policy will be available to staff and the public on the Trust’s intranet site and
website.
22.2 The policy will be sent to all Clinical Directors and Corporate Nursing for information
and dissemination amongst their teams by the author.

23.0 References

Royal Marsden Online procedures

MEHT guidelines for passing naso/orogastric tube and intermittent feeding for children
(10days to 16 yrs). 2009

NPSA/2012/RRR001, Rapid Response Report: Harm from flushing of nasogastric tubes

before confirmation of placement. March 2012

NPSA / 2011 / PSA 002. Patient safety alert: Reducing the harm caused by misplaced
Nasogastric feeding tubes in adults, children and infants. March 2011

NPSA 2005. How to confirm the correct position of nasogastric feeding tubes in infants,
children and adults, February 2005

Rajaraman D 2009 Nasogastric tubes 1: Insertion technique and confirming the correct
position. Nursing Times Vol. 105, Iss. 16, 2009     

  16
Appendix1

  17
 Appendix 2 Recommended procedure for checking the position of NG feeding tubes
Action
Check whether the patient is
on medication that may
increase the pH
level of gastric contents
Check for signs of tube
displacement
Sufficient aspirate (0.5 to 1ml)
obtained
Aspirate is pH 5.5 or below
Aspirate is pH 6 or above
Wait up to one hour before re-
aspirating to check pH level
Problems obtaining spirate?
Turn patient onto their side
Inject air (1-5ml for infants and
children, 10-20ml for adults)
using a 20ml or 50ml syringe.
Wait for 15-30 minutes and try
again This is NOT a testing
procedure: DO NOT carry out
auscultation of air (‘whoosh’
test) to test tube position
Advance the tube by 1-2cm for
infants and children or 10-
20cm for adults
Consider x-ray All radiographs
should be read by
appropriately trained staff
Additional tip
 
Rationale
Medications that could elevate the pH level of gastric contents are;
antacids, H2 antagonists and proton pump inhibitors. For those patients
who are regularly on antacids, the initial risk assessment needs to identify
actions that staff should take in this scenario, and document them in the
care plan. The initial pH of the aspirate should also be documented in the
case notes.
Documenting the external length of the tube initially and checking external
markings prior to feeding will help to determine if the tube has moved. The
documentation will also assist radiographers if an x-ray is needed.
0.5 to 1ml of aspirate will cover an adequate area on the single, double or
triple reagent panels of pH testing strips/paper. Allow ten seconds for any
colour change to occur.
Commence feed. There are no known reports of pulmonary aspirates at or
below this figure. The range of pH 0 to 5.5 balances the risk between
increasing the potential problems for clinical staff e.g. removing tubes that
are actually in the stomach, increased use of x-ray, with the as yet,
unreported possibility of feeding at pH 5.5 when the tube is in the
respiratory tract.
DO NOT FEED. Possible bronchial secretion; leave up to one hour and try
again. The initial risk assessment should identify actions for staff to take in
this scenario for each patient. The actions should be documented in the
care plan and/or in local policies. If there is ANY doubt about the position
and/or the clarity of the colour change on the pH indicator strip/paper,
particularly between the ranges pH 5 and 6, then feeding should NOT
commence – seek advice.
The most likely reason for failure to obtain gastric aspirate below pH of 5.5
is the dilution of gastric acid by enteral feed. Waiting for up to an hour will
allow time for the stomach to empty and the pH to fall. The time interval will
depend on the clinical need of the patient and whether or not they are on
continuous or bolus feeds.
This will allow the tip of the NG tube to enter the gastric fluid pool.
Injecting air through the tube will dispel any residual fluid (feed, water or
medicine) and may also dislodge the exit-port of the NG feeding tube from
the gastric mucosa. Using a large syringe allows gentle pressure and
suction; smaller syringes may produce too much pressure and split the
tube (check manufacturers guidelines). Polyurethane syringes are
preferable to other syringes. It is safe practice to use NG tubes and enteral
syringes that have non luer connectors (Building a Safer NHS for Patients:
Improving Medication Safety published 22/01/2004 available at
www.dh.gov.uk)
Advancing the tube may allow it to pass into the stomach if it is in the
oesophagus.
X-ray should not be used routinely. The radiographer will need to know that
this advice has been followed, what the problem has been and the reason
for the request. The radiographer should document this. Fully radio-opaque
tubes with markings to enable measurement, identification and
documentation of their external length should be used.
If the patient is alert, has intact swallow and is perhaps only on
supplementary feeding and is thus eating and drinking during the day, ask
them to sip a coloured drink and aspirate the tube. If you get the coloured
fluid back then you know the tube is in the stomach.
18
Appendix 3 Additional Guidelines for Nasogastric Tube Placement

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 Competency for Nasogastric Tube (NG) Insertion and Management
(Competency training should include theoretical and practical learning (NPSA/2011/PSA002)
Name

Ward

This competency document is designed to be used in conjunction with the generic core competency document.

Nasogastric tube insertion and management

Date of
Initial Self/mentor initial Date Final Signature of
Date of Final Level Comments/Action Plan
Assessment self/mentor Level preceptor/
Review Achieved
Level assessment achieved Mentor

self mentor mentor

Discusses and demonstrates understanding of
indications for nasogastric (NG) tube placement

Discusses and demonstrates understanding of

contraindications for NG tube placement

Understands the differences and indications for

fine bore feeding tubes or wide bore NG tubes
e.g. for drainage/aspirate
Abides by and understands the NPSA directives
(2011, 2012) and Trust Policy for the insertion
and management of fine bore NG feeding tubes
Demonstrates the correct procedure for NG tube
placement including all aspects of health &
safety. Maintains patient comfort throughout
Demonstrates competency in checking position
of NGT immediately after insertion using 1st line
pH testing (aspirate ≤ 5.5) and only using the
2nd line testing (x-ray) when appropriate i.e. If
no aspirate is obtained or if aspirate is >5.5
Articulates knowledge of when / how often
NGT should be checked for correct position
post insertion.
Demonstrates knowledge of what action to take
if:
• Unable to obtain aspirate
• pH > 5.5 / patient receiving PPI
Can provide care for a patient with a NG tube
including changing NG tapes, checking skin,
providing mouth care
Correctly documents insertion, care of, and
position checks of NG tubes according to Trust
policy and using Trust documentation.
Can provide enteral feeding according to
prescription and feeding regime and correctly
documents the feed according to the Trust
policy.
Understands the indications for and can
implement the Emergency Standard Enteral
Feeding Regime in the absence of dietetic
assessment

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 NG Tube Insertion & Management
To be filed in patient’s medical record
Please affix patient demographics label or complete the following details

Surname: First Name

DOB: Ward:

NHS Number: Hospital Number:

Reason for NG Tube insertion:

Identify the senior doctor responsible for the patient’s care who has agreed to the NG tube insertion:

Is Nasogastric tube feeding the right decision for this patient? Yes / No

Is this the right time to place the NG tube and is appropriate equipment available? Yes / No

Is there sufficient expertise available at this time to test for safe placement? Yes / No

Has verbal consent been given by the patient? Yes / No / NA

If NA, please give details:

NG Tube Type: _______________ Size: ______ Length: ----------------- Date: __ / __ / __ Time: __:__
Inserted by: __________________ Signature: _________________ Designation: _______________
Please note length marking:
Placement check:
First line test method
Aspirate checked using pH
indicator paper that is CE Was aspirate obtained: Yes / No Date: __ / __ / __ Time: __ : __
marked Yes / No
Is it confirmed as safe to
Initial pH test result: _______
administer feed / medication Yes / No
Safe range for feeding is 1 to 5.5
Checked by: Signature: Designation: _______________
If pH between 5 and 6, signature & designation of
second competent person checking result:
Please confirm that the tube was not flushed prior to the placement check by ticking this box

Second line check

Interpretation of x-ray:

Position of tube confirmed on: ___ / ___ / ___ Time: ___ : ____
X-ray authorised by:
Name: Signature: Designation:

Plan:

Was the x-ray reviewed the most current available? Yes / No

If tube placed in lung was the NG tube removed immediately? Yes / No

NG Tube Position Check Record (Check prior to commencing feed or giving drugs) pH of NG Aspirate
pH 1 to 5 proceed to feed or use tube
Patient Surname: _____________________ First Name _________________________ pH between 5 and 6; second checker to confirm reading
Confirmed pH 5.5 or less proceed to feed or use tube
NHS / Hospital Number ________________ Initial tube length on insertion_________ pH > 5.5 additional checks or action required
Date / Name of Signature Tapes Tube Aspirate pH Name of 2nd Signature Agreed Outcome e.g. proceed to feed;
time person intact length obtained before checker (competent pH record additional checks carried
checking NGT Y/N (daily / Y/N feed / RN) if pH between out; escalate to medical team
(print) prior drugs 5 and 6 (record name and grade of Dr)
to (Print name)
feed)

                     
 
                     
 
                     
 
                     
 
                     
 
                     
 
                     
 
 

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