Early in the Covid-19 pandemic, the NGSIG predicted the number of sick Covid-19 patients requiring nasogastric tube (NGT) feeding in critical care and high dependency areas would increase dramatically with consequent increased risk of unrecognised misplacement leading to Never Events (NE) and/or pneumothorax. Based on our Position Paper on NGT safety1 we produced an Aide Memoire2 with NHSE/I endorsed by NNNG (National Nutrition Nurse Group), The Faculty of Intensive Care Medicine, The Intensive Care Society, The Royal College of Anaesthetists and the Association of Anaesthetists before publication2. Rather than relying on aspirate pH as first line initial position check, the Aide Memoire strongly advised use of the “4-point criteria” for reporting x-rays requested specifically to take into account typical ground glass lung fields found in critical care patients. The Aide was not intended to replace current aspirate pH-based guidance in patients outside critical care.
An increase in NGT NEs seemed inevitable with the unprecedented pressure on the NHS with redeployed staff unfamiliar with protocols in HDU/CCU where risk of misplacement is greatest, the reduced nurses/patient ratio and increased staff stress and illness, prone nursing often of obese patients, and the number of NGTs required. Prior to the pandemic, the ongoing incidence of NGT NEs seemed unaffected despite multiple Alerts3 by NHSE/I. The conditions which permitted NEs to occur before the pandemic persisted into the pandemic undiminished or amplified.
According to NHSE/I data, total NEs in England fell from a mean of 452/year in the 5 years prior to the onset of the pandemic to 364 reflecting the reduction in overall NHS non-Covid related activity. The mean incidence of NGT NEs in the previous 5 years was 28.4 (range 22-40) representing 6.3% of total NEs but rising to 10.8% in the year April to March 2020-21 when 34 NGT NEs were reported. NNNG and NGSIG members report that NGT feeding patients increased at least 2-3-fold in NHS hospitals over the last year but particularly in critical care, so at least 51 to 72 cases would have been predicted on a pro rata basis.
Thus, total NEs fell during the Covid-19 response year but NGT related NEs rose in number and as a proportion of total NEs, but not to the predicted level. We have no evidence that our Aide Memoire was directly influential in reducing NGT related NEs to the level reported, but we do have anecdotal evidence from NGSIG members of greater awareness of the issues by HDU/CCU staff. We heard of nutritional leads being able to train large numbers of staff to detect misplacement in accordance with NHSE/I guidance and Alerts with emphasis on preferential use of x-ray imaging in critical care/high dependency areas.
The increase in NEs during the pandemic justifies our concerns but the failure of NE numbers to reach the predicted target could be explained by reduced reporting of NGT NEs but this would be contrary to the observed increase in total NEs during this period. The possibly that the reduced incidence of NGT NEs was related in part to the use of the Aide Memoire in critical care/high dependency units cannot be excluded. Ongoing NGT NEs still require greater attention nationally beyond the pandemic as recommended in our Position Paper.
References
1. A Position Paper on Nasogastric Tube safety; “Time to put patient safety first”. BJM Jones a-position-paper-on-nasogastric-tube-safety.pdf (bapen.org.uk)
2. AIDE-MEMOIRE: Nasogastric tube (NGT) placement checks before first use in critical care settings during the COVID-19 response BAPEN.aide-memoire-ngt-placement-13-05-20.pdf (bapen.org.uk)
3. Patient Safety Alert: Nasogastric tube misplacement: continuing risk of death and severe harm. NHS/PSA/RE/2016/006 .Patient Safety Alert Stage 2 - NG tube resource set (1).pdf