Maggie Church, RN MSN Special Care Nursery at Lucile Packard Children s Hospital at Stanford

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Alice Whitehead
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1 Maggie Church, RN MSN Special Care Nursery at Lucile Packard Children s Hospital at Stanford

2 Decrease adverse events with Evidenced- Based Nasal Gastric Tube insertion in Neonates.

3 The Aim Implement a new weight-based calculation to place a nasal gastric tube in neonates based on current literature. 3 x wt (kg) + 13cm Obtain 100% compliance of nursing staff using the new calculation. Prevent Hospital Acquired Conditions

3 x wt (kg) + 13cm Obtain 100% compliance of nursing staff

4 Background In Neonates, methods for estimation of gastric tube insertion length are not standardized, and placement errors frequently occur (Cordero, 2011). Malposition of gastric tubes can cause aspiration, bradycardia s, perforation, sepsis, malabsorption, and diarrhea (Metheny, 2007). Tube placement errors can prolong hospital stay and increase health care costs (Ellett, 2011),

Malposition of gastric tubes can cause aspiration, bradycardia s, perforation, sepsis,

5 Background Patient Safety Alert issued in Asking to reduce harm caused by misplaced nasal gastric feeding tubes in babies under the care of Neonatal Units. Studies on newborn infants indicate that morphological measures in this population are frequently inaccurate and usually underpredict the tube length, with reported error rates of 38-55% (Freeman, 2012).

Studies on newborn infants indicate that morphological measures in this population are

6 Current Practice 3 morphological methods nursing staff use to place NG tubes: Nose-Ear-Xiphoid (NEX) Nose-Ear-Mid-Umbilicus (NEMU) Nose-Ear-Xiphoid + 1cm (NEX+1)

7 Current Practice Gold standard to check NG tube placement is X-Ray Not current practice Detrimental to bones in neonates Expensive Delays treatment Current NG tube can stay in for up to 30 days Length of stay 1-8 weeks Most NG tubes are not adjusted for weight gain unless infant pulls tube out

treatment Current NG tube can stay in for up to 30 days Length of stay

8 Small Test of Change Stakeholders: Staff Nurses Doctors Manager 5 LPCH Neonatal units Binder Collected daily weights & NG tube placement on each infant in unit with an NG tube. Educate Staff on new calculation: 3 x wt (kg) + 13 cm -Huddles Four 15 min in-services on different shifts -Posted 3 research articles on Evidenced-Based Practice board -Posted new calculation formula next to NG tube supply

Educate Staff on new calculation: 3 x wt (kg) + 13 cm -Huddles Four 15 min in-services on different

9 Challenges and Rewards If an XR was obtained on infant with a NG tube, reminding MD to check placement & document in binder. Skeptical nurses -Changing nursing practice that we have been doing for the past 40 yrs. Early adpators emerged wanting to improving care Excitement on unit about participating in a project improvement that could affect all 5 of our neonatal units

Skeptical nurses -Changing nursing practice that we have been doing for the past 40 yrs.

10 Results Pre-Survey Jan 1- Mar 18, Infant s with NG tubes documented weight & current tube placement. Education Huddles New weight-based calculation 3 x wt (kg) + 13 cm 24 out of 27 nurses attended RN survey Which method do you use to place NG tube?

Education Huddles New weight-based calculation 3 x wt (kg) + 13

11 Survey Results What method do you use to insert an NG Tube? Pre-Survey Post-Survey NEX NEX+1cm NEMU Other NEX NEX+1cm NEMU Other 25 n=27 n=27

12 Results 18 infants had NG tubes from Mar 20 May 4, X-Rays were obtained for other medical reasons NG tube checked by MD & found to be in good position. Nurses found that the new calculation averaged between 1-3cm difference than their current practice. As infant lost weight in first week of life, according to the calculation, the NG tube should be shorter. As infant gained weight over time, we saw about a 200gm difference before the next increment measurement on the NG tube was needed. Small for Gestational Age (SGA) babies, does this calculation work for them?

As infant lost weight in first week of life, according to the calculation, the NG tube should be shorter.

13 Post-Survey results 96% feel comfortable using the weight-based calculation to insert NGT 100% plan to use the new weight-based calculation to insert NGT 93% plan to discontinue NEX method based on the literature review 100% found the literature helpful to make decision to use new calculation to insert NGT

NGT 93% plan to discontinue NEX method based on the literature review 100%

14 Next Steps Re-evaluate NG tube position upon transfer into unit and every Saturday night shift when weekly measurements are done. Maintain initial insertion depth of NG tube even if infant loses weight. Update LPCH NG tube insertion policy Educate all Neonatal units at LPCH of policy change Use this new calculation when teaching parents to insert an NG tube in their baby. Conduct a small pilot study at LPCH testing this weightbased calculation

Update LPCH NG tube insertion policy Educate all Neonatal units at LPCH of policy change Use this new

15 Thank you! The SCN staff at LPCH Dr Ramachandran & Dr Malek-Hanna Alice Mark RN SCN Nurse Manager Linda Ikuta RN Neonatal CNS Annette Nasr RN LPCH Nurse Scientist Sharon Aquino RN, Nannette Santos RN, Edith Aninao RN, Fanny Ni RN SCN data collectors Holly Bernal RN

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