PEG insertions at Royal Surrey County Hospital (RSCH): Audit of mortality

Abstract

2011 2. Although individual hospitals conduct local audit of practice in this area, sharing experience can improve performance. The Northern Nutrition Network is a multidisciplinary group of healthcare professionals in the North East of England, who meet regularly to discuss and share best practice in nutritional care. Collaboration between members of this group enable large, multicentre studies to be conducted. This audit aimed to assess current practice in NGT insertion across the region with reference to NPSA guidance. Eleven out of 14 acute sector hospitals in the North East of England took part in the study, conducted prospectively between March and June 2013. Hospitals were asked to collect data on 20 consecutive NGT insertions during this period. Data were collected using a standardised proforma and included patient age, gender, time of insertion, rationale for NGT feeding, consent, confirmation of tube placement, pH testing and X-ray requests. Subsequent NGT use or removal was recorded. The audit standard was 100% compliance with NPSA guidance. Data on 215 NGT placements were collected; 102 (47.4%) males, mean age of patient 71.9 years (SD +/-13.1 years). In 191 (88.8%) of cases, written documentation provided a rationale for NGT feeding. Documentation confirming consent existed in only 82 (38.1%) cases. There was significant variability between hospitals in documentation of rationale for feeding (P¼0.001), but not documentation of consent (P¼0.066). In 36 (16.7%) cases NGT insertion took place following a 'best interests' decision. 140 (65.1%) of insertions took place 'in hours' (between 0800 and 1700 hrs), 50 (23.3%) took place 'out of hours' and time was not known in 25 (11.6%) cases. Of the 50 patients who had NGTs inserted 'out of hours', only 8 had a documented reason why the tube was placed at that time. There was significant variability between hospitals in timing of NGT placement (P¼0.001). 115 (53.5%) of tubes were placed by doctors; the remainder placed by nurses. Aspiration of the NGT for pH testing was attempted in only 153 (71.2%) of cases as the first line method to confirm placement. Where aspiration was attempted, an aspirate was obtained in 86 (56%) cases, of which pH was less than 5.5 in 67 cases. The positions of 31.2% of NGTs placed were confirmed by pH testing alone. Despite this, 17 (25%) of these patients went on to have an unnecessary chest x-ray (CXR) performed. In total, CXRs were requested in 164 (76.3%) cases. 40.5% of xrays performed were done 'out of hours'. Written confirmation that a CXR had been checked was documented in 80.3% of cases, and, accompanied by a supporting statement confirming correct NGT position in only 53.6% of cases. 29 (13.5%) of NGTs were removed prior to feed commencing (17 by the patient, 4 due to identified tube misplacement and 8 no reason offered). There were no 'never events' identified. Despite clear NPSA guidance, steps to reduce the harm of misplaced NGTs are not consistently applied. Results have been shared amongst the network and areas for i...