Reducing inappropriate oral nutritional supplement prescribing to fund community dietetic support

Abstract

(1,2) of cases of serious harm and death as a result of feeding into the lung through misplaced nasogastric feeding tubes (NGT). In 2005, the NPSA provided guidance on the methods that should be used for confirming NGT position; pH testing gastric aspirates is recommended as the first line method followed by radiography (1). Since the alert was issued, further deaths and cases of serious harm due to feeding through misplaced NGT have been reported with the main causal factor being misinterpretation of x-rays (2). A local service improvement project was established using a Plan Do Study Act (PDSA) cycle to investigate current practice; assess compliance with NPSA guidance; make recommendations to improve practice and investigate the cost of radiography for checking the position of NGTs. The project's benefits link closely to the current need to deliver safe, high value and cost-effective patient care. A bedside documentation chart, including an NPSA compliant algorithm, was co-designed by a multi-professional team and nursing staff were trained to complete the chart using ward based training sessions. An audit tool was developed to assess compliance with NPSA recommendations and NGT insertion across the hospital was audited over a three month period. The results were collated and analysed by one individual. Patients in intensive care were excluded from the study. The study showed a >90% compliance with: Documentation of the rationale for NGT placement X-ray interpretation with instructions for action Use of NPSA compliant pH indicator paper, and Documentation of pH results on the bedside chart. However, there continue to be areas of concern in particular with NGT feeding being initiated without confirmation of position by either method. Aspirate checks were not carried out pre-feeding in 40% of patients and pre-medication administration in 83% of patients. 58% of x-rays were inappropriately requested. The combination of introducing a new bedside documentation chart and training staff about using pH testing appropriately demonstrated an 8 fold reduction in the number of radiological assessments requested post NGT insertion. The study demonstrated a reduction in radiology costs equivalent to almost £1,000 per month. Our study demonstrates the ongoing challenge of correct placement of NGT and risks to patient safety. However, we have demonstrated that by using a simple service improvement technique you can improve clinical practice, reduce costs and deliver safer patient care.