The alternatives: in defence

of naso-gastric tubes

Tracy Earley

Consultant Nurse

Lancashire Teaching Hospitals NHS Foundation Trust.

NGT’s Friend Or Foe?

Indications for NGT Feeding

For short to medium term feeding

Decreased appetite

Inability to feed

Gastro-intestinal disease

Increased nutritional requirements

When PEG cannot be placed safely

Positive Aspects of NGT’s Inexpensive

Low risk of complications

Can be used as a supplement to oral intake or to provide complete

nutritional requirements

Nasogastric tube insertion is a relatively simple and safe procedure

Contraindications

Absolute and Relative Recent Nasal surgery or mid face trauma

Fractured base of skull

Oesophageal disease

– Varices

– Carcinomas

– Pouches

Nasal Tumours

Nasal septum deviation

Congenital abnormalities to the nose

Severe gastric reflux or vomiting

Negative Aspects of NGT’s

Negative Aspects of NGT’s

Short to medium term usage only

Can be displaced

Can be prone to blockage

Very Obvious

Requires testing to confirm position each

day prior to usage

Resource

Implications for NGT’s

Time consuming to replace

Difficult to keep secured in some patients

Night time displacement a problem often !

Traumatic to replace for patients (and staff

sometimes !)

Successful NGT placement is

an achievement which both

patients and staff are relieved

and elated by

Now we just need to ensure it doesn't come out !!!!!!!

What are the Options?

Short term – NGT

Short term / Medium term + Community – NGT / PEG

Medium to Long term + Community – PEG

PEG is usually always preferable, however – these options may not always be possible or practical

Why PEG may

not be Possible Patient Choice

Severe contractures

Gastric surgery

Short life expectancy (and patient choice to

continue feeding)

The alternative

LTHTR model :

Offer Nasal Bridle to secure NGT in displaced tubes or short – medium term patients in community.

Training for nursing homes to re-pass their own tubes

Rapid access nutrition nursing service service mon - fri

Nasal Bridle

What is it?

It utilises magnets to

connect 2-introducer

rods behind the nasal

septum and a piece of

surgical tape to be

“pulled through”.

This tape is then

secured to the feeding

tube.

Introduction

1st described in 19801

Safe & effective2,3

Traditional uses

– Head & neck malignancy

– Critical care

– Paediatric intensive care

1. McGuirt WF, Strout JJ, „Securing of Intermediate Duration Feeding Tubes‟ Laryngoscope 1980; 90: 2046-48.

2.Levenson R, Dyson A, Turner W, „Feeding tube anchor‟ Nutr Support Serv 1985; 5: 40-42.

3.Barrocas A, Jastram C, St Romain C, „The Bridle: increasing the use of nasoenteric feeding‟ Nutr Support Serv 1982; 2: 8-10.

Patient Review

with Nasal Bridle If In- Patient – Review within two weeks of

commencing feed to assess. PEG if appropriate

If discharged with NGT / Bridle then Review by

HEF dietitian in three months to assess if enteral

route still required

Return to Rapid access clinic for replacement of

NGT / Bridle as needed.

Continued regular review.

Benefits of NGT

and Nasal Bridle

Increased security of NGT

Increased Comfort for Patients with NGT

Able to enterally feed those patients who

require short term feeding without having to

resort to PEG.

Able to enterally feed a large population

who cannot have PEG placed.

NGT replacement

in Community Targeted replacement in some nursing homes, but

not yet nasal bridle

Support from nutrition nursing team

Initial trainee in nursing home selected and then

competency assessed by Nutrition nurses

They then become cascade trainers

Rapid access nutrition nursing service mon – fri

for advice and support

Rapid Access

Nutrition Nursing

Service

Based at Royal Preston Hospital site.

Open week days except bank holidays

Dedicated telephone helpline.

Service Now:

Runs days mornings (sessions) per week based in Endoscopy

Six slots per session (follow up / day case / new patient)

Widened access gates – existing patients with enteral / Parenteral

feeding devices problems are referred via GP’s, District Nurses,

patients, carer’s.

New referrals for assessment of patient’s suitability for feeding

device, for paediatrics undergoing transition, or patients new to the

area.

Central telephone number for all referrals.

Nurse led with wide skill set for assessing and treating patients

Templated on Trust system so financial revenue as a result

Protocols accepted by Trust for band 6 and 7 nutrition nurses

Nurse led discharge

Clinic letter given to patient / carer at the end of appointment

Formal letters out to GP within 5 days

Benefits

See > 500 patient episodes annually

Patients seen by clinical specialists equipped to

trouble shoot / replace their devices.

Discharge >98% patients home the same day.

Avoids hospital admissions

Relieves pressure on IP / OP services

Liaise directly with other colleagues should the

need arise.

Summary

Where possible in medium – long term

patients who require enteral feeding place a

PEG.

However, NGT feeding in short to medium

term needs NGT with Nasal Bridle can be

successful with targeted training for

community colleagues AND support of

local hospital for trouble shooting.