According to Stevens (2013), evidence-based practice can be defined as the process of making use of the explicit and recent evidence base that is available in order to make decisions in the best interest of the patient. The nursing profession widely relies upon making use of the evidence-based practice in order to undertake effective clinical decisions and promote effective patient care (Nursing and Midwifery Council, 2015). It can therefore be said that the evidence base serves as important clinical guidelines that aid the care professionals to render effective patient care. In this regard, it should be mentioned that this paper intends to critically investigate the evidence base in order to identify the best practice for determining the correct placement of the nasogastric tube. In addition to this, the paper would also identify the potential barriers that hinder the implementation of the best evidence-based practice within a healthcare setting. It should also be noted that the paper would propose a set of recommendations that could be applied in order to overcome the potential barriers within the healthcare setting and effectively make use of the best evidence-based practice to promote positive patient outcomes.
A gastrointestinal tube which is also known as feeding tube is used in a condition where the patient is experiencing difficulty in feeding (Baker et al. 2015). In such cases, these tubes are used to deliver the nutrients to the patients. It should be noted here that the gastrointestinal tubes can be different types (Covarrubias et al. 2013). Typically, the enema tube is placed directly in the large intestine. Whereas, certain gastrointestinal tubes are placed in a manner that they deliver the nutrient directly to the small intestine or the stomach. These tubes are also used to deliver medications. Studies identify a number of medical health conditions that could lead to the impairment of the normal feeding and bowel functioning in patients (Metheny and Meert 2014). These conditions primarily include, critical illness, deformities within internal organs, cerebral palsy and other neuromuscular deformities, critical brain injury, digestive disorders and problems within the gastrointestinal tract (Boeykens et al. 2014). In addition to this, facial trauma, jaw deformities due to an accident, cancer and conditions such as oesophageal atresia with tracheoesophageal fistula or macrogastria have also been identified as conditions that lead to impaired feeding and bowel functioning (Goldin et al. 2016).
It should critically be stated that the correct placement of the G-tube is important in order to ensure positive patient outcome. Research reports indicate that despite the wide application of these tubes within the critical care unit to treat medical health conditions, a large number of cases are reported every year where the patients are suffering from fatal outcomes on account of the incorrect placement of the tube (Patient Safety Alert 2016). The incorrect positioning of the tubes could cause risks such as a blockage within the oesophagus or the bronchus of the patient (Goldin et al. 2016; Hucl and Spicak 2016). Furthermore, not noticing the faulty placement could even lead to death. Almost 15% of the in-patient deaths every year are reported because of a fatal medical error caused due to the incorrect placement of the G-tubes (Lohsiriwat 2013). On critically analysing the problem, the lack of correct knowledge about the tube-placement procedure within the care professionals and excessive workload can be attributed to be the major reasons that account for the estimated death rate.
Therefore, this research aims to investigate the electronic databases and retrieve relevant literatures in order to identify the correct placement of the gastrointestinal tubes in order to avoid medical error. Therefore, on the basis of the background information and the problem statement, the systematic review would critically revolve around investigating the best practice for determining the correct placement of the gastrointestinal tube in adult patients. It would also evaluate the risks that are involved with the incorrect placement of the gastrointestinal tube. In addition to this, the systematic review would also identify the potential barriers that hinder the application of the best practice within the healthcare setting.
The research objectives thus formulated from the above research questions can be enlisted as follows: to investigate the best practice for the determination of the correct placement of the gastrointestinal tube, to evaluate the risks involved with the incorrect placement of the gastrointestinal tube and to identify the potential barriers that hinder the application of the identified best practice within the healthcare setting.
The rationale for conducting the research can be mentioned as the need for training care professionals to use the correct method of placing the gastrointestinal tubes in order to avoid the occurrence of fatal medical errors. In addition to this, it would also help in identifying the risk factors involved with the incorrect placement of the G-tubes and accordingly create awareness among the care professionals to make use of the appropriate procedure for the placement of the G-tubes in order to avoid fatal outcomes in patient.
In order to retrieve relevant research papers for the identification of the correct placement procedure of the G-tubes in patients, the PICO framework would be used to formulate the questions that would subsequently facilitate the literature search. According to LoBiondo et al. (2013), while investigating the electronic bases in order to evaluate the best evidence-based practice for a problem, it is pivotal to formulate PICO questions as it helps in saving time and at the same time makes it convenient to identify relevant literary resources. Therefore, in this case, the PICO questions that can be formulated would comprise the following:
||Adult patients aged 18 and above with problems related to feeding and bowel movement
||Application of G-tubes to facilitate supply of nutrients and ease bowel functioning
||Ease in bowel movement and absorption of nutrients supplied
According to Stevens (2013), systematic review has been identified as the best research methodology that can be used in order to identify the best evidence-based practice to address a particular problem. Therefore, an exhaustive systematic review would be conducted in order to identify the correct placement of the gastrointestinal tube. The first step would comprise of using relevant key terms on the electronic databases Google Scholar and CINAHL to identify relevant literatures. The relevant literatures thus retrieved would be segregated on the basis of the specified exclusion and inclusion criteria. Finally, the most appropriate research studies would be considered for the identification of the best placement procedure of the gastrointestinal tubes to promote positive patient outcome.
Click To Connect
The justification for the chosen research study design can be explained as the assessment of the most recent available evidences that address the articulated research questions. Since the central idea of the research paper is to identify the best evidence base that has already been researched. Therefore, systematic review could be considered as the correct research methodology for addressing the research questions.
A through literature search would be conducted across the electronic databases Google Scholar and CINAHL in order to retrieve relevant research papers that match with the mentioned key words. The papers thus retrieved would be scanned on the basis of the specified inclusion and exclusion criteria. The key words used to conduct the search on the electronic databases comprised of the following: Correct placement, Gastrointestinal tubes, correct procedure, risks, medical error, critical care, adults, fatal outcomes.
It should be noted here that the BOOLEAN operators AND/OR were used in combination with the key terms to conduct a search on the electronic databases.
The exclusion criteria comprise of the characteristics that are used in order to exclude relevant research studies so as to narrow down the retrieved literatures and consider the most relevant research studies (LoBiondo et al. 2013). The exclusion criteria used for this research study comprised the following: papers that were published before the year 2013, papers that included animal trials, papers that were published in foreign languages other than English and papers that considered the target population as adult.
The inclusion criteria, on the other hand comprises of the characteristics that are used to include the retrieved research papers in the research study (Stevens et al. 2013). The inclusion criteria in this case comprised the following characteristics: papers that were published in between the year 2013-2017, papers that were published in English Language, papers that included the target audience as adults and senior adults
Therefore, a number of research papers were identified based on the exclusion and inclusion criteria. The findings of the research papers would be critically discussed in this section. According to Hannah and John (2013), patients that lack a functioning gastrointestinal tract require an alternative intervention in order to derive nutrition. In accordance to the recommended patient safety guideline, the use of feeding tube (G-tube) could help in providing nutrition to the patients who encounter problems with the oral administration of bolus (Patient Safety Alert 2016). The laparoscopic as well as the PEG method are the most prevalent methods that are used to treat patients (Tiancha et al. 2015). As stated by Lohrisiriwat (2013), the laparoscopic method requires general anaesthesia followed by the insertion of a 10mm port below the umbilicus under direct vision. The next step involves the creation of a pneumoperitoneum with a CO2 pressure of 5-10mmHg. The table is then tilted to 20 degrees in the head-upright position and a 10mm port is then introduced to the gastric wall under direct vision. The gastric wall is subsequently grasped with a toothed grasper and deflating the abdomen is brought through the port site. The gastric wall is then held with two babcocks and two (2-0) vicryl purse strings are then inserted to form a gastronomy within the centre using the blade numbered 11 (Merli et al. 2016; Cole 2015). The orifice is then widened using the artery clip and the feeding tube is inserted. The balloon of the feeding tube is then positioned at the back of the purse string and the stomach is secured with the suture to the abdominal wall. The correct positioning of the tube and bleeding is checked with the recreation of the Pneumoperitoneum (Hermanowicz et al. 2013; Wiegand 2013).
As stated by Hannah and John (2013) the laparoscopic method of insertion has been identified as a safer method with lower mortality rates and better visibility of the placement site while performing the procedure. As argued by Milsom et al. (2015), the best procedure for the placement of G-tube in patients was to first conduct an ultrasound followed by external magnetic guidance to be subsequently followed by capnometry. As mentioned by Bear et al. (2016), the three important characteristics that make the technique ideal for the correct placement of the tube include, effective cost, huge success rate and global applicability. The researchers typically conducted an exhaustive systematic review in order to identify the best procedure for the placement of G-tubes. The findings indicated that the electromagnetic placement of the tube yielded positive outcome. Another study conducted by Powers et al. (2013), mentioned that the use of electromagnetically guided placement device could positively help in the correct placement of the G-tube in patients. This technique has been mentioned to reduce radiographic exposure (Velázquez‐Aviña et al. 2015; Metheny and Meert 2014). The findings of the research study suggested that the duodenum or the jejunum placement was achieved by the care professionals with the use of the electromagnetically guided placement device with 97.2% accuracy (Powers et al. 2013). Further, studies also indicated that the use of the device significantly lowered the prevalence of any incorrect placement or adverse events (Metheny and Meert 2014; Bourgault et al. 2017). Studies also indicated that the measurement of the gastric pH and auscultation technique could help in determining the correct placement of the gastrointestinal tube (Baker et al. 2015; Boeykens et al. 2014; Schimidt et al. 2014). As mentioned by Covarrubias et al. (2013) and Amorosa et al. (2013), the radiologic method has been identified as the least invasive method with lower morbidity and mortality rate and with cost effectiveness that could be used to place the G-tubes. However, the method has been reported to be unfavourable for patients with abnormal stomach anatomy (Triantafyllou et al. 2014).
Therefore, the retrieved literatures were critically reviewed and then appraised with the help of CASP critical appraisal tool in order to identify the best placement procedure of the G-tubes in adult for positive patient outcome.
The research study conducted by Wang et al. (2013), clearly focused on conducting a research to investigate the best procedure for the placement of G-tubes in patients. The researchers had considered the case of critically ill patients who present severely impaired gastric functioning. The researchers essentially made use of the electromagnetically guided placement of the G-tube within the patients. Further, the important parameters were considered, and the target population comprised of 142 critically ill patients. The research outcomes were clearly addressed, and the study significantly pointed out the risks, benefits and complications related to the placement of the tube in critically ill patients. It can thus be mentioned, that the precise results of the study stated that care professionals could successfully place 135 tubes in the first attempt within a time period of 20.12 minute. The placement of the tip was confirmed with an X-ray. The sample size considered by the researchers was significant and therefore the results can be generalised. Also, the important findings can be correlated to the clinical nutrition guidelines in elderly patients (McClave et al. 2016). It can be said that the correct knowledge about the electromagnetically guided placement procedure of enteral tubes in health care professionals can help in avoiding risks and complications in adult. Another study conducted by Boeykens et al. (2014) focused on researching about the correct confirmatory test that would help in getting an accurate idea about the placement of the gastric tube in patients. The researchers conducted a large prospective observational study and compared the auscultatory method with the pH measurement method followed by comparing the results with the gold standard (conducting a X-ray) to detect the positioning of the Gastric tube. The sample size considered in this research comprised of testing the positioning of 331 tubes in adult patients. All-important parameters and confounding factors were taken into consideration. The outcome was appropriately addressed. The overall result of the research study indicated that a pH of <5.5 from tube aspirate could help in checking the positioning of tube in the stomach. Precisely, the results indicated that the auscultatory method to check the positioning was incorrect. Thus, it can be said that the results can be generalised, and the outcomes were appropriately covered. The findings are reliable and can be implied to nursing practice. The pH measurement after placement could help in determining the correct positioning of the G-tube.
Another study conducted by Milsom et al. (2015) focused on conducting an exhaustive systematic review in order to access the best method for the positioning of the gastrointestinal tube in adult patients. The researchers performed a systematic review and included 76 articles. Hence, it can be said that the results and findings can be generalised. Also, it can be said that all important and confounding factors were not taken into consideration by the researchers. The overall results can be summarized as the use of ultrasound, external electromagnetic guidance followed by capnography can help in the effective placement of the gastrointestinal tube in patients. It can also be mentioned that the best method accessed by the group of researchers essentially met the primary criteria of cost effectiveness, global application and huge success rate. The limitation of the study can be mentioned as the primary focus of the study on the selection of the best method from a wide category of methods. The study does not discuss any possible risks or complications that could occur due to the failure of the technique.
The research study conducted by Powers et al. (2013) focused on the use of an electromagnetic guided device in order to ensure the correct placement of the gastrointestinal tube. The research study considered a sample size of 632 patients. All important and confounding factors were taken into consideration by the patients and the overall results stated that Electromagnetically guided placement devise helped in accurate placement of Gastrointestinal tubes. Also, the findings predicted that Electromagnetically guided placement device could ensure 97.2% efficacy in the placement of the G-tube without radiographic confirmation. The results can therefore be generalized n account of the success rate and the large sample size. Also, the findings of the study are relevant and can be implied to future nursing practice. The use of EMPD technology could guide care professionals to place the gastric tubes appropriately without the need of a confirmatory radiography.
The study conducted by Rahnemai et al. (2014) focused on evaluating the outcome of the patients who had undergone a PEG placement. The researchers conducted a review that included case histories of patients who had undergone PEG placement to evaluate the long-term complication or adverse effect. All-important parameters were considered, and outcomes were appropriately addressed. The overall results stated that PEG placement was directly associated with three important categories that included endoscopic technical difficulties, PEG procedure related complications and PEG tube use and wound. Precisely it can be mentioned that patients who underwent PEG placement were exposed to long term high risk of morbidity related to tube placement. The results can thus be generalized, and all-important outcomes were considered in the research. The findings are reliable and can be implied into future practice. PEG related complication might manifest after many years of placement and research studies accessing risk factors associated with PEG associated complications could help promote positive outcome.
Therefore, on the basis of the findings it can be said that the most appropriate method for the correct placement of the Gastrointestinal tube would be to make use of the electromagnetically guided placement device (Metheny and Meert 2014; Powers et al. 2013). Also, the laparoscopic insertion method was identified to be safe and effective (Hermanowicz et al. 2013). However, the implementation of the techniques to practice is laden with a number of problems such as involvement of higher cost, lack of appropriate training or skills to perform the procedure and negative attitude of professionals to readily accept a change. In addition to this, the lack of monitoring tools to determine the effectiveness of the care professionals in performing the procedure can also be counted as one of the major reasons that serve as an obstacle in the implementation process. Also, lack of quality assessment and monitoring tool to check safe equipment supply can be considered as one of the causes that serve as a barrier in the implementation process (Nursing and Midwifery Council 2015). Therefore, hand on workshops can be organized within the healthcare organization to educate professionals about the use of the correct placement procedure.
Therefore, to conclude, it can be mentioned that the use of electromagnetic guided placement device could help in accurate positioning of the G-tubes in patient. Also, the PEG method of placement was identified to lead to complications in a study that considered a review of the cases that reported complications after PEG placement. Also, the laparoscopic method of placement was identified to be a safe technique and the confirmatory test for the detection of correct placement was identified to be the pH test of the aspirate. The radiography confirmation test was also found to be effective. Therefore, the implementation of the best evidence-based practice along with quality innovation and continuous monitoring by the administrative department can help in reinforcing positive implementation to acquire positive patient outcome.
Amorosa, J.K., Bramwit, M.P., Mohammed, T.L.H., Reddy, G.P., Brown, K., Dyer, D.S., Ginsburg, M.E., Heitkamp, D.E., Jeudy, J., Kirsch, J. and MacMahon, H., 2013. ACR appropriateness criteria routine chest radiographs in intensive care unit patients. Journal of the American College of Radiology, 10(3), pp.170-174.
Baker, L., Beres, A.L. and Baird, R., 2015. A systematic review and meta-analysis of gastrostomy insertion techniques in children. Journal of pediatric surgery, 50(5), pp.718-725.
Bear, D.E., Champion, A., Lei, K., Smith, J., Beale, R., Camporota, L. and Barrett, N.A., 2016. Use of an electromagnetic device compared with chest X-ray to confirm nasogastric feeding tube position in critical care. Journal of Parenteral and Enteral Nutrition, 40(4), pp.581-586.
Boeykens, K., Steeman, E. and Duysburgh, I., 2014. Reliability of pH measurement and the auscultatory method to confirm the position of a nasogastric tube. International journal of nursing studies, 51(11), pp.1427-1433.
Bourgault, A.M., Aguirre, L. and Ibrahim, J., 2017. Cortrak-assisted feeding tube insertion: a comprehensive review of adverse events in the MAUDE database. American Journal of Critical Care, 26(2), pp.149-156.
Cole, E., 2015. Improving the documentation of nasogastric tube insertion and adherence to local enteral nutrition guidelines. BMJ Open Quality, 4(1), pp.u203207-w1513.
Covarrubias, D.A., O'Connor, O.J., McDermott, S. and Arellano, R.S., 2013. Radiologic percutaneous gastrostomy: review of potential complications and approach to managing the unexpected outcome. American Journal of Roentgenology, 200(4), pp.921-931.
Frerk, C., Mitchell, V.S., McNarry, A.F., Mendonca, C., Bhagrath, R., Patel, A., O'sullivan, E.P., Woodall, N.M. and Ahmad, I., 2015. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. BJA: British Journal of Anaesthesia, 115(6), pp.827-848.
Goldin, A.B., Heiss, K.F., Hall, M., Rothstein, D.H., Minneci, P.C., Blakely, M.L., Browne, M., Raval, M.V., Shah, S.S., Rangel, S.J. and Snyder, C.L., 2016. Emergency department visits and readmissions among children after gastrostomy tube placement. The Journal of pediatrics, 174, pp.139-145.
Hannah, E. and John, R.M., 2013. Everything the nurse practitioner should know about pediatric feeding tubes. Journal of the American Association of Nurse Practitioners, 25(11), pp.567-577.
Hermanowicz, A., Matuszczak, E., Komarowska, M., Jarocka-Cyrta, E., Wojnar, J., Debek, W., Matysiak, K. and Klek, S., 2013. Laparoscopy-assisted percutaneous endoscopic gastrostomy enables enteral nutrition even in patients with distorted anatomy. World Journal of Gastroenterology:WJG, 19(43), p.7696.
https://improvement.nhs.uk/documents/194/Patient_Safety_Alert_Stage_2_-_NG_tube_resource_set.pdf [Accessed 12 February 2019].
Hucl, T. and Spicak, J., 2016. Complications of percutaneous endoscopic gastrostomy. Best Practice & Research Clinical Gastroenterology, 30(5), pp.769-781.
LoBiondo-Wood, G., Haber, J., Berry, C. and Yost, J., 2013. Study Guide for Nursing Research-E-Book: Methods and Critical Appraisal for Evidence-Based Practice. Elsevier Health Sciences.
Lohsiriwat, V., 2013. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?. World journal of gastrointestinal endoscopy, 5(1), p.14.
Lohsiriwat, V., 2013. Percutaneous endoscopic gastrostomy tube replacement: A simple procedure?. World journal of gastrointestinal endoscopy, 5(1), p.14.
McClave, S.A., DiBaise, J.K., Mullin, G.E. and Martindale, R.G., 2016. ACG clinical guideline: nutrition therapy in the adult hospitalized patient. The American journal of gastroenterology, 111(3), p.315.
McSweeney, M.E., Jiang, H., Deutsch, A.J., Atmadja, M. and Lightdale, J.R., 2013. Long-term outcomes of infants and children undergoing percutaneous endoscopy gastrostomy tube placement. Journal of pediatric gastroenterology and nutrition, 57(5), pp.663-667.
Merli, L., De Marco, E.A., Fedele, C., Mason, E.J., Taddei, A., Paradiso, F.V., Catania, V.D. and Nanni, L., 2016. Gastrostomy placement in children: percutaneous endoscopic gastrostomy or laparoscopic gastrostomy?. Surgical laparoscopy, endoscopy & percutaneous techniques, 26(5), p.381.
Metheny, N.A. and Meert, K.L., 2014. Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. American Journal of Critical Care, 23(3), pp.240-248.
Morrison, R.J., Hollister, S.J., Niedner, M.F., Mahani, M.G., Park, A.H., Mehta, D.K., Ohye, R.G. and Green, G.E., 2015. Mitigation of tracheobronchomalacia with 3D-printed personalized medical devices in pediatric patients. Science translational medicine, 7(285), pp.285ra64-285ra64.
Nursing and Midwifery Council 2015. The Code-Standards of Conduct, Performance and Ethics for Nurses and Midwives: London: NMC.
Patient Safety Alert 2016. PSA from NHS Improvement: Nasogastric tube misplacement, continued risk of death and severe harm.[Online] Available from: https://improvement.nhs.uk/documents/194/Patient_Safety_Alert_Stage_2_-_NG_tube_resource_set.pdf [Accessed 12 February 2019]
Powers, J., Fischer, M.H., Ziemba-Davis, M., Brown, J. and Phillips, D.M., 2013. Elimination of radiographic confirmation for small-bowel feeding tubes in critical care. American Journal of Critical Care, 22(6), pp.521-527.
Rahnemai-Azar, A.A., Rahnemaiazar, A.A., Naghshizadian, R., Kurtz, A. and Farkas, D.T., 2014. Percutaneous endoscopic gastrostomy: indications, technique, complications and management. World Journal of Gastroenterology: WJG, 20(24), p.7739.
Schmidt, A.R., Buehler, P., Seglias, L., Stark, T., Brotschi, B., Renner, T., Sabandal, C., Klaghofer, R., Weiss, M. and Schmitz, A., 2014. Gastric pH and residual volume after 1 and 2 h fasting time for clear fluids in children. British Journal of Anaesthesia, 114(3), pp.477-482.
Stevens, K., 2013. The impact of evidence-based practice in nursing and the next big ideas. OJIN:The Online Journal of Issues in Nursing, 18(2), p.4.
Tiancha, H., Jiyong, J. and Min, Y., 2015. How to promote bedside placement of the postpyloric feeding tube: a network meta-analysis of randomized controlled trials. Journal of Parenteral and Enteral Nutrition, 39(5), pp.521-530.
Triantafyllou, K., Papanikolaou, I.S., Stasinos, I., Polymeros, D. and Dimitriadis, G.D., 2014. Percutaneous endoscopic gastrostomy tube replacement unexpected serious events. Nutrition in Clinical Practice, 29(1), pp.142-145.
Velázquez‐Aviña, J., Beyer, R., Díaz‐Tobar, C.P., Peter, S., Kyanam Kabir Baig, K.R., Wilcox, C.M. and Mönkemüller, K., 2015. New method of direct percutaneous endoscopic jejunostomy tube placement using balloon‐assisted enteroscopy with fluoroscopy. Digestive Endoscopy, 27(3), pp.317-322.
Wang, X., Zhang, L., Wu, C., Li, N. and Li, J., 2014. The application of electromagnetically guided post-pyloric feeding tube placement in critically ill patients. Journal of Investigative Surgery, 27(1), pp.21-26.
Wiegand, D.L. ed., 2013. AACN Procedure Manual for Critical Care-E-Book. Elsevier Health Sciences.
Hire An Expert