# Placement and Confirmation of Nasogastric Tubes: An Audit of Clinical Practices at a Pakistani Tertiary Care Hospital

## TL;DR

This study shows that using X-rays and training staff improves NG tube safety and reduces pneumonia in a Pakistani hospital.

## Contribution

Demonstrates the effectiveness of X-ray confirmation and staff training in reducing aspiration pneumonia from NG tubes in a clinical setting.

## Key findings

- Aspiration pneumonia rates dropped from 88.46% to 5% after implementing X-ray confirmation and training.
- Whoosh test and X-ray usage increased significantly across data collection cycles.
- pH indicator testing was not used at all during the audit period.

## Abstract

Background

The widespread and diverse use of nasogastric (NG) tubes healthcare setting and the complications, like aspiration pneumonia that surround its placement call for detailed review of the underlying causes. The shortcomings that lie in the tube placement, securement, maintenance and follow-up are other important factors requiring addressal.

Objective

To evaluate adherence to NG tube placement protocols (confirmation via X-ray/whoosh test) and their impact on aspiration pneumonia rates.

Methodology

We conducted a prospective, clinical audit between June 2024 and July 2024 in the Medical Unit of Lahore General Hospital, Lahore. Patients above 18 years of age with the indication of nasogastric intubation were included. After implementation of the evidence-based protocols, data was collected in three cycles: Cycle 1, Cycle 2 and Cycle 3. Training workshops elaborating the correct tube placement, confirmatory tests and the follow-up care were conducted vigorously at various stages of the cycle to identify whether improvement in patient outcomes occurred or not. Google Forms (Google Inc., Mountain View, CA, USA) and SPSS version 24 (IBM Corp., Armonk, NY, USA) were utilized for data collection and analysis, respectively.

Results

The audit which spanned from 1st June, 2024 till 31st July, 2024 had three cycles of data collection. Each cycle was conducted for 10 days in two months. Pre-implementation phase included 60 patients, followed by 65,80,101 patients in Cycles 1, 2 and 3 respectively. During the first data collection cycle, whoosh test was performed in 50 patients (77%) and chest X-rays were performed on 60% (39 patients) for confirmation. The incidence of aspiration pneumonia dropped from 88.46% (46 patients) in the pre-implementation phase to 54%(n=27) by the end of first cycle. In the second cycle, chest X-rays were performed in 61 (76.25%) NG tube patients, while whoosh test was utilized in 72 patients (90%). The incidence of aspiration pneumonia further decreased, affecting 20.83% of the NG tube patients. By the third cycle, chest X-rays were taken of 96.03% (97 patients) and whoosh test was employed in 101 patients (100%). The incidence of aspiration pneumonia was significantly reduced to 5% among those with NG tube insertion. pH indicator testing was not performed in any patient (0%, 0 patients) in all the cycles of the data collection.

Conclusion

The utilization of chest X-rays in confirming nasogastric tube placement and the staff training and education regarding nasogastric tube maintenance and follow-up care can contribute significantly to lowering the incidence of aspiration pneumonia. Staff training and education regarding the best medical practices for tube insertion, securement and follow-up care is of paramount importance, emphasizing an adoption of a well-rounded approach to reduce the complications related to nasogastric tube placement.