NG insertion Doctors VS nurses

[BendyEm]

I'll start by saying I'm UK based, as I've noticed most here are US based.

I've been working in my Crit Care area for nearly 6months. We have consistent issues with getting medical cover, and, due to training changes, a lot of the junior doctors we have don't know how to place Art or Central lines (kind of important, ya'know!). So I've become used to treating blind for a few hours until an art-line is in place, lots of real close monitoring and quick responding.

What I'm not used to is a patient waiting 16hrs to get an NG inserted after one came out overnight. I get that overnight on a Saturday, an NG that just finished a feed isn't a high priority. I understand that, even though the night doctor promised he would do it, he passed it onto the day team. I even understand that they said they would wait until the patient had been reviewed on ward round.

What I don't understand is why that patient missed 3 medication rounds and the start of an increasing feed regime because the doctor was busy.

The main reason this annoys me is that I can insert NGs. The Trust I worked at before didn't require a doctor to sign off, and if the pH of the aspirate was suitable and there were no adverse symptoms with a small amount of water, this could be used.

I agree, that's not best practise, and a chest X-ray is much better, but surely I should be able to site the gosh-darn thing, so all the doctor has to do is (remotely, if necessary) order and review the chest X-ray .

Who sites NGs where you work? What training do you require if you site them? And how is the NG confirmed as correctly sited?

I'd like to see if my first Trust was a one off, or if I would be justified in requesting the training from my ward educator.

[Newbie_RN17]

Where I work nurses do NGs and protocol says to order a chest xray for placement after it is in. We learned in school how to do it and the first time I did was under the direction of a more senior nurse.

[Nalon1 RN/EMT-P, BSN, RN]

Never seen a MD insert an NG tube (well, I have at teaching hospitals with residents). It is nurses that do it where I am. ED techs used to be able to if they had been trained, but no longer allowed.

MD places the order, the nurse inserts it. No feedings or medications are allowed till x-ray confirmation, but auscultation and aspiration are enough to start low intermittent suction if needed.

Reinsertion if pt removed it/pulled out accidentaly does not require a new order, the nurse just inserts a new one. If on feedings, the nurse can order the x-ray to be able to restart the feedings.

[calivianya, BSN, RN]

I've never seen a MD put an NG/OG in, either.

For that matter, we just ordered a device so we can drop post-pyloric feeding tubes, too, and confirm them at bedside. Formerly, only MDs could place post-pyloric tubes.

[BendyEm]

Glad it's not just me then! I feel much safer using the NGs here, with them being checked with x-ray. But I'd still like to be able to site them myself rather than rely on patchy medical cover.

Having spoken to the ward educator, I'd have to do a training package, then site X number of NGs under supervision. But, seeing as none of the other nurses have done the training...who's going to supervise me? If the doctors don't have time to site an NG, how are they going to have time to watch me do it?

It's just frustating, I feel like I'm providing sub-standard care to my patients when I know I have the ability to do more.

[Julius Seizure]

I worked at one hospital (a major teaching hospital in Michigan) that only allowed MDs to place feeding tubes including both NG and ND ones.

I thought it was silly. Everywhere else that I have worked, the nurses place them (NG and ND), with placement checked by x-ray.

There were a few other strange limitations on nurse practice at that hospital. I always wondered what happened if a nurse who had only worked there for their entire career went to work someplace else...and they couldn't do several basic skills because no one had ever allowed them to before.

[Kitiger, RN]

When an NG or OG comes out at home, we just reinsert it. Sometimes, with an active kid, they get pulled out every other day. Or more often. After inserting, we push air and auscultate for the "whoosh". PH can also be checked, but that is not usually ordered. We also check placement before giving meds or feedings.

[APRN., DNP, RN, APRN, NP]

Here on the Western side of the US, the only time I've ever noted that a physician inserted an NGT or an OGT, is if it was placed during surgery.

It is within the nursing scope of practice to insert and remove NG/OGT.

EBP supports confirming placement via CXR, and daily placement checks by pH monitoring.

[irishicugal]

Hey bendyem, I'm in ireland, so fairly similar to uk scope afaik...

Have you got anaesthetists/intensivists on call at night? That's who would put in our arts, cvcs and ngs at night. Fine bore feeding tubes are put in by the dietician during the day, or nurses who've attended a course (1 day course and then signed off by the dietician) and anaesthetists. That's if they're intubated that is, if they're awake any nurse can do it. Ryles are only put in by the anaesthetists if they are tubed...

As for checking placement, my particular hospital uses ph testing before every feed or med round, but the majority of places still use cxr's.

[BendyEm]

Hey bendyem, I'm in ireland, so fairly similar to uk scope afaik...

Have you got anaesthetists/intensivists on call at night? That's who would put in our arts, cvcs and ngs at night. Fine bore feeding tubes are put in by the dietician during the day, or nurses who've attended a course (1 day course and then signed off by the dietician) and anaesthetists. That's if they're intubated that is, if they're awake any nurse can do it. Ryles are only put in by the anaesthetists if they are tubed...

As for checking placement, my particular hospital uses ph testing before every feed or med round, but the majority of places still use cxr's.

AICU have 24hr medical cover, as we (MHDU) are meant to have. But the doctors we have are also covering at least 3 other wards, and again, aren't necessarily art/central line trained. Because, theoretically, we are "covered" ICU or anaesthetics will only help/get involved if the patient is unwell enough to be an AICU potential.

Dietitians don't site NGs with us, though we have a dietitian nurse who helps with PEGs and RIGs, and I'm sure she could site NGs, but again, not a priority and covers the whole hospital.

All my patients are awake, (unless sedated for an acute situation e.g. agitation, aggression, or prior to invasive ventilation and an AICU transfer.) It's why I prefer level 2 over level 3 Crit patients, they can (mostly) actually talk back to you!

[OyWithThePoodles, RN]

Never seen a MD insert an NG tube (well, I have at teaching hospitals with residents). It is nurses that do it where I am. ED techs used to be able to if they had been trained, but no longer allowed.

MD places the order, the nurse inserts it. No feedings or medications are allowed till x-ray confirmation, but auscultation and aspiration are enough to start low intermittent suction if needed.

Reinsertion if pt removed it/pulled out accidentaly does not require a new order, the nurse just inserts a new one. If on feedings, the nurse can order the x-ray to be able to restart the feedings.

Agree. But our docs will place one if we have attempted several times with no success. I find that the docs can be much rougher though.

[DowntheRiver]

I'm sure the NHS crisis and nursing shortage is not being very helpful. I just read an article dated from December 2015 that stated 90% of hospitals in England had short staffing. Is it that bad?