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.
I'm stunned that a first-world country would mandate that OG/NG tubes be physician-level skill or require special training and supervised sign-off. They're pretty hard to screw up.
Venipuncture, arterial sticks, indwelling urinary catheters are riskier procedures than dropping a gastric tube through the esophagus.
I'm stunned that a first-world country would mandate that OG/NG tubes be physician-level skill or require special training and supervised sign-off. They're pretty hard to screw up.
Venipuncture, arterial sticks, indwelling urinary catheters are riskier procedures than dropping a gastric tube through the esophagus.
Lol, I know! When I trained back in the dark ages, we were allowed to put in both fine bore feeding tubes and ryles but not any more. I've no idea why this changed or even when! Also, nurses here aren't allowed to do arterial sticks, you don't do venepuncture until AFTER you've qualified and done an extra days training, and we also have to do extra training for male catheterisation! Backwards country is Ireland lol...
Wow, I guess. Odd that male caths require additional training when female caths are demonstrably more difficult to perform in a strict, sterile fashion.
I've never seen an MD place an NGT. The Anesthesiologist probably places the ones placed during surgeries but routine NG placements are always done by nurses. Standard of care when I worked in the hospital was to aspirate and check pH. If pH was 5 or we couldn't aspirate stomach contents, an XR was necessary. Those were read 24/7. Technically, the covering Resident had to look at the XR and write an "ok to use NGT" order but, honestly, if the XR had been read and the Radiologist noted tip in the stomach and I needed to use it, I'd use it based on that.
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.
I'd say.....the kid would be at the hospital more than home if that were the case. Especially the babies, they seem to know just how to hook that little finger and yank..... To add, we also reinsert Mickey (Gtubes).....the only ones that require a trip to a radiologist is the G/J or J tubes..
I find it surprising you do not have the authority to insert NG tubes. If my patient could not received their medication.. because a doctor did get around to inserting a tube.... that doctor would be written up to high heaven.
Our surgeons will drop an NG if needed, but I've never had another MD do it, for any reason. I did see a doc entering my pt's room carrying an NG set up, I peeked in and asked "what'cha doing?" thinking maybe he was planning on doing it himself. He replied "Getting everything ready for YOU to drop and NG" and smiled real sweet like...
We don't confirm salem sump placement with X-ray, just air and aspirate. We confirm any feeding NG tubes with a standing order for X-ray.
We place our own NGs and OGs, including the fine-bore post-pyloric tubes. Placement is verified with an x-ray and then we are good to go. If the tube is only to suction, I might start that without an x-ray (especially if stuff began squirting out the tube as soon as I got it down). I would not start feeding without a KUB to confirm placement. All our KUBs are done at the bedside. If a doctor is there I will ask him/her to read the x-ray before the tech leaves. If not, the film will be read remotely within an hour.
If a med student, student nurse, or junior resident was around I might ask them if they want to try dropping the tube. Some want to try anything, others back away asap.
Certain surgeons like to drop their own NGs. The head and neck guys come to mind...they also like to suture them to the nose. Not pretty but it's more effective than tape! If my patient comes back from OR with one of those, I usually have to order a KUB.
If any of our doctors let a patient go for hours without meds or feeds, they would be read the riot act. That's especially true in ICU.
UK based nurse here. We place our NGTs, unless we have concerns about placing the tube (altered anatomy, several failed attempts, coagualopathy etc) then we place our tubes. We ask the docs to request a CXR to confirm tube placement prior to commencing feeding. We don't rely on gastric pH for initial confirmation as it's often altered from ranitidine/PPI.
Specializes in Cardiac/Transplant ICU, Critical Care.
Unless the patient had a lung transplant, had an esophagectomy, has active varices, the RNs do it. If we are using it just to decompress, we just listen and hook it up to LIWS, if it is watery and biley then it is safe to assume it is in the stomach.
If we EVER give any medications or start TF, we always get radiographic confirmation and have an MD look it over for an order of "Okay to use".
I have only worked with only one critical care doctor that liked and would insert his on NG/OG tubes. When he came in to see a critical patient he intubated, art lined, central lined, and NG/OG'd them himself. He said that was the way he was thought in school so after his many years of practice he still did it that way. Now if it came out we could replace it. As far as any of the other doctors, they left it up to us to put in and the majority of the time it was confirmed by x-ray but not always. Sometimes it was just auscultation and aspiration alone to confirm until there morning chest X-ray was done.
bgxyrnf, MSN, RN
1,208 Posts
I'm stunned that a first-world country would mandate that OG/NG tubes be physician-level skill or require special training and supervised sign-off. They're pretty hard to screw up.
Venipuncture, arterial sticks, indwelling urinary catheters are riskier procedures than dropping a gastric tube through the esophagus.