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Article Excerpt
Pediatric nurses have always been strong advocates of providing high-quality patient care. The evidence-based practice process offers an opportunity to support updating nursing practice based on the strongest research evidence available, in combination with patient and family values and sound clinical judgment (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000). Using the evidence-based practice process results in improved patient outcomes, often while reducing costs, and provides an opportunity for bedside clinicians to demonstrate an important impact on health care. Traditional nursing practices provide a wonderful opportunity to question practice and potentially improve patient care, which can be very empowering for staff nurses.
Nasogastric (NG) tube placement is a routine procedure used for pediatric and neonatal patients. However, little research exists regarding the verification of NG tubes in children. Several clinical studies and anecdotal reports questioning the use of auscultation to verify NG tube placement have been reported, some dating back more than 20 years (Ghahremani & Gould, 1986). However, the vast majority of nurses continue to check NG tube placement by auscultation of air insufflation over the abdomen.
Purpose
The purpose of this evidence-based practice project was to improve and standardize NG tube placement verification practices used throughout a Midwestern children's hospital. An evidence-based practice approach was used to outline nursing practice and to minimize the risk of incorrectly placed NG tubes. The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001) provided a guide for completing the project, and support was provided through the Evidence-Based Practice Staff Nurse Internship (Cullen & Titler, 2004).
Evidence-Based Practice Process
The Iowa Model of Evidence-Based Practice to Promote Quality Care successfully promotes the integration of evidence into practice. The model shown in Figure 1 outlines the process for developing an evidence-based practice project. Identifying a practice problem or new knowledge triggers the evidence-based practice process. Leaders in the health care facility or on the nursing unit prioritize issues to be addressed and then assemble a team. The team selects, reviews, critiques, and synthesizes evidence in the literature. If the research evidence is sufficient, the team initiates change. If the evidence is insufficient, the team reviews other evidence or suggests more research. The team then pilots and evaluates the practice change to determine if the change worked or whether revisions are needed before integrating and applying the change in other clinical areas. Additional evaluation and dissemination of results is essential to fully integrate the change into practice.
This project began as a knowledge focus trigger with new information suggesting use of a patient's height and a graph (graphic method) as a better method for determining depth of NG tube insertion in children (Klasner, Luke, & Scalzo, 2002). The team was developed to support the staff nurse as the project director through the Evidence-Based Practice Staff Nurse Internship. An extensive literature review was conducted, current practice was evaluated, and practice changes were implemented utilizing a variety of strategies. This change was evaluated at multiple points following implementation. This article reports some of the more interesting results and processes used to implement this change.
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Synthesis of Evidence
The project began in 2003, with little evidence supporting use of height and the graphic method to determine proper insertion depth for NG tubes. Therefore, the project focus changed from measuring for tube insertion to using other evidence-based methods to ensure NG tube placement verification.
The traditional method of assessing NG tube placement has been auscultation over the abdomen after air insufflation because it is a simple and low-cost method (Eisenberg, 1994), is easy to perform (Metheny, Wehrle, Wiersema, & Clark, 1998), and was taught for years in nursing schools. Although this is a frequently used method in the clinical setting, research literature does not support the reliability of this method (Ellett, 2004; Ellett, Croffie, Cohen, & Perkins, 2005; Metheny, Aud, & Ignatavicius, 1998; Metheny, Meert, & Clouse, 2007; Swiech, Lancaster, & Sheehan, 1994; Winterholler & Erbguth, 2002), and malpractice cases have been based on this research (McWey, Curry, Schabal, & Reines, 1988; Metheny, Wehrle et al., 1998). The primary problem with auscultation is that sounds can be transmitted to the epigastrium regardless of whether the NG tube is placed in the lung, esophagus, stomach, duodenum, or proximal jejunum (Cannaby, Evans, & Freeman, 2002; Eisenberg, 1994; Ellett & Beckstrand, 1999; Gharib, Stern, Sherbin, & Rohrmann, 1996; Metheny, McSweeney, Wehrle, & Wiersema, 1990; Metheny, Wehrle et al., 1998).
The majority of research or evidence regarding the use of NG tubes is in adult patients and was pioneered by Norma Metheny in the late 1980s with scant evidence for pediatric patients, possibly due to ethical considerations (Wilkes-Holmes, 2006). Expanded search strategies included personally contacting experts about their work regarding NG tubes in pediatric patients (J. Beckstrand, personal communication, April 12, 2003; A.E. Klasner, personal communication, April 2, 2003 and April 3, 2003; N.A. Metheny, personal communication, April 2, 2003).
In adult patients, the rate of NG tube misplacement ranges from 1.3% to 89.5% (McWey et al., 1988; Niv & Abu-Avid, 1988), depending on how the error is defined, and averages about 4% (Ghahremani & Gould, 1986; Kearns, 1997). The prevalence of NG tube placement errors in children is difficult to determine because of the differing definitions across studies; however, rates of misplacement in children have been reported at 21% to 43.5% (Ellett & Beckstrand, 1999; Ellett et al., 2005; Ellett, Maahs, & Forsee, 1998), which is...
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