Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill

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Abstract
Inadvertent passage of a nasoenteric feeding tube into the tracheobronchial tree can result in pneumothorax. Measures requiring feeding tube passage to 35 cm only followed by a radiograph to verify intraesophageal placement and creation of a specialized placement team were implemented to decrease the incidence of procedure-related pneumothorax. This study evaluates the effectiveness of our safety measures. Radiology reports from January 2000 through July 2003 were searched by computer with an algorithm designed to detect feeding tube placements possibly associated with the complication of intrabronchial placement or pneumothorax. Results were manually examined to eliminate false positives and verify causality. Feeding tubes were placed in 4,190 unique patients during the study period; 87 patients had an intrabronchial malposition, and 9 experienced a pneumothorax caused by their feeding tube. The safety measures resulted in a significant decrease in procedure-related pneumothorax (0.09% versus 0.38%, p < 0.05), and a decrease in pneumothorax among patients with an intrabronchial placement (3% versus 27%, p < 0.05). More than two-thirds of patients with a misplaced tube had an endotracheal tube or tracheostomy, illustrating that such patients are not protected. Repeated malposition in the same patient was surprisingly common; 32% of patients with one intrabronchial misplacement ultimately had multiple misplacements. The risk of pneumothorax increased with misplacement at night (p < 0.05) and increased exponentially with each additional misplacement (p < 0.05). Creating a specialized placement team, and initiating the safety measure of limiting feeding tube placement to 35 cm and obtaining a radiograph before full advancement reduced the incidence of procedure-related pneumothorax.

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