Evidence-Based Review and Discussion Points.

Abstract

Feeding tubes (FTs) are commonly used for nutritional support and medication delivery in acutely and critically ill patients. Verification of physiologic positioning, known as placement verification, of FTs is an important concern for bedside practitioners. Unintended gastric FT placement or postplacement prepyloric migrations can increase the risk of aspiration and related negative clinical sequelae. Therefore, postpyloric FT placement may be indicated to promote patient safety. However, accurate determination of FT location within the gastrointestinal tract is limited by low-accuracy verification methods, lack of knowledge related to FT migration, and lack of evidence to support the frequency of FT placement verification. Verifying FT placement every 4 hours is a common practice with an unknown rationale. Electromagnetic placement devices (EMPDs) may assist bedside practitioners in efficiently verifying the accuracy of initial FT placement and subsequently verifying FT location.These authors conducted a prospective, longitudinal repeated-measures cohort study to evaluate the frequency of and factors related to spontaneous FT migration, as well as the feasibility of using EMPDs to assess FT location daily. Twenty-four critically ill patients were recruited from 2 large and geographically distinct medical centers within the United States. Patients were adults with a small-bore CORTRAK FT that had been placed within the preceding 72 hours. Before placement verification, enteral feedings were paused, the FT was flushed with sterile water, and all patients were positioned supine with the head of the bed elevated to 30°. Two clinical EMPD experts verified FT placement using EMPD every 24 hours. The EMPD placement verification procedure involved reinsertion of the FT placement stylet through the feeding tube, which then communicated with an external receiver held over the patient’s xiphoid process, providing real-time placement data. Notably, the distal stylet position served as a proxy for actual distal FT location, as the distal FT tip extended approximately 1 inch (2.5 cm) beyond the stylet tip. The FT location was categorized via 5 anatomical zones (esophageal, proximal gastric, distal gastric, duodenal, and jejunal), and FT migration was defined as FT movement between any of the 5 zones. The study’s end point was 7 days after insertion or upon removal of the feeding tube.Twenty of the 24 enrolled participants were included in the analysis. Forward migration was observed within 24 hours of insertion among 50% of the sample, with 80% of the tubes that migrated moving from the duodenum to the jejunum. Excluding these initial observations, 8 migration events were observed in 20% of the sample, all of which occurred between the duodenum and jejunum. Of the 8 migration events, 5 (62%) were retrograde. Relative risk analyses indicated patients with an endotracheal tube were 3.5 times more likely to experience an FT migration. The authors concluded that placement verification every 24 hours may be adequate, unless FT migration is suspected clinically.Annette M. Bourgault, PhD, RN, CNL, lead author of this evidence-based review article, says that this was her first multisite study and that she and her team learned many lessons, despite it being a small pilot study. She warns, “Don’t be lured into thinking that a pilot study with fewer subjects can be completed in a short time frame.” In fact, “the amount of planning and detail to obtain the necessary rigor is identical to that required for a larger study.” She describes an unanticipated challenge related to recruitment: “In the ICU [intensive care unit] setting, we frequently needed to obtain consent from [the] patient’s legally authorized representative (LAR), many of [whom] were not English speaking.” From this she learned, “knowing not only the demographics of your institution, but who the potential LAR may be is important on the front end.”To tackle such challenges, Dr Bourgault emphasizes the importance of building a balanced research team: she advises building a team “with expertise in research, statistics, and a strong clinical background.” When building a team, Dr Bourgault suggests “networking at conferences and reaching out to experts in your field. … Don’t be afraid to reach out to people that you don’t know.” Dr Bourgault highlights the role of mentorship: “I recommend that novice researchers find research mentors to learn from … try to get involved in as many research projects [as] you can, [because designing] a research study is not something that can be learned from a book. It’s one thing to have the academic knowledge and quite another to run a clinical trial.” She believes that working as a research assistant on a mentor’s project “will help you gain valuable experience without the added responsibility and accountability for the study.” The key for novice researchers, Dr Bourgault says, is to “make sure that your area of research is something that you feel passionate about.”Dr Bourgault also stresses the importance of communication among team members: “Staying in close contact with team members is very important… regular and clear communication … gives everyone on the team a chance to ask questions.” To Dr Bourgault, these varied perspectives are important, as “clinical research has many variables, often things that are beyond our scope of control.” When trying to anticipate such variables, Dr Bourgault recommends reflecting with the research team on “what could go wrong?” and “what are some examples of situations you’ve encountered in the clinical setting that wouldn’t fit this protocol”?This study “helped to reinforce our hypothesis that feeding tubes may not have spontaneous retrograde migration.” However, she acknowledges, “clinical practice should not be changed [on the basis of] one small pilot study, so it’s important for us to see if we can replicate the results using a larger sample size.” She believes that “if we find that feeding tubes have no spontaneous retrograde migration, we may be able to reevaluate and possibly reduce the frequency of tube verification, [which] could save nurses a lot of time and help reduce confusion about this practice.” In addition to this line of work, Dr Bourgault’s team is also “in the process of studying the ideal cleansing procedure for reusable feeding tube stylets.” Her team will also explore biological markers “to see if [they] may be helpful at the bedside to determine changes in feeding tube location.” Dr Bourgault concludes, “we are interested not only in whether feeding tubes migrate, but if there is any association between feeding tube location and microaspiration in the pulmonary system.”This feature briefly describes the personal journey and background story of the EBR article’s investigators, discussing the circumstances that led them to undertake the line of inquiry represented in the research article featured in this issue.Annette M. Bourgault, PhD, RN, CNL, FAAN, is an associate professor at the University of Central Florida School of Nursing with more than 35 years of critical care nursing experience. She was initially attracted to critical care because of her personal affinity for “science, math, and interacting with people. As a high school and college student, I was a swimming instructor, coach, and lifeguard. In these roles, I was introduced to teaching, first aid, and how to save people. This made nursing, especially critical care, seem like a good career fit.”Dr Bourgault recognizes her clinical experience as a potent contributor to her research: “My strong clinical background helps me to have a better understanding of nursing practices and needs at the bedside.” Her research is driven by a “desire to help nurses at the bedside to obtain the necessary tools and evidence to do their jobs, while at the same time considering optimal patient safety.” As someone who advocates for the importance of mentorship in research, Dr Bourgault describes her career path as “serendipitous. I am thankful that several people in my journey [saw] potential in me that at the time I wasn’t even aware of. I now try to pay this forward and tap others whom I see potential in.”