Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

First received xxxx xx, xxxx; Revision received xxxx xx, xxxx; Accepted for publication xxxx xx, xxxx. Blackwell Publishing Inc

Sue Peter and Fenella Gill

PURPOSE.

A Perth metropolitan hospital group

standardized changes to nasogastric tube placement, including removal of the whoosh test and litmus paper, and introduction of pH testing.
DESIGN AND METHODS.

Two audits were

conducted: bedside data collection at a pediatric hospital and a point-prevalence audit across seven hospitals.
RESULTS.

Sue Peter, SRN, RSCN, MSc, is Nursing Director, Ambulatory Care, Princess Margaret Hospital for Children, Child & Adolescent Health Service, Subiaco, Perth, WA, Australia; and Fenella Gill, RN, BN, Paediatric Certificate, MN, Graduate Certificate in Tertiary Teaching, is Paediatric Intensive Care Nurse Educator and Co-ordinator, PIC Specialty Master of Clinical Nursing, Princess Margaret Hospital for Children, Child & Adolescent Health Service, Subiaco, Perth, WA, and School of Nursing & Midwifery, Faculty Health Science, Curtin University of Technology, Bentley, WA, Australia.

Aspirate was obtained for 97% of all

tests and pH was 5.5 for 84%, validating the practice changes. However, patients on continuous feeds and/or receiving acid-inhibiting medications had multiple pH testing fails.
PRACTICE IMPLICATIONS.

Nasogastric tube

placement continues to present a challenge for those high-risk patients on continuous feeds and/or receiving acid-inhibiting medications.
Search terms: Children, nasogastric tube

testing, pH aspirate
First received August 30, 2007; Revision received December 6, 2007; Accepted for publication January 11, 2008.
(2008), The Authors Journal Compilation (2008), Wiley Periodicals, Inc.

asogastric tubes (NGTs) are placed in hundreds of thousands of hospitalized patients every year, and they are an integral part of the management of many medical and surgical conditions. They are often inserted for the therapeutic purpose of administering feeds and/or medications. Confirming correct placement avoids complications and, in particular, avoids the introduction of enteral feeds and medication into the lungs. Many tubes are inserted without incident; however, there is a risk that the tube may be misplaced during insertion or that it may migrate from the stomach at a later stage. The reported tube-placement error rate varies considerably. Metheny and Meert (2004) and Weinberg and Skewes (2006) reported error rates of between 0.3% and 20%, whereas Ellett, Maahs, and Forsee (1998) reported error rates up to 43% in children. In addition to endotracheal intubation, risk factors associated with a higher incidence of enteral tube misplacement in children include younger age, decreased level of consciousness, abdominal distension, vomiting, and orogastric tubes (Ellett et al., 1998). Although adverse outcomes related to misplaced NGT are infrequent, when they do occur the results can be catastrophic, and recent literature has questioned the reliability of traditional bedside testing methods. In 2005, a coroners findings in the United Kingdom highlighted 11 deaths over a 2-year period directly related to misplaced feeding tubes, prompting the UK National Health Service (NHS) National Patient Safety Agency (2005a) to produce a National Safety Alert recommending specific guidelines on the safe testing of NGTs. In response to this alert, it was deemed timely to review the current clinical guideline for NGT testing at Princess Margaret Hospital for Children
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Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

(PMH) to ensure a safe and practical clinical guideline that incorporated best evidence, particularly as the existing guideline was based on traditional bedside testing methods.

Clinical Practice Guideline Development

The purpose of clinical practice guidelines (CPGs) is to provide practitioners with guidance in specific areas of healthcare practice. CPGs are designed to improve the quality of health care, reduce practice variation, and reduce unnecessary, harmful, or ineffective interventions, at an acceptable cost (Graham, Beardall, Carter, Tetroe, & Davies, 2003; National Health & Medical Research Council, 1999). It was recognized that introduction of a comprehensive CPG would require the time of appropriately skilled and experienced people to develop and implement (Feder, Eccles, Grol, Griffiths, & Grimshaw, 1999; Shekelle, Woolf, Eccles, & Grimshaw, 1999). A working party was established, comprised of senior clinical nurses and research nurses (ensuring both research-evidence appraising knowledge and clinical expertise), to consider the relevance of the evidence and translate it into a form that could be implemented into practice (Gerrish et al., 2007; Shekelle et al.; Steinberg & Luce, 2005).

Literature Review
A review and critical analysis of the literature was undertaken to identify current best practice in a manner that ensured the application of evidence to practice was clear (Hewitt-Taylor, 2003; National Health and Medical Research Council, 1999).

Chest X-ray for Checking NGT Placement

The gold standard test for confirming the position of an NGT is an X-ray that visualizes the whole length of the tube, although there have been multiple reports of X-rays being misinterpreted by physicians not trained in radiology (Hendry, Akyurekli, McIntyre, Quarrington, & Keon, 1986; Scheiner, Noto, & McCarten, 2002). Although there is no sure nonradiographic method to differentiate respiratory, esophageal, gastric, and small bowel placement of NGT tubes, X-ray confirmation is not a suitable method to check NGT placement or position for every patient prior to every feed or administration of medication. Therefore, it is necessary to use the most accurate bedside methods.

Bedside Checking Methods for Checking NGT Placement

The most reliable bedside method available to confirm NGT placement is the measurement of pH of NGT aspirates
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(Colagiovanni, 1999; Metheny, 1994; Tait, 2001). There is a need to be able to differentiate between gastric contents that may have a pH between 1 and 5 (Huffman, Jarczyk, OBrien, Pieper, & Bayne, 2004), small bowel or bronchial secretions that may have a pH > 6 (Ellett, 2005), and esophageal secretions that may have a pH between 6 and 7; although esophageal pH can yield an acidic pH in the presence of acid reflux from the stomach. It is advocated that this method replace testing the acidity/alkalinity of aspirate using litmus paper, which is not adequately sensitive to distinguish between gastric and bronchial secretions (National Patient Safety Agency, 2005b). In the absence of NGT aspirates, nurses have traditionally utilized the whoosh test, whereby air is insufflated through the feeding tube while auscultating the epigastrium. The efficacy of this method is highly questionable. Although there is no evidence that the auscultatory method is effective in ruling out respiratory placement, there have been multiple anecdotal reports of its ineffectiveness leading to disastrous results (Chang, Melnick, Bedger, & Bleyaert, 1982; Creel & Winkler, 2007; Dobranowski, Fitzgerald, Baxter, & Woods, 1992; Hand, Kemster, Levy, Rogol, & Spirn, 1984; Hendry et al., 1986; McWey, Curry, Schabel, & Reines, 1988; Metheny, Aud, & Ignatavicius, 1998; Metheny & Stewart, 2002; National Patient Safety Agency, 2005a). Additionally, the whoosh test cannot determine where the tube is positioned in the gastrointestinal tract. Observing for bubbling at the proximal end of the tube is also an unreliable method because the stomach also contains air and could falsely indicate respiratory placement (Metheny, McSweeney, Wehrle, & Wiersema, 1990). In addition, none of the following methods can be relied upon to determine distal NGT tip position. However, they can be used as additional information when undertaking a risk assessment, balancing the need to feed with the risks of a malpositioned NGT. When undertaking serial observations and assessments, the strength of single indicators is increased if one or more other indicators are present (Metheny et al., 2005). Observing for signs of respiratory distress, such as choking or cyanosis, can be ineffective in detecting a malpositioned tube, especially in unconscious or debilitated patients (Metheny et al., 1990; Rassias, Ball, & Corwin, 1998; Schorlemmer & Battaglini, 1984). Small bore tubes may cause few or no symptoms when incorrectly positioned, particularly in high-risk patients such as those who are unconscious, intubated, lack a gag or swallow reflex, or are uncooperative during the procedure. Although the absence of symptoms cannot be relied upon to exclude a malpositioned tube, the presence of respiratory symptoms would certainly suggest an increased risk of misplacement. There have been significant difficulties reported in distinguishing respiratory secretions from gastric secretions withdrawn from the NGT (Hand et al., 1984; Metheny &
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Meert, 2004; Torrington & Bowman, 1981). However, aspirate appearance can help to distinguish between an NGT being positioned in the small bowel rather than the stomach because aspirates may be bile stained when mixed with intestinal secretion rather than curdled white when mixed with gastric juice. It has been noted that although the determination of color is subjective, accuracy can improve with training (Metheny & Meert). Observing for changes in gastric residual volume can also help distinguish between the NGT being positioned in the small bowel rather than the stomach because gastric volumes will be larger than intestinal volumes (Metheny & Meert). In addition, when the tube has migrated into the esophagus, the aspirate volume has been found to decrease (Metheny et al., 2005). Determining if the external length of the tube has changed since the time of the confirmatory X-ray cannot be relied upon to ascertain internal NGT distal tip position. Marking the tube as it exits from the nares or mouth serves as an indication of whether the tube has been partially removed but does not reflect the distal tip position. However, there are no risks involved with marking the tube, and it may help to alert caregivers to detect a change in tube position (Metheny & Meert, 2004; Metheny et al., 2005).

Australasia via the Women and Childrens Hospitals Australasia organization (Womens and Childrens Hospitals Australasia, 2006). A total of 10 pediatric sites participated in a survey of NGT practices, finding that 5 had introduced pH indicator strips to replace litmus paper. Various pH cut-off points were being utilized for testing aspirates, ranging from pH 4 to 6, with a number of hospitals varying the cut-off point according to the use of acid-inhibiting medications. The whoosh test was no longer endorsed in 6 sites, and indications for X-rays varied from no aspirate obtained to doctor initiated. Consultation with a number of adult hospitals in the Perth metropolitan area highlighted differences in hospital NGT management policies. A number of hospitals had moved away from the traditional bedside testing methods while others were continuing traditional NGT practices. This communication led to the establishment of a metropolitanwide hospital-nursing working party to achieve consensus in the standardization of evidence-based changes to NGT policies across hospital sites, to enable benchmarking, and to undertake a multisite evaluation.

Implementation and Dissemination of the CPG

In April 2006, the NGT CPG was introduced at PMH. The whoosh test was no longer endorsed; litmus testing of gastric aspirates was replaced with pH testing; and a risk assessment was developed to guide decision-making in balancing the potential risks with the need to feed (see Figure 1).

Alternative Bedside Testing Methods

Alternative bedside testing methods include the use of pH probes, capnography, and measurement of aspirate bilirubin, trypsin, and/or pepsin. However, each of these methods has limitations and drawbacks. Clinical utilization of pH probes has been restricted to testing between gastric and esophageal placement rather than respiratory placement. Capnography measurement indicates respiratory placement of the NGT; however, this would not occur if either a tube positioned in the tracheobronchial tree was not perfectly patent or if the eyelet holes were at the level of the cuff of the endotracheal tube or tracheostomy tube. Measurement of bilirubin, trypsin, and/or pepsin relies on obtaining an aspirate and is not currently commercially available because more research is needed before this method can be used in practice (Huffman et al., 2004).

Potential Barriers to Implementing the CPG

The PMH working party planned the process for implementation of the CPG to incorporate a number of dissemination strategies aimed at medical personnel, nursing staff, and parents of children with NGTs. The active implementation measures included the identification of potential barriers to the adoption of the new guideline (Graham et al., 2003). During the consultation period, concerns about the impact of the proposed changes expressed by many of the nursing staff were: The new guidelines would lead to an increase in the number of X-rays undertaken and repassing of NGTs. Aspirates for patients on continuous feeds or acidinhibiting medications would be > pH 5.5.

Establishing Reliability of the CPG

In the absence of good evidence and considering the limitations of available NGT bedside methods, it was essential for us to address the reliability of the NGT CPG before implementation. This was partly established by considering whether a second group would arrive at the same recommendations after reviewing the same evidence (Goolsby, 2003). The UK NHS Patient Safety Agency was consulted, and a national benchmarking process was initiated with other childrens hospitals/departments in
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Decision-making would be difficult in the absence of aspirates. Evaluation Process

To address the concerns raised and ensure a positive effect on organizational change, a comprehensive evaluation
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Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

Figure 1. Risk Assessment

process was initiated (Graham et al., 2003; Ring, Malcolm, Coull, Murphy-Black, & Watterson, 2005). A key principle of CPG development is that the implementation and impact should be evaluated (Feder et al., 1999; National Health and Medical Research Council, 1999; Ring et al.). A review was planned encompassing two separate clinical audits: an audit at PMH to address the specific clinical issues identified and a metrowide hospital point-prevalence audit to evaluate the impact on nursing practice and identify further educational needs, ensuring linkage between the data collected and key points of the CPG (Feder et al.; Gerrish & Clayton, 2004; Mersel, Mor-Yosef, & Shapira, 2005).
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Evaluation Methods
The PMH audit was conducted over a 1-month period. Data were collected by bedside nurses for all patients with an NGT in situ for each NGT testing procedure, using an adapted NHS Patient Safety audit tool (National Patient Safety Agency, 2005b). In addition, a metrowide 1-day pointprevalence audit was conducted across seven metropolitan hospitals. The nurses identified to collect the data from each hospital first attended briefing sessions to promote interrater reliability. Bedside nurses were then interviewed using a semistructured questionnaire, and documentation
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was reviewed for all patients with an NGT in situ (Metcalf, 2006).

Results PMH Audit Results

Concern: The new guidelines would lead to an increase in the number of X-rays undertaken and repassing of NGTs. While no sure nonradiographic methods exist to differentiate between respiratory, gastric, esophageal, and small bowel placement of blindly inserted feeding tubes (Metheny & Meert, 2004), minimizing the number of radiographs taken to assure correct tube placement is important, especially in young children, to avoid exposure to the risks associated with radiation. During the 1-month PMH audit, a total of 1,527 NGT tests were undertaken for 52 patients. Seven X-rays were undertaken on 6 children. Selective use of X-rays was observed because only those children who had more than one occasion of pH > 5.5 were X-rayed, with the exception of one infant who was frequently gagging where X-ray confirmed the NGT had knotted. If results from the bedside tests do not confirm correct positioning, the tube can be removed and reinserted; in this way X-rays can be kept to a minimum. This recommendation was evident in practice because 22 patients had 39 NGTs repassed (range 15). Concern: Aspirates for patients on continuous feeds or acid-inhibiting medications would be > pH 5.5. Nasogastric aspirates pH 5.5 will indicate correct placement of NGTs in most patients (adults, children, infants, and neonates), including those receiving acid-inhibiting medication (Metheny, 1994). Ellett, Croffie, Cohen, and Perkins (2005) found that using the following algorithm(a) if pH was 5, the correct placement in the stomach could be assumed, and (b) if pH > 5 or no aspirate, an X-ray should determine tube placementwould result in 92% of children eventually having correct placement in the stomach. There are limitations to using this beside testing method because measuring the pH of withdrawn fluid is only helpful in differentiating between respiratory and gastric placement when gastric pH is low (Griffiths, Thompson, Chau, & Fernandez, 2006; Metheny & Meert, 2004). When gastric pH is 6, using pH to predict tube placement is of no benefit. Furthermore, pH of a feeding tube cannot identify if it is in the esophagus. Continuous feedings negate the usefulness of the pH method in many situations, which needs to be taken into consideration when undertaking a risk assessment. A pH of 5.5 was incorporated into the NGT guideline to indicate gastric placement, because according to Metheny and Meert, no pulmonary aspirate has been reported < pH 6; therefore, pH 5.5 will exclude 100% of pulmonary placements and more than 93.9% of placements in the small
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intestine. However, there have been other rare and isolated situations in the literature where fluid aspirated from a pocket of empyema in the lung had a pH of 5. Indicator strips for pH also must have the appropriate pH range for sufficient sensitivity, and pH strips with a broad pH range are advocated (Metheny & Meert, 2004). However, a trial of various pH indicator strips at PMH found color changes of the indicator strips with wide pH values that were difficult to distinguish between. The pH indicator strips with a pH range of 4 to 7 provided more distinctive, observable color changes, thus allowing more accurate interpretation of pH levels that are relevant to NGT placement. Most enteral formulas have a pH close to 6.6, causing the pH of gastric contents to be increased in enterally fed patients. Patients who are receiving continuous feeds may have a pH > 5.5, although testing can be performed when feeds have been withheld (Khair, 2005). Ellett et al. (2005) found that there was a statistically nonsignificant difference in pH between bolus-fed and continuously fed children, and whether or not the child was receiving an acid-inhibiting medication did not significantly affect the pH of aspirate, although this study reported an inadequate sample size. For the purpose of the data results, pH 5.5 is reported as pH pass, and pH > 5.5 is reported as pH fail. For the 1,527 tests, 84% were pH pass. Of the 52 patients, 21 had pH pass for all testing, 13 had pH fail on one occasion, and 18 (9 pediatric intensive care unit patients) had 2 or more pH fails (range 242). Importantly, the PMH audit data identified that children receiving continuous feeds more often had > 2 pH fails (61%) than the children who were receiving bolus feeds (35%). A similar trend was found with those children receiving acid-inhibiting medications, where 39% had > 2 pH fails compared to 24% receiving bolus feeds. Seven patients who had more frequently recurring pH fails (range 742) were on both continual feeds and acid-inhibiting medications. Figure 2 further illustrates these findings. Concern: Decision-making would be difficult in the absence of aspirates. In the situation where no fluid aspirate is obtained from the NGT, alternative methods such as the whoosh test had traditionally been implemented. Determining the position of the NGT by auscultation of air (whoosh test) into the stomach is an unreliable method of checking NGT position. The injection of air into the tracheobronchial tree or into the pleural space can produce a sound indistinguishable from that produced by injecting air into the gastrointestinal tract (Colagiovanni, 1999; Metheny et al., 1990; Weinberg & Skewes, 2006). While the stomach is never completely empty, it is not always possible to initially obtain an NGT aspirate. The following steps were incorporated into the CPG to assist nursing staff to obtain an aspirate: turning the patient onto his or her side, advancing the tube to make sure the exit port enters a pool of fluid, and
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Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

Figure 2. Princess Margaret Hospital for Children Audit pH Levels Results. pH Pass Percentage (n = 34), and pH Fail Percentage (n = 18)

injecting air to dislodge the NGT exit port from the gastric mucosa (Khair, 2005; Metheny & Meert, 2004). Metheny et al. (2005) reported obtaining sufficient aspirate for testing in 74.2% of 2,754 tests from gastric tubes in critically ill adults. In the PMH audit, aspirate was obtained for 97% of all tests, thus not supporting staff concerns of anticipated high rates of failure to aspirate. These results correlate with similar findings of an audit conducted by the NHS Patient Safety Agency across three adult intensive care units; a 92% success rate of obtaining aspirates was reported. The success in obtaining aspirate for 97% of all tests in the PMH audit indicated the clinical effectiveness of these steps, although due to incomplete data it was impossible to identify which step achieved an aspirate. The steps are illustrated in Figure 3.

in the small percentage of nurses at PMH who indicated X-ray (11%) as a testing method in comparison to the adult nurses (61%) (Metcalf, 2006). Eight nurses reported the whoosh test, four reported blue litmus paper, and two reported the bubble test as recommended alternative methods at their hospitals. Sixty-one percent of nurses reported the correct, recommended pH level; 3% did not know; and the remainder varied between pH 4 to 6. Ninety-three percent of nurses reported checking NGTs prior to all bolus feeds, 91% prior to medication delivery, and 90% a minimum of once per day or once per shift for continuous feeds. However, only a small percentage of nurses, 9% and 6%, respectively, reported checking following vomiting or coughing episodes (Metcalf, 2006). Documentation. Seventy-nine patients with an NGT in situ were identified across the metropolitan hospitals (23 at PMH). There was incomplete documentary evidence for approximately 50% of patients for placement and testing of the NGTs, and data collection was hindered by the absence of a standardized NGT chart at any of the participating hospitals (Metcalf, 2006). There were obvious discrepancies between the knowledge of the nursing staff found during the interviews and review of the actual documentation. For example, 74% of nurses indicated the method used to check placement, yet only 51% of the notes reviewed showed this information was documented (Metcalf, 2006).

Discussion
In view of the potential catastrophic outcomes that may occur as a result of a misplaced NGT and the limitations inherent in the currently available bedside testing methods, it was important to adopt an evidenced-based approach to the introduction of a revised NGT CPG. This incorporated a literature review, consultation with clinical experts, establishment of a multisite hospital working party, benchmarking activities, implementation of a comprehensive dissemination program, and an evaluation process. Data collected during the PMH clinical audit did not support the concerns expressed by staff of anticipated high percentages of patients with pH > 5.5 or no aspirate obtained with subsequent interruptions to feeding and increased X-ray exposure. The findings of the PMH audit, however, do need to be interpreted with caution because this was a clinical audit process and not a research study. The nature of the audit, in that many different staff entered data across various wards and departments, led to incomplete data inputting and a lack of standardized data entries. Subsequently, this limited data analysis to determine the most effective actions to take in the absence of aspirates. The data results yielded a high success rate in obtaining aspirates, indicating clinical effectiveness of the recommended
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Metrowide Audit Results

Nurse Interviews. One hundred and four nursing staff across seven hospitals within the Perth metropolitan area undertook voluntary nursing interviews (18 employed at PMH). Ninety-three percent of the nurses (100% at PMH) correctly indicated the use of pH indicator strips to test stomach aspirate as their hospitals recommended method to check NGT placement, and 61% indicated X-ray as an alternative method to pH testing. The recommendation that children are not subjected to routine X-ray was reflected
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Figure 3. Confirming the Correct Position of Nasogastric Feeding Tubes in Infants and Children (For Infants Less Than 4 Weeks, Refer to Neonatal Policy)

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Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

steps to take. Further study is required to determine which of the steps were most successful, whether as a single step or in combination, to obtain aspirate. The children receiving continuous feeds were more likely to have more than one pH fail, as were the children on acid-inhibiting medications. When these two factors were combined, a trend was observed where consistently recurring pH fails were evident. Thus, it is not surprising that this group of children received additional X-rays and were more likely to have multiple NGT replacements. These factors need to be taken into account when undertaking a risk assessment for this high-risk group, and further research is required to identify if this is a subset of children that requires a variation to the current NGT CPG. Caution is also required before generalizing the results of the metrowide audit in view of the limited number of patients included together with the small number of nursing staff interviewed. There was an obvious deficit observed between knowledge reported by the nursing staff in the interviews compared with the documented evidence. Traditionally, nurses have not necessarily documented all aspects of their practice related to NGT management, evident in the absence of a specific chart to document NGT placement and testing in each of the hospitals included in the audit. Since this audit, a standard NGT checking chart has been trialed and introduced at PMH, and a re-audit is planned to assess the impact on documentation. There were a number of areas identified where nurses knowledge and, therefore, practice was not compliant with the NGT CPG, prompting the need for further education focusing on education gaps.

How Do I Apply This Information to Nursing Practice?

It is now recommended that pH testing replace the litmus paper test, and the whoosh test is no longer advocated for confirming NGT placement. It is not always appropriate to conduct an X-ray for each occasion where bedside testing methods fail. Our evaluation demonstrated that if initially nil nasogastric aspirate is obtained, the use of a flow chart of interventions will enable aspirate to be obtained and facilitate pH testing. The group of patients who will continue to pose a challenge to using pH testing are those on continuous feeds and/or receiving acid-inhibiting medications. In addition, a comprehensive individual risk assessment of the patient, using a standardized tool, is mandatory to guide decision-making by the multidisciplinary team. Author contact: fenella.gill@health.wa.gov.au and sue.peter@health.wa.gov.au, with a copy to the Editor: roxie.foster@UCDenver.edu

References
Chang, J., Melnick, B., Bedger, R., & Bleyaert, A. (1982). Inadvertent endobronchial intubation with nasogastric tube: Occurrence after head and neck surgery. Archives Otolaryngology, 108, 528 529. Colagiovanni, L. (1999). Taking the tube. Nursing Times Supplement, 95(21), 6366. Creel, A., & Winkler, M. (2007). Oral and nasal enteral tube placement errors and complications in a pediatric intensive care unit. Pediatric Critical Care Medicine, 8(2), 161164. Dobranowski, J., Fitzgerald, J., Baxter, F., & Woods, D. (1992). Incorrect positioning of naso-gastric feeding tubes and the development of pneumothorax. Canadian Association of Radiology Journal, 43, 3539. Ellett, M. (2005). Important facts about intestinal feeding tube placement. Gastroenterology Nursing, 29(2), 112125. Ellett, M., Croffie, J., Cohen, M., & Perkins, S. (2005). Gastric tube placement in young children. Clinical Nursing Research, 14(3), 238252. Ellett, M., Maahs, J., & Forsee, S. (1998). Prevalence of feeding tube placement errors and associated risk factors in children. Maternal Child Nursing, 23, 234239. Feder, G., Eccles, M., Grol, R., Griffiths, C., & Grimshaw, J. (1999). Using clinical guidelines. British Medical Journal, 318, 728 730. Gerrish, K., & Clayton, J. (2004). Promoting evidence-based practice: An organisational approach. Journal of Nursing Management, 12, 114123. Gerrish, K., Ashworth, P., Lacey, A., Bailey, J., Cooke, J., Kendall, S., et al. (2007). Factors influencing the development of evidencebased practice: A research tool. Journal of Advanced Nursing, 57(3), 328338. Goolsby, M. (2003). Clinical practice guidelines. National Guideline Clearinghouse guideline syntheses and comparisons. Journal of the American Academy of Nurse Practitioners, 15(3), 98101. Graham, I., Beardall, S., Carter, A., Tetroe, J., & Davies, B. (2003). The state of the science and art of practice guidelines development, JSPN Vol. 14, No. 1, January 2009

Conclusion
Bedside checking of NGT placement is paramount prior to either enteral feeding or medication administration. However, what were considered reliable methods of testing NGT placement previously are now questioned in the literature. It is now recommended that pH testing replace the litmus paper test and the whoosh test is no longer advocated. However, there will continue to be occasions when pH measurement is not able to confirm gastric placement, or aspirate is not obtained. In addition, it is not always appropriate to conduct an X-ray for each occasion where bedside testing methods fail. A comprehensive individual risk assessment of the patient using a standardized tool is mandatory to guide decision-making by the multidisciplinary team. Practitioners need to be ever vigilant to the possibility of a misplaced NGT even when bedside testing methods prove positive. In the absence of acceptable, alternative testing methods, safe NGT placement will continue to present a challenge, particularly for those patients on continuous feeds and/or receiving acid-inhibiting medications.
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