The findings presented here are a subset of results from a larger study that examined criticalcare nurses’ adoption of the American Association of Critical-Care Nurses (AACN) practicealert on feeding tube placement and the clinical practices recommended therein.1 Insertion

of feeding tubes to deliver enteral nutrition is a common intervention in critically ill patients; however,the methods used for feeding tube verification and the frequency of their use vary widely.2 Two verifica-tion methods that are not supported by research evidence, auscultation (air bolus)2 and water bubbling(no published evidence found), continue to be used. Unfortunately, adverse outcomes such as pneumo-nia, pneumothorax, and death have been associated with inconsistent practices for verifying feeding

Methods Used by CriticalCare Nurses to Verify Feeding Tube Placementin Clinical PracticeANNETTE M. BOURGAULT, RN, PhD, CNLJANIE HEATH, PhD, APRN-BCVALLIRE HOOPER, RN, PhD, CPANMARY LOU SOLE, RN, PhD, CCNSELIZABETH G. NeSMITH, PhD, APRN-BC

©2015 American Association of Critical-Care Nurses doi: http://dx.doi.org/10.4037/ccn2015984

Feature

BACKGROUND The American Association of Critical-Care Nurses practice alert on verification of feeding tubeplacement makes evidence-based practice recommendations to guide nursing management of adult patientswith blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improperpositioning of a feeding tube within the gastrointestinal tract, thereby increasing aspiration risk. OBJECTIVES To determine how the expected practices from the American Association of Critical-Care Nursespractice alert were implemented by critical care nurses. METHODS This study was part of a larger national, online survey that was completed by 370 critical care nurses.Descriptive statistics were used to analyze the data.RESULTS Seventy-eight percent of nurses used a variety of methods to verify initial placement of feeding tubes,although 14% were unaware that tube position should be confirmed every 4 hours. Despite the inaccuracy ofauscultation methods, only 12% of nurses avoided this practice all of the time. CONCLUSIONS Implementation of expected clinical practices from this guideline varied. Nurses are encouragedto implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patientharm. (Critical Care Nurse. 2015;35[1]:e1-e7)

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tube placement.3-5 The most common complication ofblindly inserted feeding tubes is improper placement inthe esophagus (21% of cases) or pulmonary system (4% ofcases).3,6 Case studies7,8 of feeding tubes placed in the brainand spinal column also have been published. Incorrectplacement of a feeding tube may be difficult for cliniciansto assess at the bedside, because the patient can be asymp-tomatic initially.9,10 Because of this, radiographic confirma-tion is considered the gold standard for initial verificationof placement of all blindly inserted feeding tubes.11-14

Clinical practice guidelines such as the AACN practicealerts contain recommendations for practice that areevidence-based.15 Guidelines synthesize available evidenceto assist clinicians in translating research findings intoclinical practice.16 AACN’s practice alert on verificationof feeding tube placement was originally published in2005, revised in 2009, and is available on the AACN web-site (www.aacn.org).17 Several clinical practice guidelinessupporting practices for verifying feeding tube placementhave been published by other organizations, includingthe American Association of Parenteral and EnteralNutrition, the American Gastroenterological Associa-tion, and England’s National Health Service.11,12,14

Objectives Previously published data from our larger study

examined the influence of Rogers’ diffusion of innova-tion variables on critical care nurses’ adoption of theAACN practice alert on feeding tube placement and its

recommended clinical practices in adult patients withfeeding tubes.1 The term adoption is commonly used todescribe the processes of accepting and implementing aninnovation such as the AACN practice alert.18 Implemen-tation is a term commonly used in nursing practice andrefers to the action of using an innovation. For the pur-pose of this article, the terms adoption and implementa-tion will be used in reference to the use of a clinicalpractice unless otherwise stated.

Whereas our first article1 reported on factors thatincreased the likelihood of adoption of the practice alert,this article explores how the recommendations in theAACN practice alert were used by critical care nurses toverify feeding tube placement in clinical practice. Nounique findings regarding radiographic confirmationare reported here.

The AACN practice alert on verification of feedingtube placement for blindly inserted tubes contains 3major recommendations under the heading ExpectedPractice17 (Table 1). The practice alert identifies the unre-liable auscultatory (air bolus) method as a subset of thefirst recommendation. Because auscultation is reportedas a method commonly used by nurses to verify feedingtube location, we decided to measure auscultation practice

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Annette M. Bourgault is an assistant professor and interim assistantdean for assessment and development at Georgia Regents University,College of Nursing, in Augusta.

Janie Heath is dean of the College of Nursing at University of Kentuckyin Lexington.

Vallire Hooper is the manager of nursing research at Mission Hospitalin Asheville, North Carolina.

Mary Lou Sole is the Orlando Health Distinguished Professor atUniversity of Central Florida, College of Nursing, in Orlando.

Elizabeth G. NeSmith is an associate professor and chair of the Depart-ment of Physiological and Technological Nursing at Georgia RegentsUniversity, College of Nursing, in Augusta.Corresponding author: Annette M. Bourgault, Georgia Regents University, College ofNursing, EC-4350, 987 St. Sebastian Way, Augusta, GA, 30912 (e-mail: abourgault@gru.edu).

To purchase electronic or print reprints, contact the American Association of Critical-Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949)362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org.

Authors

Table 1 American Association of Critical-Care Nursespractice alert on verification of feeding tube placement:

expected practices

1. Use a variety of bedside methods to predict tube location during the insertion procedure.

• Observe for signs of respiratory distress.• Use capnography if available.• Measure pH of aspirate from tube if pH strips are available.• Observe visual characteristics of aspirate from the tube.• Recognize that auscultatory (air bolus) and water bubbling methods are unreliable.

2. Obtain radiographic confirmation of correct placement of any blindly inserted tube before its initial use for feedings or medication administration.

3. Check tube location at 4-hour intervals after feedings are started.

• Observe for a change in length of the external portion of the feeding tube.

• Review routine chest and abdominal radiography reports to look for notations about tube location.

• Observe changes in volume of aspirate from feeding tube.• If pH strips are available, measure pH of feeding tube aspi-rates if feedings are interrupted for more than a few hours.

• Observe the appearance of feeding tube aspirates if feedingsare interrupted for more than a few hours.

• Obtain a radiograph to confirm tube position if the tube’s location is in doubt.

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separately from the 3 major practices recommended inthe practice alert.

MethodsDesign

This study had a cross-sectional, exploratory designthat used survey methods. The online survey was hostedby the University of Georgia Survey Research Center.Study approval was provided by the institutional reviewboard at Georgia Health Sciences University (now GeorgiaRegents University), and data collection occurred duringSeptember and October 2011.

InstrumentThe survey tool consisted of 86 categorical and Likert-

style questions that measured adoption of the AACNpractice alert, adoption of the practice alert’s recommendedclinical practices, perceived guideline characteristics,personal innovativeness, communication behaviors, andcollaboration. Only data from the Nursing Practice Ques-tionnaire (NPQ),19 a subscale that measured clinicalpractices related to the practice alert, are reported here.NPQ items received minor customization to capturerecommended practices from the practice alert. Our NPQscale had an internal reliability coefficient (Cronbach a)of 0.82. The NPQ consisted of 8 items for each individualpractice and required mostly yes/no categorical answers.Respondents were asked to indicate whether they use apractice: yes, sometimes; yes, always; no, not aware ofpractice; or no, aware of practice. No definition wasprovided for performing a practice “yes, sometimes,”and thus selection of a response was left to the interpre-tation of the participant.

For questions about specific verification methods,only methods recommended by the practice alert wereincluded as survey options. Therefore, auscultation andwater bubbling methods were not included as surveyoptions because these methods are not empirically based.All items were related to the care of blindly insertednasogastric or feeding tubes. A blindly inserted tube wasdefined as a feeding tube that is inserted without imagingguidance such as fluoroscopy, endoscopy, or sonography.No distinction was made between small-bore (styleted)and large-bore (nonstyleted) feeding tubes.

Original wording in the practice alert under the head-ing of Expected Practice states “Obtain radiographicconfirmation . . .” Radiographic confirmation is not an

independent practice for generalist nurses, so we revisedthe language in our survey and asked if nurses recom-mend/encourage radiographic confirmation. Surveyquestions were reviewed by expert nurses for face validity,and a pilot test of the online survey was performed by27 AACN members.

RecruitmentInvitations to participate were included in AACN’s

Critical Care Newsline for 4 consecutive weeks. Detailedrecruitment methods have been described previously.1

ResultsSample

Descriptive statistics were used to present demograph-ics and clinical practice data. The final sample consistedof 370 critical care nurses (Table 2). A complete descrip-tion of the sample was previously published.1 Participantswere 23 to 65years old (mean,43 years) andhad 1 to 40 years(mean, 13 years) of critical care nursing experience.About 83% were AACN members, 51% were CCRN certi-fied, and 14% worked in a Beacon unit. Baccalaureate orhigher nursing degrees were held by 74% of the nurses.

Use a Variety of Methods To Predict Initial Location of Feeding Tube

Seventy-eight percent of participants (n=287) useda variety of methods to verify initial feeding tube place-ment all of the time, and 12% (n=45) implemented thispractice only some of the time. Ten percent of nurses(n=38) were unaware of this practice recommendation.

Initial feeding tube placement should be verified by using multiple methods.

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Table 2 Characteristics of 370 nurses in sample

a Values represent number (percentage) unless otherwise indicated.

Characteristic

Age, mean (SD), years

SexFemaleMale

Years worked in critical care, mean (SD)

Nursing certificationCCRN

AACN Beacon unit

Valuea

42.5 (10.9)

334 (90.3)36 (9.7)

12.8 (7.9)

278 (75.1)187 (50.5)

50 (13.5)

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A total of 332 respondents answered the question aboutthe specific methods that were used to verify tube place-ment. Verification methods reported to be used all of thetime included observing for signs of respiratory distress(95%, n=315/332), observing feeding tube aspirate (82%,n=272/332), and marking the feeding tube at the exitsite (72%, n=239/332; Figure 1). Capnography and pHmeasures were used less frequently (8%, n=26/332 and9%, n=30/332, respectively). In the open comment field,participants identified the use of 2 additional methodsfor verification of initial tube placement: auscultation(20%, n=67/332) and the water bubbling technique(0.6%, n=2/332).

Check Feeding Tube Location at 4-Hour Intervals

Fourteen percent (n=50) of nurses were unawarethat feeding tube location should be reassessed every 4hours. A total of 309 respondents answered questionsabout the specific methods they used to reassess tubeposition at 4-hour intervals. Methods always used includedobserving change in aspirate volume (89%, n=276/309),observing the appearance of feeding tube aspirate (81%,n=251/309), observing change in external length of thefeeding tube (80%, n=248/309), obtaining a radiograph(66%, n = 203/309), reviewing the radiography report(52%, n=162/309), and pH measurement (7%, n=21/309;Figure 2). Five percent (n = 16/309) of nurses reportedin an open comment field that they also used auscultationfor ongoing verification of feeding tube location.

Avoid Auscultatory (Air Bolus) Method Twelve percent (n=46) of participants indicated that

they avoided using the auscultatory (air bolus) methodall of the time. Ten percent (n=38) avoided auscultationsome of the time, and 77% (n=286) never avoided usingthe auscultatory (air bolus) method to verify feedingtube location (Figure 3). Forty percent of nurses (n=149)were unaware that the auscultatory method is consid-ered unreliable.

DiscussionFifty-five percent of participants (n=203) were aware

of the practice alert, yet only 45% (n=167) indicated thatthey had used the practice alert when caring for a patient

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Figure 1 Methods used to verify feeding tube location duringinsertion procedure (n = 332).

Percen

tage

Respira

tory dis

tress

Capnog

raphy

pH measure

Observatio

n of as

pirate

Never Sometimes Always

Mark tube

exit site

1009080706050403020100

Figure 2 Methods used to verify feeding tube location at4-hour intervals (n = 309).

Percen

tage

Tube length

Reviewed radiography report

Aspirate ap

pearance

Aspirate vo

lume

pH measure

Obtaine

d radiograph

1009080706050403020100

Never Sometimes Always

Figure 3 Used auscultatory (air bolus) method to verifyfeeding tube location (n = 370).

Percen

tage

Always Sometimes Never

100

90

80

70

60

50

40

30

20

10

0

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receiving enteral feeding.1 The methods used by nurseswith CCRN certification or who were employed in a unitwith Beacon award status did not differ from the meth-ods used by other nurses. CCRN is an acute/criticalcare specialty certification through AACN.20 The Beaconaward for excellence is presented by AACN to units thatmeet rigorous criteria related to patients’ outcomes andwork environment.21

The main goal when inserting feeding tubes blindlyis to place the tube within the gastrointestinal tract, ineither the stomach or the small bowel, and avoid inser-tion of the tube into the pulmonary system or otherinappropriate locations. One of the challenges of feed-ing tube verification at the bedside is that none of thenonradiographic verification methods identifies incorrectpositioning of the feeding tube within the gastrointestinaltract, such as tubes placed in the esophagus or the gas-troesophageal junction.22 Administration of formula ormedications through a feeding tube with ports positionedabove the lower esophageal sphincter (esophageal orgastroesophageal placement) may place the patient athigher risk for aspiration of gastric fluid, medications,and/or formula into the pulmonary system.12,23,24 Becauseother methods do not allow identification of the exacttube position within the gastrointestinal tract, radiogra-phy is considered the gold standard for verification ofblindly inserted feeding tubes before administrationof formula or medications.11,12 Electromagnetic placementdevices have been suggested as a replacement for radi-ographic confirmation of feeding tube placement at thebedside, although adverse outcomes have been reported,implying that a high level of user expertise may be nec-essary to obtain consistently positive results.25

The 2 verification methods used most often by criticalcare nurses for initial verification of feeding tube place-ment in our study were observation for signs of respira-tory distress and visual observation of aspirate from thefeeding tube. These 2 methods are less reliable thancapnography and pH methods. Although signs of respi-ratory distress such as decreased oxygen saturation,coughing, and dyspnea have been reported, pulmonaryplacement has occurred without any signs of respiratorydistress.4 Critical care nurses should also be aware thatcuffs from endotracheal and tracheostomy tubes do notprevent pulmonary placement of feeding tubes.3 Visualobservation of the color and consistency of gastric aspi-rate has also been used to verify feeding tube placement.

Fluid from gastric placement has been reported as green,tan, off-white and cloudy, or brown or bloody.26 Aspiratesfrom tubes with pulmonary placement are yellow andserous or off-white/tan and mucous.26 In 1 study,26 aspi-rate from a number of feeding tubes with pulmonaryplacement resembled the color and consistency of gas-tric aspirate, and nurses accurately identified tubes withpulmonary placement only 57% of the time.

In our study, capnography and pH measures wereinfrequently used for initial verification of feeding tubeplacement, a finding similar to results of another nationalUS study of critical care nurses.2 Although these 2 meth-ods can be performed independently by nurses, barriersthat may inhibit use of either technique include the needfor additional supplies, equipment, and training.2 Addi-tional barriers to the use of pH methods for ongoing tubeverification include the use of formula or medicationsthat lower gastric acid, such as H2 blockers and protonpump inhibitors.27-30 Owing to the effects of medicationsand formula onpH measures,using the pHmethod to verifytube placementafter feeding has been started requires that formula bewithheld.30 The optimal length of time that feedingshould be suspended for accurate pH measurement wassuggested as “more than a few hours” in the practicealert, although in 1 research protocol, pH measures weredelayed for only 1 hour after medication administrationor formula being stopped.30 Researchers have also reporteddifficulty obtaining gastric aspirate from feeding tubes,which may pose an additional challenge to pH measure-ments.29 In 1 study,30 researchers recommended that 30mL of air be instilled into the feeding tube via a syringeto clear the tube of formula before aspirating fluid.

As previously mentioned, methods such as capnogra-phy and pH do not allow users to discriminate betweendifferent tube positions within the gastrointestinal tract.24,31

These methods are sensitive to differentiating betweenthe pulmonary and gastrointestinal systems,27,32 whichmay reduce risk of pulmonary placement. For example,a pH less than 5.0 typically indicates gastric placement,and a pH greater than 6.0 indicates intestinal or pul-monary placement.30,33-35 Unfortunately, feeding tubeplacement in the esophagus or gastroesophageal junc-tion cannot be confirmed, making pH and capnography

Feeding tubes misplaced in the pulmonary system do not alwaysresult in signs of respiratory distress.

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methods inconclusive for initial verification of feedingtube placement.24,31,36

The location of the feeding tube should be verifiedevery 4 hours once feeding has been established to assessfor change in tube position.2,12,17 Methods for ongoingverification may include monitoring the length of theexternally marked feeding tube from the exit site (nare or lip)12,37,38 or monitoring gastric residual volumes forchanges.17 Nurses are encouraged to inspect the external

tube mark at 4-hour intervalsto check for achange in length

of the external portion of the tube. Although this methodis not empirically based, the premise is that an increasein external length of the tube may prompt the nurse toperform additional verification methods such as radi-ographic confirmation to assess for a change in tubeposition.2,38 Moreover, radiographic confirmation is rec-ommended any time that improper placement of a feed-ing tube is suspected.12

Only 12% of nurses avoided using auscultation all of thetime when verifying feeding tube placement, suggestingthat 88% of nurses continued to use auscultation for feed-ing tube verification (all or some of the time), even thoughaccuracy of this method is disputed.39 Our results are inagreement with other studies that reported auscultationwas used by 73% to 93% of critical care nurses to verify ini-tial feeding tube placement.2,40,41 Of the practices examinedin our survey, auscultation required the least amount ofspecialized equipment or supplies, which may be oneof the reasons this practice continues to be widely used.2

It is disconcerting that auscultation continues to beone of the most commonly used methods for feeding tubeverification. More than 20 years ago, Metheny et al42

reported that auscultation methods were only 34% accurate,a message that was repeated by Rauen et al.4. Use of auscul-tation may compromise patient safety by failure to distin-guish feeding tube locations both within and outside ofthe gastrointestinal tract.11,12,14,17 Nurses should replaceauscultation practice with evidence-based methods forfeeding tube verification.

Nursing Implications for Practice and Policy

Nurses can also play a role in increasing their knowl-edge of practices for verifying feeding tube location by

reviewing AACN’s practice alert, presentation, and audittool (www.aacn.org). At the unit level, audits are recom-mended to increase awareness of local practices for veri-fying feeding tube location so that a practice improvementplan can be implemented if necessary. To support localpractices, institutional practice policies should be evidence-based and developed by an interdisciplinary team.44

On the basis of our findings, we recommend 3 revi-sions of the practice alert under the headings of ExpectedPractice and Actions for Nursing Practice. A variety ofmethods are recommended for initial confirmation offeeding tube location, yet the exact number is not explic-itly identified. It would be helpful to confirm the expectednumber of methods/techniques to be used, by includinga statement such as “2 or more.” The current practicealert states that auscultation is unreliable, but it does notinclude an action statement for nursing practice. Becausea majority of the nurses in our sample continue to useauscultation in their practice, a bold action statementshould be added, such as “Do not use unreliable meth-ods such as auscultation and water bubbling. Evidencedoes not support these methods and suggests risk forpatient harm if used.” The third recommendation is tomodify the language used for radiographic confirmation.Instead of “obtain radiographic confirmation,” a revisedstatement such as “encourage or recommend radiographicconfirmation” would be actionable by all nurses becauseit is within the scope of practice for a generalist registerednurse. It is important to note that the current practicealert suggests that nurses work with an interdisciplinaryteam to obtain radiographic confirmation.

LimitationsLimitations of this study have been previously

reported.1

ConclusionsThis study is the first to explore one of the AACN

practice alerts in detail to determine how practice rec-ommendations are being followed by critical care nurses.Although the majority of critical care nurses in our sam-ple were aware of the practice alert on verification offeeding tube placement, implementation of the expectedclinical practices from this guideline varied. We encour-age nurses to become familiar with AACN’s practice alerts.Practice alerts are evidence-based, peer-reviewed clinicalpractice guidelines that are developed by content experts.

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Nurses are encouraged to use evidence-based, peer-reviewed practice alerts.

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Implementing expected practices from this practice alertwill bring research evidence to the bedside and minimizerisk for patient harm. CCN

AcknowledgmentsThe authors thank the critical care nurses who participated in this study. Theirassistance was instrumental to the success of this project.

Financial DisclosuresThis study was supported by a grant from Sigma Theta Tau, Beta OmicronChapter.

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To learn more about caring for patients with feeding tubes, read“Effectiveness of an Electromagnetic Feeding Tube PlacementDevice in Detecting Inadvertent Respiratory Placement” byMetheny and Meert in the American Journal of Critical Care, May2014;23:240-248. Available at www.ajcconline.org.

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