key: cord-0994857-jearrkt2
authors: Pantzaris, N. D.; Stewart, J. A.
title: PEG placements during the COVID-19 pandemic An audit of the procedures performed by a single consultant operator at a tertiary teaching hospital
date: 2022-04-30
journal: Clinical Nutrition ESPEN
DOI: 10.1016/j.clnesp.2022.02.108
sha: a4b0baf3925abcaf76624c0e3bf64576e5e761c1
doc_id: 994857
cord_uid: jearrkt2

nan

confident. Comments from patients included: "I feel much happier with the tube", "very confident in cleaning and rotation, and excellent instructions from nurses". When asked about their experience overall, patient comments included "Thank you for all your support", "expert care, friendly, informative", "fantastic prompt treatment", "grateful that I have had the support", "friendly, professional staff are always willing to help and always have said 'if you need me, just ask, at any time". Due to Covid-19 the clinics had to temporarily stop, however the Dietitians and Consultants missed the instant and direct access to the homecare nurse for enteral feeding tube support, suggesting that the clinic was also highly valued by the healthcare professionals working at the clinic. In August 2021 the clinics started again and there are plans to expand the service later this year. In summary, the enteral feeding tube nurse clinic was positively evaluated by the patients attending the radiotherapy clinic. The overwhelming feedback was that having contact with an enteral tube feeding homecare nurse at least weekly throughout their radiotherapy treatment allowed them to have rapid access to support, advice, reassurance, and training if their feeding requirements changed. Due to the success of this clinic, development of similar clinics in other areas should be considered. PEG feeding provides a valuable nutritional access for patients with a functional gastrointestinal tract. The aim of this project was to audit all the PEG procedures performed by a single consultant operator during the Covid-19 pandemic including the indications, outcomes and complications. All the procedure reports were accessed to identify the patients, indications and immediate outcomes. For every patient, all the letters from all specialties were accessed for the dates following the procedure through the clinical records platforms to identify any later complications. A total of 92 procedures were performed between 15/3/2020 and 31/4/ 2021 in a total of 84 patients. Lists were operating at less than half capacity compared to pre Covid-19. 65 were planned PEG insertions, 17 were planned removals, and 10 were planned replacements. 5 of the procedures were for PEG-J insertion or replacement. The main indication was Head and Neck Ca in 59/92 procedures followed by CVA 9/92, chronic nausea/vomiting/gastroparesis in 6/92, dysphagia with or without aspiration risk in 4/92, MND in 4/92, CNS tumour post-op (pineal gland) in 2/92, cerebral palsy in 1/92, multiple sclerosis in 1/92, neurodegenerative disorder in 1/92, neuromuscular disorder in 1/92, chronic pancreatitis in 1/92, cystic fibrosis in 1/92, depression with poor oral intake in 1/92 and learning difficulties in 1/92. 83/92 procedures were completed successfully. 2 procedures had a failed intubation, 1 because of a subglottal stricture. The rest of the abandoned procedures were due to patient distress (2/92), high oesophageal stricture (1/92), failed cannulation (1/92), body habitus (1/92), stomach not translluminated and patient desaturation (1/92). One of the planned replacements failed because of a buried bumper. In two patients there was a small leak around the PEG site, 1 identified in the endoscopy room, 1 a few weeks later but both were managed conservatively and the PEG was kept in place. No other complications identified. From October 2020 the consistent use of Corflo PEGs reduced the service demands as these can be easily removed in the community. Lists during the COVID-19 pandemic were significantly impacted, especially UGI procedures, as these are aerosol generating procedures. The vast majority of the procedures are completed successfully and there are no significant complications. Most failed procedures are due to patient related factors such as tolerance and anatomical factors. The use of PEGs that can be removed in the community avoiding further endoscopic procedures is a valuable tool especially in this pandemic and early postpandemic setting. Early in the Covid-19 pandemic, the NGSIG predicted the number of sick Covid-19 patients requiring nasogastric tube (NGT) feeding in critical care and high dependency areas would increase dramatically with consequent increased risk of unrecognised misplacement leading to Never Events (NE) and/or pneumothorax. Based on our Position Paper on NGT safety 1 we produced an Aide Memoire 2 with NHSE/I endorsed by NNNG (National Nutrition Nurse Group), The Faculty of Intensive Care Medicine, The Intensive Care Society, The Royal College of Anaesthetists and the Association of Anaesthetists before publication 2 . Rather than relying on aspirate pH as first line initial position check, the Aide Memoire strongly advised use of the "4-point criteria" for reporting x-rays requested specifically to take into account typical ground glass lung fields found in critical care patients. The Aide was not intended to replace current aspirate pH-based guidance in patients outside critical care. An increase in NGT NEs seemed inevitable with the unprecedented pressure on the NHS with redeployed staff unfamiliar with protocols in HDU/ CCU where risk of misplacement is greatest, the reduced nurses/patient ratio and increased staff stress and illness, prone nursing often of obese patients, and the number of NGTs required. Prior to the pandemic, the ongoing incidence of NGT NEs seemed unaffected despite multiple Alerts 3 by NHSE/I. The conditions which permitted NEs to occur before the pandemic persisted into the pandemic undiminished or amplified. According to NHSE/I data, total NEs in England fell from a mean of 452/year in the 5 years prior to the onset of the pandemic to 364 reflecting the reduction in overall NHS non-Covid related activity. The mean incidence of NGT NEs in the previous 5 years was 28.4 (range 22-40) representing 6.3% of total NEs but rising to 10.8% in the year April to March 2020-21 when 34 NGT NEs were reported. NNNG and NGSIG members report that NGT feeding patients increased at least 2-3-fold in NHS hospitals over the last year but particularly in critical care, so at least 51 to 72 cases would have been predicted on a pro rata basis. Thus, total NEs fell during the Covid-19 response year but NGT related NEs rose in number and as a proportion of total NEs, but not to the predicted level. We have no evidence that our Aide Memoire was directly influential in reducing NGT related NEs to the level reported, but we do have anecdotal evidence from NGSIG members of greater awareness of the issues by HDU/CCU staff. We heard of nutritional leads being able to train large numbers of staff to detect misplacement in accordance with NHSE/I guidance and Alerts with emphasis on preferential use of x-ray imaging in critical care/high dependency areas. The increase in NEs during the pandemic justifies our concerns but the failure of NE numbers to reach the predicted target could be explained by reduced reporting of NGT NEs but this would be contrary to the observed increase in total NEs during this period. The possibly that the reduced incidence of NGT NEs was related in part to the use of the Aide Memoire in critical care/high dependency units cannot be excluded. Ongoing NGT NEs still require greater attention nationally beyond the pandemic as recommended in our Position Paper.

A Position Paper on Nasogastric Tube safety

Nasogastric tube (NGT) placement checks before first use in critical care settings during the COVID-19 response BAPEN.aidememoire-ngt-placement

Patient Safety Alert: Nasogastric tube misplacement: continuing risk of death and severe harm. NHS/PSA/RE/2016/006