On track to the stomach! ! Cortrak® for the insertion of nasogastric tubes amongst neuroscience patients – how effective is it?

Enteral feeding is the first choice in nutritional support when a patient cannot eat or drink (Arjaans et al, 2019). Nasogastric tubes are placed by nursing staff blindly at the bedside and are often considered a fairly harmless procedure, although it is not (Metheny et al, 2019). Misplacement in the lung is an inherent risk of nasogastric feeding tube insertions and is considered a never event and unfortunately still occurs (Bourgault et al, 2017; NHS improvement, 2016). However, placement and checking of nasogastric tube placement must be effective. First line check includes pH indicator strips followed by an X-ray to confirm the nasogastric tube position. Patients with dysphagia, vocal cord dysfunction or loss of consciousness are more prone to misplacement of nasogastric tubes (The National Patient Safety Agency (NSPSA), 2011).

Nasogastric tube insertion is a high-risk procedure as misplacement leads to death. Real-time placement could prevent misplacement and therefore the Cortrak® 2 system was explored to determine if patient safety could be improved. Cortrak® 2 can also be used to insert post pyloric tubes such as nasoduodenal or nasojejunal tubes but this was beyond the scope of this trial.

X-ray has remained the gold standard for the placement check for nasogastric tubes but this has also come with concerns due to poor quality x-rays and the inability to view all of the nasogastric tube pathway down the gastro-intestinal tract; or the x-ray has been misinterpreted (Metheny et al, 2019). Nasogastric tubes misplaced in the lungs should be removed immediately to prevent the risk of inappropriate feeding from presuming the check has been made (NPSA, 2011).

A report in the United Kingdom has shown that 100 nasogastric tubes were misplaced in the lungs between 2005 and 2010 and misinterpretation of the x-ray results had been reported in 45% of tubes and patients were consequently fed into the lung (NPSA, 2011). A further report on the incidents between 2011 and 2016 resulted in 95 further incidents where 47% of tube misplacements were due to x-ray misinterpretation and 5 of these were due to the interpretation of the wrong x-ray (NHS improvement, 2016). There may also be more misplacements that went unreported.

Internationally, there has been a need for accurate nasogastric placement to avoid x-rays, reduce delays in feeding, prevent repeated insertions and reduce healthcare costs (Rowat, Graham and Dennis, 2018). Neuroscience patients repeatedly require multiple reinsertions and experience difficult placements due to dysphagia or reduced consciousness. Therefore, accurate placement and effective securement of the tube is fundamental in this patient population. The nasogastric tube positioning needs to be accurate, affordable, avoid misplacement, and avoid gastric aspirates as these are not always possible (Fan, Tan and Ang, 2017).

In 2012 the food and drug administration (FDA) approved the Cortrak® 2 for use by qualified operators in America. However, in the United Kingdom, the Cortrak® 2 was not approved for use without x-ray confirmation due to some reports of misplacement and consequently death from an unknown insertion device (National Institute of Health and Care Excellence (NICE), 2016). NICE (2016) recommend the use of pH testing and x-ray if necessary for the confirmation of gastric placements, however the use of pH testing alone is not safe practice (Rowat et al, 2018). pH test accuracy is reported as limited and often proves problematic due to a lack of aspirate, which is reported in 44% of cases (Rowat et al, 2018; Taylor et al, 2014). The difference between the Cortrak® 1 and 2 was that clinicians using the Cortrak® 2 were now required to sign in with their own individual account to prevent use by untrained personnel. The Maude database in America identified there was 54 adverse events over 10 years with the Cortrak® system of which 98% were lung placements (Bourgault, Aguirre, and Ibrahim; 2017). The complications that occurred from this were pneumonia (21%) and pneumothorax (77%). Furthermore, 17% of lung placements led to death; where 20% of these events could have been avoided if medication administration or feeding had not occurred after insertion. Taylor et al (2017) identified that the pre-gastroesophageal junction (Pre-GO) and gastric body flexures must be recognised and the gastric body should be left of the midline. They concluded that a minimum of ten supervised placements must be completed to practice independently. A lack of education and overnight insertion may have contributed to these statistics. Clinicians are more likely to make errors at nighttime and daytime operation of inserting nasogastric tubes is fundamental to avoid error (McCutcheon et al, 2018).

Bourgault et al, (2019) studied 20 nurses who had inserted a mean of 53 Cortrak® nasogastric tubes. All super users were deemed competent, although one received remediation for improper receiver placement. Participants thought that 8 placements were required to feel competent, although confidence was improved at 10 insertions. However, the study concluded that 3 placements were necessary to demonstrate competence; although this number should be determined by each super user; with a minimum of two placements per week to maintain the skill. Patient safety is fundamental and this procedure is a high risk skill so training should be comprehensive.

McCutcheon et al, (2018) carried out a team review using Cortrack® between 2012 and 2015 in a large hospital in Florida, United States of America (USA). They reviewed 6290 placements for 4239 patients which resulted in 0 lung or esophagus placements. All placements were either gastric (12.78%), 13.39% in the duodenum or 73.83% jejunum. X-ray was not eliminated but use reduced by 74%. A cost saving of $346,000 was made. Education was extensive for a dedicated insertion team. There has been mixed reviews of the Cortrak® nasogastric tube and there is no denying the procedure is high risk as it is with any other method for insertion (Taylor et al, 2017; Metheny et al, 2017).

Brazier et al, (2017) reports 64% of nasogastric tubes in stroke patients are displaced due to patients and 9% slipped. Delays are common in feeding patients due to a loss of tubes and medications are omitted for the same reason. The Corgrip® is a feeding tube retention system that holds the nasogastric tube or nasojejunal tube in place and is inserted using magnets with the tape fastened with a clip just below the nostril to prevent tube displacement.

Ten super users were identified for training as this is thought to be the most effective method to prevent errors. Avanos the company that supplies the Cortrak® machine and nasogastric tubes provided a four-hour training session with an educator with the afternoon available for expert guided nasogastric insertions. Training was provided using a PowerPoint presentation, practical training on device operation using a mannequin, smart receiver unit placement, insertion interpretation and a quiz to assess knowledge. Trainees were provided with time to practice using the mannequin, and then two nasogastric tubes were placed, one on a patient and one on a trainee at their request supervised by the Avanos educator. For two weeks after this, the educator was contactable 24 hours per day for assistance with nasogastric tube insertions. After this time, the educator was available for discussion or support. Each placement was documented and check list completed, with insertions checked by the ward educator and monitored. The trial was set up to insert 30 tubes with x-ray confirmation of correct placement.

The trial ran over 3 months to ensure the 30 tubes were inserted. Some super users were more confident to insert nasogastric tubes and carried out more insertions. Some of the super users were worried about using the new technology and ensuring they carried out the procedure correctly which was a barrier to inserting nasogastric tubes without support.

The procedure used included gaining consent where possible from the patient, explaining the process, setting up the monitor by putting in the user id and password, and the patients’ details. The nasogastric tube was measured for length using the Nose, Esophagus, Xipisternum (NEX) measurement, preparing the tube by flushing with 10 mls of water to activate the lubricant in the lumen of the tube. The nasogastric tube was attached to the Cortrak® monitor, the patient’s bed head raised to a comfortable position and the tip of the smart receiver unit placed on the patients’ xiphoid process parallel with the spine. Tape was prepared to secure the tube in case a Corgrip® was not tolerated. A second nurse supported the first nurse with the smart receiver unit placement to ensure it did not move during placement and the patient was supported.

The main screen of the monitor allows 3 placement views – Anterior, Depth and Lateral. Anterior (the larger screen) and Depth views are the default screens for any tube placement. The Anterior View is divided into 4 quadrants with a vertical line representing a mid-sagittal line and a horizontal line representing the diaphragm. The point where these lines intersect is indicative of the patient’s xiphoid process.

The nasogastric tube was advanced into the nose for 10-15cms, once this was achieved, the button on the monitor or the smart receiver unit was pressed to activate the tube. Once this had been completed, the tube was advanced and the trace appeared on the screen of the monitor with a green ball. This ball should track near the centre of the midline. If the ball deviates to the right or left in the top upper quadrants, it is going towards the lung, and should be removed and the procedure started again. Due to the dysphagia of some of the patients, we were able to identify when this was happening in real time so we could remove and start again. However, if the tube continued to advance down towards the intersecting lines and further to the lower right quadrant then the tube was entering the stomach. On the smaller depth view screen, a blue horizontal line can be seen to move upwards as the tube is passing through the oesophagus and into the stomach. Once the tube insertion was completed and the clinician was satisfied with the position, the end button on the machine or smart receiver unit was pressed to stop the procedure. Once complete the placement recording can be observed on the screen to ensure correct tube placement and a placement view label can be printed for recording in the patients notes. Once the equipment is set up and patient positioned, it can take less than a minute to place the nasogastric tube.

Initially the super users needed some time to practice the technique as the process was slightly different to other insertions. However, some indicated that the tubes were easier to place and the monitor helped to ensure the tube was placed correctly as lung placements were detected instantly on patients with very poor swallow reflexes. Initially some super users were placing the tubes too far beyond the stomach, but as the procedure was practiced, the accuracy improved, and nurses felt comfortable after 5-7 placements. This is consistent with other reports where x-ray is used to confirm placements in 3-10 insertions until the super user feels comfortable (Bourgault, Gonzalez, Aguirre and Ibrahim; 2019).

The Corgrip® bridle system was also used during the trial. Nurses discovered that this worked more effectively without the lubrication provided in the pack as the lubrication could make the magnets less sensitive. Both tubes were prepared by angling the two ends inwards so when they meet behind the nasal bone, the magnets would connect more easily. Both tubes were inserted far more than we expected, almost the whole way in. A click would be felt when the tubes combined via the magnets. Once in place the yellow tube would be pulled out to bring the tape around and out through the other nostril. Once this happened, the other tube could be pulled out, the tape secured with the clip below the nose and tied below the clip to ensure securement.

When the trial was complete, 39 placements were recorded and observed. Out of 39 placements, 32 were in the stomach, 4 were further than the stomach and 3 results were unavailable possibly due to the tube being pulled out prior to x-ray confirmation. Some patients were difficult to pass a Corgrip® on due to agitation or patient distress.

The time taken to pass the Cortrak® nasogastric tubes and Corgrip® was 30 minutes to 1 hour and 30 minutes. The 1 hour and 30 minutes was for a very difficult patient with a head injury and was not our usual scenario. During the trial x-ray was used to confirm placement which took 1 hour 30 minutes to up to 12 hours. The exposure to x-ray would be reduced as some patients ended up with four x-rays without a Corgrip® in place. Overall, the number of x-rays completed on the patients will be reduced once the superusers felt comfortable. The cost of X-ray was $200 per department x-ray. The cost of a bedside x-ray was unknown. However, there was also an unknown cost of time visiting the x-ray department when patients were escorted by a nurse and the time for an orderly transfer and the cost of radiology staff. Regardless of this, there are occasions when the x-ray is still required to check placement such as when anatomy differs or placement has been difficult due to patient movement. Therefore, x-ray was not eliminated but reduced.

The number of health care assistants carrying out observation and engagement to prevent the removal of nasogastric tubes has been reduced for patients who can tolerate the insertion of a Corgrip® system, although it was impossible to put a cost reduction on this. If intensive care inserts the Corgrip® on sedated neuroscience patients, we would have an increased number of tubes secured with a Corgrip® system. If the Cortrak® machine was used for 3 years, the cost of nasogastric tube insertion could be reduced to $66,900 from $177,480 without Cortrak® which doesn’t factor in the cost of bedside x-ray or the cost reduction in health care assistants carrying out observation and engagement to prevent patient dislodgement of tubes.

The Cortrak® 2 EAS can be used at the bedside to prevent blind placement which is particularly fundamental in the neuroscience population, where dysphagia and consciousness impact tube insertion. Controversy has arisen over the use of the Cortrak® 2 system but the misplacement reports are favourable for Cortrak® 2 rather than x-ray. The UK had 195 reports where just under half of these were misplacements from x-ray confirmation (National Patient Safety Alert (NPSA, 2011; NHS improvement, 2016). The misplacement report from the MAUDE database in America was 54 misplacements from Cortrak® which is about half the reports of the UK one. In both reports these events are most likely underreported. However, lung placement is not unique to Cortrak® and is a real risk for all feeding tube insertions (Bourgault et al, 2017).

X-ray has been considered the gold standard, but these can be misinterpreted and have had fatal results. Although it would be fantastic to report 100% accuracy, there is a need to look at why these events have occurred, of which reports state the education was not adequate and tubes were placed overnight which McCutcheon et al (2018) warns against. McCutcheon et al (2018) achieved 100% accuracy in their 6290 placements using Cortrak® 2 and it is important to note their team approach as consistency is key. They also provided a robust education program with regular practice of the procedure to maintain competence. Koopmann et al (2011) recommends the combination of a dedicated insertion team and the use of technology eliminates morbidity and mortality in high risk patients. Furthermore, Taylor et al (2017) recommends the recognition of gastric body flexures and Pre-GOJ during education and during placements to prevent error which should be noted.

In the local trial, staff were educated by an Avanos educator and supported for two weeks during placements. The educator of the ward was trained to oversee the nurses in their placements so they had ongoing support. As this was a common procedure with new technology, nurses lacked their usual confidence in tube insertion, but with practice this improved. Insertion of nasogastric tubes in patients with dysphagia has been difficult, relying on patient observation and oxygen saturations for misplaced tube identification. However, with the Cortrak® 2 EAS the lung placement was detected early, tube pulled back and re-inserted correctly. One patient with Parkinson’s disease said he had his nasogastric tube replaced previously with sedation by an Ears, Nose and Throat clinician (ENT). On the first insertion with the Cortrak® 2 EAS, the tube was instantly observed going towards the lung, pulled back and on the second try, reinserted into the stomach. He did not have clinical signs to identify incorrect placement. Dysphagia is a common cause for nasogastric tube insertion and can more easily result in misplacement on the neuroscience ward and therefore the Cortrak® 2 EAS has been instrumental for these patients.

Initially the procedure to insert the Corgrip® system seemed difficult and not well tolerated amongst the neuroscience population but as some of the super users perfected the technique, the success rate improved and the time for insertion reduced. One patient who had pulled six tubes out, did not pull the tube out with the Corgrip®. Three health care assistant watches were removed from three patients within one week as this was the sole reason for the watch to be in place. This was a very encouraging result. Initially this procedure took a considerable amount of time up to 20 minutes with one case taking 1 hour and 30 minutes with the support of the Ears Nose and Throat (ENT) department due to agitation and a lack of compliance. Once competent this can be completed within 5 minutes if the patient is compliant. The difficulty with insertion was around the patient type and agitation or compliance. As a result intensive care has been asked to support Corgrip® insertions and insert when patients are unconscious so less distressing for them and their families. It was important to assess the comfort and the length of time the tube remained in situ with the Corgrip® in place.

There was a week where patients were constantly pulling out their tubes and once secure with a Corgrip®, three patients were able to receive their prescribed nutrition for the duration of the need for the nasogastric tube. One patient who was being discharged into the community with terminal cancer, said the tube felt much more comfortable once the Corgrip® was in position and prevented scratching of the nose due to the itchy tape. The partner who was to carry out the feeding felt much more comfortable knowing the tube was unlikely to dislodge with the Corgrip® in place. Most of the patients were unable to comment on the comfort of the tube due to their condition. However, it is known that patients scratch their nose due to the itchy sensation of the tape resulting in the removal of the tube.

Important points as identified by Bourgault et al (2019) were to correctly identify the patient and any contra-indications for tube insertion such as basal skull fracture or coagulation derangements. The head of bed at 30-45 degrees was also important for successful insertion as with all nasogastric tubes. Preparation of the tube, by flushing with water, prior to insertion activating the water soluble lubricant on the tip and lumen was essential. The smart receiver unit placement was fundamental for accurate placement and correct tracing interpretation was also important.

As a result of this trial, more super users have been trained to ensure the procedure can be sustained. The time to feeding has been greatly reduced to ensure patients receive adequate nutritional intake and the constant reinsertion of dislodged tubes has been avoided saving time. The superusers have found Cortrak® 2 nasogastric tube placements advantageous in the neuroscience patient population and misplaced tubes by the patient can easily be replaced in a matter of minutes. A detailed hospital-based guideline has been created and approved by Avanos. The superusers must practice regularly to maintain their skills. X-ray has not been eliminated but greatly reduced and supervisors can use/access x-ray at any time to confirm position.

The hospital is currently evaluating the need for a nutritional team which would include Cortrak® super users to provide a service to the whole hospital including the insertion of post pyloric tubes. The Cortrak® 2 has changed practice and improved patient safety, with the ability to instantly correct misplaced tubes and is ideally placed for use with neuroscience patients where insertion can be more challenging and time consuming. The Cortrak® 2 should be used by a small team to ensure accuracy with a robust education program.