title: Patient safety: effect of institutional protocols on adverse events related to feeding tube placement in the critically ill.
abstract: BACKGROUND
  Inadvertent passage of a nasoenteric feeding tube into the tracheobronchial tree can result in pneumothorax. Measures requiring feeding tube passage to 35 cm only followed by a radiograph to verify intraesophageal placement and creation of a specialized placement team were implemented to decrease the incidence of procedure-related pneumothorax. This study evaluates the effectiveness of our safety measures.
  
  
  METHODS
  Radiology reports from January 2000 through July 2003 were searched by computer with an algorithm designed to detect feeding tube placements possibly associated with the complication of intrabronchial placement or pneumothorax. Results were manually examined to eliminate false positives and verify causality.
  
  
  RESULTS
  Feeding tubes were placed in 4,190 unique patients during the study period; 87 patients had an intrabronchial malposition, and 9 experienced a pneumothorax caused by their feeding tube. The safety measures resulted in a significant decrease in procedure-related pneumothorax (0.09% versus 0.38%, p < 0.05), and a decrease in pneumothorax among patients with an intrabronchial placement (3% versus 27%, p < 0.05). More than two-thirds of patients with a misplaced tube had an endotracheal tube or tracheostomy, illustrating that such patients are not protected. Repeated malposition in the same patient was surprisingly common; 32% of patients with one intrabronchial misplacement ultimately had multiple misplacements. The risk of pneumothorax increased with misplacement at night (p < 0.05) and increased exponentially with each additional misplacement (p < 0.05).
  
  
  CONCLUSIONS
  Creating a specialized placement team, and initiating the safety measure of limiting feeding tube placement to 35 cm and obtaining a radiograph before full advancement reduced the incidence of procedure-related pneumothorax.
authors.affiliation: Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA. mardersteinel@msx.upmc.edu
authors.forename: Eric L
authors.initials: EL
authors.lastname: Marderstein
authors.forename: Richard L
authors.initials: RL
authors.lastname: Simmons
authors.forename: Juan B
authors.initials: JB
authors.lastname: Ochoa
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D004750:Enteral Nutrition / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006761:Hospitals; D006801:Humans; D008297:Male; D008875:Middle Aged; D005791:Patient Care / Q000592:standards*; D011030:Pneumothorax / Q000000981:diagnostic imaging / Q000209:etiology / Q000517:prevention & control*; D011785:Quality Assurance, Health Care / Q000379:methods*; D011859:Radiography; D012189:Retrospective Studies; D012449:Safety; D016896:Treatment Outcome