The Journal of Continuing Education in Nursing

Original Article 

Sumping's Up: A Multidisciplinary Educational Initiative on Gastric Drainage Tubes

Rachel N. Saunders, MD; Kathrine A. Kelly-Schuette, DO, BSN; Alan T. Davis, PhD; Tracy J. Koehler, PhD; Benjamin N. Gayed, MD; Luke T. Durling, MD; Alistair J. Chapman, MD; Charles J. Gibson, MD

Abstract

Background:

Nasogastric tube placement is widely taught, and tube maintenance relies on astute nursing care with adherence to both institutional and evidence-based recommendations. However, precise adherence to current recommendations relies on knowledge base regarding the identification of malfunctioning gastric drainage tubes. Troubleshooting skills are crucial in maintaining patient safety and recognizing malfunction.

Method:

Educational sessions on nasogastric and orogastric decompression tube management, led by a surgical intensive care fellow at a level 1 trauma center, were offered to critical care nurses. A presession and postsession survey evaluated the nurses' subjective and objective knowledge and comfort with naso/orogastric decompression tube management.

Results:

Ninety-seven critical care RNs participated. For all questions, the proportion of correct answers significantly increased from presession survey to postsession survey (p < .001). Ninety-seven percent of all participants found the session to be very helpful.

Conclusion:

Physician-led educational sessions on naso/orogastric decompression tube management were well-received and improved subjective and objective measurements of nurses' knowledge and comfort level with gastric decompression tubes. [J Contin Educ Nurs. 2020;51(10):484–488.]

Abstract

Background:

Nasogastric tube placement is widely taught, and tube maintenance relies on astute nursing care with adherence to both institutional and evidence-based recommendations. However, precise adherence to current recommendations relies on knowledge base regarding the identification of malfunctioning gastric drainage tubes. Troubleshooting skills are crucial in maintaining patient safety and recognizing malfunction.

Method:

Educational sessions on nasogastric and orogastric decompression tube management, led by a surgical intensive care fellow at a level 1 trauma center, were offered to critical care nurses. A presession and postsession survey evaluated the nurses' subjective and objective knowledge and comfort with naso/orogastric decompression tube management.

Results:

Ninety-seven critical care RNs participated. For all questions, the proportion of correct answers significantly increased from presession survey to postsession survey (p < .001). Ninety-seven percent of all participants found the session to be very helpful.

Conclusion:

Physician-led educational sessions on naso/orogastric decompression tube management were well-received and improved subjective and objective measurements of nurses' knowledge and comfort level with gastric decompression tubes. [J Contin Educ Nurs. 2020;51(10):484–488.]

Nasogastric and orogastric tubes are commonly placed in the hospital. In some situations, they are used to administer enteral medications and nutrition. In other situations, they function as gastric decompression tubes (GDTs) when used to prevent emesis and reduce patients' discomfort from gastroparesis, ileus, and bowel obstruction. Nasogastric and orogastric tube insertion and verification is extensively taught in nursing school and texts (Hallowell, 2015; Taylor et al., 2015). Additionally, the American Association of Critical Care Nurses (AACN) practice guidelines reinforce the importance of ongoing assessment of feeding tubes and necessity of radiographic confirmation for suspected displaced tubes (Metheny, 2016). However, identification of malfunctioning tubes is not explicitly defined and troubleshooting GDTs is often limited to obtaining radiographic confirmation (Hallowell, 2015; Metheny, 2016; Surratt, 1993). Furthermore, adherence to current recommendations relies on knowledge regarding the function and identification of malfunctioning GDTs.

In the authors' experience while rounding in the surgical intensive care unit, it is common to find GDTs malfunctioning. At our institution, education and guidelines on GDTs focus on insertion, removal, and feeding procedures. The current policy recommends ongoing assessment during each shift and notification of the provider upon recognition of any malfunction (Houseman, 2017). Upon further discussions with bedside nursing, we discovered a pattern of lack of recognition of GDT malfunction and difficulty troubleshooting any malfunction. Specifically, we identified a knowledge gap surrounding the bi-lumen tubes and use of the sump port. Interestingly, the use of the sump port is defined in the manufacturer's instructions for use, but our current policy only briefly mentions proper use and assessment of the sump port (Cardinal Health, 2011; Houseman, 2017). Therefore, the purpose of our study was to assess nursing understanding and comfort with maintaining and troubleshooting GDT before and after an educational session. We hypothesized there was a knowledge gap regarding GDTs and a short educational session would improve both subjective comfort and understanding.

Method

Physician-led educational sessions on GDT management were offered to surgical critical care nurses during previously planned nursing skill review sessions and surgical rounds. Development of education sessions relied on current literature, AACN practice guidelines, current institutional policy, manufacturer instructions for use, and nursing textbooks. A review of both nursing and surgical literature was conducted using PubMed® and EBSCO-host and the key word nasogastric tube with the following terms: gastric drainage, salem sump, sump port, structure, function, use, troubleshooting, guidelines, and maintenance. This was completed independently by the study investigators during the development of the education and survey.

The educational sessions were led by a surgical intensive care fellow at a level 1 trauma center. The development and assessment of this educational initiative were considered a quality improvement project and deemed to be exempt from review by the institutional review board. This initiative was not part of the research requirements for the surgical critical care fellow. The education was provided in small groups with a physician to nurse ratio ranging from 1:1 to 1:6 and lasted 10 minutes. No formal instructional design model was used; however, manufacturer guidelines, institutional policy, and current literature was used to develop the educational content. The educational sessions were delivered in a short verbal lecture format with demonstration using bi-lumen GDTs that are most commonly used in the surgical intensive care unit. Time for questions from attendees and hands-on demonstrations with the gastric drainage tube was included in the educational session.

Only RNs currently working in the surgical intensive care unit were included in the study. No students or unlicensed personnel were included. Nurses were asked to complete a presession and postsession survey to evaluate their understanding of GDTs and to evaluate the session's utility. The survey was anonymous, and participants were not asked for identifiable information. The survey was developed by a panel of board-certified surgical critical care physicians, a surgical critical care fellow, and a general surgery resident with previous experience as an RN in trauma and critical care.

Summary statistics were calculated. Individual questions were analyzed using the McNemar test. Pearson's r was used to assess correlations between years of nursing experience and scores. Significance was assessed at p < . 05.

Results

A total of 97 critical care nurses participated in the educational session. Of the participants, 17.5% were charge nurses and the median nursing experience was 4 years (Table 1). All participants completed a presession and postsession survey (Table 2).

Respondent Demographics (N = 97)

Table 1:

Respondent Demographics (N = 97)

Survey Administered to Critical Care Nurses Before and After a Physician-Led Educational Session on Naso/Orogastric (NG/OG) Decompression Tube Management

Table 2:

Survey Administered to Critical Care Nurses Before and After a Physician-Led Educational Session on Naso/Orogastric (NG/OG) Decompression Tube Management

Table 3 shows the percent of correct answers on the objective questions before and after the session. For all questions, the proportion of correct answers significantly increased from presession survey to postsession survey (p < .001). Neither years of nursing experience nor charge nurse experience were significantly correlated with scores on the presession survey (r = .09 and r = .08, respectively) or postsession survey (r = −.12 and r = −.09, respectively).

Objective Questions Percent Correct on the Presession Survey and Postsession Survey

Table 3:

Objective Questions Percent Correct on the Presession Survey and Postsession Survey

Forty-one (42.3%) of the respondents reported an increased understanding/comfort level managing naso/orogastric tubes from presession to postsession survey (p < .001). Ninety-seven percent of all participants found the session to be very helpful.

Discussion

Prior to the 20th century, nasogastric tubes were occasionally used for decompression. In the 1920s, nasogastric and nasoduodenal decompression became routinely incorporated into general practice (Friedenwald & Morrison, 1938; Wangensteen & Paine, 1933). In the past hundred years, the design of GDTs has undergone two main changes: use of more flexible materials, and in the 1960s, the addition of a second lumen, the sump (Boyes & Kruse, 1992; Ikard & Federspiel, 1987). Relative to their historical presence and common use, the bi-lumen tubes with detailed use of the sump port is rarely described in current literature and guidelines (Hani et al., 2015; Metheny, 2016; Surratt et al., 1993). Our study demonstrates that nursing knowledge around GDT function and troubleshooting is low despite their common use. The pre-education survey showed that only 4.1% to 57.7% of the four questions about GDT management were answered correctly. Surprisingly, there was no significant correlation between years as a nurse and scores on the pretest (r = .076; p = .459). With this in mind, physicians have a great opportunity to collaborate with nurses to ensure GDTs are properly functioning and maintained.

There was a significant improvement in objective GDT related knowledge after the fellow-led education measured by our postsession survey; scores improving to 87.6% to 99% correct. Prior studies have demonstrated that medical students find resident physicians to be effective educators and resident teaching sessions can be of high-quality, well-informed, and enthusiastic (Cooper et al., 2012; George et al., 2018; Karlen et al., 2016; Ting et al., 2016). Although resident physicians can be successful instructors, the effectiveness of a fellow-led educational initiative has not been studied as a method to improve ongoing nursing education. We demonstrated that a critical care fellow leading educational sessions can also be well-received, with 97% of the participating nurses finding the session to be very helpful. There is a paucity of literature on physician-led educational initiatives related to nursing knowledge and skills, specifically GDT function. However, nursing faculty teaching clinical skills such as nasogastric tube placement to medical students was well-received (Abdallah et al., 2014). Improvements in patient care have been demonstrated to occur by cultivating teamwork and facilitating the relationship between nursing and surgical providers (Cooper et al., 2012; Silinzieds et al., 2012). Additionally, prior studies have also demonstrated positive nurse–physician communication and relationships help to increase patient and nursing satisfaction, decrease nurse burnout, and patient mortality (Knaus et al., 1986; Vahey et al., 2004). In extreme cases, a collaborative education program in a Nepalese community empowered nursing and other health care staff to continue complex surgery (Silinzieds et al., 2012). Our small-group education sessions led to a discussion between the fellow and nurses, which enabled knowledge sharing, improved communication, and understanding.

In postoperative and critically ill patients, GDT dysfunction can be life threatening. Improperly placed or malfunctioning GDTs can lead to aspiration, pneumonia, and death (DeLegge, 2002; Hani et al., 2015). Even properly functioning nasogastric tubes can cause patients significant pharyngalgia (Pan et al., 2014). To ensure proper functioning, GDTs need to be regularly assessed (Surratt et al., 1993). Our study demonstrates the impact of multidisciplinary collaboration on education about a common scenario that is frequently encountered across both nursing and surgical specialties. Interprofessional education is considered the gold standard for developing and initiating educational improvements even in the absence of randomized controlled trial data. However, developing interprofessional education can be difficult due to time restrictions for clinicians and interruptions of work-flow (Seymour et al., 2013). This study is one example of a multidisciplinary educational opportunity that highlights the differing knowledge across professions and the utility of transferring this knowledge effectively.

Our approach has limitations due to the scope of education provided by one critical care fellow to one unit of nurses. Another limitation includes the lack of detailed demographic data regarding sex, education, and degree of each participant. Specifically, nurses with advanced education are expected to have increased competence in evidence-based practices. Additional investigation into the variation in knowledge of GDTs based on sex or advanced degree could be the focus of future studies. Additionally, our study only measures a short-term response without long-term follow up or assessment of patient outcomes. Anecdotally, the staff that have received the educational session are more likely to recognize and troubleshoot GDT malfunctions prior to notifying the physician. The overall number of malfunctioning GDTs found on rounds before and after the education session is unknown. Evaluation in both time frames would be helpful to validate our findings and determine the long-term effectiveness of the education. Ultimately, this approach required the development of a relationship and communication between each professional involved. Our method was easily instituted as part of the quarterly nursing education and could be incorporated into daily rounds by the critical care fellow. Continuing nursing education in real time by surgeons, residents, and fellows may be one way to improve communication, understanding, and, ultimately, patient care. Surgeons must still develop and maintain unique individual skills because surgical care does not happen in a vacuum (Seymour et al., 2013). However, a goal of educational initiatives for nursing and surgical teams should focus on improving multidisciplinary education, collaboration across professions, sharing resources, fostering communication, and enabling patient-centered care. Currently, the education we have described is not integrated into new nurse orientation; however, it is incorporated into quarterly institutional education sessions that nurses attend depending on assigned unit. The authors hope that in the future this can be incorporated into new nurse orientation and expanded to include nursing students, medical students, and patient care technicians. Additional development of interprofessional simulation, collaborative educational initiatives, and training exercises by nursing, residents, fellows, and surgeons may lead to a more sustainable improvement in both understanding and outcomes.

Conclusion

This physician-led educational session on GDTs was well-received and improved subjective and objective measurements of nurses' knowledge and comfort level with GDTs. Further studies on the long-term retention and patient outcomes of educational interventions related to GDT management would be beneficial.

References

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Respondent Demographics (N = 97)

Variablen
Charge nurse17 (17.5%)
Nursing experience (years)4 (range = 0.5–31)
Inpatient experience (years)3 (range = 0.5–31)

Survey Administered to Critical Care Nurses Before and After a Physician-Led Educational Session on Naso/Orogastric (NG/OG) Decompression Tube Management

Question/StatementResponsea
1. I understand how NG/OG tubes work and I am comfortable with ensuring NG/OG tubes are working properly:Not at all, mildly, somewhat, competent, or expert
2. What is the purpose of the blue tubing on the NG/OG tube?Free text
3. The blue tubing on the NG/OG tube can be flushed with:Nothing ever, tap water, air, or tissue plasminogen activator
4. The NG/OG tubes that we use are designed to be on:Continuous suction, or intermittent suction
5. When the NG/OG makes a whistling sound:It is malfunctioning and the white/blue valve should be flipped, or it is working properly.
6. I am a charge nurse:Yes or no
7. Years working as a nurse:Free text
8. This talk was helpful (postsession only):Not at all, mildly, somewhat, or very
9. Please include any comments to improve the talk (postsession only):Free text

Objective Questions Percent Correct on the Presession Survey and Postsession Survey

Question No.Correct (Presession)Correct (Postsession)p Value
219.6%90.7%< .001
357.7%96.9%< .001
44.1%87.6%< .001
547.4%99%< .001
Authors

Dr. Saunders is Critical Care Fellow, Dr. Kelly-Schuette is Research Fellow, Dr. Davis is Scholarly Activity Support, Dr. Koehler is Scholarly Activity Support, Dr. Gayed is Core Faculty, Dr. Durling is Core Faculty, Dr. Chapman is Core Faculty, and Dr. Gibson is Core Faculty, Spectrum Health/Michigan State University, General Surgery Residency, Grand Rapids, Michigan.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Kathrine A. Kelly-Schuette, DO, BSN, Research Fellow, Spectrum Health, Michigan State University, General Surgery Residency, 100 Michigan NE, Suite A501, Grand Rapids, MI 49503; email: Kathrine.kelly@spectrumhealth.org.

Received: December 09, 2019
Accepted: May 04, 2020

10.3928/00220124-20200914-11

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