Annette M. Bourgault

AACN Levels of Evidence: What’s New?

tice related to disease management or skills. As a leader in this area, the American Association of CriticalCare Nurses (AACN) has published numerous resources to help practitioners appraise evidence for integration into clinical practice. Publications such as Practice Alerts, Protocols for Practice, and Procedure Manual contain recommendations for clinical practice based on a comprehensive and scientific review of the evidence. To support these recommendations, AACN developed a hierarchy system to grade the level of evidence. AACN’s grading system was originally referred to as a rating scale and was used to rank individual recommendations according to the level of supporting evidence available (Table 1).

Feeding Tube Placement in Adults: Safe Verification Method For Blindly Inserted Tubes

E nteral feeding is a common and necessary practice in critical care. Clinical practice for verification of smalland large-bore feeding tubes is variable. Although radiographic confirmation is the reference standard for blindly inserted small-bore tubes, it is not consistently performed to verify large-bore tubes before administration of formula or medication. These practices raise concerns; both smalland large-bore tube placement in the tracheobronchial tree have been reported. Malpositioning has also involved the intracranial cavity. In a review of more than 2000 insertions of small-bore tubes, 50 pulmonary placements (3%) were detected. In another study, the incidence of inadvertent pulmonary placement did not differ between smalland large-bore tubes. Of note, endotracheal or tracheostomy tube cuffs do not prevent pulmonary malposition. Unfortunately, pulmonary malplacement may occur silently, without coughing, dyspnea, or oxygen desaturation. Adding confusion, aspirated fluids that resemble gastric fluids have been obtained from tubes placed in the lungs. Malpositioned tubes may cause pneumonia, pneumothorax, perforations, empyema, and bronchopleural fistula—events that can lead to death in rare cases. The Joint Commission identified pulmonary malposition of nasogastric tubes as one of the most frequent procedural complications that result in postoperative sentinel events. Expert recommendation included checking tube placement with an abdominal radiograph. Also, failure to report malpositioned tubes and complications due to insertion continues to be a problem. In addition to pulmonary malposition, aspiration risk is high when tubes are placed in the esophagus A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click “Respond to This Article” on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Circle of excellence

18 November 2008 Nursing Management R outine patient rounding, once considered a standard of care in the nursing profession, has recently reemerged with a twist. New research shows that hourly patient rounding increases patient satisfaction and decreases patient falls and call-light usage when performed in a standardized and consistent manner.1 Patients expect nurses to have the knowledge and technological skills necessary to perform their jobs, but often rank satisfaction based on perception of nurses’ caring.2 Further, hospital satisfaction is frequently correlated with patient perceptions of nursing care.3,4 Themes equated to quality nursing care include good communication, kindness, responding Does regular rounding by nursing associates boost patient satisfaction?

Cortrak-Assisted Feeding Tube Insertion: A Comprehensive Review of Adverse Events in the MAUDE Database

Background Electromagnetic devices to guide feeding tube placement such as the CORTRAK Enteral Access System have shown promising results; however, researchers in recent studies have expressed concern that a higher level of user expertise may be required for safe use. Objectives To review adverse events related to CORTRAK‐assisted feeding tube insertion reported in the Food and Drug Administrations Manufacturer and User Facility Device Experience (MAUDE) database. Methods A retrospective, secondary analysis of the MAUDE database was performed to evaluate adverse events (ie, injury or death of patient) related to CORTRAK. Results Fifty‐four adverse events between January 1, 2006 and February 29, 2016 were identified and reviewed. Most events (98%) involved feeding tube placement in the lungs (37%, left lung; 46%, right lung; 15%, not specified). Lung complications included pneumothorax (77%) and pneumonitis (21%). Death occurred in 17% of lung placements. Clinicians failed to recognize placement in 89% of CORTRAK insertion tracings reviewed. Conclusions Lung placement is not unique to CORTRAK and is an inherent risk of all feeding tube insertions. In known or suspected lung placement, feeding tubes should be removed and radiography performed to assess for pneumothorax. Clinicians must observe closely for lung placement and discriminate lung from gastric placement on insertion tracings. Clinicians require specialized training and experience to develop competency in using the CORTRAK device, although the exact amount of experience needed is unknown.

Methods Used by Critical Care Nurses to Verify Feeding Tube Placement in Clinical Practice

BACKGROUND The American Association of Critical-Care Nurses practice alert on verification of feeding tube placement makes evidence-based practice recommendations to guide nursing management of adult patients with blindly inserted feeding tubes. Many bedside verification methods do not allow detection of improper positioning 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 Nurses practice 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 of auscultation methods, only 12% of nurses avoided this practice all of the time. CONCLUSIONS Implementation of expected clinical practices from this guideline varied. Nurses are encouraged to implement expected practices from this evidence-based, peer reviewed practice alert to minimize risk for patient harm.