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Misplaced nasogastric and percutaneous endoscopic gastrostomy tubes pose a serious threat to patient safety and a liability risk for hospitals. New technology might improve the detection of misplaced tubes.
Every year, nearly 500,000 nasogastric (NG) and percutaneous endoscopic gastrostomy (PEG) tubes and suction tubes are misplaced, which result in severe complications or death, notes Paul J. Gilbert, MD, FACEP, an emergency physician who owns a private physician group of seven emergency department physicians in the Scottsdale, AZ, area.
After Gilbert lost a patient due to a misplaced tube, he realized something needed to be done to enhance patient safety. He now focuses on educating physicians and healthcare organizations about the risk of misplaced tubes, and along with colleagues, he has developed three new point-of-care diagnostic devices to provide safer NG tube placement and more accurate gastric acidity measures for critically ill patients. Gilbert’s pH indicator tools, which are the RightSpot, RightLevel, and RightSpot Infant, are sold by RightBio Metrics in Scottsdale. Each device costs $10 or $13, depending on the purchase quantity.
RightSpot is a small, non-invasive in vitro diagnostic device that is used to verify gastric acidity to avoid misplacement of nasogastric feeding/suctions tubes and PEG tubes; the infant product serves the same purpose. The RightSpot indicator is placed on the tube and gastric fluid is aspirated; a pH below 4.5 would indicate gastric acidity. The RightLevel is similar but designed to facilitate proper treatment of gastric ulcers and bleeding, which involves administering medication in dosages appropriate for a specific stomach pH level.
Gilbert provides these facts:
• Studies show between 2% and 4% of all tubes are misplaced.
• Misplaced tubes are typically misguided into the lungs, which causes significant morbidity and mortality and costs medical providers millions of dollars.
• From 2001 to 2011, medical providers in the Chicago area alone paid more than $10 million to resolve lawsuits filed for injuries and deaths caused by misplaced NG feeding and suction tubes.
• Between 1993 and 2014 there were about 1,750 malpractice cases in the United States that were in some way related to placements of tubes; 412 of these cases directly stated that there was a misplacement issue.
• Of the 412 cases that related directly to the misplacement of NG, PEG, or suction tubes, 25 of them showed the settlement costs. NG tubes were involved in 173 settlements for tube misplacement, with an average cost of settlement being $1.07 million. For PEG tubes, there were 81 settlements for tube misplacement, with an average cost of settlement being $3.28 million. There were 119 settlements for suction tube misplacement, with an average settlement cost of about $1 million.
The common methods for checking tube placement involve X-rays or using pH paper to check the fluid in the tube, but Gilbert’s devices provide what he says is a safer and easier way to check the pH of the fluids without removing them from the patient. The pH paper is contained in the plastic housing of the single-use device, so the fluid makes contact with the test strip there. “It’s a very hot topic, especially with kids because we don’t want to expose them to X-rays,” Gilbert says. “There have been some very highly publicized cases of infant death, and that looks very bad for a hospital. It’s a topic that risk managers should be involved in, so they can push for improvements on a problem that is occurring more often than they might realize.”
Defending an NG tube misplacement malpractice case can be exceptionally difficult because it is widely recognized that the standard of care requires confirmation of proper NG tube placement in some manner, says Edward McNabola, JD, a partner with the McNabola Law Group in Chicago. The traditional approach of using auscultation to confirm placement is notoriously unreliable and, therefore, does not satisfy the standard of care, McNabola says.
“I have a vivid memory of a widow coming to speak with me about the tragic loss of her husband and father of her children. In short, the physician inserted the NG tube and assumed that it was in the stomach, based upon auscultation. However, the NG tube was actually in his lung, and they delivered charcoal and other substances into the lung, resulting in cardiopulmonary collapse, anoxic brain injury, and his eventual death,” he says. “My firm filed a lawsuit against the healthcare providers and the hospital and successfully resolved the case for settlement in excess of $900,000.”