Development of a Clinical Practice Guideline
First received
Blackwell xxxx xx,Inc
Publishing xxxx; Revision received xxxx xx, xxxx; Accepted for publication xxxx xx, xxxx.
for Testing Nasogastric Tube Placement
Sue Peter and Fenella Gill
PURPOSE.
standardized changes to nasogastric tube
placement, including removal of the “whoosh
test” and litmus paper, and introduction of
pH testing.
DESIGN AND METHODS.
conducted: bedside data collection at a pediatric
hospital and a point-prevalence audit across seven
hospitals.
RESULTS.
tests and pH was ≤ 5.5 for 84%, validating the
practice changes. However, patients on
continuous feeds and/or receiving acid-inhibiting
medications had multiple pH testing fails.
PRACTICE IMPLICATIONS.
placement continues to present a challenge for
those high-risk patients on continuous feeds
and/or receiving acid-inhibiting medications.
Search terms: Children, nasogastric tube
testing, pH aspirate
First received August 30, 2007; Revision received December 6,
2007; Accepted for publication January 11, 2008.
© (2008), The Authors
Journal Compilation © (2008), Wiley Periodicals, Inc.
A Perth metropolitan hospital group Sue Peter, SRN, RSCN, MSc, is Nursing Director,
Ambulatory Care, Princess Margaret Hospital for
Children, Child & Adolescent Health Service, Subiaco,
Perth, WA, Australia; and Fenella Gill, RN, BN,
Paediatric Certificate, MN, Graduate Certificate in
Tertiary Teaching, is Paediatric Intensive Care Nurse
Educator and Co-ordinator, PIC Specialty Master of
Clinical Nursing, Princess Margaret Hospital for Children,
Child & Adolescent Health Service, Subiaco, Perth, WA,
and School of Nursing & Midwifery, Faculty Health
Two audits were Science, Curtin University of Technology, Bentley, WA,
Australia.
N asogastric tubes (NGTs) are placed in hundreds of
thousands of hospitalized patients every year, and they are
an integral part of the management of many medical and
surgical conditions. They are often inserted for the therapeutic
Aspirate was obtained for 97% of all purpose of administering feeds and/or medications. Con-
firming correct placement avoids complications and, in
particular, avoids the introduction of enteral feeds and
medication into the lungs.
Many tubes are inserted without incident; however, there
is a risk that the tube may be misplaced during insertion
or that it may migrate from the stomach at a later stage. The
reported tube-placement error rate varies considerably. Metheny
and Meert (2004) and Weinberg and Skewes (2006) reported
error rates of between 0.3% and 20%, whereas Ellett, Maahs,
and Forsee (1998) reported error rates up to 43% in children.
Nasogastric tube In addition to endotracheal intubation, risk factors associ-
ated with a higher incidence of enteral tube misplacement in
children include younger age, decreased level of conscious-
ness, abdominal distension, vomiting, and orogastric tubes
(Ellett et al., 1998). Although adverse outcomes related to
misplaced NGT are infrequent, when they do occur the results
can be catastrophic, and recent literature has questioned the
reliability of traditional bedside testing methods.
In 2005, a coroner’s findings in the United Kingdom high-
lighted 11 deaths over a 2-year period directly related to
misplaced feeding tubes, prompting the UK National Health
Service (NHS) National Patient Safety Agency (2005a) to
produce a National Safety Alert recommending specific
guidelines on the safe testing of NGTs. In response to this alert,
it was deemed timely to review the current clinical guideline
for NGT testing at Princess Margaret Hospital for Children
3
Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement
(PMH) to ensure a safe and practical clinical guideline that
incorporated best evidence, particularly as the existing
guideline was based on traditional bedside testing methods.
Clinical Practice Guideline Development
The purpose of clinical practice guidelines (CPGs) is to
provide practitioners with guidance in specific areas of
healthcare practice. CPGs are designed to improve the
quality of health care, reduce practice variation, and reduce
unnecessary, harmful, or ineffective interventions, at an
acceptable cost (Graham, Beardall, Carter, Tetroe, & Davies,
2003; National Health & Medical Research Council, 1999).
It was recognized that introduction of a comprehensive
CPG would require the time of appropriately skilled and
experienced people to develop and implement (Feder,
Eccles, Grol, Griffiths, & Grimshaw, 1999; Shekelle, Woolf,
Eccles, & Grimshaw, 1999). A working party was estab-
lished, comprised of senior clinical nurses and research
nurses (ensuring both research-evidence appraising knowl-
edge and clinical expertise), to consider the relevance of
the evidence and translate it into a form that could be
implemented into practice (Gerrish et al., 2007; Shekelle
et al.; Steinberg & Luce, 2005).
Literature Review
A review and critical analysis of the literature was
undertaken to identify current best practice in a manner that
ensured the application of evidence to practice was clear
(Hewitt-Taylor, 2003; National Health and Medical
Research Council, 1999).
Chest X-ray for Checking NGT Placement
The gold standard test for confirming the position of an
NGT is an X-ray that visualizes the whole length of the tube,
although there have been multiple reports of X-rays being
misinterpreted by physicians not trained in radiology
(Hendry, Akyurekli, McIntyre, Quarrington, & Keon, 1986;
Scheiner, Noto, & McCarten, 2002).
Although there is no sure nonradiographic method to
differentiate respiratory, esophageal, gastric, and small bowel
placement of NGT tubes, X-ray confirmation is not a suitable
method to check NGT placement or position for every patient
prior to every feed or administration of medication. Therefore,
it is necessary to use the most accurate bedside methods.
Bedside Checking Methods for Checking NGT
Placement
The most reliable bedside method available to confirm
NGT placement is the measurement of pH of NGT aspirates
4 JSPN Vol. 14, No. 1, January 2009
(Colagiovanni, 1999; Metheny, 1994; Tait, 2001). There is a
need to be able to differentiate between gastric contents that
may have a pH between 1 and 5 (Huffman, Jarczyk, O’Brien,
Pieper, & Bayne, 2004), small bowel or bronchial secretions
that may have a pH > 6 (Ellett, 2005), and esophageal
secretions that may have a pH between 6 and 7; although
esophageal pH can yield an acidic pH in the presence of acid
reflux from the stomach. It is advocated that this method
replace testing the acidity/alkalinity of aspirate using litmus
paper, which is not adequately sensitive to distinguish
between gastric and bronchial secretions (National Patient
Safety Agency, 2005b).
In the absence of NGT aspirates, nurses have tradi-
tionally utilized the “whoosh test,” whereby air is insufflated
through the feeding tube while auscultating the epigastrium.
The efficacy of this method is highly questionable. Although
there is no evidence that the auscultatory method is effective
in ruling out respiratory placement, there have been multiple
anecdotal reports of its ineffectiveness leading to disastrous
results (Chang, Melnick, Bedger, & Bleyaert, 1982; Creel &
Winkler, 2007; Dobranowski, Fitzgerald, Baxter, & Woods,
1992; Hand, Kemster, Levy, Rogol, & Spirn, 1984; Hendry
et al., 1986; McWey, Curry, Schabel, & Reines, 1988;
Metheny, Aud, & Ignatavicius, 1998; Metheny & Stewart,
2002; National Patient Safety Agency, 2005a). Additionally,
the whoosh test cannot determine where the tube is posi-
tioned in the gastrointestinal tract. Observing for bubbling at
the proximal end of the tube is also an unreliable method
because the stomach also contains air and could falsely
indicate respiratory placement (Metheny, McSweeney, Wehrle,
& Wiersema, 1990).
In addition, none of the following methods can be relied
upon to determine distal NGT tip position. However, they
can be used as additional information when undertaking a
risk assessment, balancing the need to feed with the risks of
a malpositioned NGT. When undertaking serial observations
and assessments, the strength of single indicators is increased
if one or more other indicators are present (Metheny et al.,
2005). Observing for signs of respiratory distress, such as
choking or cyanosis, can be ineffective in detecting a malpo-
sitioned tube, especially in unconscious or debilitated
patients (Metheny et al., 1990; Rassias, Ball, & Corwin, 1998;
Schorlemmer & Battaglini, 1984). Small bore tubes may
cause few or no symptoms when incorrectly positioned,
particularly in high-risk patients such as those who are
unconscious, intubated, lack a gag or swallow reflex, or are
uncooperative during the procedure. Although the absence of
symptoms cannot be relied upon to exclude a malpositioned
tube, the presence of respiratory symptoms would certainly
suggest an increased risk of misplacement.
There have been significant difficulties reported in
distinguishing respiratory secretions from gastric secretions
withdrawn from the NGT (Hand et al., 1984; Metheny &
Meert, 2004; Torrington & Bowman, 1981). However, aspirate
appearance can help to distinguish between an NGT being
positioned in the small bowel rather than the stomach
because aspirates may be bile stained when mixed with
intestinal secretion rather than curdled white when mixed
with gastric juice. It has been noted that although the deter-
mination of color is subjective, accuracy can improve with
training (Metheny & Meert). Observing for changes in
gastric residual volume can also help distinguish between
the NGT being positioned in the small bowel rather than
the stomach because gastric volumes will be larger than
intestinal volumes (Metheny & Meert). In addition, when the
tube has migrated into the esophagus, the aspirate volume
has been found to decrease (Metheny et al., 2005).
Determining if the external length of the tube has
changed since the time of the confirmatory X-ray cannot
be relied upon to ascertain internal NGT distal tip position.
Marking the tube as it exits from the nares or mouth serves
as an indication of whether the tube has been partially
removed but does not reflect the distal tip position. How-
ever, there are no risks involved with marking the tube, and
it may help to alert caregivers to detect a change in tube
position (Metheny & Meert, 2004; Metheny et al., 2005).
Alternative Bedside Testing Methods
Alternative bedside testing methods include the use
of pH probes, capnography, and measurement of aspirate
bilirubin, trypsin, and/or pepsin. However, each of these
methods has limitations and drawbacks. Clinical utilization
of pH probes has been restricted to testing between gastric
and esophageal placement rather than respiratory place-
ment. Capnography measurement indicates respiratory
placement of the NGT; however, this would not occur if
either a tube positioned in the tracheobronchial tree was
not perfectly patent or if the eyelet holes were at the level of
the cuff of the endotracheal tube or tracheostomy tube.
Measurement of bilirubin, trypsin, and/or pepsin relies on
obtaining an aspirate and is not currently commercially
available because more research is needed before this
method can be used in practice (Huffman et al., 2004).
Establishing Reliability of the CPG
In the absence of good evidence and considering the
limitations of available NGT bedside methods, it was
essential for us to address the reliability of the NGT CPG
before implementation. This was partly established by
considering whether a second group would arrive at the
same recommendations after reviewing the same evidence
(Goolsby, 2003). The UK NHS Patient Safety Agency was
consulted, and a national benchmarking process was
initiated with other children’s hospitals/departments in
JSPN Vol. 14, No. 1, January 2009
Australasia via the Women and Children’s Hospitals Aus-
tralasia organization (Women’s and Children’s Hospitals
Australasia, 2006). A total of 10 pediatric sites participated
in a survey of NGT practices, finding that 5 had introduced
pH indicator strips to replace litmus paper. Various pH
cut-off points were being utilized for testing aspirates,
ranging from pH 4 to 6, with a number of hospitals varying
the cut-off point according to the use of acid-inhibiting
medications. The whoosh test was no longer endorsed in
6 sites, and indications for X-rays varied from “no aspirate
obtained” to “doctor initiated.”
Consultation with a number of adult hospitals in the
Perth metropolitan area highlighted differences in hospital
NGT management policies. A number of hospitals had
moved away from the traditional bedside testing methods
while others were continuing traditional NGT practices. This
communication led to the establishment of a metropolitan-
wide hospital-nursing working party to achieve consensus
in the standardization of evidence-based changes to NGT
policies across hospital sites, to enable benchmarking, and to
undertake a multisite evaluation.
Implementation and Dissemination of the CPG
In April 2006, the NGT CPG was introduced at PMH. The
whoosh test was no longer endorsed; litmus testing of gastric
aspirates was replaced with pH testing; and a risk assess-
ment was developed to guide decision-making in balancing
the potential risks with the need to feed (see Figure 1).
Potential Barriers to Implementing the CPG
The PMH working party planned the process for
implementation of the CPG to incorporate a number of
dissemination strategies aimed at medical personnel, nursing
staff, and parents of children with NGTs. The active
implementation measures included the identification of
potential barriers to the adoption of the new guideline
(Graham et al., 2003). During the consultation period,
concerns about the impact of the proposed changes
expressed by many of the nursing staff were:
• The new guidelines would lead to an increase in the
number of X-rays undertaken and repassing of NGTs.
• Aspirates for patients on continuous feeds or acid-
inhibiting medications would be > pH 5.5.
• Decision-making would be difficult in the absence
of aspirates.
Evaluation Process
To address the concerns raised and ensure a positive
effect on organizational change, a comprehensive evaluation
5
Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement

Figure 1. Risk Assessment

process was initiated (Graham et al., 2003; Ring, Malcolm,
Coull, Murphy-Black, & Watterson, 2005). A key principle of
CPG development is that the implementation and impact
should be evaluated (Feder et al., 1999; National Health
and Medical Research Council, 1999; Ring et al.). A
review was planned encompassing two separate clinical
audits: an audit at PMH to address the specific clinical issues
identified and a metrowide hospital point-prevalence audit
to evaluate the impact on nursing practice and identify
further educational needs, ensuring linkage between the data
collected and key points of the CPG (Feder et al.; Gerrish &
Clayton, 2004; Mersel, Mor-Yosef, & Shapira, 2005).
Evaluation Methods
The PMH audit was conducted over a 1-month period.
Data were collected by bedside nurses for all patients with
an NGT in situ for each NGT testing procedure, using an
adapted NHS Patient Safety audit tool (National Patient
Safety Agency, 2005b). In addition, a metrowide 1-day point-
prevalence audit was conducted across seven metropolitan
hospitals. The nurses identified to collect the data from
each hospital first attended briefing sessions to promote
interrater reliability. Bedside nurses were then interviewed
using a semistructured questionnaire, and documentation

6 JSPN Vol. 14, No. 1, January 2009

was reviewed for all patients with an NGT in situ (Metcalf,
2006).
Results
PMH Audit Results
Concern: The new guidelines would lead to an increase
in the number of X-rays undertaken and repassing of
NGTs. While no sure nonradiographic methods exist to
differentiate between respiratory, gastric, esophageal, and
small bowel placement of blindly inserted feeding tubes
(Metheny & Meert, 2004), minimizing the number of radio-
graphs taken to assure correct tube placement is important,
especially in young children, to avoid exposure to the risks
associated with radiation. During the 1-month PMH audit, a
total of 1,527 NGT tests were undertaken for 52 patients.
Seven X-rays were undertaken on 6 children. Selective use of
X-rays was observed because only those children who had
more than one occasion of pH > 5.5 were X-rayed, with
the exception of one infant who was frequently “gagging”
where X-ray confirmed the NGT had knotted. If results
from the bedside tests do not confirm correct positioning,
the tube can be removed and reinserted; in this way X-rays
can be kept to a minimum. This recommendation was
evident in practice because 22 patients had 39 NGTs
repassed (range 1–5).
Concern: Aspirates for patients on continuous feeds or
acid-inhibiting medications would be > pH 5.5. Nasogastric
aspirates ≤ pH 5.5 will indicate correct placement of NGTs
in most patients (adults, children, infants, and neonates),
including those receiving acid-inhibiting medication
(Metheny, 1994). Ellett, Croffie, Cohen, and Perkins
(2005) found that using the following algorithm—(a) if pH
was ≤ 5, the correct placement in the stomach could be
assumed, and (b) if pH > 5 or no aspirate, an X-ray should
determine tube placement—would result in 92% of children
eventually having correct placement in the stomach. There
are limitations to using this beside testing method because
measuring the pH of withdrawn fluid is only helpful in dif-
ferentiating between respiratory and gastric placement when
gastric pH is low (Griffiths, Thompson, Chau, & Fernandez,
2006; Metheny & Meert, 2004). When gastric pH is ≥ 6, using
pH to predict tube placement is of no benefit. Further-
more, pH of a feeding tube cannot identify if it is in the
esophagus. Continuous feedings negate the usefulness of the
pH method in many situations, which needs to be taken into
consideration when undertaking a risk assessment. A pH of
≤ 5.5 was incorporated into the NGT guideline to indicate
gastric placement, because according to Metheny and
Meert, no pulmonary aspirate has been reported < pH 6;
therefore, ≤ pH 5.5 will exclude 100% of pulmonary place-
ments and more than 93.9% of placements in the small
JSPN Vol. 14, No. 1, January 2009
intestine. However, there have been other rare and isolated
situations in the literature where fluid aspirated from a
pocket of empyema in the lung had a pH of 5.
Indicator strips for pH also must have the appropriate pH
range for sufficient sensitivity, and pH strips with a broad
pH range are advocated (Metheny & Meert, 2004). However,
a trial of various pH indicator strips at PMH found color
changes of the indicator strips with wide pH values that
were difficult to distinguish between. The pH indicator
strips with a pH range of 4 to 7 provided more distinctive,
observable color changes, thus allowing more accurate
interpretation of pH levels that are relevant to NGT
placement.
Most enteral formulas have a pH close to 6.6, causing
the pH of gastric contents to be increased in enterally fed
patients. Patients who are receiving continuous feeds may
have a pH > 5.5, although testing can be performed when
feeds have been withheld (Khair, 2005). Ellett et al. (2005)
found that there was a statistically nonsignificant difference
in pH between bolus-fed and continuously fed children, and
whether or not the child was receiving an acid-inhibiting
medication did not significantly affect the pH of aspirate,
although this study reported an inadequate sample size.
For the purpose of the data results, pH ≤ 5.5 is reported
as pH pass, and pH > 5.5 is reported as pH fail. For the
1,527 tests, 84% were pH pass. Of the 52 patients, 21 had pH
pass for all testing, 13 had pH fail on one occasion, and 18 (9
pediatric intensive care unit patients) had 2 or more pH fails
(range 2–42). Importantly, the PMH audit data identified
that children receiving continuous feeds more often had > 2
pH fails (61%) than the children who were receiving bolus
feeds (35%). A similar trend was found with those children
receiving acid-inhibiting medications, where 39% had
> 2 pH fails compared to 24% receiving bolus feeds. Seven
patients who had more frequently recurring pH fails (range
7–42) were on both continual feeds and acid-inhibiting
medications. Figure 2 further illustrates these findings.
Concern: Decision-making would be difficult in the
absence of aspirates. In the situation where no fluid
aspirate is obtained from the NGT, alternative methods such
as the whoosh test had traditionally been implemented.
Determining the position of the NGT by auscultation of air
(whoosh test) into the stomach is an unreliable method of
checking NGT position. The injection of air into the tracheo-
bronchial tree or into the pleural space can produce a
sound indistinguishable from that produced by injecting
air into the gastrointestinal tract (Colagiovanni, 1999;
Metheny et al., 1990; Weinberg & Skewes, 2006). While the
stomach is never completely empty, it is not always possible
to initially obtain an NGT aspirate. The following steps were
incorporated into the CPG to assist nursing staff to obtain an
aspirate: turning the patient onto his or her side, advancing
the tube to make sure the exit port enters a pool of fluid, and
7
Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement
Figure 2. Princess Margaret Hospital for Children Audit
pH Levels Results. pH Pass Percentage (n = 34),
and pH Fail Percentage (n = 18)
injecting air to dislodge the NGT exit port from the gastric
mucosa (Khair, 2005; Metheny & Meert, 2004).
Metheny et al. (2005) reported obtaining sufficient aspirate
for testing in 74.2% of 2,754 tests from gastric tubes in
critically ill adults. In the PMH audit, aspirate was obtained
for 97% of all tests, thus not supporting staff concerns of
anticipated high rates of failure to aspirate. These results
correlate with similar findings of an audit conducted by the
NHS Patient Safety Agency across three adult intensive care
units; a 92% success rate of obtaining aspirates was reported.
The success in obtaining aspirate for 97% of all tests in the
PMH audit indicated the clinical effectiveness of these steps,
although due to incomplete data it was impossible to identify
which step achieved an aspirate. The steps are illustrated in
Figure 3.
Metrowide Audit Results
Nurse Interviews. One hundred and four nursing staff
across seven hospitals within the Perth metropolitan area
undertook voluntary nursing interviews (18 employed at
PMH). Ninety-three percent of the nurses (100% at PMH)
correctly indicated the use of pH indicator strips to test
stomach aspirate as their hospital’s recommended method
to check NGT placement, and 61% indicated X-ray as an
alternative method to pH testing. The recommendation
that children are not subjected to routine X-ray was reflected
8 JSPN Vol. 14, No. 1, January 2009
in the small percentage of nurses at PMH who indicated X-ray
(11%) as a testing method in comparison to the adult nurses
(61%) (Metcalf, 2006).
Eight nurses reported the whoosh test, four reported blue
litmus paper, and two reported the bubble test as recom-
mended alternative methods at their hospitals. Sixty-one
percent of nurses reported the correct, recommended pH
level; 3% did not know; and the remainder varied between
pH 4 to 6. Ninety-three percent of nurses reported checking
NGTs prior to all bolus feeds, 91% prior to medication delivery,
and 90% a minimum of once per day or once per shift for
continuous feeds. However, only a small percentage of nurses,
9% and 6%, respectively, reported checking following
vomiting or coughing episodes (Metcalf, 2006).
Documentation. Seventy-nine patients with an NGT
in situ were identified across the metropolitan hospitals
(23 at PMH). There was incomplete documentary evidence for
approximately 50% of patients for placement and testing of
the NGTs, and data collection was hindered by the absence of
a standardized NGT chart at any of the participating hospitals
(Metcalf, 2006).
There were obvious discrepancies between the knowl-
edge of the nursing staff found during the interviews and
review of the actual documentation. For example, 74% of
nurses indicated the method used to check placement,
yet only 51% of the notes reviewed showed this informa-
tion was documented (Metcalf, 2006).
Discussion
In view of the potential catastrophic outcomes that may
occur as a result of a misplaced NGT and the limitations
inherent in the currently available bedside testing methods,
it was important to adopt an evidenced-based approach to
the introduction of a revised NGT CPG. This incorporated a
literature review, consultation with clinical experts, establish-
ment of a multisite hospital working party, benchmarking
activities, implementation of a comprehensive dissemination
program, and an evaluation process.
Data collected during the PMH clinical audit did not
support the concerns expressed by staff of anticipated
high percentages of patients with pH > 5.5 or no aspirate
obtained with subsequent interruptions to feeding and
increased X-ray exposure. The findings of the PMH audit,
however, do need to be interpreted with caution because
this was a clinical audit process and not a research study.
The nature of the audit, in that many different staff entered
data across various wards and departments, led to incom-
plete data inputting and a lack of standardized data entries.
Subsequently, this limited data analysis to determine the
most effective actions to take in the absence of aspirates. The
data results yielded a high success rate in obtaining aspirates,
indicating clinical effectiveness of the recommended
Figure 3. Confirming the Correct Position of Nasogastric Feeding Tubes in Infants and Children (For Infants Less Than
4 Weeks, Refer to Neonatal Policy)

JSPN Vol. 14, No. 1, January 2009 9

Development of a Clinical Practice Guideline for Testing Nasogastric Tube Placement
steps to take. Further study is required to determine which
of the steps were most successful, whether as a single step or
in combination, to obtain aspirate.
The children receiving continuous feeds were more likely
to have more than one pH fail, as were the children on
acid-inhibiting medications. When these two factors were
combined, a trend was observed where consistently recurring
pH fails were evident. Thus, it is not surprising that this
group of children received additional X-rays and were
more likely to have multiple NGT replacements. These
factors need to be taken into account when undertaking a
risk assessment for this “high-risk” group, and further
research is required to identify if this is a subset of children
that requires a variation to the current NGT CPG.
Caution is also required before generalizing the results of
the metrowide audit in view of the limited number of
patients included together with the small number of nursing
staff interviewed. There was an obvious deficit observed
between knowledge reported by the nursing staff in the
interviews compared with the documented evidence. Tradi-
tionally, nurses have not necessarily documented all aspects
of their practice related to NGT management, evident in the
absence of a specific chart to document NGT placement and
testing in each of the hospitals included in the audit. Since
this audit, a standard NGT checking chart has been trialed
and introduced at PMH, and a re-audit is planned to
assess the impact on documentation. There were a number
of areas identified where nurses’ knowledge and, therefore,
practice was not compliant with the NGT CPG, prompting
the need for further education focusing on education gaps.
Conclusion
Bedside checking of NGT placement is paramount prior
to either enteral feeding or medication administration.
However, what were considered reliable methods of
testing NGT placement previously are now questioned in the
literature. It is now recommended that pH testing replace
the litmus paper test and the whoosh test is no longer advo-
cated. However, there will continue to be occasions when
pH measurement is not able to confirm gastric placement, or
aspirate is not obtained. In addition, it is not always appro-
priate to conduct an X-ray for each occasion where bedside
testing methods fail. A comprehensive individual risk
assessment of the patient using a standardized tool is man-
datory to guide decision-making by the multidisciplinary
team.
Practitioners need to be ever vigilant to the possibility of a
misplaced NGT even when bedside testing methods
prove positive. In the absence of acceptable, alternative
testing methods, safe NGT placement will continue to
present a challenge, particularly for those patients on con-
tinuous feeds and/or receiving acid-inhibiting medications.
10
How Do I Apply This Information to
Nursing Practice?
It is now recommended that pH testing replace the litmus
paper test, and the whoosh test is no longer advocated for
confirming NGT placement. It is not always appropriate to
conduct an X-ray for each occasion where bedside testing
methods fail. Our evaluation demonstrated that if initially
nil nasogastric aspirate is obtained, the use of a flow chart of
interventions will enable aspirate to be obtained and facil-
itate pH testing. The group of patients who will continue to
pose a challenge to using pH testing are those on contin-
uous feeds and/or receiving acid-inhibiting medications. In
addition, a comprehensive individual risk assessment of the
patient, using a standardized tool, is mandatory to guide
decision-making by the multidisciplinary team.
Author contact: fenella.gill@health.wa.gov.au and
sue.peter@health.wa.gov.au, with a copy to the Editor:
roxie.foster@UCDenver.edu
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