WINNER - Improving timeliness around the use of Naso-Gastric (NG) tube on an Acute Stroke unit
Manju Krishnan, Consultant Stroke Physician, Swansea Bay University Health Board
Introduction
In June 2023, a baseline analysis on an acute stroke unit revealed significant delays in nasogastric (NG) tube insertions, with some patients waiting up to 14 hours, and poor documentation of risk-benefit discussions for artificial nutrition. An audit showed 0% compliance with the local policy for artificial nutrition.
The root causes were identified as lack of staff awareness about the NG decision aid document and delays in NG insertion. To address this, staff education, awareness sessions, and new MDT labels were introduced, with a goal to reduce NG insertion time from 5.2 hours to under 3 hours by February 2024, improving patient care and experience.
Methods
To address delays in nasogastric (NG) tube insertions on a stroke unit, a multidisciplinary team (MDT) formed a guiding coalition to tackle the issue. Process mapping was used with multiple PDSA cycles to implement changes, including staff awareness sessions, new MDT labels for better documentation, and the introduction of a printed NG decision tool for risk-benefit discussions.
NG insertion times were tracked using a control chart, revealing an initial average of 5.2 hours from decision to insertion. Progress and barriers were regularly discussed in daily MDT meetings, with ongoing data monitored to drive improvement.
Outcomes
- Successfully improved the documentation of risk-benefit discussions from 0% to 80%
- Reduced NG insertion time from 5.2 hours to 1.7 hours, upper control limit dropping from 14.1 hours to 6.7 hours
- NG decision tool usage reached 80%, surpassing the 50% target and is now part of routine practice.
- 100% compliance not met due to NG reinsertions on weekends / out of hours within 24 hours of decision tool. Team agreed no new form needed for reinsertions within 24 hours, reducing unnecessary paperwork.
- Staff feedback: 90% felt process change improved care without adding time wastage.
- Regular staff awareness sessions and a new NG policy specific to the stroke unit have been implemented.
Learnings
- Artificial nutrition processes are complex, requiring detailed communication and decision-making, impacting care for acute stroke patients.
- Importance of documenting discussions to avoid inappropriate interventions for end-of-life patients.
- The need for clear governance structures around NG insertions.
What next?
- A related QI project on the time of initiation of NG feed after insertion is underway, overseen by the improvement advisor.
- Plans to collect Patient Reported Outcome Measures (PROM) on nutrition and dietetic input on the stroke ward, despite challenges.
- New NG policy completed; plans to scale and spread to other stroke units and eventually nationally for broader impact on patient care.
