Improving safety and timeliness around nasogastric tube feeding on an Acute stroke unit

Nasogastric tube (NGT) feeding is required for artificial nutrition and hydration in those with impaired swallow due to a stroke. A baseline analysis of new NGT insertions on our acute stroke unit revealed considerable delays in the process and poor documentation of the risk-benefit discussions. We undertook a quality improvement project aimed at improving safety and reducing the delay in NGT insertion from an average of 5.2 hours (baseline) to under 3 hours in 6 months with a secondary aim of improving the documentation of risk-benefit discussions from 0% (baseline) to 50% during the same period.

Multiple Plan-Do-Study-Act cycles of change ideas were implemented, including regular staff awareness sessions, introduction of new labels for the multidisciplinary team meetings and an NGT decision tool. The change ideas we used were directly linked to the secondary and primary drivers of the improvement journey with the help of a driver diagram. Process mapping helped to tighten our pathways. Consecutive data of timings were collected on an excel sheet and charted on a statistical process control chart. The compliance with documentation on the NGT decision tool was charted on a run chart.

The project achieved a consistent improvement in time taken from decision making to NGT insertion from a baseline average of 5.2 hours to 1.7 hours within 6 months and the new process was stable with an upper control limit reduction from 14.1 hours to 6.7 hours. The usage of the NGT decision tool increased from 0% to 80% during the same time period.

The project achieved its aims and was able to improve patient care by changing the behaviour and culture within the team. The improvement has been sustained on an 8-month review, and the change has become 'business as usual' for the team.