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June 18, 2019
Found Dead in a Bed
A year ago, the Kansas City Star ran a story on “Dead in bed” (Marso 2018). The story begins with description of an 80 year old patient who had been admitted with a partial intestinal obstruction, apparently managed nonsurgically, who was now improving. The patient was scheduled for discharge the next day. Family mentioned she would fall asleep frequently while watching TV in the hospital but otherwise seemed returning to her usual self. The patient did not survive the night. She was found dead in bed. An autopsy was inconclusive for a cause of death, but no toxicology was done. Experts who reviewed the medical record commented that the doses and cumulative dosage of Dilaudid she had been receiving were quite high for an opioid-naïve elderly patient.
Retrospectively, her family also had noted her speech at times was slurred and mumbling during the hospital stay and, when she went to the bathroom, she seemed dizzy and unsteady on her feet.
The article goes on to discuss with anesthesiologist Frank Overdyk, a leading voice in the movement for continuous monitoring to avert opioid-induced respiratory depression (OIRD), the need for continuous electronic monitoring tools that include pulse oximeters and capnography. Overdyk noted that hospitals often use these in ICU’s but that only about 20 to 25 percent of hospitals have the capacity to use them at every bed and only about 1 percent do. The main reason, he said, is cost.
Speaking of Dilaudid, don’t get us started! See our series of columns on the dangers of Dilaudid/HYDROmorphone listed below:
Khanna et al. (Khanna 2019) note that nearly half of in-hospital cardiorespiratory arrests occur on general care floors. Opioid-induced respiratory depression is one of the possible causes in many cases. Overdyk was a key researcher in the recently reported PRODIGY (Prediction of Opioid-induced respiratory Depression In patients monitoried by capnoGraphY) trial (Khanna 2019), a prospective study in 16 international sites. Subjects on general care floors who were receiving opioids had continuous monitoring of cardiorespiratory parameters, including heart rate, oxygen saturation, end-tidal CO2, and respiratory rate. Respiratory depression occurred in 41.4% of over 1000 patients. Predictors of respiratory depression were: age ≥70 to <80 or ≥80, male sex, major organ failure, chronic heart failure or cardiac disease, coronary artery disease, COPD or pulmonary disease, pneumonia, type II diabetes, hypertension, kidney failure and opioid naivety. Interestingly, negative predictors were BMI ≥35 and asthma.
The researchers were able to use a multivariate regression model to develop an OIRD risk prediction tool using age 70-79 or 80 and older, male sex, sleep disorders, hypertension, and opioid naivety. They termed this the PRODIGY score. This tool had high accuracy, using multiple measures of accuracy.
PRODIGY score ranged from 0 to 39, with low risk between 0 and 7, intermediate risk between 8 and 15 and high risk more than 15.
Khanna, the lead author of the PRODIGY trial report, notes in a video presentation that patients suffering cardiorespiratory arrest on general care floors have a much higher mortality than those who are continuously monitored, such as those in an ICU setting. 46% of patients in the PRODIGY study suffered at least one episode of respiratory depression. He notes that this frequency is almost double what prior studies had found. Why? Because PRODIGY used continuous monitoring. Most previous studies used episodic monitoring. Five variables were strongly related to the risk of respiratory depression: age > 60, male sex, presence of sleep disordered breathing, opioid naivety, and chronic heart failure. These were incorporated into the PRODIGY risk prediction score. High risk patients had a risk score of more than 15, low risk less than 8, and intermediate risk 8 to 15. He notes that all 3 risk categories had significant intergroup variation, so that intermediate risk was significantly greater than low risk and high risk significantly higher than intermediate risk.
Bradford Winters, M.D., discussed the challenges of recognizing clinical deterioration in patients outside the intensive care unit and notes the importance of early warning systems and continuous physiological monitoring in identifying such deterioration (Winters 2018). He discusses the evolution of Rapid Response Systems (RRS) and describes that such have both an afferent and an efferent limb. He goes on to describe the variety of early warning systems (EWS) developed over the years and has a great table of all those EWS’s. But he notes a number of explanations as to why they generally failed to improve clinical outcomes.
Winters notes that surveillance monitoring may be a better way to collect and act on clinical data for a patient who is deteriorating on a general ward, but needs to overcome several challenging hurdles:
1) It needs to be mobile and wireless since general ward patients are usually ambulatory as compared to monitoring of ICU patients.
2) The mobile surveillance monitor must have adequate battery life.
3) The monitor needs to be comfortable and relatively unobtrusive.
4) The vital sign data collection should be continuous, since use of intermittently collected data may miss early signs of deterioration.
5) It needs to have an acceptable accuracy and a manageable false alarm rate.
Winters notes that studies of surveillance monitoring are still limited but the results are encouraging.
Verillo et al. (Verrillo 2019) compared continuous physiological monitoring to the current standard of clinical monitoring in patients admitted to a surgical unit. Continuous monitoring resulted in a statistically significant 27% decrease in the complication rate, and a clinically significant decrease in transfers to an intensive care unit and failure-to-rescue (FTR) events rate.
Opioid-induced respiratory depression, of course, has been the topic of many of our columns (see the full list below). The lack of continuous monitoring and, in particular, the infrequent use of capnography have been major impediments to identifying patients at risk for respiratory depression. Hopefully, future studies will demonstrate that use of the PRODIGY score and continuous physiological monitoring do result in improved clinical outcomes.
Of course, this all needs to be balanced against the risk of alarm fatigue. In our many columns on alarm fatigue we have stressed that alarms should alert healthcare professionals to clinically relevant conditions and that monitoring should be focused on those at risk and only for specified periods of time. For example, we’ve often noted that hospitals should avoid using telemetry outside accepted guidelines. Our hope is that risk assessment tools like the PRODIGY score will identify specific patients at risk so that continuous monitoring is not applied to all patients on a care unit, but rather selectively to those who truly need it.
Other Patient Safety Tips of the Week pertaining to opioid-induced respiratory depression and PCA safety:
Some of our other columns on MEWS or recognition of clinical deterioration:
Our other columns on rapid response teams:
References:
Marso A. 'Dead in bed' common term in hospitals. Here's why patients should know about it. Kansas City Star 2018; March 15, 2018
http://www.kansascity.com/news/business/health-care/article203189944.html
Khanna A, Buhre W, Saager L, et al. Derivation And Validation Of A Novel Opioid-Induced Respiratory Depression Risk Prediction Tool (Abstract 36). Society of Critical Care Medicine 48th Critical Care Congress San Diego, California February 17–20, 2019; Critical Care Medicine 2019; 47(1): 18, January 2019
Video by Khanna
Khanna A. Pulmonology Consultant. Ashish Khanna, MD, on the PRODIGY Trial and Risk Score. Consultant360 2019;
Winters BD. Early Warning Systems: “Found Dead in Bed” Should be a Never Event. APSF Newsletter 2018; 33(2): 35-37
https://www.apsf.org/article/early-warning-systems-found-dead-in-bed-should-be-a-never-event/
Verrillo SC, Cvach M, Hudson KW, et al. Using Continuous Vital Sign Monitoring to Detect Early Deterioration in Adult Postoperative Inpatients. Journal of Nursing Care Quality 2019; 34(2): 107-113
Print “Found Dead in a Bed”
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June2019
We’ve done many columns (see list below) on the unwanted side effects of sleep meds. They frequently are contributing factors to patient falls, delirium, and opioid-related respiratory depression. Sometimes we’ll see withdrawal syndromes in patients who have been receiving such drugs chronically. They may also play a role in predisposing some patients to aspiration. And they are a frequent contributor to events occurring in patients with sleep apnea. Some studies have suggested a link between sedative/hypnotic drugs and mortality, hip fractures, and emergency room visits.
And that is without going into detail about the anecdotal and sometimes sensationalized stories about someone doing bizarre things at night and having no recall while on sleep meds,
But the latter is what finally led to the FDA adding a “boxed warning” to several common prescription insomnia medicines (FDA 2019). While the FDA over the years has included warnings in prescribing information on several sedative/hypnotic drugs, it was these complex sleep behaviors that finally led to the more serious action just taken. Complex sleep behaviors include sleepwalking, sleep driving, and engaging in other activities while not fully awake. These complex sleep behaviors have also resulted in deaths.
According to the FDA, these behaviors appear to be more common with eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist) than other prescription medicines used for sleep.
The FDA notes that serious injuries and death from complex sleep behaviors have occurred in patients with and without a history of such behaviors, even at the lowest recommended doses, and the behaviors can occur after just one dose. They can also occur after taking these medicines with or without alcohol or other central nervous system depressants that may be sedating such as tranquilizers, opioids, and anti-anxiety medicines.
The FDA identified 66 cases of complex sleep behaviors occurring with these medicines over the past 26 years that resulted in serious injuries, including death. Those included 20 cases of death and 46 non-fatal cases (eg, falls, burns, near-drowning, exposure, gunshot wounds, and suicide attempts).
In addition to the boxed warning, the FDA will also require a “contraindication”, the agency’s strongest warning, to avoid use in patients who have previously experienced an episode of complex sleep behavior with eszopiclone, zaleplon, and zolpidem.
The FDA also repeats its reminder that all medicines taken for insomnia can impair driving and activities that require alertness the morning after use. Drowsiness is already listed as a common side effect in the drug labels of all insomnia medicines, along with warnings that patients may still feel drowsy the day after taking these products. Patients who take insomnia medicines can experience decreased mental alertness the morning after use even if they feel fully awake.
We hope you’ll take another look at some of our previous columns on safety issues with sleep meds. On the outpatient side, knowing and understanding how to promote good sleep hygiene is extremely important in helping patients avoid the need for such drugs in the first place. You need to help patients adopt practices that promote good nocturnal sleep. That includes things like counseling them about eating and drinking habits in relation to time of day (eg. avoiding caffeinated beverages at night or avoiding large volumes of fluid that will lead to awakening to void). And you need to make sure that noise and light levels are not barriers to sleep and that the ambient temperature is conducive to sleep. Similarly, activities earlier in the day may be important. Getting some exercise, particularly outdoors, may benefit sleep as well as overall health. Attention to patterns of any naps may also identify why a patient has trouble sleeping at night. And, always try to identify some of the factors that may be causing or contributing to insommia (eg. depression, anxiety, pain, etc.).
On the inpatient side, we need to do more to promote sleep but do it more in a non-pharmacological approach and minimize the use of sleep meds. That usually means putting in place various system fixes (eg. removing them from standardized order sets, using clinical decision support tools, etc.) that may help your prescribers use alternatives to sleep meds.
And, if your patient is already taking a sleep medication, consider deprescribing it. Our June 2018 What's New in the Patient Safety World column “Deprescribing Benzodiazepine Receptor Agonists” had links to several resources and guidelines on deprescribing these medications.
Some of our previous columns on safety issues associated with sleep meds and promoting sleep in inpatients:
August 2009 “Bold Experiment: Hospitals Saying No to Sleep Meds”
March 23, 2010 “ISMP Guidelines for Standard Order Sets”
May 2012 “Safety of Hypnotic Drugs”
November 2012 “More on Safety of Sleep Meds”
March 2013 “Sedative/Hypnotics and Falls”
June 2013 “Zolpidem and Emergency Room Visits”
August 6, 2013 “Let Me Sleep!”
June 3, 2014 “More on the Risk of Sedative/Hypnotics”
May 15, 2018 “Helping Inpatients Sleep”
June 2018 “Deprescribing Benzodiazepine Receptor Agonists”
November 6, 2018 “More on Promoting Sleep in Inpatients”
Some of our past columns on deprescribing:
References:
FDA (US Food and Drug Administration). FDA adds Boxed Warning for risk of serious injuries caused by sleepwalking with certain prescription insomnia medicines. FDA Drug Safety Communication. FDA 4/30/2019
Print “June 2019 FDA Boxed Warning on Sleep Meds”
These results sound too good to be true! Such pronouncements always raise our “hype radar” or “spin radar” (see our February 16, 2010 Patient Safety Tip of the Week “Spin/Hype…Knowing It When You See It”). In that column we noted how results of one clinical trial were “spun” and published in various forms in not one, not two, but three well-respected peer-reviewed medical journals.
Khan and colleagues (Khan 2019) recently published a systematic review of published reports of cardiovascular randomized clinical trials (RCT’s) in 6 high-impact medical journals, with a focus on comparing the language in the abstracts, main text, discussion or conclusions against the actual data in the RCT. These were all RCT’s in which the primary outcome of the study failed to reach statistical significance.
Spin was identified in 57% of abstracts and 67% of main texts of published articles that met their inclusion criteria. 11% had spin in the title, 38% in the results section, and 54% in the conclusions. Among the abstracts, spin was observed in 41% of results sections 48% of conclusions sections.
The authors conclude that, in reports of cardiovascular RCTs with statistically nonsignificant primary outcomes, investigators often manipulate the language of the report to detract from the neutral primary outcomes. They caution all who read such literature be aware that peer review does not always preclude the use of misleading language in scientific articles.
There are numerous ways in which the results of a study may be “spun”. Khan and colleagues identified specific spin strategies that were used:
Perhaps surprisingly, conflicts of interest disclosures of the first authors and last authors did not correlate with spin. Even more surprisingly, it was not associated with industry funding.
The accompanying editorial (Fihn 2019) cites the following examples of “spin” in the various sections of a publication as identified by Boutron and Ravaud (Boutron 2018):
Methods misreporting
Results misreporting
Misinterpretation
In our February 16, 2010 Patient Safety Tip of the Week “Spin/Hype…Knowing It When You See It”) we noted an excellent review on the limitations of randomized controlled trials (RCT’s) that was published in Journal of the American College of Cardiology (Kaul and Diamond 2010). This paper is very good at helping you understand some complicated statistical issues but really emphasizes three points we have often made in the past:
Whenever you read a study published in a journal, even a respected peer-reviewed journal, you must carefully scrutinize the language used and make sure that such language is not at odds with the data presented. And the Khan study, along with the others noted here, put the publishers of all medical journals on notice that it is their responsibility to ensure that results of studies they publish accurately reflect the facts and are not “spun”.
References:
Khan MS, Lateef N, Siddiqi J, et al. Level and Prevalence of Spin in Published Cardiovascular Randomized Clinical Trial Reports With Statistically Nonsignificant Primary Outcomes. A Systematic Review. JAMA Netw Open. 2019; 2(5): e192622
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2732330
Fihn SD. Combating Misrepresentation of Research Findings. JAMA Netw Open 2019; 2(5): e192553 May 3, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2732324
Boutron I, Ravaud P. Misrepresentation and distortion of research in biomedical literature. Proc Natl Acad Sci USA 2018; 115(11): 2613-2619
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5856510/
Kaul S, Diamond GA. Trial and Error: How to Avoid Commonly Encountered Limitations of Published Clinical Trials. J Am Coll Cardiol 2010; 55: 415-427
http://www.onlinejacc.org/content/55/5/415.abstract
Print “June 2019 More Spin”
Most patients try to schedule their medical appointments and elective procedures around times that are convenient for themselves or their families or friends. But does that always result in the best healthcare?
Our Patient Safety Tip of the Week for May 3, 2011 “It’s All in the Timing” noted disparities in polyp detection rates for colonoscopies done later in the day. Another study (Kim 2018) Influenza vaccination rates significantly declined as the clinic day progressed. The researchers in that study also developed an active choice intervention in the electronic health record that successfully increased influenza vaccination rates that were similar in magnitude throughout the day. And another study analyzed decisions regarding antibiotic prescribing (Linder 2014). Those researchers found that primary care clinicians’ likelihood of prescribing antibiotics increased throughout the morning and afternoon clinic sessions for antibiotics sometimes indicated and antibiotics never indicated acute respiratory infections. This was consistent with the hypothesis that decision fatigue progressively impairs clinicians’ ability to resist ordering inappropriate treatments. And yet another study found that opioid prescribing for low back pain in primary care increased later in the day (Philpot 2018).
Now a new study shows that your chance of receiving cancer screening from your primary care practitioner also depends on what time of day you see him/her. Hsiang et al. (Hsiang 2019) looked at association of primary care clinic appointment time with clinician ordering and patient completion of breast and colorectal cancer screening. They found that clinician ordering of cancer screening tests significantly decreased as the clinic day progressed. Patient completion of cancer screening tests within 1 year of the visit was also lower as the primary care appointment time was later in the day.
Screening test order rates for breast cancer were highest at 8 AM at 63.7%, decreased throughout the morning to 48.7% at 11 AM, increased to 56.2% at noon, and then decreased to 47.8% at 5 PM. Trends in screening test completion rates were similar beginning at 33.2% at 8 AM and decreasing to 17.8% at 5 PM.
For colorectal cancer screening, test order rates were 36.5% at 8 AM, decreased to 31.3% by 11 AM, increased at noon to 34.4%, and then decreased to 23.4% at 5 PM. Trends in screening test completion rates were similar beginning at 28.0% at 8 AM and decreasing to 17.8% at 5 PM.
While fatigue is one obvious explanation for many of these findings, there are other factors that likely contribute. Hsiang et al. noted that, ss each shift progresses, clinicians may fall behind schedule, possibly leading to shorter interactions with the patient at the end of the morning and afternoon shifts. They also note that, if patients earlier in the day decline screening despite the clinician’s recommendation, it could influence how likely the clinician is to bring up the topic later in the day with a different patient. They also note that in this study, and several of the others noted above, behaviors improved slightly after lunch, only to decline again later in the afternoon.
In the accompanying editorial (Liss 2019), Liss and Linder note that “decision fatigue” (progressive erosion of ability, self-control, or will power that occurs as people make choices) occurs in several other industries and social situations. But they also note that other factors, like fatigue among ancillary staff (who often are the ones who arrange for preventive care). And there may well be patient factors that come into play. It may be that end-of-the-day patients were less likely to make immediate arrangements for follow-up or remember that they needed follow-up.
Whatever the cause(s), it’s important that healthcare organizations institute proper systems to identify such missed opportunities. And it is incumbent upon the astute customer of healthcare to recognize that there are vulnerabilities associated with the time of day they receive their healthcare.
References:
Kim RH, Day SC, Small DS, et al. Variations in influenza vaccination by clinic appointment time and an active choice intervention in the electronic health record to increase influenza vaccination. JAMA Netw Open 2018; 1(5): e181770
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2702210
Linder JA, Doctor JN, Friedberg MW, et al. Time of day and the decision to prescribe antibiotics. JAMA Intern Med 2014; 174(12): 2029-2031
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1910546
Hsiang EY, Mehta SJ, Small DS, et al. Association of Primary Care Clinic Appointment Time With Clinician Ordering and Patient Completion of Breast and Colorectal Cancer Screening. JAMA Netw Open 2019; 2(5): e193403 May 10, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2733171
Philpot LM, Khokhar BA, Roellinger DL, et al. Time of day is associated with opioid prescribing for low back pain in primary care. J Gen Intern Med 2018; 33(11): 1828-1830
https://link.springer.com/article/10.1007%2Fs11606-018-4521-8
Liss DT, Linder JA. Decision Fatigue, Running Late, and Population Health Management—Screening Out of Time. JAMA Netw Open 2019; 2(5): e193402 May 10, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2733166
Print “June 2019 More on the Time of Day”
One of our most surprising frequently accessed columns has been our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?”. In that column we noted numerous reports from the UK’s NPSA of incidents and bad outcomes related to NG (nasogastric) tubes and we mentioned some of our own observations.
NG tube insertion is viewed by many as a simple and routine procedure. But we have seen NG tubes in patient’s lungs, the pleural space, and even in a cerebral ventricle! So we have a great respect for proper NG tube insertion.
Then, our October 2016 What's New in the Patient Safety World column “AACN Alert on Feeding Tube Placement” discussed American Association of Critical-Care Nurses press release (AACN 2016) on their practice alert “Initial and Ongoing Verification of Feeding Tube Placement in Adults”. According to that guideline, the expected practice during the insertion procedure is to use a combination of two or more of the following bedside methods to predict tube location:
But, confirmation by radiography is still the most important element but results of the above elements can be used to determine when it is time to use radiography to confirm tube location and they may also be able to reduce the number of confirming radiographs to one. That alert also stressed that nurses should not use the auscultatory (air bolus) or water bubbling method (holding tube under water) to determine tube location.
Now, a new systematic review (Metheny 2019) reviewed guidelines/recommendations to distinguish between gastric and pulmonary placement of nasogastric tubes. The authors identified 14 such guidelines published between 2015 and 2018. Tube placement testing methods included in the review were: radiography, respiratory distress, aspirate appearance, aspirate pH, auscultation, carbon dioxide detection and enteral access devices. All fourteen guidelines agreed that radiography is the most accurate testing method. Of the nonradiographic methods, pH testing was most favored; least favored was auscultation.
Regarding the use of radiography for NG tube placement confirmation, recommendations ranged from ‘always required’ to ‘use only when other methods fail’. But they noted that geographical location influenced whether or not radiography was recommended as the first-line method. Whereas US guidelines favor radiographic testing as the first-line method for tube placement determination, those from Europe and Australia often favor radiographic testing only when the pH-method has failed or patients are ‘at risk’.
Of course, we always observe the patient for signs of respiratory distress after NG tube placement (eg. coughing, choking, tachypnea, cyanosis, etc.) but that should never be a method of determining tube placement. Patients who are obtunded or neurologically impaired may not have such signs even when the tube is in their lungs.
The review discussed that the physical appearance of the NG tube aspirate is not an accurate way of differentiating pulmonary vs. gastric placement. The review then notes considerable variation in the nine guidelines regarding the utility of aspirate pH as a predictor of nonpulmonary placement. Both the reliability of the method and the pH cutoff level vary from guideline to guideline.
Five of the guidelines reviewed discussed the efficacy of carbon dioxide detection devices in distinguishing between gastric and pulmonary placement. All five agree that the method is helpful but insufficient as a sole method to distinguish between gastric and pulmonary tube placement.
Only one guideline referred to auscultation as being sufficient to determine gastric placement. All the others either said auscultation should not be used at all or was unreliable to be used as the sole method of placement determination.
The review also gives little support for use of an enteral access device as a solitary method to distinguish between gastric and pulmonary placement.
The report concludes that there is general consensus among the guidelines that a properly obtained and interpreted x-ray is the most accurate method to distinguish between gastric and pulmonary placement of NG tubes.
Our 2 previous columns include important considerations for the radiologic confirmation of tube location. Our November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?” stressed that particular attention be paid to the x-ray requisition, which should clearly state the x-ray is for determination of tube placement. All too often we still see x-ray requisitions filled out with something like the admission diagnosis rather than the real reason for the x-ray. And you need to make sure that the person doing the interpretation is appropriately credentialed to do so (for example, if someone other than the radiologist is doing the interpretation). And feeding should not be commenced via that tube until the radiologist (or appropriately credentialed person) has documented the tube is in the correct location.
Our October 2016 What's New in the Patient Safety World column “AACN Alert on Feeding Tube Placement” noted that correct placement of a blindly inserted small-bore or large-bore tube should be confirmed with a radiograph that visualizes the entire course of the tube prior to its initial use for feedings or medication administration. Once correct tube placement is confirmed, the exit site from the patient’s nose or mouth should be immediately marked and documented to assist in subsequent determinations of tube location. After feedings are started, tube location should be checked at four-hour intervals.
Our original column (November 1, 2011 Patient Safety Tip of the Week “So What’s the Big Deal About Inserting an NG Tube?”) had links to the UK’s National Patient Safety Agency reports that detailed many incidents and complications related to improper NG tube placement. It also had links to a video and other resources on proper placement.
References:
AACN (American Association of Critical-Care Nurses). Feeding Tubes Require Initial and Ongoing Verification to Minimize Complications. American Association of Critical-Care Nurses updates Practice Alert on feeding tube placement. Press Release 15-Sep-2016
AACN (American Association of Critical-Care Nurses). AACN Practice Alert: Initial and Ongoing Verification of Feeding Tube Placement in Adults. CriticalCareNurse 2016; 36(2): e8-e13 April 2016
http://www.aacn.org/wd/practice/content/feeding-tube-practice-alert.pcms?menu=practice
Metheny NA, Krieger MM, Healey F, Meert KL. A review of guidelines to distinguish between gastric and pulmonaryplacement of nasogastric tubes. Heart & Lung 2019; 48(3): 226-235
https://www.heartandlung.org/article/S0147-9563(18)30562-4/fulltext
Print “June 2019 Guidelines for NG Tube Placement”
Print “June 2019 What's New in the Patient Safety World (full column)”
Print “June 2019 FDA Boxed Warning on Sleep Meds”
Print “June 2019 More Spin”
Print “June 2019 More on the Time of Day”
Print “June 2019 Guidelines for NG Tube Placement”
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